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The third M – motivation |
Previous GPSpeak articles have discussed the complications of obesity causing metabolic and mechanical problems. Often the mechanical complications of being overweight can be demotivating. For instance, pain in the knees with or without arthritis, stress incontinence or daytime sleepiness from sleep apnoea can be significant deterrents to going walking. Others may not have mechanical problems but still lack the motivation to address their overweight or obese problem.
The GPs’ role in motivating their patients
The issue is not so much how GPs can motivate their patients but how GPs can steer their patients towards an environment where they can motivate themselves - so called ‘intrinsic motivation’ versus ‘extrinsic motivation’ (where one is cajoled into doing something by someone else). However before discussing options of how one could lose weight, it is necessary to consider where they are in terms of readiness to engage in a therapeutic lifestyle change.
If they are precontemplators we don’t have much choice but to express concern about their risk factors. If we can sensitively and opportunistically do some measurements like weight, BMI, waist and blood pressure, fasting lipids, LFTs and BSL that turn out to reveal the metabolic syndrome or high cardiovascular risk, it may be helpful in moving their thinking along to the contemplator stage. If not, we could at least recommend appropriate follow up.
If they become contemplators we then need to begin to look at options of what they could do. This may involve the GP giving them ideas on how to lose weight, joining a program like Weight Watchers or the Professor Trim Program, or being referred to a dietitian or exercise consultant etc.
The key to becoming sufficiently intrinsically motivated is to plan what to do and then take appropriate and sustainable
action. This can be helped by:
1) SETTING GOALS – setting realistic goals is vital remembering that a meagre 5-10% weight loss will give the main health benefits needed (see chart). Ask a person how much they think they should lose and they are likely to give a figure that is 30% lighter – this is a totally unrealistic goal and should be discouraged to avoid failure and the resulting disappointment, disillusionment or even depression. Also it is important the goals are owned by the patient and not imposed by the doctor or other person. Quality of life goals are just as important as other health goals.
2) PROVIDING CHOICE OF STRATEGIES – this can be done by the GP if he or she has the time and skills, or by the health professional referred to or just by one’s own ability to self educate or be educated through a program. Unfortunately there is confusion out there as to whether one should go on this diet or that, or whether one should look at overall lifestyle changes (which will more likely have long term benefits).
3) COACHING – this means going a bit further in gaining knowledge and lifestyle skills such as learning new and healthier cooking techniques, making better choices when shopping for food, learning how to use exercise equipment such as a fitball, light weights or gym equipment.
4) BEING CHALLENGED AND GAINING COMPETENCE – the process is a journey and it is important that we are challenged with new ideas, skills and goals as we go. Gaining competence and confidence is an important part of the process. As competence grows so does the level of personal satisfaction and enjoyment.
5) BALANCING LIFE – this means reorganising one’s life and time management so that eating, being physically active, relaxing and quality socialising with family and friends are given appropriate time slots to counterbalance time spent with computers, television, work desk etc. Whilst people will always say they don’t have time for this, it is actually the key to long term success in weight management. In other words stress and time management is a high priority and GPs have a role to encourage their patients to take this seriously. There are always busy and successful people who are good role models in their own healthy lifestyle management for people to aspire to.
6) PROVIDING POSITIVE FEEDBACK – this is where GPs play a vital role in providing meaningful rewards for their patients. Encouraging the patient to self monitor and to come back for GP review is very important as it is not only measurement of weight, waist and blood pressure that requires feedback. In fact for some, such measurements may be counterproductive and are best left alone at least in the early stages of weight loss. However quality of life issues such as how one feels, how easy it to do up shoe laces, fit into clothes, assessment of self esteem etc are helpful things to focus on. Some of the measurements including blood lipid and sugar changes may take some months to improve. Waist measurements are probably the best guide for fat loss and may come before weight loss. This is because becoming more physically active may increase muscle bulk and muscle is heavier than fat.
7) MAINTENANCE – GO FOR ‘FLOW’ – the ultimate aim is to become master over one’s destiny and at the same time enjoy what one is doing. Mihalyi Csikzentmihalyi, professor of psychology at the University of Chicago, first identified the concept of optimal experience which he termed flow to describe the subjective state that commonly occurs in people when they experience a certain type of internal order. The state of flow arises from involvement in a perceived challenge with a simultaneous perceived capacity to manage and engage it effectively.
“The main dimensions of flow - intense involvement, deep concentration, clarity of goals and feedback, loss of a sense of time, lack of self consciousness and transcendence of a sense of self, leading to an autotelic, that is, intrinsically rewarding experience - are recognized in more or less the same form by people the world over.” [1].
People who successfully lose weight and avoid regain seem to achieve this by developing a certain healthy lifestyle flow in their busy lives that can be maintained. This happens despite time constraints and involves long-term healthy lifestyle habits, diet, levels of physical activity and stress management. To get people to this level is a challenge and the GP role is to encourage and coach often with the need to seek help from other health professionals. The important thing is to never give up trying to encourage our patients even if progress is slow and even if some strategies fail.
[1] M. Csikzentmihalyi, “The future of flow,” in Optimal experience - psychological studies of flow in consciousness. Cambridge: Cambridge University Press, 1988, page 365.
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