Drawing on my own experience as a registered dietitian (RD), I found counseling patients on weight loss to be difficult. As a clinician, I understand
that weight loss may be necessary for patients who need to:

  • Qualify for transplant
  • Improve diabetes and cardiovascular health
  • Improve overall quality of life

Yet many patients struggle to lose weight and even more importantly maintain it. They may feel overwhelmed with additional kidney disease
and/or diabetic dietary restrictions, or perhaps they recognize the need to lose weight but lack the motivation to get there. Food is often considered one of life’s simple pleasures and for patients on dialysis, it may be the one area of a patient’s life that they feel they still can control. It may be hard to let go of lifelong eating habits that bring comfort and enjoyment.

If you are a dietitian, you may find weight loss counseling to be a daunting and unenjoyable assignment, and you are not alone! Suresh et al found through surveying dialysis dietitians that there are many barriers to weight loss counseling in the dialysis setting. The most frequently reported challenge
for the RDs? Insufficient time.

Supporting a patient through a weight loss journey is much more complex than handing over a meal plan along with suggested lifestyle changes.
Most literature on successful weight loss programs utilizing counseling and dietary restrictions unsupported by surgery or medications points to the need for intensive counseling on a frequent basis for several weeks. Where do we find the time?

Here the research may provide a few clues. Motivational interviewing (MI) has been found to be an effective skill set to promote weight loss
and maintenance.

In short, MI is a collaborative approach that is patient centered and promotes autonomy. It is a skill set that requires time and practice but can be very rewarding. And one of the best parts of MI is that it can be effective even in short sessions, 10 minutes or less.

One way to utilize MI to fit into a shorter time frame is to consider breaking it down into segments and spreading it out over multiple sessions.
It might look something like this:

  • Session 1 – explore patient’s interest in weight loss
    • Have they chosen to lose weight or is the weight loss “assigned” or “prescribed”
    • What could they gain/lose by losing weight?
  • Session 2 – explore patient’s weight loss history
    • What has been tried in the past?
    • What did they like/dislike about different weight loss approaches?
    • What caused them to stop moving forward with their weight loss attempt?
    • What is different about this time?
    • How would they like it to be different this time?
  • Session 3 – understand patient’s projected timeline for weight loss
    • Have they set reasonable expectations for weight loss?
    • Can their timeline be adjusted if needed?
    • Why have they set that specific timeline?
  • Session 4 – nail down clear weight loss goals and plan for maintenance
    • What will happen when they’ve achieved their weight loss goal?
    • What will they do to maintain their weight loss?
  • Session 5 – assess patient’s commitment to losing weight
    • Recap their motivations, their plans, and their goal
    • Determine how important this goal is in the context with the rest of their life, how high of a priority is it?
    • What would need to change to make it a higher priority?
  • Session 6 – put into action the first SMART goal for weight loss
    • Hammer out a clear first step. This may be something like:
      • Keeping a 3-day food record to understand baseline diet intake
      • Start eating breakfast daily to reduce afternoon snack cravings
      • Go one month without missing any dialysis sessions to better understand their true dry weight

As you work each session, keep the following in mind to help things go smoothly:

  1. Allow the patient to set the agenda.
  2. Use summaries to catch you and the patient up on what has been discussed in previous sessions, this gives you a frame of reference to move to the next topic
  3. Ask open-ended questions.
  4. Actively listen, express empathy, and build on what you hear.
  5. Listen for and cultivate change talk.
  6. Guide the patient toward a specific plan.

Remember: The patient is in the driver’s seat and owns the journey; the RD wears the clinical hat and provides the guidance! To learn more about motivational interviewing, check out the following resources:
Clinician Portal links

References:

  • Suresh, A., Robinson, L., Milliron, B. J., Leonberg, K., McAdams-DeMarco, M., Earthman, C., … & Harhay, M. N. (2020). Approaches to obesity management in dialysis settings: renal dietitian perspectives. Journal of Renal Nutrition, 30(6), 561-566.
  • Twells, L. K., Harris Walsh, K., Blackmore, A., Adey, T., Donnan, J., Peddle, J., … & Pace, D. (2021). Nonsurgical weight loss interventions: A systematic review of systematic reviews and meta‐analyses. Obesity Reviews, 22(11), e13320.

We thank our guest blogger Kathryn Collins RDN, CSR Nutrition Therapy Consultant for sharing her knowledge and writing this blog post!