Does motivational interviewing improve retention or outcome in cognitive behaviour therapy for overweight and obese adolescents?

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Obesity Research & Clinical Practice (2015) xxx, xxx—xxx

SHORT REPORT

Does motivational interviewing improve retention or outcome in cognitive behaviour therapy for overweight and obese adolescents? Leah Brennan ∗ School of Psychology, Australian Catholic University, Australia Received 11 January 2015; accepted 31 August 2015

KEYWORDS Adolescent; Overweight; Obesity; Motivational interviewing; Treatment outcomes

Summary This study aimed to determine whether motivational interviewing improved retention and/or outcome in cognitive behaviour therapy for overweight and obese adolescents (M = 14.4, SD = 2.0; 52% female). The first 23 participants were allocated to a standard semi-structure assessment interview, the remaining 19 to a motivational interview, prior to commencing the intervention. The groups did not differ at baseline or on anthropometric (weight, BMI, BMI-z-score, waist circumference, waist—hip or waist—height ratio), body composition (percent body fat, fat mass, lean mass) or attrition measures post-treatment or post-maintenance (p > .01). MI did not improve retention or outcome of cognitive behaviour therapy for adolescent overweight and obesity. © 2015 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

As the prevalence and biopsychosocial consequences of overweight and obesity in adolescence increase so too does recognition of the limited effectiveness of interventions and the challenges of motivating overweight and obese adolescent to ∗ Correspondence to: School of Psychology, Australian Catholic University, Locked Bag 4115, Melbourne, VIC 3065, Australia. Tel.: +61 3 9953 3662. E-mail address: [email protected]

engage in treatment and achieve long term health improvements [1,2]. Behavioural and cognitive behavioural interventions (CBT) have demonstrated efficacy in the treatment of adolescent overweight and obesity at and beyond 12-months [1,3]. However, adolescent obesity treatment compliance and retention, and therefore outcome, is less than optimal prompting calls for strategies to improve treatment engagement and motivation [1—6].

http://dx.doi.org/10.1016/j.orcp.2015.08.019 1871-403X/© 2015 Asia Oceania Association for the Study of Obesity. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Brennan L. Does motivational interviewing improve retention or outcome in cognitive behaviour therapy for overweight and obese adolescents? Obes Res Clin Pract (2015), http://dx.doi.org/10.1016/j.orcp.2015.08.019

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Motivational interviewing (MI) is a collaborative client-centred approach to resolving ambivalence and enhancing motivation for change. It can be used as a prelude to other treatment, a permeating style throughout treatment, or a fall back option when motivational issues arise. It was developed for the treatment of substance disorders and demonstrated success in improving treatment engagement and outcome [7,8]. MI has since been used to improve treatment engagement and outcome for a range of areas of mental (e.g., alcohol and other substance abuse, eating disorders) and physical (e.g., diabetes, cardiovascular disease) health including diet and physical activity. MI has generally been shown to be more effective than usual care, no-treatment or placebo control, and as effective as other active time matched treatments [9—18]. MI has also been shown to improve weight loss in adult obesity treatment. In a meta-analyses of randomised controlled trials examining the effect of adding MI to other adult obesity interventions, MI demonstrated a medium effect (0.51 SDs; 1.47 kg; 0.25 kg/m2 ) on weight loss over and above control interventions (e.g., usual care, print material, attention control, behavioural weight loss programs (BWLI)). Studies combining MI with BWLI demonstrated the greatest weight loss. However, data regarding the additional benefit of adding MI to BWLI was mixed [19]. The addition of MI resulted in significantly greater weight loss in two studies [20,21], but there were no significant group differences in the remaining two studies [22,23]. Despite research indicating that MI may be effective in the treatment of other adolescent conditions (e.g., alcohol and substance use), including diet and exercise [24], and encouragement for the use of MI in the treatment of paediatric obesity [12,25], few studies have examined the use of MI in the treatment of adolescent overweight and obesity. The limited available research suggests that MI results in weight losses similar to comparison conditions [26—28]; little is known about non-weight outcomes [25]. Findings regarding MI effects on attendance and retention are mixed [26—28]. Reviews of MI interventions have highlighted the importance of the use of effective behavioural intervention, comparing MI to an attention matched control, and assessment of the fidelity of the MI intervention in future research [9—13,19,25]. This study was designed to address these limitations and to determine whether MI improved treatment retention and/or body composition and anthropometric outcomes in CBT for overweight and obese adolescents.

The trial is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12610000111077). Ethical approval was obtained from relevant Human Research Ethics Committees. Sixty-three adolescent—parent pairs were recruited from the community and randomly allocated to CBT (n = 42) or wait-list control (n = 21). The CBT program aimed to promote maintained improvements in body composition, cardiovascular fitness, eating and activity behaviours and psychosocial wellbeing. It was conducted on an individual basis and included a treatment (twelve 60-min face-to-face sessions, one 15-min telephone session) and a maintenance phase (two 60-min face-to-face sessions, seven 15-min telephone sessions). Physical, behavioural, and psychological assessments were conducted at baseline, after the completion of the treatment phase, and after completion of the maintenance phase. The full methodology of this study has been described elsewhere [29]. CBT intervention resulted in significant improvements total body fat, percent body fat, lean mass, weight, BMI, BMI-for-age z-score [30], health behaviours, impulse regulation, social support from family and parent—adolescent problem communication [31] relative to wait-list controls. This study reports on the 42 adolescents (M = 14.4, SD = 2.0; 52% female) randomly allocated to commence treatment immediately. Assessment interviews were conducted prior to commencing the study with both the adolescent and their parent present. The first 23 participants were allocated to a standard semi-structure assessment interview (SI), the remaining 19 were allocated to a motivational interview (MI) conducted as per Miller and Rollnick [7,8]. Thus MI was used as a prelude to treatment in the current study. All assessment sessions were videotaped and coded using the Motivational Interviewing Treatment Integrity (MITI) Code: Version 2 [32]. MITI coding confirmed the quality of the implementation of MI, and demonstrated a significant difference between MI and SI interviews. While the importance of considering biopsychosocial outcomes is recognised, the current analyses focuses on the primary body composition and anthropometric outcomes to minimise the risk of type 1 error. Body composition assessment was conducted using dual-energy X-ray absorptiometry apparatus (DEXA, Lunar DPX densitometer), total fat mass, lean mass and percent body fat are reported. Anthropometric measures (standing height, weight, waist and hip circumferences) were taken using standard procedures and used

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Motivational interviewing for adolescent obesity to calculated BMI, BMI z-score, waist—hip and waist—height ratios. All analyses were preceded by data cleaning and checking. An adjusted p-value of.01 was used to reduce the risk of Type1 error. Both completer and intention-to-treat analyses were conducted. Baseline value carried forward method was used to impute missing data for the intention-to-treat analyses [33]. One-way ANOVA’s, with assessment condition (MI, SI) as the independent variable, were used to assess pre-treatment differences. The CBT and MI condition did not differ significantly on baseline demographic, anthropometric or body composition measures (Table 1). A cross-tab with Chi-square analysis, with assessment group (MI, SI) and completion status (completer, drop-out) [4], was used to determine whether assessment group was associated with treatment completion. The SI and MI groups did not differ significantly in terms of participant completion rate at the end of the treatment (2 (1) = 0.42, p = .551) or the maintenance (2 (1) = 0.19, p = .663) phases of the intervention. Between-subjects ANCOVA’s were used to assess treatment outcome differences for SI and MI conditions. Pre-treatment data was the covariate and assessment group (MI, SI) the factor. The groups did not differ significantly in terms of fat mass, lean mass and percent body fat, weight, BMI, BMI-z-score, waist circumference, waist—hip or waist—height ratio following the treatment or the maintenance phase of the intervention. Table 1 displays intention-to-treat analyses, similar results were obtained in completer analyses. These results indicate that MI did not improve retention or body composition and anthropometric outcomes of CBT for overweight and obese adolescents. Previous research regarding the impact of MI on adolescent overweight and obesity interventions attrition is mixed. Of the two studies examining the addition of MI to BWLI, one reported no group differences [27], one reported lower attrition in the MI condition but significance testing was not reported [26]. One study comparing MI to social skills training control condition reported greater attendance in the MI group [28]. The finding that MI did not improve weight loss outcomes is consistent with previous research examining MI for the treatment of adolescent overweight and obesity. Two studies comparing BWLI alone to BWLI with MI [26,27], and one study comparing MI to a social skills training control condition [28], demonstrated weight losses in both conditions, with no significant differences between groups. These studies used more intensive MI interventions (4—6 sessions) than the current study, so

3 it is unlikely that the lack of effect in the current study is due solely to the low intensity MI intervention. Research examining the addition of MI to BWLI for adults has been more promising with some research indicating that the addition of MI results in significantly greater weight loss than BWLI alone [19]. There are suggestions that MI may not work for adolescents in the same way as it does for adults, and that MI needs to be modified (e.g., use of more questions than reflections) to suit the psychosocial development of adolescents [25,34]. Further there is little evidence to guide decisions regarding parent involvement in MI for adolescents. The current study used a family based treatment approach, recognising the benefits of both adolescent behaviour change and family environment change, therefore, the MI session was conducted with both the parent and adolescent present. The efficacy of MI in the current study may have been influenced by parental involvement in the session. Further research is required to examine the modification of MI, and the involvement of parents, for use with adolescents. The MI empirical literature has been widely criticised for its poor research methodology [9—19,25]. The current study improved on previous research in terms of clinician training, observation and coding of MI and SI interviews to assess MI fidelity, providing equivalent therapeutic time in both conditions, and examining the addition of MI to an effective evidence based treatment approach. Limitations include the small sample size (similar to other research examining MI with adolescents [26,28]) resulting in a lack of power to detect small to medium effects, and the lack of randomisation to assessment (MI, SI) conditions, and the exclusive focus on body composition and anthropometric outcomes (i.e., not considering biopsychosocial outcomes). In summary, consistent with the few studies examining MI in adolescent overweight and obesity treatment, a brief MI intervention did not improve retention or outcome in a CBT interventions for adolescent overweight and obesity in the current study. Results are not as promising as those seen in adults suggesting that MI may need to be adapted for use with adolescents. Further research is also required regarding the optimal involvement of parents in MI interventions for adolescents and the impact of MI on non-weight outcomes. Given its potential to improve treatment outcomes, the use of MI with adolescents, and the incorporation of MI into obesity interventions, warrants further research.

Please cite this article in press as: Brennan L. Does motivational interviewing improve retention or outcome in cognitive behaviour therapy for overweight and obese adolescents? Obes Res Clin Pract (2015), http://dx.doi.org/10.1016/j.orcp.2015.08.019

Body composition and anthropometric data for standard and motivational interview groups at baseline, post-treatment and post-maintenance. Pre-treatment M(SD)

ANOVA assessing pre-treatment group differences

Post-treatment M(SD)

ANCOVA assessing post-treatment group differences after controlling for baseline

Post-maintenance M(SD)

ANCOVA assessing postmaintenance group differences after controlling for baseline

F(1,41) = 0.08, p = .780

36.81(13.29)

F(1,41) < 0.01, p = .966

36.71(13.38)

F(1,41) = 0.47, p = .499

MI

38.39(12.86)

Lean mass

SI MI

39.32(11.01) 47.24(10.37)

% body fat

SI MI

44.84(8.82) 42.98(7.98)

Weight

SI MI

44.88(5.42) 89.39(19.67)

BMI

SI MI

88.51(18.05) 31.77(4.27)

BMI z-score

SI MI

31.90(4.81) 2.09(0.38)

Waist

SI MI

2.07(0.37) 92.00(10.47)

Waist:hip

SI MI

92.97(11.19) 0.83(0.06)

Waist:height

SI MI

0.85(0.08) 0.55(0.06)

SI

0.56(0.06)

F(1,41) = 0.66, p = .422 F(1,41) = 0.84, p = .366 F(1,41) = 0.02, p = .881 F(1,41) = 0.01, p = .927 F(1,41) = 0.03, p = .861 F(1,37) = 0.07, p = .784 F(1,37) = 0.52, p = .475 F(1,37) = 0.38, p = .539

37.84(11.93) 47.06(10.35) 45.00(8.95) 41.95(9.31) 43.59(6.30) 87.79(19.39) 87.29(18.92) 31.17(4.38) 31.14(4.96) 2.01(0.46) 1.96(0.47) 90.84(11.19) 91.43(12.68) 0.83(0.06) 0.85(0.08) 0.54(0.06) 0.55(0.07)

F(1,41) = 0.51, p = .480 F(1,41) = 0.64, p = .427 F(1,41) = 0.15, p = .699 F(1,41) = 0.19, p = .670 F(1,41) = 0.28, p = .600 F(1,37) = 0.16, p = .688 F(1,37) = 1.22, p = .277 F(1,37) = 0.97, p = .332

38.55(12.29) 47.50(10.65) 45.94(9.06) 47.72(9.65) 43.50(6.58) 88.14 (18.99) 88.67(18.99) 31.08(4.32) 31.43(5.24) 2.00(0.45) 1.97(0.52) 91.51(12.22) 91.69(12.19) 0.84(0.13) 0.85(0.14) 0.55(0.07)

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Fat mass

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F(1,41) = 0.96, p = .333 F(1,41) = 0.16, p = .689 F(1,41) = 0.97, p = .330 F(1,41) = 0.19, p = .662 F(1,41) < 0.01, p = .990 F(1,37) = 0.36, p = .550 F(1,37) = 0.02, p = .868 F(1,37) = 0.42, p = .520

0.55(0.07)

L. Brennan

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Table 1

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Motivational interviewing for adolescent obesity

Funding This project was partially funded by RMIT University and VicHealth PhD scholarships.

Disclosures Nothing to declare.

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Please cite this article in press as: Brennan L. Does motivational interviewing improve retention or outcome in cognitive behaviour therapy for overweight and obese adolescents? Obes Res Clin Pract (2015), http://dx.doi.org/10.1016/j.orcp.2015.08.019