Fostering Reflection

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. @DrSharma Copenhagen, DK

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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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