Today’s post comes from Maryam Kebbe, a fourth year Doctoral student studying under the supervision of Dr. Geoff Ball in the Department of Pediatrics at the University of Alberta. Maryam has a passion for patient-oriented obesity research in children and plans to continue doing health research in this area after completion of her PhD.
As readers are probably well aware, often times, the first line of treatment for adolescents seeking health services for obesity management consists of behavioural changes targeting nutrition, physical and sedentary activities, and sleep habits, including an addressing possible issues of mental health.
However, health professionals often encounter a lack of adherence to a healthy behaviours by adolescents with overweight or obesity, resulting in challenges in maintaining or losing weight. This may be due to a number of factors, including difficulties in changing established habits and a lack of consideration for adolescents’ priorities in managing weight. To help with clinical consultations, both adolescents and health professionals can benefit from tools and resources that can be tailored to adolescents with obesity attempting to change their lifestyle habits.
Our team conducted a multi-phase project that included adolescents, health professionals, and researchers to develop Conversation Cards for Adolescents (CCAs), an adolescent-tailored, bilingual (English and French) clinical tool aimed at streamlining conversations and facilitating lifestyle behavior change in adolescents via collaborative goal- setting. Specifically, we completed a review of the literature (1) and a qualitative study including in-person interviews, focus groups, and patient engagement panels (2-5) from which we identified 153 factors that help, may help, or deter adolescents with obesity from adopting healthy lifestyle behaviors. Next, we asked adolescents to prioritize (online survey) and validate (telephone consultations) these factors to help refine our tool (6). The design of this tool included another three rounds of refinements with The Burke Group in collaboration with Obesity Canada.
CCAs comprise a deck of 45 cards. Each card contains an individual statement pertaining to a barrier, enabler, or potential enabler (15 statements per category) that adolescents often encounter in making and maintaining healthy lifestyle changes. These cards are organized across seven categorical suits: nutrition, physical activity, sedentary activity, sleep, mental health, relationships, and clinical factors.
CCAs are intended to be used by adolescents and health professionals and are complementary to an already existing deck of cards (Conversation Cards©) created for parents and health professionals by our research team in 2012 (7-10). Our future steps include completion of a pilot randomized controlled trial to determine the feasibility and user experience of using CCAs by adolescents with obesity and health professionals working in primary care.
- Kebbe M, Damanhoury S, Browne N, Dyson M, McHugh TL, Ball GDC. Barriers to and enablers of healthy lifestyle behaviors of adolescents with obesity: a scoping review and stakeholder consultation. Obesity Reviews, 2017; 12: 1439-1453.
- Kebbe M, Perez A, Buchholz A, Scott S, McHugh TLF, Dyson M, Ball GDC. Health care providers’ delivery of health services for obesity management in adolescents: a multi- centre, qualitative study. BMC Health Services Research, 2019; Under Review.
- Kebbe M, Perez A, Buchholz A, McHugh TLF, Scott SD, Richard C, Dyson MP, Ball GDC. Recommendations of adolescents with obesity to facilitate healthy lifestyle changes: a multi-centre, qualitative study. BMC Pediatrics, 2018; Under Review.
- Kebbe M, Perez A, Buchholz A, McHugh TLF, Scott SD, Richard C, Mohipp C, Dyson MP, Ball GDC. Barriers and enablers for adopting lifestyle behavior changes among adolescents with obesity: a multi-centre, qualitative study. PLoS ONE, 2018; 13: e0209219.
- Kebbe M, Perez A, Buchholz A, Scott SD, McHugh TLF, Richard C, Dyson MP, Ball GDC. Adolescents’ involvement in decision-making for pediatric weight management: a multi-centre qualitative study on perspectives of adolescents and health care providers. Patient Education and Counseling, 2019; In Press.
- Kebbe M, Perez A, Buchholz A, McHugh TLF, Scott SD, Richard C, Dyson MP, Ball GDC. Conversation Cards for Adolescents: a communication and behavior change tool for health care providers and adolescents with obesity. Health Services Research, 2019; Under Review.
- Kebbe M, Byrne J, Damanhoury S, Ball GDC. Following suit: using Conversation Cards for priority-setting in pediatric weight management. Journal of Nutrition Education and Behavior, 2017; 49: 588-592.
- Ball GD, Farnesi BC, Newton AS, Holt NL, Geller J, Sharma AM, Johnson ST, Matteson CL, Finegood DT. Join the conversation! The development and preliminary application of conversation cards in pediatric weight management. Journal of Nutrition Education and Behavior, 2013; 45: 476-478.
- Farnesi BC, Ball GD, Newton AS. Family-health professional relations in pediatric weight management: an integrative review. Pediatric Obesity, 2012; 7: 175-186.
- Farnesi BC, Newton AS, Holt NL, Sharma AM, Ball GD. Exploring collaboration between clinicians and parents to optimize pediatric weight management. Patient Education and Counseling, 2012; 87: 10-17.
Anyone who has ever seriously looked at the genetics of obesity should be well aware that body weight and size is a highly heritable trait.
As one may expect, this heritability extends across the entire spectrum of body size. Thus, if there are genes that explain obesity, then perhaps certain variations of these very same genes may do the exact opposite – i.e. promote “skinniness”.
In fact, we all know these people, who appear to be highly weight-gain “resistant”, in that they can apparently eat all day without gaining a gram of body fat or simply find it very difficult to “overeat” even when surrounded by highly-palatable food.
Now, a study by Fernando Riveros-McKay and colleagues, published in PLOS Genetics, compares the genetics of thinness with that of severe obesity.
Using genome-wide association studies, the researchers not only show that the heritability of thinness was comparable to that of severe obesity but they also confirmed the existence of 10 genetic loci that had been previously associated with obesity (as well as an addition obesity and BMI-associated locus (PKHD1).
As there may well be non-genetic reasons for people to fall into the “thin” end of the size spectrum, the researchers were careful to only include individuals who appeared in good health and especially excluded individuals with anorexia.
Overall, these finding are consistent with animal studies that have also identified loci/genes associated with thinness/decreased body weight due to reduced food intake/increased energy expenditure/resistance to high fat diet-induced obesity, mechanisms that the authors hypothesise may also contribute to human thinness.
Clearly, further genetic and phenotypic studies focused on persistently thin individuals may provide new insights into the mechanisms regulating human energy balance and may uncover potential anti-obesity drug targets.
While I am currently teaching at a Harvard Medical School course on obesity for obesity educators here in Las Vegas, I thought it may be appropriate to post a link to my recent Obesity Canada webinar (about 60 mins) on why obesity is a chronic disease.
The full video can be accessed by clicking here
Las Vegas, NV
If there is one thing for sure, when it comes to managing obesity, one size does not fit all. In the same manner as there are hundreds of paths that lead to obesity, predicting the treatment that works best for any given patient is almost impossible – what works for one, may do nothing for another (treatments fail patients, patients never fail treatments).
Thus, in our analysis of interviews with patients and providers, published in Clinical Obesity, the eighth theme that emerged, was the importance of experimenting and reevaluating.
“Participants experimented with different actions, arranged appointments with interdisciplinary providers, or tried out community resources. Some changed their action plan and implemented different behaviours inspired through the consultation. During follow-up interviews, people reflected on what worked, what did not and what needed adjusting. Participants found that having someone ask how things are going was helpful for accountability and motivation. These conversations also helped them develop solutions for barriers.
It became glaringly obvious that, as with any other chronic disease, obesity care needs creating a supportive long-term relationship in order to respond to emerging barriers, shifting experiences, illness and treatment burden – what works great at one point may stop working when situations change. Things that seem impossible at first may well become possible over time.
If there is one thing that I have learnt in my dealing with patients, it is modesty in professing to have the solution for every problem.
As I have said, people who think there is a simple answer to every question, generally don’t even understand the question.
As should be clear by now, obesity management often involves reframing the story, changing misconceptions about obesity, managing expectations, reorienting from weight to health goals.
All of this requires reflection both on part of the patient and the provider.
Thus, fostering reflection was one of the key themes that emerged from out interviews with patients and providers published in Clinical Obesity.
“For many participants, the insights and shifts in beliefs about self and health required time to reflect and integrate.People processed new understandings in different ways and internalized them to different degrees.”
While some patients went though this process of reflection in conversations with family, friends or their clinician, many reported that keeping a journal of their progress was a key instrument:
I routinely tell my patients to write down key events, emotional issues, stressors, milestones, challenges, and successes in their journals (not just their food intake and physical activity). Many have told me how helpful they find this and how much they have discovered about themselves through this exercise.
Although many of the comorbidities associated with obesity are directly linked to excess body weight, and losing weight has been shown to dramatically improve overall health and well-being (at least in people living with obesity), it is always important to remember that the ultimate goal of obesity management is to improve health and not just move numbers on the scale.
In this context, it is important to help patients identify and focus on health rather than on weight goals – indeed, patients tend to do best when they focus goals that are important to them – independent of what may or may not happen to their weight.
Thus, in our recent analysis of patient and provider interviews, published in Clinical Obesity, we found that both patients and providers agree on the importance of orienting all actions on goals valued by the patient.
“Context integration and priority setting led into thinking about what actions, strategies and resources may be of interest for the patient. Providers and patients identified a functional or value goal that served as an overarching orientation for action planning. A majority of participants wanted to plan actions, some chose to first reflect on thenew understandings gained from the conversation. Possible actions emerged from the conversation and differed widely between patients. They included addressing mental health, pain, sleep, seeking financial and social supports, considering anti-obesity medication or bariatric surgery.”
This is where it is always important to remind ourselves that losing weight cannot be a behavioural goal, as it is not a behaviour (losing weight is something your body may or may not do in response to a behaviour – you can control your behaviour but not how your body responds to this behaviour). Also, healthy behaviours will always improve your health, irrespective of whether or not you lose weight.
“While helping with accountability and motivation, action planning was described as less decisive than the cognitive and emotional work that led to context integration and priorities. However, this perception shifted over time, andmany participants later reflected on the benefits of planning specific and achievable actions for outcomes.”
Again, obesity management is best done in a long-term therapeutic partnership (as with any other chronic disease), and reorienting patients away from weight to non-wieght goals is a process that takes time but reaps significant rewards.
For many patients, searching for the underlying reasons for their weight journey is fraught with shame and self-blame.
This is why it was not surprising that from our interviews with patients and providers, published in Clinical Obesity, it became apparent that helping patients make sense of their journey was such an important step.
Not only did this lead to context integration but also reprioritizing what was important to them:
“Providers summarized and integrated all relevant factors from the patient’s story andassessment that led to their current health status, highlighting strengths, and offering a perspective on which challenges to address first. Providers validated their interpretation with the patient, asked for clarification, and agreed on a priority. This provided an alternative narrative of the patient’s obesity: one that explained and acknowledged underlying root causes, offered an alternative, capable and resilient, patient identity, and set a direction for change that made sense in light of their life context. From the patients’perspective this offered a tremendous shift in the way they thought about themselves and their ability toimprove their health.”
In my own practice I have often witnessed patients going through “aha moments” and ultimately shifting their focus on health rather than weight goals.
This is of course a process – insights, reflections, and reorientation of goals does not happen overnight – but when it happens, I often witness the transformation that takes place before my very eyes.
There should not be any misconceptions about how many misconceptions about obesity, its causes, its consequences, and its treatments exist – not just in the general public but also amongst people living with obesity (not to mention health professionals, most of who also have a very limited understanding of this chronic disease).
Thus, as we found in our extensive interviews with patients and providers, published in Clinical Obesity, the importance of providing credible evidence and shifting beliefs about obesity is a key step in any obesity consultation.
Not only is it important for patients to understand the chronic (life-long) nature of obesity but also the limitations of treatments, which in turn is fundamental to managing expectations.
“Frequently, the conversation uncovered areas in patients’understanding of obesity that were misaligned with current medical knowledge. In response, providers assessed and explained drivers of weight gain such as medications, sleepapnea, emotional issues and metabolic processes. Providers coached patients in focusing on functional outcomes instead of weight, adopting realistic expectations for weight loss and maintenance, and choosing sustainable goals. A number of participants shared how lowered weight-loss expectations resulted in both relief but also asense of grief.”
Overall, the goal has to be to shift patients (and providers) away from a primarily weight-focussed approach, to a whole-person approach focussed on health.
“The focus on improving whole-person health was crucial as, in many cases, diet and exercise behaviour wasintimately linked to comorbidities, life events, emotional trauma, workplace stress, finances, relationships or loss of meaningful occupation. In addition, it offered renewed motivation and courage for patients who were discouraged by repeated experiences of weight loss and regain.”
Overall, the better the patient (and provider) understand the complex psycho-social-biology of obesity and the limitations of current obesity therapies, the better we can manage expectations and focus on whole-person health rather than just massaging numbers on the scale.