Using Teachable Moments to Improve Nutrition and Physical Activity in Patients
Am Fam Physician. 2008 Jun 1;77(11):1510-1511.
In this issue of American Family Physician, Demark-Wahnefried and colleagues encourage physicians to find “teachable moments” during which to persuade patients to adopt healthy lifestyles.1 In addition to avoiding tobacco use, the American Cancer Society recommends lifestyle interventions in the areas of nutrition and physical activity to reduce cancer risk and improve prognosis following a cancer diagnosis.2,3 These recommendations are: achievement and maintenance of a healthy weight (body mass index [BMI] = 18.5 to 24.9 kg per m2); regular physical activity of at least 30 minutes per day on at least five days per week; a plant-based diet high in fruits, vegetables, and whole grains and low in saturated fats and red meats; and moderate, if any, alcohol consumption.
The prevalence of these additional lifestyle interventions does not seem to be improving significantly among persons in the United States.4 Achieving a major reduction in these disease risk factors will undoubtedly require a concerted public health effort that includes societal-wide programs that provide multiple levels of communication on disease risk, as evidenced by the tobacco control programs.5 However, the primary care physician, who is familiar with the patient's history and has an ongoing relationship with the patient, has a unique opportunity to personalize the risk of disease for an individual patient. Furthermore, experience with smoking cessation has shown that physician advice and assistance to patients can be effective tools in helping to change patients' health behaviors.6,7
The concept of a “teachable moment” was introduced by Maccoby and colleagues in the early 1960s as a way to describe a time period in which people were seeking information on a topic and were ready to accept different types of advice on what they should do.8 The example given was pregnant women and the teachable moment was limited to the last trimester of their first pregnancy—a very limited time period, indeed.8 Since then, the teachable moment has been broadened to refer to opportunities that link a health message to a presenting problem, regardless of the receptivity of the patient. This means that the task of the physician is to motivate, as well as educate, the patient. Physicians may find it helpful to use some of the techniques from motivational interviewing.9 The four general principles are: (1) express empathy with the patient's current position and accept that their ambivalence toward change is normal; (2) encourage the patient to present the arguments for change; (3) actively involve the patient in problem solving; and (4) enhance the patient's self-confidence so that the patient can cope with obstacles and succeed in changing behaviors.
However, even the best motivator may need help remembering to use the teachable moment. Smoking status and BMI are both easy to measure, and there are consensus standards for determining risk level (i.e., high-, medium-, or low-risk). They are now accepted as part of the “vital signs” that are recorded with every visit and they can serve as reminders for the busy physician to address a lifestyle issue if an appropriate teachable moment occurs. However, we currently do not have simple instruments to measure a patient's level of physical activity or dietary pattern as part of the patient's “vital signs.” Nor do we have an easy consensus classification system for what represents the risk level (i.e., high, medium, or low) for either of these behavior patterns. Until researchers are able to supply physicians with such tools, effective patient education on diet and physical activity will probably be limited to energy balance recommendations needed to control body weight.
With appropriate prompting in the medical record and skills in motivational interviewing, many presenting problems could become teachable moments for physicians to encourage patients to achieve and maintain a healthy weight. At the initial visit for a condition, the physician could encourage the patient to set a goal for one small, achievable change in the target behavior before the next visit. For example, the patient could decide to add one brisk walk to their weekly routine. This goal could be recorded in the patient's medical record, which would then prompt the physician to ask the patient at his or her next visit, “How did it go?” and, “What is the next step that you feel ready to take?” In this way, physicians can help motivate patients toward long-term change without taking too much time away from resolving the presenting problem.
Primary care physicians are in a unique position to give personalized, motivational messages to patients about healthier lifestyles. Such messages will be particularly effective when coupled with a public health program promoting behavior change.
1. Demark-Wahnefried W, Rock CL, Patrick K, Byers T. Lifestyle interventions to reduce cancer risk and improve outcomes. Am Fam Physician. 2008;77(11):1573–1578.
2. Kushi LH, Byers T, Doyle C, et al. American Cancer Society Guidelines on Nutrition and Physical Activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity [published correction appears in CA Cancer J Clin. 2007;57(1):66]. CA Cancer J Clin. 2006;56(5):254–281,313–314.
3. Doyle C, Kushi LH, Byers T, et al. Nutrition and physical activity during and after cancer treatment: an American Cancer Society guide for informed choices. CA Cancer J Clin. 2006;56(6):323–353.
4. U.S. Department of Health and Human Services. Healthy People 2010 Midcourse Review. Washington, DC: U.S. Government Printing Office; 2006. http://www.healthypeople.gov/data/midcourse/html/default.htm. Accessed January 10, 2008.
5. Pierce JP, Gilpin EA, Emery SL, et al. Has the California tobacco control program reduced smoking? [published correction appears in JAMA. 1999;281(1):37]. JAMA. 1998;280(10):893–899.
6. Lancaster T, Stead L. Physician advice for smoking cessation. Cochrane Database Syst Rev. 2004(4):CD000165.
7. Fiore M. Treating Tobacco Use and Dependence. Rockville, Md: U.S. Department of Health and Human Services, Public Health Service; 2000. Clinical practice guideline no. 18.
8. Maccoby N, Romney AK, Adams JS, Maccoby EE. “Critical periods” in seeking and accepting information. In: Paris-Stanford Studies in Communication. Stanford, Calif: Institute for Communication Research, Stanford University; 1962:47–57.
9. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York, NY: Guilford Press; 2002.
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