Whiteley, Jessica A. Ph.D.; Milliken, Laurie A. Ph.D., FACSM
Obesity remains a major public health concern in the United States, with 31.9% of children 2 to 19 years old and 66.3% of adults older than 20 years who are overweight or obese (10,11). Both the American College of Sports Medicine (3) and the American Dietetic Association (14) have issued position stands on the respective roles of physical activity/exercise and food intake in the management of weight. It is common knowledge that expending more calories than consumed must occur for weight loss; however, this has been a difficult task to accomplish from both a population and an individual standpoint. It is estimated that 33.8% of men and 47.9% of women are trying to lose weight; the most common weight loss practices include exercising, eating less, eating less fat, and/or replacing high-calorie foods with lower calorie foods (15). Given that being overweight/obese is widespread and many are attempting to control their weight, health and fitness professionals will routinely deal with clients who are trying to lose weight with varying levels of success. Therefore, practitioners need both an understanding of the factors related to energy balance (3,14) and the ability to implement behavior change strategies to elicit weight loss and long-term weight maintenance. Although other resources are available that describe the evidence-based weight loss strategies (3,14), the goal of this article is to identify some of the behavioral barriers and opportunities that the family presents in the effort to help a client accomplish and maintain weight loss. In addition, a client-centered approach, rather than a directive approach, will be described as it has been shown to be an effective approach to motivating clients to accomplish difficult behavioral changes such as weight loss.
A BEHAVIORAL CLIENT-CENTERED APPROACH TO WEIGHT LOSS
The behavioral client-centered approach is based on motivational interviewing techniques (8). In this style of working with clients, the practitioner does not counsel and direct the client. Rather, the practitioner works with the client in a partnership toward behavior change such as those related to weight loss (5,16). This client-centered approach seeks to elicit the strengths of the individual and guide him or her toward weight loss (13). Although this approach requires practice, we believe that it is possible to incorporate some of these techniques into your sessions with clients. Behavioral strategies from the transtheoretical model (12) and social cognitive theory (1), such as goal setting, problem solving, enlisting social support, evaluating the pros and cons of making a decision, and mastery experiences (2,9) that are known to be successful in behavior change, can be incorporated in this client-centered approach toward weight loss. A practical example will be used to illustrate the approach we are advocating (see Box below for a client example).
The dialogue in Table 1 provides an example of how the directive approach varies from a client-centered approach (4). This dialogue might occur after the initial meeting with our client, Karen, where the practitioner has learned about Karen's current eating and physical activity practices. The dialogue in Table 1 focuses on how goals are set either for Karen (directive approach) or with Karen (client-centered approach).
Note that in the directive approach, the practitioner is telling the client what to do. Some clues to know when you are taking a directive approach are when you find yourself saying "I recommend," "what you should do is…," "It would be better if you…," "For next week, do the following…," and so on. In a client-centered approach, the practitioner asks questions to find out what the client would like to do or believes they are capable of doing. This approach then can be used to work together to set goals collaboratively. If the client states that he or she does not know what to do, a client-centered practitioner could say "I have some ideas, may I share them with you?" and then proceed with providing information and recommendations. The distinction may seem small but can make a big difference in building rapport and a partnership with the client. A client-centered approach may take more time in the session; however, the advantages of this approach are that you fully assess the barriers, you do not make assumptions about what a reasonable goal might be for the client, you enlist the client as an agent in her own behavior change, and you improve compliance and adherence (13).
ROLE OF THE FAMILY: BARRIER AND OPPORTUNITY
Health and fitness professionals often see adults (and sometimes children) individually in their sessions. However, McLean et al. (7) and Gruber et al. (6) have reported that the family can present an obstacle, as well as an underutilized opportunity to the individual regarding the adoption of weight loss behaviors. The value of family involvement is especially important when a child is the focus of weight loss efforts (6). The family composition may vary from a spouse or a partner, to children, to extended family. We will define family as any of these for the purposes of this article. The family can be an agent of change, wherein family members support one another in developing healthy habits that lead to weight loss and maintenance. Conversely, the family can serve as a barrier to change. The health and fitness professional should be aware of the role a family may play in the behavior change process with an individual client. If the health and fitness professional asks questions such as "what factors help you with losing weight?" and "what factors are barriers to you losing weight?" and answers surface regarding the family, the professional then should be able to help the client work on incorporating the family indirectly by building on strengths, as well as helping the client to tackle the obstacles that the family may present. If in using these questions and/or the following techniques, the family is never mentioned, we do not recommend incorporating the family into your work with your client. If at some point later in your work with your client this changes and the family is mentioned, that would be the appropriate time to include the family in the behavior change process.
THE FAMILY AS A BARRIER TO CHANGE
There are times when the family may not be supportive of change. For example, there are some partners who become threatened by the weight loss of a partner, thinking that a slimmer partner will lose interest in them if they are unfit or overweight. There also are some families who value eating big meals as part of family time and may view your client's refusal of second, third, and even fourth helpings as an insult. An individual also models behaviors, good or bad, for the family. If the client has always modeled poor eating habits, a predominance of sedentary behaviors, and little physical activity, this has likely been a negative influence on other family members, particularly children. After the behavior change process begins, a client who is making positive changes may want to extend these changes to the family, which may be resistant to replacing television time with a walk to the park or exchanging fast-food meals for home-cooked healthier dishes. If these familial barriers are not identified and incorporated in the behavior change process, the client can be left unsupported and frustrated with his or her family and ultimately discouraged about his or her own ability to succeed.
THE FAMILY AS A FACILITATOR OF CHANGE
How then does the health and fitness professional incorporate the family into individual sessions? This might seem difficult, but there are ways to incorporate the family to varying levels.
The first level of incorporating the family is to bring the family into the discussions by learning about the client's barriers and facilitators of change; many times, this conversation with the client will include topics of family lifestyles and habits. Whiteley and colleagues (16) describe tools for these discussions, which will be discussed here in brief. First, based on the transtheoretical model (12), have the client fill out a Decisional Balance Worksheet by simply listing the "pros for losing weight" on one side of a sheet of paper and the "cons for losing weight" on the other side. Both the pros and cons are important to your work with the client. The pros side includes what motivates a client to change and will represent a client-specific list of his or her motivators, or facilitators, to weight loss efforts. The cons side will give you the barriers to weight loss, as seen by the client. If a client has not listed the family on either side, you might recognize from the beginning that the family may not play an important role from the client's perspective in the change process. At this point, you could prompt the client by stating "I notice that you have not mentioned your family in these lists; can you think of any reasons why you losing weight could be good for your family, a pro; or how they may make losing weight difficult for you, a con?" In this manner, you can learn from the client how the family serves as a barrier or facilitator to change. Table 2 is an example of the Decisional Balance Sheet generated by Karen, our 40-year-old client example.
The pros and cons list is a simple way to elicit the client's facilitators and barriers to change. You may want to use the "pros" side of this list to remind a client who is struggling why he or she wants to make this change by saying "I know you have had a tough week in meeting your goals. Let's step back for a second and remember why weight loss is important to you. I remember you wanted to be a positive role model for your family and you wanted to have more energy to play with your kids. Is that right? What else can you remember about why losing weight is important to you?" Clients can even write these reasons on a card to carry in their wallet or post prominently to remind themselves of these important motivators.
The "cons" side represents the barriers that will stand in the way of behavior change for a client. These are barriers that you can work with the client to problem solve. A brainstorming session can help to problem solve with your clients. In a brainstorming session, the client proceeds through four steps: step 1, the client identifies the problem fully; step 2, the client brainstorms solutions to the problem; step 3, the client evaluates and chooses the best solution(s); and step 4, set goals to implement these solutions (16). It is important that you guide the client in this process rather than prescribe a solution, even if the solution seems apparent to you. An important component in step 2, brainstorming, is to not evaluate or judge the options in any way during the brainstorming. Often in the midst of obviously unviable, impractical, or silly solutions, a great idea might emerge that the client would not have thought of otherwise. In step 3, the client does go back through the possible solutions to evaluate them for feasibility, viability, and soundness. After the solutions are chosen, an additional step to the traditional problem-solving process listed above is to set concrete goals with your client so he or she will know how to implement them in the coming week. It is best to work with the clients to try to determine smaller realistic goals to reach the overall goal. For more information on how to implement goals and determine the action plan steps to create to implement, refer to other more detailed descriptions in Bandura (1), Gavin (4), and Whiteley and colleagues (14). Returning to our client, Karen, we have learned after a few sessions that she reports making good progress in changing her diet but is having difficulty fitting in exercise outside of her one session per week with you. Table 3 shows what a brainstorming worksheet might look like for our client, Karen; her words are shown in italics. Karen starts with identifying the problem in step 1, moves on to generating a list of any possible solution without evaluating them in step 2, moves on to evaluating the list of possible solutions from step 2 in step 3, and then moves on to determine how she could set specific realistic goals for the generated solutions in step 4. Please remember that in step 2, the "Brainstorm Solutions" are not all going to seem practical, viable, or sound; it will be in step 3, the Evaluation of Solutions, that the client works through the practicality of the possible solutions. We have found that in working with clients, you will often need to remind them not to judge solutions when brainstorming. The idea is to suggest anything, even if it seems drastic or unrealistic, so that other ideas might surface.
The goal of a problem-solving session is to take into account the client's barriers and to set concrete achievable goals to work on overcoming these obstacles (1). In this example, you can see that when the client, Karen, fully identified the problem of "not enough time to exercise," the family was among her barriers to exercise. This knowledge is important for the health care practitioner and will need to be incorporated into the solutions to fully address the problem and to ensure the best chances for success. Karen was able to think of some reasonable solutions that either incorporated her family as in the case of a family bike ride or did not detract from the kids' extracurricular activities, such as choosing to walk during the soccer game. In this manner, the family can become a source of support and facilitate progress rather than hinder it.
The second level of working with the family would be to have a session where all of the family members are invited. This might not be practical in many cases; however, if possible, this could further advance the family's role in your client's behavior change process. Such a session could contain several elements: 1) an assessment of how mom's (dad's or partner's) change has impacted the family, 2) areas the family thinks that mom needs more help, and 3) ideas on how to help mom make these changes. The idea is to take a client-centered approach (16), where the client, and in this instance, her family, is generating the ideas and strategies for change. If the family is brought in and enlisted to support your client, this can be an inroad to not only helping your client, but to changing the family's behaviors as well. Another advantage to this family-centered approach is that the family members will be more likely to follow through on strategies that they identify rather than strategies you prescribe to them. Enlisting social support or helping relationships are two techniques from social cognitive theory and the transtheoretical model that can aid in behavior change (1,12). If you are the practitioner using the directive approach and are trying to persuade reluctant family members, your efforts will likely be met with resistance and, in some cases, defiance.
BEHAVIORAL WEIGHT LOSS STRATEGIES
In the process of change, when using the client-centered approach, it is important to have the client generate the strategies whenever possible (13). You can facilitate this process as previously described. If a client is unable to generate ideas, it may be necessary to get them started with suggestions. Table 4 shows some examples of behavioral strategies for weight loss that you can keep in mind when working with clients.
Although the prospect of long-term weight loss seems to be unattainable by most people who are currently overweight, recent evidence suggests that for those who do lose a significant amount of weight, about 20% can maintain the lower weight (17). However, a multifaceted approach that includes individual behavior changes plus the reduction of the impact of an obesogenic environment is necessary to attain that initial weight loss (3,14,17). We encourage a client-centered approach to weight loss, wherein behavioral strategies are used to reduce the impact of the family as a barrier to change and to use and build on the inherent strengths of the family structure to elicit change for the client and potentially all family members. In addition, the practitioner should recognize that a sound knowledge of the factors related to energy balance also is required when working with clients who have weight loss goals.
CONDENSED VERSION AND BOTTOM LINE
In the United States, 66% of adults are overweight or obese; 33.8% of men and 47.9% of women have reported trying to lose weight. Although most know something about what to do to lose weight, many have not determined how to accomplish it. Health and fitness professionals can help clients strategize ways to overcome barriers, including familial barriers. In addition, the health and fitness professional can help clients use the family structure to engage family members around the common goal of weight control. The process described in this article involves a client-centered approach, rather than a directive approach, in which we use behavioral strategies, such as decisional balance sheets, problem solving, and collaborative goal setting. This client-centered approach has been shown to be an effective approach in motivating clients to accomplish difficult behavioral changes such as weight loss.
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