Motivational Interviewing to Reduce Pediatric Obesity in Primary Care: A Disparity Perspective of the BMI 2 Trial Ken Resnicow, PhD Professor University of Michigan School of Public Health Department of Pediatrics Comprehensive Cancer Center Center for Health Communications Research Ann Arbor, MI [email protected]http://chcr.umich.edu Ann Arbor, MI Phone (734) 904-3888 [email protected]
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Motivational Interviewing to Reduce Pediatric …...Motivational interviewing for pediatric obesity: conceptual issues and evidence review. Journal of the American Dietetic Association
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Motivational Interviewing to Reduce Pediatric Obesity in Primary Care:
7Class 3 obesity = BMI > 140% of the 95th percentile
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12Prevalence of Childhood and Adult Obesity in the United States, 2011-2012 Cynthia L. Ogden, Margaret D. Carroll, Brian K. Kit, Katherine M. Flegal, JAMA. 2014;311(8):806-814.
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Kraschnewski JL, Sciamanna CN, Stuckey HL, Chuang CH, Lehman EB, Hwang KO, et al. A silent response to
the obesity epidemic: decline in US physician weight counseling. Med Care. 2013;51(2):186-92.
Kraschnewski JL, Sciamanna CN, Stuckey HL, Chuang CH, Lehman EB, Hwang KO, et al. A silent response to
the obesity epidemic: decline in US physician weight counseling. Med Care. 2013;51(2):186-92.
Kraschnewski JL, Sciamanna CN, Stuckey HL, Chuang CH, Lehman EB, Hwang KO, et al. A silent response to
the obesity epidemic: decline in US physician weight counseling. Med Care. 2013;51(2):186-92.
Accelerating Progress in Obesity Prevention: Solving the Weight of the
Nation
May 8, 2012
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Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, IOM 2012
WHY MI ?
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Perceived Barriers in the Treatment of Overweight Children and Adolescents
Percentage Responding “Most of the Time” and “Often”
RDs PNPs Pediatricians
Barrier (n= 441) (n = 293) (n = 201)
Lack of patient motivation 61.9 78.2 85.7
Lack of parent involvement 71.8 82.5 81.2
Lack of clinician time 31.2 45.9 58.0
Lack of reimbursement 68.1 46.8 45.8
Lack of clinician knowledge 23.8 32.2 44.0
Lack of treatment skills 27.3 32.2 45.0
Lack of support services 55.5 57.0 60.0
Treatment futility 37.4 52.6 53.0
Eating disorder concerns 17.2 12.9 10.0
Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210-4.
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Motivation mentioned 1x
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Two Elements of Behavior Change Counseling
WHY to Change HOW to Change
ENERGY STRUCTURE
VIGILANCE STRATEGY
Starting with a strong WHY leads to better outcomes
More open to TRYING a HOW
Devote more energy during HOW
Exhibit more persistence during HOW
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Two Elements of Behavior Change Counseling
WHY to Change HOW to Change
MI CBT/Lifestyle Mgmt
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Comfort the afflicted
and
Afflict the comfortable
Essence of Motivational
Interviewing
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Roll with Resistance
Then
Find Meaning for Change
Acknowledge Dread
Link with Role, Goals, and Values
Essence of Motivational
Interviewing
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MI vs. Usual Care
Reflect vs. ask
Roll with resistance vs. counterpunch
Elicit change talk vs. inform/advise
> 50% patient talk time
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MI Evidence Base
> 2200 papers; 220 RCTs
Multiple reviews Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: a meta-analysis of
VanWormer, J. J., & Boucher, J. L. (2004). Motivational interviewing and diet modification: a review of the
evidence. Diabetes Educator, 30(3), 404-406.
Vasilaki, E. I., Hosier, S. G., & Cox, W. M. (2006). The efficacy of motivational interviewing as a brief intervention for
excessive drinking: a meta-analytic review. Alcohol Alcohol, 41(3), 328-335.
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Recent Meta-Analysis
McMaster F, Resnicow K, et al Motivational Interviewing for Chronic Disease
Prevention: A systematic review and meta-analysis . (under review) 34
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Healthy Lifestyles Pilot Study
Schwartz R P, Hamre R, Dietz WH, Wasserman R, Resnicow K, et al. Arch Pediatr Adolesc Med. 2007;161: 495-501
Can Brief Motivational Interviewing in Practice
Reduce Child Body Mass Index?
Results of a 2-year
Randomized Controlled Trial
Funding provided by a grant from National Heart Lung and Blood Institute (R01HL085400), PROS core funding from the Health Resources and Services Administration Maternal and Child Health Bureau (R60MC00107) and the American Academy of Pediatrics
Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:649 -57
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2-year national randomized controlled trial in 42 PROS practices
Test use of MI vs. usual care among children ages 2-8 with BMI 85th to 97th percentile
3-arm design:
Group 1 – Usual care
Group 2 – MI delivered by pediatricians (4 sessions)
Group 3 – MI delivered by pediatricians (4 sessions) plus registered dietitians (6 sessions)
Methods
Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:649 -57
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Overall Enrollment
n= 42 practices
n= 645 patients
Group 1
Usual Care
n= 11 practices
n= 198 patients
Lost to follow-up
1 practice
40 patients
Analyzed
n=158 patients
(80%)
Group 2
Pediatricians
n= 16 practices
n= 212 patients
Lost to follow-up
3 practices
67 patients
Analyzed
n=145 patients
(68%)
Group 3
Pediatricians and RDs
n= 15 practices
n= 235 patients
Lost to follow-up
1 practice
81 patients
Analyzed
n=154 patients
(66%)
Study Overview
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Thank you to participating PROS practices!
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Assess the impact of brief Motivational
Interviewing (MI) counseling on child BMI
percentile over a 2-year period
Primary Objective
Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:649 -57
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Hypotheses
At 2 year follow-up, children in group 2
(PCP only) will show a 3 point decrease in
BMI percentile relative to group 1
At 2 year follow-up, children in group 3
(PCP + RD) will show a 3 point decrease in
BMI percentile relative to group 2.
Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:649 -57 42
Intervention Elements
2-day MI training
MI booster training DVD
Parent Behavior Screener
Autonomy Supportive Materials
Tip Sheets (Optional)
Diaries (Optional)
Autonomy Supportive Skills (MD to Parent)
You Provide They Decide
Engagement-Choice
http://chcr.umich.edu/project.php?id=1032
What did our providers do?
Reflect 2x-3x for every question asked
Talk < 50% of the time
Support parent and child autonomy
Affirm effort
Elicit Change Talk
Link behavior to role and goals
Undersell advice
Provide menu of options
Client: We eat at Wendy’s a few
times a week. It’s cheap, fast, my
kids like it, and it’s better than
those other places. There’s a lot
worse we could be eating. Sure
there are better foods than that but
I don’t have time to cook…
AFFIRM
Old School
You know, Wendy’s is no better
than McDonalds so you are not
doing your kids any favors by
eating there.
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New School
Because you are so busy and
exhausted it is hard to find the time
to cook healthier meals. But you
care about your kids’ health and
are want them to eat better than
fast food.
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Because you are so busy and exhausted
it’s hard to cook healthier meals. But you
care about your kids’ and their health and
ideally you want them to eat something
better than fast food.
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We tried to reduce the amount of TV she watches
but it didn’t go so well. In the morning I need to
get dressed, take a shower, make some breakfast
and I usually end up letting her watch TV just to
give me some free time. In the afternoon I feel it
might be easier…since maybe I could get her
involved in an art project or playing outside.
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So it might be more realistic to work on the afternoon TV first
Getting her involved in something creative like art or a craft project might be worth talking about…
Art is the way to go
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Values List for Parents
Values For Your Child Values for You Values for Your Family
Be Healthy Good Parent Cohesive
Be Strong Responsible Healthy
Have many friends Disciplined Peaceful Meals
Being fit Good Spouse Getting along
Not feeling abnormal Respected at Home Spending time together
Not being teased On top of things
Not feeling left out Spiritual
Be able to communicate
his/her feelings
Fulfill her potential
Have high self-esteem
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X
X
X
X
X
X
X
X
SAMPLE PARENT Q
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Autonomy Supportive Handouts
BMI2 Diaries
Beverages (Bi-directional)
Snack (Bi-directional)
Dining out
F & V
TV
Activity
Generic (everything else)
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Autonomy Support: Parent to Child
YOU PROVIDE THEY DECIDE
TV/Screen Time
– You set limit (can be collaborative)
– They decide when and how to cash in
Treats/Sweet Drinks/Fast Food
– You set limit (can be collaborative)
– They decide when and how to cash in
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Autonomy Support: Parent to Child
YOU PROVIDE THEY DECIDE
How much to eat
– Provide “green” and “yellow” foods
Let them determine seconds & satiety
– Query “how full are you”
– Do not encourage, comment, or reward clean
plate
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Autonomy Support: Parent to Child
YOU PROVIDE THEY DECIDE
Meal Construction
– “Chicken or steak” tonight
– “Pasta or Pizza”
– “Broccoli or Peas”
Shopping
– Brand
– Which “apple”
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Involve/Engage
Cooking
– Peel
– Stir
– Flip
– Pour
– Sprinkle
– Spice
– Mix
– Skewer
Decorate
Set Table
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Baseline Sample Description By Study GroupGroup 1 Group 2 Group 3 Total
Control MD MD+RD
(n= 198) (n=212) (n=235) (n=645)
Mean Child Age (sd)* 4.87 (1.72) 5.08 (1.94) 5.32 (1.78) 5.10 (1.82)