Physicians can use motivational interviewing and proven dietary recommendations to help patients lose weight.
Although the cardiovascular and other health benefits associated with weight loss are well known, many patients still struggle to implement the dietary and lifestyle changes that are necessary to lose weight. Family physicians can play an important part in counseling their patients about the benefits of maintaining a healthy weight. During his presentation, “Words Work! Motivational Interviewing for Healthy Lifestyles” Thursday at the 2010 AAFP Scientific Assembly, Frank J. Domino, MD, said that the technique known as motivational interviewing is a proven and easy-to-use method that physicians can implement to help their patients change their eating and exercise habits and lose weight.
Domino said that motivational interviewing is “a style of talking with people constructively about reducing health risks and changing behaviors,” that is “designed to enhance the patient’s own motivation to change.” He said that with motivational interviewing (MI), success is based on resolving the patient’s ambivalence to change. And getting patients to talk about their desire and need for positive, healthy change is the key. “People change when they hear their own ambivalence to change voiced,” Domino said.
Motivational interviewing involves four main steps; the first step is to establish a rapport with the patients elicit what Domino called “change talk,” which involves getting the patient to verbalize what they want to change, how, and why. Examples of change talk during conversations with patients about losing weight include getting the patient to express not only their desire to lose weight, but also to talk about their ability to do so, their reasons for wanting to change, and their commitment to doing so. Domino said that the goal is to have the patient express their own reasons for change. During these conversations, physicians should express empathy but avoid argumentation; “don’t correct the patient’s misbeliefs,” Domino said. Instead, physicians should “roll with the resistance put up by the patient.” Remember: ambivalence is necessary to motivate change.
Domino used the mnemonic OARS to describe the techniques that physicians can use during this first step: physicians should ask Open-ended questions; offer Affirmation by supporting the patient, conveying respect and understanding, and helping the patient reveal the less positive aspects of themselves that drive their desire for change; practice Reflective listening that facilitates further comment by restating the patient’s own words in a non-judgmental manner; and Summarize the information the patient has shared as the precursor to designating a “transition point” that opens up the conversation to the steps the patient can take to achieve his or her goals.
The second step in motivational interviewing is to “develop the discrepancy” between the patient’s ambivalence to change and their desire to change. Physicians can use what Domino referred to as “discrepancy rulers,” which are questions designed to help patients quantify their ambivalence and desire. He suggested asking the patient “On a scale of 1-10, how important is it to you to lose weight?” and then “develop discrepancy” by asking them “How confident are you in your ability to lose weight?”
The third and fourth steps in motivational interviewing involve offering non-specific advice to the patient in order to elicit from them suggestions on how they can achieve their goals, and developing an action plan based on the patient’s suggestions. Domino said that the plan should provide options for the patient and should always include follow up and short-term, easily attainable goals.
One of the main barriers to patients losing weight (and physicians’ ability to offer effective advice) is that there is so much misinformation out there about food and nutrition. Domino said that additional barriers to nutritional counseling include the act that physicians are not well trained in doing this, there is substantial confusion over current guidelines (which use old data), the lack of time and compensation for nutritional counseling, the dearth of good data about the effectiveness of interventions, and confusion over the relationship between nutrition and disease.
Nonetheless, Domino said that there are several specific steps to a healthy diet that have been shown to be effective that physicians can recommend to their patients:
Increase the amount of fiber in their diet. Easiest way to do this is to eat more fruits and vegetables every day. Physicians can ask patients to count the number of fruit and vegetable servings they have each day; the goal is 10 servings per day, which equals 25-30 grams of fiber. Patients should aim for a minimum of five servings per day (15 grams of fiber).
Increase their daily intake of water. Studies show that increased water intake prior to meals can lead to reduced caloric intake. Physicians should remind patients that juices, soft drinks, and other beverages are no substitute for water and can be hidden sources of calories.
Prescribe exercise. Physicians should literally write it down on a prescription pad. Domino said that although “nobody knows how much and what kind is ideal for weight loss,” 30-50 minutes of aerobic exercise five days a week is good for cardiovascular health; for weight loss, patients should do aerobic exercise and weight training five days a week. Patients should also forgo “after exercise” treats.
Mindfully eat calorie-hypodense foods. Patients’ increase in awareness of what they’re eating is the most important part of long-term weight loss and maintenance. Domino recommended counseling patients to “divide the food on their plate in half before eating and then, at the halfway point, ask themselves ‘Am I still hungry?’” Patients seeking to lose weight should be encouraged to eat low-calorie, high-volume foods (again, such as fruits and vegetables). They should also eat more foods that are high in water content and low in fat.
Limit TV and screen time. More than 10 hours of screen time per week raises the risk of obesity.
HCPLive wants to know:
What approaches do you take when counseling patients on the benefits of weight loss?In your experience, what has been harder: motivating patients to take the first step, or ensuring that they maintain progress?