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Co-Constructing A New Story

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. @DrSharma Copenhagen, DK

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Shifting Beliefs About Obesity

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. @DrSharma Edmonton, AB

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Recognising Strengths

The longer I work in our bariatric clinic, the more I am convinced that this is where you will see some of the strongest people alive. Certainly, no one can begin to imagine what it takes to live as a large person in a fat-phobic society, where carrying excess weight is constantly linked to failure, not to mention ridicule, shame, and blame. Add to this, the trials and tribulations that many of my patients have faced (some of which are often directly linked to their weight gain), I often wonder just how much effort it takes to go on day after day, never mind showing up in our clinic. It is therefore absolutely no surprise to me, that our interviews with patients and providers, published in Clinical Obesity, identified the importance of reminding our patients on just how strong they really are. “Patients attributed great importance to the process of recognizing their own strength. Data bears witness to the powerful impact internalized stigma had on peoples’view of self and their ability to be healthy. By listening for examples of resiliency in patients’ past and labelling them as strengths, providers fostered a shift in participants’view of themselves, which improved their confidence in implementing changes.Patients noticed this as an unexpected impact of a conversation about obesity. Many shared that they had expectedadvice on diet and exercise, behaviours they felt they were failing at. Instead, recognizing strengths opened up a space of potential for identifying strategies that people could succeed at, enjoy and find meaningful for their life. This strength-based approach positively impacted participants’ confidence, self-worth and hope.” Indeed, it is not hard to identify strengths in any patient. In fact, I often find myself listening to my patients and silently wondering how they have managed to not be twice their size, given what they have been through. Most patients have heroically mastered other aspect of their lives (e.g. raising four kids as a single parent, surviving an abusive marriage, coming clean from a long-history of substance abuse, etc., etc.). Many have excelled in their professions or serve as important pillars of their communities. Only when it comes to controlling their body weight, they perceive themselves as “failures”. Usually, this perception of failure is based on a flawed understanding of the real biological challenges that patients face in trying to manage their weight. Clearly, identifying and building on inherent strengths, is a far… Read More »

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Making Sense of The Story

When it comes to obesity, every patient has a story. Understanding the “how” and “when” (it began) often provides clues to the “why” and “what”, which are crucial in answering the question of why someone may have obesity. Thus, it is not at all surprising, that a key theme emerging from our analyses of patient and provider interviews published in Clinical Obesity, was the importance of helping patients make sense of their story. “For many, weight gain was linked to crisis events that put strain on coping resources. Sharing their perspective helped people to feel valued and acknowledged. Most importantly, it allowed for collaborative identification of root causes, linkages between life and health, contextual factors and patients’ value goals.” One approach to this that was deemed helpful was to draw a timeline of patient’s weight throughout their life to foster insight into their weight gain story and how they relate to life events. “This visualization of the intersecting patterns of life events and health emerged as an impactful tool and was subsequently adopted as a standard part of the 5AsT approach. Acknowledging the impact of life context on weight in an empathic dialogue helped participants to adopt an attitude of self-acceptance and increased insight into personal drivers of weight gain. Patients consistently asked to take the timeline home and reflected on the insights gained over time.” Indeed, in my own practice, I don’t believe I have ever encountered a patient in whom, at the end of the assessment, I still had no idea why this person may have had obesity. Rather, in the majority of (dare I say all) cases, it sooner or later becomes rather evident why a given patient would have developed obesity. Helping patients understand how seemingly unrelated life events, medical issues, or even their mental health causally relates to their obesity can not only serve as an “eye-opener” but also goes a long way to address shame and (self-) blame. The latter is an absolute pre-requisite to a constructive dialogue about possible treatment and management options. A key learning out my own practice – never make assumptions about the “whys” of someone’s obesity – every patient has their own (often surprising) story. Taking the time to find out and make “sense” of it all is vital to the entire process of obesity management. @DrSharma Edmonton, AB  

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Listening With Compassion

One of the key themes that emerged from our interviews with patients recently published in Clinical Obesity, was the importance of “real” listening and the role of compassion. “People described feeling validated and ‘like a human’. Many reflected in later interviews on how this experience impacted their ability to cope with frustrations while implementing their plan. Patients appreciated that providers repeatedly summarized what they understood and validated their interpretations with them. Patients experienced this as ‘real listening’ that resulted in an accurate understanding of their specific circumstances as basis for appropriate care plans.” In my own practice, I have made it a rule to dictate my notes right in front of the patient. Not only does this allow my patient to correct me if I get a detail wrong, but it also provides direct feedback to my patient that I have indeed heard their story and understand the issues that are important to them. Thus, I see my dictations not just as a means of communicating my assessment and recommendations to their family doctor, but also as an important part of my actual intervention (many patients have told me just how much listening to me dictate and interpret their story has meant to them). Obviously, compassion is a big part of the approach. I have long learnt to keep judgement out of my medical practice. I am not there to judge any of my patients (who am I to judge anyone?). Rather, it is my job to accept them as they are and hopefully help them move things forward to the goals that they find important. This simple “attitude adjustment” (that I made a long time ago), was perhaps the single most important change to my practice. More on the other themes that emerged from our interviews in coming posts. @DrSharms Edmonton, AB

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What Do Patients With Obesity Want From Their HCPs?

Although health care professionals (HCP) are generally not the first people that people living with obesity turn to for help, when they do, the advise they get is not always helpful. This is perhaps because most health care professionals don’t fully understand what exactly patients with obesity do find helpful (no, it is not advice to “eat less and move more”!). Obviously the best way to find out what patients find helpful, is by actually asking them and listening to their answers. This is exactly what we did in a paper by my colleague Thea Luig published in Clinical Obesity which reports on extensive analyses of video recordings of patient-HCP consultation as well as patient interviews and journals. Participants included 20 patients presenting in primary care, who were re-interviewed 2 and 4-8 weeks after the initial consultation. The initial consultation was was guided by the 5As of Obesity Management (Obesity Canada), 5As Team (5AsT) tools, Kushner’s obesity-focused life history, literature on aetiology and management, patient perceptions and provider-patient communication. As readers may be aware, core principles of the 5As approach include framing of obesity as a multifaceted, chronic disease and a focus on improving health rather than just on losing weight. Goals aim at improving function (functional goals) and regaining the ability to do things that are of value and enhance quality of life (value goals). Based on the extensive analyses of hundreds of pages of verbatim transcribed notes, eight important themes emerged (all extensively discussed in the paper): 1) Engendering compassion and ‘real’ listening 2) Making sense of root causes and contextual factors in the patient’s story 3) Recognizing strengths 4) Reframing misconceptions about obesity 5) Co-constructing a new story 6) Orienting actions on value goals 7) Fostering reflection 8) Experimenting and reevaluating The immediate impacts of the 5AsT approach during the consultation led to cognitive and emotional shifts: 1) Sense-making of the linkages between life context, emotions and health 2) Focus on whole person health rather than weight loss 3) Recognition of own strengths in overcoming difficulties 4) Sense of direction for action 5) Self-compassion, self-acceptance, hope and confidence to make changes and improve health. Although limited by the relatively short follow-up period, identifiable reported outcomes were generally positive and covered a range of improvements including activation, establishing healthy sustainable habits, improved function, as well as benefits for perceived mental, physical and social health. I will explore each of the identified themes in upcoming posts – stay tuned. @DrSharma Edmonton, AB

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Time To Change The Obesity Narrative

This week, I once again presented on the need for recognising obesity as a chronic disease at the annual European Society for the Study of Obesity Collaborating Centres for Obesity (EASO-COMs) in Leipzig, Germany. Coincidently, The Lancet this week also published a commentary (of which I am a co-author) on the urgent need to change the obesity “narrative”. So far, the prevailing obesity “narrative” is that this is a condition largely caused by people’s lifestyle “choices” primarily pertaining to eating too much and not moving enough, and that this condition can therefore be prevented and reversed simply by getting people to make better choices, or in other words, eating less and moving more. As pointed out in the commentary, this “narrative” flies in the face of the overwhelming evidence that obesity is a rather complex multi-factorial heterogenous disorder, where long-term success of individual or population-based “lifestyle” interventions can be characterised as rather modest (and that is being rather generous). This is not to say that public health measures targeting food intake and activity are not important – but these measures go well beyond “personal responsibility” ” The established narrative on obesity relies on a simplistic causal model with language that generally places blame on individuals who bear sole responsibility for their obesity. This approach disregards the complex interplay between factors not within individuals’ control (eg, epigenetic, biological, psychosocial) and powerful wider environmental factors and activity by industry (eg, food availability and price, the built environment, manufacturers’ marketing, policies, culture) that underpin obesity. A siloed focus on individual responsibility leads to a failure to address these wider factors for which government policy can and should take a leading role. Potential health-systems solutions are also held back by insufficient understanding of obesity as a chronic disease and of the necessary integration across specialties.“ It is also important to recognise that the prevailing “lifestyle” narrative plays a major role in the issue of weight-bias and discrimination: “Behind every obesity statistic are real people living with obesity. The prevailing narrative wrongly portrays people with obesity in negative terms as “guilty” of obesity through “weakness” and “lack of willpower”, succumbing to the siren call of fast and other poor food choices. This narrative leads to stigmatisation, discrimination—including in health services, employment, and education—and undermines individual agency.“ Thus, it is time to change this narrative: “If the narrative is instead reframed around individuals at risk of… Read More »

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The Clinical Importance of Using People-First Language in Obesity Management

Regular readers should by now be well aware of the importance of using people-first language when referring to people living with obesity (as in “patient with obesity” not “obese patient”). As I have noted in previous posts, living with a condition is not the same as being defined by that condition – this is why we do not refer to people living with dementia or cancer as being “demented” or “cancerous”. As elegantly pointed out by Lee Kaplan in a presentation he delivered at the Harvard Medical School Center For Global Health Delivery consultation on obesity, currently being held in Dubai, there is also a pressing clinical argument for speaking of obesity as a disease rather than a descriptor of a “state”. Take for e.g. the case of a patient with hypertension, who, thanks to effective on-g0ing anti-hypertensive treatment has managed to control his blood pressure levels over the past 10 years. In fact, at no time in the past 10 years has the patient ever presented with elevated blood pressure. Any clinician would agree that this patient would still be declared to have “hypertension” despite currently not being “hypertensive”. Similarly, a patient whose depression is well-controlled with an anti-depressant is still a patient living with “depression”, although they are not currently “depressed”. Likewise, we can probably all agree that a patient who has undergone coronary bypass surgery, is still someone living with coronary artery disease, even if they have not experienced a single angina pectoris attack since their surgery. In all of these cases, hypertension, depression, and coronary artery disease would continue to appear on their medical problem list. When applied to obesity, this means that even if someone has successfully managed to lose their weight to a level that they are no longer clinically “obese”, they are still someone living with “obesity”. Even if their BMI (not a good measure of obesity) should drop to below 25, they are still someone living with obesity (albeit, as in the case of the above examples, living with “controlled” or “treated” obesity). Thus, they continue to have “obesity” even if they are currently not “obese” – ergo, the diagnosis “obesity” should remain on their problem list. Furthermore, given the high rates of recidivism, keeping obesity on the problem list serves as an important reminder to the clinician to continue supporting and reinforcing ongoing obesity treatment (even if this treatment is only… Read More »

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