CE for NURSES! Talking to Patients About Bariatric Surgery

| November 1, 2015

*This is a Complimentary Clinical Nursing Education Activity*

Nurses: Earn 1 Contact Hour. See instructions below.

Talking to Patients About Bariatric Surgery: Guiding Meaningful Conversations and Evoking Commitment to Change

by Gretchen E. Ames, PhD, ABPP; Matthew M. Clark, PhD, ABPP; Karen B. Grothe, PhD, ABPP; Maria L. Collozo-Clavell, MD

Gretchen E. Ames, PhD, ABPP, is from the Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, Florida. Mathew M. Clark, PhD, ABPP, and Karen B. Grothe, PhD, ABPP, are from the Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota. Maria L. Collozo-Clavell, MD, is from the Department of Endocrinology, Mayo Clinic, Rochester, Minnesota.

Bariatric Times. 2015;12(11):16–24.

Abstract
The purpose of this article is to discuss potential applications of a method of communication called motivational interviewing. This educational article is based on the book, Motivational Interviewing: Helping People Change, 3rd Edition. It is designed to introduce readers to the fundamental processes and core skills of motivational interviewing and how they may be applied in conversation with patients with obesity.


 

CoverTO COMPLETE THE ACTIVITY:
Participants must read the designated article and take, submit, and pass the post-test by November 1, 2016. Participants must answer at least 70% of the post-test questions correctly to pass and receive credit for the activity. Upon successful completion of the post-test, participants will receive a certificate of completion. Take the test at http://tinyurl.com/BTCENov2015

More information at the end of this article.


Introduction
Obesity is a significant public health problem in our country, and most people who start a weight loss program will dropout or regain lost weight.[1] There is now a significant body of research supporting bariatric surgery as the most effective multidisciplinary treatment for patients with medically complicated obesity (body mass index [BMI] >35kg/m2) that reliably produces significant weight loss and health benefits that are well maintained overtime.[2] Bariatric surgery has the potential to also improve mood, self-efficacy, and quality of life.[3–5] Yet, misconceptions about obesity and negative perceptions about bariatric surgery persist. Barriers such as lack of understanding about the level and severity of one’s obesity or perception that bariatric surgery is too risky or “is the easy way out” are common.[6] Thus, a style of communication between the provider and the patient with obesity that embraces shared-decision making and resolution of ambivalence, while at the same time supporting the patient’s autonomy and choice, is needed. The purpose of this article is to discuss two potential applications of a method of communication called motivational interviewing (MI) for engaging patients in a conversation about bariatric surgery when it is likely to be the most effective treatment option for a specific patient with obesity. MI is a person-centered guiding method of communication between the healthcare provider and patient that elicits and strengthens the patient’s own reasons and motivation for change. This article first focuses on using MI to guide conversations and shared-decision making with patients who are ambivalent about bariatric surgery when it is medically indicated. Second, strategies for using MI to guide commitment when patients are ambivalent about making lifestyle changes necessary for optimal outcome following bariatric surgery are outlined.

Barriers to effective treatment for medically complicated obesity are multifaceted and encompass both patient and healthcare provider issues.[7,8] There is lack of awareness among healthcare providers about the complexity of a patient’s struggle with obesity as a chronic disease in a society that promotes high-calorie foods and a sedentary lifestyle.[9,10] The ubiquitous message promoted by providers continues to be “eat less and exercise more” even when this approach is likely to fall short of patients’ expectations for successful weight loss.[10] Lifestyle change recommendations alone are likely to be inadequate for patients with a longstanding history of severe obesity. Furthermore, many providers have a poor understanding of biological adaptations to weight loss that attenuate the long-term effectiveness of behavior change interventions.[10–12] Because of increased metabolic efficiency, maintaining lost weight will require an indefinite reduction in calorie intake and a high level of physical activity that, for most patients with obesity, will be unsustainable in modern society.[13] Therefore, it is imperative that healthcare providers better educate themselves about their patients’ struggle with obesity as a chronic medical condition in order to engage in shared-decision making on whether bariatric surgery is the right treatment for them.

Previous research has shown that many patients report disinterest in bariatric surgery and will choose nonsurgical weight loss when they would likely receive greater health benefits from bariatric surgery.[7] This choice may be related to lack of understanding of the causes of one’s own obesity and lack of understanding of the risks to health, wellness, and survival of associated medical comorbidities.[14] Furthermore, many patients lack knowledge about the safety and efficacy of bariatric surgery.[6] A recent survey of adults in the United States population asked participants to identify their weight status and whether weight loss surgery was an acceptable treatment option.[6] More than 40 percent of the participants who were identified as having class III obesity (BMI ≥40kg/m2), according to self-reported height and weight, underestimated their class of obesity. Overall, 45 percent of the participants with class III obesity indicated bariatric surgery was an unacceptable option for treatment and provided reasons such as “too risky,” “doesn’t work,” or “don’t need it.” The authors concluded that, in their sample, the people likely to receive the greatest benefit held the most misconceptions about bariatric surgery.[6]

In our clinical experience, we have found that patients have other reasons for choosing a method of weight loss that has a lesser chance of helping them reach their desired outcome. For many patients, there appears to be a culture of shame around bariatric surgery that includes a desire for secrecy and fear of negative judgment. They find it difficult to admit to themselves and perhaps to family and friends that bariatric surgery may be a necessary next step needed to treat their medically complicated obesity. The culture of shame is fueled by public perception and media images that bariatric surgery is a gimmick and unnecessary to achieve substantial weight loss.[15] Relatedly, the predominant idea among many patients is one of self-reliance, such as “I should be able to do this on my own without surgery” or that “surgery is the easy way out.” Even after years of failed attempts at dieting, many patients continue to believe that if they simply eat less and make more time for exercise, they can achieve any amount of weight loss they desire. Thus, they continue on a cycle of dieting that includes losing some weight before reaching a plateau as biological adaptation to weight loss occurs and further weight loss stops. When weight loss stops short of their desired outcome, patients typically either choose to attempt more extreme dieting or they abandon their weight loss efforts altogether. Either of these choices is often followed by gain of more weight than was initially lost. After multiple failed dieting attempts, patients commonly attribute their lack of success to personal failure.

A challenge for providers then is determining how best to engage patients in a thoughtful conversation about weight and a shared decision about what will be the best option for obesity treatment. This may be particularly challenging for healthcare providers who may lack confidence in their skills to discuss weight.[16] Obesity is not simply a condition resulting from lifestyle choices and/or lack of personal responsibility. Rather, once a certain level of obesity is reached and maintained for a period of time, a biological intervention like bariatric surgery is likely to be the only therapeutic option that will result in meaningful weight loss that can positively impact associated health conditions.[10] Moreover, providers can help address challenges like patients’ insistence on self-reliance (e.g., “I just need to give dieting one more try.”) or shame about considering bariatric surgery as viable treatment option (e.g., “If I have bariatric surgery that means I lack willpower and ambition.”). Supporting autonomy and choice in the process of shared-decision making is equally important during the conversation. Bariatric surgery is not an appropriate treatment for every patient with medically complicated obesity, and some patients who choose to undergo a bariatric operation will regain weight.[17]

Brief Overview of MI
MI is a clinical method of communication that can effectively be used to change the conversation between healthcare providers and patients about treatment options for obesity. This method is applicable when a shared and informed decision is necessary or when behavior change is needed to optimize health.[18] MI is defined as a person-centered guiding method of communication between healthcare provider and patient that elicits and strengthens the patient’s own reasons and motivation for change.[19] The spirit of MI is to create a nonjudgmental, supportive environment where patients can explore and resolve ambivalence about making changes in beliefs and behavior that will promote better health. MI was developed over the past 30 years as a treatment method for a wide range of problem behaviors, including drug, alcohol, and tobacco addiction, and more recently has been applied to other problem behaviors associated with chronic diseases, such as diabetes management and obesity treatment. [19–21]

MI has four fundamental processes for engaging patients in a conversation about their health that focuses on potential areas for change in beliefs and behavior, evoking patients’ reasons for change while building and strengthening their motivation, and finally planning next steps. The core skills used to guide patients through the MI processes are open-ended questions (O), affirmations (A), reflections (simple and complex [CR]), and summaries (S) offered at key transition points in the discourse (Table 1).

Open-ended questions. Open-ended questions cannot be answered with a “yes” or “no” and are designed to engage patients in a conversation about change related to their struggle with obesity. These questions offer an opportunity for patients to explore their current experience and to focus on what life would be like without the barriers associated with their severe obesity. One such open-ended question may be, “What concerns you most about your weight right now?” Effectively, a conversation moves forward toward change by helping patients connect with their core values and experiences that give meaning to their lives.

Affirmations. Following open-ended questions, healthcare providers offer affirmations and reflective statements while refraining from playing the role of an expert and giving advice. Affirmations involve attributing genuine positive traits to the patient to build rapport, demonstrating active listening, and highlighting their strengths (e.g., “It’s great that after all these years of dieting, you have never given up on trying to achieve a healthy weight.”).

Reflective statements. Reflective statements are the essential core skills of MI that move conversations forward by hypothesis testing or guessing about patients’ meaning (e.g., “What I think you are saying is that right now your weight is holding you back from accomplishing life goals that are important to you.”). They are designed to evoke change talk—any patient language in favor of movement toward a behavior change goal (e.g., “You are ready to consider bariatric surgery so that you will be healthy enough to take your grandchildren to the park and travel with your husband.”). Reflections can also evoke ambivalence and give patients the opportunity to explore their concerns about behavior change (e.g., “On one hand, your past experiences with dieting have been frustrating and you just want to give up, and on the other hand, losing weight and being active with your family is very important to you.”). A patient’s expression of ambivalence—feeling two ways about making a change—is a normal part of the MI process. Patients frequently engage in sustained talk or speech in favor of not changing.

In the spirit of MI, providers must resist the urge to correct logic (i.e., righting reflex) or give information or advice prematurely. Reflective listening ultimately helps patients build inquiry around their present behavior or circumstance and their larger goals and values. If discrepancies arise between present behavior and future goals, patients will verbalize their own reasons for making changes, which enhances motivation (e.g., “I’ve seen the bad things that happen to people who have diabetes for a long time, and I don’t want that for myself.”).

Reflections are the most important, yet the most difficult skill to master in MI.[19] They range from simple and stabilizing, such as rephrasing what the patient said to complex and forward moving. Forward moving reflections that guide patients toward a targeted change may include anticipating what the patient may say next, paraphrasing, reflection of feeling, amplification, using metaphors, or double-sided reflections (Table 1). Ideally, the provider listens for change talk (e.g., “I’m tired of dieting and regaining weight. Something has to change.”) and may respond with a reflection using a metaphor (e.g., “Dieting seems like a vicious cycle to you, and you are ready to make a positive change.”). Relatively simple tools like assessing importance and confidence using change rulers can be used to help prepare and mobilize patients for change. Patients may be asked to rate the importance of a change on scale from 0 (not at all) to 10 (extremely). For example, a provider may ask, “How important is it for you on a scale of 0 to 10, where 0 is not at all important and 10 is extremely important, to reduce consumption of fast foods in preparation for bariatric surgery.” If the patient responds with, “about an 8,” the provider may ask, “so given your busy schedule, what makes you an 8 instead of a 3?” The resulting response from the patient will be change talk (e.g., “I know I won’t be able to tolerate those foods after bariatric surgery, so I need to start planning my meals better now.” A follow-up response by the provider may be, “How confident are you on scale from 0 to 10 that you will be able to reduce your fast food consumption over the next month?” The patient may respond with, “about a 5,” and the provider may ask, “What would need to happen to make your confidence rating a 7?” The response by the patient is likely to be change talk. Ideally, the provider and patient enter into the planning process of MI when the patient arrives at high ratings of both importance and confidence regarding a change (Table 2).

Using MI to Discuss Bariatric Surgery
MI is a potentially useful method for changing a negative conversation about bariatric surgery and, in effect, reducing or eliminating patient barriers to bariatric surgery. The intention of using MI with your bariatric patients is to resolve ambivalence about bariatric surgery while supporting autonomy and choice, keeping in mind that patients’ choice may still be to refuse bariatric surgery. Even if patients say they do not want to have bariatric surgery, they may come away from the conversation with a better understanding of their struggle with weight and reduced self-judgment and criticism.

Table 3 contains MI strategies that can be implemented in a brief office visit to facilitate change in beliefs and/or behavior.

MI is also appropriate for helping strengthen patients’ commitment to lifestyle changes to support an optimal postoperative course. A recent study showed that in a large sample of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2), there were relatively high rates of problematic eating behaviors prior to bariatric surgery.[22] These behaviors included skipping breakfast, evening hyperphagia, eating when not hungry or when full, eating with a sense of loss of control, and frequent consumption of fast foods. In the LABS-2 sample, 16 percent of participants met criteria for binge eating disorder (BED), and those with BED had higher rates of symptoms of depression than those without binge eating problems. Addressing these issues prior to bariatric surgery is important as some patients may experience the return of low mood and disordered eating contributing to weight regain after initial successful weight loss following bariatric surgery.[5,23]

Patient Vignettes
The following are prepared vignettes to demonstrate the use of MI illustrating common barriers patients with obesity present to seeking bariatric surgery. The vignettes also illustrate the core skills of MI listed in Table 1.

Vignette 1: Fear of surgery. Vignette 1 presents a conversation with a 54-year-old female patient with a BMI of 39kg/m2 and a history of type 2 diabetes mellitus (T2DM). She was divorced, employed, and has no mental health history. She was fearful of bariatric surgery and assumed that it did not work.

Patient: I know I was referred here by my doctor to talk about weight loss surgery, but there is no way I would ever consider it. That’s not for me.

Provider: I’m interested in hearing more about what you already know about weight loss surgery. Can you tell me a little bit about that? (O)

Patient: Well, my sister-in-law had it last year, and she has been horrible to my brother. She thinks she is too good for him now. She goes out with her friends all the time, and he has no idea where she is. Also, one of my co-workers had it too and hasn’t lost any weight. She’s sick all the time and actually looks like she’s gained some weight. She eats all the same stuff she used to eat before the surgery. I think she had the adjustable gastric band procedure—I’m not sure.

Provider: I can see why having weight loss surgery would seem like a bad decision to you. (A) All of the people you know who have undergone weight loss surgery have had experiences that you do not see as positive. (CR-amplified)

Patient: Well, I guess not all of them. One of my cousins had it about 10 years ago and he lost a lot of weight and was able to stop most of his medications. He was over 400 pounds though and he needed to lose a lot of weight. I’m certainly not that big.

Provider: So, you have seen your cousin lose a lot of weight after having bariatric surgery and also saw his health improve dramatically. (CR-continuing the paragraph)

Patient: I think so. I don’t talk to him much but I’ve heard he’s kept his weight off pretty well and that he is much more active, like going camping with his family. Something he could not do for many years.

Provider: He’s been able to keep his weight off for many years. That’s pretty difficult. (CR-continuing the paragraph)

Patient: Yes. I’ve lost and gained over 30 pounds at least 10 times in my life, but I’m never able to keep it off. And usually I gain back more than I lost. So I’ve given up trying for the last year.

Provider: You have put a lot of effort into weight loss over the years and are frustrated with always regaining even more than what you’ve lost. So frustrated by this weight loss followed by weight regain cycle that you’ve given up on trying to lose weight. (CR-reflection of feeling)

Patient: Yes, and that’s bad because now my diabetes is getting worse. My A1C was up to 8.5 at my last visit. My doctor says the next step is insulin if I don’t lose some weight. I don’t want to have to mess with that; it worries me. One of my aunts died from complications of diabetes so I know how bad it can get.

Provider: On one hand, you are not at all confident that you can lose weight and keep it off, and on the other hand, the increase in your A1C is bothering you and you don’t want to start insulin. (CR-double sided)

Patient: Pretty much. First, I hate shots, so having to take insulin would be very difficult for me. And I have seen the long-term problems associated with poorly managed diabetes. My doctor did tell me that gastric bypass surgery could get rid of my diabetes. That’s why he sent me to you. But the thought of that surgery really scares me.

Provider: Even though you are scared of weight loss surgery, you are concerned enough about your diabetes getting worse that you came to the appointment today and may be ready for a change. (CR-guessing about meaning)

Patient: Yes. I don’t think I can lose weight on my own. I’ve been trying for years. But I know I need to find a way to lose weight and keep it off.

Provider: So, you are worried about your health, particularly your diabetes getting worse. And you have seen the complications associated with poorly managed type 2 diabetes. At the same time, you are frustrated with the cycle of dieting and weight regain that you’ve experienced up until now and are feeling somewhat hopeless about your ability to lose weight and keep it off. Your primary care physician mentioned Roux-en-Y gastric bypass surgery (RYGB) to you recently as a possible treatment for your diabetes27 but you have some concerns. (S) Many patients in your situation are fearful about weight loss surgery—that’s perfectly normal. If you would like, I can share with you more information about RYGB as a treatment for diabetes. How does that sound to you?

Patient: OK. I suppose I should know more about it.

Provider: Of course the decision to undergo weight loss surgery is entirely yours. If you wish, the bariatric surgery team will provide you with the information necessary to make an informed choice about whether or not RYGB is the right treatment for you.

Vignette 2: Self-reliance. Vignette 2 presents a conversation with a 59-year-old male patient (height 175cm, weight 303 pounds) with a BMI of 46kg/m2 and obstructive sleep apnea (OSA). He was married, employed, and considering retirement in the next five years. He had strong feelings about self-reliance and was determined to lose weight on his own.

Provider: You mentioned you have struggled with your weight since your mid-20s. Have you ever considered weight loss surgery?

Patient: No. Weight loss surgery is the easy way out. It’s for people who don’t have will power. Me, I want to give it another try on my own first. I’ve changed some things and lost 25 pounds in the last three months.

Provider: That’s great you decided to make a change. (A) Tell me what you think is going well with your eating right now. (O)

Patient: Well, I cut out soda and sweet tea. That was a problem. I was having about six per day. I also stopped taking second helpings at dinner too. But I’m still snacking after dinner when I watch TV.

Provider: Some things you think are helping with weight loss are cutting out sugary drinks and reducing portions, and you see some other areas for improvement. (CR-guessing about meaning)

Patient: I guess because the weight loss has slowed down. I lost 25 pounds pretty quickly but now I’m not losing much at all. This always happens. I lose weight easily at first and then I get frustrated and give up.

Provider: You’ve had times in the past where you hit weight loss plateaus and it becomes really hard to lose more weight. (CR-continuing the paragraph)

Patient:  Yes, but then I remember the time I was able to lose 70 pounds by cutting back on my junk food and exercising a lot. At that time I was running six miles every day. I’ve done it before; I just need to try harder and make more time for exercise.

Provider:  You think if you tried a little harder you could weigh anything you want to weigh. (CR-amplified)

Patient: I’m not sure. The 70 pounds I lost was years ago. I was younger and could really exercise. Now, I have knee problems and back pain. It seems like weight loss gets harder as I’ve gotten older and my health is getting worse. Now I’m on medication for high blood pressure and high cholesterol, and my doctor said I am getting closer to diabetes—whatever that means.

Provider: You’ve hit a plateau with your weight loss and you are concerned enough about your health that you came in today to discuss your options for successful weight management. (CR-guess about meaning)

Patient: Yes. I need to lose 100 pounds at least. There are things that I want to be able to do like travel with my wife now that the kids are out of the house. I want to be healthy enough to enjoy my retirement when that time comes, which might be in five years.

Provider: You have a vision for your future and have thought a lot about the kind of life you want to live when you retire. (CR-continuing the paragraph)

Patient: I suppose so.

Provider: Losing weight is very important to you for many reasons (A). How confident are you that you can achieve your weight loss goal with dieting like you are doing now? (O)

Patient: I’m not sure I can succeed.

Provider: So, you lack confidence for success and at the same time your motivation to lose weight is high (CR-double sided). If it’s OK with you, at this point I would like to share with you options for weight management treatment.

Patient: OK, it would be good to have more treatment options.

Provider: A patient’s struggle with obesity is not about lack of desire, effort, or will power to lose weight. It is more complicated than that. We know that with lifestyle changes alone the initial goal for weight loss is 5 to 10 percent of initial body weight. For you, a 5 to 10 percent weight loss represents 15 to 30 pounds. So, with your recent efforts you have been successful at achieving a 25-pound weight loss that is within the range expected. However, we also know that for the majority of patients, maintaining that weight loss is challenging. This is not a personal failure but rather the result of biological processes that occur during weight loss that make you feel hungrier, less full, and desire highly palatable foods10,13 and this makes it more difficult to adhere to the dietary changes you’ve made. There is also a decrease in the body’s calorie burning capacity during weight loss that contributes to weight regain. Bariatric surgery is associated with more weight loss and better chances at keeping it off. Depending on the operation, weight losses of up to 20 to 35 percent17 can be observed after the first year. For you, that would represent an additional weight loss of 75 to 105 pounds. That degree of weight loss has a more positive impact on obesity-related diseases like metabolic syndrome and sleep apnea. But there is more to learn about bariatric surgery in order to help you make an informed choice about whether it is the right treatment for you. Would you like to hear more?

Vignette 3: Dietary change challenges. Following are prepared vignettes that demonstrate conversations with patients who have decided to undergo bariatric surgery but are struggling with changing behaviors in preparation for it.  Vignette 3 presents a conversation with a 43-year-old female patient with a BMI of 42kg/m2 and hypertension. She ate many meals away from home. She was employed, married, and had several adolescents in the home. She was struggling to reduce the frequency of eating out and making healthy choices when she did dine out.

Provider: So you’ve decided to move forward with the recommended  sleeve gastrectomy procedure (SG). That’s great. I know achieving a healthy weight is important to you. (A)

Patient: Yes. I’ve been thinking about it for two years now, and I’m finally ready.

Provider: You met with the dietitian last month and talked about the recommended dietary changes in preparation for SG. What changes do you think are going well so far? (O)

Patient: Well, I understand that I will be eating a lot less after surgery, so I’ve been trying to work on reducing portions. It’s hard though because I eat out a lot. I don’t have much time to prepare meals at home with my work schedule and my kid’s activities. I figure the surgery will help me eat less, so I don’t really need to change how much I eat out.

Provider: It’s great that you’ve been thinking about the dietary changes and that you’ve started paying attention to how much you are eating. Awareness is an important first step in making positive lifestyle changes. (A) With your busy schedule, you don’t have much time for meal planning and preparation. (CR-continuing the paragraph)

Patient: Yes, and it doesn’t help that I don’t really like to cook. My family complains about my cooking, and I am tired when I get home from work. If nothing is planned for dinner, we end up eating out a lot or getting fast food. My husband does help out with the grocery shopping at times, but no one really cooks or plans meals.

Provider: It’s easier to eat out, and no one in your family enjoys cooking or is interested in meal planning and preparation. (CR-amplified)

Patient: I wouldn’t say no one is interested. My husband and I have talked about eating more at home because we are worried about our daughter’s weight. She’s much heavier than she should be for her age, and we don’t want her to have the same struggles with weight that I’ve had.

Provider: You would probably eat better if you didn’t eat out so much, and this would be good for your daughter too. (CR-guessing about meaning)

Patient: I think so. Less fast food at least.

Provider: So, the dietary changes that are required to get ready for bariatric surgery might be good for your whole family, like hitting a reset button. (CR-continuing the paragraph and metaphor)

Patient: Yes. My husband and I have talked about that a little bit.  If we all worked together, it would be easier to make healthy changes.

Provider: You have decided to take an important step toward improving your health, which will benefit you and your family. You are aware that in order to experience the best outcome after bariatric surgery, you will need to make some significant changes in your current eating habits, the number of times per week you eat out in particular. (S) If you think it would be helpful, I can share with you some things we know are important factors to being successful.

Patient: Yes. I would like to know more.

Provider: As you have already identified, reducing how much you eat is very important. But what you are eating is equally important because of how your body reacts to the nutrient composition of certain foods.28 For example, diets high in fat and processed foods may interfere with hormones that send signals to your brain that tell you when to stop eating.29 Also, high-fat foods are very calorie dense so you can consume a lot of calories even with small portions. So, if you eat high-fat foods after bariatric surgery, you will start to regain weight even if your portions remain small. Many of the obstacles that you identify may not change with the SG, like your busy schedule or challenges in meal planning and preparation. Making changes in your eating habits will be challenging, but you have identified some really important reasons to do so. It’s your choice if and when to make changes in your eating habits. Should you decide to put your efforts toward preparing more meals at home, I’m confident that with support from your family you will be able to do it.

Vignette 4: Food as primary coping mechanism. Vignette 4 presents a conversation with a 50-year-old female patient with a BMI of 48kg/m2 and impaired fasting glucose, OSA, and hypertension. She was single, employed, and had been in counseling in the past for stress reduction. She was scheduled to undergo RYGB and, since she used food as a primary coping strategy for negative emotion, she worried about not being able to rely on food for stress and mood management.

Patient: I know after I have gastric bypass, I won’t be able eat as many sweets as I do now. The dietitian told me about the dumping syndrome and that those types of foods may make me feel sick. That’s probably a good thing—knowing more about the negative consequences of eating sweets. My difficult times are when I’m at work feeling stressed or in the evening at home when I’m relaxing. That’s when I go for the ice cream or whatever sweets are around.

Provider: It’s great that you’ve already been thinking about some healthy changes in your eating patterns that will optimize your weight loss after RYGB. (A)  You’ve been thinking about how taking the dietary change recommendations from the dietitian to heart will help you avoid negative consequences. (C-using a metaphor)

Patient: I really want to do well after surgery. It would be awful to go through all of this just to gain the weight back, or to feel sick all the time. But I’m worried about what I will do when I feel stressed, especially at work. I always reach for the chocolates in the candy dish on my co-worker’s desk or sweets in the break room when something upsets me. Food is my emotional crutch. I often turn to food for comfort.

Provider: You are worried that after RYGB when stress comes up at work, it will be hard to resist eating something sweet to calm you down, to comfort you. (CR-guess about meaning)

Patient: Yes. That worries me a lot. Ever since I was a little kid, I remember eating when I was upset. My mom was critical about my weight and put me on my first diet when I was 12 years old. She was always watching what I ate so, I used to sneak food into my room so that no one would see me eating. Then, when I went to college, I gained a lot of weight from school-related stress. I kept this pattern of emotional eating when I started working. Food has been my companion for as long as I can remember.

Provider: Eating for emotional comfort has been a long-standing pattern of behavior for you. (CR-continuing the paragraph)

Patient:  I think so. I wonder what will happen when I can’t eat my comfort foods anymore after surgery. I mean, if I take this drastic of a step for weight loss, I want it to work.

Provider: Right now you lack confidence in your ability to control emotional eating. (CR-guessing at meaning)

Patient: I haven’t been able to do it in the past. I always try to avoid my favorite foods when I diet, but I can never do that for very long. Eventually, I get stressed out and turn to sweets for comfort. Then I feel like a failure and give up on my diet.

Provider: It may even seem that dieting makes the problem worse. When you diet, you focus on foods you can’t have, like sweets. (CR-continuing the paragraph)

Patient: Yes, and that only lasts for so long, especially when I’m feeling stressed and there are sweets everywhere. My office environment is horrible. My co-workers bring in treats every day. What will I do after surgery when I want to eat things that I know I shouldn’t be eating? One of my friends who had RYGB told me that surgery fixes your stomach but not your head.

Provider: You have obviously put some thought into the negative consequences of emotional eating on your weight, and you have a lot of insight about some of the challenges you may encounter after surgery. (A) If you would like, we can talk more about what other patients who struggle with emotional eating have tried when dealing with emotional distress after RYGB. This is a common issue and you certainly are not the only patient who has these concerns. (A)

Patient: Sure. That would be helpful.

Provider: RYGB is what we call a metabolic operation that produces the opposite effect on many hormones in your body when compared to dieting. What this means is that even though you will be eating smaller amounts of food during the first year, you will feel less hungry and experience fewer cravings and desire for sweets. I can’t say that the desire for sweets will be gone entirely or won’t come back a year or so after surgery, but it should be less of a struggle than it has been with dieting. As the body adapts to the operation and weight loss reaches a plateau, many patients say that hunger and desire for sweet or salty comfort foods increases, usually around 9 or 12 months after surgery. So, it’s a good time to start thinking about managing negative emotions without food. What are some of your ideas about things you could try right now to manage stress and negative emotion (O)?

Patient: Well, my work offers an employee wellness program. I could give that a try.

Vignette 5: Depression. Vignette 5 presents a 48-year-old female patient with BMI of 60kg/m2 with hypertension, OSA, and no past mental health treatment
She was married, disabled, and suffered from depression. She was struggling with motivation and anticipated that her mood would improve if she could lose some weight.

Provider: I know the purpose of our visit today is to talk about weight management. Often, when people have complex health problems, they also have low mood. When I reviewed the pre-surgery paperwork you completed, I noticed that your score on the depression screener is elevated.  In particular, you endorsed feeling down and bad about yourself nearly every day.

Patient: I’m just so frustrated with not being able to lose weight. When I look in the mirror, I just can’t believe how I let myself get like this. I hate how I look.

Provider: What you see in the mirror is disappointing to you. (CR-reflection of feeling)

Patient: Yes. I think if I could just lose some of this weight, I would be a lot happier. That’s why I am looking forward to this surgery. I know I will be happy once I lose weight.

Provider: You are hoping that a lot of things in your life will be different when you lose weight. (CR-guessing about meaning)

Patient: Right now, I can’t do anything. I have to use a motorized scooter to get around.  My husband has taken over most of the household stuff because I’m too tired and can’t stand for more than 15 minutes. Worst of all is that my four-year old grandson asks me to play with him outside and I have to tell him I can’t.  If I can lose weight, I could do all these things again.

Provider: I can see why not being able to do all of those things would make you feel pretty bad about yourself (A). You are hoping that weight loss will help you return to doing the things in your life that you value. (CR-guessing at meaning)

Patient: Yes. I spend of all of my energy just trying to get through my day. I spend most of my days alone while my husband works. I don’t see my friends much anymore. Pretty much I just watch TV all day or lay in bed. I don’t want to keep living like this. I have to do something.

Provider: You sound like you are ready to make some changes, but may be feeling overwhelmed and don’t know where to begin. (CR-reflection of feeling and guessing at meaning)

Patient: Well, the dietitian gave me some diet changes to work on, and I’ve been trying to get started but haven’t made any progress. It’s hard because my husband is doing all the shopping now. We sort of have different ideas about what healthy eating is. He brings home take-out food a lot and likes his sweets. I end up eating them too. I want to lose weight, but I just don’t have the motivation or energy to plan meals or to cook.

Provider: You are unable to do any of the grocery shopping or meal planning and preparation because of low mood and low motivation. (CR-amplified)

Patient: I wouldn’t say unable; I’m just too tired most days, and I just let my husband take over.

Provider: When you are ready to begin making some of the changes you and the dietitian discussed, where would be a good place to start? (O)

Patient:  I just don’t see myself being able to make any kind of positive change. I feel down a lot and struggle with motivation. But I know if I lose weight, I will feel better.

Provider:  Sometimes to succeed at weight management, mood issues need to be addressed. Do you think if your mood were more positive you might be able to make changes in your diet (O)?

Patient: Yes, but it’s my weight that is making me depressed.

Provider: I understand feeling that way. (A) I have worked with many patients with low mood and weight challenges. It’s been my experience that it is very difficult to change behaviors without first improving mood. If it’s OK with you, I would like to make an appointment for you to see one of my colleagues for help with your depression. After you meet with her, we can schedule a follow-up appointment to return to a weight management plan for you. How does that sound? (O)

Patient: OK. It makes sense to me.

Provider: Now, let’s schedule you an appointment with the psychologist I work with, and then schedule an appointment with me.

Who Can Learn MI?
Previous research has shown that many different types of healthcare providers can learn how to apply MI effectively in the clinical setting.[24] MI is an appropriate clinical method for any provider willing to relinquish the role of expert and become an active collaborator with patients to increase the probability of change and improve their adherence to treatment recommendations.[19] That is to say, the role of the provider transforms from an expert, i.e., informing, advising, and taking responsibility for changing patients’ behavior, to an empathetic listener who supports patients in discovering their own reasons and means for change. Think of the patient as the expert on his or her own life and the how, when, and why change should occur for him or her.

Being a partner in change does not imply that healthcare providers ignore their professional training. For example, if a patient plans to fast for several days to lose weight, asking them about what they know about potential negative consequences of fasting would be important. Or, if a sedentary patient with cardiovascular disease and weight concerns sets a goal to start running three miles every day this week, a discussion about healthy exercise goals would be important. During conversations about weight loss, provider empathy and reflective listening result in higher patient satisfaction and patient perception of choice about treatment options.[25] To use MI effectively, the provider must possess qualities of respect and empathy while honoring patients’ autonomy and choice, even if that choice is not to change.19 Empathy, or the capacity to accurately understand patients’ meaning, is necessary in order to generate accurate reflections that move conversations forward toward change. Becoming a skillful practitioner of MI takes time and regular practice. Initial instruction in an immersion workshop by a trained and credentialed motivational interviewing expert is recommended, ideally followed up with periodic consultation and feedback from others proficient in MI.

Recommended Readings
1.    Miller WR, Rollnick, S. Motivational Interviewing: Helping People Change. (3rd Ed.). New York: The Guilford Press, 2013.
2.    Miller WR, Rollnick S. Ten things that motivational interviewing is not. Behav Cogn Psychother. 2009;37:129–140.
3.    Rosengren DB. Building Motivational Interviewing Skills: A Practitioner Workbook. Guilford Press, 2009.
4.    Rollnick SR, Miller RW, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Publications, 2008.

References
1.    Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403.
2.    Sjostrom L. Review of the key results from the Swedish Obese Subjects (SOS) trial—a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273:219–234.
3.    Batsis JA, Lopez-Jimenez F, Collazo-Clavell ML, et al. Quality of life after bariatric surgery: a population-based cohort study. Am J Med. 2009;122:1055 e1051–1055 e1010.
4.    Batsis JA, Clark MM, Grothe K, et al. Self-efficacy after bariatric surgery for obesity: A population-based cohort study. Appetite. 2009;52:637–645.
5.    Mitchell JE, King WC, Chen JY, et al. Course of depressive symptoms and treatment in the longitudinal assessment of bariatric surgery (LABS-2) study. Obesity. 2014;22:1799–1806.
6.    Stanford FC, Kyle TK, Claridy MD, Nadglowski JF, Apovian CM. The influence of an individual’s weight perception on the acceptance of bariatric surgery. Obesity. 2015; 23:277–281.
7.    Afonso BB, Rosenthal R, Li KM, Zapatier J, Szomstein S. Perceived barriers to bariatric surgery among morbidly obese patients. Surg Obes Relat Dis. 2010;6(1):16–21.
8.    Merrell J, Ashton K, Windover A, Heinberg L: Psychological risk may influence drop-out prior to bariatric surgery. Surg Obes Relat Dis. 2012;8:463–469.
9.    Colbert JA, Jangi S. Training physicians to manage obesity—back to the drawing board. N Engl J Med. 2013;369:1389–1391.
10.    Ochner CN, Tsai AG, Kushner RF, Wadden TA. Treating obesity seriously: when recommendations for lifestyle change confront biological adaptations. Lancet Diabetes Endocrinol. 2015;3(4):232–234.
11.    Ochner CN, Barrios DM, Lee CD, Pi-Sunyer FX. Biological mechanisms that promote weight regain following weight loss in obese humans. Physiol Behav. 2013;120:106–113.
12.    Rosenbaum M, Leibel RL. Adaptive thermogenesis in humans. Int J Obes (Lond). 2010;34 Suppl 1:S47–55.
13.    MacLean PS, Wing RR, Davidson T, et al. NIH working group report: Innovative research to improve maintenance of weight loss. Obesity (Silver Spring). 2015;23(1):7–15.
14.    Jakobsen GS, Hofso D, Roislien J, Sandbu R, Hjelmesaeth J. Morbidly obese patients–who undergoes bariatric surgery? Obes Surg. 2010;20:1142–1148.
15.    Calderone A, Coulton AY, Oyla G, et al. We lost half our size. People. January 5, 2015.
16.    Block JP, DeSalvo KB, Fisher WP. Are physicians equipped to address the obesity epidemic? Knowledge and attitudes of internal medicine residents. Prev Med. 2003;36(6):669–675.
17.    Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310(22):2416–2425.
18.    Resnicow K, McMaster F: Motivational Interviewing: moving from why to how with autonomy support. Int J Behav Nutr Phys Act. 2012;9:19.
19.    Miller WR, Rollnick, S. Motivational interviewing helping people change (3rd Ed.). New York: The Guilford Press, 2013.
20.    West DS, Gorin AA, Subak LL, et al. A motivation-focused weight loss maintenance program is an effective alternative to a skill-based approach. Int J Obes (Lond). 2011;35(2):259–269.
21.    Barnes RD, Ivezaj V. A systematic review of motivational interviewing for weight loss among adults in primary care. Obes Rev. 2015;16(4):304–318.
22.    Mitchell JE, King WC, Courcoulas A, et al. Eating behavior and eating disorders in adults before bariatric surgery. Int J Eat Disord. 2015;48(2):215–222.
23.    Colles SL, Dixon JB, O’Brien PE. Grazing and loss of control related to eating: two high-risk factors following bariatric surgery. Obesity (Silver Spring). 2008; 16:615–622.
24.    Poirier MK, Clark MM, Cerhan JH, et al. Teaching motivational interviewing to first-year medical students to improve counseling skills in health behavior change. Mayo Clin Proc. 2004;79(3):327–331.
25.    Pollak KI, Alexander SC, Tulsky JA, et al. Physician empathy and listening: associations with patient satisfaction and autonomy. J Am Board Fam Med. 2011;24(6):665–672.
26.    Rollnick SR, Miller RW, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior: Guilford Publications, 2008.
27.    Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567–1576.
28.    Ryan KK, Seeley RJ. Physiology. Food as a hormone. Science. 2013;339:918–919.
29.    Arble DM, Sandoval DA, Seeley RJ. Mechanisms underlying weight loss and metabolic improvements in rodent models of bariatric surgery. Diabetologia. 2015;58:211–220.

FUNDING: No funding was provided.

DISCLOSURES: The authors report no conflicts relevant to the content of this article.


Complimentary Continuing Education Course: Talking to Patients
About Bariatric Surgery: Guiding Meaningful Conversations and Evoking Commitment to Change

Take the test at http://tinyurl.com/BTCENov2015

Participants must read the designated article and take, submit, and pass the post-test by November 1, 2016. Participants must answer at least 70% of the post-test questions correctly to pass and receive credit for the activity. Upon successful completion of the post-test, participants will receive a certificate of completion. NOTE: Hard copy responses will not be accepted.

Course Overview: The purpose of this article is to discuss potential applications of a method of communication called motivational interviewing. This educational article is based on the book, Motivational Interviewing: Helping People Change. It is designed to introduce readers to the fundamental processes and core skills of motivational interviewing and how they may be applied in conversation with patients with obesity.

Course Description: This educational program is designed to educate, through independent study, multidisciplinary clinicians on shared-decision making and improving communication with patients seeking treatment for medically complicated obesity.

Course Objectives: Upon completion of this program, the participant should be able to:
1.) Identify provider and patient barriers to effective treatment for medically complicated obesity.
2.) Define motivational interviewing and discuss potential applications for patients with medically complicated obesity.
3.) List the four fundamental processes and four core skills of motivational interviewing.
4.) Describe applications of motivational interviewing with patients who are ambivalent about bariatric surgery or who are struggling with changing behaviors in preparation for bariatric surgery.

Completion Time: This educational activity is accredited for a total of 1.0 contact hour.

Target Audience: This accredited program is intended for nurses who treat patients with obesity.

Provider: This educational program is provided by Matrix Medical Communications. Provider approved by the California Board of Registered Nursing, Provider Number 14887, for 1.0 contact hour.

About the Instructors: Gretchen E. Ames. PhD, APPP, and Karen B. Grothe, PhD, ABPP, are board certified clinical health psychologists and hold the rank of Assistant Professor of Psychology in the Mayo Clinic College of Medicine.  Matthew M. Clark, PhD, ABPP, is board certified clinical health psychologist and is a Professor of Psychology in the Mayo Clinic College of Medicine. Maria Collozo-Clavell, MD, is board certified in Endocrinology and an Associate Professor of Medicine in the Mayo Clinic College of Medicine. The instructors are part of multidisciplinary treatment teams providing care for patients seeking bariatric surgery at Mayo Clinic.

Sponsored by Matrix Medical Communications.

Provider Contact Information: Angela M. Saba, Matrix Medical Communications, 1595 Paoli Pike,Suite 201, West Chester, PA 19380; E-mail: asaba@matrixmedcom.com

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Category: Clinical Nursing Education Series, Past Articles

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