Continuing Education Activity

Obesity is a complex and multifactorial neurobehavioral condition. One aspect of obesity is that it shares features with other types of maladaptive behaviors, as does the management. Therefore, successful behavioral approaches to obesity treatment are derived from counseling tools similar to those used in the psychotherapy world for conditions such as smoking and alcohol abuse. Behavioral approaches are also in evolution as research sheds new light on the characteristics of weight loss maintainers. The goal is to shift towards the patient-centered approach to the treatment of this growing pandemic. This activity reviews the use of behavioral approaches in treating obesity and highlights the role of the interprofessional team in improving care for patients with obesity.

Objectives:

• Describe the basic principles of behavioral approaches to obesity management including motivational interviewing.
• Identify the goals and principles of motivational interviewing in a patient encounter including OARS, create ambivalence and elicit change talk, summarizing, and planning.
• Review the clinical significance of cognitive-behavioral therapy and its efficacy in treating common eating disorders associated with obesity.
• Summarize the importance of collaboration and communication among the interprofessional team to enhance care coordination for persons with obesity with behavioral treatment needs.

Introduction

Obesity is a complex and multifactorial neurobehavioral condition where eating behavior is affected by many things, including an imbalance between strong physiologic forces that resist weight loss and weak forces that resist weight gain. Eating behavior is also influenced by the environment, five senses, stress, emotions, habitual time cues, reward, sleep, eating disorders, and information gap.

Some standard behavioral approaches to obesity treatment include the following:

1. Motivational interviewing (MI)
2. Behavioral therapy (BT)
3. Cognitive therapy (CT)
4. Cognitive-behavioral therapy (CBT)
5. Interpersonal therapy (IT)
6. Acceptance-based therapy (ABT)

Eliciting behavioral change is a significant challenge to clinicians in managing obesity, especially with limited time in an office or clinic setting. Motivational interviewing (MI) is a collection of behavioral tools that have been proven to evoke change in patients who are ambivalent, reluctant, and otherwise not motivated to change.[1][2][3][4][5][6] The patient must be ready for change for a weight management plan to be successful. A successful patient encounter that utilizes MI techniques would get the patient to think, increase confidence, help the patient initiate change, facilitate commitment to change, and foster continued commitment to change. It draws out the patient’s thoughts and ideas towards solutions and fosters autonomy. The clinician acts as a guide towards these goals. This activity reviews the importance of MI in obesity management and how clinicians can use MI tools to elicit behavioral change.

Issues of Concern

There are six stages in the transtheoretical model of change that are worth review:[7][8]

1. Pre-contemplation (I can’t/wont)
2. Contemplation (I might)
3. Preparation/determination (I will)
4. Action (I am doing)
5. Maintenance (I am still doing)
6. Relapse to the undesired behavior or, very rarely, termination with no desire to resume the behavior after a long maintenance period.

MI is a counseling approach that has relational components (principles) and technical components (processes). The principles of motivational interviewing can be strategically applied to the patient’s stage of change. They include expressing empathy, avoiding arguments or rolling with resistance, developing discrepancy, creating and resolving ambivalence, and supporting self-efficacy. MI processes include engaging, focusing, evoking, and planning.

Express Empathy

Obesity and other maladaptive behaviors respond poorly to the traditional paternal model of medicine. In the MI model, the clinician creates a platform of empathy and has a collaborative relationship with the patient. The clinician does less advising, and the patient does more of the talking. When patients feel understood and respected, they are more likely to consider change – one of the first MI processes. Evocation, another MI process, involves drawing out the patient’s thoughts regarding solutions. OARS is a MI acronym and tool that can be used for this purpose. It includes Open-ended questions, Affirmation, Reflections, and Summaries. Open-ended questions allow the patient to elaborate their thoughts. It encourages answers that are not binary, such as ‘yes’ or ‘no.’ They can be used at the beginning of a patient encounter to help explore the patient’s reasoning for change and at the end of the summary to evoke change talk. Reflection is a crucial tool that demonstrates that the clinician has accurately heard the patient.

Supporting Self-efficacy

This is a principle of MI where the clinician focuses on successes, strengths, and skills and provides affirmation. Patients are more likely to change behavior if they and the clinician believe that they can accomplish it. Clinicians foster autonomy and empower the patient to own the solutions. It can be used over many stages of change, especially in the preparation, action, and maintenance stages.

Rolling With Resistance

When we provide education, it may be met with resistance and reluctance. Patients may have internalized weight bias and feel that the clinician is judgmental and authoritative, which manifests as interrupting, arguing, denying, and ignoring during the encounter. Rolling with resistance is encouraged, where the clinician avoids arguments by reflection, reframing, shifting focus, and siding with the negative. If resistance is encountered, this is a cue for the clinician to pull back and adjust the counseling approach. Examples of rolling resistance include:

• Therapeutic paradox (“reverse psychology”): “you seem to be saying that now is not the best time to make changes, so what do you think is the best way for us to move forward?”
• Siding with the negative: making a reflective statement hoping that the patient would eventually counter with a positive argument. For example, if a pessimistic statement is made, such as “I’ll never lose weight,” the clinician agrees with the statement using a non-judgemental stance such as - “For you, it would seem to be quite a challenge.”
• Shifting focus: as part of the guiding motivational interviewing approach, a clinician seeks to redirect a discussion to the intended topic. For example – “Your feelings about taking time off from work during your flare-ups of back pain are obviously stressful to you, but remind me, what led you to make this appointment to discuss your weight?”
• Reframing: reconstructing a statement made by the patient to one that favors change talk. It is a directive measure, guiding the patient away from sustain talk (talk from the patient that supports keeping the current behaviors) and argument.

Ambivalence and Discrepancy

Ambivalence is defined as the uncertainty in the desire for change. It is a challenge in evoking change talk. Developing discrepancy involves drawing out from the patient the perception of how current behaviors match (or not match) with core values or desired behaviors. This clarity guides the patient to target the maladaptive behavior and build motivation to change it. If a clinician can develop and amplify discrepancy by contrasting where the patient is from where they want to be, this helps with resolving ambivalence. For example, a clinician can have the patient explore their current behavior’s positive and negative aspects. The patient can consider the benefits of change, the risks of change, and the benefits and risks of no change. Another approach to evoking change talk would be to ask the patient to rate on a scale of 1 to 10 how important, ready or confident they are that they can change. Depending on the response, the clinician can further ask, “why are you not at a lower/higher number?” or “what would take you from a 6 to an 8?” to elicit change talk.

Evidence supports the efficacy of 3 constructs of motivational interviewing. Patient experience of discrepancy and patient change talk lead to better outcomes, and therapist MI-inconsistent behavior is linked to worse outcomes.[9]

Additional micro-counseling approaches that help provide a framework for a short visit include:

1. The five A’s of obesity management:[10]

• Ask permission to discuss weight. This non-judgemental approach gives autonomy in a population with a high prevalence of weight bias internalization. The clinician can also explore the patient's readiness for change.
• Assess basic parameters related to weight, including BMI, waist circumference, waist to hip ratio, and obesity stage. Complications and drivers of increased weight need to be explored.
• Advise the patient on health risks of obesity, health benefits of 5 to 10% weight loss, long term strategies, and treatment options.
• Agree to realistic weight loss expectations. The clinician engages in respectful negotiation on goals, behavior change, and specifics of a weight loss plan.
• Arrange/assist by identifying barriers to weight loss goals, referrals to other providers, e.g., a dietitian, resources, and follow-up. Without training, most clinicians are proficient at Ask and Advise but used Assess and Assist/Arrange less frequently. There is evidence that improving the frequency of the latter has the most impact.[11]

2. FRAMES is a technique that constitutes:

• Feedback about personal risk
• Responsibility of the Patient
• Advice to change
• Menu of strategies
• Empathetic style
• Self-Efficacy

Clinical Significance

In the US, obesity rates have increased to current rates of 42% for men and women in 2017-2018, per the Centers for Disease Control. Of note, it disproportionately affects non-Hispanic black women with a prevalence as high as 56.9% in this group.[12] It is now considered an epidemic. In the Medicare population, screening for obesity is a grade B recommendation by the U.S. Preventive Services Task Force (USPSTF). Since November 2011, CMS has covered intensive behavioral therapy for obesity as a preventive service that includes face-to-face visits with clinicians. Private insurers have also done the same. The covered intervention includes assessment and the 5-As framework.

Effectiveness

MI - in a large meta-analysis of 48 studies (9618 participants), patients receiving MI were shown to have one and a half times the chance to make positive behavioral changes to impact healthcare outcomes compared with controls.[13] It takes as little as 1 session to enhance readiness to change. Any healthcare provider can deliver this technique as long as a small amount of extra time is devoted to building a relationship with the patient. This guiding/directive approach includes agenda-setting and finding a common focus. It can be delivered in a relatively brief encounter, but there needs to be a ‘minimum dose’ of 15 minutes for MI to be effective.[4] All providers can expect a 10 to 15% improvement in medical outcomes.[13]

CBT - Eating disorders have a prevalence of 3% in US adults and up to 50% in persons with severe obesity. CBT is recommended as a first-line treatment for eating disorders and is also the most effective treatment for depressive symptoms that co-occur with eating disorders.[14] It must be noted that CBT is effective at reducing pathologic eating behaviors but does not directly produce weight loss.[15]

Application

When treating a person with obesity, MI acts as a bridge between evaluation and management decisions in the clinician's mind and interventions. Standard interventions for obesity management include intensive lifestyle interventions (diet, exercise, and behavioral treatments), pharmacotherapy, and bariatric surgery. Intensive lifestyle intervention remains one of the most foundational tools available for treating obesity. It has the lowest cost and lowest risk. Persons with eating disorders do not respond as well to MI and may need further behavioral treatments, specifically CBT or ACT. This is especially applicable if the patient is being considered for bariatric surgery - a high cost and high-risk procedure, where there is a high prevalence of eating disorders and depression in preoperative candidates.[13][16] Therefore perioperative guidelines recommend that patients undergo a clinical evaluation with a mental health professional before surgery.[17]

Weight regain is turning out to be one of the most significant obstacles in obesity treatment, perpetuating the epidemic. Of all the therapies available for weight loss, behavioral treatments have the most impact on maintenance, with some treatments producing a magnitude of 10% weight loss maintained after 36 months.[18] There is a gap between payor sources being willing to pay for this low-cost intervention and clinicians who are willing and qualified to deliver it, to a degree large enough to turn around the epidemic of obesity.

Other Issues

Other therapies used by psychotherapists and well-qualified clinicians include:

• Behavioral therapy is used to reinforce or extinguish a behavior with less emphasis on its thought process. The addition of a reinforcing stimulus or positive reinforcement is usually more effective for behavior change than negative reinforcement. Positive reinforcement can include verbal praise or behavioral contracting for non-food-related rewards.
• Cognitive therapy - Some patients with obesity may verbalize thoughts lacking in validity, known as cognitive distortions. Cognitive therapy aims to target these cognitive distortions and guide them towards less maladaptive thinking, behavior, and emotional reactions. Compared with MI, the cognitive shift is the key mechanism of change.
• Cognitive-behavioral therapy (CBT) - includes cognitive therapy and utilizes the relationship between thoughts, emotion, and behavior. The goal is to change behaviors through cognitive restructuring, reinforce desirable behaviors, and extinguish undesirable ones.[19] Some CBT components include stimulus control to treat impulsivity, goal setting, self-monitoring, stress management, behavioral contracting (rewards), and problem-solving. CBT is beneficial in pediatric populations and post-bariatric surgery patients to improve psychological health and maintain weight in the longer term.[20] It can also help with eating disorders, including night eating syndrome, bulimia disorder, and binge eating disorder. Typical CBT treatments done by mental health clinicians are carried out in 60-minute sessions, weekly for 8 to 12 weeks.[21] A simple CBT tool that any clinician can use is to set SMART goals – specific, measurable, assignable, realistic, and time-related.
• Interpersonal therapy is a short-term, focused form of psychotherapy that improves interpersonal functioning to relieve symptoms. It is especially useful in treating depression, which has a high prevalence in persons with obesity.
• Acceptance-based therapy - this is considered a third-generation behavioral intervention. With the prevalence of obesity being higher among non-Hispanic black adults than other races, it is crucial to ensure that recommended behavioral therapies work just as effectively in these groups. At least one randomized control trial has shown that rates of achieving clinically significant weight loss were higher among non-Hispanic black adults who received acceptance-based therapy in addition to traditional behavioral therapy, compared with behavioral therapy alone.[22] Acceptance-based therapy, also known as acceptance and commitment therapy (ACT), is based on recognizing human tendencies to cope with unpleasant situations by avoidance. It is focused on private experiences and changing the individual’s relationship with them to pursue values-based actions. ACT uses strategies of mindfulness and acceptance of unpleasant feelings and experiences rather than avoidance. The desired outcome is a tolerance of internal cues that lead to cravings or negative health behaviors that allows for psychological flexibility. This method has promise in producing longer-term weight loss outcomes.[23]

Enhancing Healthcare Team Outcomes

Using a behavioral approach to obesity management is an effective way for physicians, surgeons, extenders, dietitians, nurses, pharmacists, mental health clinicians, social workers, and other health professionals, coordinating their knowledge and activity as an interprofessional team, to produce better weight loss outcomes.[24] As a part of intensive lifestyle interventions, it augments pharmacotherapy and bariatric surgery. Care coordination between these health professionals can elevate the level of care offered to complex patients who have failed initial weight loss measures. Primary care providers are generally on the frontlines when it comes to identifying and treating psychiatric disorders associated with obesity and are encouraged to be part of an interprofessional team to facilitate appropriate referrals. In any clinical setting, clinicians should create a healthcare facility environment where the team prioritizes weight-friendly infrastructure, uses unbiased language, and encourages the spirit of empathy. This environment will foster the patient-centered spirit of MI.