Obesity is complex disease that can result from environmental and genetic factors, which influence metabolism and appetite regulation (Wang, Wong, Alfonso-Cristancho, He et al, 2013). These factors have an affect on obese subjects that can cause suffering from both psychological and physiological health consequences (Bean, Mazzeo, Stern, Bowen, Ingersoll, 2011). According to the World Health Organization (WHO), Obesity has been described as the greatest threat to human health. In 2008 1.4 billion adults aged 20 or over were classified as overweight with 500 million of these classified as Obese (WHO, 2008). The WHO classifies Overweight and Obesity as a person having a Body Mass Index (BMI) of 25-29.9kg/m2 for Overweight, a BMI of ≥30kg/m2 for Obese, and a BMI of ≥ 40 or ≥35 for Morbid Obesity if associated with substantial commorbidities. However, a person falling within a BMI range of 18-24.9kg/m2 is classified as normal weight.
A recent study carried out in the United States has found that one third of the population has a BMI of ≥30kg/m2 (Wang et al, 2013). It is broadly accepted that the diet industry is a multi-billion dollar business that has played on the vulnerability of overweight and obese people for many years, highlighted by an $18.8 billion in sales in 2003. Indeed, the successful results of these over the counter treatments for obese subjects appear to be limited in the treatment of obesity (Atkinson, blank, Loper et al, 2012). Other methods of helping Overweight and Obese individuals are becoming more popular with Healthcare providers as an alternative to over the counter quick fix weight loss products. One method that is growing in popularity is that of Behavioural Therapies to aid practitioners in changing the behaviour of obese patients towards weight loss and increasing physical activity. One of these therapies that have gained momentum and popularity is Motivational Interviewing (MI). MI is considered an appropriate approach to the promotion of healthier behaviour (Rollnick, & Miller, 2002).
Motivational Interviewing for Obesity originated from the positive treatments reported from using the technique with patients suffering from alcohol abuse (Van Dorsten, 2007). MI is a clinical intervention that could enhance treatment effects by increasing internal motivation that change behavior and increase compliance to achieve certain goals (Bean et al, 2011). The strategy that MI favors is one of a therapeutic style that targets an individuals’ stage of change. This form of behavioural change is non confrontational and encourages a change in behaviour through exploration and resolving an individuals ambivalence and resistance to change and promoting an increase in the clients confidence levels (Wong, & Cheng, 2013). As MI is not based on any one particular theory, it is difficult to draw firm conclusions as which processes induce behaviour change during treatment (Hardcastle, Taylor, Bailey, Harley, & Hagger, 2013). MI has been refined and the clinical procedures have been improved, with the improved concept being introduced and promoted by Miller and Rollnick in 1991 (Van Dorsten, 2007). We shall look at the motivational Interviewing model, how MI is measured, from the perspective of Primary Care Practitioners and also from the viewpoint of dealing with MI with children and Adolescents.
Motivational Interviewing Model.
In the United States over 50% of deaths arise from cardiovascular disease, stroke and cancer. These diseases are preventable if treated properly as they generally result from poor nutrition, poor physical activity levels, smoking, and alcohol consumption (Bishop, & Jackson, 2012). By addressing these issues it is possible to reduce mortality rates and improve a patients quality of life.
Motivational Interviewing assumes that an individual will change their behaviour more by motivation than by information (Resnicow, Davis, & Rollnick, 2006). MI is an effective approach to low intensity intervention in the promotion of health related outcomes such as weight loss (Hardcastle et al, 2013). This approach differs from other behavioural models, in that the essence of the technique lays within the spirit MI, which uses strategies and techniques, that envoke this spirit when used correctly (Resnicow et al, 2006). MI does however, draws its base from several other theories in order to empower the individual to understand one essential aspect of behavioral change, which is motivation.
MI evolved from the experiences of Miller in the treatment of problem drinkers (Britt et al, 2003). It dealt with individuals that suffered from alcohol dependence, and was an alternative to the other addiction models that saw patient resistance to change as denial. MI is a communication technique, rather than applied techniques that instigates changes in behavior that is initiated by the patient rather than the councilor (Gourlan, Sarrazin, & Trouilloud, 2013).
As MI is a theoretical based therapy, it allows practitioners to direct the assessment, conceptualization, intervention and evaluation of patients (Lundhal, & Burke, 2009). The model allows the individual achieve a distinct sequence of stages. Evidence suggests that when MI is introduced to the treatment of a patient, results back up its inclusion compared to either a placebo or no treatment at all (Wilson, & Schlam, 2004). Both males and females benefit equally from the treatment. However, using MI on cognitively challenged patients or very young children is not applicable, but works as a treatment for both genders from adolescence to geriatric (Lundhal et al, 2009).
Measurement of stages of change in MI:
MI has demonstrated that it is as effective treatment compared to other treatments and more effective than no treatment at all. MI also increases the patients’ engagement into the treatment (Lundhal et al, 2009). Therefore, the practitioner has many tools and techniques for implementing MI successfully with patients. Different researchers and different authors have defined different methods and stages for using MI. These stages will vary depending on the study, but in broad terms they are as follows: pre-contemplation, contemplation, preparation, action, and maintenance (Wilson et al, 2004).
Some of the supportive techniques that are used by MI practitioners include the acronym FRAMES, which consists of Feedback of personal risk, Responsibility for change, Advice giving, Menu of options for change, Empathetic style, and Self-efficacy improved (Britt et al, 2003). Within MI advice is not given without the permission of the patient, and is always encouraging the patient to make informed and correct decisions based on the advice received (Britt et al, 2003).
It is important from the outset that the client does most of the talking to establish trust and allow the client explore their concerns. The counselor should do most of the listening. A technique that the practitioner can use to establish the degree of importance/confidence of how ready the client is to change is by applying the readiness ruler. The readiness ruler establishes the client’s state of mind to change. Zero being ambivalent to change, and 10 being most willing to make changes (Miller, & Rollnick, 2002). To establish how willing the client is to change, the practitioner can use another Technique, under the acronym OARS to establish where the patient is on the readiness ruler. Oars stand for: Open ended questions, Affirmations, Reflective listening and summarizing. By using OARS, the counselor can encourage the patient into more speech during sessions (Miller et al, 2002).
When the practitioner feels the time is right for the client and they are ready to change their behaviour, the client will be set achievable goals. These goals come under the heading of Smart: Specific, Measurable, Attainable, Realistic, and Timely. If goals are unrealistic, it is possible that the client will become not only demotivated but may become even more ambivalent to change if they fail to see results from the changes they have been willing to make. For motivational interviewing to succeed with an individual, the individual needs to be empathized with and guided towards change. Defining Motivational Interviewing (MI) Miller and Rollnick (2002) stated that MI is a ‘collaborative, person-centered, form of guiding to elicit and strengthen motivational change’.
Implementing Motivational Interviewing.
The implementation of MI works best when a practitioner sees a patient face to face for a set number of visits over a set period of time. Individuals with a higher motivation to lose weight yielded greater results than individuals that show signs of ambivalence to weight loss (Webber et al, 2013). This is where MI may be used to help individuals understand how meaningful and important not only the benefits of weight loss, but also the benefits of introducing and maintaining physical activity in their lives (Gourlan et al, 2013).
The Implementation of a weight loss program with MI added to the program may need to be done on a one to one format on a regular basis to yield results that are greater than other commercial weight loss programs. It is important the PCPs’ recognise that many different problems and barriers may overlap that causes changes in behavior of patients towards their food intake and physical activity.. Some problems such as marital problems, depression, violence, financial, personality disorders, workplace problems, to name but a few may impact on how the patient behaves towards addiction. To address the patients’ main addiction problem, these other problems may also need to be addressed. By understanding the complex nature of the patient’s state of mind, the PCP should be tailoring a program to the individual needs of the patient ( Shinitzky, & Kub, 2001).
MI delivered in a group setting, may not have the same effect on patients compared to one to one sessions, regardless of how motivated the patient may be to change their behavior. While it is more time and cost effective, the overall results from group therapy sessions are not as good as a period of one to one MI treatments. This is highlighted by a study from Webber & Rose, (2013), where the investigators reported that face-to-face consultations did not yield greater results than commercial Internet weight loss programs. This, according to the investigators may have been due to the study using a group format to conduct MI sessions and not having enough sessions to impact the group to actively lose weight over the period of time. One theory for this is that the group format delivery of MI may not yield the best results for the patients, may be down to MI’s reliance on therapeutic alliance and client centered skills, which do not translate into certain group formats (Lundhal, & Burke, 2009).
Motivational Interviewing and Primary Care Intervention.
Health care providers care for more overweight patients now than they ever had before (Barlow et al, 2002). Health services that promote behavioral counseling for obesity should be commended as the benefits of this approach have yielded positive results in the reduction of overall weight reduction, type 2 diabetes and cardiovascular disease (Carvajal, Wadden, Tsai, Peck, & Moran, 2013). However, public health policy makers are now expecting health care providers to identify at risk groups and reverse the trend with the correct intervention for these at risk groups (Lakerveld, Bot, Chinapaw, Van Tulder, Kostense, Dekker, & Nijpels, 2013). However, not all address, evaluate or treat the problem as recommended by expert guidelines (Barlow et al, 2002). Different aspects of behavioural counseling can be adopted, with motivational interviewing yielding positive results amongst practitioners that engage their patients using this method
A recent study by Chisholm, Mann, Peters, and Harte (2013) found that the current guidelines set out by the United Kingdom’s General medical council recommended that graduating students be competent in discussing obesity and weight loss management with patients. The researchers reported that there is a lack of clarity and consensus on how best to design a curriculum for students to follow in real world circumstances. It is vitally important that frontline staff were not only competent but also confident when addressing obesity and the related diseases.
For MI to have successful patient outcomes, it is also important that the clinician is not only properly trained but is also truly motivated towards using MI as a technique. Should a PCP show less motivation for MI, this could be noticed by the patient, who already suffering from ambivalence to weight loss and physical activity, may become totally disillusioned with using PCPs to aid them in starting or achieving a weight loss goal. A study by Decker and Martino (2013) highlighted the unintended effects of MI training on the commitment, confidence and interest on clinicians. Using data from a multi-site study, the researchers used a mixed-effects regression model to compare three methods of training in MI on the 92 clinicians taking part in the study. The researchers reported that the commitment, confidence and interest of clinicians declined over time regardless of whether the clinicians received intensive training or self-study materials for MI. This, according to the researchers was due to the fact that the MI training received by the clinicians bore little relationship to the integrity in which the clinicians used MI to deal with their patients.
The style of interaction used by the therapist or PCP is important. Patients, as stated before, will be ambivalent to change at the outset of therapy sessions. Therefore therapists using MI techniques should use a collaborative technique as opposed to a confrontational technique to influence the patient to start the process of change (Wilson et al, 2004). PCP’s using counseling techniques to motivate families, reinforce techniques, identify family conflicts that interfere with change are more likely to achieve positive results with weight loss with families (Barlow et al, 2002).
Behaviour modification therapy may not be a new way of addressing the behaviour of overweight and obese individuals, however, recent research has shown that with correct training practitioners can improve the success of weight management within primary care (Vallis, Piccinini-Vallis, Sharma, & Freedhoff, 2013). Swartz et al (2007) reported that 80% of pediatricians interviewed were frustrated at not being able to impact pediatric obesity. Pediatricians appeared to have perceived or real deficiencies in their ability in motivational interviewing and behavioral counseling skills in dealing with patients suffering from obesity. Enhancing the pediatrician’s ability to deliver confident motivational interviewing techniques would improve outcomes with motivated patients according to the investigators.
Health care providers face a many barriers in convincing patients to adopt weight loss and physical activity regimes. Attending sessions would be the biggest obstacle PCPs would face. Patients would be unwilling to travel, felt uneasy about the use of public transport, and due to lack of mobility they would have a poor knowledge of their neighborhood, financial issues and the ability to actually schedule an appointment (Ariza, Hartman, Grodecki, Clavier, & Ghaey, 2013). Webber (2013) also reported that Face-to-face sessions tend to be costly, inaccessible to some, and inconvenient due to the time required to travel to a clinic for and including the session. However, this may all change with advances in technology.
A counseling collaboration between GPs and persons qualified to deal with Obesity related subjects may be more effective than PCPs counseling at risk groups alone (Carvajal et al, 2013). MI is not a standard health educational tool, the use of a standard manual has been reported to yield pooper results and may encourage practitioners to push for premature change (Lundhal et al, 2009). It takes time to establish a relationship between practitioner and patient and explore family perspectives to weight loss and physical activity in order to formulate a plan (Grace-Cleveland, 2013). This is time consuming for already busy practitioners, and it may require adding an additional member of staff to deal with this area of weight management. As most practitioners have a nurse working in the practice that already deal with patient’s lifestyle modifications. It may be prudent to train them up in MI techniques to deal with obese patients and relieve the pressure on GPs (Wong et al, 2013).
Nurses tend to have well rounded education that allows them deal with health promotion and disease prevention. They can use their interpersonal skills confidently to educate and promote proper health issues with patients through building a relationship built on trust with patients and families (Bishop et al, 2012). This would not only allow patients attend more visits where PCPs, allow PCPs’ to deal with other patients, but also allow the nurse to deal with these issues on the patient visits (Bishop et al, 2012). By having additionally trained staff and resources for the improved obesity management would have greater benefits for the patient, and could have a positive impact on further motivational goals. This is supported by Lowenstein, Perrin, Campbell, Tate, and Cai, (2013), who’s study into PCPs’ self-efficacy and outcome expectations for childhood obesity counseling concluded that practitioners with resources already in place for healthy eating and physical activity, reported higher levels of self-efficacy and counseling frequency than PCPs’ that did not have resources in place.
Improved technology should make the potential of using MI to treat patients more appealing to pcps. As these technologies develop, it will become easier and possibly more practical to deliver MI sessions through Internet sources from smart phones and tablet computers (Carvajal, 2013). This will allow practitioners to deal with more clients on a one to one basis. The use of technology may also be less costly and remove some of the barriers that PCPs’ now face such as cost of travel and the willingness of patients to travel. How successful this will be has yet to be determined, but it will certainly remove a major barrier from the patients ability to see the PCP.
Motivational Interviewing and Adolescent Obesity.
Obesity amongst children and adolescents is rising at an alarming rate. The health implications associated with this rise has implications both short term and long term for children and adolescence, leading to an increase in the need for clinical services dealing with assessment, treatment and prevention of obesity and obesity related illnesses (Storey, Neumark-Stzainer, Sherwood, Holt, Sofka, Trowbridge, Barlow, 2002). A World Health Organization (WHO) report into childhood obesity in 2009 estimated that in 2010 43 million children under 5 would be overweight, with a staggering 35 million overweight/obese children in developing countries, and 8 million overweight or obese in developed countries (WHO, 2009). With this growing prevalence of Obesity, early intervention among overweight children is necessary (Kirk, Scott, & Daniels, 2005).
Families, as a whole, need to be educated not only on healthy eating and improved physical activity, but also in not creating barriers if obesity is to be tackled. MI Practitioners face certain challenges when dealing with childhood obesity, such as the age of the patient. Younger patients will need parent involvement as questions rather than reflections may need to ask in order to elicit responses. With older children, parents may be a barrier to the patient opening up, in these circumstances it may be better if the practitioner sees the patient on their own (Resnicow et al, 2006). Lack of parent involvement, patient motivation and the correct support systems act as barriers to successful obesity treatment with adolescents (Story et al, 2002). Kirk et al (2005) reported that education alone is not enough to establish more healthy eating habits. The researchers argue that diet and activity levels need to be changed by using a framework that is presented in a concrete and manageable fashion that is tracked and reinforced daily to help with sustained motivation.
Many adolescent teenagers show ambivalence to adding physical activity to their weight loss program. With the growing evidence that MI is a successful tool in assisting patients with weight loss and achieving goals associated with weight loss. For effective weight loss, correct diet and physical activity should go hand in hand. However, if the client is overweight or obese, they may see this as a barrier to increasing their physical activity. MI may be a valuable role to play in encouraging patients to increase physical activity levels when motivational barriers arise (Gourlan et al, 2013).
MI is increasingly becoming more popular amongst practitioners dealing with childhood Obesity. Gourlan et al (2013) reported the effectiveness of conducting a MI program alongside a standard weight loss program as a further aid in reducing weight in obese adolescents. The researchers wanted to promote a balanced diet, healthy lifestyle and increased physical activity amongst obese subjects using logical and rational arguments to convince the individual to adopt new behaviors. This consisted of making the acquaintance of the individual and building awareness where the councilor would eventually address weight and physical activity concerns and the ambivalence that the subject may have to change. The second phase consisted of the patient realisng that some lifestyle changes needed to be made, and what options were open to them depending on the needs of the patient. The third phase consisted of goal setting, that were both realistic and achievable for the patient. The fourth phase consisted of the patient maintaining their behaviour and the possibility of adopting new physical activity habits were discussed. The researchers reported greater reductions in BMI and increased Physical Activity amongst the standard weight loss group that had a motivational intervention compared to the standard weight loss group. The researchers concluded that adding MI to a weight loss program is an efficient tool in the promotion of physical activity amongst obese subjects.
Stewart, Chapple, Hughes, Poustie, and Reilly (2008) investigated a qualitative method of Behavioral change techniques to assess whether families could adopt this method to change their lifestyle. The investigators found that parents who had taken part in the behavioral change were very positive about the techniques used, compared to parents who found the primary care treatment less successful. The researchers concluded that practitioners should use behavioral change as a method of engaging families into positive thinking by dieticians.
It is important to ensure that parents of overweight and obese adolescents are committed to the MI technique in order to have the adolescent fully committed to losing weight, and that the program is tailored to suit the needs of the individual, as a one size fits all approach won’t yield satisfactory results. A study by Baidel et al (2013) studied the perception of parents to MI. The researchers reported that depending on the sex and ethnicity of the parents, determined how motivated the children were and also the level of satisfaction the parents had with using MI as an intervention tool. Parents born outside the United States had a lower success rate and thus lower satisfaction with MI compared to parents born in the United States. Therefore, its important that specific interventions are used for specific populations as cultural beliefs and differences must also be accounted for.
Obesity is a growing problem right across the globe, that is currently costing governments huge amounts in budget spending, that could be used in other areas. Obesity and Obesity related illnesses need to be managed more effectively and efficiently from prevention to treatment, not only by the individuals themselves, but also by practitioners and governments. We can see that the use of behaviour modification techniques such as MI may aid in helping sufferers reduce weight and increase their physical activity.
PCPs that promote MI need to confident in delivering this style of treatment to patients who show ambivalence to behavior change. Barriers to change that patients throw up to practitioners can be overcome in the most part, with correct counseling by the practitioner if the patient is open to change. By putting the emphasis on the patient to initiate the change, it may bring patients to enjoy the sessions as they see themselves in control of their lives, possibly something they have not experienced before or for many years.
Addressing physical activity and correct diet are two of the biggest barriers to reducing weight in Obese and overweight patients. Encouraging patients through MI to become less ambivalent to making these changes to their lives. It is important that practitioners are educated correctly to engage the patient correctly with properly designed and standardized procedures. Education of practitioners in MI techniques will need to be prioritized by government bodies if MI is not only going to continue to grow but also if new techniques are to be developed (Burke, Arkowitz, & Menchowla, 2003). To ensure that MI is more widely available, more practitioners from different professions can learn MI techniques in a timeframe as quickly as a two-day intensive workshop with ongoing supervision and coaching (Lundhall et al, 2009).
As technology improves, we will probably see a move away from actual physical face-to-face sessions and more sessions done via smart phone or tablet. This may aid PCPs more with adolescent and children patients, as there will not only be a novelty factor associated with the treatment but something they can relate to. However, more studies will need to be conducted to ensure that the use of the Internet and Internet tools yield the same results as that of the traditional sessions.
To aid adolescent and child weight loss amongst young obese patients it is vitally important that families and parents at the very least see the benefits of using MI techniques to instigate change in behavior. As obesity rises at an alarming rate within the young population, it is this area that we must target to ensure change in attitudes towards healthy eating and physical activity is carried forward. MI is one tool that may aid in this change.
Akinson, R.L., Blank, R.C., Loper, J.F., Schumacher, D., Lutes, R.A. (2012). Combined drug treatment of Obesity. Obesity Research 3 (4), 497s-500s.
Ariza, A.J., Hartman, J., Grodecki, J., Clavier, A., Ghaey, K. (2013). Journal of Health Care for the Poor and Undeserved, 24 (2), 158-167.
Barlow, S.E., Dietz, H. 2002. Management of Child and Adolescent Obesity: Summary and Recommendations Based on Reports From Pediatricians, Pediatric Nurse Practitioners, and Registered Dietitians. Pediatrics, 110 (236).
Bean, M.K., Mazzeo, S.E., Stern, M., Bowen, D., Ingersoll, K. (2011). A Values-Based Motivational Interviewing (MI) Intervention for Pediatric Obesity: Study Design and Methods for MI Values. Contempory Clinical Trials, 32 (5), 667-674.
Bishop, C.J., Jackson, J. (2013). Motivational Interviewing: How Advanced Practice Nurses Can Impact the Rise of Chronic Diseases. The Journal for Nurse Practitioners, 9 (2), 105-109).
Britt, E., Hudson, M.S., Blampied, N.M. (2004). Motivational interviewing in health settings: a review. Patient Education and Counseling, 53, 147-155.
Burke, B.L.,Arkowitz, H., Menchowla, M., 2003. The efficacy of motivational interviewing: a meta –analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71 (5), 843-861.
Carvajal, R., Wadden, T.A., Tsai, A.G., Peck, K., Moran, C.H. (2013). Managing Obesity in primary care practice: a marrative review. Annals of The New York Academy of Sciences, 1281, 191-206.
Chisholm, A., Mann, K., Peters, S., & Harte J. (2013). Are medical educators following General Medical Council guidelines on obesity education: if not why not?. BMC Medical Education, 13 (53).
Decker, S., Martino, S. 2013). Unintended effects of training on clinician’s interest, confidence, and commitment in using motivational interviewing. Drug and alcohol Dependence, dx.doi.org/10.1016/j.drugalcdep.2013.04.022
Gance-Cleveland, B. (2013). Motivational Interviewing for Adolescent Obesity: Using a collaborative approach with patients and family can empower them to change. American Journal of Nursing, 113 (1), 11.
Gourlan, M. Sarrazin, P., Trouilloud, D., (2013). Motivational interviewing as a way to promote physical activity in obese adolescents: a randomized-controlled trial using self-determination theory as an explanatory framework. Psychology & Health, 10.1080/08870446.2013.800518.
Kirk, S.,Scott, B.J., Daniels, S.R (2005). Pediatric Obesity Epidemic: Treatment Options. Journal of the American Dietetic Association, 105 (5), 44-51.
Lakerveld, J, Bot, S.D., Chinapaw, M.J., Van Tulder, M.W., Kostense, P.J., Dekker, J.M., Nijpels, G. ( 2013). Motivational interviewing and problem solving treatment to reduce type 2 diabetes and cardiovascular disease risk in real life: a randomized control trial. International Journal of Behavioral Nutrition and Physical Activity, 10 (47).
Lowenstein, L.M., Perrin, E.M., Campbell, M.K., Tate, D.F., Cai, J. (2013). Primary care Providers’ Sef-Efficacy and Outcome Expectations for childhood Obesity Counseling. Childhood Obesity, 9 (3), 208-215.
Lundahl, B., Burke, B.L. (2009). The effectiveness of and applicability of motivational Interviewing: a practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65 (11), 1232-1245.
Miller, W.R., Rollnick, S. (2002). Motivational interviewing: preparing people for change. (2nd ed.)New York, NY, US: Guilford Press.
Resnicow, K., Davis, R., Rollnick, S. (2006). Motivational Interviewing for Pediatric Obesity: Conceptual Issues and Evidence Review. Journal of American Dietetic Association, 106 (12), 2024-2033.
Schwartz, R.P., Hamre, R., Dietz, M.H., Wasserman, R.C., Slora, E.J., Myers, E.F., Sullivan, S., Rockett, H., Thoma, K.A., Dumitru, G., Resnicow, K.A. (2007). Office-Based Motivational Interviewing to Prevent Childhood Obesity. A feasibility Study. Archives Pediatriatrics & Adolesence Medicine, 161, 495-501.
Shinitzky, H.E., Kub, J. (2001). The art of Motivational behavior Change: The use of motivational Interviewing to promote health. Public Health Nursing, 18 (3), 178-185.
Stewart, L, Chapple, J., Hughes, A.R., Poustie, V., & Reilly, J.J. (2008). The use of behavioural change techniques in the treatment of paediatric obesity: qualitative evaluation of parental perspectives on treatment. Journal of Human Nutrition and Dietetics, 21, 464-473.
Storey, M.T., Neumark-Stzainer, D.R., Sherwood, N.E., Holt, K.,Sofka, D., Trowbridge, F,L., Barlow, S.E. (2002). Management of child and Adolescent Obesity: Attitudes, Barriers, Skills, and Training Needs Among Health Care Professionals. Pediatrics, 110, 210-214.
Van Dorsten, B. 2007. The Use of motivational Interviewing in Weight Loss. Current Diabetes Reports, 7 (5), 386-390.
Vallis, M., Piccinini-Vallis, H., Sharma, A.M., Freedhoff, Y. (2013). Minimal intervention for obesity counseling in primary care. Canadian Family Physician, 59,27-31.
Wang, B.C.M., Wong, E.S., Alfonso-Cristancho, H.E., Flum, D.R., Arterburn, D.E., Garrison, L.P., & Sullivan, S.D. (2013). Cost Effectiveness of bariatric surgical procedures for the treatment of severe obesity. European Journal of Health Economics DOI 10.1007/s10198-013-0472-5
Webber, K.H., Rose, S.A. (2013). A pilot based behavioral Weight Loss Intervention with or without Commercially Available Portion-Controlled Foods. Obesity, DOI: 10.1002/oby.20331.
Wilson, G.T., Schlam, T.R. (2004). The transtheoretical model and motivational interviewing in the treatment of eating and weight disorders. Clinical Psychology Review, 24, 361-378.
Wong, E.M.Y., Cheng, M.M.H. (2013). Effects of motivational interviewing to promote weight loss in obese children. Journal of Clinical Nursing, 22 (17-18), 2519-2539.