You’ve seen Dave in the family practice clinic several times. He’s 52, obese, and he has diabetes, hyperlipidemia, and hypertension. Each time you see him, you advise him to lose weight. Yet, here he is again today, not having made any health behavior changes. You want to help him, but you understand the challenges in making lifestyle changes, as well as time limitations with the busy clinic schedule.

Time: Our greatest enemy

Time is a limited commodity for nurses in almost any healthcare setting, and it often seems there’s not enough of it to provide individualized health behavior change counseling. How can we make the most efficient and effective use of limited time when it comes to this important aspect of patient care? The modified 5As framework and the Transtheoretical Model of Behavior Change (TTM) help nurses provide individualized behavior change counseling in clinic and office settings.

The modified 5As: An evidence-based model for behavior change

The modified 5As framework consists of Ask, Assess, Advise, Agree, and Assist, and it has been used in several areas of behavioral change counseling. (See Modified 5As framework flowchart.)

Let’s look at how you can use this model along with TTM to help Dave approach weight loss.

Ask—Begin by asking Dave, “Can we talk about your weight today?” Asking permission communicates respect. Patients are more likely to discuss making a change when asked rather than lectured to or told they need to change. Weight is a sensitive issue, and it should be approached without judgment. Don’t make assumptions, blame, or attempt to elicit guilt.

If Dave agrees to have a discussion about his weight, use TTM to learn more about him; ask if he’s been thinking about trying to lose weight and if he’s made any recent weight-loss attempts. Assessing Dave’s stage of readiness for change allows you to tailor interventions that are specific for him. (See TTM stages of change.)

Dave tells you that he often thinks about needing to lose weight and has made several short-term and unsuccessful attempts. He says he knows what he should eat because of his diabetes and thinks his biggest problem is that he’s an emotional eater—he eats when he’s under stress, angry, or sad. He also tells you that with his busy work schedule, just grabbing lunch at a fast-food restaurant is easier than preparing and packing lunches. Dave identifies that his work schedule also doesn’t leave much time for exercise. His greatest motivations to lose weight are to improve his health and to be able to play more actively with his grandchildren. Dave is ready to make a change; he’s in the TTM Contemplation stage, so you can move to Assess, the next component of the 5As model.

However, if Dave wasn’t ready to address his weight at this visit, you could go on to discuss his other concerns and ask if he would be willing to speak about his weight at the next visit. Trying to initiate change if Dave isn’t ready might lead to frustration and may hinder future efforts to address weight management.

Assess—For Dave, risks related to obesity extend to his other health conditions—diabetes, hyperlipidemia, and hypertension. This is where you can review his current status regarding these comorbid conditions. Discuss the risks of being overweight to his current and future health and the benefits of even modest weight loss. In the Ask component, Dave identified specific stressors that contribute to emotional eating and excessive caloric intake, which means stress management will be important in his weight-loss plan.

Advise—Personalize advice to Dave and his particular situation. He’s the expert on himself, and he knows what he’s capable of doing. Listen to learn what motivates him to want to lose weight as well as what concerns he has about his ability to succeed. Motivators identified in the Ask component included improving his health and playing more actively with his grandchildren. Revisit and strengthen these motivators by asking Dave to be even more specific. In what ways does he believe weight loss will improve his health? What are some of the specific activities he wants to participate in with his grandchildren?

Together, you and Dave must anticipate barriers that might hinder achievement of his goals or lead to relapse. He already identified emotional eating and a perception that his work schedule doesn’t allow time for healthy lunches and physical exercise. Discuss specific strategies to address these and other barriers, providing him with information about stress-management techniques as well as a counseling referral.

Dave says he’s planning to take healthy lunches to work and to walk the dog for both exercise and stress relief. He also describes some specific barriers that have led to his previous failed attempts at weight loss. For example, he doesn’t like to walk in the rain or cold weather. You and Dave establish an alternative plan for inclement weather—walking at the mall or using the treadmill at a nearby gym.

Dave also tells you he hasn’t felt fully supported by his wife in previous weight-loss efforts. She’s also overweight and has some of the same health problems as Dave. You suggest that he bring his wife with him to his next visit so you can discuss his weight-loss needs and plans with her. You provide Dave with a weight-loss packet that contains information on how to not only change the numbers on the scale but also improve overall health; you encourage him to share this with his wife.

Agree—You and Dave are now ready to work collaboratively on a weight-loss goal. It should be specific and achievable within a realistic timeframe. It may be that the most realistic starting target is slowing weight gain or simply maintaining current weight. From there, work on a modest weight loss of 0.5 to 1 pound per week. Dave agrees that a weight-loss goal of 0.5 pound per week is manageable.

The plan for specific behavior changes also should be realistic and achievable on a daily basis. Dave plans to cut back on his soda intake every day and to eat more balanced meals. He’ll work with his wife on the weekends to prepare his meals for the week, and he’ll take his lunch to work every day rather than going to fast-food restaurants. Dave will take his dog for a 30-minute walk every day after work. He thinks walking his dog also will be a way to relieve stress rather than turning on the television and going to the refrigerator to look for a snack, which has been a typical habit for him. Dave also will work on getting to bed by 10:00 p.m. every day, so he can get at least 7 hours of sleep.

Assist—Obesity is a chronic condition, and relapse and weight gain can be expected. Appropriate referrals and frequent follow-up can help keep Dave on track.

Dave has progressed to the TTM Planning/Preparation stage of change. He agrees to a referral to a dietitian and psychologist for counseling. You schedule a follow-up meeting with Dave in 2 weeks. At that visit, you’ll obtain feedback on his progress, provide encouragement, and address any concerns he has.

Improve counseling skills and confidence

Weight loss is difficult for many overweight and obese individuals and can take lifelong attention to stay on track. The Modified 5As framework, combined with TTM, guides nurses to provide patient-centered, collaborative weight-loss counseling that promotes self-efficacy. The Ask, Assess, Advise, Agree, and Assist components can be completed as a brief intervention in 10 minutes or less.

Nurses can feel confident in behavior change counseling by learning more about the 5As framework and TTM. (See Learn more.)

Andrea Bearden is nurse practitioner who has served in primary care/women’s health and is currently working in the specialty clinic at VA Northern Indiana Health Care System in Fort Wayne. Beth Kelsey is an assistant professor and the DNP Program Director at Ball State University in Muncie, Indiana, and editor-in-chief of Women’s Healthcare: A Clinical Journal for NPs.

Selected references

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Glasgow RE, Emont S, Miller DC. Assessing delivery of the five ‘As’ for patient-centered counseling. Health Promot Int. 2006;21(3):245-55.

Jay M, Gillespie C, Schlair S, Sherman S, Kalet A. Physicians’ use of the 5As in counseling obese patients: Is the quality of counseling associated with patients’ motivation and intention to lose weight? BMC Health Serv Res. 2010;10:159.

Rueda-Clausen C, Benterud E, Olszowka R, Vallis MT, Sharma, AM. Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care. Clin Obes. 2014;4(1):39-44.

Shape of things to come: New toolkit for health practitioners provides roadmap for obesity management. Conduit. 2013;6(1):16-7.

Vallis M, Piccinini-Vallis H, Sharma AM, Freedhoff Y. Clinical review: Modified 5As: Minimal intervention for obesity counseling in primary care. Can Fam Physician. 2013;59(1):27-31.