Karen R. Koenig, M.Ed., LCSW, and Paige O’Mahoney, M.D., CHWC joined us for an interview on their book, Helping Patients Outsmart Overeating: Psychological Strategies for Doctors and Health Care Providers. What follows are our questions in italics and their thoughtful responses.
Can you please explain the goal of your book, Helping Patients Outsmart Overeating: Psychological Strategies for Doctors and Health Care Providers?
Our goal is to change the conversation between patients who have eating and weight concerns and the professionals who treat them. The target audience is two-fold—doctors, nurses, dietitians, psychotherapists, trainers, health and wellness coaches and physical therapists—and patients of higher weight who have mindless, binge, emotional or over-eating problems. Whereas, the current focus of discussion about health is typically on dieting, nutrition and weight loss, our approach is a no-blame, no-shame, no-diets approach to eating that fosters sustainable wellness and well-being. This involves self-care and other skills in many areas of life that impact patients’ relationship with food and their bodies.
Our aim is to provide health professionals with relevant tools from the fields of motivational interviewing and eating and success psychologies which support their treatment efforts and those of their patients. One of our most important messages is that diets don’t work long term, for which we present the latest research on how chronic weight-loss dieting often causes rebound eating, weight regain, and lowered self-esteem, resulting in patients giving up on taking care of their health. Due to how weight stigma and anti-fat bias negatively affect patients, we also focus on how replacing lectures, shaming, and a one-size-fits-all treatment model with empathy, compassion, and a weight-inclusive approach makes professionals’ jobs easier, improves the provider-patient relationship, and fosters patient success.
What skill sets do you encourage providers to develop or sharpen to treat their patients with weight concerns?
The first set of skills relates to how providers view their role vis a-vis patients with eating and weight concerns. We discourage a teacher-pupil relationship which plays out in providers solely dispensing information which patients passively take in (or not). Rather, we encourage health care professionals to use relational skills that foster collaboration, win-win solutions, and mutual respect. We discuss these skills and how to implement them in detail in the book.
The second skill set involves how providers feel about their patients. While many practitioners are frustrated that they’re not being listened to, their patients are frustrated at not being heard. We teach providers to listen with empathy and compassion and to make a concerted effort to put themselves in the shoes of their struggling patients. By offering compassion to patients, professionals are not letting them off the hook, but offering kindness in the face of patient suffering. This approach encourages patients to be self-compassionate, which is actually an empowering first step toward sustainable change.
The third skill set is using motivational interviewing and appreciative inquiry with patients, rather than preaching a canned lecture applied to every patient with eating and weight concerns. These techniques are explained in detail in the book, but, in general, motivational interviewing asks questions of patients that promote non-judgmental awareness and prompts them to connect their self-care behaviors to what is most important to them in life. Appreciative inquiry looks at patients’ innate strengths, what is already working well, and how a patient can leverage his or her strengths and accomplishments to sustain motivation and persevere in the face of obstacles.
A fourth set of skills is teaching both providers and patients how to find effective support to reach their goals. Health professionals may feel that they need to solve their patients’ eating and weight problems single-handedly, which is ironic because many patients with eating problems feel similarly. Our goal is to encourage providers to learn more about psychology, develop lists of ancillary practitioners to educate and to support the efforts of their patients toward attaining and sustaining their health goals, and talk with colleagues and staff about how to provide more respectful and effective treatment for these patients.
A fifth skill set is identifying “the dysregulated eater” and helping this patient population recognize that weight is not the problem: eating is. Providers need to understand the dynamics of and causes of emotional, compulsive, mindless, binge, and over-eating. The book teaches professionals and patients about underlying problems that cause or exacerbate eating dysregulation, including perfectionism, all-or-nothing thinking, habitual reliance on food and eating to manage life, and in some cases, depression, anxiety, PTSD, and borderline personality disorder. Providers must know enough to recognize when patients with eating problems might benefit from psychotherapy or health coaching because their mental health issues or skills deficits are preventing them from eating normally and nutritiously and taking consistently good care of themselves.
Although the literature is ripe with information on reasons not to diet, can you please elaborate on the comment in the book that reads, “Dieting is actually a proven risk factor for weight gain, weight regain, disordered eating, and, ultimately, weight cycling…”?
The recent literature demonstrates that, rather than being an effective means to lasting weight loss and improved health, the deprivation and over-focus on food that accompany calorie restriction and the hopelessness and despair that often accompany repeated cycles of weight loss and re-gain (also known as weight cycling) can cause more harm than good, particularly long-term. Most dieting behaviors are unsustainable for patients, and actually can predispose patients to bingeing and reactive overeating, which can promote weight gain, rather than sustained weight loss. We discuss the case against dieting and provide references to experts and the literature on the metabolic, psychological, and behavioral consequences of calorie restriction dieting as a means to weight loss in Chapter 3 and in the Resources section of the book.
The point is that habit change that is unsustainable does not accomplish the goal of improved health and fitness for patients, and diets are generally not sustainable for patients long-term. On the other hand, when patients learn the life skills (including non-judgmental awareness, self-compassion, and self-regulation) to feed and care for themselves healthfully on a consistent basis, they are less likely to engage in reactive or mindless overeating (see Karen’s book, Outsmarting Overeating, for more on this topic). When good self-care and a balanced approach to health and wellness is the focus of patients’ eating habits, chaotic and reactive eating are reduced and dieting becomes unnecessary to maintain a comfortable weight. We discuss the “wellness skill set,” which includes habits and learnable life skills that can help patients implement and maintain wellness-promoting self-care practices in the book. We also provide suggested resources to help health professionals and patients learn and practice these skills.
Within the pages of your book, you include sections entitled, “Brain food for providers” and “Brain food for patients.” You then ask a series of questions relevant to your entries. What feedback have your received from professionals about these reflective questions?
The feedback from health professionals has been positive. Health professionals are accustomed to reading and assimilating huge amounts of information in a short time. By using the questions as a guide to consider specific elements of their own circumstances, practice patterns and relational skills, doctors and health professionals can focus on what works for them and their patients and what does not. Moreover, the questions are designed to expand providers’ armamentaria of available resources, modalities and skills, so that they may be better prepared to determine how to approach this complex issue with each individual patient.
Can you please speak to the complex problem of language and its impact on weight bias, fat stigma, and belief systems?
This is a topic that some doctors and health professionals may not have considered before, because weight bias and fat stigma is part of our culture and for many of us, is ingrained in our training. Language can either promote or interfere with healing for patients who overeat, and it matters a great deal. For both providers and patients, word choice influences both the definition of the problem and beliefs about possible solutions in several ways.
First, since weight problems are often eating problems, using language that makes weight “the problem” puts both providers and patients at risk for missing important information about what is driving overeating behaviors and chronic dieting for an individual patient. It also fuels the simplistic belief that people above a certain weight or BMI are automatically unhealthy and that those below a certain weight or BMI are automatically healthy. This use of body mass index to determine whether a person is of a “healthy” weight is potentially dangerous because BMI does not account for body fat percentage or distribution, two measures that have important metabolic and health consequences. With the current guidelines, people above a certain BMI are told to lose weight and those below the “overweight” threshold risk having their providers not ask them about their nutrition, lifestyle and self-care habits, which are important health practices for people of any size. Importantly, patients who struggle with disordered or dysregulated eating patterns may be of any weight or size, and we may fail to address and mitigate their suffering if we use stigmatizing language and make assumptions and treatment decisions based solely upon weight.
Second, word choice drives attitudes and beliefs. Fat stigma, internalized or within the health care system, hurts patients. Referring to patients as “overweight” or “obese” is both judgmental and stigmatizing. The term obese is derived from Latin, “having eaten until fat,” perpetuating the assumption that higher weight people got that way deliberately or through laziness and lack of motivation. This negative bias and failure of language to account for the many genetic, involuntary, biologic and psychologic contributors to body size drives negative attitudes on the part of health professionals and, often, shame and body dissatisfaction on the part of patients. Stigma and shame undermine health. Negative attitudes toward patients puts providers at risk for burnout and poor patient care practices. Stigmatizing language hurts everyone.
When we wrote the book, we polled both patients and experts and ultimately chose to use the term “higher weight,” which is descriptive without being judgmental. The use of a more compassionate and respectful term is an important first step in patients’ learning to be more kind and compassionate with themselves about their bodies and their eating habits. By rejecting stigmatizing language, patients open brain space to become more accepting of body size diversity and curious about what may be driving their eating if they are engaging in disordered or dysregulated eating behaviors (overeating, chronic dieting, etc.). Choosing non-stigmatizing language and self-talk promotes self-acceptance and body appreciation, empowering patients to develop positive beliefs, skills and habits to engage in and sustain healthy behaviors. By choosing to utilize respectful and non-judgmental terms, health professionals can better appreciate the complexity of the eating and self-care issues that often underlie patients’ weight struggles. When doctors realize that they do not need to have all of the answers, they can choose an interdisciplinary approach and acquire additional skills or find additional resources to help these patients.
Each of your chapters ends with bullet points for the benefit of providers and patients to “try.” Please share a few.
For providers to:
- take a dieting and weight history and ask patients about their body image and feelings about their weight.
- solicit help and not feel responsible for “fixing” patients with eating and weight concerns by themselves.
- feel compassion and empathy for patients who’ve had long-term eating and weight concerns.
- ask more questions, particularly about what patients believe would motivate and has motivated them to take better care of their bodies.
- reflect upon and become aware of the likelihood that they likely are biased against fat patients (and heavy people in general) and that their words and body language may convey their feelings.
For patients to:
- speak up if they don’t feel a provider is listening to their individual health concerns and only wants to talk about weight loss.
- talk openly about their struggles with diets and weight loss—and rebound eating, dysregulated eating, weight regain, weight-cycling, and the toll it has taken on their mental health.
- make an effort to tell providers when they are being disrespectful about their eating or weight and seek providers who will treat them with compassion and acknowledge the difficulty of their struggles.
- let providers know what works for them regarding improving their eating and what does not.
What are some goals providers can incorporate into their practice that will change their office “climate”?
- Use terminology of high/higher weight rather than overweight or ask patients what terminology they prefer.
- Ask patients if they wish to know their weight when they’re weighed.
- Focus on self-care, wellness, and patient well-being rather than weight and weight-loss.
- Make sure office and waiting room chairs can comfortably accommodate higher weight patients.
- Make sure hospital gowns are large enough to comfortably fit higher weight patients.
- Provide all staff with sensitivity training about fat bias, weight stigma, and the suffering endured by people who have experienced the frustration and heartbreak of dysregulated eating, chronic dieting, and weight re-gain.
- Make sure that they and their staff are not projecting their shame about struggling with unhealthy or stress eating or weight concerns onto their patients, and that their own issues with food and weight are not interfering with patient care.
- Talk frankly with colleagues about their frustrations of dealing with dysregulated eaters and higher weight patients and about which treatment strategies are effective and which are not.
Disclaimer: Please note that this article is intended for informational and educational purposes only. It is not intended as a substitute for the medical or psychological assessment, advice and individualized care from your personal health care provider or mental health professional. Please consult with your personal health care professional regarding your individual situation and concerns. For health care providers, the information contained herein may not be applicable or appropriate for every patient. Paige O’Mahoney, M.D., Karen R. Koenig, M.Ed., LCSW, and Deliberate Life Wellness LLC specifically disclaim any and all liability arising directly or indirectly from the use of any information or products contained in these materials.
About the authors:
Karen R. Koenig, M.Ed., LCSW, is a psychotherapist, blogger, health educator, and international author of seven popular books on eating and weight. Her 30 years of practice in Boston, then Sarasota, have focused on the psychology of eating—the how and why, not the what of it. Visit her website at http://www.karenrkoenig.com to learn more about her and to sign up for her twice weekly blogs.
Paige O’Mahoney, M.D., CHWC, is a health and wellness coach, certified Intuitive Eating counselor, retired pediatrician, author and foodie. She is the co-author, with Karen R. Koenig, M.Ed., LCSW, of the award-winning book, Helping Patients Outsmart Overeating: Psychological Strategies for Doctors and Health Care Providers. Information about her coaching practice and educational offerings may be found at www.deliberatelifewellness.com.