Motivational Interviewing for Weight Loss & Exercise

1. Motivational Interviewing for Weight Loss & Exercise Frank J. Domino, M.D. Professor Frank.domino@umassmemorial.org

2. By the end of this session, the learner will: Understand the basic components of Motivational Interviewing Learn how to apply Motivational Interviewing to weight loss and exercise Review the current literature on what is effective in helping patients lose weight

3. Consider Brianne…. • 26 year old female, G0P0; Tobacco use x 5 yrs • Ht: 65 inches; Weight: 285 lbs • BMI: 47.4 • Normal: 20-25 • Overweight: 25-29.9 • Obese: >/= 30 • “I’ve tried everything & can’t lose weight” • You think: “I’ve tried everything too!!!!”

4. Motivational Interviewing A style of talking with people constructively about reducing their health risks and changing their behavior. Designed to Enhance the patient’s own motivation to change using strategies that are empathic and non-confrontational.

5. Behavioral Problems Addressed by MI • Lifestyle • Chemical dependency • Non-adherence to treatment • Miscellaneous risky or unsafe behaviors

6. Reasons for MI’s Popularity • Carefully defined and rigorously studied psychosocial substance abuse treatments. • Is a relatively brief intervention. • Positively impacts treatment and retention. • Has wide application to behavioral domains • Compatible with many different approaches.

7. Efficacy of MI in Obesity & Exercise • Improved weight controlprogram behavioral adherence, glucose control and weight loss outcomes among Type 2 diabetic patients. Smith et al. Diabetes Care; 1997;20:52-4; Harland et al., Brit Med J. 1999;319:828-31. • Increased physical activityand exercise energy expenditure among cardiac rehabilitation patients Scales R, Miller JH. Current Sports Medicine Reports. 2003;2:166-72. Bowen

8. Efficacy of MI in Habits • Increased fruit & vegetable consumption Bowen et al. 2002; Resnicowetal. Am J PubHealth. 2001;91:1686-93; Resnicow et al. Health Psych. 2005;24:339-48; • Motivational interviewing was 5 times as effective as brief advice for achieving sustained smoking cessation. Soria, R.; A randomised controlled trial of motivational interviewing for smoking cessation, Br.J.Gen.Pract., 2006, 56, 531, 768-774 • Helped patients change problematic behaviors related to hypertension. Woollard J et al. Clin Exp Pharm Phys. 1995;23:466-8.

9. Motivational Interviewing • Establish rapport & Elicit Change Talk: OARS • Open questions • Affirmations • Reflections • Summarize • Develop Discrepancy to Facilitate Change Talk using Rulers • Offer advice • End interview with a summary & plan

10. How does MI Work • AMBIVALENCE is the key issue to be resolved for change to occur. • People change when they hear their own discussion of their ambivalence. • This discussion is called “change talk” • Getting patients to engage in “change talk” is critical element of the MI process. *Glovsky and Rose, 2008

11. Change Talk • Desire- “I really want to lose weight.” • Ability- “I have done it before.” • Reason- “My kids really want me to.” • Need- “I can’t live like this.” • Commitment- “I can get this under control.” GOAL: Have Patient Express Reason for Change

12. Motivational Interviewing (MI) Rules (EARS) • Express Empathy: • “I know it must be hard…” • Avoid Argumentation • Follow patient’s lead (even if incorrect) • Roll with Resistance • Ambivalence is necessary to motivate change • Support Self Efficacy: • Person is responsible for the change

13. Brief MI in 5 Steps • Establish rapport & Elicit Change Talk: OARS • Open questions • Affirmations • Reflections • Summarize • Develop Discrepancy to Facilitate change talk using Rulers • Offer advice • End the interview with a summary and plan

14. OARS Open-Ended Questions “Would you like to lose weight?” Vs. How do you feel about your weight?

15. Open-Ended Questions “How much ice cream do you eat?” Vs “Please tell me more about what you eat for dessert?”

16. OARS Affirmations Support the patient Convey respect & understanding Help patients reveal less positive aspects of themselves

17. Affirmations (continued) “Dealing with weight issues is difficult” “You have worked so hard.” “I can understand why eating feels good to you.”

18. OARS Reflective Listening • Goal: to facilitate further patient comment • Method: Restate patient’s words in non judgmental manner • Speak a statement, not a question:“You eat an entire bag of chips at once? Vs. “sometimes you can eat a bag of chips”

19. Reflective Listening “My boyfriend gets really angry when I eat French fries.” You respond: “So, he gets mad when you eat French Fries”

20. Reflective Listening “I can’t control myself if I am stressed out” You Say: “It must be hard to control yourself when you are worried”

21. OARS Summarize • Goal: Designate transition point • “What you’ve said is important.” • “This is what I hear you saying” • “We covered that well. Now let's talk about..”

22. Brief MI in 5 Steps • Establish rapport & Elicit Change Talk: OARS • Open questions • Affirmations • Reflections • Summarize • Develop Discrepancy to Facilitate change talk using Rulers • Offer advice • End the interview with a summary and plan

23. 2. dIsCrepancy Rulers Discrepancy: On a scale of 1 – 10, how IMPORTANT is it for you to lose weight? On a scale of 1 – 10, how CONFIDENT are your ability to lose weight?

24. Discrepancy Rulers Important 1 5 10 Confident 1 5 10

25. 2. Discrepancy Rulers Discrepancy: On a scale of 1 – 10, how IMPORTANT is it for you to lose weight? “8” “GREAT! sounds like losing weight is important to you” On a scale of 1 – 10, how CONFIDENT are you in your ability to lose weight? “3”

26. 2. Discrepancy Ruler Ambivalence: 8 vs 3 “Really.., I thought you would have said 1 or 2 (a number less). What would it take you to go up 1-2 points? “Well, I guess I could get all of the bad foods out of the house”

27. Brief MI in 5 Steps • Establish rapport & Initiate Discussion: OARS • Open questions • Affirmations • Reflections • Summarize • Develop Discrepancy to Facilitate change talk using Rulers • Offer advice • End the interview with a summary and plan

28. Advice • Advice: • Very few specifics • “top down” statements from their doctors • Have patient decide what they want to do, then advise. “Well, I could get all the tempting snacks out of the house & not buy any more…”

29. 4. Action Plan • Action Plan • Based upon patient’s suggestion • Provide options for patient • Be open to whatever they suggest • ALWAYS schedule Follow up with agreed upon Goal

30. 3/4: Advice & Action Plan “Terrific! Getting snacks out of the house is a great start. But, what will you do when you get the urge to snack? Do you know what snacks to have in the house that are healthy?” “Kind of…” “Well, we have a few options. I can give you a few ideas, refer you to a dietician, or would you consider a group like Weight Watchers? GOAL SETTING: “Let me see you back in a month. How much weight will you try lost by then?”

31. Useful References & Resources Miller, W.R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change(New York, Guilford Press).Rollnick, S., Mason, P., & Butler, C. (1999). Health Behavior Change: A Guide for Practitioners(London, Churchhill Livingstone).Rollnick, S., Miller, W.R., & Dunn, C. (2008). Motivational Interviewing in Health Care(New York: Guilford Press).www.motivationalinterview.org and www.casaa.unm.edu

32. SummaryMI in 5 Steps • Establish rapport & Elicit Change Talk: OARS • Open questions • Affirmations • Reflections • Summarize • Develop Discrepancy to Facilitate change talk using Rulers • Offer advice • End the interview with a plan

33. “What to do I do?”Counseling for Weight Loss Frank J. Domino, M.D. Professor Dept. Family Medicine & Community Health Un. Of Massachusetts Medical School

34. Barriers to nutritional counseling Confusion over current guidelines Lack of time Lack of insurance compensation Effectiveness of interventions Lack of knowledge about nutrition as it relates to disease GOAL: 5 Brief Concepts to Recommend to Patients

35. “Successful Losers” The National Weight Control Registry >5000 successful losers Members lost an average of 66 lbs (range=30-300 lbs) x 5.5 years 78% eat breakfast every day. 75% weigh them self at least once a week. 62% watch < 10 hours of TV per week. 90% exercise, about 1 hour per day. http://www.nwcr.ws

36. What about the average person?Daily Practices Survey 2004 US > 18 Yrs. “Successful Weight Loss Maintainers” Eat Fast Food < 2/Week > 5 Fruits & Vegetables/day ** AND 150 Minutes physical activity (25 Min/Day)

37. What else can your Patients Do? 3200 Japanese, 30-69 Yrs Survey 2003-6 BMI, Eating “until full” & speed of eating Odds of Being Overweight Male Female Eating Till Full 2.00 1.84 Eating Quickly 1.84 2.09 Full & Quickly 3.13 3.21 Triple the odds !!! BMJ 2008: 337: a2002 Eat Slowly and question if still wants more

38. First Some Basics Training

39. Calories Energy IN vs Energy OUT 3500 calories= 1 pound 500 calories/day x 1 Week = 1 lb +10 calories/day = 1 lb weight/year

40. Body Weight Ideal Body Weight:Women: 100 lbs first 5 feet + 5 lbs/inch. +/- 10% Men: 106 lbs for first 5 feet + 6 lbs/inch +/- 10% Calories Needed to Maintain Weight Active male: Lb x 15 = total calories per day. Active female: Lb x 12 = total calories per day. Inactive male: Lb x 13 = total calories per day. Inactive female: Lb x 10 = total calories per day.

41. Daily Requirements Female adult (5’4”) ~ 1,500 calories/day Male adult (5’7”) ~ 2,250 calories/day Remember: • Fat = 9 Kcal/gm • Protein = 4 Kcal/gm • CHO = 4 Kcal/gm • Alcohol = 7 Kcal/gm

42. US Recommended Dietary Allowances Males Females Water 4 L/d 3 L/d Carbohydrates(50%) 280 g/d 190 g/d Protein (20%) 110 g/d 75 g/d Fat (30%) 75g/d 50 g/d Fiber 35 g/d 25 g/d

43. What is a Serving Size? Meats: 3 oz. (deck of cards) Dairy: 4 oz = ½ cup Grains: ½ cup or 1 slice bread Veg: ½ cup cooked or 1 cup raw Fruit: ½ cup cut up or 1 medium

44. The Label Look at serving size saturated fat dietary fiber sugars Glance at carbohydrate Read ingredients (for hydrogenated oils and whole grains)

46. 5 Steps to Healthy Diet • Increase Fiber • Increase Water 16 Oz before meals • Prescribe Exercise • MINDFULLY Eat Calorie “hypodense” foods • Limit Screen Time to < 10 Hr/week

47. Increase Fiber • 24 Hour Dietary Recall

48. “Tell me everything you ate and drank yesterday, starting with breakfast.”

49. “Oh no, not yesterday!”

50. Count Fruit and Vegetable Servings • Goal: 10 servings/day •  25-30 Grams of Fiber • Min: 5 servings/day (15 Grams/Day) • Potatoes, Pasta &White Rice do NOT count