The Five A's Framework for Patient Behavior Change

Dr. Ellen Csepe // #ClinicalTuesday // www.ptonice.com

In today's episode of the PT on ICE Daily Show, MMOA faculty member Ellen Csepe discusses using the "Five A's" model in the clinic with patients to begin to address obesity management as part of a plan of care.

Take a listen or check out the episode transcription below.

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EPISODE TRANSCRIPTION

INTRODUCTION Hey everyone, this is Alan. Chief Operating Officer here at ICE. Before we get started with today's episode, I want to talk to you about VersaLifts. Today's episode is brought to you by VersaLifts. Best known for their heel lift shoe inserts, VersaLifts has been a leading innovator in bringing simple but highly effective rehab tools to the market. If you have clients with stiff ankles, Achilles tendinopathy, or basic skeletal structure limitations keeping them from squatting with proper form and good depth, a little heel lift can make a huge difference. VersaLifts heel lifts are available in three different sizes and all of them add an additional half inch of h drop to any training shoe, helping athletes squat deeper with better form. Visit www.vlifts.com/icephysio or click the link in today's show notes to get your VersaLifts today. ELLEN CSEPE Hey, good morning, everybody. Welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. I'll be your host today. My name is Dr. Ellen Csepe. I'm with the MMOA Older Adult Division, whose life's mission is to give grandma gains this Christmas to fight off frailty and level up what it means to be a geriatric clinician. So before we get started today, let's talk about our upcoming courses. We have two courses online that are eight week long cohorts where we talk about discharging the ankle pump and dialing in our skills for dosing in the level one course, which starts on January 10th. January 11th, our L2, level two course, we take it to the next level to really dial in our skills for older adults with specific conditions like osteoporosis, osteoarthritis, and even we have a new segment recently added on cognitive changes in dementia. So we're really glad that you're here today. Our topic for today is gonna be on obesity in the five A's framework. So your job, as a clinician and managing obesity in the Five A's framework. So I don't need to tell you guys, obesity is a growing health concern. Obesity and pre-obesity affect nearly 70% of the American population. This is obviously a big concern for us as a community, as a country, and as clinicians. And believe it or not, most patients believe that this is our job to manage, Managing obesity is something that is within our scope, and talking about the health considerations and health behaviors that contribute to obesity are within our scope as providers. But we have to take on this responsibility with excellence. We do everything here with excellence. And it's unfair to give this patient population anything less than that. And I've been saying this for a while, friends, but Our profession is uniquely positioned not to just add our opinion on how we should manage obesity, but in my opinion, we should be the leaders in health care. for how to manage obesity. We squander so many different resources that puts our profession above others. Things like time. We have more time with patients than any other provider and we often waste that resource because we're not confident in managing this problem well. We spend so much time with our patients and we have the strongest therapeutic alliances with them. We know our patients and spend hours with them as they recover from injury where they're kind of uniquely positioned at a position for behavior change. They're really primed to make the most with their health because they're afraid, unfortunately, because of their injury, because of what happened to them. prime time for us to change behaviors and we really waste that opportunity for lots of different reasons. And friends, we can no longer pass the buck off to other health care providers and say that this is their job. You know what I'm talking about. We ask our patients, does your doctor ever talk to you about exercise? Does your PCP ever talk to you about nutrition? They're like, no, they've got five minutes with me and they didn't do that. And we raise our hands and say, this is the problem with our healthcare today. No, we have a job to play in managing obesity. We have a role in this and we have to do it well because Friends, if you wish to treat obesity, you're responsible for not just identifying it as a problem in your patient population, but knowing what's going to work. For example, if I have a car and my battery is dead and I know my battery is dead and I take it to a mechanic and that mechanic says, yeah, your battery's dead. Good luck. That didn't help me at all. I need a mechanic that can identify the problem and then take the next steps to helping me fix it. We can no longer merely identify that obesity is a disease that causes significant harm to our patients. We cannot just merely identify it, cross our arms, look down the end of our nose and blame our patients. We can't do that anymore. We cannot just watch our patients suffer with a chronic illness and do nothing pragmatically to help support them. With that in mind, that same analogy of a car battery, if you had a car that needed a new battery and you came to me and I was your mechanic, I have no idea how to change a car battery. No clue. But if you came to me and I said, oh yeah, I've got this handled. I can help you out. That's an even bigger problem. We cannot address this concern with merely confidence. We have to have the skills to help our patients manage obesity. We can't just have confidence that we're providers of choice and that we're excellent. We need to have real skill in treating this concern. And friends, patients know that their weight is contributing to their problem. That's not that telling them is not the skill. That's not the skill. We need to be able to create an environment that's free of stigma. free of bias and filled with empathy for our patients that are struggling. Because patients know their weight is contributing to their issue, but in this void, in this vacuum of clinically meaningful discussion around weight and around behavior change, things like fad diets, diet pills, failed attempts at managing weight, ignorance to what might actually work, poor access to health care, and really at the bottom line, addressing their health alone. That's what happens if we don't bring skill to this discussion. If we can't bring skill to this issue, to this massive health crisis, what happens is the flip side. Patients having to figure it out on their own. So what I mean to say is there's a big difference in shooting from the hip and saying, yeah, you know, you'd probably have less pain if you weren't overweight or obese. There's a difference in that versus, can you tell me more about your exercise habits? Can you tell me, have other health care workers talked about how your weight might be changing or your weight might be impacting your condition? There's a huge difference and what that skill, if I could really articulate what that skill is, this skill is the hardest job that we have. The skill that you need is really the soft skills of being a good clinician. That's the hardest job we have. It's way easier to needle somebody's trap than it is to develop therapeutic alliance with them and make sure that they know that you're on their team and that you're an empathetic listener. That is way more abstract of a skill than just being able to do one small part of our job tactically. And I would argue that it might be the most important skill that we have. Patients need empathy if they're facing a health concern. Patients need us to see them as a person and not just as a patient. We need to address our own biases to really be impactful for this patient population. We need to acknowledge that if it were easy to lose weight, everybody would do it, but it's hard. Obesity is a relapsing chronic health condition that's multifactorial and it has a lot of psychological impact or impact bi-directionally that we don't even really fully grasp yet. Obesity is not easy to change and we need to address that first. So the next part of our discussion today, we're going to be talking about the five A's in obesity management. Now, when we talk about workouts, we're often given ideas and options to scale a workout. And so friends, if treating your patients with empathy and understanding and listening and patient-centered language is too big of an ask, I'm going to give you an option to scale this discussion with them. If the 5 A's and treating your patients with dignity and empathy and listening and respect sounds too hard, here's your scaled option for this discussion. You can say, it sounds like you're concerned that your weight is a contributor to this issue. I can refer you to a colleague of mine that has more empathy than I do and can have this discussion with you better. Bottom line, if you don't have empathy for your patients, if you haven't done the work to check your bias and how you might look down the end of your nose towards people struggling with your weight, looking for your help, then please step to the side and let a clinician come in to intervene that can have empathy and listening. Because unfortunately, you're likely doing more harm than good. Patients know that you're biased against them. They don't need you to tell them. Your face says it. And unfortunately, negative interactions with health care providers with weight bias often leads to further binge eating episodes for patients with a binge eating disorder. So no, you're not just telling them what they need to hear. You're actually being supremely unhelpful and likely making their problem worse. So if you can't have empathy, please scale this discussion and relay them to a provider that can actually be helpful. THE FIVE A'S MODEL So what are the five A's? The five A's model originates from the U.S. Department of Health and Human Services where it was developed as a framework for encouraging smoking cessation because, believe it or not, sticking your nose up in the air and saying, you know, those things are going to kill you actually doesn't help anybody quit smoking, shockingly. The same is true for older or for people struggling with obesity. So this framework was really developed to help put the patient who needs to make decision making changes in the driver's seat for their behavior change. So the five A's. ASK The first A is ask. Ask, is it okay to discuss lifestyle factors today during our session? Is it okay to talk about how weight might be contributing to your condition? Is it okay for us to talk about contributing factors like sleep and stress and nutrition? Have other health care workers discussed your weight in a way that was helpful or meaningful? So the five A's first, we want to ask for permission and some patients might tell you, no, that's okay. If somebody says, no, you know what? This really stresses me out. I'm not interested in talking about this with you. I just met you. That is understandable. We don't need to have a wrestling match with our patients. And if you have these soft skills, it should not feel like a wrestling match. It should feel like a natural discussion because again, patients already likely assume that their weight is contributing to their problem. You can ask which factor of their health they want to address today. So whether we know that sleep, stress, weight, exercise, diet, all interweave in regards to behavior change. We know that those things are interwoven and impact each other. ASSESS So our next A is assess. Assess, so you can ask a patient, hey, what do you want to talk about today? There are a few different things about your lifestyle factors that might be contributing to your condition. Yeah, your weight might be part of it. Also, sleep has a bidirectional relationship with weight. Exercise habits, dietary habits, stress, which do you kind of want to dive into today? And then let that drive the next tool of assessment. So if your patient says, you know, I actually don't know how much I weigh, do you have a scale here? Of course, that's within our scope to weigh our patients, to calculate BMI, to look at waist circumference. An important note should be that we do that in a private area because discretion with privacy is super important with this patient population. So we can't make good decisions with bad data. That's from our CEO, Jeff Moore. We can't, give patients and shoot from the hip that they need to lose weight when we don't know anything about their body composition. So weighing patients, providing that information about their waist circumference or their BMI is our next A for assessment. ADVISE The next advise, so the third A is advise. advising patients that sleep, exercise, appropriate nutrition management can be helpful in reducing pain. Most patients come to see physical therapists because they're in pain and so understanding that those factors deeply influence our success with rehab, and those are things that we can modify, that is hugely important for our patients to know. Also, not setting the goal too high. We might say, here's what your BMI window would be if it were normal, but who cares? Our goal initially should be to manage weight for five to 10% because even small percentages of weight change can be hugely impactful on lifespan. There's a lot of discussion about whether or not weight cycling and trying to lose weight only to gain it can be bad for our metabolic health, and meta-analyses recently would show that, hey, even if you lose weight and regain it, that can be beneficial for your overall health long-term, and you can still have a decreased risk of experiencing diseases. Noting that, you know, advising the patients that, hey, if you've tried losing weight in the past and it was a real stressor for you, we can talk about just increasing your activity level. It doesn't have to be a goal to lose weight. That does not have to be our goal. We can advise patients to just increase their activity level or decrease their added sugar, irrespective of weight changes, and that alone can be helpful in managing pain and managing injury. Third A is advise. AGREE The fourth is agree. So this is super important for our patients. We have to agree. We have to come to an agreement as to what we're going to do next. This is a pro tip. Let your patient set the goal. set what they want to do. Being told, okay, we are going to agree for you to stop smoking. We are going to agree for you to cut back to two cigarettes a day. Nobody likes to be told what to do. So asking your patient, what would you like the goal to be for the next week before we see each other again? Let's agree to talk about this again in the future, but I want you to set the goal for what sounds realistic for your life. I'm not going to tell you what that is. ARRANGING And then the fifth A, likely the most important, is arranging. So arranging for services for our patients. This is probably where we like to, you know, shoot from the hip and say, have you tried cold plunges? Have you checked out this latest app? Have you seen this new meal subscription plan? So arranging for our patients to access services is a huge, role to play in a patient's weight management, I would advocate for you guys. Really challenge your biases here. If you had a patient that had a resting blood pressure of 200 over 130, you'd be like, shoot, man, you are in danger. You are not okay. We need to send you to your PCP to talk about blood pressure medicine. That's what it's there for, right? Friends, if we can say that about blood pressure medicine, Why can't we say the same thing about medicine that would help manage obesity? We know obesity is a chronic, relapsing, difficult to treat condition. We know that it's a disease that requires medical management in some cases, and that people with just diet and exercise alone still struggle with success with managing their weight. If we're going to say that our goal is to manage weight for people that struggle with obesity, why are we so against referring them to get medicines. Why are we so averse to referring out to clinicians that would do this better than we would? It's no shame to say that you might need medicine to help manage a chronic health condition. So referring patients back to their primary care doctor to determine if it's appropriate for them to be a candidate for bariatric surgery, or talk with a nutritionist, or talk with a dietician, or be on medications. That is within our scope as well. And you really, friends, have to check your bias. If that puts a knot, a ball of wax in your throat, that you're like, oh, I really don't wanna do that, that's cheating, cheating. It's cheating for a patient to use medication to lose weight. They should do it the hard way. Like, we're not gonna be effective to patients coming at a chronic health condition with that bias. Can people be successful with managing their weight without medicines? Absolutely, but those medicines are underutilized for the people that truly need them and overutilized by Instagram models. So I think that we can do our patients a favor and check our bias when we're talking about medications and other procedures related to weight loss. SUMMARY First, ask. Then, assess. Third, advise. Fourth, agree. Fifth, arrange. So those are the five A's for obesity management and the conversation that we had around them. Friends, I am so honored that you would spend your time with me to talk about how to serve this patient population better. This patient population deserves our best stuff. They deserve excellence. They deserve people who are truly compassionate. And friends, we have a strong role to play in this huge problem in society. You know, it's really easy to acknowledge that chronic pain, um, chronic pain and over-utilization of obese or of opioids is a huge problem in our world. We know that overdosing from opioids is a huge problem that physical therapists can be super impactful in treating. I would argue that we have a much bigger role to play in managing obesity and supporting our patients than we assume. We really don't do enough for our patients because we're often limited by fear. We're often limited by a lack of skill and a lack of knowledge into what we should do. And I am so honored that you would spend your morning with me sharpening those skills. Our patients suffer in the void of these meaningful discussions. Our patients suffer by themselves, not knowing if there's a clinician who has empathy and support for them. I'm so thankful that you listened to this podcast today to really better serve those patients who are vulnerable in our healthcare world. Thank you so much for joining me. Have a great rest of your day.

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