Stages of change of behavior in women on a multi-professional program for treatment of obesity

ABSTRACT Objective: to ascertain the effectiveness of an intervention program in relation to anthropometric measurements and stage of readiness for behavioral change in women with excess weight. Methods: the intervention group (IG) was made up of 13 women, and the control group (CG), by 20. The intervention lasted 16 weeks, and included the practice of guided physical activity three times a week, and health education once a week. The application of the questionnaire on stage of readiness for behavioral change, and the anthropometric evaluations, were undertaken at two points - before and after the period of intervention. The statistical analysis involved tests of comparison and association. Results: in general, at the first point, the participants in the two groups were predisposed to make changes in what they ate and in their physical activity. However, significant difference was only observed in relation to weight, body mass index (BMI), waist circumference and waist-hip ratio and readiness for change among the members of the intervention group. Conclusion: the intervention programmed was effective in weight loss, reduction of waist circumference and waist-hip ratio, and in changing behaviors related to the practicing of physical exercise and eating habits.


Introduction
The increase in the prevalence of obesity found in various countries characterizes this situation as an epidemic and a worldwide problem (1) . Since the 1980s, the rates of obesity have increased by about three times, in regions such as the Middle East and countries such as China and Australia. Even in countries with a lower prevalence, the rates observed are considered high. It is estimated that, in the coming two decades, the increase in the number of new cases of obesity will be over hundreds of millions (2) .
It is possible to observe that in countries where obesity affects a large proportion of the population, such as the United States, investments are made in public and private initiatives with the aim of preventing obesity among the young through Special Nutrition Programs, interventions, programs and actions encouraging healthy eating and the undertaking of physical activity (1)(2)(3) .
It is known that genetic and metabolic factors directly influence weight gain; however, other factors, such as physical inactivity, an unhealthy diet and psychosocial stress increase the risk of developing obesity. As a result, interventions geared towards these factors must be undertaken to prevent or reverse the situation of obesity in the individual and populational ambit (4) .
In spite of obesity and the proposals for its treatment being widely publicized, as far as is known, there have been few intervention studies aiming for the control not only of body mass, but principally changes in behaviors of risk. In this regard, as part of the therapeutic process, it is important to assess and determine how the individual feels in relation to a possible change in behavior, and how to motivate the person to change his or her lifestyle, as this will be reflected directly in the results desired and in healthier standards (5) .

As a result, the Stages of Readiness for Behavioral
Change (SRBC) model, or trans-theoretical model (TM), is used for assessing behaviors related to the practice of physical activity and eating and to propose necessary intervention strategies (6)(7) . It allows one to classify the individuals in their respective stages of change, making a distinction between those subjects who are genuinely disposed to change their lifestyle, and those who do not have the intention of doing so. It is emphasized that the changes tend to occur more efficiently among those who are disposed to change behaviors (6) .
In the light of the above, this study's objective was to ascertain the effectiveness of an intervention program on the anthropometric variables and on the Stage of Readiness for Behavioral Change among women with excess weight.

Method
An intervention study, of the before and after type, undertaken with adult women with excess weight (BMI≥25 kg/m²), resident in the municipality of Paiçandu in the Brazilian state of Paraná (PR).
The sample was made up of women recruited in a study titled "Populational study regarding the prevalence of risk factors and protection factors for cardiovascular diseases in the metropolitan region of Maringá (PR)", undertaken in Maringá, Paiçandu and Sarandi. In the municipality of Paiçandu, a total of 415 individuals were evaluated, of whom 287 were female. Of the latter, 83 were overweight. All were invited to participate in this study.
The 51 women who accepted to participate in the study were randomly allocated to two groups, 25 in the intervention group (IG), and 26 in the control group (CG). Only 33 were evaluated at the end of the 16 weeks of intervention: 13 in the IG, and 20 in the CG. The six women who dropped out of the CG did not attend for assessment at the second point, in spite of numerous attempts at contact. In the IG, 12 women were excluded for various reasons, with one having an orthopedic fracture, two becoming pregnant, and nine alleging difficulty in traveling to the place where the interventions were undertaken and/or lack of time.
All 33 women participating were subjected to a general protocol of assessment including: identification of the sociodemographic characteristics, the taking of a patient history, aptitude for the practicing of physical exercise, anthropometry and Stage of Readiness for Behavioral Change (SRBC). The anthropometric assessments were undertaken through measurements of body mass, height, and circumference of the waist and hips. Height was determined with the person standing straight, their arms extended by their side and with the hands turned towards the thighs. The feet were bare, with the heels together and the weight equally distributed through both feet.
The measurement of the waist circumference (WC) was taken using a flexible tape measure, at the midpoint between the costal margin and the iliac crest, with the individual standing up and breathing normally.
Central obesity was considered to be present when WC was superior to 88 cm. In addition, the measurements referent to body mass index (BMI) and waist-hip ratio were made using the Biospace InBody 520 ® multifrequency bioimpedence device, which as well as being available in the signatory institution, allows the study participants themselves to see the distribution of their body mass.
anthropometric variables was ascertained based on the difference between the final and initial measurements. The ability for the practicing of physical exercises was determined through the application of the PAR-Q questionnaire (Physical Activity Readiness Questionnaire) (8) .
The evaluation of the food-related SRBC and of physical activity (PA) was made through applying the Stage of change (SoC) questionnaire, based on the transtheoretical model proposed by American researchers and validated for the Brazilian context (9) .
The SRBC is determined according to the mean score Central obesity (concentration of adipose tissue in the abdominal region) was determined when the abdominal circumference was superior to 102 cm for men and 88 cm for women (9) , measured at the midpoint between the costal margin and the iliac crest.
The intervention included the practicing of physical exercises, nutritional guidance, and education in health.
The physical exercises were undertaken three times a week, for 60 minutes, structured in three points: initial warm-up and stretching (15 min), aerobic activity followed by localized exercises (35 min) and final stretching (10 min). The participants were monitored using heart rate Rev. Latino-Am. Enfermagem 2016;24:e2809 this study derived was approved by the Brazilian Clinical Trials Registry (RBR-6673s5). All the participants signed two copies of the terms of free and informed consent.

Results
The mean age of the women in the IG was 43.08 (±11.79) years old, and in the CG was 49 (±8.86) years old. In relation to the purchasing power, the majority of the women were classified as being from class C (70% and 75% of the IG and CG, respectively), while the other women belonged to class A/B. In the IG, four women were overweight, seven had grade I obesity and two had grade II obesity. In the CG, four were overweight, 12 had grade I obesity, two had grade II obesity, and two had grade III obesity.
After 16 weeks, the women from the IG presented significant reduction for all the variables analyzed. In the CG, no reduction was observed; on the contrary, an increase occurred in the mean of three of the four measurements analyzed (Table 1).
It is emphasized that in spite of the CG having presented, for some variables, a higher mean value after the weeks of the study, no evidence was found through the hypothesis test that there had been change between the two evaluations in this group.
It is underlined that of the 20 women in the CG, Considering only the members of the IG, one can observe in Table 2       One can observe in Table 5 that the women of the IG presented significant difference in the three aspects related to physical activity and which denote the inclusion of some daily attitudes, such as adopting a routine with various activities, parking the car some distance away so as to walk more, and undertaking heavy work at work. The women of the CG, on the other hand, presented significant difference in relation to two aspects: the use of the stairs instead of the elevator, and parking the car a certain distance away.
Bevilaqua CA, Pelloso SM, Marcon SS.  which is more favorable to physical activity and/or eating habits, thus reducing the risks to his or her health (16) .
In this regard, it was observed that the IG presented significant changes in the stages of readiness for change after the 16 weeks of the intervention. This indicates that the advice related to appropriate foods, and to the regular practicing of physical exercise, caused the IG participants to effectively include certain changes in their day-to-day.
These changes involve three domains of the SRBC: the size and quantity of the portions, the quantity of fat in the diet, and the practice of physical activity. The control group did not present changes in any of the domains.
One study undertaken with 90 Iranian women showed there to exist a significant association between the loss of body weight and the SRBC, emphasizing that for effective changes to occur it is necessary for the individual genuinely to perceive her health condition and to be in a stage of preparation and/or action. It also indicated the importance of providing these subjects with support through systematized interventions and in the long term, emphasizing that individual readiness to change may not be sufficient. It is therefore necessary to intervene directly through offering activities which promote food education, healthy habits, and the regular practice of physical activity (17) .
In Brazil, a study with 145 users of the health service, which used TM for assessing the eating-related behavior, observed that individuals classified in the initial stages, such as "contemplation" and "precontemplation" were more susceptible to having a diet rich in fats. Those, on the other hand, who were in a stage of "action" showed greater concern with the quality of their eating habits (18) .
This condition, therefore, can be determinant for the individual who has as her proposal to begin a process of behavioral change with the aim of losing weight.
In analyzing specifically the issues which are integral to each one of the domains of the SRBC, one can observe that habits related to adjustment of eating habits determined by quantity of food, consumption of fruits and vegetables and quantity of fat were significantly changed for the women of the IG. It is emphasized that food choice is a complex process which involves numerous determinants, such as experiences acquired throughout life, influences of cultural ideals, personal factors, resources available and demographic determinants, among others (19)(20). .
One factor which is related directly to success in behavioral change is the perception of the risk that excess weight can cause in health. One Brazilian study which assessed behavioral change related exclusively to consumption of fruits and vegetables indicated that 83.3% of the individuals who were most concerned with appropriate consumption were in the stages of action and maintenance (21).
Another study which evaluated whether the SRBC are related to consumption of fat evidenced that all the 131 women evaluated consumed more fat than recommended, and that the consumption of fat was lower among the women who were in the stages of action and maintenance (22) . The authors emphasized that the use of the questionnaire for classification of the SRBC makes it possible to identify the eating-related errors present and, as a consequence, makes it possible to promote a direct and accurate intervention regarding these (22) .
It is highlighted that, in recent decades, how Brazilians eat has changed in ways that have been reflected directly in their body composition. One frequently-observed change is the increase in the consumption of ultra-processed foods, it being common for these to contribute more than half of the total calories consumed. As a result, greater consumption of ultra-processed foods is associated positively with the excessive consumption of harmful substances such as fats, cholesterol, sodium and calories -and negatively, with the consumption of carbohydrates, proteins and dietary fiber, which triggers weight gain and metabolic changes (23) .
As a result, it is believed that nutritional guidance favors the development of individual strategies which can influence the choice of foods, as with the quantity and quality of what is consumed.
In spite of the low quality of evidence related to the impact of the interventions regarding sustainable behavioral change, even with multi-professional actions, it is observed that the individuals evaluated through this model tends to seek improvements in the quality of their food, principally reducing consumption of fat and increasing consumption of fruits and vegetables (21) , as observed in the present study. One systematic review on interventions based in theoretical models indicates, with a strong degree of evidence, that individuals benefit from the diet-related changes implemented (24) .
As well as a balanced diet, the habitual practice of physical activity is a fact which contributes, both to weight loss and to the maintenance of body weight (25)  In spite of these limitations, this study presents

Conclusion
The study's results show that, generally speaking, the participants from the two groups were predisposed to undertaking behavioral changes; however, only the women from the IG presented anthropometric indicators that the changes had really taken place.
The results allow one to infer that for significant behavioral changes to happen, that is, for there to be impact on the anthropometric components, it is not enough for the individuals to present good indicators for disposition for change. It is necessary for there to be support, encouragement and the offering of actions which aim to promote the regular practice of physical exercise and a balanced diet. It is emphasized that in this study in particular, the multi-professional support was important for the changes observed to occur.