Achieving lifestyle change in primary care' RCT of motivational interviewing

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Achieving lifestyle change in primary care. RCT
of motivational interviewing
WCPD 2008

• Colin Greaves

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Research team

• Mark Daly Diabetes Consultant (RDE)
• Andy Middlebrooke Exercise scientist
• Lucy O'Louglin PCT Health promotion
• Sandi Holland PCT Health promotion
• Jane Piper Diabetes Nurse (RDE)
• Anna Steele Diabetes Nurse (RDE)
• Tracy Gale Dietitian (RDE)
• Fenella Hammerton PCT cardio nurse
• Colin Greaves Health psychologist

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Context lifestyle change

• Pre-diabetes affects around 15 of adults aged
  4075. There is strong evidence that lifestyle
  change prevents or delays progression to type 2
  diabetes

Number of targets met
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Background

• However, intensity and personnel needed are major
  obstacles to delivery in the UK and many other
  countries

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Objectives

• To assess the effectiveness of a low cost
  lifestyle intervention, delivered by non-NHS
  staff, in primary care, to change behavioural
  risk factors (PA, diet) for type 2 diabetes

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Motivational interviewing

• Draws on multiple theoretical perspectives
• Strongly patient-centred. Techniques for reducing
  resistance, engaging patient
• Enhancing perceived importance of change and
  confidence about taking action
• Elicit and address barriers to change
• Make action plans
• Monitor and manage progress over time

Miller WR, Rollnick S (2002). Motivational
interviewing Preparing people for change (2nd
ed). www.motivationalinterviewing.org
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Non motivational interviewing

• Focus on changes for life, r.t. short-term
• Intensive at start, then tailing off
• Clearly stated from start to minimise dependence
  on therapist

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Delivery

• Five lifestyle counsellors recruited from the
  local community, but with relevant experience
• 4 days of training
• motivational interviewing
• assessment of physical activity and dietary
  behaviour
• Up to 11 sessions one-to-one counselling (median
  8, mean 33mins)

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Methods

• Single blind pragmatic RCT (patients aware)
• Computer search gt 142 people with BMI gt 28
• Randomised to intervention or information-only
• Exclusion Diabetes, heart disease, mental
  health, limitations for PA

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Measures

• Proportion achieving 5 weight loss
• Proportion achieving 150 mins /wk moderate
  physical activity (MAQ)
• Weight (Kg), Waist (cm)

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Results

• 114 (81) follow-up data.
• Intention-to-treat, 6 months after study entry
• More in intervention group with 5 weight loss
  (24 vs 7 OR 3.96 95CI 1.37 to 11.42).
• More 14 (vs 7) with 150 min/wk physical
  activity (OR 2.1 95CI 0.7 to 6.4, ns)
• NNT 5 weight loss 6.1 (95CI 4 to 21)

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Discussion

• Smaller effects than US and Finnish DPS (NNT3.3
  for 5), but lower cost /patient (estimated 263
  compared with 1800-2000)
• Compares well w orlistat (NNT 6)
• Compares well with other pragmatic UK
  interventions
• Counterweight (17 success for 5 weight loss)
• Walking interventions (14 success for 5x30)

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Discussion

• Longer term outcomes (sustainability) were not
  assessed, and this needs to be a focus of future
  work

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Conclusions

• Lifestyle change may be deliverable in primary
  care, with low use of health services resources
  (staff, money)
• Motivational interviewing is effective for
  initiating lifestyle change
• Further trials needed to establish best
  combination of effectiveness and feasibility

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• The devil has put a penalty on the things we
  enjoy in life. Either we suffer in health or we
  suffer in soul or we get fat. Albert
  Einstein

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Process measures

• Intervention fidelity checked by applying BECCI
  to transcripts of consultations with an actor
• Satisfactory standard achieved
• Measured changes in PI, PC (0-3 mths), contact
  time and looked for practice effects

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Process analyses

• Weight loss significantly associated with
• N sessions (R0.25)
• Change in confidence VAS _at_ 3 wks (R0.31)
• Not ch. in importance (R0.2, ns)
• Counsellor success rates varied 18 to 44

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A European guideline for Preventing Diabetes
evidence recommendations on achieving behaviour
change

• Colin Greaves, Kate Sheppard, Charles Abraham,
  Wendy Hardeman, Michael Roden, IMAGE Guideline
  Development Group, Peter Schwarz (project
  Co-Ordinator)
• 5th World Congress on Prevention of Diabetes and
  its Complications

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Recommendations

• Interventions offered to people at high risk of
  developing type 2 diabetes, should.
• Support both diet and physical activity
• Use well defined behaviour change techniques
• Initiation eg. Specific goal-setting, coping
  strategies, MI
• Maintenance eg. Social support, self-monitoring,
  review
• Maximise intervention intensity. However,
  lower-intensity interventions may still deliver
• Include ongoing support of behaviour change
  maintenance

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Practical issues

• Trade-off between intensity and cost
• Non-health professional delivery
• Using effective BC techniques /good training
• Targeting intensity according to risk
• Stepwise intervention approaches
• Designing real-world r.t. research interventions
• More focus on maintenance phase
• Individual tailoring

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Gaps in the literature

• Evidence for longer-term increases in physical
  activity
• Evidence on different support approaches for
  longer-term weight-loss (gt12 months)
• Evidence on the impact of job title of the person
  delivering the intervention, group vs. individual
  delivery and setting
• Evidence on longer-term effects of specific
  approaches, such as motivational interviewing