IOv2Motivating-1- Motivating Patients To Lose Weight

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Motivating Patients & Lifestyle ChangeMODULE 1MOTIVATING PATIENTS TO LOSE WEIGHTContentsMotivating Patients to Lose Weight. 3Introduction. 4Think Ahead: Motivating Patients . 5Motivational Interviewing Overview. 6Poll: On average, for patients with weight problems, I devote minutes per visit to motivatingthem to lose weight. 7Motivational Interviewing Steps. 7Patient-Centered Approach. 7Patient-Centered Examples 8Case #1: Ms. Campbell. 9Quiz: Talking About Weight. 10Empathy and Affirmations. 11Normalizing and Reassurance. 12Open-Ended Questions. 12Determine Readiness for Change. 13Using Readiness Rating. 14Quiz: Eliciting Thoughts, Feelings . 15Reflective Listening. 15Reflective Listening Tips. 16Tailoring Approach by Stage of Change.17More Reflective Listening. 17Ms. Campbell: Case Skills Review. 18Quiz: Motivational Skills. 18Case #2: Mr. Murphy. 20Engaging the Patient. 20Quiz: Patient Awareness. 21Page 1 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangeBuilding Confidence. 22Elicit Motivational Statements. 23Quiz: Eliciting Motivation. 24Working With Ambivalence. 24Quiz: Resolving Ambivalence. 25Case: Working With Ambivalence. 26Mr. Murphy: Skills Review. 26Case #3: Mr. Harris. 27Mr. Harris' Weight History. 27Understanding the Patient's View. 28Quiz: Responding With Empathy. 29Avoiding Resistance. 30De-Escalating Resistance. 30Rolling With Resistance. 31Quiz: Putting It Altogether 32Discord. 33Lack of Motivation. 34Mr. Harris: Case Skills Review. 34Video: Motivational Interviewing - Managing Patient Resistance.35Applications Case: Ms. Benson. 35Quiz: Engaging and Focusing. 35Quiz: Exploring Personal Barriers. 36Readiness, Motivation, Confidence.37Assessing Motivation and Confidence. 37Quiz: Eliciting Ideas, Feelings. 38Quiz: Expressing Empathy. 39Reflective Listening. 39Quiz: Evaluating Ambivalence. 40Quiz: Plan For Change. 41Personalized Plan. 41Clinical Protocol Steps in This Module. 41Module Summary. 42Resources available through this module:. 42Page 2 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangeReferences used in this module:. 43Module 1MOTIVATING PATIENTS TO LOSE WEIGHTGoal:To prepare the learner to effectively motivate patients who need to lose weight to participate in theirweight-loss management programs.After completing this module participants will be able to: Follow the basic steps of motivational interviewing when counseling adult patients on weightloss in primary care. Apply motivational interviewing techniques when counseling adult patients on weight loss inprimary care. Tailor counseling of adult patients on weight loss in primary care to meet individual needs. Respond effectively to common challenges that are faced when trying to motivate primary carepatients to lose weight.Professional Practice GapsEvidence-based guidelines recommend that providers use motivational interviewing techniques as atool for encouraging behavior change when managing and preventing obesity in adults (Fitch et al.,2013). Studies suggest that training in motivational interviewing skills will benefit physicians in helpingtheir patients lose weight (Pollak et al., 2007). Use of motivational interviewing by physicians withobese patients was associated with a reduction in body mass, body weight, BMI (Armstrong et al.,2011), and positive intentions and behavioral changes, such as motivation to lose weight (Jay et al.2009).Despite these recommendations and findings, primary care physicians do not consistently counsel oradvise patients who are overweight or obese (Simkin-Silverman et al., 2008; Smith et al., 2011). Infact, the majority of obese patients are not even told that they are overweight or obese by a physician(STOP, 2010; Bardia et al., 2007).In our needs analysis survey (N 25), 96% of providers felt they needed the training to counselpatients on weight control based on best practice recommendations. Only 35% of providersacknowledged using motivational interviewing techniques with overweight or obese patients, while92% of providers acknowledged a need for additional training using counseling or motivationalinterviewing (Tanner, 2011).Page 3 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangeINTRODUCTIONUSING MOTIVATIONAL INTERVIEWING TO PROMOTE WEIGHT LOSSMotivational interviewing is a patient-centered counseling style, originally developed for use insubstance use counseling. It is often effective when an individual is being guided to make a behaviorchange to improve health, including achieving and maintaining a healthy weight (DiLillo & West,2011). Basic steps from this technique can be integrated into a primary care visit (Rahm et al., 2014).Motivational interviewing techniques support the development of rapport, which is important whentalking about the topic of weight. It is a sensitive subject for many people, both patients, andphysicians. Motivational Interviewing also helps healthcare providers facilitate a patient in developingthe motivation to lose weight and a plan with concrete steps to take.Meet the Patients:We will follow the stories of these patients in order to illustrate how to approach the 4 steps ofMotivational Interviewing (M.I.) and use clinical skills effective in each step.MS. CAMPBELLPresenting for a diabetes check-up, Ms. Campbell has not lost any weight despitereceiving dietary and exercise recommendations to support weight loss many times.How can she be motivated?MR. HARRISPresent for a follow-up on weight-related comorbidities. He is resistant to trying to dietafter many failed attempts.How can you best respond to his resistance?Mr. MurphyIn for a physical exam. His BMI is in the obesity range, but he thinks he's "just a fewpounds up."How can you raise his awareness without offending him?MS. BENSONObesity-related infertility. She lists several personal barriers to weight loss.How can you help her get past these barriers?THINK AHEAD: MOTIVATING PATIENTSThink Ahead: Elma Taylor seems resistant to talking about a weight-loss plan. You have madeattempts, but she either changes the subject or describes reasons weight-loss attempts would notPage 4 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle Changework. You have tried brainstorming ideas to get around these barriers and suggesting small steps shecould take but to no avail. Which of the following techniques might best break through her resistanceafter she says in response to your latest suggestion, "That won't work for me."Choose one1. "I get frustrated from making suggestions when you reject all of them." Feedback: Incorrect. This topic is discussed on De-Escalating Resistance.2. "That may be. It may not work for you." Feedback: Correct. This topic is discussed on De-Escalating Resistance.3. "It seems like you don't really want to lose weight. Do you?" Feedback: Incorrect. This topic is discussed on De-Escalating Resistance.4. "It has worked for countless other patients of mine." Feedback: Incorrect. This topic is discussed on De-Escalating Resistance.MOTIVATIONAL INTERVIEWING OVERVIEWMotivational interviewing (MI) elicits behavior change through apatient-centered counseling style for addressing ambivalence aboutchange (Miller & Rollnick, 2012). Although originally developed forsubstance abuse counseling, these motivating techniques can beused in primary care to facilitate any health behavior change,including weight loss.The Fundamental ApproachCollaboration, evocation, and patient autonomy rather thanconfrontation, education, and authority. Elicit from patients their ideas and insights regarding the problematic health behavior ratherthan imposing ideas and insights on the patient. In the case of weight loss, it is important notto make assumptions. There are a lot of variations in patient attitudes about obesity andrelated behaviors. An attitude of partnership, acceptance, and compassion builds rapport. (Miller & Rollnick, 2012)FULL DEFINITIONMotivational interviewing is a collaborative, goal-oriented style of communication withparticular attention to the language of change. It is designed to stimulate personalmotivation for commitment to a specific goal by eliciting and exploring the person's ownreasons for change within an atmosphere of acceptance and compassion" (Miller andRollnick, 2012).Page 5 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangePRACTICE TIPSTo apply motivational techniques in weight management, recognize the patient's expertise on his orher own motivations to lose weight and how they can best go about it.Motivational interviewing can make a difference even if you only spend one minute using one of thetechniques described in this module. Longer interventions of 10 minutes or more are more effective,however. It is also important to keep doing motivational and supportive interventions at eachappointment.POLL: ON AVERAGE, FOR PATIENTS WITH WEIGHT PROBLEMS, I DEVOTEMINUTES PER VISIT TO MOTIVATING THEM TO LOSE WEIGHT.1. Less than 1 minute 22% (31 votes)2. 2 minutes 22% (32 votes)3. 5 minutes 33% (47 votes)4. 10 minutes 13% (19 votes)5. Greater than 10 minutes 10% (15 votes)Total votes: 144MOTIVATIONAL INTERVIEWING STEPSBrief Counseling Protocol Step: Use the four steps of Motivational Interviewing to facilitateadvancements in the stages of change as needed.FOUR BASIC STEPS ARE FOLLOWED IN MOTIVATIONAL INTERVIEWING:1.2.3.4.Engaging – Gain the patient's trust and interest in making a changeFocusing – Help the patient focus on the problemEliciting – Use questions to guide the patient in stating feelings and goalsPlanning – Facilitate the patient in establishing a plan for achieving the goals(Miller & Rollnick, 2012)The cases in this module illustrate how these steps are achieved. A variety of counseling skills areused to motivate patients to change behavior patterns and take actions needed to lose weight.DID YOU KNOW?Motivational interviewing is most useful after initial screening for overweight/obesity and beforemaking any recommendations (Rounsaville, 2002).Page 6 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangePATIENT-CENTERED APPROACHIn a patient-centered, motivational approach, the provider guides the patient rather than tells thepatient. These non-directive approaches differ from advice-giving (directive) by healthcareprofessionals. Instead, the healthcare provider recognizes the expertise of the patient on his or herown motivations. The provider is only somewhat directive as they guide the patient to examine andresolve any ambivalence about the problem (Miller & Rollnick, 2012).Guiding: A little directing is still needed in this approach, but it takes the form of facilitationand guidance. Guide patients toward being introspective, discuss certain topics that are likelyto lead toward readiness for change and resolve any ambivalence about it. Use gentle,guiding questions to direct. Non-Directive or Patient-Centered: Be non-directive or patient-centered by allowing patientsto come up with their own motivations, goals, and ambivalent feelings surrounding theirproblem behaviors. They can even develop their own plan to resolve their problems. (Miller & Rollnick, 2012)Does a Non-Directive Approach Work for All Patients?A directive, motivational approach may not work for every individual. Some patients may do betterwith more guidance. In some cultures, people may prefer to receive advice from an authority figurerather than participate in decision-making. However, the stage of acculturation varies amongindividuals who have moved into a culture that is new to them. Assumptions about preferences basedon ethnicity or race may not be accurate for a particular individual.The same interventions work for all racial-ethnic groups. At the same time, differences in individualneeds due to cultural, ethnic, and racial differences should be elicited from the patient and addressed(Miller & Rollnick, 2012).PATIENT-CENTERED EXAMPLESThe following table compares a more authority-centered approach with a more patient-centeredapproach, as is used in Motivational Interviewing. A patient-centered approach uses a skillful blend ofa non-directive counseling plus guidance when needed.Authority-CenteredPatient-CenteredDoctor: "I'd like to work with you to figure outDoctor: "I can tell you what works for weight loss." what's behind your recent weight gain so that wecan better figure out a plan to address it."Doctor: "Because of your risk for developingdiabetes, you need to reduce the amount of fastfood you eat."Doctor: "Reducing your fast food intake wouldlikely reduce your risk for developing diabetes.Can we talk some about that?"Doctor: "You need to get more exercise."Doctor: "So, you're telling me that you'reunhappy with your weight, but you don't havetime to exercise."Doctor: "I want you to add 3 servings ofvegetables a day and check back with me in 90Doctor: "We have identified low vegetable intakeas a problem area in your eating habits. What'sPage 7 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle Changeone thing you can do in the next 90 days toimprove your diet?"days."Doctor: "You need to lose 15 pounds. I will havemy assistant give you a copy of the weight-lossdiet plan I want you to follow."(Miller & Rollnick, 2012)Doctor: "I noticed that you've been gainingweight over the past few years. Can we talkabout that?"PRACTICE TIPBe sincere: As you use these techniques, be sure to stay connected to the patient and their struggleswith sincerity and respect. Patients are often very astute about when a technique is being used "on"them and resent condescension.CASE #1: MS. CAMPBELLThe following case will show how obesity can be brought up and briefly addressed using the firstseveral steps of motivational interviewing. This approach is comfortable and supportive of the patient.The scenario takes place during a patient encounter to evaluate several obesity-relatedcomorbidities.Case ScenarioPatient Name: Mary Campbell Age: 70 y/oHeight: 5'3” Weight: 193 lbs BMI: 34.2 kg/m2 Waist: 40"BP: 125/83 Pulse: 88 Respiration: 20/minChief Complaint: Diabetes check-up, also experiencing ankle and knee painHistory of Present Illness: Long-standing history of type 2 diabetes. Chronic,moderate ankle and knee pain, moderately well controlled with naproxenMedical History: Type 2 diabetes mellitus, dyslipidemia, hypertension (treated), incontinence, andosteoarthritis, especially in knees. Gained 10 lbs since the last visit 6 months ago. Insufficientlymotivated to follow recommendations for weight loss. Has low confidence due to previous failedattempts at weight loss.Medications: HCTZ (hypertension), naproxen (ankle and knee pain).Weight History: Lost 30 lbs last year but is starting to regain it. Diet: Admits to loving sodas and junkfood too much and using them to heighten low moods.Physical Activity Level: Insufficiently active, no exercise of moderate intensity. (Attributed by thepatient to advanced age and health problems).Weight-Related Diagnoses: E66.9 Obesity, unspecified; E65 Localized Adiposity (Central)CASE OBJECTIVESThis case will cover the following objectives: Follow the basic steps of motivational interviewing when counseling adult patients on weightloss in primary care.Page 8 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangeApply motivational interviewing techniques when counseling adult patients on weight loss inprimary care. Tailor counseling of adult patients on weight loss in primary care to meet individual needs. Respond effectively to common challenges that are faced when trying to motivate primary carepatients to lose weight. QUIZ: TALKING ABOUT WEIGHTMs. CampbellQuestion: After building a rapport with Ms. Campbell, by asking about her familyand congratulating her on good glycemic control, the provider next wants to focusthe interview on her weight. Which of the following is the best choice, using aMotivational Interviewing approach, to start talking about weight with Ms. Campbell?Choose one1. In order for me to treat your ankle and knee pain, we have to talk about your weight. Feedback: This statement is very directive. It does not elicit Ms. Campbell's permission to talkabout a potentially sensitive subject and sets her up to be wrong if she does not agreeto the discussion.2. I am sorry to hear that you are still experiencing ankle and knee pain, even with medication.One thing that would be likely to help is weight loss. With your approval, I'd like to talk aboutyour weight. Feedback: Using the current health concern as the context for bringing up weight is an excellentapproach.3. Your family cares about you a lot. Therefore, I think they would want you to improve yourhealth by losing weight. Feedback: This statement could be interpreted as the provider placing guilt on Ms. Campbell. Itimposes the provider's motivation on Ms. Campbell, rather than eliciting hermotivations.4. While your glycemic control has been good, losing weight would further improve it. Feedback: This statement does again acknowledge Ms. Campbell's success in achieving goodglycemic control. However, it is directive and does not elicit permission from Ms.Campbell to talk about weight, nor does it elicit her point of view.5. I know weight is a sensitive topic, but you are obese and we have to address that issue. Feedback: This approach labels her as obese rather than saying, "You have a diagnosis of obesityor your body mass is in the obese range, meaning it puts you at risk for healthproblems".Page 9 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangeEMPATHY AND AFFIRMATIONSThe use of empathy and affirmations in patient interviews is important in gaining patient connectionand trust. These skills are useful in several steps of the motivational technique.EmpathyDEFINITION Expressing an understanding of things as the patient feels sees and thinks about them(Rollnick et al., 2008). Empathy is also communicated through an expression of caring in your eyes,facial expression, tone of voice, and body language.Rationale: When people feel empathy from someone, they feel understood and validated (Rollnick etal., 2008). When patients experience empathy from a provider, they are more likely to open up to theprovider and to their own experience. They will be more comfortable examining their ambivalence, forexample, about making a lifestyle change to lose weight. They will also be more open to gentlechallenges from the provider.AffirmationsDEFINITION A supportive statement made by the provider in response to what a patient has said thatverifies and acknowledges the patient's attempts to change their behavior (Miller & Rollnick, 2012).Rationale: Failure to achieve weight loss goals can lead to a downward spiral of confidence and selfesteem accompanied by weight gain (Miller & Rollnick, 2012). A pattern of weight cycling up anddown often results. This can be frustrating for both the clinician and the patient. Use of affirmationscan increase patients' confidence in their ability to make healthy changes. These statements showthat the provider recognizes patient strengths, efforts, and successes in making the long-term changethat is needed.EXAMPLE OF EMPATHY AND AFFIRMATIONSMs. Campbell responded positively to the provider's question regarding a discussionconcerning her weight.Provider: I appreciate that you are interested in talking with me about weight and your health.[Affirmation] Please tell me more about your concerns.Ms. Campbell: I try to exercise, but when my arthritis is flaring up, I can't on some days.Provider: I can see how this must be hard. [Expressing empathy] But you still try, which is a personalstrength. [Affirmation statement] That is something that will help you in other important ways in aweight-loss program.When To Use These SkillsEmpathy and affirmations are especially helpful early in the Engaging step. This is when you aretrying to connect with the patient and gain their trust and interest in making a change.Connecting with the patient is also important later in the patient interview during the Eliciting step.This is when you guide the patient in stating their thoughts and feelings.Page 10 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangeNORMALIZING AND REASSURANCENormalizingDEFINITION Communicating that the patient's experience or feelings are typical of many people.Rationale: "Normalizing" helps communicate to patients that they are not alone in their experienceand struggles, including feelings of ambivalence and resistance to change. Normalizing helpspatients understand that many people have difficulty changing their behaviors and beliefs (Westra,2012).ReassuranceDEFINITION Communicating that a situation is safe or a that a positive outcome is likely.Rationale: Reassurance that other patients have succeeded despite similar difficulties or feelings ofambivalence helps patients believe that they can succeed, thus building confidence.EXAMPLES OF NORMALIZATION AND REASSURANCEMs. Campbell: Last time you told me I'd have to exercise to maintain myweight loss. I used to like to walk, but not so much anymore. It's a bit of a strugglewith my knees and when I'm feeling down.Provider: That does sound difficult [Empathy]. I can see how being active ischallenging with your knee pain. And many people struggle with being active when they feeldepressed [Normalizing]. There may be some ways to help [Reassurance]. [Proceeds with a quickdepression screening (negative) and discusses the use of a cane and a physical therapy referral.]When To Use These SkillsNormalizing and reassurance are especially helpful early in the patient interview in the Engagingstep. These skills help when you are trying to connect with the patient and gain their trust and interestin making a change.Connecting with the patient is also important later in the Eliciting step when you guide the patient instating their thoughts and feelings.OPEN-ENDED QUESTIONSUse Open-Ended QuestionsDEFINITION Those that cannot be answered "yes" or "no."Rationale: Open-ended questions require the patient to start the process of self-examination (Miller &Rollnick, 2012). They build momentum that can be used to explore issues that may lead to behaviorchange. For example — "What do you mean by that exactly?" "What ideas do you have?"In contrast, closed-ended questions, those that lead to "yes" or "no" answers or very brief answers,do not encourage much introspection. — For example: "How many times did you eat fast food thisweek?" or "Did you have success with your exercise plan since I last saw you?" Closed-endedquestions can be conversation stoppers.Page 11 of 40June 14, 2018 Update - Motivating Patients to Lose Weightwww.obesity.ClinicalEncounters.com

Motivating Patients & Lifestyle ChangeEXAMPLE OF OPEN-ENDED QUESTIONS[After attending to Ms. Campbell's blood pressure, dyslipidemia, and osteoarthritis, herweight is addressed:]Provider: What do you think has contributed to your weight gain these past fewmonths? [Asking an open-e

their patients lose weight (Pollak et al., 2007). Use of motivational interviewing by physicians with obese patients was associated with a reduction in body mass, body weight, BMI (Armstrong et al., 2011), and positive intentions and behavioral changes, such as motivation to lose weight (Jay et al. 2009).

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