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Motivational Interviewing As A Treatment For Childhood Obesity In The Primary Care Setting. Literature Reviews Examples
Literature Review
Chairman:
Committee member:
Committee member:
Masters of Arts in Psychology
2016
Introduction
With childhood obesity on the rise, there is increasing concern about the prevention and treatment of obesity. Current national data on childhood and adolescent obesity show 16.9 percent of 2-to-19-year-old children and adolescents are obese (Ogden, Carroll, Kit, & Flegal, 2014). An effective intervention to manage obesity is essential. The current weight management practices involve dietary modification, behavioral change therapies involving exercise, pharmacological therapy and surgical intervention. The purpose of this literature review is to explore the current research on Motivational Interviewing (MI) as an effective method for improving the weight loss of obese children. MI is designed to resolve ambivalence, enhance intrinsic motivation and promote confidence in a person’s ability to make behavior changes. Motivational Interviewing has proved to be an effective strategy in targeting behavioral change and has been shown to aid in changing weight-related behaviors for adults. The present literature review intends to evaluate the effects of Motivational Interviewing on children/adolescents as an obesity intervention.
Background and Significance
Definitions of obesity.
Current definitions of childhood obesity in the literature include classification of children as fat if body fat is 25 percent or more of total body weight for male children and if body fat is 30 percent or more of total body weight for female children (Deghan, Akhtar-Dinesh, & Merchant, 2005); classification of children as being at risk for overweight if they are between the 85th and 95th percentile of the body mass index (Deghan, et al., 2005); and classification of children as obese if they are in the 95th percentile of the body mass index for their ages (Strauss, 2007).
Epidemiology and current demographics of childhood obesity in the US
In the United States, 34.9 percent of adults are obese (Ogden, et al., 2014). Approximately 16.9 percent of 2-to-19-year-old children and adolescents are obese (Ogden, et al., 2014). And approximately 8.1 percent of infants and toddlers have high weight for recumbent length (Ogden, et al., 2014) Children. But also notable is that obesity rates vary by demographics (Chin, 2011). More children of minority populations are obese than are children of the non-minority (Chin, 2011): “Obesity rates for boys [are] highest among Mexican-Americans (26.8%), followed by non-Hispanic Black boys (19.8%), and non-Hispanic white boys (16.7%). Obesity rates for girls [are] highest among non-Hispanic Black girls (29.2%), followed by Mexican-American girls (17.4%), and non-Hispanic white girls” (Chin, 2011, p. 6).
Etiology of Obesity
Another small amount of literature is dedicated to explaining the causes of obesity (Kalra, De Sousa, Sonavane, & Shah, 2012; Spruijt-Metz, 2012; Collins & Bentz, 2009; Chin, 2011)
Obesity-related behaviors and psychological risk factors.
Puder and Munsch (2010) explain that with childhood obesity, “interrelatedness between obesity and psychological problems seems to be twofold, in that clinically meaningful psychological distress might foster weight gain and obesity may lead to psychosocial problems” (p.). These include impulse and eating regulation deficits and correlative depression, anxiety, somato-form problems, and social withdrawal and isolation. And Deghan, et al. (2005) find that, “psychological disorders such as depression occur with increased frequency in obese children” (n.p.).
Collins and Bentz (2009) affirm these findings and assert that childhood obesity causation is attributed to a combination of the associated risk factors, categorized as psychosocial, environmental, and genetic or biological attributes. The authors verify that stress as well as the comorbidity of psychological disorders contribute to the challenge for the individual to control excessive intake of food(s). The insidious and “perpetual cycle of mood disturbance, overeating, and weight gain” (n.p.) referenced earlier in this review is wrought with the factors impelling children to overeat “as a coping mechanism” (n.p.), becoming disturbed by the overeating and the obesity, and overeating in response to these secondary psychological responses, ad infinitum—thereby lending to the challenges for the primary care practitioner making efforts at treating childhood obesity. In addition, affirm Collins and Bentz (2009), eating behaviors that include “‘mindless eating, ‘” binge eating—also categorized as binge eating disorder or BED—night eating—also known as night eating syndrome (NES)—and the excessive caloric consumption associated have been found to contribute to childhood obesity.
Physical activity.
Chin (2011) explains that the excess of caloric intake combined with the lack of caloric expenditure is an initial combined cause of childhood obesity. Spruijt-Metz (2012) asserts that stress is a correlate of obesity in childhood and that obesity-related behaviors are at the core of the causes of obesity—including energy intake, physical activity, and sleep habits. First, stress has been found to be physiologically tied to the intake of high-energy foods, as according to the author, when a child becomes stressed, the hypothalamic pituitary axis (HPA) becomes activated, which in turn releases glucocorticoids. One glucocoticoid, cortisol, is implicated as “[increasing] the expression of corticotropin-releasing factor mRNA in the central nucleus of the amygdala, which plays an important role in processing emotion[and which therefore] enables recruitment of a ‘chronic stress response network’, [in turn inducing] a chronic elevation of glucocorticoids, [and in turn increasing] the salience of pleasurable or compulsive activities such as ingestion of sucrose, fat, or other ‘comfort foods’” (p. 130). While the physical response to stress is in play, cortisol is also facilitating the creation of fat, especially around the midriff.
Second, the increased intake of food(s) contributes to childhood obesity, not just in terms of surplus of calories consumed but in terms of what types of extra calories are consumed. Third, Spruijt-Metz (2012) proposes that the lack of physical activity plays a significant part in childhood obesity rates. According to the author, the recommended amount of physical activity for children and adolescents under the age of 18 is for 60 minutes a day of “moderate to vigorous physical activity (MVPA)” (p. 132). However, as of 2008, the results were well below these standards:
Only 48.9 % of boys and 34.7 % of girls aged 6–11 meet the physical activity guidelines; [and] [l]ongitudinal data shows that physical activity declines by 37.6 minutes per year between the ages of 9–15, with only 11.9 % of boys and 3.4% of girls meeting the guidelines by ages 12–15 (n.p.).
Genetics, family, and culture.
These etiological factors—from excess of caloric intake combined with the lack of caloric expenditure to abnormal eating behaviors combined—will inform the motivational interviewing paradigm as parts of the process of treating and/or preventing childhood obesity. But also significant to the problem of childhood obesity are the environmental—familial, cultural, etc.—factors. For instance, Chin (2011) notes that according to the research, “children with parents with obesity have 25 times more chance of developing obesity than children without obese parents” (p. 11); that obesity in disorders such as Prader-Willi syndrome has been attributed to family genetics; and that in addition to genetic defects, “such as the absence of or deficit in the protein leptin” (p. 12) being associated with causes of obesity in childhood, the family’s value systems and cultural values, which vary according to culture or subculture, can markedly influence childhood obesity. Chin (2011) provides an example of the latter, showing that studies by researchers such as Kimm, Barton, Berhane, Ross, Payne, and Schreiber (1997) reveal how differences in attitudes toward body type on the part of African American and Caucasian girls can be an influence :
Black girls were more tolerant of heavier body types than white girls. Perceived social rejection due to obesity was also greater in white girls than black girls. [W]hite girls may have a different ideal body type than black girls, such that white girls strive for an “extreme leanness.” Black girls may not view this “extreme leanness” as desirable. Thus, black culture may be more accepting of a larger body type (p. 13).
And specific to this review, Kalra, De Sousa, Sonavane, and Shah (2012) outline the similar pathogenic psychological factors associated with childhood obesity, including parental use of food as part of a reward system that the child will come to internalize and practice when stressed, when depressed, or when desiring a treat or reward for work well done. Added to this are the dietary and mealtime habits of the family that become conditioned for children who obese: according to the authors, children who are obese tend to eat less at breakfast and eat more in the evening after dinner (after 6 p.m,); children who are obese eat more, eat more often, and eat faster than their non-obese peers. In addition, eating out more often and eating in groups are both shown to contribute to childhood obesity.
Psychosocial factors/aspects and obesity.
A portion of the literature is devoted to the psychosocial factors associated with obesity (Agrawal, Gupta, Mishra, & Agrawal, 2015; De Niet & Nieman, 2011; Sgrenci & Faith, 2011; Puder & Munsch, 2010; Salvy, Bowker, Nitecki, Kluczynski, Germeroth, & Roemmich, 2010; Collins & Bentz, 2009; Deghan, Akhtar-Dinesh, & Merchant, 2005; Strauss, 2000; Mustajoki, 1987).
Diminished self esteem.
Mustajoki (1987) notes that obese individuals can suffer from poor self-esteem, which can also occur as a result of weight-related ostracization. And Agrawal, et al. (2015) find evidence that overweight in women often results in diminished self esteem combined with poor body satisfaction.
Social isolation.
Puder and Munsch (2010) note that social isolation is one of the complexities of obesity; and Schwitzer and Rhodes (2013) add that social isolation is an indicator and function of eating disorders and obesity.
Dissatisfaction with body-image.
Mustajoki (1987) notes that dissatisfaction with body-image can be a factor for individuals who are obese. Collins and Bentz (2009) add that this dissatisfaction can occur for individuals who have received no input from others, but can especially occur for those who are ostracized or teased. And Sgrenci and Faith (2011) emphasize that several studies have found that among other negative factors, poor body image is evidenced to be correlated to weight-related teasing.
However, these three factors are typically understood as conditions that come as combined factors, and rarely occur in a vacuum: Mustajoki (1987) explains that while no overall mental health issues are more predominant in people who are obese versus people who are not obese, some psychosocial factors can distinguish the overweight and obese from those individuals who are at healthy weights: these include, for example, altered body image and eating disorders such as compulsive eating (binging) and compulsive eating and purging (bulimia). Collins and Bentz (2009) outline the sequelae or conditions that can arise from obesity that include complex and overlapping conditions such as 1) ostracization, whereby the individuals experience negative responses from others who see them as lazy and/or weak-willed and whereby the obese individuals internalize the negativity—which in turn lends to the potential for substance abuse, mood and anxiety disorders, depressive disorders, and/or perpetuation of the poor eating habits; 2) low self esteem and dissatisfaction with body image; 3) compromised interpersonal relationships; and 4) feelings of futility to change body weight that can result in “discouragement, frustration, hopelessness, and learned helplessness about the prospect of losing weight in the future on their own” (para. 7) as well as last-resort efforts that include seeking surgery (bariatric surgery, liposuction, etc.).
More specific to this review, De Niet and Nieman (2011) and Sgrenci and Faith (2011) add to the understanding of the factors of childhood obesity that include impaired psychological well-being due to the psychosocial consequences of obesity in general and present findings of empirical studies on childhood obesity, stigmatization, and disordered eating behaviors in particular. Meta-reviews of the evidence find that obese children face stigmatization at several levels—at the family and peer level, at the school and community level, and even at the institutional level with the media. Similarly, children who are obese and who are stigmatized and teased have been found to engage in disordered eating habits and in substance abuse—with one study by Haden-Wade, et al. (2005, in Sgrenci and Faith, 2011), Neumark-Sztainer, et al. (2007, in Sgrenci and Faith, 2011), and several more studies revealing that “appearance-related teasing [is] more prevalent in overweight children; [that] weight-related teasing [is] positively correlated with, dieting, restrictive eating, poor body image, binge eating, bulimic behaviors, [and] restrictive eating; [and that there is a] prevalence and co-occurrence of overweight, binge eating, and extreme weight control behaviors” (Sgrenci and Faith, 2011, p. 426). Additional studies such as a study of simulated ostracism by Salvy, et al. (2010) demonstrate that the effects of ostracism on the motivation to eat and on food intake of overweight and normal-weight young adolescents include that socially excluded and/or teased participants responded more for food and had a greater energy intake than overweight participants who were not excluded or teased.
Salvy, et al. (2010) find that “the experience of being ostracized can impair individuals abilities to self-regulate, which in turn, leads to negative health behaviors, such as increased unhealthy eating” (p. 39). Moreover, several studies show that obesity lends to body image dissatisfaction and poor self-esteem combined, which in turn often leads to or can lead to other disorders. A location-specific (India) study by Agrawal, et al. et al. (2015) demonstrates the body image dissatisfaction of overweight and obese women. In the investigation of 325 women between the ages of 20 and 54, the researchers found a higher percentage of day-to-day problems, body image dissatisfaction, sexual dissatisfaction, and stigma and discrimination (and their consequences) in overweight than in non-overweight women. More specific to this review, research by Strauss (2000) of obesity in childhood points to the same body image dissatisfaction and poor self-esteem combined, which also in childhood instances can lead to other psychological disorders.
Current treatment strategies for Childhood Obesity
Our standard approach to obesity problems is to conduct an assessment, determine a diagnosis, develop a plan, and tell the patient or her or his family what to do. Such a prescriptive approach often has the effect of focusing blame for the problem on the patient or parents. We know that traditional counseling for obese children to exercise more, eat more fruits and vegetables and less fat, and decrease sedentary time has been unsuccessful, yet this approach continues ( Cleveland, 2013).
Motivational interviewing.
There are several treatment approaches and tools for the treatment of childhood obesity in the primary care setting, some of which reach back to traditional practice, some of which are newer alternatives, and all of which must take into account the complexity of the genetic, developmental, behavioral, and environmental mechanisms at work that require attention and care. But according to several authorities such as Skelton (2015), in primary care setting, only some environmental influences are modifiable for children. Thus, it is the behavioral factors that are addressed and emphasized in treatment plans. Drohan (2002) reports that of the three
developmental stages wherein childhood obesity is most fully developed–the prenatal period, the period of adiposity rebound (AR), and adolescence—the best practices treatment will occur during the AR stage, during the child’s late pre-school years and involve targeting decreases in sedentary behavior, targeting physical activity, and implementing family-based nutrition programs that include nutrition and behavior modification education, as opposed to focusing on food restricting diets and weight reduction . However, several other studies have found that the effectiveness of such programs is questionable and perception by primary care practitioners and non-primary care practitioners alike is that there needs to be more effective treatment approaches (Silverberg, Carter-Edwards, Murphy, Mayhew, Kolasa, Perrin, Armstrog, Graham, & Menon 2012; Haemer, Cluett, Hassink, Liu, Mangarelli, Petersen, Pomietto, Weil, & Young, 2011). One of the alternatives proposed by researchers, clinicians, and practioners is motivational interviewing, supported in the theoretical literature (Spruijt-Metz, 2012; Anstiss, 2009; Luttikhuis, Baur, Jansen, Shrewsbury, O’Malley, Stolk, & Summerbell, 2009; Miller & Rose, 2009) and reinforced by the empirical evidence (Henderson, Ells, Rubin, & Hunter, 2015; Hardcastle, et al., 2013; Okihiro, Pillen, Ancog, Inda, & Sehgal, 2013; Sargent, Pilotto, & Baur, 2011: Taveras, Gortmaker, Hohman, Horan, Kleinman, Mitchell, Price, Prosser, Rifas-Shiman, & Gillman, 2011; Irby, Kaplan, Garner-Edwards, Kolbash, & Skelton, 2010: Martins & McNeil, 2009; Hughes & Reilly, 2008; Vignolo, Rossi, Bardazza, Pistorio, Parodi, Spigno, & Aicardi, 2008; Schwartz, Hamre, Dietz, Wasserman, Slora, Myers, Sullivan, Rockett, Thoma, Dumitru, & Resnicow, 2007).
General concepts.
Anstiss (2009) describes motivational interviewing as both “‘a client centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence’ [and] ‘a person-centered method of guiding to elicit and strengthen personal motivation for change’’’ (p. 88, citing Miller & Rollnick, 2009). Originating in the addiction field to employ techniques of self-determination, motivational interviewing has since been applied in several contexts for treatment of gambling and mental disorders, for health coaching, and for other fields and other behavioral control stratagem (Spruijt-Metz, 2012; Anstiss, 2009; Luttikhuis, et al., 2009; Miller & Rose, 2009).
In describing motivational interviewing, Miller & Rose (2009) find several justification theories emerge, including Festinger’s theory on cognitive dissonance, which sees the advantage of change that occurs when a client hears him- or herself positing change; Brehm’s extension of self-perception theory; and Rogers’ theory of client-centered counseling fostering change through reflective listening. Combined with motivation theory and self-determination theory, these approaches provide the conceptual framework for which motivational interviewing serves as a means to engage external motivation to change behavior and resolve ambivalence (Miller & Rollnick, 2009, in Söderlund, 2010). The technique of motivational interviewing involves 5 skills considered to be requisite to facilitating behavior change:
1) asking open-ended questions, which leaves room for variety of responses and does not restrict the dynamics of counseling to yes/no muttering with no room to grow;
2) reflective listening, mirroring the patient’s/client’s feelings in detached but empathetic manner to elicit meaningful expression;
3) affirmations, to reinforce positive attitudes and positive behavior change;
4) summarizing, to focus the sessions and anchor them in goal-oriented behavior; and
5) eliciting change talk, which engages the client/patient in self-determination (Söderlund, 2010, pp. 11-12).
Motivational interviewing is based on four principles, described by Söderlund ( 2010) as 1) expression of empathy; 2) development of discrepancy; 3) rolling with resistance; and 4) supporting client self-efficacy (p. 10), principles applied in the primary care setting for the treatment and prevention of childhood obesity by practitioners to make the patients/clients feel valued and understood; to distinguish behaviors contributing to obesity that conflict with the individual’s needs, desires, and/or goals to remediate the condition; to work within the bounds of client/patient resistance; and to reinforce and empower the individual’s abilities to change and his/her beliefs in those abilities to do so. Roger’s theory informs the first principle of developing empathy with client-centered counseling that uses reflective listening developed by Rogers and that works with the therapist as the main agent of change (Söderlund, 2010). Festinger’s theory of cognitive dissonance informs the second principle, whereby the individual has a disconnect between a behavior and a belief about that behavior (or has two conflicting beliefs) and whereby the practitioner can help to point out the discrepancy (between the behavior and the belief, between the two beliefs), as feeling the discrepancy on the part of the client/patient will create a stress or discomfort that facilitates awareness and subsequent change (Söderlund, 2010). Brehm’s theory of psychological reactance informs the third principle, ensuring the practitioner accept and not try to squelch the resistance on the part of the client/patient as according to the theory, a person forced up against a wall with restrictions to his/her freedom (of thought, belief, attitude) will attempt to increase the will toward more freedom, so the practitioner goal is to ease the resistance, not add to it (Söderlund, 2010). And Bandura’s social learning theory and social cognitive theory in general and his concept of self-efficacy in particular informs the fourth principle, whereby first, it is believed that a person engaged in his/her own improvement/recovery is more apt to change than one who is not engaged, and second, it is believed a person is motivated by rewards and incentives and by empowerment—when he/she has control over results, when he/she is confronted with limited barriers, and when he/she believes in his/her ability to change (Söderlund, 2010).
Method
Results
Results were recorded and quantitative data synthesis was performed. Table 2 illustrates the findings.
The empirical evidence of motivational interviewing effectiveness/benefits for treating/preventing obesity is severely limited in quantity. Although a greater body of research literature focuses on cognitive-behavioral treatment in general to treat child obesity or on motivational interviewing to improve health incomes in general, only a small amount of research literature exists to evidence the effectiveness of motivational interviewing as a primary intervention technique for childhood obesity treatment and prevention in particular. This includes feasibility and case studies (Okihiro, et al., 2013; Irby, et al., 2010; Schwartz, et al., 2007), longitudinal studies (Vignolo, et al., 2008), randomized controlled trials (Hardcastle, et al., 2013; Taveras, et al., 2011; Martins & McNeil, 2009), and systematic reviews (Henderson, et al., 2015; Sargent, Pilotto & Baur, 2011; Hughes & Reilly, 2008) .
Feasibility and case studies
Irby, et al. (2010) find that motivational interviewing is effective in supporting efforts toward making health behavior changes in general. The authors find the issue, however, is in the lack of specific research into how motivational interviewing specifically supports childhood obesity treatment with family-based care in a multidisciplinary, team-based setting (such as one with a pediatrician, dieticians, and counselors). The authors report on a case study to model the potential effectiveness of applying motivational interviewing in obesity treatment of 14-year-old Tina, who with her mother participated in a multidisciplinary weight management program using a pediatrician and motivational interviewing. Tina was being treated for obesity, so the authors integrated motivational interviewing to some degree of success: using phone coaching with a counselor who conducted motivational interviewing and participation in a clinic under the guidance of a registered dietitian, Tina reduced her body mass index from 35 to 3.6. However, the authors suggest that further studies, training, and feasibility determinations must be done.
Schwartz, et. al (2007) conducted a non-randomized clinical trial for identifying the feasibility of implementation by pediatricians and dietitians of office-based motivational interviewing as a primary intervention. Fifteen pediatricians and 5 registered dietitians participated, conducting motivational interviewing in pediatric primary care office settings and in sessions with 91 children, aged 3 to 7 years, having either a body mass index in the overweight range or in the normal weight range (the latter having a parent with a 50 or greater body mass index). After training was done for the primary care professionals, parents received minimal intervention consisting of 2 sessions, 1 from the pediatrician and 1 from the dietitian; or intensive intervention of 4 sessions, 2 from the pediatrician and 2 from the dietitian. After 6 months, the control group participants showed a total decrease of body mass of 0.6; the minimal intervention group participants showed a total decrease of body mass of 1.9; and the intensive intervention group participants showed a total decrease of body mass of 2.6. Given that the decrease was greater according to intensity of intervention, despite the fact that 2 (10%) of the control group, 13 (32%) of the minimal intervention group, and 15 (50%) of the intensive intervention group dropped out before the sessions ended, and given that a total of 15 (94%) of remaining parents admitted their thinking about family nutrition had changed, the researchers conclude that there is promise in the motivational interviewing strategy for the treatment and prevention of childhood obesity/overweight.
And Okihiro, et al. (2013) report on implementation of a location-specific [Hawaii] Obesity Care model combining pediatrician-guided primary care with a community-based intervention program. The mission of the comprehensive program to reduce the prevalence of obesity is rooted in principles of making changes to the way health care is delivered (redesigning clinic flow and integrating registered dieticians to care for the 50% obese patient population), using capacity and team-building (developing quality improvement teams), using community patient outcome data to inform improvement of community participation, and partnering between schools and the community. Among the principles are practices of the Obesity Care Model including application of motivational interviewing techniques that the authors conclude make for potentially effective ways of addressing the obesity problem on the island.
Longitudinal studies
Vignolo, et al. (2008) conducted a longitudinal study with a 5-year follow-up investigating a hospital-based cognitive behavioural program focused on weight gain regulation that uses motivational techniques in general. The study included 31 simple obese children ages 6 to 12 (accompanied by their parents) treated by a multidisciplinary team comprised of a pediatrician, a cognitive-behavioral psychologist, and a physical therapist applying “cognitive-behavioural techniques, nutrition education, promotion of physical activity, [and] setting a high value on free play in motion” (p. 1047). Despite a dropout rate of 35.5 percent, participants showed a decrease in total energy intake and improvement of family habits as well as subsequent decreases in waist measurements and improvement of emotional and social obesity-related behaviors. While they do not address motivational interviewing as a primary intervention technique, per se, the researchers conclude that positive childhood obesity treatment outcomes are credited not only to a lifestyle-centered approach, parental involvement, and nutrition education but to cognitive-behavioural strategies.
Randomized controlled trials
Taveras, et al. (2011) investigated the effectiveness of obesity prevention for 475 children, aged 2 to 6 years and with a body mass index in the 95th percentile or higher or 85th to less than 95th percentile if at least 1 parent was overweight, in primary care settings in a cluster randomized control trial with 10 participating pediatric practices—5 typical care and 5 intervention with motivational interviewing. Of the 445 children who stayed in the study for one year, those receiving intervention and motivational interviewing made small improvements of their body mass index. Other studies, such as those by Hardcastle, et al. (2013), were conducted to evaluate the effectiveness of motivational interviewing intervention strategy in primary care settings for reducing risk factors of cardiovascular disease—whereby motivational interviewing intervention strategy was found to make a significant difference.
Systematic reviews
Martins and McNeil (2009) reviewed 37 studies in diet and exercise, diabetes, and oral health domains to find that motivational interviewing is a technique effective in all of them. The authors determine that in the application of motivational interviewing as a technique for behavior modification in particular, 24 published articles (on the use of MI to modify diet and/or exercise behaviors) show favorable support both as a solitary treatment strategy and as one used in combination with other interventions:
Specifically, patients who received MI reported in-creased self-efficacy related to diet and exercise (e.g., Bennett et al., 2008; Resnicow et al., 2004), increased physical activity (e.g., Bennettet al., 2007; Carels et al., 2007; Harland et al., 1999; Hardcastle et al., 2008), reduced caloric intake (e.g., Befort et al., 2008), and increased fruit and vegetable consumption (e.g., Ahluwalia et al., 2007; Befort et al., 2008; Elliot et al., 2007; Hardcastle et al., 2008; Resnicow et al., 2000, 2001, 2004, 2005; Richards, Kattelmann, & Ren, 2006). Further, patients who received MI demonstrated decreased BMI (e.g., Hardcastle et al., 2008; Schwartz et al., 2007) after the intervention (p. 288).
Similarly, Hughes and Reilly (2008) conducted a system review summarizing the lack of high-quality evidence on the management of pediatric obesity, the greater availability of useful guidance on promising strategies to treat pediatric obesity, and reiteration of the successful weight management protocol that includes increasing physical activity, improving dietary habits, reducing sedentary behaviors, involving parents in processes, and applying cognitive-behavioral techniques—with MI among the latter. The authors find in favor of such programs, as they can result in anywhere from 10 to 20 percent weight reduction in addition to improved health outcomes. Sargent, Pilotto, and Baur (2011) also conducted a systematic review of 17 studies of controlled interventions (and their specific components) used to treat childhood overweight or obesity in the primary care or office-based setting. Of these 17 studies, 12 evidence at least one significant outcome in the treatment of childhood obesity; of these 12, the majority was found by the researchers to be in support of behavioral change strategies:
Use of the motivational interviewing technique to support behaviour change has been shown to outperform traditional advice giving in 80% of studies and delivery in a small number of contacts is feasible in primary care. Long-term support and motivation to comply, of the type that may be provided by primary care, is likely to facilitate uptake and maintenance of desired behaviours (p. e233).
And Henderson, et al. (2015) present a third type of systematic review—of 19 peer-reviewed and grey papers on 28 countries using national surveillance data for children in primary care settings to discern the potential of such data to inform childhood obesity policy and best practices. In reviewing how the countries each use the data and for what programs they use it, the researchers identified motivational interviewing in 2 countries:
The Netherlands/ ‘Eat right, be active’ RCT program through Youth Health Care invited families to 3 annual counselling sessions with both lifestyle advice and motivational interviewing, but was found to have poor attendance and no change in body mass index at the 2-year follow-up.
The United States’ ‘High Five for Kids’ RCT included a survey of parents’ perceptions of motivational interviewing to find that at the 1-year follow-up, higher satisfaction levels were reported by on-US born, low SES, and high BMI parents.
Summary of the literature review
Limitations of the studies reviewed.
The most notable finding here is that the empirical evidence of motivational interviewing effectiveness/benefits for treating/preventing obesity is also severely limited in scope. Therefore, there is much room for development of feasibility, randomized control trials, case studies, and longitudinal studies of the same. One explanation for the lack of specific studies done on motivational interviewing as a primary intervention for treating childhood obesity is perhaps that there are conceptual and attitudinal barriers (Resnicow, Davis, & Rollnick, 2006; Story, et al., 2002) as well as practical barriers (Wright, Taveras, Gillman, Horan, Hohman, Gortmaker, & Prosser, 2014) to practicing motivational interviewing in the primary care setting.
Story, et al. (2002) administered a national needs assessment survey to 202 pediatricians, 293 pediatric nurse practitioners, and 444 registered dietitians and found that for the treatment of childhood obesity, health care professionals perceived major barriers that include the lack of parent involvement, the lack of patient/client motivation, and the lack of support services. Treatment futility was also cited by half of the responding pediatricians and pediatric nurse practitioners and a third of the responding registered dietitians. Additional self-perceived barriers were reportedly in the lack of behavioral management proficiency, and lack of capabilities to provide parenting techniques and to address family conflicts. Low proficiency in behavioral management was least often cited by registered dieticians who more often cited specific lack of proficiency in handling family conflicts and providing guidance in parenting techniques. Likewise, Resnicow, Davis, and Rollnick (2006) identify conceptual issues found in the application of motivational interviewing in the pediatric care setting, including 1) that while treatment can be done with parents, with the child, or with both parents and child, evidence points to a lack of benefits to older obese children working with parental involvement; and 2) that because obesity is not a behavior (but is a condition associated with certain behaviors), practitioners must work with the child to set an agenda for changing behaviors that might need more than just motivational interviewing, that might require n entire regimen of behavior therapy or cognitive behavioral therapy. In addition, say the authors, in motivational interviewing itself, the “high level of reflective listening involves selectively reinforcing positive change talk that might be embedded in a litany of barriers” (p. 2025), as well. And Wright, et al. (2014) identify the costs of treatment for children who are obese or at the risk for obesity, measured against the costs of primary care treatment alone for the same, make for what they determined is “resource-intensive intervention” (p. 44).
In addition, there is some concern over the cost of motivational interviewing as treatment option for childhood obesity in the primary care setting. The studies thus far have suggested that in comparison with the cost of obesity treatment, MI intervention is far less significant (Gorin, et al., 2014; Martins & McNeil, 2009). For example, according to Moseley (2014), “hospital costs of treating children for obesity-associated conditions rose from $35 million
And according to Resnicow, et al. (2006),
Although the efficacy and cost-effectiveness of motivational
interviewing for the prevention or treatment of
pediatric obesity have not yet been clearly established,
evidence from motivational interviewing for other health
concerns combined with the considerable research on client-
centered communication can be sufficient to encourage
food and nutrition professionals to consider obtaining
training in motivational interviewing and to begin incorporating
these techniques into their practice (p. 2031).
Future Directions
Current, recent, and progressive policy and initiatives are in progress, but the future is more primed for solutions than prepared for them. For instance, given the statistics on the prevalence of childhood obesity in the United States, there have been a few important initiatives in response: in Louisiana, an Obesity Reduction Strategic Initiative was launched in 2014 to provide a toolkit for treating childhood obesity treatment that included assessment tools, an outline of the stages of treatment, a survey of program components and a provision of exemplary models of childhood obesity treatment (Staiano, Gonugunta, & Drazba, 2014). In Massachusetts, Texas, and California, the Childhood Obesity Research Demonstration Project (CORD) has been launched to treat and prevent childhood obesity by reducing high-energy/calorie-dense food intake, increase activity, and ensue sound sleep habits are in place, as well as by way of the CORD Obesity Chronic Care Model, which specifically focuses on the use of motivational interviewing for which training is provided to healthcare centers for working with parents and children to set nutrition and physical activity goals as part of the intervention (http://www.cdc.gov/nccdphp/dnpao/division-information/programs/ researchproject.html). In New Mexico, the Envision Program supports primary care providers with tools for practicing a comprehensive pediatric overweight prevention and treatment program that makes best practices use of healthcare provider support including motivational interviewing. And Mosely (2014) points to the childhood obesity initiative designed by First Lady Michelle Obama. Launched in February of 2010, Let’s Move! was created to educate parents and caregivers in promoting and making healthy food and exercise choices and changes. The initiative has taken on momentum and has been reinforced by Disney, who committed to “[requiring] all food and beverage products advertised on their media and served at their theme parksmeet federal nutritional standards by 2015” (Mosely, 2014, p. 44); by the Department of Defense who was in the beginning stages of updating its nutritional standards (Mosely, 2014); and Blue Cross Blue Shield, the health insurance enterprise that sponsored Play Streets for urban-dwelling children needing places to “be physically active without fear of traffic (Mosely, 2014, p. 44). But significant to the initiative’s success is the individual adoptions of the plan that include hiring motivational interviewing specialists to coach parents and put children at ease while helping them re-think, reformulate, and reorganize their eating and activity behaviors.
In addition to the statewide and independent initiatives, a few tools and applications have been developed for motivational interviewing and the treatment of childhood obesity in particular. For example, Apple has put out “Change Talk: Childhood Obesity and Overweight” which is a motivational interviewing skill building simulation for pediatricians, nurses, family physicians, and nutritionists, among others. And the Center for Applied Behavioral Health Policy (n.d.) at the University of Arizona provide the support for motivational interviewing training, practice, and feedback, which can be carried out online with a web portal for uploading motivational interview practice recordings for specialty feedback which is otherwise limited in most training and which has been proven to make a difference in improving motivational interviewing skills (see graph below) (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004).
However, there is still a paucity of evidence and thus of evidence-based treatment and prevention programs for children and teens in the primary care setting. Haemer, et. Al (2011) point out that there are major gaps in the capacity of the US medical system to participate meaningfully in childhood obesity-prevention efforts and to meet the treatment needs of obese children” (p. 571), with current childhood obesity treatment and prevention practices varying from “only 52% of primary care providersroutinely plotting a BMI percentile” (p. 573) to childhood obesity specialists working in collaboration with schools and organizations in limited capacities. Besides a lack of training for pediatricians, nurse practitioners, and dieticians, perhaps the most prevalent problem with implementing motivational interviewing as a primary intervention strategy in the treatment and prevention of childhood obesity is with the lack of evidence to support it as a strategy for treating and preventing childhood obesity. And as Söderlund (2010) recounts, “Burke et al. (2003) noted that few of the MI studies could be described as being ‘pure MI,’ as they modified the method in some way, and hence should be considered adaptations of MI” (p. 16). That is, there is a robust body of literature on motivational interviewing for other disciplines, domains, and dimensions of behavioral management. These studies do on the average consider the efficacy of forms of motivational interviewing such as brief motivational counseling; and they do emphasize the effectiveness of motivational interviewing as a primary intervention: Rubak, Sandbæk, Lauritzen, and Christensen (2005) offer a systematic review and meta-analysis of 72 randomised controlled trials using motivational interviewing as the intervention in different healthcare settings. They conclude that “Motivational interviewing had a significant and clinically relevant effect in approximately three out of four studies, with an equal effect on physiological (72%) and psychological (75%) diseases” (p. 325). Teixeira, Silva, Mata, Palmeira, and Markland (2012) offer a meta-review of general motivational interviewing studies that are not specific to children: they note that some studies have used motivational interviewing as a secondary intervention—secondary to behavioral treatments or to standard care approaches and have delivered mixed results, from finding an advantage for motivational interviewing over comparison or control conditions to finding no distinct advantage of motivational interviewing as an adjunct to behavioral interventions for weight loss. However, the authors add, several studies conclude there are advantages to motivational interviewing that extend beyond weight loss advantages, including those that find such benefits as increased physical activity and improved dietary behaviors. Yet the researchers also determine that, “Overall the evidence is at least suggestive that MI can be useful in weight control interventions but it remains unclear just how effective it is, and the extent to which it is effective in different populations” (n.p.).
Several studies of the effectiveness of motivational interviewing are not specific to childhood obesity and/or are those investigating the effectiveness of dual- or integrated treatment interventions: Vanbuskirk and Wetherell (2014) conducted a meta-analysis synthesizing the findings from randomized controlled trials of motivational interviewing for health behavior outcomes within primary care populations in general and found effectiveness of motivational interviewing in clinical settings for weight loss, blood pressure, and substance use. Barrowclough, Haddock, Tarrier, Lewis, Moring, O’Brien, Schofield, and McGovern (2001), investigating treatments for comorbidity of substance abuse disorders with schizophrenia, conducted a randomized controlled trial to compare routine care with routine care and motivational interviewing interventions and found significantly greater improvement in patients’ general functioning with the integration of routine care and motivational interviewing interventions than with routine care alone. Hoek, Marko, Fogel, Schuurmans, Gladstone, Bradford, Domanico, Fagan, Bell, Reinecke, and Van Vorhees (2011) investigated depression in youth by developing and testing a program called CATCH-IT (Competent Adulthood Transition with Cognitive Behavioral and Interpersonal Training), an Internet-based behavior change model for teens, and conducted a randomized controlled comparison of a) primary care provision integrated with motivational interviewing and CATCH-IT and b) primary care provider brief advice and CATCH-IT. The researchers found reduced depression in both groups but significantly fewer depressive episodes with a) primary care provision integrated with motivational interviewing and CATCH-IT at 6-month follow-up.
Other studies are in progress: Gorin, Wiley, Ohannessian, Hernandez, Grant, and Cloutier (2014) are implementing Steps to Growing Up Healthy (Added Value), a randomized controlled trial testing the efficacy of brief motivational counseling (BMC) when it is delivered by primary care clinicians and when BMC is augmented by combining it with monthly visits by community health workers. The patients were Latino and Black children between the ages of 2 and 4 years who participated with their mothers in a 12-month trial aimed at one specific obesity prevention goal such as reducing sugary beverage intake. They anticipate that 1) motivational interviewing will be a step in the best direction for the prevention of childhood obesity and 2) this will be the case especially given the potential for value add with home visits by community health workers to reinforce progress. And Brennan, Walkley, Fraser, Greenway, and Wilks (2008) have begun clinical trials to discern the effectiveness of both cognitive behavior therapy and motivational interviewing for the treatment of childhood overweight and obesity treatment using the 12-session CHOOSE HEALTH Program to find primary and secondary outcomes that included improvement in body composition; and improved cardiovascular fitness, improved eating and physical activity habits, and improved family and psychosocial functioning, respectively.
Yet, for childhood obesity in the primary care setting there is a notable paucity of evidenced support—as was found by this researcher and has been noted by several authorities (e.g., Hardcastle, et al., 2013; Taveras, et al., 2011; Martins & MacNeil, 2009; Resnicow, Davis, & Rollnick, 2006). Thus, what needs to be done first is more specific studies on the effects of motivational interviewing on childhood obesity in the primary care setting. Then there needs to be policy that promotes and supports the informing, activating, engaging, motivating of child patients and their parents to help children who are obese or overweight live healthier lifestyles. And finally there needs to be training, education, and advocacy efforts in place to implement motivational interviewing as a primary intervention in childhood obesity treatment and prevention.
As previous studies have also identified and as has been reiterated here, another problem found to be the case with lack of motivational interviewing for obesity treatment and prevention is that practitioners in the primary care setting including pediatricians, pediatric nurse practitioners, and registered dietitians self-report they have a lack of behavioral management proficiency, a lack of capabilities to provide parenting techniques and a lack of proficiency in addressing family conflicts in the context of treatment of childhood obesity using motivational interviewing strategies (Story, et al., 2002). Silverberg, Carter-Edwards, Murphy, Mayhew, Kolasa, Perrin, Armstrong, Graham, and Menon (2012) duplicate these findings in a study surveying primary care providers and staff at 13 primary care practices in the state of North Carolina, self-reporting respondents who not only perceived effectiveness of obesity treatment was low but who reported low comfort and confidence levels for primary care provider capacity for conducting motivational interviewing. These shortcomings are in spite of the fact that they demonstrate an interest in developing such competencies (Story, et al., 2002). Story, et al. (2002), Martins and MacNeil (2009), and others conclude that this points to the need for increased training opportunities. Indeed, Martins and MacNeil (2009) reiterate the importance of training and practice for health care practitioners, which the authors note has been minimally addressed in the literature, which nevertheless requires variability of skill acquisition, and which might also require more than just the training itself: “Training alone may not be sufficient for the absorption and integration of motivational skills. Although increases in MI proficiency often were noted after training workshops, a tendency to return to baseline over time, with no additional training, feedback, or coaching, has been observed. Ongoing practice and feedback are needed to fully learn and maintain skills” (p. 291). And perhaps most significant is the ambiguity of advocacy of motivational interviewing and the support through policy of motivational interviewing initiatives, training, and support by policy—at both the institutional and state/federal levels. At the institutional level, according to authors such as Midboe, Cucciare, Trafton, Ketroser, and Chardos (2011), implementing evidence-based training should be accompanied by policy supporting assessment of optimum motivational interviewing protocol. Harland, White, Drinkwater, Chin, Farr, and Howel (1999) reiterate that evidence based policy is necessary as opposed to policy that is driven by fashion or the “popularity of the latest schemes” (p. 828). At the state and/or federal level, there needs to be policy advocating motivational interviewing as a primary intervention, as current health policy is more broad in scope and only goes so far as to advocate primary care setting orientation toward prevention and treatment of childhood obesity in general. That is, a more focused policy would emphasize the need for primary care practitioner education, training, and feedback support for effective implementation motivational interviewing as a primary intervention strategy.
Implications for Future Research
This study highlights the gaps and barriers that are still persistent in both the research and clinical practical arenas. Beyond a need for more investigation there exists the need for training, policy, and advocacy for program development for using MI in the primary care setting and for obesity trends currently prevailing in the U.S. in particular. Special emphasis in research and in clinical practice might best lend to solutions for treating child and adolescent obesity including combining treatment strategies—where what has been identified is a combination of etiological and epidemiological factors that insidiously combined or overlapping lend to and require reinforced treatment strategy—such as a combination of parental leadership behavior modification, cognitive therapeutic techniques, and motivational interviewing combined. Perhaps this study has at least returned attention to the seriousness with which obesity must be treated. Perhaps this study will bring more attention to motivational interviewing as a young, barely tested, but thus far credible and qualified approach to helping American children to be healthy in body and mind and continue as healthy adults.
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