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Recommendations Summary

AWM: Assess Motivation for Weight Management 2014

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    AWM: Assess Motivation for Weight Management

    The registered dietitian nutritionist (RDN) should assess motivation, readiness and self-efficacy for weight management, based on behavior change theories and models (such as cognitive-behavioral therapy, transtheoretical model and social cognitive theory/social learning theory). While research supports cognitive-behavioral therapy as an effective method of overweight and obesity treatment, there is limited research in the areas of the transtheoretical model and social cognitive theory and social learning theory.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      Behavior change theories or models are used to design and implement nutrition interventions. Theories and theoretical models consist of principles, constructs and variables, which offer systematic explanations of the human behavior change process. Behavior change theories and models provide a research-based rationale for designing and tailoring nutrition interventions to achieve the desired effect. Theories and models guide determination of:

      • The information patients or clients need at different points in the behavior change process
      • The tools and strategies that may be best applied to facilitate behavior change
      • Outcome measures to assess effectiveness in interventions or components of interventions.
      The ADA Nutrition Counseling Evidence Analysis Project explored the evidence related to the following theories or models and nutrition therapy:
      • Cognitive-behavioral therapy (CBT): Based on the assumption that all behavior is learned and is directly related to internal factors (e.g., thoughts and thinking patterns) and external factors (e.g., environmental stimulus and reinforcement) that are related to the problem behaviors. Application involves use of both cognitive and behavioral change strategies to effect behavior change.
      • Transtheoretical model: A theoretical model of intentional health behavior change that describes a sequence of cognitive (attitudes and intentions) and behavioral steps people take in successful behavior change. The model, developed by Prochaska and DiClemente, is composed of a core concept known as Stages of Change, a series of independent variables, the Processes of Change and outcome measures including decision balance and self-efficacy. The model has been used to guide development of effective interventions for a variety of health behaviors.
      • Social cognitive theory and social learning theory: Provides a framework for understanding, predicting and changing behavior. The theory identifies a dynamic, reciprocal relationship between environment, the person and behavior. The person can be both an agent for change and a responder to change. It emphasizes the importance of observing and modeling behaviors, attitudes and emotional reactions of others. Determinants of behavior include goals, outcome expectations and self-efficacy. Reinforcements increase or decrease the likelihood that the behavior will be repeated.

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions vary; however, MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      From the Nutrition Counseling Project

      • Two small positive-quality RCTs provide evidence that short-term (10-week) cognitive-behavioral therapy is an effective method of overweight and obesity treatment (Kalodner and DeLucia, 1991; Stahre and Hallstrom, 2005)
      • One neutral-quality six-month randomized controlled trial (86 obese adults) provides evidence that intermediate-duration (six to 12 months) behavioral therapy and behavioral therapy combined with a personalized system of skill-acquisition targeting weight loss is more effective than weight-loss education alone in facilitating weight loss, decreasing both total energy intake and percentage of calories from fat and increasing physical activity (Fuller et al, 1998)
      • Two positive randomized controlled trials (65 participants received behavior therapy and a very-low-calorie diet, Melin et al, 2003; Kajaste et al, 2004) and one neutral quasi-experimental study (84 participants received behavior therapy, Dornelas et al, 1998) evaluated behavior therapy as a component of a weight-loss program of long-term duration (at least 12 months). Behavior therapy was not always the variable of randomization. Participants receiving behavior therapy lost weight at the conclusion of treatments. Upon follow-up, there was some weight regain, but participants remained at a lower weight than baseline. Studies that included a very-low-calorie diet (VLCD) to initiate rapid initial weight-loss, combined with behavior therapy, also appeared to produce long-term weight loss. [Note: This is not a statement recommending VLCDs or suggesting that VLCDs are more beneficial than low-calorie diets.]
      • One positive-quality intervention study strongly supported application of the Transtheoretical Model or Stages of Change in improving health and food behavior change (Jones et al, 2003). Much research has been accomplished to validate instruments used to measure stage of change in the dietary context. Additional research is needed to support its effective application in nutrition counseling.
      • One RCT, a positive-quality study, evaluated the effect of six telephone-delivered counseling sessions targeting increased self-efficacy outcome expectancy (Social Learning Theory constructs) in 65 hyperlipidemic patients not adherent to their cholesterol-lowering diet (Burke et al, 2005). The intervention involved goal-setting, self-monitoring, self-reinforcement and verbal persuasion. The intervention group significantly reduced saturated fat and cholesterol intake and had significantly decreased LDL-cholesterol levels relative to the control group. There was no increase in perceived self-efficacy in the intervention group vs. the usual care group. Outcome expectancy significantly increased in the intervention group, but was not correlated to the improvements in dietary adherence or decreased LDL-cholesterol. Despite positive behavioral and clinical outcomes, researchers failed to show a specific relationship between self-efficacy or outcome expectancy and change in behavior.
      • One randomized controlled trial of neutral-quality evaluated a five-week nutrition education (NE) and a nutrition education plus social learning (NE+SL) intervention in 78 patients with type 2 diabetes (Glasgow et al, 1989). In addition to nutrition education, the social learning intervention group received information on goal-setting based on individual barriers to adherence, modeling of strategies used successfully by other individuals with type 2 diabetes and was taught a problem-solving method. This five-week study failed to show a significant advantage of social learning intervention over nutrition education alone. RCTs of longer duration are needed to further explore the effect of social learning theory on diabetes management.
      •  

    • Recommendation Strength Rationale

      The six Conclusion Statements from the Nutrition Counseling project in support of this recommendation received:

      • What is the evidence that cognitive-behavioral therapy of short-term duration (less than six months) for weight loss, results in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade III 
      • What is the evidence that cognitive behavioral therapy of intermediate duration (six to 12 months) for weight loss results in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade III
      • What is the evidence that cognitive-behavioral therapy of long-term duration (more than 12 months) for weight loss, results in health and food behavior change in adults counseled in an outpatient or clinic setting? Grade II
      • What is the evidence that nutrition counseling based on the Transtheoretical model results in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade III
      • What is the evidence that nutrition counseling, based on social learning theory targeted to reduce cardiovascular disease risk factors results in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade III
      • What is the evidence that nutrition counseling based on social learning theory for diabetes management results in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade III.  

    • Minority Opinions

      Consensus reached.