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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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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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Some Limitations In Applying The Etiological Framework To Obesity Assessment

To conclude this series of citations from my article in Obesity Reviews on an aeteological framework for assessing obesity, that guides us through a systematic assessment of factors influencing energy metabolism, ingestive behaviour, and physical activity, it is important to consider some limitations of this (and any other) etiological approach to obesity management: While we have taken efforts to provide a comprehensive and wide‐ranging list of considerations in the assessment of obesity, we fully recognize that a full work‐up of all permutations of the proposed factors may well be beyond the scope of a busy practitioner. In this regard, the old saying applies: ‘when you hear hoofs, think of horses not zebras’. Thus, consideration should be first given to the most common and obvious reasons laid out in this paper, many of which should be immediately apparent to the experienced clinician (e.g. homeostatic hyperphagia resulting from meal skipping, hedonic hyperphagia related to depression, immobility due to osteoarthritis, weight gain due to atypical antipsychotics, etc.). Also, the use of comprehensive self‐directed questionnaires such as the Weight and Lifestyle Inventory, a multiple‐page self‐report questionnaire that the patient completes before treatment visits, designed to identify the root causes of obesity and perform an environmental analysis, may be helpful in this regard. Future efforts must also aim to provide simple clinical algorithms that will guide the busy clinician through the maze of factors that can potentially precipitate and/or exacerbate positive energy balance. Nevertheless, as in a patient with oedema, despite complete recognition of the underlying factors, the clinician often has no option but to manage the patient with the judicious use of fluid restriction and diuretics. Similarly, in patients presenting with obesity, the underlying contributing factors (e.g. genetics, addiction, depression, back pain, etc.) may not be easily amenable to causal treatment. In these cases, ‘symptomatic’ treatment of obesity with caloric restriction and exercise regimens may well in many cases prove to be the only option. Nevertheless, we maintain that careful identification and management of the possible socio‐cultural, psychological and biomedical barriers will likely increase the feasibility, compliance and adherence to these measures. Recognition of the causes and barriers will also help set out realistic expectations regarding the degree of weight loss that is likely to be achievable and sustainable, an important aspect of weight management. Despite the increased time required for the comprehensive work‐up of an obese patient, we believe that this framework will… Read More »

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The Canadian Obesity Network Is No More – Long Live Obesity Canada!

Over a decade ago, together with over 120 colleagues from across Canada, representing over 30 Canadian Universities and Institutions, I helped found the Canadian Obesity Network with the support of funding from the Canadian National Centres of Excellence Program. Since then the Canadian Obesity Network has grown into a large and influential organisation, with well over 20,000 professional members and public supporters, with a significant range across Canada and beyond. During the course of its existence, the Network has organised countless educational events for health professionals, provided training and networking opportunities to a host of young researchers and trainees, developed a suite of obesity management tools (e.g. the 5As of obesity management for adults, kids and during pregnancy), held National Obesity Summits and National Student Meetings. raised funds for obesity research, the list of achievements goes on and on. Most importantly, the Network has taken on important new roles in public engagement, voicing the needs and concerns of Canadians living with obesity, and advocating for better access to evidence-based prevention and treatments for children and adults across Canada. To better reflect this expanded mission and vision, the Board of Directors has decided to convert the Canadian Obesity Network into a registered health charity under the new name – Obesity Canada – Obésité Canada. So with one sad eye, I look back and hope that the Canadian Obesity Network rests in peace – Long Live Obesity Canada! @DrSharma Edmonton, AB

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