IOv2Motivating-1- Motivating Patients To Lose Weight

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).