Motivational interviewing is often one of the more challenging areas of obesity medicine because of its somewhat subjective nature. Many questions have several seemingly reasonable answer choices, and there are numerous acronyms, tools, principles, and communication strategies to keep straight. Over the past year, I have reviewed several of these scenarios in the Facebook study group, Obesity Medicine Boards Prep–2026, as part of the question of the week. I decided to compile some of those discussions into a consolidated blog focused on walking through a challenging motivational interviewing question.

Let’s start with the question:

A patient present to her primary care physician to discuss pharmacologic treatment for obesity. She eats fast food four times weekly out of convenience due to evening kids’ activities, and seldom has time to exercise given her work schedule and traveling. She has seen multiple advertisements for tirzepatide and wants to initiate this medication. What question is the most appropriate response?

A. Do you think you can restrict eating out to twice weekly?

B. Do you have any family history of medullary thyroid carcinoma?

C. What do you think is preventing you from achieving weight loss?

D. Would you be open to discussing an exercise prescription?

E. Would it be okay to discuss your weight with you?

I would say this would be one of the more difficult questions you would see, but there are some great discussion points. First, I always recommend reading through the answer options first to see the question’s objective. It appears to be aimed at management/advice. In other words, it’s not focused on evaluating genetics, diagnosis, etc. That insight helps with reading the question in a more focused light. Also, anytime you see an advice question, see if there is a motional interviewing technique that is in there. They are subtle and mixed with other very attractive answer choices!

The patient is presenting to discuss obesity. In particular, they are wanting to start pharmacotherapy to treat the excess weight. Hopefully, you get the sense that the patient doesn’t have great habits in place- too busy for physical activity and eating fast food frequently out of convenience. In addition, the patient doesn’t seem to have great insight to correlate her excess weight to her lifestyle habits.

I’ll say none of the answer choices are wrong- in fact, they are all quite reasonable, and likely would all be addressed during the visit. This is exactly why these sorts of questions are so difficult. So why is one better than the other? Let’s change the entire question and make it about smoking and see if it helps.

A patient presents to her primary care physician to discuss pharmacologic treatment for smoking cessation. She smokes 1.5 packs per day. She occasionally will use nicotine gum out of convenience instead of smoking during her kids’ indoor school events. She admits her job is very stressful, so this has been a way to reduce that stress. She saw some advertisements for varenicline and wants to start the medication. What question is the most appropriate response?

A. Do you think you can restrict smoking to 0.5 packs per day?

B. Do you have any history of seizures or heart disease?

C. What do you think is preventing you from stopping smoking?

D. Would you be open to discussing tapering off cigarettes?

E. Would it be okay to discuss your smoking cessation with you?

Sometimes, the same question changed to another condition helps bring to light some of the nuances. Again, not any blatantly wrong answer options, but this patient feels like varenicline is the answer to the problem (smoking). This convenient option doesn’t correct any of the insight-disconnect being experienced. One thing I know from smoking cessation counseling is if the patient doesn’t see the importance of it, medications alone likely will not be the solution.

Similarly, obesity medicine questions that focus on treating the symptoms of a condition only without addressing underlying issues, including lack of motivation or insight, tend to be less effective. Obesity is complex, so often pharmacotherapy is a great option, but should not be the sole focus of improving body mass index. So, for this reason, motivational interviewing techniques that assist by helping the patient gain some insight, or at least help self-evaluate barriers, can be so helpful.

Answer E is very attractive and commonly selected. In a prior blog, I discussed making sure to ask for permission, but the patient is specifically coming in to discuss obesity. ‘Ask’ is important when the provider is the one initiating the discussion (about weight, complications of weight, etc.), but if the patient presents specifically wanting to address it, you can assume the ‘ask’ portion has been satisfied. Below is a modified question stem where answer E would be the best option.

A patient present to her primary care physician to discuss fatigue. On social history review, she endorses eating fast food four times weekly out of convenience due to evening kids’ activities, and seldom has time to exercise, given her work schedule and traveling. Her BMI is 39 kg/m2. She has seen advertisements for a vitamin patch that advertises helping improve energy. What question is the most appropriate response?

In this case, you are trying to initiate the conversation on weight, thus asking for permission would be the best option. When someone comes to you for weight management, asking to discuss weight is less relevant. However, asking something would it be okay to discuss your level of physical activity or eating behaviors may still be relevant.

Also, on boards, always try to avoid giving advice if there are options to select from that allow the patient to self-reflect and come up with solutions. Therefore, “Do you think you can restrict eating out to twice weekly?”, which is answer A, is not the best option. This patient is showing ambivalence to eating out, and rather is coming to you to fix the BMI, not a behavior that may be contributing to the BMI. Ambivalence is where motivational interviewing shines. Your goal would be to have her identify that eating out may be a contributor to the excess weight, such as “What do you think is contributing to your excess weight?” and then help them discover alternatives to that behavior such as, “What do you feel like would be a way to maintain the convenience on busy days, but reduce the overall caloric intake?” For any patient on boards who wants a medication to treat a BMI and ignores, or does not see the importance of lifestyle changes, you can almost guarantee motivational interviewing will be the best answer choice.

Finally, “Would you be open to discussing an exercise prescription?” is premature at this point. This patient has time constraints and telling the patient they need to exercise X amount of time weekly, etc. is likely not going to go over well. Again, getting the patient to have some buy-in is the first step. This would be similar to saying do you want me to tell you how many less cigarettes you should smoke? Yes, it can be helpful to discuss strategies, but they are now only in the pre-contemplative state, of which motivational interviewing is more successful.

I don’t want you to infer that medications cannot be used on the first visit. In fact, the AHA/ACA came out saying that GLP-1 medications should be utilized as first-line for weight loss. It is not that you couldn’t ask questions about contraindications to the medications, etc. However, it is vital to treat all pillars of obesity. This patient is looking at the medication as a first-line treatment for treating the BMI, which it would likely do. However, without incorporating lifestyle modifications, the results will likely be subpar. The ABOM wants you to provide thorough obesity care, not just prescribe medications to fix a BMI.

This was a challenging question. If it helps changing the disease condition or asking yourself which would have the most efficacy for this patient long-term, try that. Look for patients who are ambivalent about lifestyle modifications who are not connecting that lifestyle modification is contributing health concerns.

Below is the final question and explanation:

A patient present to her primary care physician to discuss pharmacologic treatment for obesity. She eats fast food four times weekly out of convenience due to evening kids’ activities, and seldom has time to exercise given her work schedule and traveling. She has seen multiple advertisements for tirzepatide and wants to initiate this medication. What question is the most appropriate response?

A. Do you think you can restrict eating out to twice weekly?

B. Do you have any family history of medullary thyroid carcinoma?

C. What do you think is preventing you from achieving weight loss?

D. Would you be open to discussing an exercise prescription?

E. Would it be okay to discuss your weight with you?

(C) Motivational interviewing (MI) is aimed at changing the narrative from jumping to providing solutions to promoting self-reflection, which can lead to behavioral change. Although many options including pharmacologic, eating pattern improvements, and physical activity should ultimately be discussed, the suboptimal lifestyle behaviors and her complex schedule are likely the underlying drivers for the behaviors seen. Her goal of treating the weight with pharmacologic treatment may address the underlying body mass index, but not the behaviors that led to the caloric intake/utilization mismatch. Similarly, metabolic and surgery is not the answer if underlying behaviors may contribute to diminished outcomes.

Note: Although Ask is one of the first components of the 5 A’s, this patient has already opened up a conversation. The ‘Ask’ portion is utilized when the clinician is the one initiating the discussion on weight or its complications.

Change behavior occurs when the patient recognizes the discrepancy between their current behaviors and where they want to be, allowing them to provide personalized solutions. Avoiding the righting reflex is a MI principle, where the provider avoids telling patients how to improve, and instead allow the patient to self-reflect to discover the discrepancies in their behaviors and goals is most effective.

For more practice, check out the following related blogs:

Next Week: Monthly Knowledge Check. This is a review checklist of must-know items for ABOM exams based on the previous four blog topics. In addition, this will include a brief explanation of the correct answers to previous sample questions.

Upcoming:

For more practice questions, check out the following:

  • Obesity Medicine Board Review Questions (2026): Qs 170, 184, 212, 223, and 243.
  • Obesity Medicine Practice Tests (2026): Qs 38, 42, 143, 157, 307, and 437.

(Copyright 2026) Obesity Medicine Board Review Questions, LLC: obesitymedicinereview.com

Featured image: Modified from VectorStock (image license purchased)

Copyediting by Kelly Smith

Now available: A full line of ABOM study resources with 775+ challenging questions in a mobile or book format. Access to both formats is available in a discounted Ultimate Package, which also includes a Pass Guarantee (if you fail the exam in 2026, you get the 2027 edition free), 50 bonus questions released in August, and the newest book, Obesity Medicine: Sample Questions and Study Blogs, which includes all the updated previous study blogs in a paperback format. Check it out here!