Vol 59: january • janVier 2013 | Canadian Family Physician • Le Médecin de famille canadien 27
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Can Fam Physician 2013;59:27-31
Modified 5 As
Minimal intervention for obesity counseling in primary care
Michael Vallis PhD RPsych Helena Piccinini-Vallis MD MSc CCFP Arya M. Sharma MD PhD FRCPC Yoni Freedhoff MD CCFP
Objective To adapt the 5 As model in order to provide primary care practitioners with a framework for obesity
Sources of information A systematic literature search of MEDLINE using the search terms 5 A’s (49 articles
retrieved, all relevant) and 5 A’s and primary care (8 articles retrieved, all redundant) was conducted. The National
Institute of Health and the World Health Organization websites were also searched.
Main message The 5 As (ask, assess, advise, agree, and assist), developed for smoking cessation, can be adapted
for obesity counseling. Ask permission to discuss weight; be nonjudgmental and explore the patient’s readiness
for change. Assess body mass index, waist circumference, and obesity stage; explore drivers and complications
of excess weight. Advise the patient about the health risks of obesity, the benefits of modest weight loss, the need
for a long-term strategy, and treatment options. Agree on realistic weight-loss expectations, targets, behavioural
changes, and specific details of the treatment plan. Assist in identifying and addressing barriers; provide resources,
assist in finding and consulting with appropriate providers, and arrange regular follow-up.
Conclusion The 5 As comprise a manageable evidence-based behavioural intervention strategy that has the
potential to improve the success of weight management within primary care.
Mr Cortez is a 57-year-old man with type 2 diabetes and hypertension. He has been gaining weight since retiring from
the military. His body mass index (BMI) is 37.4 kg/m2, and you are frustrated that he has not followed your recommenda-
tions to lose weight. During his most recent visit you told him that if he did not lose weight he faced a future of disability
from diabetes. You are concerned about him but wonder if talking about weight is a good use of time. What should your
Sources of information
A systematic literature search of MEDLINE using the search terms 5 A’s (49 articles retrieved, all relevant) and 5 A’s
and primary care (8 articles retrieved, all redundant) was conducted. The National Institute of Health and the World
Health Organization websites were also searched.
Primary care is an important setting for obesity management.1 Yet many primary care providers feel ill-equipped
or inadequately supported to address obesity.2-9 This is in part because obesity outcomes depend more on
patient behaviour than on physician recommendations and educa-
tion. Behaviour change theories exist, as does evidence that behaviour
change interventions are effective.10,11 However, the time and support
necessary to learn behavioural counseling are barriers. In this context,
minimal intervention strategies such as the 5 As (ask, assess, advise,
agree, and assist) can guide the process of counseling a patient about
The 5 As, developed for smoking cessation,12 can be adapted for
obesity counseling.13,14 The 5 As are appealing, as they are rooted in
behaviour change theory (eg, self-management support, readiness
assessment, behaviour modification, self-efficacy enhancement) and
can be implemented in busy practice settings.
However, recent studies show that they are only
partially implemented: ask and advise are used
key points Primary care is an important
setting for obesity management, yet many
primary care providers feel ill-equipped or
inadequately supported to address obe-
sity. Minimal intervention strategies such
as the 5 As (ask, assess, advise, agree, and
assist) can guide the process of counseling
a patient about behaviour change. They are
rooted in behaviour change theory and can
be implemented in busy practice settings.
28 Canadian Family Physician • Le Médecin de famille canadien | Vol 59: january • janVier 2013
but not agree and assist.13-15 Nevertheless, when used,
agree and assist were related to diet improvement,
and advise was related to increased motivation and
confidence to change dietary fat intake and to lose
The 5 As are also appealing because they enable
providers to raise the issue of obesity, and they can
be incorporated into recent obesity classification and
Ask. Asking questions (and minimizing state-
ments) is a principle of motivational interviewing,
an evidence-based interviewing style that facilitates
patient-driven behaviour change.16-18 Ideal initial ques-
tions should seek permission to talk about weight,
such as, “Are you concerned about your weight’s effect
on your health or your quality of life?” and “Would it
be alright if we discussed your weight?” This is impor-
tant because body weight is a sensitive topic for most
owing to embarrassment, fear, blame, and stigma, and
weight bias exists among physicians, dietitians, nurses,
With permission to talk about weight, a nonjudg-
mental (another core principle of motivational inter-
viewing) conversation is more likely. Nonjudgmental
curiosity helps avoid challenges to effective communi-
cation. It is important not to make assumptions about
the patient’s lifestyle—many obese patients might
already be working hard at weight management.
Language is also important. The term obesity might
be perceived negatively by some patients.24 Research
suggests that patients prefer the term weight.25 Asking
about lifestyle, relationship with food, motivation, etc,
reduces any tendency toward biased assumptions,
such as unhealthy weight equating with unhealthy
lifestyle. Asking can be educational, as in the ques-
tion, “What do think you could do to better manage
An important early step when asking is assess-
ing patient readiness to manage weight. Readiness
can be assessed by general questions (such as, “Are
you ready to try to work on your weight?” followed
by, “Would you be comfortable if I tried to help?”), a
readiness ruler (a 10-cm visual analogue scale), or
Prochaska’s Stages of Change model (ie, precontem-
plation, contemplation, preparation, action, mainte-
nance).26 Assessing readiness establishes where the
patient is and helps the physician avoid working
harder than the patient.
If patients are unwilling or reluctant to talk about
weight (asking a question obliges one to listen to the
answer), the physician can summarize that this indi-
cates the patient is comfortable with their weight. One
can then reassure the patient that if weight becomes a
concern the issue can be revisited.
You ask Mr Cortez’s permission to discuss his weight.
He appears relieved by your nonjudgmental attitude.
He shares your concern and frustration and men-
tions that he downloaded a food diary app, which he
stopped using after a few days owing to lack of moti-
vation, and that he has been trying to order “healthier”
foods at his office cafeteria.
Assess. Asking elicits important information from the
patient. This leads naturally to the second A: assess.
It is important to assess health status (BMI, waist cir-
cumference), the effects of weight on psychosocial
factors, and “root causes” of obesity. Health status
can be assessed using the Edmonton Obesity Staging
System,27 which ranks patients (stages 0 to 4) based on
weight-related medical, psychological, and functional
limitations and predicts mortality better than BMI.28,29
Psychosocial and root-cause factors can be further
assessed using the 4 Ms framework: mental health,
mechanical, metabolic, and monetary factors.30,31
Mr Cortez has class 2, stage 2 obesity based on his BMI
and health status, respectively. In addition, you find
symptoms of atypical depression (increased appetite,
lack of interest, feelings of worthlessness) that appear
to be related to his retirement.
Following assessment the physician can introduce
the possibility of change (weight management)—that
Advise. Asking and assessing establish a collabora-
tive relationship in which the complexity of obesity
is identified for the individual. The next step is to ask
permission to give advice—ie, offer a clinical manage-
ment plan (eg, “Now that we have a better understand-
ing of your situation, can I recommend a plan of action
to improve things?”). Patients are likely more receptive
when advising follows asking and assessing (another
principle of motivational interviewing called express-
Weight-management advice can be complicated.
Current guidelines suggest that all obese patients
should be advised to lose weight, but this recom-
mendation is not based on strong evidence. Given
the high rates of recidivism, common unhealthy
weight-management practices, the negative health
and emotional consequences of weight cycling, and
the need for ongoing support for weight-loss mainte-
nance, it might be prudent to limit weight-loss advice
to individuals experiencing weight-related complica-
tions (stages 1 to 4 of the Edmonton Obesity Staging
System).27 Emphasizing personal obesity risks and the
benefits of modest sustained weight loss (5% to 10% of
initial weight)32 can be helpful. Those in stage 0 might
Vol 59: january • janVier 2013 | Canadian Family Physician • Le Médecin de famille canadien 29
benefit from advice to avoid weight gain and reassur-
ance that, regardless of their weight, there are tre-
mendous benefits to healthier lifestyles and that the
weight-independent benefits of healthy diets, stress
management, adequate sleep, and regular physical
activity will mitigate many of excess weight’s associ-
ated risks. It is also crucial to point out the chronic
relapsing nature of obesity that necessitates a long-
term weight-management strategy.
Finally, patients should be advised about treatment
options, including lifestyle monitoring, behavioural and
psychological counseling, medications, low-calorie
diets, and bariatric surgery. This is also the time to
discuss the benefits and shortcomings of commercial
Given Mr Cortez’s stage 2 obesity and his depression,
you advise him to consider self-monitoring with a food
journal, activity log, and regular weighing to help pre-
vent further weight gain. You also suggest he meet with
a psychologist for further help with his mood.
Agree. Before proceeding with treatment, it is impor-
tant to obtain explicit agreement about the treatment
plan—that is, the patient’s buy-in. Although the physi-
cian might believe he or she is in the best position to
determine the most effective course of action, it is the
patient who must do the work of change. That is why
the agree step is so important. Just as many patients
might require multiple conversations before they can
agree with a physician’s recommendations, many phy-
sicians might need to modify their recommendations
in order to establish treatment plans that particular
patients are comfortable following. The agree step is
about respectful negotiation.
Research shows that most patients have unreal-
istic weight-loss expectations and are discouraged
when these unrealistic goals cannot be achieved. It
has therefore been suggested that patients attempt
to achieve a “best” weight that is achievable and sus-
tainable while still enjoying life.33 Setting goals sur-
rounding weight-management behaviour—and not
weight itself—might help patients achieve a mean-
ingful weight loss as, ultimately, it will be behaviour
changes that will get them there.
Any treatment plan should use effective behaviour
modification principles such as goal setting and behav-
iour shaping. Goal setting is easily done using the
SMART framework (find behavioural goals that are spe-
cific, measurable, achievable, rewarding, and timely).34
Shaping involves sequencing goals that are meaning-
ful and achievable, so that patients experience success
and enhanced self-efficacy.
It is important to focus on improving mental and
physical health rather than on kilograms lost—success
will look different for each patient. Agreement should
also be reached about any additional aspects of the
treatment plan (eg, adherence to medications, learning
more about bariatric surgery, etc).
Mr Cortez appears sceptical about seeing a psy-
chologist, as he does not think he is depressed.
After you explain that this is not an uncommon
problem and might well be an important cause
of his weight gain, he agrees to meet with the
psychologist. He also agrees that, for now, simply
avoiding further weight gain could be seen as the
first sign of “success.”
Assist. After agreeing on treatment objectives, physi-
cians should assist patients by identifying and address-
ing facilitators (eg, motivation, support) and barriers
(eg, social, medical, emotional, and economic barriers
that can make weight management challenging)35 to
the treatment plan. Consistent with minimal interven-
tion, assisting does not mean that the physician does
the work. In fact, given the reality of primary care set-
tings, the role of the assisting physician is to identify,
educate, recommend, and support.
Patients should be assisted in identifying and seek-
ing out credible weight-management resources and be
referred to appropriate providers for management (ie,
emphasizing an interdisciplinary approach). Arranging
follow-up is important so that the support of the physi-
cian recommendations can continue.
Mr Cortez responded well to the 5 As. By asking per-
mission you were able to identify his communication
challenges (your frustration and his fear of judgment).
After clarifying your interest he disclosed that he was
worried about weight gain. Once you understood that
his depression was due to the loss of his work role,
which he coped with by eating, he was open to your
recommendations. After agreeing that he seek help
from a local community-based healthy living resource,
he began to take action.
Primary care is a hub for supporting realistic weight-
management interventions. Yet the work of behaviour
change cannot be taken on solely by the physician.
The ideal role for the physician is to start sensi-
tive conversations, achieve agreement on following
through with effective weight-management strate-
gies, and support the patient in the initiatives that he
or she undertakes. The 5 As, summarized in Table 134
and Figure 1,27,34 comprise a manageable evidence-
based behavioural intervention strategy that has the
potential to improve the success of weight manage-
ment within primary care.
30 Canadian Family Physician • Le Médecin de famille canadien | Vol 59: january • janVier 2013
Dr Vallis is Associate Professor of family medicine and psychiatry and
Adjunct Professor of psychology at Dalhousie University, and Lead of the
Behaviour Change Institute at Capital Health in Halifax, NS. Dr Piccinini-
Vallis is Clinician Investigator in the Department of Family Medicine at
Dalhousie University. Dr Sharma is Scientific Director of the Canadian
Obesity Network and Professor and Endowed Chair in Obesity Research and
Management at the University of Alberta in Edmonton. Dr Freedhoff is the
founder and Medical Director of the Bariatric Medical Institute in Ottawa, Ont,
and Assistant Professor of Family Medicine at the University of Ottawa.
We thank the following individuals who provided their time as well as criti-
cal feedback and assessment of the 5 As method as part of the Canadian
Obesity Network’s Primary Practice Working Group: Geeta Achytutan, MD,
CCFP (Regina, Sask), Eleanor Benterud, RN, MN (Calgary, Alta), Andrew
Cave, MD, FCFP, FRCGP (Edmonton, Alta), Cyd Courchesne, OMM, CD,
MD, DAvMed, CHE (Ottawa, Ont), Heather Davis, MD, FRCPC (Halifax, NS),
Robert Dent, MD CM, FRCPC (Ottawa, Ont), Eric Doucet, PhD (Ottawa, Ont),
Angela Estey, RN, MSc (Edmonton, Alta), Mary Forhan, OT, PhD (Hamilton,
Ont), Tracey Hussey, MSc, RD (Hamilton, Ont), Marie-France Langlois, MD,
FRCPC, CSPQ (Sherbrooke, Que), Patricia Marturano (Mississauga, Ont),
Rick Tytus, MD, CCFP (Hamilton, Ont), Shahebina Walji, MD, CCFP (Calgary,
Alta), Sean Wharton, MD, FRCPC (Hamilton, Ont), Ron Wilson, MD, CCFP
This article was developed out of the Canadian Obesity Network’s
Primary Practice Working Group. Dr Vallis wrote and edited the
article. Drs Piccinini-Vallis, Sharma, and Freedhoff reviewed the drafts
and contributed to the adaptations of the 5 As model.
Figure 1. The 5 As for obesity counseling
Ask permission to discuss weight:
“May I talk to you about your weight?”
“Are you concerned about the effects of your weight on your
health or quality of life?”
“Would it be alright if we discussed your weight?”
Be sure to affrm that you hear what the patient says
Explore readiness to change:
“Are you ready to work on your weight? Would it be okay if I helped?”
“How important is it for you to work on your weight?”
“How confdent are you that you can take action on your goal?”
Assess health status, BMI, waist circumference, waist-hip
ratio, root causes of weight gain, and effects of weight on
Use the Edmonton Obesity Staging System27
Advise about the risks of obesity; explain the benefts of
modest weight loss and the need for long-term strategies
“Now that we have a better understanding of your situation,
can we explore and come up with a plan of action to improve
Explore all treatment options
The agree step is about respectful negotiation to achieve
“best weight” focused on SMART34 goals and health
Any treatment plan should use effective behaviour modifca-
tion principles such as goal setting and behaviour shaping
Address facilitators (motivation, support) and barriers
(social, medical, emotional, and economic) that make
weight management challenging
The clinician’s role is to identify, educate, recommend, and
Arrange follow-up to keep the conversation going
BMI—body mass index, SMART—specifc, measureable, achievable,
table 1. The 5 As of obesity management
AskAsk permission to discuss
weight; be nonjudgmental;
explore readiness for
Weight is a sensitive issue;
avoid verbal cues that
imply judgment; indication
of readiness might predict
BMI alone should never
serve as an indicator for
obesity is a complex and
with multiple causes—
drivers and complications
of obesity will vary among
Health risks of excess
weight can vary;
avoidance of weight gain
or modest weight loss can
have health benefits;
treatment options should
account for risks
Most patients and many
physicians have unrealistic
should focus on changing
should seek patients’ “buy-
in” to proposed treatment
Most patients have
substantial barriers to
patients are confused and
cannot distinguish credible
and noncredible sources of
information; follow-up is
an essential principle of
Assess Assess BMI, WC, obesity
stage; explore drivers and
complications of excess
Advise Advise on health risks of
obesity, benefits of modest
weight loss, the need for a
long-term strategy, and
AgreeAgree on realistic weight-
loss expectations and
changes using the SMART
framework,34 and specific
details of the treatment
Assist in identifying and
provide resources and
assist in identifying and
arrange regular follow-up
BMI—body mass index; SMART—specific, measurable, achievable,
rewarding, timely; WC—waist circumference
Vol 59: january • janVier 2013 | Canadian Family Physician • Le Médecin de famille canadien 31 Download full-text
Dr Freedhoff is the cofounder of Bariatric Medical Institute, coauthor,
with Dr Sharma, of Best Weight: A Practical Guide to Office-Based Obesity
Management, and author of Why Diets Fail and How to Make Yours Work. None
of the other authors has any competing interests to declare.
Dr Michael Vallis, Dalhousie University, Family Medicine, Suite 4060,
Lane Bldg, 5909 Veteran’s Memorial Lane, Halifax, NS B3H 2E2;
telephone 902 789-9545; e-mail email@example.com
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