(Help, I’m Losing Patience with My Patients!)
■Description of doctors’ and providers’ chief complaints when working with patients who have eating and weight concerns
■What treatment approaches are not working with these patients
■Special challenges in working with pediatric patients
■Who, if anyone, is to blame for escalating weights
■A new direction for treatment of eating and weight concerns
As physicians and health care providers, we have devoted our lives to helping others. We have spent years in training, and more years staying abreast of the most recent developments in medicine to promote wellness and heal our patients. As a profession, we can cure many diseases that killed people a mere half century ago, we have incredible technologies that allow us to fix problems inside the human body in a minimally invasive way, and scientists have even mapped the human genome. Yet we feel powerless to help our patients achieve and maintain a natural, comfortable weight with our current nutritional and exercise recommendations, medications, and surgery. We confront that failure daily in our busy practices, operating rooms, and hospitals.
Our patients experience even greater frustration. Some have struggled all their lives to lose weight and not regain it. They feel fed up and beaten down by decades of dieting, battling the scale, and watching the number on it continue to creep up. Some have tried to diet but gave up when their weight plateaued and they stopped shedding pounds. Now they no longer even try to watch what they eat. Desperate or depressed, they enter medical offices complaining about aching knees, hips, and back, their high blood pressure medications not working as well as they’d hoped, what a struggle it is to lose and keep off even a few pounds, and how easy it is to put them back on.
To both our credit and our detriment, many providers take this scenario personally, as we worry about the consequences of our patients’ lifestyle choices and health problems, both for them and for our ability to care for them. We are apprehensive that their self-care behaviors will compromise the best possible outcomes of any intervention, despite our dedication and best efforts. Worse, we suspect that this downward health spiral will only become more of a problem as our patients age. “Why,” we ask ourselves and our colleagues repeatedly, “is this so hard, and why are our efforts not working?”
Let’s look at a typical case that a primary care physician might encounter in order to examine and understand what’s not working well in the relationship between patient and provider. Say Ms. Smith, a fifty-nine-year-old female executive, has been your patient for the past twenty-four years. She presents with a primary complaint of bilateral knee and hip pain, which has worsened progressively over the past two months and is exacerbated by climbing stairs and walking for long periods. This is interfering with her ability to move efficiently through airports as part of her busy travel schedule. Her medical history is significant for “pre-diabetes,” hypertension, obstructive sleep apnea, and episodic depression and anxiety. She has gained 4 kg (almost 9 pounds) since her last wellness check twelve months ago. Today, her height is 5’3” and her weight is 85 kg, or 187 pounds. She is distressed by her weight gain, particularly because she suspects that the extra pounds are aggravating her knee and hip pain, not to mention her other health concerns.
Despite the fact that she has been on and off diets for the past thirty years and has lost a substantial number of pounds each time, she has regained it all, and her weight continues to rise as her energy level continues to wane. When you ask for more details about her efforts, Ms. Smith reports that her joint pain interferes with her ability to exercise comfortably, and she feels caught in a vicious cycle. She tells you that her sleep apnea prevents her from getting a good night’s rest, even with the home Continuous Positive Airway Pressure machine designed to help her, and that she is exhausted pretty much all the time. She breaks down in tears in your office, telling you that she feels ashamed, frustrated, and hopeless about ever improving her situation, and she doesn’t understand how she could have managed to raise three children, serve her community, and build a thriving business, and yet she can’t manage to accomplish “this one thing”—that is, attaining and maintaining a comfortable weight. Your heart goes out to her, and—carrying an extra 20 pounds yourself after twenty-five years of practicing medicine—you understand her frustration. The ensuing conversation with Ms. Smith puts you ten minutes behind schedule, and your heart sinks with the expectation that the two of you are likely to have a similar discussion the next time she returns to your office.
In spite of their best intentions, after having the same conversations over and over for many years, some clinicians can’t help but heave a mental sigh of frustration or feel a flicker of annoyance. We very much want to care and feel compassion for our patients struggling with eating and weight concerns, but after years of repeating our best advice without coming close to achieving the desired health outcomes we or they wish for, what we often feel is exasperation and despair, which cannot help but spill over into our treatment of the very patients who look to us for help and hope.
Unfortunately, these disheartening feelings, when combined with our rampant, undeniable cultural prejudice against fat and people who carry a great deal of it, may sometimes find expression in the form of weight bias and weight stigma (defined as making negative assumptions about health, motivation, or worthiness, solely or primarily based upon how much someone weighs). Sadly, the medical literature tells us that these prejudices are all too common among physicians, residents, medical students, and other health care providers,1 and that this adversely impacts patient trust2 and compliance and “can impair the quality of health care delivery.”3 Although we cannot make it disappear overnight, by acknowledging that we may, by virtue of living in this culture, harbor weight bias, we can bring it out of the shadows and into the light of day to be understood and eliminated. We can then discuss how it has come about and how it impacts the way we treat our patients, and also how it makes us feel about ourselves to experience cynicism and burnout when our goal is simply to help our patients optimize their health.
As health care providers, we are weary of proffering the same old eat-less-and-move-more advice that seems to go in one ear and out the other. We are tired of hearing how hard patients have “tried” to eat healthier or become more fit, and saddened that their meager progress may not mean much in their overall health picture, particularly if those small advances are not sustained over the long term, as is most often the case. More than anything, we frequently feel burdened with the magnitude of a job we never signed up for when we chose a career in the health professions: convincing patients to eat more nutritiously, become more active, and take better care of themselves on a consistent, sustained basis. Our patients are overwhelmed with this seemingly insurmountable task, and, frankly, so are we.
WHAT EXACTLY ARE DOCTORS’ CHIEF COMPLAINTS?
Ineffective treatment recommendations, even for patients who are high functioning and generally successful
Doctors and health care providers often feel exasperated and ineffective, as many of their patients, despite being talented, educated, high-functioning, productive members of society, become heavier and sicker with each passing year. Some of our patients own and run enormously prosperous businesses, outearning us by leaps and bounds. Some have successfully overcome obstacles and adversity in their lives that seem to us to be much more challenging than losing and keeping off weight. “Why is this so difficult?” we ask ourselves and each other. We worry about our patients and think, “If you could just eat more healthfully, exercise, and lose and keep off 10, 20, or 50 pounds, your diabetes, hypertension, and hip problems might improve, and you would likely feel better, maybe even live longer. You have enormous talent, drive, resources, and intelligence. What can I do to convince you to take better care of yourself and motivate you to change your lifestyle for good?”
Inadequate training and ineffective recommendations
Health care providers who care for patients with eating and weight concerns face myriad frustrations in trying to get and keep their patients healthy. Armed with inadequate training in nutrition,4 we follow the guidelines of our esteemed medical societies in recording and reporting each patient’s weight and BMI at each visit. For patients whose BMI falls above “acceptable” parameters, we are trained to prescribe calorie restriction and exercise and, in “extreme” cases, weight-loss drugs and surgery. Each year, despite their efforts, the majority of our patients on the high end of the weight spectrum, who wish to eat less or more healthfully, fail to achieve lasting success, leaving us more and more discouraged about our abilities to help them.
At the same time, our medical journals continuously remind us that we face a national and worldwide “obesity crisis,” and that despite the time, energy, and resources that we dedicate to managing the conditions that we are told are caused by excess fat, our patients’ weight struggles only intensify with each passing year. Many of our patients suffer a decreased quality of life, days missed from work due to conditions related to metabolic dysfunction, and hours and hours of productivity and satisfaction lost to food obsession, dieting, depression, and despair.
Responsibility without control
Although we make the argument later in this book that weight in itself is not the sole cause of all our higher-weight patients’ health problems, there are certain medical circumstances in which patients with larger bodies and greater adiposity can face greater risks of a missed diagnosis, in the case of adipose tissue or body habitus compromising imaging quality,5 or complications during and after anesthesia and surgery.6 Metabolic derangements associated with obesity, poor nutrition, and chronic inflammation can compromise wound healing and recovery.7Undiagnosed obstructive sleep apnea often worsens with increasing BMI, and this can lead to dangerous desaturation before, during, and after surgery, particularly with narcotic use in untreated patients.8 Higher-weight patients are at greater risk of blood clots and wound separation in general,9, 10 and weight-loss surgery in particular entails unique risks in those who undergo this intervention.11, 12
Maximally invasive, minimally effective options
Speaking of surgery, over the past several decades, the medical establishment has concluded that if diet and exercise are not effective in achieving weight loss, then perhaps weight-loss medications and surgery will be. The side-effect profile and safety considerations of weight-loss medications have led to several being withdrawn from the market. The side effects and failure rate attendant to bariatric surgery serve as another source of frustration for surgeons and primary care physicians alike, as research indicates that 20–30 percent of postsurgical patients start to regain weight within two years, continuing to struggle with untreated emotional eating and body dissatisfaction.13 We, as health care providers, know that we must be missing something important, when patients lose weight after bariatric surgery, then gain it back, despite their bodies having been anatomically altered. We cannot help concluding that there must be a better way to help these patients achieve lasting success.
Pediatric Considerations: More responsibility without control
In pediatrics, doctors face even graver considerations. According to the Centers for Disease Control and Prevention, “Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.”14 Our medical societies and peer-reviewed publications admonish us that if we do not take action, our children’s generation may not outlive their parents, due to the adverse health consequences of obesity.15Obesity has been described as “an epidemic disease that threatens to inundate health care resources by increasing the incidence of diabetes, heart disease, hypertension, and cancer.”16 We are desperate to help our young patients, to put an end to this present and future misery, to prevent the impending health-related disaster that we are told is happening before our eyes and outside of our control.
And yet the options available to our pediatric patients, when calorie restriction and increased activity fail to deliver the sustainable weight optimization that we are told is required for health improvement, give us great pause. How can a child or adolescent truly consent to the available weight-loss medications whose side effects and long-term effects are still largely unknown? Is it appropriate to surgically alter the gastrointestinal tract of a youngster who will have to live with the consequences of that decision (including altered eating patterns for life) before he or she is even old enough to truly appreciate or evaluate the long-term repercussions of such a choice? Isn’t it worth trying additional and more intense psychology-based measures prior to treating children who have high weights with invasive anatomical alteration, as though they were merely smaller versions of adults? Their brains, psyches, and bodies are not like those of their adult counterparts, and yet we in medicine are confronted with studies and guidelines from well-intentioned experts recommending bariatric surgery for our young patients.17, 18
Promoting weight-loss surgery and medications of questionable long-term efficacy and safety without investigating all available alternatives amounts, in our opinion, to metaphorically trying to push a boulder up a mountain with one or two fingers rather than using both hands. For some patients, surgical or pharmaceutical interventions may truly be their only hope to avoid metabolic disaster and certain death, despite the risks, and each individual must be treated by his or her personal physician on a case-by-case basis. For the vast majority of patients, however, such drastic (but too often minimally effective) corporeal interventions might well be avoided by focusing on building a psychological foundation for ending emotional and dysregulated eating. This means addressing the eating-related psycho-emotional issues and subconscious internal conflicts (often fueled by diet failures) that plague many of our patients with high weights and dysregulated eating patterns before taking more drastic measures.
Brain food for providers: What is your rate of success in helping your patients of size, who are dissatisfied with their weight, attain a healthy body and lifestyle that feels good to them? What other approaches, beyond calorie restriction and more exercise, have you recommended to them? Which approaches have been most and least successful? What strategies would you like to know more about that would help you further, given your time and practice constraints?
Despite the compelling medical explanations for why our patients (both young and old) might benefit from attaining and maintaining a “healthier weight,” the calorie-restricted diet and exercise recommendations that we are trained to recommend ultimately fail to result in sustained weight loss for the vast majority of people. Studies show that, although most diets result in weight loss in the short term, the recidivism rate (or relapse and weight regain to even more than the pre-diet starting weight) is astoundingly high.19Furthermore, as we discuss in Chapter 3, a growing body of evidence indicates that deprivational dieting behaviors, particularly in childhood, may lead to bingeing, compulsive and/or disordered eating, and ultimately, weight gain—immediately, or even years later.20, 21
How frustrating that our best advice, the very recommendations that our medical societies and peer-reviewed publications promulgate, often results in abject failure, dangerous weight cycling, and despair in so many of our patients. How frustrating that we are doing the best we can and still failing dismally to help our patients succeed. Moreover, we, as health care providers, too often find ourselves in the same sinking boat as our patients: out of shape, sleep deprived, snacking non-nutritiously, stressed out, and foregoing exercise despite the fact that, more than anyone, we should know what is required to stay healthy and fit. Is it really fair to ask our patients to do what we haven’t been able to achieve ourselves? There has to be a better way.
There is. Upon further reflection, many practitioners and researchers in the medical field have begun to wonder if there isn’t a missing piece of the eating-weight puzzle. All of the daily small decisions that patients make about self-care, eating, and exercise take place outside of our offices and hospitals. Yet their frustrations and failures become ours when they return for appointments without having achieved the results that they, and we, desire for them. They believe that our advice is failing them and, thus, that we are failing them. And we might even subconsciously conclude that they are failing us. There’s more than enough frustration and blame to go around.
WHAT IS IT THAT WE’RE DOING WRONG?
We give our patients directives (sometimes even coupled with scare tactics, shaming, and threats), in order to motivate them, but we don’t provide them with effective tools to sustain their motivation to eat better, exercise more, and care for themselves well and consistently. Their time with us is limited. Assuming they have the skills to eat well and take care of their bodies when they haven’t been able to do so consistently in the past makes no sense. Without sufficient support, skills, and understanding of themselves, when destructive internal monologues, irrational impulses, and day-to-day stresses wear them down, the pressure of the ingrained habit to seek food for comfort or distraction will nearly always win out. It is in these moments that our patients need our very best advice and our most effective tools to help them think, eat, and act in their own best interest. “Eat less, move more” just doesn’t cut it.
ALL TOO TRUE—BUT THEN, WHAT DOES CUT IT?
Until recently, effective strategies, as applied to eating, weight, and health struggles, have been largely missing from our medical training. Fortunately, the fields of psychology (particularly the psychologies of eating and of success) and motivational theory have produced exceptional tools that will enable our patients to understand why they don’t take adequate care of themselves consistently, assume responsibility and accountability for their health, and feel empowered to think and behave in a way that promotes sustained wellness. We maximize patients’ chances of success when we help them learn and implement more empowering and effective psychological strategies, so that they can feed themselves well while maintaining internal motivation and a constructive mindset outside of our offices. Much less physically invasive, and without the side effects and morbidity of some of the behavioral, medical, and surgical alternatives just discussed, a psychology-based approach provides practitioners with useful tools and strategies that build patients’ emotional intelligence, internal motivation, self-efficacy, and resilience, promoting the kind of consistent, sustainable behavior optimization that drives lasting wellness. These lessons, tools, approaches, methods, and strategies will hopefully reshape both clinicians’ and patients’ perspectives toward engaging in a more psychologically oriented, success-promoting approach to resolving eating, weight, and health concerns for good.
Consider this: What if our patients are not unaware, unmotivated, or lazy? What if they desperately wish to follow our advice but don’t realize they’re conflicted about implementing it and don’t have the skills even if they were unilaterally gung ho? The truth is that many patients with eating and weight concerns are often reminding themselves of our recommendations for health improvement (and may be beating themselves up for their lack of consistent adherence) multiple times per day, living in an exhausting state of shame and anxiety over the present and future consequences of their “failure” to take better care of their health. The truth is that eating, food, and weight issues are incredibly complex, involving much more than the physiologic effects of a simple nutrition and exercise regimen for the body and far more than an earnest desire for wellness.
Brain food for providers: Was your medical training adequate preparation for you to work with patients who have overeating problems? If not, why not? What training would have better prepared you? What training or partnerships would help you be more successful now, given your time, clinical focus, and practice constraints?
ARE YOU SAYING THAT PATIENTS’ EATING AND WEIGHT CONCERNS ARE OUR FAULT?
No! As physicians (especially those over 30), most of us are poorly prepared to treat eating and weight concerns.22Rather than blame ourselves for our shortcomings in serving patients with weight struggles, we must understand that our training simply has not kept pace with new insights and research concerning motivation, eating, self-care, and weight.
Just as we have moved from viewing alcohol and drug addiction as moral issues to recognizing them as medical and biological ones, it’s time to start thinking about eating problems not as moral failings or the result of a weak character but as biopsychosocial-emotional conditions that are multifaceted. Most of us received zero training in the psychology of eating, motivational theory, self-care skills, and personal development. Recent research suggests that these subjects are of critical importance in effectively treating patients with eating and weight concerns.
We maximize patients’ chances of success when we help them learn and implement more empowering and effective psychological strategies, so that they can feed themselves well while maintaining internal motivation and a constructive mindset outside of our offices. Much less physically invasive, and without the side effects and morbidity of some of the behavioral, medical, and surgical alternatives just discussed, a psychology-based approach provides practitioners with useful tools and strategies that build patients’ emotional intelligence and self-efficacy, promoting the kind of consistent and sustained behavior optimization that drives lasting wellness.
ARE YOU SAYING THAT I NEED TO LEARN A WHOLE NEW SKILL SET IN ORDER TO HELP MY PATIENTS?
Right about now, we suspect that some of you might be thinking, “Don’t I have enough to do without adding this time-consuming, touchy-feely, psychological mumbo-jumbo to the mix? How am I going to learn this psychology stuff well and fast enough to be of help to my patients with everything else I have to do?” Don’t panic. We understand your trepidation and that you’re already feeling overburdened and maxed out. With ever-increasing pressures for efficiency and speed in the practice of medicine (particularly in primary care, where patients typically present for “weight-loss” advice), physicians barely have time to adequately address medical conditions that may be immediately life threatening, much less explore the arguably less pressing, but no less essential, psychological underpinnings of eating and weight struggles.
Furthermore, the time spent by physicians in investigative or motivational interviewing and individualized emotional- and food-management counseling, which might get to the root of maladaptive eating and activity patterns, is often not remunerated. In the current climate of reduced reimbursements for medical care, it may seem overwhelming and unrealistic to dedicate precious time to implement a more cutting-edge, individualized, biopsychosocial treatment approach.
Brain food for providers: How are you feeling about learning new strategies from the fields of eating and success psychologies and motivational theory that will help your high-weight patients achieve their health goals?
The good news for doctors and health care providers is that the relevant material is relatively simple to learn and to implement once you understand why it is so important to the patient who struggles with overeating, regardless of his or her weight. Furthermore, more and better resources are emerging so that we as physicians do not need to have all of the answers for our patients in order for them (and us) to experience the success that has eluded them in the past. What providers really need to know (and what this book will teach you) is how to initiate productive, constructive discussions with patients on how they can implement strategies and practices that are successful for the long term. Our job is to collaborate with a motivated patient and, equally, to encourage a relatively unmotivated one.
Moreover, how clinicians define the problem for themselves and for their high-weight patients is critical to successful treatment. For some patients, weight struggles are genetically based and for others, they are simply the result of over-dieting for decades. However, in our experience, “weight” problems in many cases are actually rooted in what we call dysregulated eating and ineffective self-care, problems which must be resolved before patients can achieve consistency in the health-promoting behaviors that actually generate improved outcomes in physical and psychological health metrics.23, 24“Dysregulated eating” means eating when not hungry and not stopping eating when full or satisfied. Dysregulated eating involves lack of attunement or mis-attunement to appetite cues, misreading emotional discomfort as food craving, and inattentiveness to the act of eating which results in an inability to know when enough is enough. If health care providers are treating patients for “weight” problems, which are really dysregulated eating problems, how will our patients ever make progress?
We hope you’re not thinking, “Eating disorders, what do I know about eating disorders? Isn’t that the domain of psychotherapists and dieticians? Haven’t I got enough on my plate as it is?” For the most part, when we speak of eating problems in this book, we’re not referring to anorexia nervosa or bulimia nervosa. We’re talking about eating mindlessly or emotionally due to stress, distress, avoidance, or boredom and not knowing when, or not being able, to stop eating or not start. Some dysregulated eaters might meet criteria for binge eating disorder, which will be discussed in more detail in later chapters. However, many of your patients who are living at a higher weight than they would prefer are simply overeaters, mindless eaters, emotional eaters, and compulsive eaters—in short, dysregulated eaters.
Engage in any of these behaviors often enough and, voilà, you have a “weight problem,” a term, by the way, that does not accurately define what’s going on with these patients, because, for many, the problem actually stems from one or more skill deficits in awareness, self-care, self-efficacy, and/or self-regulation that impede the consistent, sustained implementation of healthy lifestyle behaviors. Fail to address emotionally based eating and self-regulation problems as such, and you have a patient who appears to engage in “self-sabotage” and “lack of adherence” to the “treatment plan.” Obviously, something is very wrong with this picture, and that wrongness is based in blaming the patient and defining the problem narrowly as one strictly of weight, when true health and wellness is about so much more.25
If you are ready to accept that most of your patients are desperate to attain a comfortable and healthy weight that reflects a balanced, healthy, self-directed life, but are continually undermining themselves due to subconscious internal conflicts and suboptimal life skills, read on to learn more about how patients really feel inside and outside of the doctor’s office. If you do now or ever have struggled with your size or with eating dysregulation, and believe your struggles affect your ability to successfully treat patients with weight and eating concerns, our goal is to help and support you in your efforts for improved health. If you know that what you’ve been doing to help your patients attain and maintain healthy eating habits hasn’t been working as well as you and they would like, and if you are ready for some simple psychological strategies to turn your work around, you’ve come to the right book.
Providers, try . . .
Brain food for providers: Do you make assumptions about what type of person a patient is based upon his or her body habitus? How much of your frustration is based upon how ineffective your “diet and exercise” advice seems to have been in helping your patients maintain improved health in the long term? How much is due to your own feelings of failure and ineffectiveness in achieving success as defined by weight loss?
1.Accepting that you are not a failure because your patients do not lose weight or keep it off after you have given them diet and exercise instructions, weight-loss medications, or they have had bariatric surgery.
2.Recognizing that the missing key to success with patients who overeat lies in the mind. We have been trained to recommend ineffective and incomplete strategies. If we can learn all that we did in our professional training, we can also incorporate approaches that harness the power of the mind-body connection and how it relates to food.
3.Telling yourself that you are perfectly competent to acquire new skill sets to help you and your patients succeed with resolving their eating and self-care problems.
4.Remembering that you are not responsible for implementing all of the elements of a successful eating or fitness approach for your patients.
5.Recognizing that nonjudgmental provider-patient collaboration is the most effective model for resolving eating and weight concerns and sustaining results.
6.Resisting the urge to be impatient with yourself for all you believe you need to know about the psychology of eating and reminding yourself that you will learn slowly like we all do, the way you did in medical, nursing, or other professional school.
7.Ignoring the urge to lecture patients about diet and exercise when you become frustrated that they’re not changing quickly enough—or at all—and telling yourself that you are doing the best you can to help them and that they are doing the best they can to help themselves.
8.Learning how to ask questions that inspire awareness, introspection, compassion, understanding, and, ultimately, change. More on this skill set will be presented in future chapters.