Is Motivational Interviewing Key to Sustaining Weight Loss?

Lasting outcomes are often elusive in obesity treatment, and for decades, patients have been caught in an endless cycle of losing and regaining pounds. Enter the glucagon-like peptide-1 receptor agonists (GLP-1s), a new lifeline for (mostly) keeping the pounds at bay. Though they’ve proven highly effective for treating obesity, helping patients lose as much as 22% of their total weight, they are only one part of the puzzle and do not address other contributing factors, like biology and environment.

They also don’t directly support behavior change, which Kathryn Ilonka Pollak, PhD, a professor in population health sciences and associate director of Population Sciences in the Duke Cancer Institute in Durham, North Carolina, said is one root cause of the obesity epidemic.

Pollak noted that many clinicians might be surprised to learn that the onus for keeping off the pounds falls not on one, but on two shoulders. We live in an “explicitly size-ist” society, and that often includes doctors, she said.

“They make comments that are inadvertently stigmatizing or try to motivate patients with stigmatizing language,” she said.

This is where motivational interviewing (MI), or patient-centered counseling — a technique that centers and places the patient in charge — can yield lasting transformation, and even help physicians recapture the reasons why they entered medicine in the first place.

Flipping the Script

The whole idea is to talk to people “about change and growth to strengthen their own motivation and commitment; it’s really seeing the capabilities that patients have and supporting their self-efficacy,” said Carol DeFrancesco, RD, a Portland, Oregon–based researcher and member of the Motivational Interviewing Network of Trainers (MINT).

“It’s essentially very careful listening (ie, reflective listening) combined with compassion, and respect, and evoking from the patient their concerns, their goals and desires, and what they want to do about it,” she said.

The biggest thing is to form a collaborative relationship with the patient, and “try not to lecture (even though we know what the right answer is from a treatment perspective) and try to get buy-in,” added Angela Fitch, MD, an obesity medicine specialist and co-founder and chief medical officer of Knownwell Health, a primary care/metabolic health organization based in Needham, Massachusetts, and Dallas.

Toward that end, Robert Kushner, MD, obesity medicine specialist and a professor in the Departments of Medicine and Medical Education at Northwestern University in Chicago, said that the first step is careful (or reflective) listening.

Kushner recalled a research project that he worked on where a patient shared that they needed to lose weight. He paused, and then asked the patient how important losing weight was on a scale of 1-10. Ironically, the patient answered, “not that important.”

Pursuing it further, he pointed out the disconnect to the patient, who finally shared that what was important was being strong and in good shape so he could play and keep up with his kids.

“The goal is ‘getting to know what’s important to somebody, and then allowing the patient to talk themselves into change,’” said Kushner. (This concept is formally known as change talk.)

“For example, in return I said, ‘it’s not so much the weight but keeping up with your kids. What would you add, what else is important to you about your health?’ This gives the patient enough space to articulate the reason for change vs the physician supplying to reason,” he said.

Asking open-ended questions (which are not generally considered efficient) are also important.

“Ask ‘how are you doing? What’s getting in the way? What are your challenges (eg, medication, meeting personal goals and values),” Kushner said.

Doctors can also narrow the scope of the question for efficiency purposes. “Rather than ‘tell me how you are feeling,’ they could say ‘you’ve been on a GLP-1 for the past 2 months. Are you feeling any better? Tell me what it’s like, having lost X pounds.’”

Simple affirmations like “it sounds like you’re doing great,” and “congratulations,” and expressing empathy through comments like, “I can see that this has been hard for you, you are not losing as much weight as your friends, I understand what that must feel like” also go a long way in supporting patient self-efficacy.

Ultimately, MI entails removing the layers and numbers, and really getting to the core of what weight loss means to the patient.

Resource Drain or Practice Boon?

On average, primary care patient visits last only 18 minutes. Given this constraint, how is it even possible to integrate MI into a visit, let alone attend training sessions?

For Fitch, putting the key components of MI on view in her office served as a reminder. She said that she would practice one technique a day, so it became more natural and part of regular patient visits.

“You don’t have to use every single component with every single patient,” advised Kushner. “It’s a toolbox of skills you pull out and use according to the patient, for example, you may use more empathy with one patient, reflections with a second, and support self-efficacy with another.”

It turns out that MI can also bring the joy back into the practice of medicine.

A sprinkling of one technique here and another there was transformational, said Damara Gutnick, MD, professor of family and social medicine and director of Office of Community and Population Health, Montefiore Medical Center, Albert Einstein College of Medicine in New York City. 

Gutnick, who is also a member of MINT, said, “we were transitioning to electronic health records and I was really burnt out; there was not a lot of time with the patient. I felt like a glorified secretary and was exhausted all of the time — where most health providers are today.”

“When I learned motivational interviewing, it shifted my entire practice, and brought joy into my work again,” said Gutnick. She said that transitioning to the MI model put a stop to patient push-back. It’s led to true connections with her patients. And for patients on GLP-1s, may lead to sustained weight loss.

“You’re dancing with the patient instead of wrestling with them,” she said.

Fitch is co-founder and CEO of Knownwell Health. Pollak, DeFrancesco, Kushner, and Gutnick reported no relevant financial relationships.

Liz Scherer is an independent health and medicine journalist.