decorational arrow Obesity Care | 5 min. read

Let’s talk about weight: time for a different conversation in obesity care

COVID-19 has put obesity on the healthcare agenda and created even a greater need to rethink how we view and treat this disease. While much progress has been made to better understand the science of weight regulation and evolve treatment options for obesity, discussing weight with a healthcare provider remained a challenge for a long time. But there is a silver lining in this domain too.

By Dr. Michael Vallis, August 2020

“Why should I listen to anything you say? Actually, why should I talk to you at all?”

Despite the harshness of such questions, as a Health Psychologist working in the field of obesity management, I don’t mind them at all. Actually, I find them very illuminating.
                    
Much of my work is training medical professionals in obesity management. Not the medical part of obesity management but the caring part of obesity management.
                    
In that context, how are the harsh questions above helpful? Well, they expose a major problem regarding the role healthcare professionals play in obesity management. And if your weight has ever come up in your visits with a healthcare provider, maybe you’ve asked these questions (more or less audibly) too.

“The doctor is a tiny speck in a person’s life – and probably the first to be ignored. Expert advice is fine, but it doesn’t control behaviour over time.”

-Dr. Michael Vallis

Two sides to every story. The doctor/patient divide

I often find myself leading a training session on obesity management with a room of 30 or 40 doctors. Asking the question “Why should your patient listen to anything you say?”, I tend to get 3 answers.
                    
The most common answer is, “Patients should listen because I am an expert.” To which I respond by reminding the doctor he/she is a tiny speck in a person’s life – and probably the first to be ignored.
                    
Just think about it: You visit your doctor, agree on a plan, then go home and find out that your life partner is skeptical and challenges your doctor’s recommendations. Who do you keep happy? Your life partner or your doctor? Right. Next, you go out with your friends and they want to go in a different direction than what you and the doctor agreed on. What happens? Do you keep your doctor happy and end up alone, or do you keep your friends happy? Expert advice is fine, but it doesn’t control behaviour over time and it certainly doesn’t override the important relationships and cultural aspects of your life.

 

“Emotions dominate logic in the normal human.”

-Dr. Michael Vallis

Want versus should

The second most common answer to this question is “My patients know they should.” Well, this raises the issue of “wants” versus “shoulds”. As humans, we truly have competing demands. We have an emotional side, based on wants and interested in the pursuit of happiness. And we have a logical side that can calculate risks and benefits. Which is stronger, do you think? Correct, emotions dominate logic in the normal human.

The power of intrinsic motivation

Ok, so what is the third, least common answer? The doctor says “the patient has personal and meaningful reasons to seek and follow my advice”. Bingo! Humans are most likely to pursue behaviours that are consistent with their beliefs and values.
                    
So, contemporary obesity management is based on asking, listening and understanding the person’s experience first. From that common ground, the person and doctor can negotiate different options for management.

 

“Contemporary obesity management is based on asking, listening and understanding the person’s experience first.”

-Dr. Michael Vallis

Collaborate and empower

I tell this story because it illustrates the problem I alluded to above. That is, the medical system has been set up as an expert system where the doctor is the expert and you are the uninformed.
                    
This set-up works in the emergency room or in the operating room but not when it comes to the behavioural choices people make day-to-day. In our lives we need to be in charge. Have kids? How old was your child when she/he first said to you “you’re not the boss of me”? Exactly. And why do I know that your child’s first words were “No!” and “Me do!” not “Mommy” or “Daddy?
                    
There is a time and place for “teach and tell” healthcare and expert recommendations, but it is not what obesity management requires. Obesity management requires an approach I call “collaborate and empower”.


“In our lives we need to be in charge. Obesity management requires an approach I call collaborate and empower.”

-Dr. Michael Vallis

Contemporary approach to obesity management

Contemporary approaches to obesity management embrace this “collaborate and empower” perspective and base themselves in respect, caring, and supporting the personal expertise of an individual. Imagine your doctor saying “You are an expert in you and I have some expertise in obesity management”. Do you think we could work together to find solutions that work for you?
                    
It is my belief that such an invitation is the only way in which healthcare providers and people with obesity can begin collaborating towards effective obesity management. But sadly, very few health professionals are aware of this yet.

A nightmare on ELMM street

There is a huge amount of research that shows that healthcare providers display bias and stigma toward those living with obesity, who in turn don’t view healthcare providers as sources of support.
                    
Here is where the second question I mentioned above comes in; Why Should I Talk To You At All? Well, if you feel this way or have an experience of being judged by a healthcare provider, I would like you to know that the problem is me not you. Regrettably enough, like virtually all members of society, healthcare providers too have developed the too-simplistic notion that weight loss is only about eating less and moving more.
                    
All due to the individual; a simple equation between energy in and energy out. So, if you want to lose weight just eat less and move more; if not there is something wrong with you. Within the society called Obesity Canada, of which I am a founding member, we call this “Nightmare on ELMM Street” where ELMM refers to “eat less, move more”.

“As treatment advice, Eat Less Move More is ripe for retirement.”

-Dr. Michael Vallis

Weight is not a behaviour

As treatment advice, ELMM is ripe for retirement. The evidence is overwhelming that obesity is a medical condition – risk of obesity is related to your genetics, appetite is complex and involves several brain systems that protect against weight loss, and food is as much about social and emotional issues as it is about weight.
                    
As a result, we know that weight is not a behaviour and cannot be directly controlled, and that fat loss results in neurohormonal changes that increase appetite, reduce fullness; the body tries to protect its highest weight.

A pivotal moment in medical profession

We have dug ourselves into a very deep hole. The “eat less, move more” mindset adopted from advertising has created bias against people living with obesity, bias by healthcare providers and society in general and also self-bias by those living with obesity.
                    
Resolving the situation is going to require that healthcare providers are educated about the science and ethics of obesity management. On behalf of my profession, I believe that we need to work extra hard right now to regain the trust of individuals living with obesity. Why would they give us another chance if we can’t prove we’ve changed?

“We need to acknowledge that our past beliefs about obesity and how to treat it were wrong, and we now understand obesity differently.”

-Dr. Michael Vallis

Towards better obesity management

But if you have been the victim of obesity bias, it can be hard to forget. I want to emphasize this. We have treated you badly. You have suffered the harmful consequences.
                    
You can’t just forget it. That is why I have developed a teaching module for healthcare providers called “The Grand Apology”. What I mean is that we need to acknowledge that our past beliefs about obesity and how to treat it were wrong, and we now understand obesity differently. We own this and acknowledge that it is has been harmful. We ask for you to consider renegotiating your relationship with your provider using a new belief system.

More than one strategy to treatment

Being a medical condition, the same way type 2 diabetes, hypertension and asthma is, treating obesity requires a combination of medical (surgical when required) and behavioural strategies.
                    
Also, chronic diseases require self-management and self-management support, which the relationship between doctor and patient should provide. In this relationship, you are not passive, and you certainly are not submissive. You are an equal partner. I say this because I believe that if you are not satisfied with the care you receive, you have the right to inform your provider, have a critical opinion, and engage in constructive discussion.

“Don’t give up, compassionate healthcare providers practicing collaborative approach in obesity care do exist! ”

 

-Dr. Michael Vallis

Everyone wants to do better

I have occasionally asked doctors the following question: “If your patient experienced you as judgmental, dismissive and uncaring, would that distress you?”
                    
The answer I invariably get is an emotional “Yes, it would absolutely upset me!” This tells me that the average doctor is trying. This is good news and makes me hopeful that if you were to communicate “When you say what you just said it feels like you are judging me,” you would receive an invitation to collaborate.
                    
If you are not satisfied with the response you get, then that provider might not be a good match for you. Like in other areas of your life, in obesity management you may need to screen a few doctors until you find the right one to partner around your health.
                    
But, don’t give up, compassionate healthcare providers practicing collaborative approach in obesity care do exist!

References
  • Vallis M. Are Behavioural Interventions Doomed to Fail? Challenges to Self-Management Support in Chronic Diseases. Can J Diabetes. 2015;39:330–4.
  • Vallis M, Piccinini-Vallis H, Freedhoff Y, Sharma A. A Modified 5 As Minimal Intervention For Obesity Counselling in Primary Care. Can Fam Physician.
  • Vallis M, Lee-Baggley D, Sampalli T, Ryer A, Ryan-Carson S, Kumanan K, et al. Equipping providers with principles, knowledge and skills to successfully integrate behaviour change counselling into practice: a primary healthcare framework. Public Health. 2018 Jan;154:70–8.
  • Vallis M, Lee-Baggley D, Sampalli T, Shepard D, McIssaac L, Ryer A, et al. Integrating behaviour change counselling into chronic disease management: a square peg in a round hole? A system-level exploration in primary health care. Public Health. 2019 Oct;175:43–53.
  • Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000 Jan;55(1):68–78.
  • Forman EM, Butryn ML. A new look at the science of weight control: how acceptance and commitment strategies can address the challenge of self-regulation. Appetite. 2015 Jan;84:171–80.   

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