Abstract
Physicians should counsel overweight adolescents about nutrition and exercise. We audio recorded 30 physician-adolescent encounters. Female, older, normal weight physicians and pediatricians were more Motivational Interviewing adherent. When physicians used MI skills, patients increased exercise, lost weight, and reduced screen time. Physicians should use MI techniques to help adolescents change.
Keywords: obesity, adolescents, patient-physician communication, Motivational Interviewing
Few physicians are trained to counsel adolescents about healthy weight. Counseling using Motivational Interviewing (MI) techniques has been effective.[1, 2] MI is a patient-centered, directive counseling style used to explore and resolve ambivalence around behavior change[3] that shows promise for parents of overweight children[4] and adolescents.[5] We conducted this study to: 1) assess the quantity and MI quality of weight-related discussions between physicians and overweight adolescents; 2) examine physician characteristics related to discussion quality, and 3) assess whether discussion quality related to changes in fat reduction behaviors, exercise, screen time, sleep, and self-reported weight by one month post-encounter.
Method
Participants
Sixteen physicians consented; none refused. We reviewed physicians’ schedules to identify eligible patients: English-speaking, BMI ≥ 85th percentile for age and gender, age 12−18, not pregnant, and preventive or return visit scheduled. We sent patients and their parents letters, signed by the patient's physician, including a toll-free number for refusal. We obtained parents’ and patients’ verbal assent and administered a baseline telephone survey. Our research assistant then met patients in clinic and audio recorded their visits. Patients answered a follow-up survey one month later, and both patients and physicians received $20 upon completion. This project was approved by Duke's Institutional Review Board.
Measures
Patient and physician demographics
Birth date, race, gender, self-reported weight and height, actual weight and height, MD specialty (pediatrics/family practice), and patients’ self-reported weight at follow-up.
Patient fat intake
At baseline and follow-up, assessed preparation method and food consumption with the 33-item Kristal Food Habits Questionnaire[6] (α = .62 in this sample).
Patient physical activity
At both surveys, used an adaptation of the 13-item Framingham Physical Activity Index[7] with the Compendium of Physical Activities to determine frequency and duration of moderate or vigorous physical activity (MVPA).[8]
Sleep
At both surveys, assessed average daily time patients spent sleeping and napping.
Screen time
At both surveys, assessed hours and minutes of daily (excluding school) television/video/computer time.
Audio recording measures
Content
Coded five “weight-related” topics: nutrition (including breakfast, sweetened beverages, and fast food), exercise, screen time, sleep, and BMI.
Motivational Interviewing
Two independent coders used the Motivational Interviewing Treatment Integrity scale (MITI).[9] Coders made global ratings of Empathy (conveying an understanding of patients’ perspective) and “MI Spirit” (includes evocation: “eliciting” patients’ own reasons for change; collaboration: acting as partners, supporting and exploring patients’ concerns; autonomy: conveying that decisions to change lie within patients).
Coders also counted closed and open questions, simple reflections (conveys understanding, but adds no meaning to what the participant said), complex reflections (conveys understanding and adds substantial meaning), MI adherent behaviors (asking permission, affirming, providing supportive statements, and emphasizing control), and MI non-adherent behaviors (advising without permission, confronting, and directing). We created four scores (overall ICC = .92) based on ratios of: (1) Open questions to all questions, (2) Reflections to questions, (3) Complex reflections to all reflections, and (4) MI adherent to MI non-adherent behaviors.
Results
We sent 173 potentially eligible patients letters describing the study. Of 160 screened, 16 (10%) refused; 91 (57%) were ineligible. Twenty-three (43%) of the 53 eligible patients had no audio recordings (missed appointments or technical error); these 23 patients did not differ from the 30 in the final sample on gender, race, age, BMI percentile or self-reported BMI (.20≤ p≤ .89). All 30 with audio data completed the follow-up survey.
Sample characteristics
See Table 1. Patient self-reported weight over the phone (M=173.7, SD=36.3) strongly correlated with measured weight (M=181.2, SD=38.2; r=.93).
Table 1.
Characteristics of patients and physicians
| Characteristic | Patient (n=30) M (SD) or % | Physician (n=14) M (SD) or % |
|---|---|---|
| Age (M, SD) | 14.3 (1.6) | 41.1 (8.7) |
| Race (%) | ||
| White | 26.7 | 78.6 |
| Black | 73.3 | 21.4 |
| Female (%) | 63.3 | 64.3 |
| New patient with physician (%) | 26.0 | -- |
| BMI percentile (M, SD) | 94.7 (4.6) | -- |
| BMI | 30.5 (6.0) | 23.6 (4.6) |
Quantity of weight-loss discussions
Weight-related topics were addressed in 27 of 30 encounters and comprised a mean of 6.0 (SD =4.9) minutes per encounter. These were, in order of decreasing frequency: nutrition, exercise, BMI/weight, sleep, and screen time.
Quality of discussions
Physicians had low to moderate mastery of MI skills: open/all questions (M=0.2, SD=0.1), reflections/questions (M=0.3, SD=0.3), complex/all reflections (M=0.2, SD=0.2), and MI adherent/MI non-adherent behaviors (M=0.5, SD=0.2). They also had low to moderate global ratings of Empathy (M=2.7, SD=0.8) and MI Spirit (M=2.2, SD=0.8).
Physician predictors of MI skills
Female physicians and physicians with BMIs below the median asked more open-ended questions and made more reflections than questions (.05≤ p≤ .001). Older physicians also made more reflections (p=.05). Pediatricians were more MI adherent than family physicians (p=.02).
Relationships between MI skills and patient outcomes
When physicians were more MI adherent, patients reported increasing moderate physical activity (r = .41, p=.06; Table 2). With higher physicians’ MI Spirit score, patients reported reduced weight (r = −.46, p=.02). When physicians used more complex reflections, patients reduced their screen time (r = −.41, p=.08).
Table 2.
Spearman correlations between MI skills and changes± in patient weight-related behaviors from baseline to one month after the encounter
| MITI scores | Mean or ratio (SD) | Behaviors to reduce fat intake | MVPA | Sleep | Screen time | Self-reported weight |
|---|---|---|---|---|---|---|
| Empathy1 | 2.7 (0.8) | .13 | .00 | .02 | −.09 | −.19 |
| MI Spirit2 | 2.2 (0.8) | −.06 | .05 | −.14 | .00 | −.46** |
| Open-ended/all questions | 0.2 (0.1) | .23 | −.30 | .17 | −.11 | .27 |
| Reflections/questions | 0.3 (0.3) | .08 | −.31 | .02 | .17 | .14 |
| Complex/all reflections | 0.2 (0.2) | .05 | −.17 | .02 | −.41* | .08 |
| MI-ad/MI non-ad | 0.5 (0.2) | −.01 | .41* | .25 | .04 | −.32 |
± Change in behavior = 1 month behavior – baseline behavior: For MVPA and sleep, positive correlation indicates an increase in physical activity and sleep. For fat intake, screen time and self-reported weight, a negative correlation indicates a reduction in fat intake, screen time and weight.
Empathy assessed on 5-point Likert scale with 1=Not at all empathic and 5=Extremely empathic
MI Spirit assessed on 5-point Likert scale with 1=Very low MI Spirit and 5=Very high MI Spirit
p≤.10
p≤.05
Discussion
As most of these physicians had no training in MI, their low MI skill level is not surprising. Some, however, were more skilled than others. Female physicians, older physicians, pediatricians, and those with lower BMIs demonstrated higher level of MI skills. This is consistent with studies suggesting female physicians are better communicators than male physicians.[10]
MI skills used during weight-related discussions were associated with patient behavior change. Physicians’ higher MI Spirit was associated with patients’ self-reported weight and greater MI adherence was associated with more patient exercise. These findings replicate those found in adult,[1] pediatric,[4] and adolescent samples.[5] Thus, encouraging and training physicians to use MI techniques may help adolescent patients attain a healthy weight.
Limitations and strengths
The small sample limited power; however, correlations were strong and suggest relationships beyond chance. We did not conduct nested analyses. Results may not generalize to settings outside of academic medical centers; however, we likely portray a best-case scenario. Our measures for nutrition, exercise, and weight were simple; yet, self-reported weight at baseline correlated highly with measured weight.
Implications
This is the first study to examine weight-related discussions between primary care physicians and overweight adolescents. Findings suggest that physicians should be taught to address weight-related topics more effectively to encourage behavior change in adolescent patients. In addition, male, younger, family physicians, and those with higher BMIs, may benefit more from training.
Acknowledgements
We would like to thank Ayana Simon for her work on this project. We also would like to thank the gracious physicians (Michelle Bailey, MD, Jeffrey Baker, MD, Debra Best, MD, Dennis Clements, MD, Elizabeth Landolfo, MD, Beatriz Blanco Morris, MD, John Moses, MD, Betty Staples, MD, Gloria Trujillo, MD) and adolescent patients and their parents who agreed to have the adolescent-physician encounters audio recorded.
This work was supported by internal funds from the Department of Community and Family Medicine and the Department of Pediatrics at Duke University Medical Center. The authors were supported in part by grants R01CA114392, R03CA113151, R01CA100387, R01DK64986, and R01DK075439.
Footnotes
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Statement of Conflict of Interest
No authors have any conflicts of interest to report.
References
- 1.Pollak KI, Ostbye T, Alexander SC, et al. Empathy goes a long way in weight loss discussions. J Fam Pract. 2007 Dec;56(12):1031–1036. [PubMed] [Google Scholar]
- 2.Rubak S, Sandbaek A, Lauritzen T, et al. Motivational interviewing: A systematic review and meta-analysis. Br J Gen Pract. 2005 Apr;55(513):305–312. [PMC free article] [PubMed] [Google Scholar]
- 3.Emmons KM, Rollnick S. Motivational interviewing in health care settings: Opportunities and limitations. Am J Prev Med. 2001;20(1):68–74. doi: 10.1016/s0749-3797(00)00254-3. [DOI] [PubMed] [Google Scholar]
- 4.Schwartz P, Hamre R, Dietz W, et al. Office-based motivational interviewing to prevent childhood obesity. Arch Pediatr Adolesc Med. 2007;161:495–501. doi: 10.1001/archpedi.161.5.495. [DOI] [PubMed] [Google Scholar]
- 5.Olson AL, Gaffney CA, Lee PW, et al. Changing adolescent health behaviors: The healthy teens counseling approach. Am J Prev Med. 2008 Nov;35(5 Suppl):S359–364. doi: 10.1016/j.amepre.2008.08.014. [DOI] [PubMed] [Google Scholar]
- 6.Patterson RE, Kristal AR, Shannon J, et al. Using a brief household food inventory as an environmental indicator of individual dietary practices. Am J Public Health. 1997;87(2):272–275. doi: 10.2105/ajph.87.2.272. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Kannel W, Sorlie P. Some health benefits of physical activity: The Framingham Physical Activity Index. Med Sci Sports Exerc. 1997;29(6 Suppl):533–538. [Google Scholar]
- 8.Ainsworth BE, Haskell WL, Whitt MC, et al. Compendium of physical activities: An update of activity codes and MET intensities. Med Sci Sports Exerc. 2000 Sep;32(9 Suppl):S498–504. doi: 10.1097/00005768-200009001-00009. [DOI] [PubMed] [Google Scholar]
- 9.Moyers TB, Martin T, Manuel JK, et al. Assessing competence in the use of motivational interviewing. J Subst Abuse Treat. 2005 Jan;28(1):19–26. doi: 10.1016/j.jsat.2004.11.001. [DOI] [PubMed] [Google Scholar]
- 10.Hall JA, Irish JT, Roter DL, et al. Satisfaction, gender, and communication in medical visits. Med Care. 1994;32(12):1216–1231. doi: 10.1097/00005650-199412000-00005. [DOI] [PubMed] [Google Scholar]