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Motivational interviewing (MI), a departure from the way clinicians typically interact with patients, may be a potent tool in helping people control their diabetes and lose weight, suggests a recent study.1
In the study, women with type 2 diabetes who received MI counseling in conjunction with a group weight-loss program achieved better blood glucose control and lost significantly more weight than women who did not receive the intervention. They also kept the weight off longer. The technique—in which clinicians elicit information directly from patients about why they would like to change, instead of dispensing advice patients may or may not follow—appeared to help women adhere to proven diabetes-care strategies, says the study's lead author, psychologist Delia Smith West, PhD, of University of Arkansas for Medical Sciences in Little Rock.
"MI appeared to make people more likely to attend their weight-control sessions and to self-monitor their behavior—the two things we know are the most effective predictors of who will succeed in weight loss," West says. "These findings may generalize to other conditions as well, in that MI may help people to focus on available treatments that we know work."
Noting MI's long history of success in people with addictions—a 2004 meta-analysis of 72 studies, for instance, showed that people who had problems with alcohol and substance abuse, gambling, smoking, and other conditions were more likely to stay in and adhere to treatment after MI than those who received other treatments or treatment as usual—researchers have been interested in its applications in primary care.2 This is the impetus for studies such as West's and for increasingly available MI training for clinicians country-wide. The National Institutes of Health (NIH) also has entered the fray, helping through studies to disseminate MI techniques to diabetes educators, nurses, physicians, and other clinicians in primary care.
STUDY FINDINGS
The study of MI use for weight loss and glycemic control in type 2 diabetes, the first large-scale, randomized controlled trial of its kind, involved 217 Caucasian and African-American women who were overweight and had type 2 diabetes. The women were divided into two groups. Both groups of women received the same group-based behavioral weight-control program for 18 months. However, the experimental group also received six individual MI sessions with a psychologist to help them work on diabetes-related issues. The control group received six individual sessions of standard health education. All participants were assessed for weight loss, glycated hemoglobin (A1C) levels, and treatment adherence at 3, 6, 12, and 18 months.
| Motivational Interviewing Fundamentals Clinicians who use the techniques of motivational interviewing (MI) assume the role of guide on the side, instead of the usual sage on the stage. The idea behind this revolutionary approach to patient-clinician communication is to help patients take charge of their own care. Basic tenets of MI include:
Educators and clinicians can learn these skills through a training protocol that includes audiotaping patient sessions, analyzing the interactions via standardized MI coding schemes, and using a feedback-and-coaching approach based on the coding findings to improve clinician skills, notes MI trainer Garry Welch, PhD, of Tufts University School of Medicine.
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The average weight loss of women in both groups combined was 4.1 kg (9 lb) over the course of the study. The women in the MI-therapy group, however, lost significantly more weight than controls: about 1.81 kg (4 lb) more after 6 months. The MI group continued to keep that weight off for another 6 months, while women in the control group began to regain weight after their 6-month visit, so that by the end of the study, at 18 months, the MI group had lost about 3.5 kg (8 lb) on average, and the control group had lost about 1.7 kg (4 lb). The MI women also had significantly lower A1C levels compared to the controls at the end of the study. When the data were analyzed to determine why the MI women kept off more weight longer, it turned out they were more likely than controls to adhere to the existing weight-loss plan, West says.
Not everyone benefited equally from the intervention, West adds. African-American women lost less weight overall and were less likely to show improvement with MI than white women. To this end, West says, further studies should examine whether MI techniques can be tailored to work more effectively with different populations.
HOW MI WORKS
MI requires clinicians to shift from a didactic to an inclusive communication mode, in which they ask open-ended questions and help patients create action plans (see sidebar).3
"This is not the old model where the clinician is the expert, and the patient needs your expertise," says psychologist Garry Welch, PhD, an MI trainer and researcher at Tufts University School of Medicine in Boston. "It's more like, the patient is the expert on their life—they're the ones who have to do this and live with the consequences of their behavior. You're the expert on health care and on working with patients in various ways. MI brings those two sources of expertise together."
As one example, when MI counselors in West's study asked the women why they had agreed to participate, their initial response was simply that they wanted to "improve their health," West says. But when the counselors probed further using open-ended questioning, many women revealed they wanted to feel more comfortable in meaningful areas of daily life.
"They'd say things like they wanted to be able to play with their grandkids or walk up the stairs without huffing and puffing the whole time," she says. The counselors then used that information in later sessions to encourage women who were struggling to keep on track with their diet and exercise plans. "It was much more powerful to have that more elaborate visualization of what it meant for them to be healthy," she notes.
MI IN ACTION
MI experts know physicians may not have time to get trained in these techniques—though there are excellent training programs available, and the techniques don't necessarily take a lot of time in practice, they say (see "FYI").
To help disseminate proper MI techniques in light of this reality, two NIH-funded studies are under way: One, headed by Welch, is teaching MI techniques to diabetes educators; the other, run by physician and researcher Robert Gabbay, MD, PhD, of Pennsylvania State University in Hershey, is training nurses to practice MI with diabetes patients, thus easing the load on primary care physicians (see "FYI").
Gabbay, who also is incorporating MI training into Penn State's medical school curriculum, says he thinks such techniques will become increasingly important, given that an already overburdened health care system is handling an ever higher load of patients with chronic conditions.
"In the end, diabetes is not going to be something we're going to
manage as providers," Gabbay says. "It's going to be about us
giving patients the tools they need, so that they manage it."
Footnotes
More information on motivational interviewing (MI) training is available on the Motivational Interviewing Network of Trainers' Web site at www.motivationalinterview.org/training/mint.htm.
For more information on the ongoing National Institutes of Health dissemination study on MI and nurses, visit http://www.hmc.psu.edu/diabetes/dynamic/.
References
2. Hettema J, Steele J, Miller W: Motivational interviewing. Annu Rev Clin Psychol 1:91–111, 2005.[Medline]
3. Welch G, Rose G, Ernst D: Motivational interviewing and diabetes:
What is it, how is it used, and does it work? Diabetes
Spectrum 19:5–11, 2006.
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