A recent analysis, published March 29 in the Annals of Internal Medicine, found that when healthcare providers engaged in motivational interviewing (MI) with patients as part of a weight-loss program, it added little to no benefit. On average, those people lost no more weight than people getting other types of help. “I’m somewhat surprised by these results,” says Fatima Cody Stanford, MD, MPH, associate professor and obesity medicine physician scientist at Massachusetts General Hospital and Harvard Medical School in Boston. Dr. Stanford was not involved in the review. “I feel like if you asked my patients if they have issues with motivation, there are a sizeable number that would say yes, they do,” she says. That being said, motivation, or lack thereof, can often be traced back to the general public’s misperception around obesity, not the lack of desire or effort on the part of the patient, says Stanford. “I think it may be more a case of people with obesity feeling discouraged because other people don’t recognize that they have a disease that can be very complex to treat,” she says. Some people think that obesity is somehow caused by the individual and that they simply need to “do something better” to not have their disease, says Stanford. “That’s not what we find to be true in the actual clinical treatment of obesity,” she adds.
What Is Motivational Interviewing?
Motivational interviewing is centered around empathy and avoiding argument, judgement, or direct confrontation. The technique was first conceived in the early 1980s, when it was used by the American psychologist William R. Miller, PhD, for patients with alcohol problems, according to the American Academy of Family Physicians. In MI, the interviewer asks questions designed to explore the individual’s own reasons for change based on the principles that everyone possesses the resources and skills needed for change, and that people are the experts in their own lives. After careful listening, the clinician can offer advice and encouragement based on the client’s responses. MI is especially helpful in situations when ambivalence about whether or not to change is high, or if people lack confidence or desire, or aren’t sure if the benefits of change outweigh the disadvantages of the current situation, according to the Motivational Interviewing Network of Trainers.
Motivational Interviewing Didn’t Add Value as Part of a Weight Loss Program
Researchers analyzed results from 46 randomized trials aimed at weight loss or weight loss maintenance that included a total of 11,077 adults and adolescents. All participants had either overweight (a body mass index, or BMI, between 25 and 29.9) or obesity (a BMI of over 30). Nearly 3 in 4 adults — 73.6 percent — over age 20 has overweight or obesity, according to the Centers for Disease Control and Prevention (CDC). Compared with no or minimal intervention, people in programs using MI lost an average of about 2 more pounds at three and six months of follow-up; in the two studies that had a one-year follow-up, there was no evidence of a sustained difference between the groups. The authors concluded that given the amount of training and time involved to include motivation interventions, it may not be a worthwhile addition to weight loss programs.
Weight Loss Is Difficult — but Not Because People Lack Motivation
Motivation isn’t really the issue that makes weight loss hard for many people, says Sarah Sterling, LCSW, a licensed clinical addiction specialist and clinical team lead in behavioral weight management at the UNC Weight Management, part of the family medicine program in Chapel Hill, North Carolina. Sterling has extensive training in MI and clinical experience in using the technique for tobacco treatment and weight management counseling. Sterling was not an author in the analysis. “We never assume that people who are overweight aren’t ‘motivated enough’ to lose weight. That attitude contributes to weight stigma, which can directly harm patients’ health outcomes,” she says. Obesity is a complex disease that includes behavioral factors but also genetics, environment, social determinants of health, and biological factors influenced by medications, illnesses, hormones, and more, says Sterling. “Suggesting a motivational intervention would produce weight loss means assuming both that the issue is primarily behavioral, and that people aren’t already attempting behavior change,” she says.
Motivational Talks May Help People Who Aren’t Already Seeking Weight Loss Support
Although the analysis wasn’t designed to figure out why or why not MI leads to improved weight loss, the authors speculate that it may be because study participants were already enrolled in a weight loss program, indicating that they are already motivated to lose weight; motivational interviewing is typically recommended for people who aren’t motivated to change. Stanford agrees, noting that there are several steps that an individual has to take before embarking on a medically supervised weight loss intervention. “Step 1, recognizing they have overweight or obesity; step 2, deciding to talk to their primary care doctor; and then beyond that, enrolling in a weight loss program that may last several months. Those people are highly engaged and ready to take action to address their disease,” she says. “The majority of patients presenting to behavioral weight management services already have high desire to lose weight,” echoes Sterling. “In fact, sometimes that desire itself can becomes detrimental to health if it is not combined with the eating-disorder informed treatment.” It’s not clear from this analysis whether MI might be impactful in other scenarios, says Stanford. “For example, a person with obesity who is just visiting their doctor for an annual checkup might benefit from motivational interviewing.”
Finding the Right Treatment Plan for Obesity Takes Patience
These findings don’t mean that healthcare providers should never discuss obesity or weight loss with patients, but there are factors that need to be considered, says Sterling. “Providers can help patients with obesity by screening for disordered eating before recommending weight loss and by recognizing the nonbehavioral factors that contribute to weight regulation. When recommending behavior change, they can refer to counseling programs so that patients have support,” she says. “One thing that I find in treating my patients with obesity: No two stories are the same and there’s no solution that’s going to work for everyone. Be patient — even though I know that can be hard,” says Stanford. The reason why we see failure of population-wide strategies is because this disease is so varied, she says. “Because people often respond differently to different interventions, it takes working with your physicians and other healthcare providers who can tailor your treatment for your specific needs,” says Stanford.
