The Uncertainty Of Behavioural Obesity Management
Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Aug 21, 2011: In the past few posts, I have discussed some of the recommendations in the recent Scientific Statement on New and Emerging Weight Management Strategies for Busy Ambulatory Settings From the American Heart Association. The Statement includes a number of suggestions on how to assess eating behaviour and physical activity in a busy clinical setting and touches on the use of internet and other electronic resources for assessment and management. In summary, the Statement concludes that: – Discussions of weight should be performed in a nonjudgmental, respectful, and unhurried manner. – Readiness and self-efficacy to change behaviors should be assessed before weight loss strategies are initiated, and this information should be factored into decisions about what type of approach to use. – Validated tools such as the Eating Pattern Questionnaire, the Starting the Conversation tool, and the WAVE and REAP-S tools should be used to assess behaviors that contribute to excess body weight gain. – Central planning and training should be incorporated into collaborative approaches that involve physicians, nurses, or other providers. – Studies of Internet and other technologies for weight loss have shown promise, but at this time, there is insufficient evidence to make recommendations about their use in busy clinical settings. The authors also make the following pertinent suggestion: “…because many weight management interventions involve understanding and applying detailed and sometimes complex information by patients, the health literacy of patients should be taken into account in the design and selection of interventions.” While all of this is a good start, I do wish that the statement had given greater emphasis to the fact that obesity is a heterogeneous and complex disorder and that it may be more important to spend time evaluating the ‘whys’ than the ‘whats’. Thus, while it is certainly informative to assess ‘what’ people are doing, it is perhaps of even greater value to evaluate the underlying drivers (the ‘whys’) of these behaviours, be they environmental, cultural, biological or psychological. Unfortunately, the Statement remains largely locked into the ‘how-do-we-get-obese-people-to-eat-less-and-move-more‘ paradigm, an approach that has so far largely failed to deliver. Indeed, there is yet no convincing evidence that ‘traditional’ approaches to ‘lifestyle’ intervention for obesity can produce lasting effects – nor… Read More »
How To Discuss Weight With Your Patient
Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Sep 16, 2011: One of the reasons that many health professionals do not bring up the issue or weight, is simply because they feel uncomfortable doing it. So what is the best strategy and what does the research on this issue actually show? This topic is a significant part of a new Scientific Statement From the American Heart Association, endorsed by the Society of Behavioral Medicine, published in the latest issue of Circulation. Based on a systematic search of the literature on this topic (published between 2002 and 201), it is clear that patients describe a need for empathy, nonjudgmental interactions, and specific personalized recommendations. As regular readers will recall, this is actually rule 1 of my 10 tips for family docs, and if nothing else, this is the only rule that all health professionals should adhere to – always! While some patients associate even the word “obese” with discrimination, patients rate “‘weight” as the most desirable term, and “fatness” as the most undesirable term. In my practice, I often also use the terms ‘large’, ‘size’, or ‘big’ and have never had a negative response – much of how you use the language is determined by the general ‘non-judgemental’ manner in which the words are used. When I do use the term ‘obese’, I generally explain that I am using this ‘clinically’ as the ‘medical’ definition. “Patients also express a preference for clinicians taking time to deliver weight loss counseling, rather than offering weight loss advice as an afterthought as they leave the room.” “The importance of verbally recognizing patients’ small weight losses as well as their unsuccessful weight management efforts was also noted, because nonrecognition by providers was seen as a judgment that the patient did not care or was not making an effort toward weight loss.” I generally do acknowledge changes in weight, but do not make them the topic of discussion unless I am specifically asked. Any comment would always be objective, non-judgemental and generally encouraging, no matter what – even a small weight gain could be worse! When the patient brings up and insists on discussing the weight – this is always a good opportunity to explain (once again) that obesity management is not about… Read More »
Is Weight-Loss Advice Unethical?
Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Aug 31, 2009: This week’s issue of Newsweek quotes me as saying, “A lot of our weight-loss recommendations are unethical because we shouldn’t be saying lose weight when there is no chance people will keep it off“. This quote appears in the context of a lengthy article by Daniel Heimpel that examines whether or not the obesity epidemic is being oversold. While I personally do not think that the obesity epidemic is being oversold, I do stand by my statement that most of the weight-loss advice given to patients with overweight or obesity is unethical. In medical school, I was tought the principle of “primum non nocere” or “first, do no harm.” This principle begs us to always consider the possible outcomes (including the unintended ones) of any actions that we take with our patients, including of course the advise we give them. So what are the potential ethical concerns about telling someone to lose weight? 1) The way this advise is presented: it is certainly no secret to the readers of this blog that weight-bias is widespread, not least amongst health professionals. As a result, the weight issue is not always addressed in the most sensitive or professional manner, thereby often resulting in little more than having the patient cancel all future appointments. 2) The advise that is given is of little help: as most health care professionals lack even the most basic understanding of the sociocultural, psychological and biological determinants of energy regulation, they generally boil this down to “less energy in and more energy out” or “eat less, move more”. Most physicians will in fact primarily recommend exercise, actually the least effective method to lose or control weight. Patients, who recognize the futility of this advice (most often because they’ve been there and done that), are likely to have less confidence in their physicians’ recommendations, even in areas in which the physician may well be competent and knowledgeable. This can clearly have a negative impact on the patient-doctor relationship. 3) Rates of recidivism or weight regain are virtually 100%: In General, interventions, where the rate of recidivism is that high (especially in severe obesity, with the exception of bariatric surgery), should be recommended with caution.… Read More »
Why Obesity Management and Weight Loss are NOT the Same
Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Sep 29, 2009: As I attend the 45th Annual Meeting of the European Association for the Study of Diabetes (EASD) here in Vienna, I am not surprised to see many talks and abstracts related to obesity and weight loss on the program. Time perhaps to muse on an important aspect of obesity management, namely that successful obesity management does not necessarily require any weight loss at all. Obesity, as we all know, is a chronic progressive condition. Left untreated, patients generally continue to gain weight – those, who do not already have weight-related health issues, will eventually get them. This situation is really not different from the situation in other chronic conditions. As a nephrologist, I like to use the example of chronic renal failure. When I see a patient who has lost 50% of their kidney function, it is my job to make sure that this patient does not continue to lose kidney function year after year, as this patient would otherwise eventually require dialysis or a kidney transplant. The measure of success in treating chronic renal failure is therefore not to try and restore kidney function to 100% (virtually impossible without a transplant) but rather to slow or (even better) halt progression of kidney failure. The same could be said for preventing the progression of other chronic diseases like diabetic retinopathy, artherosclerosis, osteoarthritis, etc. Stopping all of these conditions, for which we have no cure, in their tracks would certainly be considered a success and in fact, many treatments and medications are specifically indicated for halting progression of chronic conditions rather than reversing them. Thus, for e.g. while laser ablation may halt the progression of diabetic nephropathy, it certainly does not restore eyesight. Similarly, while putting a patient on an ACE inhibitor or ARB may slow progression of chronic renal failure, it does not bring renal function back to normal. If, as we now know, obesity is a chronic progressive condition, then simply halting progression (or even just slowing down the rate of weight gain) must already be considered a success. If I had a treatment that would allow all my patients who are currently at 300 lbs to simply stay at 300 lbs rather than… Read More »
Unrealistic Weight-Loss Expectations Guarantee Disappointment
Over the next little while, I will be taking a few days off and so I will be reposting some of my favourite past posts. The following article was first posted on Aug 27, 2008: One of my all time favourite quotes is “No one is admired for failing to achieve the impossible.” I have previously blogged about the issue around unrealistic expectations when it comes to weight management. In fact, one of the principal reasons that we have successfully introduced the Orientation Sessions in the Weight Wise program, is to temper patients’ often ridiculously optimistic expectations about how much weight they can lose and keep off. While a large proportion of patients are hoping to lose about 50% of their initial weight, the sad truth is that even with surgical treatment, the average patient can hope to lose only 25% – and that is when all goes well! Why is managing expectations so important? Because unrealistic expectations guarantee disappointment. (for my mathematical readers S=O/E where S=Satisfaction, O=actual Outcome, E=Expectations; if S<1 the patient is unsatisfied or disappointed). The issue of ridiculous expectations is not limited to weight loss. In fact, Janet Polivy (University of Toronto), in a wonderful article published in the International Journal of Obesity (2001 – free PDF for download), termed this the “False Hope Syndrome”. In the context of weight management, this syndrome is characterized by often completely unrealistic expectations as to: 1. the amount of weight loss that can be achieved (and maintained!) 2. the speed with which the weight can be lost 3. the ease with which lifestyle changes can be made 4. the effects that these changes (weight loss) will have on other (mostly non-health related) aspects of one’s life (e.g. finding a better job, attracting a partner, etc.) When any of these unrealistic expectation are not met, the result is simply disappointment, discouragement and a sense of failure. It is therefore a moral and ethical obligation for health professionals to actually talk patients out of thinking they can all become happy Ken and Barbie dolls if only they tried hard enough. Unfortunately, it is very easy for health professionals to be caught up in the ridiculous expectations of their patients or even feed these expectations by demanding and expecting the impossible. Thus, for e.g. the orthopedic surgeon who expects his obese patients to lose 30% of their body weight before hip-replacement surgery… Read More »
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