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.
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.
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.
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.