Monday, April 04, 2011

Book Review: Atul Gawande's The Checklist Manifesto

If you've read this book, you may be wondering why I'm reviewing it on Weighty Matters. After all, it certainly doesn't superficially seem to have anything to do with nutrition or weight management.

But yet, I think it does.

The book itself can be very simply described as a collection of stories that illustrate the value of checklists in ensuring a greater likelihood of success. The author, a surgeon named Atul Gawande by means of a truly marvelous gift for storytelling, takes us through the use of checklists on construction sites, in airplanes and most importantly to him, in the operating room.

It's a compelling and easy read, and the clear cut case he makes for checklists made me pause to think about how they might be employed for weight management.

We know that for some reason, keeping track of intake is one of the foremost predictors of success. Could checklists be utilized to help make record keeping easier and bolster other health promoting behaviours? Would going through a simple checklist a few times a day impact on success?

Interestingly there's often a great reluctance on the part of those unfamiliar with them, to embrace the use of checklists. Gawande posits that perhaps our own senses of infallibility are offended by the notion of something so simple as a checklist being useful; that we think ourselves to be above them.

Checklist design is discussed as well and Gawande explains,

"The checklist gets the dumb stuff out of the way, the routines your brain shouldn't have to occupy itself with"
I wonder if therein lies the issue with food diarizing. With studies demonstrating that people lose twice as much weight when utilizing a food record, and with food record keeping taking all of 5 minutes a day once you're good at it, why then is it such a challenging behaviour for people to adopt? Perhaps a checklist that forces us to look at what many might feel is, "the dumb stuff", would help in fact get it out of the way.

I'm going to explore this a bit with my patients, and whether you choose to or not, there's one thing this book makes abundantly clear. If you're having a surgery, for the love of all that's holy, ask your surgeon if he or she uses a checklist, and if he or she doesn't, buy them a copy of this book before your operation. It might be the best $15 you'll ever spend.

(BTW - read the book and you'll likely never look at Van Halen the same way again.)

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  1. I'm a big fan of checklists, too. It accounts for the automaticity of performance/cognition interfaces.

    Anecdotally, I kept an online-based food, activity and clinical indicator diary, and although my goal was to see if I was meeting vitamin, mineral and nutrient goals, I still found that I frequently forgot foods. I came to the realization that a lot of my eating is automatic and comes from habitual eating times, certain staple dietary foods, and stressor responses.

    I learned to adjust for this by documenting the food after acquiring it (ready to eat state) and prior to eating it. If I didn't finish it, I was more aware and motivated to edit the diary.

    But this automaticity might have something to do with the notorious inaccuracy of diaries. Even though my motivation was to capture everything to demonstrate nutritional completeness (in other words, documentation was reward-based instead of restriction/deprivation based), I still fell short.

  2. Paulette7:37 am

    A very interesting concept. As a sometimes food diarist, I find the repetition & time dedicated to it on a daily basis becomes a nuisance after being vigilant for a few weeks.
    A checklist may be just the thing.. Having a food Quality Assurance background I well understand the value of checklists (think safety audits etc), but I had never thought of applying this concept to eating habits.
    After all, when embarking on a new program of any type it is common to be very careful initially in the first flush of commitment, but after a while a certain amount of slippage occurs and this is why maintaining a weight reduction is so challenging.
    I am going to read the book. This post is definitely food for thought.

  3. Jim H9:02 am

    I have been a fan of Dr Gawande's for years and he is doing this program our company is participating in that fans of his might like. It sounds like it will really show you how to apply checklists at work and in life

  4. Arya Sharma9:58 am

    I have long recommended that my patients use the simplest of checklists - six tick boxes one for each meal and 3 snacks. All I have asked them to do is tick each box when it happens and note the time. Then see how many days in a week you've actually ticked all boxes at approximately the appropriate time.

    Thats what I tell some of my patients, but then they meet the dietitians and things become more complicated, So I don't have results to report - bur I am still convined that even this most basic of checklists would work fine for most people.

  5. Anonymous2:55 pm

    My problem with checklists is I haven't found a good easy to use, template/form/style. My checklists look like the final draft edit of a student essay.

  6. motera5:24 pm

    Great book...highly applicable to my weight loss efforts. I found traditional methods of tracking intake tedious, after reading Dr. Gawande's book I realized I do not eat 10,000 foods, so I don't need access to a huge food database, I eat a limited number of foods, and for me *planning* my intake was more important that tracking it, so I plan it, make a checklist, with space for additions, then check off what I eat. I use google docs. In addition to what I eat, I indicate time of day and mood, if notable.

  7. When I lose weight, I use an portion control based checklist. It is organized in columns with days of the week along the top. The rows contain blank boxes where you can record what you eat--as well as categories marked "fruit", "Vegetables", "dairy", "protein", "Starches", "fat", and "water." Beside each category is a number of boxes representing one portion (though one "box" of protein=one ounce to keep it simple). It is remarkably easy to fill out for 90% of what I eat when I'm restricting my calories.
    It is based on Weight Watcher's portion control program from the 80's (which, in turn, is based upon the whole system of diabetic exchanges.)

  8. Nurse Ingrid7:11 pm

    It may not be for everyone, but keeping a food diary is certainly what works for me. I use the iPhone app "LoseIt" every day, and I have been for almost 2 years now. I have lost 50 pounds and kept it off for almost a year. My plan is to keep this up for life, and I'm okay with that. It really doesn't feel like a hardship anymore; it's like brushing my teeth or something. I give myself one day off a month, plus the occasional vacation out of town. So far it's worked great. And if anything, I enjoy my food more now because I keep track so I know what's in my "budget." No guilt!

  9. "With studies demonstrating that people lose twice as much weight when utilizing a food record, and with food record keeping taking all of 5 minutes a day once you're good at it" - Yoni, did you already post about this elsewhere? If yes can you please paste a link in?

    Maybe the food diary is a first step that people can do for a finite period in order to set a baseline, work out nutritional gaps or identify emotional triggers for eating. What's learnt from keeping a food diary can then be incorporated into personalised checklists.

    I've done this with time. Firstly I tracked all my waking minutes and what I used them for. Then I thought about what my priorities were and how much time I wanted to alloacate to those priorities. Now I'm at the checklist stage and I can easily monitor whether I'm following through. I can see how this would relate to diet. It's a bit of work to set up but it's very effective for long-term management and self-monitoring.

  10. Hi Growing Raw,

    The study most often cited is this one.

    Experientially I can confirm the relationship exists in my clinic as well.