motivational interviewing to reduce pediatric …...motivational interviewing for pediatric obesity:...

Motivational Interviewing to Reduce Pediatric Obesity in Primary Care:

A Disparity Perspective of the BMI2 Trial

Ken Resnicow, PhD

Professor

University of Michigan

School of Public Health

Department of Pediatrics

Comprehensive Cancer Center

Center for Health Communications Research

Ann Arbor, MI

[email protected]

http://chcr.umich.edu

Ann Arbor, MI

Phone (734) 904-3888

[email protected]

Today…..

US Obesity Prevalence/Trends

Why MI in Primary Care

BMI2 Methods

BMI2 Results

BMI2 Ethnic/Racial Analyses

5

7Class 3 obesity = BMI > 140% of the 95th percentile

12Prevalence of Childhood and Adult Obesity in the United States, 2011-2012 Cynthia L. Ogden, Margaret D. Carroll, Brian K. Kit, Katherine M. Flegal, JAMA. 2014;311(8):806-814.

Kraschnewski JL, Sciamanna CN, Stuckey HL, Chuang CH, Lehman EB, Hwang KO, et al. A silent response to

the obesity epidemic: decline in US physician weight counseling. Med Care. 2013;51(2):186-92.

Accelerating Progress in Obesity Prevention: Solving the Weight of the

Nation

May 8, 2012

19

20

Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation, IOM 2012

WHY MI ?

21

Perceived Barriers in the Treatment of Overweight Children and Adolescents

Percentage Responding “Most of the Time” and “Often”

RDs PNPs Pediatricians

Barrier (n= 441) (n = 293) (n = 201)

Lack of patient motivation 61.9 78.2 85.7

Lack of parent involvement 71.8 82.5 81.2

Lack of clinician time 31.2 45.9 58.0

Lack of reimbursement 68.1 46.8 45.8

Lack of clinician knowledge 23.8 32.2 44.0

Lack of treatment skills 27.3 32.2 45.0

Lack of support services 55.5 57.0 60.0

Treatment futility 37.4 52.6 53.0

Eating disorder concerns 17.2 12.9 10.0

Story MT, Neumark-Stzainer DR, Sherwood NE, Holt K, Sofka D, Trowbridge FL, et al. Management of child and adolescent obesity: attitudes, barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210-4.

Motivation mentioned 1x

24

Two Elements of Behavior Change Counseling

WHY to Change HOW to Change

ENERGY STRUCTURE

VIGILANCE STRATEGY

Starting with a strong WHY leads to better outcomes

More open to TRYING a HOW

Devote more energy during HOW

Exhibit more persistence during HOW

27

Two Elements of Behavior Change Counseling

WHY to Change HOW to Change

MI CBT/Lifestyle Mgmt

28

Comfort the afflicted

and

Afflict the comfortable

Essence of Motivational

Interviewing

29

Roll with Resistance

Then

Find Meaning for Change

Acknowledge Dread

Link with Role, Goals, and Values

Essence of Motivational

Interviewing

30

MI vs. Usual Care

Reflect vs. ask

Roll with resistance vs. counterpunch

Elicit change talk vs. inform/advise

> 50% patient talk time

31

MI Evidence Base

> 2200 papers; 220 RCTs

Multiple reviews Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: a meta-analysis of

controlled clinical trials. Journal of Consulting & Clinical Psychology., 71(5), 843-861.

Dunn, C., Deroo, L., & Rivara, F. (2001). The use of brief interventions adapted from motivational interviewing

across behavioral domains: a systematic review. Addiction, 96(12), 1725-1742.

Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational Interviewing. Annual Review of Clinical Psychology,

1(1), 91-111.

Knight, K. M., McGowan, L., Dickens, C., & Bundy, C. (2006). A systematic review of motivational interviewing in

physical health care settings. Br J Health Psychol, 11(Pt 2), 319-332.

Madson, M. B., Loignon, A. C., & Lane, C. (2009). Training in motivational interviewing: a systematic review. J

Subst Abuse Treat, 36(1), 101-109.

Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6),

527-537.

Noonan, W., & Moyers, T. (1997). Motivational interviewing: A review. Journal of Substance Misuse, 2, 8-16.

Resnicow, K., Davis, R., & Rollnick, S. (2006). Motivational interviewing for pediatric obesity: conceptual issues and

evidence review. Journal of the American Dietetic Association 106(12), 2024-2033.

Eating. Elk Grove Village: American Academy of Pediatrics.

Suarez, M., & Mullins, S. (2008). Motivational interviewing and pediatric health behavior interventions. Journal of

Developmental & Behavioral Pediatrics, 29(5), 417-428.

VanWormer, J. J., & Boucher, J. L. (2004). Motivational interviewing and diet modification: a review of the

evidence. Diabetes Educator, 30(3), 404-406.

Vasilaki, E. I., Hosier, S. G., & Cox, W. M. (2006). The efficacy of motivational interviewing as a brief intervention for

excessive drinking: a meta-analytic review. Alcohol Alcohol, 41(3), 328-335.

32

Recent Meta-Analysis

McMaster F, Resnicow K, et al Motivational Interviewing for Chronic Disease

Prevention: A systematic review and meta-analysis . (under review) 34

36

Healthy Lifestyles Pilot Study

Schwartz R P, Hamre R, Dietz WH, Wasserman R, Resnicow K, et al. Arch Pediatr Adolesc Med. 2007;161: 495-501

Can Brief Motivational Interviewing in Practice

Reduce Child Body Mass Index?

Results of a 2-year

Randomized Controlled Trial

Funding provided by a grant from National Heart Lung and Blood Institute (R01HL085400), PROS core funding from the Health Resources and Services Administration Maternal and Child Health Bureau (R60MC00107) and the American Academy of Pediatrics

Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:649 -57

37

2-year national randomized controlled trial in 42 PROS practices

Test use of MI vs. usual care among children ages 2-8 with BMI 85th to 97th percentile

3-arm design:

Group 1 – Usual care

Group 2 – MI delivered by pediatricians (4 sessions)

Group 3 – MI delivered by pediatricians (4 sessions) plus registered dietitians (6 sessions)

Methods


38

Overall Enrollment

n= 42 practices

n= 645 patients

Group 1

Usual Care

n= 11 practices

n= 198 patients

Lost to follow-up

1 practice

40 patients

Analyzed

n=158 patients

(80%)

Group 2

Pediatricians

n= 16 practices

n= 212 patients

Lost to follow-up

3 practices

67 patients

Analyzed

n=145 patients

(68%)

Group 3

Pediatricians and RDs

n= 15 practices

n= 235 patients

Lost to follow-up

1 practice

81 patients

Analyzed

n=154 patients

(66%)

Study Overview

39

Thank you to participating PROS practices!

40

Assess the impact of brief Motivational

Interviewing (MI) counseling on child BMI

percentile over a 2-year period

Primary Objective


41

Hypotheses

At 2 year follow-up, children in group 2

(PCP only) will show a 3 point decrease in

BMI percentile relative to group 1

At 2 year follow-up, children in group 3

(PCP + RD) will show a 3 point decrease in

BMI percentile relative to group 2.

Resnicow K, McMaster F, Bocian A, et al. Motivational Interviewing and Dietary Counseling for Obesity in Primary Care: An RCT. Pediatrics 2015;135:649 -57 42

Intervention Elements

2-day MI training

MI booster training DVD

Parent Behavior Screener

Autonomy Supportive Materials

Tip Sheets (Optional)

Diaries (Optional)

Autonomy Supportive Skills (MD to Parent)

You Provide They Decide

Engagement-Choice

http://chcr.umich.edu/project.php?id=1032

What did our providers do?

Reflect 2x-3x for every question asked

Talk < 50% of the time

Support parent and child autonomy

Affirm effort

Elicit Change Talk

Link behavior to role and goals

Undersell advice

Provide menu of options

Client: We eat at Wendy’s a few

times a week. It’s cheap, fast, my

kids like it, and it’s better than

those other places. There’s a lot

worse we could be eating. Sure

there are better foods than that but

I don’t have time to cook…

AFFIRM

Old School

You know, Wendy’s is no better

than McDonalds so you are not

doing your kids any favors by

eating there.

47

New School

Because you are so busy and

exhausted it is hard to find the time

to cook healthier meals. But you

care about your kids’ health and

are want them to eat better than

fast food.

48

Because you are so busy and exhausted

it’s hard to cook healthier meals. But you

care about your kids’ and their health and

ideally you want them to eat something

better than fast food.

49

We tried to reduce the amount of TV she watches

but it didn’t go so well. In the morning I need to

get dressed, take a shower, make some breakfast

and I usually end up letting her watch TV just to

give me some free time. In the afternoon I feel it

might be easier…since maybe I could get her

involved in an art project or playing outside.

50

So it might be more realistic to work on the afternoon TV first

Getting her involved in something creative like art or a craft project might be worth talking about…

Art is the way to go

51

Values List for Parents

Values For Your Child Values for You Values for Your Family

Be Healthy Good Parent Cohesive

Be Strong Responsible Healthy

Have many friends Disciplined Peaceful Meals

Being fit Good Spouse Getting along

Not feeling abnormal Respected at Home Spending time together

Not being teased On top of things

Not feeling left out Spiritual

Be able to communicate

his/her feelings

Fulfill her potential

Have high self-esteem

52

54

X

X

X

X

X

X

X

X

SAMPLE PARENT Q

Autonomy Supportive Handouts

BMI2 Diaries

Beverages (Bi-directional)

Snack (Bi-directional)

Dining out

F & V

TV

Activity

Generic (everything else)

59

Autonomy Support: Parent to Child

YOU PROVIDE THEY DECIDE

TV/Screen Time

– You set limit (can be collaborative)

– They decide when and how to cash in

Treats/Sweet Drinks/Fast Food

– You set limit (can be collaborative)

– They decide when and how to cash in

63



How much to eat

– Provide “green” and “yellow” foods

Let them determine seconds & satiety

– Query “how full are you”

– Do not encourage, comment, or reward clean

plate

64



Meal Construction

– “Chicken or steak” tonight

– “Pasta or Pizza”

– “Broccoli or Peas”

Shopping

– Brand

– Which “apple”

65

Involve/Engage

Cooking

– Peel

– Stir

– Flip

– Pour

– Sprinkle

– Spice

– Mix

– Skewer

Decorate

Set Table

66

Baseline Sample Description By Study GroupGroup 1 Group 2 Group 3 Total

Control MD MD+RD

(n= 198) (n=212) (n=235) (n=645)

Mean Child Age (sd)* 4.87 (1.72) 5.08 (1.94) 5.32 (1.78) 5.10 (1.82)

Mean Child BMI percentile (sd) 91.50 (3.29) 92.17 (3.26) 92.09 (3.44) 91.93 (3.34)

Parent BMI (sd) * 28.43(6.77) 30.13 (7.43) 28.48 (6.43) 29.01 (6.91)

Child Gender % Male 47.0 42.9 39.6 42.9

% Female 53.0 57.2 60.4 57.2

Parent Completing Questionnaire**

% Mother 87.2 92.4 91.7 90.5

% Father 12.2 4.3 7.5 7.9

% Other 0.5 3.3 0.9 1.6

Child Race **

% White 67.9 53.6 59.1 60.0

% Black 2.6 11.0 6.1 6.6

% Hispanic 13.3 30.1 20.9 21.6

% Asian 6.63 1.4 8.7 5.7

%Other 9.7 3.8 5.2 6.1

Household Income*

% < $ 40,000 27.2 38.6 29.8 31.9

% >=$ 40,000 72.8 61.4 70.2 68.1

Parent Education **

% < College 61.8 70.1 52.6 61.2

% College or

higher38.2 29.9 47.4 38.9

Child Insurance Coverage

% Any 99.5 98.1 97.3 98.3

% Private* 74.0 59.8 65.9 66.4

% Medicaid ** 17.4 36.4 23.0 25.7

* p < .05 ** p < .01

Baseline Characteristics: Selective and Differential Attrition

Cohort Drop Outs Selective Differential

(n=457) (n=188)

Mean Child Age (sd) 5.1 (1.8) 5.1 (1.9) **

Mean Child BMI percentile (sd) 91.8 (3.4) 92.2 (3.1)

Parent BMI (sd) 28.9 (6.8) 30.3 (7.0) **

Child Gender

% Male 45.1 37.8

% Female 54.9 62.2

Parent Completing Questionnaire

% Mother 90.9 89.6

% Father 7.5 8.8

% Other 1.6 1.7

Child Race ** *

% White 64.0 50.0

% Black 5.5 9.3

% Hispanic 18.3 29.7

% Asian 6.4 3.9

% other 5.7 7.1

Household Income **

% < $ 40,000 27.7 42.5

% >=$ 40,000 72.3 57.5

Parent Education **

% < College 55.8 74.4

% College or higher 44.2 25.6

Child Insurance Coverage

% Any 99.3 95.6 *

% Private 72.4 51.4 **

% Medicaid 22.7 33.2 **

Results for BMI Percentile

Year 2 BMI Percentile and BMI Percentile Change by Study Group

Study Group NYear 2 BMI

Percentile^ (SE)

BMI Percentile

Difference#^ (SE)

Group 1 – Usual Care 158 90.31 (0.94) 1.82 (0.98)

Group 2 –PCP 145 88.1 (0.94) 3.8 (0.96)

Group 3 –PCP & RD 154 87.11 (0.92) 4.92 (0.99)

Groups with matching superscripts differ p < .05

# Subtracting post-intervention BMI percentile from baseline BMI percentile.

^ Adjusted for age, race, sex, baseline BMI, household income, parent BMI,

provider age, and practice effects (clustering)

Results using Raw BMI

Year 2 BMI by Study Group

Study Group N Year 2 Raw BMI (SE)

Group 1 – Usual Care 15819.751

(0.17)

Group 2 –PCP 14519.33

(0.18)

Group 3 –PCP & RD 15419.171

(0.17)

Groups with matching superscripts differ p < .05

^ Adjusted for age, race, sex, baseline BMI, parent BMI, income, provider age,

and practice effects (clustering)

BMI2: Behavioral Outcomes^ at 2-year Follow-up

Study

Group

Fruit &

Veg

Serving

p/day

Sweet

Beverages

Serving

p/day

Physical

Activity

Hrs.

p/day

Screen

Time

Hrs. p/Day

Control 3.8 1 (.12) 2.1 (.05) 1.3 (.11) 2.51 (.10)

PCP only 4.1 (.14) 1.9 (.06) 1.3 (.11) 2.42 (.11)

PCP + RD 4.31 (.13) 2.1 (.06) 1.0 (.12) 2.21,2(.10)

^ Adjusted for age, race, sex, baseline value, and practice effect

Number and Percent of MI Contacts

Completed by Intervention Group in BMI2

GROUPNumber and Percent of MI Contacts Completed

0 1 2 3 4 5 6

GROUP 2

PCP

(n =145)

3

2.1%

14

9.7

8

5.%

14

9.7%

106

73.1%NA NA

GROUP 3

PCP

(n =154)

3

1.9%

18

11.7%

17

11.0%

12

7.8%

104

67.5% NA NA

GROUP 3 RD

(n =154)

21

13.6%

24

15.6%

29

18.8%

30

19.5%

22

14.3%

9

5.8%

19

12.3%

Number and Percent of MI Contacts

Completed by Intervention Group in BMI2

32.4% of families received 4 or more RD calls.

GROUPNumber and Percent of MI Contacts Completed

0 1 2 3 4 5 6

GROUP 2

PCP

(n =145)

3

2.1%

14

9.7

8

5.%

14

9.7%

106

73.1%NA NA

GROUP 3

PCP

(n =154)

3

1.9%

18

11.7%

17

11.0%

12

7.8%

104

67.5% NA NA

GROUP 3 RD

(n =154)

21

13.6%

24

15.6%

29

18.8%

30

19.5%

22

14.3%

9

5.8%

19

12.3%

Baseline to Year 2 BMI Percentile Change by

Completed# MI Dose in BMI2, 2009-2013

Study Group Dose (n=425)

Adherence Adjusted^^

BMI Percentile ∆

Mean (SE)

Control 149 1.71,2

Group 2 Low < 3 MI 23 3.2

Group 2 High > =3 MI 112 4.2

Group 3 Low < 8 MI 104 4.61

Group 3 High >= 8 MI 37 5.52

^ adjusted for age, race, sex

^^ adjusted for sex, age, income, education, race, and psychosocial predictors of adherence.

# - High Dose defined as 75% of expected sessions.

Where’s the disparity data ?

Didn’t you look at the conference title?

Baseline Demographics by Race/Ethnicity

Study GroupWhite

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

Parent BMI mean 28.4 32.1* 30.7* 29.0

Income < 40k % 24% 58%* 54%* 32%

Education

< College %55% 70% 81%* 61%

* P < 0.05 compared to white

BMI2: Baseline Attitudes by Race/Ethnicity

Study GroupWhite

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

Concerned about

child’s weight

(0-10)

3.8 3.4 4.9* 4.0

Concerned about

child’s health (0-10)4.0 4.4 6.0* 4.6

Argue about child’s

weight (1-4)1.2 1.2 1.4* 1.3

Adjusted for child age, child sex, and parent BMI


BMI2: Baseline Attitudes by Race/Ethnicity

Study GroupWhite

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

We will be able

to change TV

Habits (0-10)

7.5 8.3 8.1* 7.7

Adjusted for child age, child sex, and parent BMI


Drop Out Rate by Race/Ethnicity

Study GroupWhite

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

Drop Out Rate 24% 41%* 39%* 29%


Intervention Dose (MI Sessions Completed) by

Race/Ethnicity

Study

Group

White

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

MD Dose

(4 max) 2.9 2.8 2.4* 2.8

RD Dose

(6 max)2.4 1.6 1.8 2.2


BMI2: BMI Difference Score by Race/Ethnicity

Study

Group

White

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

Control Ref Ref Ref Ref

PCP only 2.4 8.4 3.1 2.2

PCP + RD 1.8 1.0 9.0* 2.8*

^ Adjusted for child age, child sex, and parent BMI


BMI2: Behavior Changes by Race/Ethnicity

Study GroupWhite

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

Change F & V .32 .21 .81* .36

Change Sweet Drinks - .14 .74* - .90* - .23

Change Screen Time 1.8 2.3 1.8 1.9

Change Activity 0.06 0.09 - .07 0.05



BMI2: Correlation of Behavior Change with BMI

Change

Study GroupWhite

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

Change F & V 0.05 -0.04 -0.02 0.05

Change Sweet Drinks 0.06 - 0.09 - 0.20 -0.02

Change Screen Time 0.01 - 0.14 - 0.24* -0.08

Change Activity 0.08 -0.41* 0.18 0.06


* P < 0.05

Strengths

National study generalizability

Realistic dose

Physical outcome

Limitations

Attrition (30%)

Low completion of RD MI

Lack rigorous diet and activity measures

Lack of other biologic data

Unexpected large change in UC group

Next Steps

Dissemination research

Increase MI dose

Maximize reimbursement (99214 and beyond)

Integrate short message service (SMS) and other

E-Health components to increase uptake of MI

and overall intervention impact

Link to Electronic Health Records

85

Acknowledgements

Thank you: Pediatric Research in Office Settings (PROS)

and Dietetics Practice-based Research Network

practitioners, study coordinators and family participants

_______________________________________________

National Heart Lung and Blood Institute (R01HL085400)

Health Resources and Services Administration Maternal

and Child Health Bureau (R60MC00107)

Academy of Nutrition and Dietetics

American Academy of Pediatrics

Report

race

changeFV c

changetotalscree

ntime

changesweetdrinkyescho

cchangetotalactiv

tyWhite Mean .3199 -.0857 1.8340 -.1373 .0586

N 272 245 268 255 269Std. Deviation 1.61082 .95213 1.28716 1.18753 .74536

Black Mean .2083 .4783 2.3200 .7391 .0962N 24 23 25 23 26Std. Deviation 1.95558 1.44189 1.75523 2.04978 .73170

Hispanic Mean .8133 -.5882 1.7967 -.9014 -.0691N 75 68 75 71 76Std. Deviation 1.80610 1.76394 1.32204 2.00111 1.11997

Asian Mean .1154 .0400 1.8750 .0385 .1538N 26 25 26 26 26Std. Deviation 1.75104 1.17189 1.27916 1.50946 .78446

OtherRace Mean -.1852 -.2400 2.0741 -.4800 .1019N 27 25 27 25 27Std. Deviation 2.03880 2.45425 1.71646 2.48529 .68028

Total Mean .3561 -.1425 1.8741 -.2325 .0466N 424 386 421 400 424

BMI2: F & V Difference Score by Race/Ethnicity

Study

Group

White

(n=278)

Black

(n=22)

Hispanic

(n=80)

All

(n=434)

Control

PCP only

PCP + RD


* P < 0.05

motivational interviewing to reduce pediatric …...motivational interviewing for pediatric obesity:...

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