Nutritional counselling: quantitative evaluation of achievements in maintaining long-term weight loss
ARTICOLO ORIGINALE
Nutritional counselling: quantitative evaluation of achievements in maintaining long-term weight loss
Dietitians and counsellors from a clinic in Italy review the effectiveness of nutritional counselling techniques in helping patients achieve and maintain their weight loss goals
Oliveri Emanuela , Scaramelli Fabio , Macagno Stefania
Pubblicato il 22 Aprile 2022. “ DIETETICS TODAY ”
Dietitians and counsellors from a clinic in Italy review the effectiveness of nutritional counselling techniques in helping patients achieve and maintain their weight loss goals
During the weight-loss journey, one of the greatest barriers encountered by the – and by the nutrition professional – shows once the weight-loss target has been achieved, the maintenance of the goal weight in the long term is much harder. Data from the literature confirm such problem: a 2017 systematic review of 26 studies affirms that, within one year, one-third of the lost weight is regained; the remainder is regained in three-t-=five years (Greaves et al, 2017).
Several studies have tried to analyze what happens in such a sensitive moment. Thanks to the data emerged from two systematic reviews (Greaves et al, 2017; Texeira et al, 2015), it is possible to identify several difficulties which can show at the end of the weight-loss journey and, at the same time, the components which can support the maintenance process.
The importance attached to one’s body image is central (Charon, 2019) and there is a danger at the time of any partial weight regain could lead to an emotional, cognitive and behavioural vicious cycle, where food provides a temporary relief to negative feelings about body image; at the same time, the following weight gain may arouse further negative feelings and sense of guilt, as well as a further damage to self-esteem. A positive sight of one’s own body image associates with a greater self-efficacy perception. Self- efficacy perception consists in “a person’s own judgment of capabilities to perform a certain activity in order to attain a certain outcome” (Rodgers et al, 2008). Therefore, contributing towards the raising of confidence and competence about a certain health behaviour is likely to help overcome barriers, as well as representing a first step towards the increase of the motivation to change (Greaves et al, 2017; Texeira et al, 2015).
The kind of motivation which leads to change is no less important: if the push for change is feeble, the odds that new habits will establish in the patient’s lifestyle decrease, and one will tend to give up the new lifestyle, which is considered no longer sustainable. Therefore, it is necessary that the push raises just from the person concerned, in order to build a kind of motivation defined as “intrinsic motivation”: indeed, only if one keeps a strong and rooted motivation will it be possible for the patient to have clear goals, even at the end of the weight-loss intervention. Intrinsic motivation comes frequently along with the pursuit of personal challenges, health and wellbeing maintenance, and personal development which, all together, contribute to support the constant application of the new behaviours. The patient acquires, step by step, consciousness, through the behaviour patterns and strategies applied in difficult times. Moreover, a person
whose intrinsic motivation is strong enough is able to consider the achievements obtained through the weight loss as a good “reward” for all the attention paid to their lifestyle.
Another important point is the point of view from which the person deals with the change process: if it is experienced as a set of strict rules which are perceived as imposed from the outside, the patient is likely to trigger a vicious cycle of restriction and loss of control over food, leading to a weakening of their self-efficacy perception. The impossible goal to adhere to a strict nutritional plan is likely to trigger the sense of failure as soon as something which does not appear in the diet plan is consumed; the recurrent frustration will add to the negative feelings which come from the weight gain, to such an extent that the change process is abandoned. Indeed, a more flexible approach to the nutritional intervention, involving gradual changes which are agreed with the patient, has been observed to help the new habits last longer. Furthermore, a lower strictness in the dietary therapy, which does not exclude (except specific medical conditions) the patient’s favourite foods, would help to reduce the phenomenon known as “psychological reactance”.
The above-mentioned mechanisms are just a few of those which may show once the dietetic treatment has come to an end. In addition to this, each person has their own complexity, individuality, behaviours, rules and rooted beliefs: there are several obstacles which may show once the weight goal has been reached.
A valid approach consists in keeping setting new goals: those which have been defined at the beginning of the therapy become, during the maintenance phase, less relevant. Therefore, they need to be “refreshed” with more incentives: literature shows that an intrinsic motivation and a change in self-perception are essential to ensure a long-lasting result.
All this big picture brings out the necessity of an instrument that leans on those aspects favourable for the therapy’s success. Nutritional counseling makes use of several techniques to raise the patient’s self-efficacy perception, working on goals and achievements obtained through weight loss. More specifically, the aim of the study consists in the qualitative and quantitative evaluation of the goals and the achievements reached through the nutritional intervention, in order to make the maintenance of the weight reached last longer.
Aim of the study
The study suggests the use of nutritional counseling to sustain the patient during the process, until the achievement and maintenance of the new dietary habits. A qualitative-quantitative evaluation instrument of the achievements was adopted in the nutritional counseling meetings in order to support the maintenance of the weight lost in the long term through the increase of the patient’s self- efficacy and by working on the differences between before and after the journey: the benefits’ restitution is expected to allow a counterbalance to the attention that the patient will have to pay to their lifestyle through time, making them more sustainable and long-lasting.
Study design
The study was conducted in the “Officina di Counseling Nutritionale”, a private clinic specialising in nutritional counseling located in Bra (Piedmont, Italy). The team consists of two dietitians who make use of nutritional counseling techniques and a counsellor with systemic orientation.
We enlisted 28 patients who came to the clinic in order to start a weight-loss journey; the qualitativequantitative evaluation was based on their goals before and on the achievements after the intervention.
Patients
The sample consisted of 28 patients, enlisted between September 2018 and May 2019 and who had completed their whole weight-loss journey until the maintenance phase.
The patients to be enlisted were randomly picked at the moment of the first nutritional counseling meeting; we kept out those who had come to the clinic for reasons other than weight loss.
During the first meeting the patients’ goals are examined, through the open question “What brings you here today?”. The nutritional professional reports what the patient expresses and they examine together which feelings may get better and the situations where the person may get benefits through weight loss.
This exploration sheds light on what is more or less important for the patient, in order to define the intervention’s focus (Nardone, 2009). In other words, the push to change has to be found among the patient’s motivations. The process is rather complex, since it involves contradictions and ambivalence: on one hand, the patient is pushed by their goals to change habits; on the other hand something will always row against such change. Such complexity makes it necessary to explore the patient’s intrinsic motivation.
Motivation is what makes the change possible and, moreover, it is the “result of a delicate balance between the importance that the person attributes to change and his confidence in his own chance of making it happen” (Oliveri e Scaramelli, 2019). Motivation differentiates in external and intrinsic: the two of them have different depths and concern the individual’s needs. The first one derives from external pushes and the recognition of the achievements come from the outside. Intrinsic motivation has deeper roots, which sprout from the inner search of self-recognition. Its function is private, has a positive effect and satisfaction comes from the patient themself (Oliveri e Scaramelli, 2019).
Goals exploration allows us to figure out intrinsic motivation, in order to pursue those goals; the patient is encouraged towards the progression of the change
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process. Similarly, results maintenance is made possible by new, strong enough goals, which also come from intrinsic motivation.
In the following step, the patient is asked to express current perceptions in numbers from 1 to 10. For example: “How much do you feel light from 1 to 10?”, where the lowest vote is 1 (“not light at all”) and 10 is the maximum (“completely light”). The professional writes down the answer on a paper, reporting the time of the intervention’s beginning.
During the remainder of the meeting, other pieces of information are collected including medical history, diagnostic exams and nutritional exams (blood count, glycaemia, HbA1c, total and HDL cholesterol, triglycerides, AST, ALT, GGT, creatinine, eGFR, serum iron, ferritin, vitamin D…), the potential current drug therapy and/or supplements, smoking, menstrual cycle regularity, intestinal regularity and gastric symptoms, physical activity, employment and composition of the family unit. A part of the meeting is dedicated to the patient’s weight history and to the past experiences which the patients would potentially have tried in order to modify lifestyle and dietary habits.
After that, the professional collects the dietary history, with a focus on the patient’s habits and personal taste, social life, hunger and fullness perception, chewing habits, potential presence of emotional or external eating, compulsion and sense of guilt.
“On the one hand, the patient is pushed by their goals to change habits. On the other, there is always an obstacle to change”
The last part of the meeting is addressed to the measurements: the professional measures the patient’s height, weight, waist circumference (at the navel), right thigh and right arm circumferences. The dietitian asks the person about their weight goal and, according to the professional’s expectations and health goals, if necessary, they set a different or intermediate weight goal.
At this point, the professional has got a complete picture of the patient’s goals, habits and lifestyle from which customised recommendations will be tailored. The meeting will have revealed the patient’s abilities and potential future complications. The professional shows them to the patient through the restitution technique, with the aim of giving value to the behaviours which may be useful and revealing those which need to be worked on. The professional makes some proposals to the person, planning together the changes to dietary habits, consistent with the person’s taste and habits, in order to make the change practicable and to safeguard the good relationship established between the dietitian and the patient. It is essential that the person feels they have been listened to and considered in the whole process.
Maintenance phase and achievement exploration
At the end of the journey, the nutrition professional and the patient agree upon the ways and the behaviours which can be to keep the new habits, according to the experience gained during the change process. After that, some follow-up meetings will happen at a variable distance of time: the whole year of time will be covered, in order to evaluate the new lifestyle and weight goals maintenance and to intervene in case of complications.
During this step, the professional again measures the weight, waist, right arm and right thigh circumferences.
The same paper which had been filled out during the first meeting is employed again at the end of the journey. The patient is asked to rate how their perceptions have changed with the weight loss. Referring to the lightness example again, the patient is asked to rate how much do they feel light now, again from 1 to 10. The numbers are written down on the paper, along with the end date, where the weight goal has been reached. After that, the patient is asked to think about other positive circumstances, situations, and feelings which have helped them achieve the weight loss. This last question explores those achievements (that we will call “unexpected achievements”) which added to the preset goals and that had not been taken into consideration at the beginning of the journey. All the unexpected achievements are written down on the paper, below the first goals; since they were not mentioned at the beginning, we have no start rates, so the end rates are reported without any rate, too. Then, all these goals and achievements are reminded to the patient, with the start and end rates, in order to show them all the improvements compared to the beginning. This technique is employed with the aim of showing to the patient that all the attention which they have paid during the process have been, are and will be fully counterbalanced by all the obtained achievements.
Data collection
Data was recorded a spreadsheet. A page contains the information about the sample: a number was assigned to each patient and, in the same row, the following data: n Gender (“M” or “F”) n Age n Height (m) n Starting weight (kg) n Starting Body Mass Index (kg/m2) n End weight (kg) n End Body Mass Index (kg/m2) n Time of the beginning of the weight loss n Time of the end of the weight loss A second page hosts the goals set during the first meeting, along with their starting and final rate from 1 to 10, assigned from each patient to each goal. In the same page the percentage increase in rates has been calculated, in order to evaluate the differences between the start and the end of the nutritional path. With the aim of easing the evaluation of the motivations which lead to the start of a change of the dietary habits, on a third page we have written down the starting goals again, in order to be categorised.
Data analysis
The continuous variables were analysed through the paired Student T test and mean and standard deviation (SD) were calculated. The discrete variables were analysed through the employment of the chi square test.
Twenty-six of the 28 patients who completed the dietary intervention are women (92.9%). The average age corresponds to 40.1±14.3 years old. On the whole, the sample started with an average weight of 69.8±11.9 kg and reached a final mean of 62.1±9.5 kg. The difference is statistically significant ((p<0.0001).
From the starting exploration, 152 goals emerged, of which we considered 149. From the starting goals’ exploration, a mean of 5.4±1.9 goals per person came out; at the attainment of the goal weight, adding together the starting goals and the unexpected achievements, the mean was 8.5±3.1 achievements a person. Such difference is statistically significant (p<0.0001). The number of goals has increased by 65.4±56.2%. The start mean of the scores assigned by the patients was of 2.99±1.97, while the end mean was of 7.94±1.87. The difference is statistically significant (p<0.0001).
At the beginning of the nutritional programme, an unsatisfactory rate (below a rate of 6) was assigned to 131 goals (87.9%), while 18 (12.1%) had a rate greater than 6. At the end of the programme, 12 (8.1%) goals were still unsatisfactory, while 137 (91.9%) had a grade greater than 6. The difference is statistically significant (p<0.0001). One-hundred-and-fory-four out of 149 goals have been reached, with an achieved rate of 96.6%. The goals which, at the end of the journey, had the same or a lower rate than the beginning were considered as not reached.
Figure 1: comparison between average number and mean number of the start and end goals
Through the analysis of the start goals one by one, common areas of interest came to light: indeed, they were arbitrarily split into categories in order to study the motivations behind the decision to start a change of dietary habits. The achievements which have been added at the reach of the goal weight have been split in the same way, too. In this case all the 152 initial goals have been studied, keeping those which could not be analysed at the end of the journey, in order to have a comprehensive view of the initial motivation. The main categories are listed below.
n Freedom of dress: involves 34 out of 152 goals
(22.4%) and affects 20 out of 28 patients (71.4%) n Feeling comfortable in your own body: 24 out of 152
(15.8%) goals are involved and 15 out of 28 patients
(53.6%) are affected n To like yourself: 20 out of 152 goals (13.2%) are
involved and 16 out of 28 patients are affected (57.1%) n Slimming down: 20 out of 152 goals (13.2%) are
involved and 16 out of 28 patients are affected (57.1%) n Being lighter, feeling more agile: 19 out of 152 goals
(12.5%) are involved and 14 out of 28 patients are
affected n Wellness and food education: 32 out of 152 (21.1%) goals are involved and 18 out of 28 patients are affected n More besides (goals less frequently mentioned, which
did not belong to any of the other categories): 3 out
of 152 goals (2%) and 3 out of 28 patients (10.7%) Similarly to the initial goals, the unexpected achievements were split into categories, too. Twentythree out of 28 patients (82.1%) revealed to have got further achievements, for a total of 86 unexpected achievements. Some achievements belonged to the categories which had been employed for the initial goals; others were placed in new categories.
n Freedom of dress: 24 out of 86 (27.9%) unexpected
achievements, involving 13 out of 23 (56.5%) people n Feeling comfortable in your own body: 16 out of 86
(18.6%) unexpected achievements, involving 10 out of
23 people (43.5%) n To like yourself: 2 out of 86 (2.3%) unexpected
achievements, involving 2 out of 23 (8.7%) people n Being lighter, feeling more agile: 9 out of 86 (10.5%)
unexpected achievements, involving 8 out of 23
people (34.8%) n Wellness and food education: 6 out of 86 (7%)
unexpected achievements, involving 6 out of 23
people (26.1%) n External recognition (compliments): 13 out of 86
(15.1%) unexpected achievements, involving 13 out of
23 people (56.5%) n Food management: 5 out of 86 (5.8%) unexpected
achievements, involving 4 out of 23 people (17.4%) n Achieving the goal: 8 out of 86 (9.3%) unexpected
achievements, involving 8 out of 23 people (34.8 %) n Being an example for others: 3 out of 86 (3.5%)
unexpected achievements, involving 3 out of 23
people (13%)
Discussion
The aim of the study is to propose a tool for the quantitative evaluation of the achievements inside nutritional counseling meetings, in order to help the maintenance of the weight lost in the long term. It is assumed that this goal may be reached working on the
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Figure 3: Percentage of the frequency of each category among the unexpected achievements
start goals and on the achievements in order to increase the patients’ perception of self-efficacy: reporting the benefits could help them counterbalance the attention they will have to pay to their lifestyle in the long term, in order to make them more sustainable and long-lasting.
A limitation of the study consists in the sample, which is not representative of the general population, both due to its small number (28 people) and to the strong presence of women, who represent 92.9% of the whole sample. The average age is 40 years old.
Through the analysis of BMI, we can see that the population, at the beginning of the nutritional path, belonged on average to the overweight range and 59.2% of the patients showed an excess weight. At the end of the intervention, the sample belonged on average to the healthy weight range and 37% were in the overweight range, with a statistically significant difference.
The analysis of the goals was both quantitative and qualitative, in order to evaluate the level of reach. The patients reported, at the beginning of the intervention, a mean of 5.4 goals each; the average rate was insufficient, corresponding to 5.43 out of 10. At the end of the intervention, the majority of people (23 out of 28) reached further unexpected achievements: on average, the end achievements (which included the initial goals, too) are 8.5 each person, with an average rate of 7.94 out of 10. The difference in the number of goals and in the rates assigned is statistically significant. According to this picture, it is possible to say that the patients, on average, at the end of the process had gained more than they had hoped during their first nutritional counseling meeting.
As far as the non-reached goals are concerned, we chose those which got an equal or lower rate in relation to the beginning, in order to minimise the differences in the employment of the scale among the people. Five out of the 149 had non-reached goals; for four of these it is possible to observe the influence of the context. Indeed, the variability in the employment of the scale shows not only among different people, but also for the same person: during different moments of the process, the person may have different perceptions. This variability may represent a limitation of the assessment tool.
We compared the frequency of each rate assigned to the goals at the start and at the end of the process: the most prevalent rate at the start was 1, representing the 34.2% (51 out of 152 goals). Only two goals received a rate ranging from 8 and 8.8 (1.3% of the total goals) and none had assigned a rate greater than or equal to 9 at the beginning. At the end, the results are quite different: only two goals (1.3%) received the lowest rate, while the most assigned rate ranged from 8 to
8.8; 49 achievements gained this rate, representing the
32.9% of the goals; the second most common was 10, assigned 39 times, representing the 26.2%. According to such differences, it is possible to say that the start feelings definitely improved, confirming that most of the goals have been reached.
“A body which makes someone feel unable to dress as they wish may lead to a lack of confidence and regret when they try”
Through the analysis of the categories of the initial goals and final achievements, it is possible to see that the most common category is the one concerning the freedom of dress, whose importance is due to its daily frequency.
A body which makes the person feel uncomfortable and unable to dress as they please may lead to a lack of confidence and regret every time they try.
The second most common category is “feeling comfortable in your own body”, highlighting the person’s need to live in a body which makes them feel at ease and which is not shameful for them. The meaning of wellness is not the same for everybody:
it may not have an entirely clinical connotation and concern a health concept anyway, as stated by the World Health Organization (WHO). WHO says that “Health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity” (WHO, 1946). From this perspective, anything that makes it difficult to peacefully live (in our case the need to feel comfortable in your body) represents a barrier to achieving of a state of health. These considerations strengthen the importance given to the first two achievements, both harbingers of psychophysical wellbeing.
The task of the nutritional counseling, which considers each patient as unique and as a key player in the dietary therapy, is to see these barriers, to embrace the discomfort and, according to the professional’s health goal, plan with the patient the nutritional intervention. It is important, in such cases not to fall into
the error of trivialising the person’s feelings (Oliveri and Scaramelli, 2019): when a person who weights slightly more than their usual weight comes to us, it is important to avoid diminishing any flaws they notice, since these are real for them. It is necessary to give the patient an external point of view which is impartial, expert and positive: it is true that we can work on some spots, and at the same time there are others which contribute to the body’s beauty and harmony.
Without substantial differences between before and after, categories concerning “wellness and food education” and “lightening, feeling more agile” follow: they are both tied to a health concept, since they consider, besides learning a correct nutrition appropriate for the individual’s needs, goals related to the removal or improvement of the symptoms and overweight.
Thereafter, the first four categories were arbitrarily grouped into two classes: one related to the importance of feeling at ease in your own body (including the two categories of “freedom of dress” and “feeling comfortable in your own body” and another related to health in its simple connotation (including “wellness and food education” and “lightening, feeling more agile”).
The two following categories are related to the aesthetics, that is “slimming down” and “to like yourself”, but no less important for that: these kinds of motivation may represent an important push if they meet a need of the person (intrinsic motivation). Both these categories appear just at the beginning of the intervention, in the form of initial goals, except for two achievements reported at the end of the process and belonging to the “to like yourself” category; they were, however, mentioned by more than half of the sample. Such differences between before and after may be random or they may be due to a greater attention paid, at the end of the intervention, to other feelings which came to light during the journey. Aesthetics did not play a central role as a motivation for 12 individuals, but provided a further stimulus for 16 people and so have to be strategically employed by the professional. For example, the “to like yourself” category involves the goals of being in a good shape for a specific event: the dietitian who employs nutritional counseling techniques will make use of that time period as a “deadline” in order to encourage the patient. It is important, however, not to underestimate the risk that the expectation and the preparation for an event may lead to. It is possible that the individual focuses all their effort on that deadline and, once that date passes, the motivation is reduced. Therefore, the professional has to explore the initial goals in depth, in order to not to keep out the preparation for the event, but to add different motivations which do not have deadlines. Thus, once the event is finished, the nutrition professional will own a whole series of other goals to focus on in order to encourage the patient to keep on doing well.
The results related to motivational pushes agree with the data in literature, which show health goals being most important, followed by aesthetics motivations (referred by around 30% of the girls); other sources of motivation include improving self-esteem and in the decreasing perceived stigma, especially in the form of bullying; literature agrees upon the importance of dressing, too, which represents a further stimulus to lose weight.
Through the analysis of the unexpected achievements, we can see that, besides the increase in the number of the already mentioned categories, whole new classes which had not been taken into consideration at the beginning of the intervention. For example, we can see that no one had mentioned the desire to receive compliments from others once they had reached their weight goal; rather, the first desire was to avoid or reduce the criticisms and comments from more or less close people. This can be seen in a positive light: the ones who looks for others’ approval direct their behaviour towards that direction (Jones et al, 1962) and risk to focus on the external confirmation rather than on themselves and on their own selfefficacy; the fact that any patient did not mention that at the beginning of the intervention is indicative of the kind of motivational source. The compliments showed among the achievements – something that had not
Another category which made its appearance just at the end of the intervention is the one concerning the management of one’s own nutrition, which is different from learning how to get balanced nutrition. A barrier which frequently shows during the maintenance of the results is the inability or the impossibility to keep the new habits in the long term (Greaves et al, 2017). Learning how to organise is essential in order to go on carrying out the correct behaviours and lead to less effort in the goal weight maintenance. In other words, the individuals learnt an ability that they had not taken into account: when one starts a weight loss journey, their thought goes to how they will see themselves, to how they will feel and to how they will dress once they get to the final results; the attention is diverted from what may happen during the process and from the experience that they will gain along the way. Nevertheless, it is exactly that experience, which had not been taken into account at the beginning, which will come in handy in the hard times, in the fallout phase, as well as during the maintenance phase and, at last, at the moment of the permanent change, exiting the wheel of change.
To the unexpected achievements you can add the satisfaction in having reached the goal: this helps to power the individual’s perception of self-efficacy: this is the true success, inclusive of all the skills gained during the process. The last category is the example given to others which again shows support of the person’s abilities: they perceive themselves as a true reference point for people close to them, who use their inspiration as a turning point to change their own dietary habits and behaviours.
The tool was shown to be easy to use during clinical practice and useful to keep a record of the patient’s progress. Indeed, it allows us to refer exactly to the goals reached by the patient, not just differentiating between the kinds and the rates of goals. Such progress, besides the unexpected achievements, are referred to the patient, with the aim of allowing them to counterbalance, in the long-term, the attention paid to nutrition and lifestyle, lessening the “constant battle” of the goal weight maintenance (Greaves et al, 2017). As shown by the data in literature, the patients who have a greater chance to maintain the goal weight are those who show an intrinsic motivation and who, at the end of the journey, are able to find new motivational sources, shifting the focus on all the gained benefits, rather than on the efforts needed to keep them, and on the desire to not come back to the body before the weight loss (Greaves et al, 2017; Texeira et al, 2015). It is assumed that the nutritional counseling techniques which are employed during the whole process, intended to bring out the patient’s own skills and to give value to those talents, may allow the patient to keep the gained results in the long-term: now they have the proof of their ability to reach a hard goal, they have gained experience of encountering and overcoming different barriers, and they have developed problem solving skills. Since, as shown in literature (Texeira et al, 2015), a better self-efficacy perception allows a person to achieve success at the end of the process and to keep the results, then our task is to nourish those perceptions and feed the patient’s confidence in their own abilities and knowledge of specific behaviours. It helps, moreover, to raise the motivation to change.
One of the weak points of the study is the limited sample size and the strong gender imbalance with a majority of women, which makes it difficult to make a comparison between the genders and understand whether there are differences between the kind of goals and skills employed. Another is in the categorisation of the goals, which was arbitrarily made and depends on the individual who makes it: some goals, indeed, could belong to more than one class (for example, “feeling at ease in swimsuit” could be placed in the “freedom of dress” or in the “feeling comfortable in your own body” category), but with the aim of making the analysis easier, just one category was chosen.
There is also the fact that the rates given to the feelings before and after the weight loss journey can be susceptible to change driven by mood, the specific moment of life and modified perceptions. The person might therefore not have chosen the same parameter while employing the scale, leading to an alteration in the results.
At last, since the period of time was limited, it was not possible to report in the study the patients’ evolution in a year of follow-up after the attainment of the goal weight: such piece of information would be important to evaluate the efficacy of the nutritional counseling intervention and the employment of the quantitative evaluation tool for the maintenance of the results in the long term, in order to confirm the theory of the study.
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