Supporting Patients and Providers in Attaining and Maintaining Success

(Finally, the Right Prescription!)

■Appropriate and attainable goals/outcomes for patients with eating and weight concerns

■The “weight-inclusive” approach, expressing empathy, encouraging compassion, motivational interviewing, individualizing care and goals based upon the patient’s stages of change, values identification, “S.M.A.R.T.” goal setting

■Additional support and training for a wellness-focused, interdisciplinary approach: Intuitive Eating community, Lifestyle Medicine, Health and Wellness Coaching

■Strategic opportunities for creative programming: culinary medicine, group work, mobilizing technology, and creating a culture of wellness in the office

■How an interdisciplinary, collaborative team approach to patient care enhances prognosis for successful, sustainable behavior change

Now that we have redefined patient success in psychological terms related to self-care, self-compassion, self-understanding, self-regulation, and life skills, you are probably wondering how to help your patients improve their skill sets, relationship with food, and their body image during a 10-minute office visit. At first glance, utilizing a psychologically based approach may seem far more complicated and burdensome than simply putting patients on a diet or prescribing an exercise regimen. However, if we are to be successful in helping patients gain competency in managing eating and weight concerns for the long term, we must empower them with strategies that are both physically and psychologically sound.

The good news is that it’s not as complicated or time-consuming (or expensive) as you might expect, and you don’t have to do it all yourself in a vacuum. A slew of dedicated researchers and clinicians have generated effective tools and methods that you can apply without reinventing the wheel. Please note that not all of these tools, methods, and strategies have an evidence base for this application. Where an evidence base exists or is emerging, we have noted it. We expect this to be a field of ongoing research over the next several decades, and we encourage you to track best practices and the evolution of the evidence as you implement your own approach to caring for patients with eating and weight concerns.

IF NOT WEIGHT LOSS, WHAT ARE EFFECTIVE GOALS FOR MY PATIENTS WHO HAVE EATING AND WEIGHT CONCERNS?

As health care providers, we seek health and wellness for all of our patients, including those who struggle with eating and related health challenges. Here are seven goals that both patients and providers can pursue:

1.Optimal wellness for all of our patients, including those who struggle with overeating, body dissatisfaction, and related health challenges.

2.Consistent and sustainable implementation of wellness-promoting lifestyle behaviors, including those related to eating and nutrition, activity, sleep, stress management, life skills, and effective self-care.

3.The development of a solid psychological foundation so that patients can (with provider support) create and execute their own wellness strategy, regardless of their weight.

4.An end to the suffering, weight cycling, and associated metabolic harm1 2 promoted by dieting, and the development of skills to reconnect to appetite via an attuned, mindful approach such as Intuitive Eating.

5.Increased patient self-compassion for his or her current size, health, and past suffering to facilitate a greater sense of well-being and enhanced emotional resilience.3

6.Improved body image and acceptance of size diversity.

7.Increased self-efficacy and pride through the development of effective life and self-care skills (especially emotional regulation and stress management) and the resolution of internal psychological conflicts which may undermine lasting success.

DO I NEED TO SPEND ANOTHER DECADE IN SCHOOL TO LEARN HOW TO HELP MY PATIENTS REACH THESE GOALS?

In a word, no. The competencies and strategies involved in creating a winning provider-patient relationship with dysregulated eaters are not at all complicated, esoteric, or even technical. In fact, we doubt they’ll surprise you. Many of them are likely relational skills that you use already, albeit refined and implemented in a slightly different way, in order to enhance patients’ growth, development, and success by improving their self-efficacy over time. Used flexibly and individualized for each patient, they comprise an integrative approach.

The following are seven skills that you can learn and develop in order to improve your relationship with and the prognosis of success for your patients with eating and weight concerns.

First, do no harm by adopting a “weight-inclusive,”4 wellness-focused approach, then support the development of empowering self-awareness and positive body image

When it comes to helping patients resolve dysregulated eating, we must start with the tenet to do no harm, particularly with children. As physicians, we naturally feel responsible for preventing and relieving suffering. In our thin-obsessed culture, nothing is guaranteed to cause needless suffering like “being too fat.” Children are perceptive, and when clinicians (or parents) express concern about the number on the BMI chart, or look disappointed or annoyed when a child’s weight rises “too fast,” he or she often internalizes our disappointment as shame. Kids generally want to please their doctors and their parents, and when they are led to believe (through our well-intentioned alarm) that they are defective, not measuring up, or that there is something wrong with them, there can be significant, lasting psychic damage.5

So please give special attention to how you approach this sensitive topic with children, and feel free to refer to Tribole and Resch’s Intuitive Eating 3rd ed.,6 for specific approaches and evidence-based strategies to guide you. Understandably, physicians may panic because we are told that preschoolers who are at the high end of the weight continuum are five times more likely than normal-weight children to be overweight or obese as adults.7 The truth is that healthy bodies come in a variety of shapes and sizes. Additionally, many of these children will grow taller prior to and during puberty, and with some attention to and training in self-care, attunement to appetite, and life skill development, they will be capable of remarkable psychological growth and maturity that will help them attain healthy eating habits, provided we don’t destroy their self-trust and innate attunement to their internal signals first.

If we override their innate attunement to appetite cues by expressing our concern or dissatisfaction with their developing bodies, or by putting them on a restrictive diet and exercise regimen, we do two things. First, we may effectively traumatize them through the perceived deprivation that accompanies calorie restriction, which drives “seeking and overeating of restricted foods,”8 while we also deprive them of their innate ability to tune into and trust their internal hunger and satiety signals. Second, our well-intentioned advice may promote body dissatisfaction and set up the highly motivated or approval-seeking child for overdoing exercise and seeking perfectionism in the fitness arena, thereby setting the stage for injury cycles that prevent him or her from sustaining a healthy, sane activity schedule.

We know that dieting, body dissatisfaction, and unhealthful weight control practices are a set up for weight gain and eating disorders in teens,9 not to mention a risk factor for chronic yo-yo dieting and weight cycling in adulthood.10 We compound the problem several-fold when we react in fear and fail to modulate our own response to that fear and concern. Leading with empathy and sensitive age-appropriate, child-centered discussion can mean the difference between despair and self-efficacy for the young patient, and hence the difference between improved health and fitness over time and a life of yo-yo dieting, disordered eating, ever-increasing weight gain, metabolic and hormonal derangement, struggle, shame, frustration, and lowered self-esteem.

With both children and adults, the first step in managing dysregulated eating and weight struggles, particularly for those who are uncomfortable with their weight, is to provide empathic, nonjudgmental listening and a sensitive initial discussion that encourages them to acknowledge and feel compassion for their own suffering, internalized weight stigma, and body dissatisfaction. Such a discussion reflects a “weight-inclusive” approach, as defined by Tylka et al. in their 2014 review article, “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being Over Weight Loss.”11 Tenets of the weight-inclusive approach, which assumes that patients are “capable of achieving health and well-being independent of weight, given access to non-stigmatizing health care,”12 include avoiding harm; appreciating size diversity; maintaining a holistic, process focus toward wellness promotion, rather than the attainment of a certain weight or BMI; incorporating sustainable, empirically supported practices into prevention and treatment efforts; emphasizing access to health-promoting foods, environments, and practices for all persons; and promoting patient autonomy and social justice.13 Implementing a weight-inclusive approach is a way to facilitate success for our patients, rather than increasing their struggle by focusing narrowly on weight-based goals.

Before discussing weight or BMI in the presence of children, it is useful to get a sense of their body image. Inquire of children and adolescents what they appreciate most about their growing bodies and what concerns and expectations they have in the eating and weight arenas. The information gained in such an inquiry may prove useful because emerging evidence suggests that “positive body image is likely to be protective of physical health and psychological well-being” and is “positively related to intuitive eating” and other self-care behaviors.14 Conversely, according to research cited by Bacon and Aphramor, “body dissatisfaction is associated with binge eating and other eating disordered behaviors, lower levels of physical activity and increased weight gain over time.”15 Tracy Tylka, Ph.D., and Nichole Wood-Barcalow, Ph.D., have created a ten-item comprehensive assessment of body appreciation, called the Body Appreciation Scale-2, that can be used to evaluate body appreciation and predict psychological well-being related to body image.16 Links to this scale and other helpful evaluative tools may be found on the provider page of Dr. O’Mahoney’s website at http://www.deliberatelifewellness.com.

Additionally, consider a discussion of cultural bias and unrealistic expectations concerning body size as part of preventive guidance with the eight-to-twelve-year-old set. They are sure to have opinions or questions if queried. This will help you recognize if your patient is in danger of using food and manipulation of his or her eating to resist pubertal change, able to cope with the emotional roller coaster that often characterizes adolescence, or simply considering dieting to try to fit the cultural ideal of thin. Rather than emphasizing weight or BMI, it is helpful to discuss how healthy growth promotes optimal body and brain function, encouraging a holistic approach to wellness. Implementing a “weight-inclusive” approach, as described by Tylka et al.,17 and embodied in the Health at Every Size movement,18 shifts the focus from weight to well-being by focusing on health promotion, lifestyle improvement, and excellent self-care for patients of any size and any age. For more information on opportunities to translate the principles embodied in a weight-inclusive approach into actual practice, we refer you to the above-referenced article by Tylka et al., and Table 1 therein, titled “Translating weight-inclusive principles into weight-inclusive practice.”19

Taking a weight-inclusive approach with children encourages them to develop wellness-enhancing perspectives and skills early in life, which can improve their ability to care for themselves well as they navigate the transition to adulthood. And, of course, a weight-inclusive approach is an effective strategy to promote awareness, healing, and recovery for adults as well.

In terms of nutritional life skills, providers can focus discussions on how to choose the kinds of foods that fuel a strong, vibrant body and mind, and on how specific foods affect a particular patient. Age-appropriate topics might include how to identify (and prepare/pack food for older kids) whole, nutrient-dense versus nutrient-depleted, processed foods. Children can be encouraged to keep a list of breakfast foods that make them feel satisfied and support sustained energy and concentration at school, and also a list of those snack foods that result in sustained energy after an hour or two, for example. Providers can also promote attunement to internal signals20 and emotional regulation by conversing with children about how they experience and identify internal signals of hunger and fullness, fatigue, and stress, and specific emotions (sadness, loneliness, shame, anger, anxiety, relief, joy, etc.), all of which can impact eating and coping behaviors. This is an important skill set that can support Intuitive Eating, which is associated with “both lower BMI and better psychological health.”21 The Intuitive Eating Scale-2 “measures individuals’ tendency to follow their physical hunger and satiety cues when determining when, what, and how much to eat.”22 A link to this scale may also be found on the provider page of Dr. O’Mahoney’s website at http://www.deliberatelifewellness.com.

Encouraging children and adults to learn to distinguish emotional states from internal signals that indicate physical-mental needs (for fuel, water, rest, activity, relaxation, etc.) is an important step in empowering them to care for themselves, and it can help them learn how to refuel without using food when that is not what they are needing. The goal is to support emotional and body attunement and help patients develop and maintain an internal locus of control when it comes to their own wellness at an early age, so that they can learn to trust their ability to make choices that serve their health.

The need to first do no harm, then guide the acquisition of self-awareness is just as relevant to the preventive care of adult patients as it is to children and adolescents. Adults may not possess these skills or even recognize their importance, and you can help them tremendously by exposing them to the concepts of awareness, self-compassion, emotional regulation, internal locus of control, and self-trust. It sets the stage for patient empowerment and enhanced patient self-efficacy that can prevent dysregulated eating before it starts or mitigate it if it has already begun.

Brain food for providers: When you speak to patients about nutrition, do you tell them what foods are beneficial and why (as opposed to telling them only what to avoid), and do you focus on how specific foods make their bodies and minds feel? Do you generally assess patients’ emotional intelligence and attunement to emotional and appetite signals as a measure of their ability to consistently and sustainably make healthy lifestyle choices?

Brain food for patients: What do health care providers say that supports your efforts to eat more “normally” and nutritiously? What do they say that doesn’t connect, resonate with you, or that doesn’t feel helpful?

Harness the power of empathy with the skillful use of perceptive reflections

By now it should come as no surprise that your patients with dysregulated eating or higher weights are actually the ones most likely to be dissatisfied with and self-critical of their body habitus and ashamed of their size. Rather than being unmotivated or complacent, most of them desperately want to improve their body image, feel better, and enjoy a satisfactory level of physical fitness and function. After repeated failures to keep weight off with restrictive dieting, however, they have suffered tremendously, not just physiologically but psychologically as well. Consequently, many of them become depressed, resentful, hopeless, and demoralized. In this state of mind, they then give up and too often turn to food to soothe their broken spirits.

Patients with this mindset can benefit enormously (far more than you would likely imagine) from empathic providers. Empathy is defined in the Wellcoaches® Coaching Psychology Manual as “the respectful understanding of another person’s experience, including his or her feelings, needs, and desires.”23 We can feel and express empathy without necessarily sharing the same experiences, emotions, or opinions of the patient. Empathy from providers can strengthen the patient-provider relationship and encourage patients to harness and sustain internal motivation in a way that judgment, criticism, or fearmongering cannot. To quote Rollnick, Miller, and Butler, authors of Motivational Interviewing in Health Care, “There is very little evidence for the belief that people will change if you can just make them feel bad (scared, ashamed, humiliated) enough. To the contrary, it is the supportive, compassionate, empathic practitioner who is most effective in inspiring behavior change.”24

So, how do you express empathy with and encourage curiosity and nonjudgment in a patient who is tempted to give up on her exercise or eating plan after experiencing repeated failures in the wellness arena? By using a time-tested psychological approach pioneered by humanistic psychologist Carl Rogers, Ph.D., called reflective listening, or active listening.25 By tuning in to how patients feel, we can then express understanding of their feelings. Expressing empathy for patients communicates acceptance and creates a safe psychological space for them to explore their beliefs and feelings about change, as well as how their “self-sabotaging” behaviors might indicate unmet needs and desires.26

The expression of empathy (through reflective listening statements or empathy reflections) is a powerful, learnable relational skill, rooted in Marshall Rosenberg’s Nonviolent Communication (NVC) model,27 that builds trust and, ultimately, promotes self-efficacy for the patient. As explained in the Coaching Psychology Manual, perceptive reflections “enable clients to hear what they are saying from the vantage point of another person . . . when coaches perceptively paraphrase and reflect what they think clients are saying, clients react with a deeper, more emotional response,”28 which supports introspection and self-determination.

So, for example, with a patient who is considering giving up her exercise regimen due to a pattern of repeated injury, a provider could start with the statement, “I hear that you know that exercise is good for you, but that you are tired of being injured.” With a patient who is mindlessly overeating to cope with being overwhelmed, you might say, “You are trying to take care of yourself with food, because everything in your life is feeling like work, you are feeling depleted, and you want to take a break and relax.” With a patient who is constantly “self-sabotaging” by choosing the fast-food drive-thru over the home-prepared, nutritious meal she had planned, you might offer, “You want to eat healthfully, but after work, you feel too tired to prepare a meal.” Notice that these statements are an attempt by the provider to understand and reflect how the patient is feeling without making a judgment or recommendation on how to fix the problem. This creates psychological space for patients to consider their true feelings about their situation and explore the underlying reasons for the choices they make.

Without the distraction of judgment or self-criticism, patients will then be more apt to identify (and possibly resolve) unconscious, internal conflicts about a given lifestyle choice and make a more deliberate choice about how to proceed. Thus a nonjudgmental, empathic approach encourages patient autonomy and encourages the process of change.29 For more information on these and other powerful relational tools that enhance patients’ internal motivation to change, as well as a discussion of foundational theories and methods, we refer you to the Coaching Psychology Manual, 2nd edition.

Encourage patients to accept and have compassion for themselves as a tool to promote change

Compassion, as defined by Kristin Neff, Ph.D., in her book Self-Compassion: The Proven Power of Being Kind to Yourself, “involves the recognition and clear seeing of suffering. It also involves feelings of kindness for people who are suffering, so that the desire to help—to ameliorate suffering—emerges.”30 Neff explains that compassion implies absence of judgment or disdain for a person who suffers, even due to his or her own mistakes or shortcomings. According to Jennifer Taitz, Psy.D., author of End Emotional Eating, “self-compassion, not self-condemnation, cultivates change. . . . Self-compassion nourishes you, protecting you against emotional distress and promoting your health.”31 Thus, expressing compassion (and encouraging self-compassion) for a patient who suffers from food and eating issues is not just the right thing to do. It actually increases patients’ chances of success in making lasting changes in the service of their own wellness.

You may worry that de-emphasizing weight loss and encouraging patients to be compassionate with and accepting of themselves will lead them to be complacent, self-indulgent, and lower their standards for their own behavior. Such is not the case. Taitz cites an Adams and Leary study from 2007 that demonstrated that, rather than being used as an excuse to overindulge, self-compassion led to reduced distress and decreased reactive overeating in response to “breaking their diet.” “Compassion reduced distress and led to improved eating.”32

Research cited by Kristin Neff, Ph.D., in her book Self-Compassion, demonstrates that “far from being a form of self-indulgence, self-compassion and real achievement go hand in hand,”33 because self-compassion “provides the emotional safety needed to take responsibility for our actions”34 and value ourselves enough to make “choices that lead to well-being in the long-term.”35 Self-compassion ultimately promotes self-efficacy beliefs, which enhance self-regulation and consistency in wellness-promoting behaviors. Self-criticism (and the fear and despair that it generates), on the other hand, undermines self-efficacy.36

Self-compassion is beneficial for both patient and provider, and is actually a first step toward developing and sustaining wellness. It helps patients become more resilient in the face of lapses or failures (such as straying from their nutritional behavioral goals) and gives them the courage to continue to strive toward their health and fitness goals, rather than self-sabotaging or giving up. Encouraging patients to practice self-compassion as part of a weight-inclusive approach37 can be contagious, and in clinicians, maintaining compassion for patients and practicing mindful self-compassion may help to prevent burnout, promote provider wellness, and reduce stress.38 39 Importantly, according to Tylka et al., “empirical evidence suggests that self-compassion is an adaptive mindset to cultivate in the context of improving body image and eating behavior.”40 Moreover, how can we not feel better about ourselves when we are kind to our patients rather than when we are frustrated, aloof, critical, and shaming?

Brain food for providers: How do you feel about yourself when you judge patients for their failures or for not trying harder? How do you feel when you are empathic and compassionate toward them? How do they react to your attitude?

Brain food for patients: How do you feel about providers who lack compassion and invalidate your feelings and experiences? How does this affect your motivation to improve your self-care? How does provider compassion and empathy affect your motivation to become healthier?

Practicing empathy and encouraging self-compassion empowers patients to reduce their shame and quiet their negative self-talk long enough to focus on the thoughts and behaviors that lead to enhanced self-regulation, self-efficacy, and lasting change. Rather than undermining success, empathy and compassion actually facilitate success by encouraging patients to keep trying, despite circumstantial obstacles, and despite their own imperfect adherence to healthful eating and exercise, for example. It is this resilience that promotes the persistence that leads to lasting change.

We would not consider this discussion of empathy and compassion to be complete if we did not mention the importance of providers engaging in self-compassion and self-reflection. Applying these principles to our own struggles and shortcomings actually makes us more resilient and relatable. By knowing ourselves, we increase our effectiveness by relating to patients in a more humane and compassionate manner.

Practice motivational interviewing and active listening methods and techniques

One effective way to start the conversation with patients, regardless of where they are on the readiness-for-change spectrum is through the skillful use of motivational inquiry (MI) and appreciative inquiry (AI) techniques. MI is an evidence-based counseling method, developed by William R. Miller, Ph.D., and Stephen Rollnick, Ph.D., that works by “activating patients’ own motivation for change and adherence to treatment.”41 Motivational Interviewing techniques, as described in the Coaching Psychology Manual, include expressing empathy, developing discrepancy through open-ended inquiry, dealing with resistance effectively, and supporting self-efficacy.42 Originally utilized within the addiction field, MI has now been applied to an expanded range of health-related behaviors. Coaching psychology incorporates MI as a method for eliciting and supporting patients’ autonomous motivation and self-efficacy for change, which helps support sustainable behavioral improvement.

According to Ellen Glovsky, Ph.D., R.D., L.D.N., editor of Wellness, Not Weight: Health at Every Size and Motivational Interviewing, “The concepts and techniques of Motivational Interviewing work beautifully with a non-diet and HAES approach. The basic approach of MI is that practitioners enhance motivation for change in health behavior by helping clients examine their own motivation for change, and then decide if, when and how they will change.” Rather than being the change agent, “the practitioner is a guide who helps them make decisions about change.”43 Motivational interviewing by a skillful provider also helps the patient become aware of and verbalize ambivalence, which, as mentioned previously, is an important first step toward resolving internal conflicts that can otherwise lead to self-sabotage or inconsistency in sustaining wellness-related behaviors.

It takes time and practice to master the techniques that form the basis of MI, but the information elicited (and the improved relationship it engenders between patient and provider) can pay huge dividends in terms of patient compliance, and can actually save time in the long run.44 Linking goals to values is an important strategy in motivational interviewing, and wellness coaches are trained to utilize this method. Later in this chapter, we will share how wellness coaches can be powerful allies in supporting and facilitating incremental change for patients between office visits. More information on Motivational Interviewing may be found at http://www.motivationalinterviewing.org.

Appreciative Inquiry (AI) is an approach developed by David Cooperrider, Ph.D., and Diane Whitney, Ph.D.,45 that complements motivational interviewing and is being widely applied to health care improvement efforts. AI helps patients identify their strengths and best experiences and leverage them to enhance their chances of success in reaching their goals. For example, through skillful dialogue, a practitioner might ask the patient who struggles to incorporate daily activity into his or her life when he or she has achieved success in doing it in the past. Alternatively, by asking a patient to share how he or she has overcome similar obstacles or achieved success in other contexts (work, family, community) in the past, a provider can guide a patient to identify possible strategies that he or she may not have considered applying to wellness behaviors. A patient might recall that creating a detailed plan for each week helped her to manage a large ongoing architecture project with her team at work. Applying that strategy to fitting exercise into her day can tip the balance toward success for her, by promoting her autonomy and by reminding her of her own past successes. It is also empowering, because it comes from within, rather than being forced upon her as advice. In this way, “AI encourages clients to be creative by imagining, articulating, and designing their dreams for the future . . . generating the energy for change.”46 More on how the AI approach can be applied to wellness-promoting behavioral change, including the “5-D Cycle” of transformation, can be found in the Coaching Psychology Manual, 2nd ed., listed in the resources section at the back of this book.

Consider the patient’s stage of change in order to individualize your treatment approach to promote patient autonomy and need recognition

In order to help ourselves and our patients who have suffered repeated cycles of striving and failure with weight loss and weight regain, it helps to have an understanding of the transtheoretical model of change. The Transtheoretical Model of behavioral change was developed by Dr. James Prochaska and colleagues.47 It explains that change is a process, and that helping patients identify where they are in the stages of change vastly enhances their chances of success in implementing and sustaining health-promoting behaviors. This process of stage identification also helps providers who are trained in the model identify which approaches, strategies, and types of goals will likely prove most effective for the patient or client at that particular stage.48 The stages of change are as follows:

■Precontemplation (patients are not yet ready for change, because they are unwilling or feel that they cannot change)

■Contemplation (patients are thinking about change)

■Preparation for change

■Action

■Maintenance49

A working knowledge of Prochaska’s Transtheoretical Model of Change can be particularly useful when caring for dysregulated eaters and chronic dieters, because people who have failed multiple times at weight loss end up subconsciously not believing that they have the ability to change (precontemplation), even though, in their conscious mind, they are “trying” (action). They may attempt to implement changes in their behavior and make wellness-promoting choices, but they “self-sabotage” or become easily frustrated or thwarted by obstacles, because, at a subconscious level, they have become disempowered and demoralized and are not yet ready to try again.

These patients need to work on identifying and processing their beliefs, feelings (including mixed feelings), and thoughts about their goals, prior to implementing behaviors.

They will also benefit greatly from working with a skilled coach or therapist who understands motivation and how to help guide them from precontemplation to contemplation, where they achieve conscious awareness of their internal conflicts and ambivalence about success. The truth is that most patients initially are motivated to improve their eating behaviors and remain remarkably motivated until they experience repeated failures through dieting and/or injuries due to overexercising. Then they often cease to believe that change is possible for them. They are effectively back in precontemplation without realizing it. They may continue the cycle of trying and failing without realizing that they lack the psychological foundation and understanding of the change process for success.

For more information on the Transtheoretical Model and the psychology of behavior change, we refer you to Wellcoaches® Coaching Psychology Manual, 2nd edition, and to http://www.prochange.com, both in the resources section at the end of this book.

Encourage patients to explore and define their values and also to view past failures as opportunities for learning and personal growth

Helping patients recognize that they are stuck in precontemplation is one of the most potentially empowering things that you can do for them. Rather than focusing on behaviors, these patients benefit from doing thinking and feeling work around their behavioral goals.50 This process has the added benefit of helping patients clarify their values and goals (a key competency from success psychology) and resolve mixed feelings.51 Helping patients identify their core values and how these values apply to their wellness goals is another way to empower them. While you can plant the seeds of change during an office visit, cultivating a vision and a plan for wellness-promoting behavior change takes time. So does learning from past failures and frustrations by identifying the needs that must be met and the ambivalence that must be resolved for change to be sustainable for a given patient.

For this reason, referring patients to a certified lifestyle medicine or health and wellness coach, or to a dietitian, therapist, or other clinician trained in Intuitive Eating and behavioral change, can be life-changing for the patient. Many of these experts are trained to facilitate and support constructive, incremental, ongoing behavior change for patients in this situation, and they have the time to devote to that critically important process. Once patients have had an opportunity to do this work with a coach or therapist, their readiness to implement your behavioral recommendations increases immeasurably.

Information on training opportunities for clinicians and referral resources may be found later in this chapter and in the resources section at the end of this book. Additionally, you may download worksheets that you can use to encourage patient awareness and start the conversation about readiness for change from the provider page of Dr. O’Mahoney’s website, http://www.deliberatelifewellness.com.

Learn effective goal-setting techniques to help patients keep their goals S.M.A.R.T.

Health and wellness coaches are trained to help patients set goals that are specific, measurable, action-based, realistic, and time-bound.52 This technique, borrowed from the business literature and attributed to George Doran,53 encourages the creation of goals for which progress can be evaluated based upon the specific measures, as outlined above. Framing and refining goals to make them S.M.A.R.T. helps patients to be very clear and specific about their goals and also makes them mindful of the small, incremental steps, potential obstacles, and consistent and sustained action (self-regulation) that will be necessary to achieve them. Framing goals in this way (and writing them down) promotes success by encouraging ongoing evaluation of progress according to specific, measurable criteria, according to experts in success psychology.54

In the health professions, we tend to focus on measurable outcomes when we recommend goals to our patients, because this is what medical research often assesses and tracks. However, there are other types of goals that patients and providers can focus on to enhance their patients’ chances of success with the outcome goals. These include cognitive goals, such as thinking about the pros and cons of change versus those of staying the same, identifying feelings about a potential behavioral change, including ambivalence/conflicted feelings (e.g., wanting to start an exercise regimen in order to improve health, but also not wanting to commit to it because it is time-consuming and has not resulted in a trimmer body in the past), behavioral goals, skill goals, and goals related to improving self-trust, self-confidence, self-pride, consistency, and perseverance (self-regulation). By learning how to help patients identify appropriate goals for both their stage of change and refine their goals to be S.M.A.R.T., you provide them with the ability to evaluate their progress objectively, toward goals that resonate with their values and vision for their best life. More information on S.M.A.R.T. goal setting may be found in the resources section of this book, and in the Coaching Psychology Manual.55

Established and emerging resources for support and collaboration

Working with collaborative providers from different disciplines provides patients with resources and skills to improve their emotional intelligence (the ability to identify, express, and manage feelings effectively), which has been shown to correlate with both health and success.56 By engaging in deliberate self-development and by learning to prioritize and engage in effective self-care, either on their own or in conjunction with therapy or coaching, patients are able to develop the life skills and resilience that support a consistent practice of wellness-promoting beliefs, thoughts, and behaviors. We recommend that you familiarize yourself and your colleagues with the following emerging resources that will help patients improve on implementing your professional recommendations, based upon their individual situation.

The Intuitive Eating and Health at Every Size® communities

As you seek support and resources to help your patients achieve success in overcoming dysregulated eating, we encourage you to investigate the Intuitive Eating and Health at Every Size® (HAES) Communities. Providers and qualified staff may obtain targeted training in helping patients achieve eating attunement and related self-care skills through the Intuitive Eating ProSkills Intensive teleseminar. Information for both providers and patients may be accessed at https://www.intuitiveeating.com.

Pioneered by Linda Bacon, Health at Every Size® is an evidence-based, weight-inclusive approach that encourages the promotion of health (rather than weight management) respect for body diversity, and compassionate self-care. According to Bacon and Aphramor, “Randomized Controlled clinical trials indicate that a HAES approach is associated with statistically and clinically relevant improvements in physiological measures (e.g. blood pressure, blood lipids), health behaviors (e.g. eating and activity habits, dietary quality) and psychosocial outcomes (such as self-esteem and body image), and that HAES achieves these health outcomes more successfully than weight loss treatment and without the contraindications associated with a weight focus.”57 A fact sheet on the HAES approach, as well as additional information, may be found through the Association for Size Diversity and Health (ASDAH) at https://www.sizediversityandhealth.org/content.asp?id=161.

Both organizations offer support communities for patients as well as resources, education for providers, and information for others interested in the ongoing research in this area.

Leverage the best evidence and practices from Lifestyle Medicine

As we strive to help patients improve their abilities to better care for themselves and achieve improved health outcomes, we have the opportunity to integrate an emerging source of education, support, and evidence-based best practices to help us. This is the relatively new field of Lifestyle Medicine. According to the American College of Lifestyle Medicine, “eighty percent or more of all healthcare spending in the U.S. is tied to the treatment of conditions rooted in poor lifestyle choices. Chronic diseases and conditions—such as hypertension, heart disease, stroke, type 2 diabetes, obesity, osteoporosis, multiple types of cancer—are among the most common, costly and preventable of all health conditions.”58 In an effort to address and reverse this trend, lifestyle medicine practice focuses on utilizing lifestyle interventions related to nutrition, physical activity, stress reduction, rest, smoking cessation, and avoidance of alcohol abuse as first-line therapy, for prevention, treatment, and reversal of chronic disease.59

Behavioral change counseling in the interest of promoting improved health and quality of life is thus an important part of this approach, and lifestyle medicine education initiatives, including the Lifestyle Medicine Education Collaborative, seek to enhance medical trainees and practitioners’ competency in this area.60 This is an exciting movement, because it makes proven behavioral change techniques and psychology-based strategies available to medical trainees and providers that they might not have had access to in the past—an empowering skill set to offer patients. More information for providers may be found at http://lifestylemedicineeducation.org/.

According to David Katz, M.D., M.P.H., president of the American College of Lifestyle Medicine, “Lifestyle as medicine has the potential to prevent up to 80% of chronic disease; no other medication can match that. It’s free of all but good side effects and is safe and appropriate for children and octogenarians alike. It is, quite simply, the best medicine we’ve got.”61 By adding competency in lifestyle medicine and success psychology to our toolbox, or by committing to maintaining a network of high-quality referral providers with this expertise, we have the potential to help millions who have not been helped—or have even been hurt—by business-as-usual diet-and-exercise advice.

The only reference to a “dream team” you may recall is the legal squad that was pulled together during the O. J. Simpson trial in 1995. Well, medicine can have its dream team as well, in the service of health promotion. The “Dream Team” approach, as described at the June 2015 Lifestyle Medicine Conference hosted by Harvard Medical School,62 has the potential to save time and money, and it may help prevent both patient and practitioner burnout in the long run. The “dream team” includes a physician trained in lifestyle medicine, a lifestyle medicine or health and wellness coach, a mental health provider or therapist, a dietitian, and an exercise physiologist, optimally all under one roof, for convenience and continuity of patient care. For patients who suffer from dysregulated eating behaviors, this interdisciplinary collaborative model holds exciting potential for streamlining the process of healing and improving self-care. It can provide patients with unprecedented access to providers with complementary skill sets, enabling them to make more rapid progress than they could working with you alone (no matter how caring and competent you are).

Several top medical schools are offering fellowships in lifestyle medicine for physicians seeking additional training in this new specialty, and, as mentioned previously, a Lifestyle Medicine Education Collaborative has been formed to include training in Lifestyle Medicine for medical students.63 This is a burgeoning area of health care and wellness promotion, which we believe will be integral to successful medical practice in the future. We hope that the psychology of eating approach outlined in this book will help to advance the state of the art and become standard practice in lifestyle medicine and wellness coaching when treating dysregulated eaters. Additional information may be found through the American College of Lifestyle Medicine at http://www.lifestylemedicine.org and at http://lifestylemedicineeducation.org.

Brain food for providers: How open are you to learning about Lifestyle Medicine? How much does it speak to your treatment needs with patients who struggle with overeating and weight concerns? How open are you to the concept of working with a “dream team”? Do you fear you don’t have the time, that you don’t know the kind of professionals you would include in such a team, or that you might lose control of treatment decisions?

Brain food for patients: What is your reaction to working with a team of providers who can help you with the psychological and physical aspects of resolving your eating and weight concerns? Are you thinking this might be too much of a time and energy commitment for you or that this is just what the doctor ordered?

Health and Wellness Coaches: An emerging resource for helping patients implement and sustain health-promoting practices

The good news is that, despite the fact that you as a clinician are unlikely to have the time to do all of this work personally with your patient, the evolving discipline of coaching psychology can provide practical support for helping patients build a psychological foundation for persistence and success in reaching and sustaining their goals. Coaches can provide much-needed support for patients who do not otherwise suffer from psychological dysfunction. For patients who suffer from dysregulated eating with psychological dysfunction, a referral to an appropriate mental health professional is necessary. Maintaining a referral network of qualified providers, including certified health and wellness coaches, certified Intuitive Eating counselors, and eating disorders therapists, can provide you with appropriate, patient-specific sources of collaborative support for helping your patients improve their eating, self-care behaviors, and wellness-related outcomes.

The National Consortium for the Credentialing of Health and Wellness Coaches (NCCHWC) defines the coach as “a professional trained in evidence-based motivational strategies, behavior change theory and processes, healthy lifestyle knowledge and powerful communication techniques that assist clients (or patients) to develop inner resources and intrinsic motivation for sustaining lifestyle improvement, and health and well-being.”64 National training and education standards leading to NCCHWC certification are designed to ensure that health and wellness coaches have the specific skills to help patients in a constructive, safe, progressive manner.65 Not surprisingly, health and wellness coaches usually have a background in the health and wellness professions. They may be registered nurses, dietitians, psychotherapists, diabetes educators, other mental health providers, athletic trainers, or even physicians, who undertake additional training in behavior change theory and coaching psychology.

Wellness coaches work to promote clients’ autonomous motivation, self-efficacy, and self-regulation skills, attributes which support successful, sustained behavioral and wellness improvement. Based upon a recent systematic review, these three attributes “emerge as the most promising individual-level mediators of positive weight outcomes and increased physical activity.”66 Emerging evidence demonstrates that coaching improves client-patient outcomes, compliance, employee health, and productivity, and may lower health care costs.67 This specialized training, in combination with a weight-inclusive approach68 to wellness, holds tremendous promise for our patients in healing dysregulated eating.

According to Margaret Moore, M.B.A., CEO of Wellcoaches® corporation, who in 2002 founded the first coaching school for health and wellness professionals and since then has been instrumental in establishing a coaching science foundation in the United States, “certified Health and Wellness Coaches are uniquely qualified. . . . The coaching curriculum is science-based, integrating 15 evidence-based theories and domains in behavior change and coaching psychology.”69 Certified health and wellness coaches receive strategic training in behavior change and success-promoting, client-centered strategies that transcend disciplines. Most health care providers are not exposed to this approach in their medical, nursing, dietetics, or other training. If you would like to learn more about training opportunities, or to find a certified health and wellness coach in your area, you may refer to the NCCHWC at http://www.ncchwc.org/, or to the Wellcoaches®website at http://www.wellcoachesschool.com/. Additionally, Wellcoaches® has recently published the second edition of the Coaching Psychology Manual, which describes the theoretical foundations of coaching psychology, along with evidence-based coaching protocols.

A compelling example of how interdisciplinary collaboration can increase our ability to help our patients, Wellcoaches® and the American College of Lifestyle Medicine recently established a partnership to “co-develop Lifestyle Medicine and Healthy Behaviors Curriculum for Health and Wellness Coaches.”70 According to David Katz, M.D., M.P.H., president of the American College of Lifestyle Medicine, “Coaches reach an enormous number of people, and, with standardized training in lifestyle medicine, they’ll have an enhanced ability to promote health and prevent disease. The public can be confident that certified coaches are practicing at a high standard and providing evidence-based guidance. Certified Health and Wellness Coaches who specialize in lifestyle medicine will become integral members of the lifestyle medicine practice team, contributing importantly to the treatment and even reversal of disease.” Moreover, “A national standard for health coaching in [the area of lifestyle medicine] will . . . [allow] many more people to benefit from the opportunity lifestyle medicine uniquely offers: adding years to our lives, and life to our years.”71 Additional information on health and wellness coaching and the Lifestyle Medicine/Wellcoaches® collaboration can be found at http://wellcoachesschool.com and http://www.lifestylemedicine.org.

MORE STRATEGIES FOR CLINICIANS TO HELP PATIENTS SUCCEED

Think outside the box—and inside the “teaching kitchen”

Another option, provided that space is available, is to offer access to a “teaching kitchen” for staff and patients. This concept was introduced and the advantages beautifully explained in a 2015 article by David Eisenberg, M.D., and Jonathan Burgess,72 and in a 2016 summary of emerging programs by Rani Polak, M.D., Chef, M.B.A., et al.73 The idea behind teaching kitchens and culinary medicine programs is that providers are more likely to provide useful counsel to patients on nutritious eating if they themselves have been exposed to strategies for success in meal planning, procurement of ingredients, and preparation. For this reason, lifestyle medicine programs, medical schools, and hospital systems are starting to provide culinary medicine training to providers and patients.74

In an office-based setting, the teaching kitchen could be a break room or even the waiting room of an office after office hours, where meal planning and simple preparation classes (assembling previously cooked and frozen items into a salad, for example) could be made available to staff and patients. Such classes would not only contribute to patients’ self-efficacy in the kitchen but also provide ideas and techniques for planning and assembling a high-nutrient-density meal for people who want to eat better but lack the time and skill set to plan and execute one. The physician’s office is a trusted, accessible venue for many people, and making these services available to patients during or outside of office hours can serve to maximize access for the patient and revenue for the practice.

We expect that you must be wondering how you can possibly integrate these ideas into your already hectic schedule, particularly with limited time to see each patient and the lack of insurance reimbursement for counseling-based services. By integrating a collaborative interdisciplinary approach based upon lifestyle medicine principles with a group therapy–based model and a little help from twenty-first-century technology, we can help patients achieve consistency and persistence in wellness-promoting behaviors in an efficient manner. At the same time, we can control costs by providing information-based services to more than one person at a time and outside of office hours. What follows are some possible options for consideration within the constraints and resources of your individual practice situation.

Harness the power of groups and workshops

In the 1970s, psychotherapist Susie Orbach published the groundbreaking book, Fat Is a Feminist Issue, in which she recommended a support group model for helping emotional eaters.75 The group model has been proven to work through programs like Alcoholics Anonymous and in both inpatient and outpatient eating disorder treatment programs, which provide support, psychoeducation, and a new social norm to persons who are in recovery. In our current health care environment, counseling services by physicians, for example, are poorly reimbursed. Moreover, barriers to mental health services (based upon both access and cost) are significant.

In this economic context, the group model saves money in multiple ways. First, the clinician need not repeat the same information over and over. Second, the group setting allows people to process their experiences and feelings at different rates over time within a supportive context, a luxury which is rarely available in a 10-minute physician visit. Third, it facilitates access, even for those with limited economic means, by allowing each participant to pay a smaller amount out of pocket, while still allowing the provider to receive an hourly rate sufficient to keep the lights on and the office running.

Opportunities for implementing the group model to help patients build a psychoeducational foundation for success are limited only by your imagination. Practices can hire or collaborate with a therapist or coach experienced in group work to facilitate weekly sessions covering a rotating curriculum of topics of interest to those in recovery from dysregulated eating. Education and transformational discussion could thus take place outside of (or even during) office hours, allowing patients to experience growth and progress between clinician visits. Coordinating the group’s curriculum with the patient’s stage of change and running several weekly groups for patients at different stages could help to further differentiate the group curriculum and meet patients where they are.

For an even simpler and more cost-effective approach, you could start a book club for patients of your practice, using books that deal with dysregulated eating, body image, etc. The book club could meet at set intervals either during or outside of office hours and could be facilitated by a staff member trained in counseling, motivational interviewing, Intuitive Eating, or health and wellness coaching. Examples of cost-effective training programs and opportunities for further reading may be found in the resources section at the end of this book.

Use technology to promote wellness

By combining tools from eating psychology and coaching psychology with twenty-first-century technology, we have the ability to combine forces with other experts and design classes and workshops for our patients that will help them implement our best advice. For practices with a wide catchment area, or for populations with transportation challenges, other strategies for patient psychoeducation during nonoffice hours exist. For example, a lifestyle medicine-trained clinician or multidisciplinary group could collaborate with a registered dietitian or culinary medicine-trained chef to create group e-mail blasts or YouTube videos on various wellness-promoting topics, and e-mail the links weekly to interested patients.

Potential topics for group e-mails or videos could include meal planning techniques to maximize nutrient density and minimize waste on a budget, suggestions for safe physical activity options that bring pleasure and where to find them in the area, and alternatives to food-seeking for comfort. Additional tools for disseminating information and providing relational support for patients include Skype/VSee group sessions, webinars or Google hangouts, or other social media resources. Validated scales from cutting-edge researchers in this area can be used to measure patient progress. Links to these and other resources may be found on the providers page of Dr. O’Mahoney’s website at http://www.deliberatelifewellness.com.

Institute some climate change in your office

Still another potentially empowering and cost-effective idea is creating an office culture that encourages both staff and patients to combine wellness-related behaviors with involvement in something larger than themselves. This is a very real way to help patients cultivate meaning and purpose by helping others while incorporating physical activity and self-care into their lives. Staff and/or patients might train with others to walk, bike, or run a 5K to raise money for ALS, cancer, MS, or diabetes research, or form a crafting group to knit blankets for babies in the NICU or make jewelry for women returning to work. Walk With a Doc is an example of community-based effort that combines community-based patient education with exercise.76 These group-based, community-building activities serve a dual purpose. They create community around fun, altruistic physical activity and provide a support network for staff and patients, both of which have been shown to reduce stress and improve health.77 This contributes to the creation of a culture of mutual purpose and wellness among providers, staff, and patients.

Another option for promoting a culture of wellness in your office is to provide office staff access to training in weight-inclusive practices, lifestyle medicine topics, health and wellness coaching principles, and Intuitive Eating practices. Staff trained in such skills and methods might participate in the creation of educational materials or lead book club-type discussions for patients. Web- or video-based educational materials can be used repeatedly, updated when necessary, and shared with staff and patients alike, for a relatively small financial investment. Such an investment can improve retention and minimize costs associated with training staff in a high turnover situation. Done well, this investment also improves both efficiency and morale among the members of the treatment team, because everyone is on the same page with an important mission of the practice, and everyone has the opportunity to grow in a way that can improve not only his or her professional life but also his or her personal life.

Perfection is not required. Patients benefit from seeing providers and staff walk the walk, increase their own wellness, work to overcome obstacles and, by cultivating resilience, maintain progress. In fact, accepting imperfection and seeing others strive facilitates trust and communication and cohesiveness among providers and patients, which can’t help but improve care and promote change for the better.

You may not be able to help every dysregulated eater with this proposed approach, but you are likely to at least do no harm, and it is probable that more of your patients will be well-served by this approach than were served with restrictive diets that rarely can be sustained and which studies tell us are bound to fail for the long term. Moreover, the general trajectory of progress will finally be headed in the right direction, as patients increase their awareness, self-care and life skills and stop unconsciously sabotaging their own best efforts. After all, as the first law of holes states, “If you find yourself in a hole, stop digging.”78

We hope that this information has been illuminating and will be empowering for both you and your patients in treating the causes and finding individualized solutions to dysregulated eating. What we offer is an innovative approach to improving patient care and outcomes through a weight-inclusive,79 psychologically oriented paradigm. Our goal is to reduce weight and fat stigma, investigate best practices to promote patient empowerment and self-efficacy, and to provide strategies for success and support to patients and to the providers who care for them.

Doctors and health care providers can make an enormous difference in the lives of their patients with eating and weight concerns. However, a prescription for even the most optimal nutrition or exercise regimen will likely fail to improve our patients’ health long-term if they lack the self-efficacy, internal locus-of-control, and persistence to implement and sustain the behaviors that promote lasting wellness. This is done by encouraging patients to make a cognitive shift to sustainable self-care by connecting to their emotions, appetites, and personal reasons for lifestyle improvement. By asking change-promoting questions and collaborating across disciplines, we have an opportunity to support patients’ commitment to their own wellness and to taking charge of their health.

Providers, try . . .

1.Practicing being an active listener, a good empathizer, and having compassion for your patients at whatever weight, level of wellness, or stage of change they are in.

2.Focusing less on weight and other outcomes measures and more on the process of how they will get there.

3.Making sure that you are not clinging to the idea that diets work for the long term just because you think that learning and implementing new strategies may be difficult, cost-prohibitive, or time-consuming.

4.Being compassionate with yourself for not doing your job perfectly, with the expectation that learning and implementing the psychology of success strategies in this chapter will take time and will ultimately improve the quality of your patient care and your relationships with patients.

5.Imagining what kind of a “dream team” you could put together, including getting ideas from colleagues on competent professionals they have consulted.

6.Being open with your patients who have eating and weight concerns about the fact that you are changing your approach to treating them and welcome their ideas and feedback.

7.Learning more about lifestyle medicine competencies and practices on the ILM website at http://www.instituteoflifestylemedicine.org/.

Patients, try . . .

1.Learning more about lifestyle medicine and health and wellness coaching through the websites http://www.lifestylemedicine.org/ and http://www.ncchwc.org/.

2.Telling your physician or health care provider if you believe that you would benefit from more support for psychological and behavioral changes related to improving your relationship with food.

3.Thinking about why you’re afraid to give up dieting and discussing your feelings with your health care provider.

4.Considering consulting a certified health and wellness coach who understands Intuitive Eating and Health at Every Size principles for coaching on eating or health goals, making an appointment with a registered dietician, hiring a qualified fitness coach, scheduling a session with an eating disorders therapist, or finding a group to support positive changes in your eating and lifestyle choices.