Orienting Actions On Value Goals
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.
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.
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.
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.
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).
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.