Guidelines support behavioural weight management interventions as gold standard treatments for people living with obesity1. However, these treatments often fail in the long-term due to lack of motivation to maintain changes among patients. In fact, most patients experience significant weight regain within a year of completing treatment2. What are the “hidden” factors often underestimated by clinicians that may explain patients´ lack of motivation to engage with treatment as well as their high relapse rates?
In the context of treatment, be it nutritional, psychological, or medical, I believe that one of these factors is the underestimation of the patients’ core values when we are asking them to make lifestyle changes. Given that achieving a healthier weight involves overcoming a lot of challenges -not always weight-related (i.e. food cravings, food availability, social pressure, changing family habits, among others)-, a sustained behavioural change is more successful when the behaviours chosen by the individual are consistent with his/her core values. Is the person really interested in changing his/her eating habits? Is he/she really interested in changing the eating habits of his/her whole family? Is he/she enough confident in his/her own capacities that would allow him/her to make this change? What do we really know about our patient´s core values, in terms of his/her aspirations or objectives that he/she has planned to follow in life? Do these aspirations have really anything to do with changing lifestyle? Maybe not…
Another factor is the underestimation of the obesogenic environment, an environment that will still be there, even if the person changes. In fact, we are asking these people to make rapid lifestyle changes without considering that the person may change but the obesogenic environment around him/her, which promotes the consumption of rapid and high-palatable food, will not. Don’t forget that the person living with obesity is also part of a social context where people, including his/her own family and friends, eat for pleasure, or eat in response to emotions, to advertisements, to peer influence… This makes change even harder: avoiding exposure to obesogenic environment or to social media is unrealistic…. Imagine a person with alcohol abuse who is currently in treatment having to come back to a stressful environment that promotes the consumption, for instance, imagine him/her having to attend daily a pub for “after-work drinks”. Would it be possible for him/her to adhere to treatment?
Finally, another factor that we often underestimate is obesity stigma and its effects. According to the World Health Organization3, “obesity stigma involves actions against people with obesity that can cause exclusion and marginalization, and lead to inequalities”. On the one hand, health professionals often think that weight stigma may be even an incentive and positive motivator for people to lose weight and they carry out their medical/nutritional/psychological interventions as if this were true. On the other hand, people who are continuously feeling discriminated due to their weight end up internalizing discrimination with the expectation that their life would be better if they lose weight. So, they internalize laziness, lack of intelligence, lack of willpower or physical unattractiveness, they isolate themselves socially, they even lose their friends… All this can really hurt their self-esteem and self-confidence, even their health. Imagine that many of them avoid or delay healthcare because of weight stigma. “Body weight is never as simple as calories in, calories out, or how much you move and eat, although that’s the stereotype we live by,” says Sarah Nutter, from the University of Victoria in British Columbia who carries out research on weight stigma. In conclusion, I believe that weight stigma should be considered as a public health issue as it harms individual´s health, promotes social exclusion and maintains, even worsens, the obesity pandemic.
A paradigm change is necessary to establish more effective interventions for the treatment of people living with obesity. How can we achieve that? By trying to “value” more the factors mentioned above and carry out individualized interventions focused on the improvement of patient-centred health outcomes rather than weight alone.
In the SOCRATES project, we consider obesity as a chronic and complex disease whose treatment does not only depend on individual responsibility. We work with the patient’s core values and explore his/her real interest to make lifestyle changes, following the Motivational Interviewing spirit4. We also follow the “Health At Every Size” paradigm5 and, when intervening with patients, we always take into consideration weight stigma and its implications as well as the power of the obesogenic environment. Patients living with obesity are trained by experts in the field about how to make their own motivational self-conversation using the SOCRATES’ Virtual Reality platform, called ConVRself. A patient says after having used ConVRself: “It’s the first time that, thanks to the experiment with ConVRself, I have been able to put myself in the place of my doctor and say what I would have liked him to tell me without feeling discriminated, without keep listening to someone saying that all my problems would be solved by eating less and exercising more”.
References
1. Wharton S, Lau DCW, Vallis M, Sharma AM, Biertho L, Campbell-Scherer D, et al. Obesity in adults: a clinical practice guideline. Can Med Assoc J [Internet]. 2020 Aug 4;192(31):E875–91. Available from: http://www.cmaj.ca/lookup/doi/10.1503/cmaj.191707
2. Wadden TA, Butryn ML, Wilson C. Lifestyle Modification for the Management of Obesity. Gastroenterology [Internet]. 2007 May 1 [cited 2021 Mar 15];132(6):2226–38. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0016508507005781
3. https://www.euro.who.int/__data/assets/pdf_file/0017/351026/WeightBias.pdf
4. Miller W, Rollnick S. Motivational interviewing: Preparing people for change. 2nd editio. New York: The Guilford Press; 2002.
5. Bacon L. Health At Every Size: The Surprising Truth About Your Weight [Internet]. Dallas, TX: BenBella Books, Inc.; 2010 [cited 2021 Oct 15].
About the author
Dr. Dimitra Anastasiadou is a psychologist and researcher with a PhD in Clinical and Health Psychology (International Mention). She has expertise in the prevention, assessment and psychological treatment of Eating Disorders and Obesity as well as in eHealth interventions. She is currently working as a post-doctoral researcher at the Vall d’Hebron Institute of Research in Barcelona, Spain, and is actively involved in the project SOCRATES being responsible for the coordination and smooth implementation of the Randomised Controlled Trial, which is going to be carried out at the Vall d’Hebron Hospital in the upcoming months.