Within our clinical research setting, services provided to our patients include participating in group sessions, taking repeated physical measurements, and receiving self-administered quality of life, dietary, or exercise measures. Patients’ progress is monitored periodically throughout the course of the program using information from questionnaires or weight-related assessments. We also assign workbook activities between sessions. (See Appendix I.) Workbook activities help us to gather necessary information on patients’ personal goals and perceived barriers to change so that the treatment plans devised reflect these target areas.

The clinical approach requires more resources and is most appropriate for patients with serious physical or emotional health risks. Clinical weight control programs and diabetes education programs that include a weight control component are examples of this level of intervention. Patients are measured and monitored throughout treatment, which may involve the use of medication or more invasive procedures. In some settings, patients are assessed and treated by multidisciplinary health care teams. In other settings where such teams are not available, health care providers may provide referrals for services based on identified needs. Within our clinical research setting, patients were accessed by multidisciplinary teams who treated or provided necessary referrals based on the severity of patients’ presenting problems. In each of these settings, patients may be referred for psychological testing to examine comorbid emotional or psychiatric problems.

How Can Tailoring Be Applied in Various Clinical Settings?
In our experience, time constraints, budget constraints, and limited resources sometimes function as barriers, making it difficult for us to implement care guidelines and to provide a range of services for patients presenting with different health problems. In addition, we have found that clinicians who are often in a position to make treatment recommendations may have varying knowledge and understanding of nutritional and behavioral interventions. In such cases, clinicians may feel more comfortable approaching patients from the perspective that best represents their knowledge base and not from the perspective best suited to the patients’ presenting problems.

Figure 1 provides a simple model of components involved in tailoring treatment interventions to patient needs. We believe that matching patients to a specific intervention requires prioritizing patients’ specific problems and assessing the level of intervention intensity necessary to promote behavioral change.

In beginning this process, our patients are screened for eligibility in a weight-reduction program. During the assessment phase, we try not to limit our evaluations to the patients’ appropriateness for our program but expand our data collection to areas that may provide additional insights into other contributing factors. In essence, our goal is to create a profile or picture of the patient.

When patients are confronting multiple competing stressors, we are forced to make a decision about which areas can have the greatest negative impact on overall treatment success. Once that is established, we can take the necessary steps required to alleviate these barriers (i.e., through referral services) and increase the possibility of a positive, long-term treatment outcome.

We have found, for example, that some patients are highly motivated to change and report few external stressors. These patients tend to be more receptive to nutritional and physical activity interventions than those who report more external stressors. Patients who report more external stressors may, in some cases, benefit from relaxation training, stress management, and problem-solving approaches during the initial phase of treatment. This, of course, is only in cases where patients are at lower risk for complications.

We find that instruments such as the Eating Patterns Questionnaire, Perceived Obstacles to Physical Activity (POPA), General Obstacles to Changing Habits (GOTCHA), Diet Readiness Questionnaire, and the General Well-Being Schedule are useful during the initial assessment process.^2,4,5

How Can Clinicians Match Patients’ Needs to Available Treatment Options?
We have outlined in Table 1 some of the criteria necessary for making these decisions. We recognize that a patient seldom fits perfectly into any one category. Patient problems may fall within the many shades of gray. Therefore, clinical judgment is important when making decisions regarding patient care.

We find that a thorough baseline assessment helps simplify the decision-making process. The level of intervention that we ultimately prescribe is primarily based on the severity of the patients’ symptoms and complaints. As mentioned earlier, matching patients to a particular treatment plan requires careful evaluation of psychological and physiological variables, such as those we have categorized under Figure 1.

As a general rule, we believe any problem that increases patients’ risk for complications warrants consideration for admittance into a clinical program. For example, a patient who smokes or is in an acute phase of psychiatric illness needs the medical management available in a clinical program to address these primary problems or provide the appropriate referrals. Patients who have not managed these types of problems are at greater risk for exacerbating their condition and overall risk for complications.

How Can a Busy Clinician Assess Patient Needs and Provide Weight-Related Services?
Clinics with access to computers in medical settings can collect relevant patient information and tailor questions based on patients’ medical history. Even if computers are not available, patients can receive reports after their initial assessments that provide comprehensive information regarding their health status.

Within our clinical research setting, patients receive some feedback by computer after answering a series of baseline measures. Additional information collected within the assessment phase is carefully evaluated and, depending on the severity of patients’ problems, patients can be encouraged to arrange appointments with their health care providers or are given appropriate referrals by clinic staff. Patients we identify at greatest risk for complications are contacted by staff directly, and concerns are either addressed over the phone or appointments are scheduled with staff trained to address the issues. For example, patients who indicate problems controlling binge eating or use of diuretics to lose weight are further evaluated for eating disorders.

In settings with time constraints and fewer resources available to make formal assessments, patients can be evaluated through a brief clinical interview with questions based on variables outlined in Figure 1. The risk in using this quick-and-dirty approach is that it may not provide the most accurate profile of the patient. Because barriers to care may not be thoroughly assessed, this can lead to less effective treatment recommendations.

We believe that maintenance and follow-up should also be based on the level of intervention, the severity of patients’ problems, adherence to previous treatment, and risk for future complications. Therefore, patients at lower risk may receive little or no follow-up in comparison to patients participating in more supportive programs.

Case Examples of the Various Approaches
Case 1: A "Do-It-Yourself" Approach
Sarah is a 47-year-old mother of four. She is 5'4"and weighs 158 lb. (BMI = 27.6). After an initial blood glucose test, Sarah had a fasting glucose level of 133 mg/dl. Her repeated fasting glucose test was 131 mg/dl. Her health care provider told her that having two fasting glucose tests >125 mg/dl indicates that she has diabetes.

Sarah has gained weight in recent years, most noticeably around her waist. Her waist circumference is 35 1/2 inches. Her weight and body distribution place her at an increased risk for cardiac problems. Sarah reports attempts to lose weight only after the birth of each of her children. She was somewhat successful during each attempt, but admits that she was never able to lose all of the weight she had gained.

She states that she has a supportive relationship with her children and husband, and she appears highly motivated to change her current habits.

Sarah is someone who may benefit from a do-it-yourself approach. During the next health care visit, Sarah needs to be reevaluated. If she reports difficulty in managing her weight, and if her weight and fasting glucose levels increase, she may need to join either a nonclinical weight program or a clinical diabetes program that offers more support and guidance.

Case 2: A Nonclinical Approach
Maria, 25 years old and single, desperately wants to lose weight. She states that her biggest problem is that she lacks motivation to stick to any weight loss plan.

Maria describes herself as the "human yo-yo," having been on and off diets most of her life. Throughout high school, she felt she was unattractive because she was not thin. She skipped meals and experimented with crash diets. She went into therapy for a few years to work through some of these issues and now recognizes that her eating patterns were highly self-destructive. Maria states that she does not want to starve herself, but wants to learn how to do it the "right way."

Having relapsed many times, Maria is already discouraged about her ability to make permanent changes. However, she is motivated to make another attempt at change.

If Maria loses weight, begins to feel more confidant in her abilities to manage her weight, and shows improvements in her risk profile, she could eventually be given a more do-it-yourself approach. Based on her assessment at the present time, she does not appear to require any clinical intervention.

Case 3: A Clinical Approach
Paul, 55 years old and single, has type 2 diabetes. He has had difficulty managing his diabetes and has been hospitalized because of various complications.

Paul is overweight and hypertensive. Recently he has experienced foot problems and been forewarned about potential amputation. Paul states that his job is very stressful and demands that he put in long hours. He confesses that he often relies on fast-food restaurants near his office. Although Paul is concerned about his foot problems, he admits that he has difficulty controlling his eating.

Although a formal assessment has not been made using the DSM-IV,⁷ Paul may suffer from binge-eating disorder. His health habits place him at an increased risk for diabetes complications.

Paul requires a clinical program that focuses on psychosocial issues to help him to learn ways to better manage his reported bingeing episodes. Paul needs to be followed regularly by a diabetes team. With his erratic eating habits, blood glucose levels may fluctuate. A comprehensive clinical program that provides self-management training on blood glucose monitoring and dose adjustment would be beneficial. Behavioral strategies that address Paul’s problems with binge eating need to be incorporated into the intervention.

Conclusion
Clinicians need to take an active role in tailoring programs to meet patient needs and promoting lifestyle changes. Although it is not feasible for all clinicians to conduct in-depth assessments, primary care providers can use brief, weight-related clinical interviews and make referrals.

We have found that a brief clinical interview is particularly useful when time constraints, budget constraints, and resources are barriers to in-depth assessments. The assessment needs to address psychological and physiological variables, such as patients’ past history, present situation, current available resources, and current health status.

Based on the assessment, we recommend that clinicians make referrals to various treatment interventions (do-it-yourself, nonclinical, and clinical programs) that match patient needs. There are countless do-it-yourself or self-help weight, diet, and exercise books. In addition, nonclinical weight programs are offered through adult education and commercial vendors. More recently, there are a growing number of clinical weight and diabetes programs.

We recommend that patients who have poor diabetes control be referred to a clinical diabetes program that can address issues related to adjusting medications and monitoring blood glucose levels. Diabetes-specific clinical programs also provide diabetes education and weight management. In our experience, we have learned that the assessment process can provide valuable information in developing a tailor-made, individualized intervention.

References

¹National Institutes of Health: Obesity Guidelines. NIH Statement 06/03/98.
http:/pharmacology.tqn.com/library/98news/bln0603b.htm.

²Thomas PR (Ed.): Weighing the Options: Criteria for Evaluating Weight-Management Programs. Washington, D.C., National Academy Press, 1995.

³Swencionis C, Peters M, Wylie-Rosett J, Cimino C: Profiling weight control interventions while maximizing use of staff time. Diabetes Spectrum 7:130-32, 1994.

⁴Wylie-Rosett J, Segal-Isaacsson CJ, Caban A, Schaeffer N, Klien LA, Swencionis C, Axelrod B: Leader’s Guide to the Complete Weight Loss Workbook. Alexandria, Va., American Diabetes Association. In press.

⁵Shannon J, Kristal AR, Curry SJ, Beresford BA: Application of a behavioral approach to measuring dietary change: the fat and fiber related diet behavior questionnaire. Cancer Epidemiol 6:355-61, 1997.

⁶Prochaska JO, Diclemente CC, Norcross JC: In search of how people change: applications to addictive behaviors. Am Psychologist 47:1102-14, 1992.

⁷American Psychiatric Association: Diagnostic and Statistical Manual. 4th ed. Washington, D.C., American Psychiatric Association, 1994.

⁸American Diabetes Association: Position statement: Management of dyslipidemia in adults with diabetes. Diabetes Care 21 (Suppl 1):S36-39, 1998.

⁹American Diabetes Association: Position statement: Standards of medical care for patients with diabetes mellitus. Diabetes Care 21 (Suppl 1):S23-31, 1998.

Appendix I: American Diabetes Association Weight Publications

For Patients in Do-It-Yourself, Nonclinical, and Clinical Programs
Wylie-Rosett J, Swencionis C, Caban A, Friedler A, Schaeffer N: The Complete Weight Loss Workbook: Proven Techniques for Controlling Weight Related Health Problems. Alexandria, Va., American Diabetes Association, 1997.

American Diabetes Association: Month of Meals. Alexandria, Va., American Diabetes Association, 1998.

American Diabetes Association: Type 2 Diabetes: Your Healthy Living Guide. Alexandria, Va., American Diabetes Association, 1997.

Hansen BC, Roberts SS: The Commonsense Guide to Weight Loss for People with Diabetes. Alexandria, Va., American Diabetes Association, 1998.

For Clinicians Educating Patients in Clinical Programs
Wylie-Rosett J, Segal-Isaacsson CJ, Caban A, Schaeffer N, Klien LA, Swencionis C, Axelrod B: Leader’s Guide to the Complete Weight Loss Workbook. Alexandria, Va., American Diabetes Association. In press.

Arlene Caban, MA, is a research coordinator at the Diabetes Research and Training Center at Albert Einstein College of Medicine in Bronx, NY. Portia Johnson, RN, MSN, is a doctoral student in the School of Nursing at Columbia University in New York. David Marseille, BS, is a medical student at Albert Einstein College of Medicine. Judith Wylie-Rosett, EdD, RD, is a professor in the Department of Epidemiology and Social Medicine and director of the Demonstration and Education Division at the Diabetes Research and Training Center at Albert Einstein College of Medicine.