More than one third of U.S. adults are obese.1 The estimated medical cost of obesity in 2008 was $147 billion, with the medical costs for people who are obese being $1,429 higher than the costs for those of normal weight.2 Despite these statistics and a high rate of obesity that has not changed for more than a decade, physicians continue to struggle with speaking constructively with patients about weight.
Motivational interviewing is a collaborative conversation style that can strengthen a person's own motivation and commitment to change.3 In skillful hands, this tool can encourage patients to make behavioral changes they previously have been ambivalent about or have found difficult by linking the changes to the things most important to them. But even without proficiency, family physicians, with time and by leveraging the longitudinal relationship they often have with their patients, can learn, adapt, and use skills from motivational interviewing to support changes toward healthy eating and active living necessary to achieving and maintaining healthy weight.4
This article describes six key skills adapted from motivational interviewing and the evidence on which it is based. An annotated transcript of a discussion between a physician and patient illustrates key concepts. To improve conversations with patients about obesity and healthy weight, you may wish to incorporate some or all of these ideas:
Share the agenda,
Raise the issue,
Be respectful and express empathy,
Build on what you hear (Ask-Tell-Ask),
Cultivate change talk,
Guide toward a specific plan.
Share the agenda
Many family physicians were trained to focus visits on the patient's chief complaint. Some practices limit visits to a single issue or problem suggested by the patient, and others attempt to gather and address the patient's full list of concerns at each visit. It is assumed that physicians will also address important but unrelated issues such as abnormal laboratory results and age-appropriate screening as needed at any visit. But without a clear plan of what issues will be discussed and how they will be prioritized, encounters can become chaotic and not effectively meet the expectations of physicians or patients. Developing a shared agenda can help.
Sharing the agenda is straight-forward. After greeting the patient, the physician can ask open-ended questions to begin mapping the plan. Some physicians find it helpful to mention how much time they have.
An example will help to illustrate this and other concepts described in the article. Mrs. Jones is a 55-year-old female who is well known to the physician and followed for high blood pressure, glucose intolerance, and obesity with a body mass index (BMI) of 32 and waist-to-hip ratio of 0.95. She is scheduled for a 15-minute appointment, primarily to check her blood pressure. Her vital signs are unremarkable with a blood pressure of 128/82. She has gained three pounds over the last three months and seven pounds over the last year. An A1C drawn last week is 6.3 percent.
|Physician||“Hi, Mrs. Jones! It is good to see you!”||Greet the patient.|
|Mrs. Jones||“Good to see you too, doctor.”|
|Physician||“How would you like to spend our time together today?” OR “We have about 15 minutes today. How would it be best to spend our time together?”||Ask an open-ended question with or without time specification.|
When the patient answers with a specific problem, simply ask “What else?” until the patient runs out of topics.
|Mrs. Jones||“Well, I wanted to ask you about my knee. It is hurting whenever I do anything!”||Patient expresses her concern.|
|Physician||“OK, we can definitely talk more about your knee. What else?”||Don't begin assessment of the first problem until the patient's concerns have been fully surfaced and catalogued.|
|Mrs. Jones||“Well, I also want to know what you think of my blood pressure. I think it is good!”|
|Physician||“OK, so your knee and blood pressure. Anything else?”||Summarize what you heard so far, and ask again.|
|Mrs. Jones||“Oh, and I did get some blood drawn. We should talk about that too.”|
|Physician||“OK, your knee, blood pressure, and the lab results from last week. Anything else?”|
|Mrs. Jones||“No, I think that's everything!”|
If there are too many topics to cover within the allotted time, tell the patient and negotiate what will be addressed today and what should wait. Allowing the patient to prioritize is optimal, but your clinical judgment should ensure that anything pressing is included in today's discussion.
There are many benefits to sharing the agenda: The patient and physician can agree where to focus and what is important to both sides; the patient feels respected and listened to; the visit is more likely to stay on track because of mutual agreement up front; and fewer “oh by the way” additions are likely when wrapping up the visit.
Raise the issue
In sharing the agenda, discussions of weight typically should be prioritized. A 2011 poll found that 19 percent of morbidly obese respondents (BMI of 35.0 or greater), 46 percent of obese respondents (BMI between 30.0 and 34.99), and 72 percent of overweight but not obese respondents (BMI between 25.0 and 29.99) said that their physicians had never told them to lose weight.5 Those numbers are largely unchanged from a 2000 study.6 The implications of unhealthy weight present every day. Physicians may avoid the topic because it is a sensitive issue for patients, they lack the skills to comfortably have the conversation, they think having conversations about weight loss with certain patients are futile, or they believe they lack the time. Others may have an unconscious bias against people who are obese that interferes with treatment. Focusing on skills that make these conversations more constructive can help physicians gain the confidence to raise this important issue.
|Physician||“OK. I have a concern to add to our conversation as well. Would that be OK? I want to talk about a trend I noticed with your weight. So where should we start?”||The physician likely wanted to discuss the blood pressure and lab results as well. But weight is added as a clinical concern. Asking permission is respectful and further engages the patient despite the sensitive topic. Finally, the patient is given the option to prioritize the agenda.|
|Mrs. Jones||“Well, my knee is giving me a fit when I walk! So let's start there. You mentioned my weight, and I think it is a problem because everything I do makes my knee hurt so I can't do anything but eat!”||Often when you raise the issue of weight patients will begin to think about it even though they may not want to tackle it first.|
A problem-specific history and physical is completed. The physician explains that the symptoms and exam are consistent with osteoarthritis and deconditioning. After discussing the options, Mrs. Jones agrees to a standing x-ray to confirm the diagnosis. Acetaminophen is recommended for pain. A more comprehensive treatment program will be discussed once the diagnosis is confirmed.
|Physician||“I think the topics of increasing weight, high blood pressure, and the trouble with the glucose in your blood are related. Would it be OK if we talked about those together?”||Having addressed the patient's first priority, the physician moves to the next items on the agenda. Because they are related, they can be integrated. If they were not related, the patient could be asked which item to discuss next.|
Be respectful and express empathy
Maintaining a healthy weight can positively benefit many clinical issues, so you should regularly make it a priority to discuss what benefits even modest weight loss can produce, but it is important to do so with respect and empathy. Most overweight and obese patients have lost tens if not hundreds of pounds. It is not as though they do not wish to be healthy or don't care. However, for many, achieving and maintaining a healthy weight is truly challenging. We as physicians understand the negative effects of weight on health and are frustrated when we cannot “fix it.” But it is helpful if we respect the patient's perspective and express empathy, not impatience or frustration. How you raise the issue can either set the stage or sabotage the best of intentions. A good approach is simply to ask and use the answers to help understand what is on the patient's mind.
|Physician||“What do you understand about how your weight affects your health?”||Ask an open-ended question that elicits the patient's perspective.|
|Mrs. Jones||“I know how important it is for me to lose weight, but nothing I have tried has worked for long!”||Physicians are trained to listen for problems and may hear “nothing worked.” Instead, focus on the importance of weight loss.|
|Mrs. Jones||“I know my weight makes my sugar go up too. It is so frustrating that I cannot get this under control.”||This response again indicates that the patient understands the importance of weight loss, and the idea of gaining control is raised by the patient.|
|Physician||“I can see how challenging this is for you. You understand a lot about how weight is related to your health, and you really want to be in more control. Would it be OK if we talk about some ways that we could work together on this?”||Empathize with the patient's struggle. Don't jump in with suggestions or advice, but rather seek partnership with the patient to move forward.|
|Mrs. Jones||“I would really appreciate that!”|
Remember to let patients tell their story. According to one study, physicians interrupt their patients an average of 23 seconds into discussing their initial concern.7 Patients allowed to completely state their concerns used only 6 seconds more on average than those who were redirected before completion. Listening for a minute or two is well worth what is gained to better understand your patient's thinking.
After the patient has told his or her story, resist the temptation to simply reiterate that excess weight is making medical conditions worse or lecture the patient about the benefits of weight loss. Even though well intended, making unsolicited suggestions about what patients should do is disempowering and rarely works. It is an example of our “righting reflex,” our desire to fix or solve the problem. Instead, express your support and actively partner with the patient.
Build on what you hear (Ask-Tell-Ask)
Rather than making assumptions about what type of support the patient will find most helpful, acknowledge what he or she has told you and ask permission to explore the topic further.
|Physician||“You have been successful at losing weight in the past, right? What has worked for you before?”||Asking the patient to discuss a past success is one way to discover patient strengths.|
|Mrs. Jones||“Well, I lost weight a few times just by eating fewer carbs. I was able to do a lot more walking and working in the garden and playing with Gracie, my granddaughter. But then I started having problems with my knee, and I couldn't move around as well and started to eat more.”||Besides describing what worked in the past, the patient may also tell you what caused weight loss to stop.|
|Physician||“OK, let me recap what I think I heard. When your knee started to hurt, you slowed down your activities and the weight came back – in fact you gained even more. Until then, you were able to lose weight several times by cutting back on bread and pasta. You found you had more energy and were able to do more walking and gardening. Your granddaughter even noticed that you played more with her! Did I get that right?”||Summarize what you've heard. Emphasize what worked, acknowledging that the patient was frustrated when the weight loss stopped and that healthier weight appears to be important to him or her. This shows that you have been listening, summarizes the reasons for change, and highlights past success. Notice that this summary ended on the weight loss benefits that Mrs. Jones described. Patients most often will respond to what they hear last.|
|Mrs. Jones||“Oh yes! Gracie and I had the best time! We even flew a kite together. She loved it!”|
|Physician||“Playing with Gracie is fun and really important to you!”||Acknowledge the enthusiasm, and mirror the patient's emotion. This links the conversation with a value the patient holds dear.|
After identifying one reason that truly motivates the patient to lose weight, you can transition to next steps. One approach is to give information to the patient in a format called “Ask-Tell-Ask.” (See “How Ask-Tell-Ask works in motivational interviewing.”)
HOW ASK-TELL-ASK WORKS IN MOTIVATIONAL INTERVIEWING
|Ask permission to share information |
Ask what they know or want to know
|“Would it be OK if we talked about … ?”|
“What do you know about … ?”
“What would you most like to know about?”
|State information clearly and in small chunks||Make it pertinent|
Focus on one or two key messages
Use plain language
Use pictures and figures as appropriate
Avoid using “can't,” “must,” or “have to”
|Ask for feedback or check understanding||For feedback, ask:|
“What do you think of that?”
“How are you feeling about what I just talked about?”
For understanding, ask:
“I'd like to make sure I did a good job explaining. Would you mind describing what you will do so I know I was clear?”
This is also a great opportunity to explore expectations for weight loss and reframe them if needed. Reaching a high school dress size may not be feasible, but losing 5 percent to 10 percent of one's current weight might be. Even the idea of simply not gaining more weight can be woven into the “tell” part of “Ask-Tell-Ask” and could be important for the patient to hear.
|Physician||“We should talk about next steps. Would it be OK if we talked about your lab and blood pressure briefly first?”||“Ask.”|
|Physician||“You are right that your blood pressure is good today. I am concerned that your A1C is a bit higher than last year at 6.3 percent. That is even closer to diabetes range. We know that weight loss will benefit your glucose level as well as help that blood pressure stay in control.”||“Tell.” Information is given in a context important to the patient and linked to weight.|
|Physician||“How do you feel about what I just said?”||“Ask.”|
|Mrs. Jones||“Oh, I was afraid of that honestly. I knew gaining weight was bad. I am even more frustrated now! I have to get this under control.”||The patient voices frustration but also reasons to change.|
The purpose of “Ask-Tell-Ask” is really two-fold. First, a suggestion based on your expertise might appeal to a patient or give information not previously considered. Second, and perhaps more important, you are helping the patient explore the issue and begin to visualize a path forward. People most often make changes when they decide to, not because they were told.
Listen for and cultivate “change talk”
“Change talk” is what people say in favor of changing behavior. “Sustain talk” is speech that favors the status quo. People often use both types of speech in the same sentence. For example, “I know how important it is for me to lose weight” indicates that the patient has reasons for and perhaps a desire to change. The rest of the sentence, “but nothing I have tried has worked for long,” implies the patient will not try to change because it is too hard or she does not know how.
There is compelling evidence that people who use stronger change talk and use it more often are more likely to follow through with a change. The good news is that we can support this change talk. We want the patient to state his or her reasons and commitment to change, so our role is to encourage the patient to keep talking. People are more likely to be persuaded by what they hear themselves say.3
At the same time, we want to prevent patients from getting mired in sustain talk. Although barriers and challenges are real, it is not helpful to discuss them at length. Studies indicate that sustain talk may be inversely proportional to change.8 Guiding the patient gently back to his or her values and strengths encourages the patient to explore how to move forward with change despite the hurdles. (See “OARS skills in motivational interviewing.”)
OARS SKILLS IN MOTIVATIONAL INTERVIEWING
The following techniques help to advance motivational interviewing.
Open-ended questions: Encourage the patient to think out loud.
Affirmations: Recognize the patient's strengths.
Reflections: Say back what you heard or what you thought was meant.
Summaries: Summarize key parts of a conversation to help keep the conversation going or to transition to new steps.
In our scenario, Mrs. Jones has just stated some reasons to change mixed with some frustration about past failures. Our goal is to strengthen the change talk (denoted in bold) and diminish the sustain talk (denoted in italics). Motivational interviewing skills will be helpful.
|Physician||“Yes, I am sure that was not news you wanted to hear. On the other hand, we agree that weight loss is a good idea. You know that it will help your health and allow you great times with Gracie. We can figure out together what might work best for you.”||Practice reflective listening with empathy, and emphasize your partnership.|
|Mrs. Jones||“Yes, I have to do something. I have lost weight before. It is just this darned knee.”||Change talk, sustain talk.|
|Physician||“Yes, you did a great job changing your diet and increasing your activity. Would it help if we talk about how some of my other patients with knee problems stay active?”||Acknowledge the patient's sustain talk, but move the conversation forward by beginning “Ask-Tell-Ask.”|
The physician describes activities including walking, swimming, and tai chi in the “tell” portion, adding that these would likely benefit her knee as well as increase activity – and that any weight loss would in turn help her knee. The physician then “asks” her what she thinks.
|Mrs. Jones||“I have heard about tai chi but have never tried it. I used to like to swim but hate the way I look in a bathing suit. I can walk, though, as long as I know I won't be causing further damage. I want to figure this out!”||Exploration, sustain talk, change talk.|
|Physician||“OK, it sounds as though you have some options to think about. That's great! If it is OK with you, we can talk more about the specifics once we get your x-ray back.”||Close the visit on a hopeful note with a bridge to the next encounter. It is premature to plan.|
Guide toward a specific plan
When the patient seems ready to make a change, you can suggest helping him or her create an action plan. That can be done during the same visit, over the phone, or at a follow-up visit.
You can preface the discussion by confirming the patient wants to take some next steps, explaining the benefits others have received from having a specific action plan, and asking if the patient wants to make one. If so, the plan should follow the SMART model – specific, measurable, achievable, relevant, and timed.
In our scenario, when Mrs. Jones returned for follow-up of her knee pain, she learned that the x-ray confirmed osteoarthritis and that gentle exercise would actually help.
|Physician||“Now that we know more about your knee, could we talk more about those options for exercise we discussed at your last visit?”|
|Mrs. Jones||“Well, I like to walk when the weather is nice like it is now.”|
|Physician||“It sounds as though you are ready to take some next steps. Many people find it helpful to make a specific plan about what they will do. Is that something you would be willing to do?”|
|Mrs. Jones||“OK. I guess I could do that.”|
|Physician||“If you were to decide to walk regularly, what would that look like for you?”||Resist the temptation to guide her. Let the patient tell you what she is thinking.|
|Mrs. Jones||“Well, I was thinking about walking around my neighborhood. There are some beautiful gardens!”|
|Physician||“You look pretty happy about that. How far do you think you might go?”||Guide toward as much specificity as seems natural.|
The physician leads the patient toward a SMART plan without making any suggestions. Mrs. Jones decides that she will walk three days a week, starting at about 20 minutes and trying to work up to 30 minutes each time. She plans to start tomorrow.
|Physician||“That sounds like a great plan. Just to make sure I am clear about what you plan to do, could you say your plan back to me?”||Having the patient repeat the plan provides another chance for the patient to say what he or she will do – and commit to it out loud.|
|Mrs. Jones||[Restates her plan.]|
|Physician||“Sometimes when people plan to make a change, it may be a bit daunting. On a scale of 0 to 10, where 0 is not at all confident and 10 is absolute certainty that you can do this, how would you rate your confidence to follow through on your plan?”||When patients state their plan, you may see their enthusiasm or that they are having second thoughts.|
|Mrs. Jones||“I think I am about a 5.”|
|Physician||“That is a lot of confidence! What makes you a 5 instead of a 2 or 3?”||Try not to look disappointed if the patient expresses a lack of confidence. Ask about the confidence level in a way that encourages the patient to talk about his or her strengths, not his or her barriers.|
|Mrs. Jones||“Well, I really want to do what is best for my health. But, honestly I am worried about wearing myself out. I haven't done much walking lately.”|
|Physician||“I can see how important it is to you to be as healthy as you can be. We know that people are more likely to be successful following through with their plan when their confidence is 7 or above. What do you think you could do to raise your confidence a bit more?”||Reflect the change talk and sidestep the barriers. Explain why the confidence level is important, and invite the patient to think about how to enhance his or her confidence.|
|Mrs. Jones||“Well, I think I would feel better about starting out for just 10 minutes. Would that be OK?”||Patients may try to create plans that are not realistic because they want to please us. Resist the urge to give your permission.|
|Physician||“You really know yourself. That's great. With that change in your plan, what do you think your confidence level would be?”||This is the patient's plan, so affirm her thinking and her autonomy. Then check back with her confidence.|
|Mrs. Jones||“I think I could do 10 minutes. I'm sure I can. And I am determined to work my way up to longer walks.”|
|Physician||“You are really committed! Walking will really benefit your health, and I look forward to talking with you about how things are going at your next visit.”|
The physician ends the visit by talking with Mrs. Jones about arranging a check in, which helps provide some additional accountability and contributes to success. She agrees to check in with her husband in two weeks to talk about how it is going, putting the date in her calendar.
You may be accustomed to setting self-management goals or action plans with patients. But if time is a factor, other staff can fulfill this role. There is no one way to create action plans (for options, see http://bit.ly/2aYDkLY), but there are resources available to help ensure the plan is patient-directed and more likely to be followed. (See “Resources.”)
Rollnick S, Miller WR. Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: The Guilford Press; 2012.
Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: The Guilford Press; 2008.
Rosengren DB. Building Motivational Interviewing Skills: A Practitioner Workbook. New York, NY: The Guilford Press; 2009.
For many physicians, motivational interviewing is interesting, but they question how to fit it into their already constrained visits. Actually, this is just a different way of doing what we already do: providing medical care. Think of these skills as an evidence-based approach to behavior change with proven efficacy. The same techniques described in this article could be used to motivate behavior change related to chronic illness, prevention, addiction, and other challenges.
Many physicians who adopt these skills find that it just takes practice and time to convey these ideas in their own style. But using skills based on motivational interviewing is well worth the effort.