Motivational Interviewing For Weight Loss

FrankJ.Domino,M.D.Professor

Dept. of Family Medicine & Community Health Un. Of Massachusetts Medical School

Worcester, MAFrank.domino@umassmemorial.org

Twitter: dominof

BLOG: http://www.ebpupdate.com/PODCAST: FranklySpeakingAboutFamilyMedicine

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Disclosures:FrankJ.Domino,MD• EditorinChief:5MinuteClinicalConsult• ManualMedicineforPrimaryCareClinicians

• FastFactsforFamilyMedicineBoardExam• AuthorandformerEditorforUpToDate• Author/Editor:www.Epocrates.com• Author:www.ebpupdate.com

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http://www.oecd.org/health/Obesity-Update-2014.pdf

ObesityRates

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• Meta-analysis: 12studies ofWeightLossAdvice.

• OURWeightlossadviceà (OR)=3.85(95%(CI)2.71,5.49;P<0.01)forweight loss.

• PCPadviceonweightlosshasasignificant impact onpatient changeofbehaviorsrelatedtotheirweight.

• “Providersshouldaddressweightlosswiththeiroverweightandobesepatients”

“Howdoyoufeelaboutyourweightandyourhealth?”Int JObes (Lond). 2013Jan;37(1):118-28

WhyWE MustCounselforWeightLoss

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“Hewhotakesmedicineandneglectsdietwastestheskillofhisdoctors.”

~ChineseProverbCOPYRIG

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CONSTRUCTIVEcommunication

methodtoreducehealthrisks

&changingbehavior.

ENHANCESthePATIENT’SOWNMOTIVATIONtoCHANGE

Strategies are:• EMPATHETIC• NON-CONFRONTATIONAL

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Successat12months<10%

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ü Carefullydefinedandrigorouslystudied

ü Isarelatively brief intervention.

ReasonsforMI’sPopularity

ü Positivelyimpactstreatmentandretention.COPYRIG

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Behavioral Problems Addressed by MI

• Lifestyle

• Chemicaldependency

• Non-adherencetotreatment

•Miscellaneousriskybehaviors

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MIinPrimaryCareSetting:SystematicReview

• MIStudiespatientsachievingatleast5%lossofinitialbodyweight.

Obes Rev. 2015Apr;16(4):304-18

• MIEffectiveforDietaryChangeandWeightLossinType2DMPatientEduc Couns. 2016Jun;99(6):944-52

• BehavioralprogramsImprovesAdherencetolifestylechangesinObesity

ClinObes. 2017Apr;7(2):105-114

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MotivationalInterviewing

1. ElicitChangeTalk: OARS§ Openquestions

§ Affirmations

§ Reflections

§ Summarize

2. DevelopDiscrepancy(Rulers,?’s)

• Discrepancy:Important,Confident

• Like: CurrentBehavior,Change

• Dislike: CurrentBehavior,Change

3. OfferAdvice(OPTIONS)

4.EndwithaSummary&Plan

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ConsiderBrianna…26yearoldfemale,G0P0;Tobaccousex5yrsHt:65inches;Weight:285lbsBMI:47.4

• Normal: 20-25• Overweight: 25-29.9• Obese: 30-34.9• SevereObesity: 35-39.9• MorbidObesity: 40-44.9• SuperObesity: >/=45

“I’vetriedeverything&can’tloseweight”

Youthink:“I’vetriedeverythingtoo!!!!”

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BRIEFMOTIVATIONALINTERVIEWINGinFourBasicSteps

STEP1:OARStoEstablishRapport&ElicitChangeTalk

• Openquestions• Affirmations

• Reflections• Summarize

STEP2:DevelopDiscrepancy (Rulers,?’s)STEP3:OfferAdviceSTEP4:EndtheinterviewwithaSummaryandPlan

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Insteadof:“Wouldyouliketoloseweight?”

Howdoyoufeelaboutyourweight?

STEP1:OARSOpen-EndedQuestions

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“Doyoueatdessert?”

Vs

“Pleasetellmemoreaboutwhatyoueatfor

dessert?”

Open-Ended Questions

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STEP1:OARSAffirmations

• Supportthepatient• Conveyrespect&understanding•Helppatientsreveallesspositiveaspectsofthemselves

²“Dealingwithweightissuescanbesodifficult”²“You’reworkingsohard!”²“Sometimeseatingyourfavoritefoodsfeelssocomforting.”

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STEP1:OARSReflectiveListening

• Restate patient’swordsinNON-JUDGEMENTALmanner• Speakasstatement,notaquestion:

Patientsays:“Icaneatanentirebag ofchipsatonce”

Youreflect:“sometimesyoueatabagofchips”

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Reflective Listening

“MyboyfriendgetsreallyangrywhenIeatFrenchfries.”Yourespond:

“So,whenelsedoeshegetsmadaboutyoureating?”

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Reflective Listening

“Ican’tcontrolmyselfifIamstressedout”

YouSay:

“Itmustbehardtocontrolyoureatingwhenyouare

worried”

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STEP1: OARSSummarize

Goal:DesignateTransitionPointincludingyouraddedsuggestions

• “ThisiswhatIhearyousaying”• “Whatyou’vesaidisimportant.”

• “Wecoveredthatwell.Nowlet'stalkabout..”

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Brief MI in 4 Steps

1. Establish rapport & Elicit Change Talk: OARS§ Open questions§ Affirmations§ Reflections§ Summarize

2. Develop Discrepancy (Rulers, ?’s)3. Offer advice4. End the interview with a summary and plan

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STEP2:DIsCrepancy RulersUsingDiscrepancyToMotivateChange:

PEOPLECHANGEBEHAVIORWHENTHEYRESOLVEDISCREPANTFEELINGS:

Onascaleof1– 10,howIMPORTANT isitforyoutoloseweight?

Onascaleof1– 10,howCONFIDENT areyourabilitytoloseweight?

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STEP2:DiscrepancyRulers

EstablishDiscrepancy:

Onascaleof1– 10,howIMPORTANTisitforyoutoloseweight?“8”

“GREAT!soundslikelosingweightisimportanttoyou”

Onascaleof1– 10,howCONFIDENTareyouinyourabilitytoloseweight?“3”

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STEP2:DiscrepancyRuler

Discrepancy:8vs3

“ItSoundslikeyoureallyWANTtoloseweight….“

“WhatONETHINGYoucanyoudoTODAYtomoveyouup1-2confidencepoints?”

“Well,IguessIcouldgetalloftheJUNKfoodsoutofthehouse”(DiscrepancyResolved--alittle)

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DEVELOPDISCREPANCY:LIKE/DISLIKE:Behavior&Change

• Important/Confidentwithoutscale:NOW&CHANGE

• “IknowwhyIwantyoutoloseweight;pleasetellmewhyYOUwanttoloseweight.”

• “WhatisEasy/Like abouthowthingsarenow?”• “WhatisHard/Dislikeaboutthingsnow?”

• “WhatwouldyouLike aboutchanging?”• “WhatbeHard/Dislike aboutchanging?”

• “Whatis1thingyoucandothatmighthelpyouchange?”

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ExerciseDiscrepancyQuestions

• “Exercisedoesn’tmakeyouloseweight,butsittingmakesyougainweight”

• WhydoYOUwanttostartExercising?• Whatdoiseasyabouthowthingsarenow?• Whatwouldyouliketoseechanged?

• Whatwouldbechallengingaboutstartingtoexercisenow?• Whatwouldbethebenefityouwouldwanttosee?

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STEP3:ADVICE

ØVeryfewspecifics:GiveOPTIONSbaseduponPATIENT’sideas(&sometips)

ØLimit:“topdown”statements

ØHavepatientdecidewhatthey wanttodo,thensupportandofferrelatedadvice.

“Whatis1thingyoucanchangetomorrowtoreachourgoal?”“IguessIcouldgetallofthebadsnacksoutofthehouse….”

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STEP4:SUMMARY&ACTIONPLAN

• CONTINUITY:OnceaMonthfor1st x3Months

•ALWAYSscheduleCLOSE Followupwitha

Goal (weightlost,exercise)COPYRIG

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STEP4:ACTIONPLANGOALSETTING:

“Let’sscheduleafollowupappointmentinonemonth…”“Howmuchweightlosscanyoulosebeforeournextvisit?”

�0.5– 1.0Lb/Week

AND/OR

“Whatwouldyouliketosetasanexercisegoalforthenextvisit?”� Consistentlywalking8,000Steps/day?

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RealWorld:CombiningSteps3(Advice)&4(ActionPlan)

� “Thatisterrific!Gettingallofthesnacksoutofthehouseisagreatstart.

�Whatwillyoudowhenyougettheurgetosnack?Doyouknowwhatsnacksarebettertoeat?”

� “Kindof…”� “Well,wehaveafewoptions;Icangiveyouafewideas,orreferyoutoadietician,orwouldyouconsideragrouplikeWeightWatchers;andthenIwanttoseeyoubackinabout4weeks…”

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MotivationalInterviewing: Summary1. Establishrapport&ElicitChangeTalk:OARS

§ Openquestions

§ Affirmations

§ Reflections

§ Summarize

2. DevelopDiscrepancy(Rulers,?’s)

• Discrepancy:Important,Confident

• Like: Behavior,Change

• Dislike: Behavior,Change

3. OfferAdvice(OPTIONS)

4.EndwithaSummary&Plan

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LiveRolePlay:WRITEDOWN

OARS,Discrepancy,Summary,ActionPlan

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MotivationalInterviewing:NextSteps

1. OARS:ChangeTalk,Affirmations,Reflections,Summary2. Discrepancy:Like/Dislike:Now,future3. PtCenteredAdvice4. Plan&CloseFollowUP

NextBestSteps• IntegrateMIforthosewithBMI>30

• FIBER:24HourDietRecallAndCount7-10Veg+Fruit/day,

• TeachMindfulEating(andpracticeittoo!)

• ObesityisChronicDiseasethatisTREATABLE

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IncreaseFiber:

24HourDietaryRecall

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“Tellmeeverythingyouateanddrankyesterday,

startingwithbreakfast.”

NOTYesterday!!COP

YRIGHT

YOU:Count FruitandVegetableServings• Goal:10servings/day

• à 25-30GramsofFiber

• Min:5servings/day

• Potatoes,Pasta&RicedoNOT count

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“ListenfortheOreoCookie”

OK,NowTurnToYourNeighbor&“Tellmeeverythingyouateanddrankyesterday,starting

withbreakfast.”

COUNTVeg&Fruitservings!

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WhyFIBER?:ItLowersWeightandA1c• RCTofObeseT2DM10.5gmPsylliumvscontrolx8Weeks• Results: Psylliumsignificantly REDUCED:

Weight (7lb),

↓BMI,FBSHbA1c (8.5->7.5 %),

↓Insulinlevel,

↓C-peptide,

↓HOMA.IR

↓HOMA-β%

NutritionJ.2016;15:86.doi:10.1186/s12937-016-0207-4

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High Fiber & Lean Protein à Weight Loss• Pilot study: MO Adultes; 35 g/d fiber/d

& 0.8 g/kg/d lean protein

• AD LIB DIET/No exercise• 12 weeks, lost 4.4 lbs

Nutrition 2018; 22:5412-18

My Approach:• Psyllium Powder (17 gm/1 TBL) BID

or Capsules

• Bran Buds (insoluble)1/3 cup = 12 gram/day

Total = 46 gm/day Psyllium WheatInsoluble

7-10Fruits&

Vegetables

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EATMindfully

• Most important part of long term weight loss and maintenance

• Divide Plate in Half & Stop“Am I still Hungry?”

• PUT YOUR FORK DOWN/ Chopsticks

• Eat at Table; No Screen, Smaller Plate

• TRACK WHAT YOU EAT: Apps• Eat Right Now• Add to Lose• Amihungry.com• NOTEPAD

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Diets:Whatcanyoudoforever?

• DietOptions:• LowCarb/Keto• 16/8IntermittentFasting

• RefertoDietician

• SmallerPortions

• MealReplacement(JoslinClinic):• JennyCraig,HelloFresh,Nutrisystem• Metagenics,BoostGlucoseControl/CalorieSmart,GlucernaHungerSmart

• ZonePerfect,Balance,(~15GProtein,7Fat),CliffProtein(13GFat)

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MotivationalInterviewing&WeightLoss

1. OARS:ChangeTalk,Affirmations,Reflections,Summary2. Discrepancy:Like/Dislike:Now,future3. PtCenteredAdvice4. Plan&CloseFollowUP

NextBestSteps• IntegrateMIforthosewithBMI>30

• FIBER:24HourDietRecallAndCount7-10Veg+Fruit/day,

• TeachMindfulEating(andpracticeittoo!)

• ObesityisChronicDiseasethatisTREATABLE

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Motivating Patients and Optimizing Adherence for For Weight Loss

FrankJ.Domino,M.D.Professor

Dept. of Family Medicine & Community Health Un. Of Massachusetts Medical School

Worcester, MAFrank.domino@umassmemorial.org

Twitter: dominof

BLOG: http://www.ebpupdate.com/PODCAST: FranklySpeakingAboutFamilyMedicine

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