The intake questions that predict who sticks to a plan

A nutrition coaching intake form should predict adherence

An intake form has two questions to answer before you write a single meal: how likely is this person to follow a plan, and which part of the plan should stay small. The answers that carry signal describe behaviour the client has already performed. What they ate last Saturday beats what they intend to eat next Monday, and it costs less to ask.

Most forms answer neither. They collect a food history, a goal weight and a list of allergies, then sit in a folder while you guess.

Ask for three days of records before you ask anything else

Look AHEAD is a behavioural weight loss trial in overweight adults with type 2 diabetes: 5,145 people, randomly assigned to an intensive lifestyle programme or to diabetes support and education, working towards 7% weight loss and 175 minutes a week of moderately intense activity. Before anyone was assigned, every applicant spent two weeks writing down what they ate and how they moved, every day. The trial then used that fortnight as a filter.

Those who did not complete at least 12 of 14 days of record keeping were deemed ineligible because of their low likelihood of completing the extensive self-monitoring required during treatment.

A trial funded to run for more than a decade screened its applicants on whether they could keep a food diary. It did that because the diary is the load-bearing part of the treatment. Burke, Wang and Sevick reviewed 22 studies published between 1993 and 2009, 14 of them on food records, one on exercise records and six on self-weighing. A significant association between self-monitoring and weight loss was found consistently, and the reviewers are careful about what that is worth: the level of evidence was weak, they write, because of methodological limitations.

You cannot ask a paying client for 14 days of records before you take their money. Three days, one of them a weekend day, is enough to see whether records arrive at all. We would drop half the questions on a typical intake form and ask for those three days instead, because what a client has already logged predicts adherence better than anything they tell you they will do.

Eight questions that earn their place on the form

Eight questions and three days of records fit on one screen. A form longer than that buys detail you will not read before the first call.

Ask what ended the last attempt, and how many weeks in

Wing and Phelan describe what the National Weight Control Registry has learned from people who succeeded. About 20% of overweight individuals manage long-term weight loss, counted as losing at least 10% of initial body weight and holding the loss for at least a year. Registry members have lost an average of 33 kg and kept the loss for more than 5 years. Alongside diet and exercise, the authors list low levels of depression and disinhibition, and medical triggers for weight loss, among the things that go with long-term success.

You cannot screen for depression on an intake form and should not try. You can ask what ended the last attempt and how many weeks in, and the mechanism usually arrives in the answer: a holiday, a night shift rota, a partner who cooks, a knee. The Diabetes Prevention Program treated this as core work. Lifestyle coaches were encouraged to work with each participant individually to name that person's own barriers and the possible solutions, backed by a toolbox of strategies funded at about $100 per participant per year.

Write the answer down as a date, not a feeling. "Week 6, October, work trip" is something you can plan around. "Lost motivation" is not.

Ask about Saturday separately from Tuesday

Registry members report a consistent eating pattern across weekdays and weekends, along with about an hour a day of activity, a low-calorie and low-fat diet, breakfast eaten regularly and weighing themselves. Of that list, the weekday and weekend split is the one an intake form can reach cheaply, and it is often what explains the client whose week looks tidy and whose month does not move.

So name Saturday in the question. A client eating 1,800 kcal on five days and 3,500 on two is averaging about 2,290 a day, which is a different problem from the one their weekday plan is solving.

Every question should set up a technique you will use

Spahn and others reviewed 214 articles for the American Dietetic Association's evidence analysis library and kept 87 studies. Their summary of what works in counselling is short enough to pin above the desk.

Goal setting, problem solving, and social support are effective strategies, but additional research is needed in more diverse populations.

The same review found strong evidence for self-monitoring and for structured meal plans, and rated motivational interviewing highly effective, particularly alongside cognitive behavioural therapy. Each of those strategies needs something the intake form can supply. Goal setting needs a baseline. Problem solving needs the barrier. Social support needs the name of the person who does the shopping.

Michie and others gave this vocabulary a fixed form: 93 behaviour change techniques, clustered into 16 groups, agreed by panels of experts so that two people describing the same programme describe it the same way. Your form does not need the taxonomy printed on it. It does need each question to earn a technique, and a question that earns none is filing rather than intake.

Do not offer money for hitting a number

Spahn and others rate the evidence against financial rewards as compelling: paying a client for reaching a target does not improve the outcome. That is an argument against the refund clause that some intake packs carry, the one promising a free month for a 5% loss. Take it off the form and put the problem-solving question in the space.

Score the form in five minutes

This part is ours rather than anyone's research, and it takes about as long as reading the answers twice. Count how many of the eight answers describe something the client has already done, and how many describe an intention. Then sort the client into one of three starts.

• Three days of records and five or more behavioural answers: write the full plan.
• One or two days of records: write one week, and make the goal logging rather than a number.
• No records: the first call is about that, and nothing else.

The third case is the one worth being honest about. A client who does not send three days of food during the week they are most motivated is unlikely to send anything in week 9, and a 12 week plan written for them is a plan you will rewrite.

The plan that follows should take minutes

The form has done its job once the answers are in, and the work moves to the number. Setting a client's calories from their intake answers is the next step, and it uses the same answers. After the number comes the plan, which is where the evening goes; we built Peas & Pans so that part takes minutes instead.

Send the request for three days of records with the booking confirmation, not after the first call. The client who does not send them has told you something the rest of the form cannot.