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Let’s talk about weight: time for a different conversation in obesity care
“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.
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.
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.
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”.
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”.
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?
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.
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
Related articles
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