Motivational Interviewing
for Weight Loss &
Exercise
Frank J. Domino, M.D.
Professor
Frank.domino@umassmemorial.org
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
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!!!!”

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 nonconfrontational.
Behavioral Problems
Addressed by MI
• Lifestyle
• Chemical dependency
• Non-adherence to treatment
• Miscellaneous risky or unsafe behaviors
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.
Efficacy of MI in Obesity &
Exercise
 Improved weight control program 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 activity and exercise energy
expenditure among cardiac rehabilitation patients
Scales R, Miller JH. Current Sports Medicine Reports. 2003;2:166-72. Bowen
Efficacy of MI in Habits
 Increased fruit & vegetable consumption
Bowen et al. 2002; Resnicow et al. Am J Pub Health. 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.
Motivational Interviewing
1.
2.
3.
4.
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
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

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
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




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
OARS
Open-Ended Questions
“Would you like to lose weight?”
Vs.
How do you feel about your weight?
Open-Ended Questions
“How much ice cream do you eat?”
Vs
“Please tell me more about what
you eat for dessert?”
OARS
Affirmations
Support
the patient
Convey respect &
understanding
Help patients reveal less positive
aspects of themselves
Affirmations (continued)
“Dealing
with weight issues is difficult”
“You have worked so hard.”
“I can understand why eating feels good
to you.”
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”
Reflective Listening
“My boyfriend gets really angry
when I eat French fries.”
You respond:
“So, he gets mad when you eat
French Fries”
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”
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..”
Brief MI in 5 Steps
1.
2.
4.
Establish rapport & Elicit Change Talk:
OARS

Open questions

Affirmations

Reflections

Summarize
Develop Discrepancy to Facilitate
change talk using Rulers
3.
Offer advice
End the interview with a summary and
plan
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?
Discrepancy Rulers
Important
1
5
10
Confident
1
5
10
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”
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”
Brief MI in 5 Steps
1.
2.
4.
Establish rapport & Initiate Discussion:
OARS

Open questions

Affirmations

Reflections

Summarize
Develop Discrepancy to Facilitate change
talk using Rulers
3.
Offer advice
End the interview with a summary
and plan
3.
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…”
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
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?”
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
Summary
MI in 5 Steps
1.
2.
Establish rapport & Elicit Change Talk:
OARS

Open questions

Affirmations

Reflections

Summarize
Develop Discrepancy to Facilitate change
talk using Rulers
3.
Offer advice
4.
End the interview with a plan
“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
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
“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
What about the average person?
Daily Practices

Survey 2004 US > 18 Yrs. “Successful
Weight Loss Maintainers”
1.
Eat Fast Food < 2/Week
> 5 Fruits & Vegetables/day ** AND
150 Minutes physical activity (25 Min/Day)
2.
3.
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
 Eating Quickly
 Full & Quickly

2.00
1.84
3.13
1.84
2.09
3.21
Triple the odds !!!
BMJ 2008: 337: a2002
Eat Slowly and question if still wants more
First Some Basics Training
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

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.
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

US Recommended Dietary
Allowances
Males
Water
L/d
Carbohydrates(50%)
Protein (20%)
Fat (30%)
g/d
Fiber
25 g/d
4 L/d
280 g/d
110 g/d
75g/d
35 g/d
Females
3
190 g/d
75 g/d
50
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
The Label

Look at






serving size
saturated fat
dietary fiber
sugars
Glance at carbohydrate
Read ingredients (for
hydrogenated oils and
whole grains)
5 Steps to Healthy Diet
1.
2.
3.
4.
5.
Increase Fiber
Increase Water 16 Oz before meals
Prescribe Exercise
MINDFULLY Eat Calorie “hypodense”
foods
Limit Screen Time to < 10 Hr/week
1. Increase Fiber
24 Hour Dietary Recall
“Tell me everything you ate
and drank yesterday,
starting with breakfast.”
“Oh no, not yesterday!”
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
OK, Now
You Count
2. Water:
Rx: WATER for Children

32 Elementary Schools, 2nd/3rd Graders
(2950) children x 1 Yr
 “Socially Deprived areas” Germany
 Water Fountains + 4 lessons
 Overweight: Int=3.8% vs. 6.0%
 1.1 glasses/day more (220 ml)
Pedia 2009; 123(4): e661
Water Consumption and Dieting
for Adults
 RCT
over 12 weeks of adults
 Compared Low Calorie Diet vs. Low
Calorie Diet + 16 Oz water prior to
each meal
 44% RRR (~4.5 Lbs) greater weight
loss in Water group.
Obesity. 2010; 18(2): 300-7
Pre Meal water and all you can eat
Non Obese adults given 16 ounces water before ad
libitum lunch
 2 age groups: 21-35 and 60-80 years



Energy Intake and
hunger measured
Obesity (Silver Spring). 2007 Jan;15(1):93-9
Apples to Oranges…
Calories
1
Orange
 8 Oz OJ
 8 Oz Cola
 Coffee Black
2
 Coffee + 2 Sugar
 Coffee + 1 Oz Cream
 Staryucks Café Mocha 400
40
120
100
30
100
3. Prescribe… EXERCISE
6300 adults Observational Study
 Dx: Sed Lifestyle HTN, DM, OB, M/Skel
 “Inactive” Baseline = 33%

At 3 Months= 17%;
 At 12 Months = 20%

WALK
BMJ 2008: 337:a2084
Scandinavian Journal of Medicine and Science in
Sports, doi: 10.1111/j.1600-0838.2008.00820.x
How Much and What Kind of Exercise????
 No
one knows what is ideal for weight loss.
 For
CHD:
30-50 Min Aerobic exercise 5 days/week.
 For

Weight loss:
Aerobic + Weight training 5 days per week
 No
“after exercise treat”
Why bother?
Weight
loss
Reduced cardiovascular and all-cause mortality
Cognitive benefits.
Anxiolytic effects of exercise: a meta-analysis
J Sports & Exer Psychol. 2008 Aug; 30(f):392-410
Improved quality of life (RCT)
Martin , Exercise dose and quality of life. Arch Int
Med. 2009;169(3):269-78.
The
cost of NOT exercising: the STRRIDE trial
We are health role models
Warburton DE Health benefits of physical activity: the
evidence. CMAJ. 2006;174(6):801-9.
STRRIDE Study:
Cost of NOT exercising







RCT, 4 groups
INTERVENTION:
Low amount/Mod intensity,
Low amount/Vigorous intensity,
High amount/Vigorous
Low/High: 120 min vs 200 min
Intensity: Moderate 40-55% V02 max, High 65-80%

Non-exercisers: +1% body weight, +8.6% visceral fat in
6 months!
Exercisers: -1-2% body weight, no change/-7% visc. Fat

Slentz CA, STRRIDE; J Appl Physiol. 2005;99:1613-8.
1. Exercise efficiently
2. Keep your lifestyle active
3. Incorporate resistance training
Exercising efficiently: Interval
training and “threshold”

HIIT as a health
promotion strategy
Gibala, MJ. High-intensity interval training:
a time efficient strategy for health
promotion? Curr Sports Med Reports.
2007;6:211-3.

HIIT training
increases aerobic and
anaerobic capacity
Tabata I, Nishimura K, et al. Effects of
moderate-intensity endurance and
high-intensity intermittant training on
anaerobic capacity and V02 max. Med
Sci Sports Exerc. 1996;28(10):1327-30
http://www.xiser.com/store/pdf/Sprint_In
terval_Training.pdf
2. Keep lifestyle active
Lifestyle Importance
DESIGN: 16 week RCT in 40 obese women,
both observing similar diet, 16 wk and 1 yr
follow up
INTERVENTION: structured aerobic activity
or moderate lifestyle activity
OUTCOME MEASURES: body weight and
composition changes, cardiovascular risk
profile, physical fitness
RESULTS: at 1 year, equivalent reductions in
triglycerides, LDL, HDL, resting DBP;
lifestyle group had significantly greater
3. Incorporate resistance training
How does resistance training provide
lasting benefits?
Muscle mass as a “metabolic sink”
 Increased insulin sensitivity
 Decreased HbA1c (0.5%-1.0%)
Maintain muscle mass lost with age (1 lb/yr after 50)
Increased strength (falls in the elderly!)
Increased basal metabolism beyond expected with adding
muscle (21 kcal/kg vs 28-218 kcal/kg)
Reduced visceral fat on par with aerobic exercise
Increased bone mineral density
Recommend: single set of 8-10 reps covering major
muscle groups min 2x/week
Braith RW Circulation. 2006;113:2642-50.
How little is “enough”?

Simple answer: whatever you can fit into your
day, anything is better than nothing

Better answer: Review of observational cohort
studies of exercise and reduction in all-cause
mortality

1000 kcal/week associated with 20-30% risk
reduction
Haennel RG and Lemire F. Physical activity to prevent cardiovascular disease: How much is enough? Can
Fam Physician. 2002;48:65-71.
Fitness is more important than fatness
I was short, fat and bald when I started running, but after running nearly every day for more
than 30 years and covering about 70,000 miles...I am still short, fat, and bald. But I
suspect I'm in much better shape than I'd be if I didn't run. – Steve Blair
METHODS: 58 sedentary obese men and women, 12 wk supervised aerobic exercise (500
kcal, 70% max HR, 5 times/wk)
OUTCOME MEASURES: body composition, aerobic capacity, BP, psychological response
score, measured at weeks 0 and 12
RESULTS: 26/58 had less than predicted weight loss, but all had significantly increased
aerobic capacity and positive mood, decreased SBP/DBP, waist circumference, resting
HR
 The concept of exercise “nonresponder”
 No association between weight loss and improvements in health markers
King NA, Hopkins M, et al. Beneficial effects of exercise: shifting the focus from body weight
to other markers of health. Br J Sports Med. 2009;43:924-7.
Workout to recommend


Warm-up
HIIT



20 seconds on/10 seconds off
8 sets
Resistance training



Turkish getup
Kettlebell swing
Squat jumps
4.
Mindfully eating Calorie Hypodense foods

 Most
Increase in awareness of Eating
important part of long term weight
loss and maintenance

Divide Plate in Half before eating, and at ½
point, ask “Am I still Hungry?”

Eat at table, not TV or paper
Hypodense Foods:
Volumetrics
People eat a constant weight of food each day.
 Volumetrics: ↓calories but maintain volume.
Energy Density categories:
Very low (<0.6): fruit and vegetables
Low (0.6-1.5): cereal, cottage cheese, ham
Medium (1.5-4.0): eggs, bagels, bread products
High (>4.0): cookies, salty snacks, nuts, candy bars
 Select foods high in water content, low in fat:
fruit, vegetables, soups.

Rolls, BJ et al. Am J Clin Nutr
1999;69:863-871
5. Limit Screen Time
Pediatric & Adolescent Literature
 > 10 hrs/week ↑ Risk of Obesity & T2DM
 Journal of Public Health 2008 30(2):153-160


Changing Sedentary to Active Screen Time  Weight
Loss
PEDIATRICS; 2006. 118(6) e1831-e1835
Eat Together, Get to Bed, & Turn off that
TV…
Cross Sectional analysis of 8550 US Children
 18% Children Obese (BMI >/= 95th percentile)


Association of childhood obesity & 3 routines:
 Eating as a family > 5 nights/week
 Obtaining adequate sleep (>/= 10.5 hr/night)
 Limit Screen time (TV, Video, DVD) </= 2 Hr/day
Habits to Encourage
Dinner w/Family 5/wk
Adequate Sleep (10.5 hr)
Limiting Screen Time (<2 Hr)
Obesity
Children exposed all 3
14.3%
Children exposed to none 24.5%
Pediatrics 2010; 125: 420-28
Other things to consider…



Calcium: Calcium is needed for fecal fat excretion.
Sstematic review found supplementation of about
1,200 mg of calcium per day leads to an increase in
fecal fat excretion. Obes Rev 2009; 10(4): 475-86
Sleep: A small pilot study compared a low calorie
diet w/either 5.5 hours of sleep vs 8.5 hours over
14 days. 8.5 hr had greater weight loss of body fat,
and less hunger. The authors postulate it was due to
the neuroendocrine changes decreased sleep
induces. Ann Intern Med 2010; 153: 435-441
Chronic PPIs: Case control study obesity
developed in patients with GERD who were treated
chronically with PPIs vs other treatments World J
PPI’s: What to do??






Moderate-Severe: PPI x 8 weeks, then Step
Down
Mild: H2RA for 8 weeks, then prn
Step Down:
Double dose for 1 month, then Q Day for one
month, then PRN
Carry Antacid
LIFESTYLE: BEST EVIDENCE: Sleep Left
Simple
Approach
Simple
Rule:
Drugs: Looking to 2011…..

Orlistat: (Xenical) Inhibits Pancreatic Lipase ->↓
Intestinal Fat Absorption


Sibutramine (Meridia): may reduce appetite


14% over 56 weeks
Contrave: (bupropion 360 + naltrexone 32mg)


(24 Kg x 1 Yr; no better than placebo; x = 9 lbs)
Qnexa: (phentermine 15 + topiramate 92 mg)


6.5 lbs x 12 months
5-7% BW over 24 weeks
Locaserin: Serotonin antagonist
What are your favorite hints?
SUMMARY
Steps to Healthy Diet
1.
2.
3.
4.
5.
Increase Fiber: 24 Dietary Recall
Increase Water 16 Oz before meals
Prescribe Exercise
MINDFULLY Eat Calorie
“hypodense” foods
Limit Screen Time to < 10 Hr/week
Summary: The Other Stuff




Get Adequate Sleep
Get RID of the PPI’s
Add Calcium
Lifestyle, not “diet”