Obesity Canada have published new guidelines on clinical practice which include a chapter on psychological and behavioural interventions in obesity management. If you work with people who live with obesity it’s really worth reading. Here’s a glimpse of what’s in the chapter.
Some people want support changing particular habits or behaviours
The authors say at the outset that as all obesity management interventions involve behaviour on the part of the person living with obesity (whether that’s to do with eating, activity or medication adherence for example), behavioural change support should be incorporated into all obesity management plans.
The focus should be on achievable and sustainable behaviour change, as for any psychological intervention. The relationship between the person making the changes and the professional should be collaborative – very much how we work using cognitive behavioural therapy generally.
Outcomes should be measured in terms of the degree to which the work enables people to achieve their own goals around quality of life, health and overall functioning. Habit change can be difficult, and working on goals that are consistent with the person’s core values will make much more sense and be more achievable.
Understanding the nature of the condition
With obesity being understood as a chronic medical disease, principles relevant to any chronic disease management are relevant:
- Outcomes that matter are changes that the person living with obesity is able to do, not what the clinician does. Whereas in the past interventions have focused on nutrition or exercise as the changes that people need to make, research suggests that we should think about changes to nutrition or activity levels as the positive outcomes that follow from helping people identify what they want to change and how to go about making sustainable changes.
- When obesity management focuses on the goals the patient wants to achieve, and the sustainability of those goals, it becomes important to view sustained behaviour and psychological change as the ultimate goal. And the behavioural pathway needs to be incorporate into the person’s lifestyle (instead of trying to shoehorn the patient’s lifestyle to fit a particular type of diet).
- Success in obesity management should be about quality of life, psychosocial functioning and health behaviour change – not a narrow focus on weight loss.
We need to be able to offer a range of useful strategies and tools
Behaviour change counselling identifies sequential steps that guide the provider to empower the individual to engage in and sustain health behaviours in the face of barriers.
Burgess et al carried out a systematic review of factors that may make it difficult for people to use obesity management interventions that are on offer. They concluded that the main barriers to behavioural intervention in adults with obesity are poor motivation, lack of time, environmental, societal and social pressures, health and physical limitations, negative thoughts/ moods, socioeconomic constraints, gaps in knowledge, lack of awareness and lack of enjoyment of exercise. We need to be able to listen to what barriers people are up against and to think with them about whether there are ways of overcoming or getting round those barriers.
The authors of the chapter take three particular areas of psychological functioning that are supported by evidence and consider each in some detail:
Addressing reflective psychological processing
People living with obesity are subjected to both explicit (conscious, clear and overt) weight bias and implicit weight bias (unconscious thoughts associated with social prejudice) from other people.
Internalised weight bias is the extent to which a person living with obesity has come to believe negative weight-based beliefs about themselves. Given that intrinsic motivation and a sense of self-efficacy appear to be central mediators of sustained behaviour change, if the person you’re working with accepts a negative prejudiced view of themselves, change will be harder.
Importantly, and contrary to popular belief, weight bias does not encourage positive behaviour change.
Part of helping someone to change involves developing self-compassion and the ability to talk to themselves with empathy rather than self-criticism.
We need to pay attention to controllability attributions (the extent to which you believe you can influence something), as these may produce self-blame (“If I wasn’t so weak I could do this”) or feelings of hopelessness (“nothing I can do will make any difference”) which will have a negative effect on self-esteem. Your professional role will determine how much you focus on attributions – if you’re a psychologist or therapist this may be something you work on directly, and if you’re a dietitian or nutritionist it may be something to be aware of and to notice and discuss with your client.
- Weight loss expectations/ evaluations
The authors of the chapter are clear that people living with obesity who seek treatment may have expectations of weight loss that exceed what obesity management interventions are capable of achieving. But interestingly, excessive expectations of weight loss do not seem to interfere with the success of interventions. I wonder if this is because someone’s goals may alter as they start to make changes
On the other hand, how satisfied you are with the weight loss you’ve achieved determines whether you’re likely to stick with a programme. Satisfaction with your weight loss achieved to date may be a key factor in whether you are able to sustain the changes you made to get to where you are. For professionals this means checking in with your client how they feel about progress they are making and adjusting the way you’re working together accordingly as you go.
Addressing associative learning
The appetite system is highly responsive to signals of palatable food available in the environment, and palatable food cues can overwhelm the body’s homeostatic satiety mechanisms. We vary in the degree to which our individual brain chemistry – “reward sensitivity” – responds to hyper-palatable foods.
Reward sensitivity is the result of a combination of
- The sensory pleasure associated with eating – the “liking” response which is based on opioid receptors in the brain
- The degree to which food and food cues elicit the motivation to eat – the “wanting” response which is associated with dopamine pathways in the brain’s mesolimbic system
- The degree to which associative learning takes place
There is clear evidence that reward sensitivity is a factor in the development of obesity. People living with obesity should have this explained: that the urge to eat is based on powerful neurobiological underpinnings and strong learned associations, and these vary between people. Behavioural interventions to help people manage such drives and cravings need to include behavioural coping skills to manage those drives.
Self-regulation is described as a key behavioural attribute of people who lose weight and keep it off. Weight, health and quality of life outcomes are primarily a product of sustained adherence to any reduced energy diet and not affected significantly by the type of diet. Disruption in adherence, or lapses in self-regulation, are mostly a result of temptation to hyper-palatable foods.
Unlike the brain areas involved in the drive to eat, self-regulation is governed primarily by the dorsolateral pre-frontal cortex. Self-regulation varies between people (between-individual variation) and some of us have more capacity for this than others. I would add that our ability to self-regulate also varies across time (within-individual variation) – we may have greater self-regulating capacity at different times of the day, at different points in the menstrual cycle, and depending on what is happening in our lives right now.
The ability of an individual to change how they eat involves an interaction between bottom-up processing (the drive to eat generated by the dopaminergic pathways in the midbrain) and top-down regulation from the pre-frontal cortex. Psychological and behavioural interventions need to incorporate both in order to be helpful and effective.
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Burgess, E et al (2017) Behavioural treatment strategies improve adherence to lifestyle intervention programmes in adults with obesity: a systematic review and meta-analysis. Clin Obes, 7(2) : 105-14
Vallis, M., Macklin, D. and Russell-Mayhew, S. (2020) Effective Psychological and Behavioural Interventions in Obesity Management. In: Canadian Adult Obesity Clinical Practice Guidelines.