April 2018 #obsm chat: Viewing Physical Activity Through the Lens of Obesity

Guest blog post written by Dr. David Creel

Imagine a pharmaceutical commercial touting that a drug improves mood, makes sleep more restful, helps our memory and concentration, decreases our potential of developing dementia, lowers our risk of colon and breast cancer, and makes our bones stronger. But there’s more--the health benefits of this product can also treat or help prevent the negative consequences of obesity. It improves insulin sensitivity, can normalize blood pressure, and prevents cardiovascular disease. And just when you were waiting to hear a long list of potential side effects spoken at the speed of an auctioneer’s voice, the commercial ends. Of course, I’m not referring to a drug, I’m talking about physical activity. Like some medications, exercise prevents disease, heals ailments, and gives us the best chance of living a long, energetic life. It’s an inexpensive endeavor with few side effects to speak of.

 

Despite these benefits, only 20 percent of American adults get the recommended 150 minutes per week of moderate to vigorous physical activity. Unfortunately, those with obesity are even less likely to exercise regularly. In our upcoming #obsm chat, we will discuss the role of physical activity in health and weight loss.

What does exercise mean to those with excess weight?

How many times have we heard it, or said it-- “To lose weight you’ve got to change the way you eat… and begin exercising.” For those with obesity, healthy eating and exercise are sometimes closely linked together. Go on a diet and start exercising, break the diet and stop. It’s a unique coupling of behaviors that has not been studied extensively. Think about it--we rarely hear someone say they blew their diet and stopped brushing their teeth or wearing their seatbelt. I would argue that professionals have put too many eggs in one basket when it comes to exercise. We’ve failed to promote exercise for all of the general health reasons noted above and instead hyper-promote it for weight loss.

Does exercise help with weight loss?

From a calorie perspective, exercise often pales in comparison to dietary changes. Many studies have shown that in the short-run exercise contributes little to weight loss. However, data from many longer-term studies show that 250 minutes per week or more of physical activity predicts who will maintain weight lost through traditional approaches. We know much less about the impact of exercise on weight loss after bariatric surgery.

Exercise challenges for those with obesity

When people feel like they must exercise to lose weight, it is easy to focus on intensity and burning calories rather the enjoyment of the activity and how much better we feel when we do it. This obviously makes exercise less appealing. As the severity of obesity increases, poor cardiorespiratory fitness, orthopedic issues, and ill-fitting exercise equipment further limit the variety of exercises people can perform. In fact, activities of daily living can be quite strenuous. According to a recent study we conducted, a majority of bariatric surgery candidates would be unable to push mow a small yard. Among those with a BMI of 50 or higher, two-thirds would find vacuuming to be at least moderately difficult.

How can we help people exercise more?

Some believe that weight loss leads to exercise. However, research doesn’t fully support this. Even after bariatric surgery, physical activity only increases modestly, on average. One study showed that 25% of patients were less active one year after bariatric surgery than before. So, if weight loss won’t do it, how can we promote more activity? Studies examining motivational factors for exercise suggest that people maintain an exercise regimen for at least one of the following two reasons:

1)      They like it. Therefore, it makes sense to help people find activities they enjoy and can fit into their lifestyle.

2)      They do it for the benefit. These are the people who view exercise as a medication.

Most people don’t enjoy the act of taking meds, but many do it anyway. If we can help people with exercise adherence in similar ways as we do with medication adherence (buying into its importance, scheduling, etc.) we may be on to something.

No matter our weight, many things compete for our time. Those with obesity have additional layers of physical and sometimes psychological obstacles to regular physical activity. In the upcoming Twitter chat (April 8, 2018 at 9 pm EST) we will discuss the following questions:

1. What type of exercise-related education/resources help people with obesity?
2. What are common mistakes healthcare professionals make when promoting exercise among those with obesity?
3. For patients, does it help when your provider “practices what they preach?” For professionals, do you think you’re a better exercise counselor if you are committed to physical activity?
4. High Intensity Interval Training has become quite popular. What are the pros/cons of undertaking this type of exercise for those with excess weight?
5. How do you motivate patients/clients -- or what motivates you -- to move more? Any success stories?

March 2018 #obsm Chat: Disordered Eating

When people discuss dietary issues related to overweight and obesity, the concerns tend to be overeating, making less healthy food choices, skipping meals, or taking in too many liquid non-nutritive calories.  Underlying disordered eating patterns may be missed. However, these patterns need to be addressed to help someone achieve long term weight loss success. Even in the case of bariatric surgery, disordered eating patterns may persist or emerge after the procedure, and this can have a significant negative impact on weight loss outcomes.

In the U.S., binge eating disorder is closely associated with obesity and has become the most common form of disordered eating, affecting nearly 3 million people.  Hallmarks of the condition include the rapid consumption of very large amounts of food within a relatively short period of time, a sense of feeling out of control, feeling overly full, and feeling the need to hide the behavior.  Approximately 1.6% of women exhibit binge eating behavior as do 0.8% of men, and there is a relatively even distribution among ethnicities. For bariatric patients, about 25% of candidates have this condition, and though it decreases for many after surgery, it remains an ongoing concern for half of those individuals post-operatively.  Defining a binge after a bariatric procedure is challenging as it may be impossible to eat an objectively large amount of food; loss of control while eating may be the overriding characteristic.

Another common disordered eating pattern linked with obesity is grazing, in which individuals snack or nibble in an unplanned and repetitive manner, most typically on carbohydrates, without regard for portions.  For those who diet or have a bariatric procedure, this habit can be insidious and is easy to fall into.  Grazing may also be a form of compulsive overeating.  Night eating syndrome is a newer category which encompasses those who eat a large percentage of their calories in the evening after dinner or wake up in the night to eat again.  Other related eating issues can include eating too quickly, as well as mindless eating or emotional eating in response to stressors.  In these cases, food provides a self-soothing strategy, a reward which brings about short term pleasure in exchange for potential long term disordered eating and weight gain.

For many individuals, disordered eating tends to be a more secretive behavior which can lead to hiding food, eating when others aren’t around, and commonly leads to feelings of guilt and shame.   Persons who have struggled with weight may have the added burden of trying to overcome problematic eating styles while also learning to shift nutrition and activity levels.  When someone has had significant weight loss, a return to old, disordered eating habits, particularly when experiencing unexpected stress, can be devastating.  Professionals working in the field of obesity and bariatric surgery have a duty to assess and address these patterns and help individuals to overcome the struggle.

Addressing disordered eating among those intent on losing weight is the focus of our next #obsm #obesity tweetchat. We will focus on the following questions:

1.    For those familiar with struggles with disordered eating, what circumstances facilitate acknowledging the patterns and seeking help?  What assistance is needed most?

2.    Are providers working in the obesity field aware of disordered eating patterns and making appropriate referrals for treatment?  What education is needed?

3.    After successful weight loss, what specific factors might lead to a return to disordered eating?

4.    As disordered eating is frequently correlated with other mental health and quality of life issues, how does one prioritize treatment?

5.    What successful strategies can be employed to treat disordered eating behaviors which are related to obesity?

Weight bias, stigma, and discrimination - barriers to access to care?

The #obsm obesity chat has been going strong for just over a year now, adding new participants with each chat! In honor of that success, we’ve decided to revisit a popular topic this month -- weight bias, stigma, and discrimination -- but with a new twist: how does weight bias impact access to science-based care for obesity?

Bias, stigma and discrimination based on body size are a reality for many people with obesity. One manifestation of obesity bias is fat shaming, which some believe encourages weight loss. The reality is, however, that it can have severe detrimental consequences for patients’ emotional and physical wellbeing. As Rebecca Puhl, PhD writes, “If fat shaming were an effective approach to provide incentive or motivation to lose weight, the majority of Americans wouldn't be struggling with overweight and obesity.”

Data has shown that another common belief, that obesity is a result of poor individual choices, is false. Rather, obesity develops from a combination of genetic, biological, and environmental factors in addition to behavioral factors. Research shows that obesity bias can affect nearly every aspect of patients’ lives--including educational and work environments, hiring practices, and health care.

In medical settings, patients with obesity report being treated disrespectfully and receiving inappropriate comments about their weight. Unfortunately, some physicians view patients with obesity as being lazy or non-compliant. Indeed, about half of physicians admit to weight bias.

Unfortunately, government policymakers and individuals who make coverage decisions for health-insurance companies are not immune to these biases. Unlike other chronic diseases, basic health-insurance policies rarely include coverage for obesity treatments. Instead, this coverage is usually a “rider” that must be added at an additional cost. Even when policies cover some obesity treatments, patients face unusual restrictions. For instance, bariatric surgery patients are often forced to participate in lengthy managed weight-loss programs before getting access to this potentially life-saving surgery.

While government-funded programs cover some obesity treatments -- Medicare now covers bariatric surgery for some patients and a small amount of behavioral counseling -- these benefits are limited and do not include coverage for any weight-management medications.

How can we change policymakers’ and health insurers’ biases against offering a full range of science-based care for people with obesity? This is a conversation enriched by having all stakeholders at the table.

With our next #obsm #obesity tweetchat, we hope to raise awareness of obesity bias and discuss strategies for gaining greater access to care. Specifically, we plan to pose the following questions:

How do weight bias, stigma, and discrimination affect obesity treatment/coverage decisions?

How can we educate policymakers and insurers that obesity is not a matter of personal choice but a chronic disease that should be treated like any other disease?

Have you, as either a patient or provider, successfully appealed a denial of coverage for an obesity treatment? If so, what worked?

What can societies such as The Obesity Society, the American Society for Metabolic and Bariatric Surgery and the Obesity Action Coalition do to improve access to care? What are they already doing?

What actions can individuals take to advocate for increased access to care for obesity?

Resources:

http://www.obesity.org/obesity/resources/facts-about-obesity/bias-stigmatization

http://www.medscape.com/features/slideshow/lifestyle/2016/public/overview#page=7

Sabin J, Marini M, Nosek BA. Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS ONE. 2012;7(11): e48448.

Puhl RM, Luedicke J, Grilo CM. Obesity bias in training: attitudes, beliefs, and observations among advanced trainees in professional health disciplines. Obesity. 2014;22:1008-1015.

Phelan SM, Burgess DJ, Yeazel MW, Hellerstedt WL, Griffin JM, van Ryn M. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obesity Rev. 2015;16:319-326.

Puhl R, Brownell KD. Bias, discrimination, and obesity. Obesity Res. 2001;9(12):788-805.

http://www.aafp.org/news/practice-professional-issues/20170209obesityhospice.html
those with obesity receive less hospice care, less likely to die at home

http://www.obesityaction.org/weight-bias-and-stigma

#ILookLookLikeASurgeon is Catfished: #TimesUp

Since the inception of #ILookLikeASurgeon in 2015, many of us have taken great pride in the positivity of the movement. It is with great sadness that I share the article below, written by an individual* in the #ILookLikeASurgeon community, detailing how a single individual used the movement to harass and manipulate women surgeons for ulterior motives we may never fully understand.

Per request of the author, this blog post has been deleted. I apologize for the inconvenience and hope you understand.

The original post listed an email account that is no longer being managed.

If you would like further information, feel free to contact me at @LoggheMD.

January 2018 #obsm chat: Dealing with the Aftermath of Successful Weight Loss

You’ve lost a lot of weight either through bariatric surgery or another weight-loss method.  Now what? Before embarking on a weight loss or bariatric surgery program, most individuals are informed of the lifesaving benefits of the treatment and anticipate the possibility of a brighter, healthier, longer future.  Visions of greater choice of clothes, friendlier numbers on the scale, decreased pain, and increased self-confidence perfuse the pre-weight-loss psyche.  Outstanding weight-loss success can bring so many positive things into one’s life, yet much less attention is typically paid to the emotional costs of that success.

The Guardian recently published an excellent article on the issue of dealing with excess skin following highly successful weight loss.  Reading the post offers an honest window into the torment of no longer feeling comfortable, or even literally fitting into, your own skin.  Despite dramatic weight loss success, many individuals experience a newfound insecurity when their familiar curves are replaced by loose appendages.  This can be both physically uncomfortable and emotionally scarring.

Highly effective weight loss can lead to very different responses from some around the successful individual, some of whom are enthusiastically supportive.  Spouses or significant others, however, may become jealous or resentful and fear that their relationships will be jeopardized.  Changes in sexual interest and responsiveness may sound enticing, but what if it puts you out of sync with your partner? Newly differing levels of physical activity may be another source of disconnect.  Eating buddies may mourn the loss of the shared joys of eating out together as they had in the past.  Though some may treat successful weight loss patients with more respect, this raises suspicions that they were being judged by their appearance, rather than their personhood in the first place.  That can feel good yet be confusing and even upsetting at the same time.  Getting attention for your physique may seem desirable, but not always, especially when there is a history of sexual abuse.

With bariatric surgery, there are increased risks of substance abuse, particularly with alcohol, especially following gastric bypass.   Some have struggles with acid reflux, particularly with the band or sleeve.  Others find that taking medications can be challenging in addition to trying to remember to take all the necessary vitamins and supplements in the proper amount and at the right time.  Going through a period of thinning hair can be unnerving and can impact self-confidence.  Finding that you can no longer tolerate specific foods can be quite an adjustment as well.  Lastly, while many experience a boost in mood, there is still the specter of increased suicidal risk over time, a very serious concern.

In our next Twitter chat (Sunday, January 14 at 9 pm EST) we will discuss dealing with some of the less positive aspects of successful weight loss. Specifically, we will be addressing the following:

Questions:

1. How does overcoming #obesity impact one’s personal relationships?

2. In what ways has excess skin after weight loss proven to be a concern, and what role does body contouring surgery play?

3. To what extent do substance issues, sticking with vitamin regimens, food intolerance, and issues such as thinning hair affect the successful weight loss patient?

4. How does successful weight loss affect self-esteem and mental health? How can those changes be addressed?

5. What are some other negative or unexpected consequences of successful weight loss?  What are ways to deal with those?
6. What can healthcare providers do to help one prepare for and deal with some of the downsides or challenges of successful weight loss?

December #obsm chat: Staying healthy over the holidays

Photo Credit

As we head into the holiday bustle, we want to focus our December #obsm chat on challenges around this time of year. Although the media suggest that people gain 7-10 pounds between Thanksgiving and New Year’s Day, the data suggest the weight gain is actually only about one pound per person. This means that although some of us expect to gain a significant amount of weight or go up a clothing size over the holiday season, that is not actually what happens most commonly. So, rest happy with the knowledge that while we should all expect to gain a little weight, it should only be about a pound or so. Now, armed with that knowledge we can plan around it.

Photo Credit

There are a number of common reasons weight gain occurs at this time of year--increased social gatherings (typically with unhealthy foods provided); stress around family matters including gift shopping and traveling; variations from the normal routine. Also, as the weather gets colder for many, physical activity may decrease. These and other factors affect all of us. Thus, it can be very hard (if not impossible) to actually lose weight at this time of year. But we can all focus on trying to minimize weight gain and maintaining a positive attitude.

In this chat, we will discuss practical tips and strategies for preventing the seemingly inevitable weight gain around the holidays.

Photo Credit

Specifically, we will discuss:

How can we avoid making food choices that are not the best for us? Any tips for eating at social gatherings?

What are the best options among typical party foods and drinks? Are there useful sources of protein to be found?
How can health care providers best support patients during the holidays?
How can we maintain an exercise program even when traveling?
How can we minimize the stressors of the holidays that sometimes lead to poor food choices?
What are some possible healthy holiday traditions we can create?

#obsm chat November 2017: Highlights from Obesity Week 2017

Obesity Week is an interdisciplinary scientific meeting that happens annually in the fall. This year’s meeting took place October 29th to November 2nd. The meeting covers numerous topics of interest to those with #obesity and those involved in the care of patients with #obesity. For our November chat, we will highlight the four topics that jumped out at us as the most interesting or impactful.

Weight bias

We were impressed to see multiple sessions related to weight bias on the program. The one that stood out to us the most was a session highlighting research by Rebecca Puhl, Rebecca Pearl, and Allison Grupski. Dr. Puhl talking about internalized weight bias and how it occurs. Essentially, over time people who face external weight bias start to engage in self-blame, self-criticism, and other negative behaviors toward the self that ultimately lead to self stigmatization. This internalized weight bias may have an impact on health outcomes even if external bias is no longer experienced. Internalized weight bias may also impact willingness to seek health care. Dr. Pearl taught us about how weight loss is associated with improvement in mental health including improved body image, self-esteem, and quality of life. Importantly, she pointed out that legislation that outlaws discrimination (including weight-based discrimination) can reduce self-blame and lead to better mental and physical health among people exposed to discrimination. Legislation may also be associated with lower levels of internalized weight bias. From Dr. Grupski we learned about behaviors that can minimize weight bias in the clinical environment. Tips included avoiding biased language (e.g., “You really just need to decide if this is important to you.”), being empathetic, and learning about psychological processes such as ego depletion.

Social media

There were multiple sessions on social media and its utility in delivering and amplifying messages. For example, there was a behavioral health session which included Rachel Goldman, Alexis Conason, and Nina Crowley, which focused on increasing awareness of why health professionals should be on social media, as well as ethical considerations. There was also an integrated health session with Alexis Conason, Allison Grupski, Yoni Freedhoff, and Kimberly Sasso. This session focused on topics in the news and how the headlines affect our practice and treatment of patients. Finally, there were sessions focused on the growth and development of #obsm and advanced Twitter skills for busy people.

Biggest Loser

The American Society of Metabolic and Bariatric Surgery (ASMBS) hosted Kevin Hall as the keynote speaker. Dr. Hall has done extensive research with participants from The Biggest Loser. In this fascinating address, Dr. Hall covered a lot of ground regarding metabolism and changes related to weight loss and weight gain. One major takeaway was that, among people who had lost a significant amount of weight on The Biggest Loser, those who were successful in keeping most of the weight off were those who exercised more. He also examined the changes to metabolism on a low carbohydrate, high protein diet and found that energy expenditure actually decreases under these conditions.

ACTION study

A distinguished panel including lead author, Dr. Lee Kaplan, announced important results from the Awareness, Care, and Treatment In Obesity Management (ACTION) Study sponsored by Novo Nordisk. The ACTION study investigated barriers to effective obesity management from the perspectives of people with obesity, health care professionals (HCPs), and employers. Although two-thirds of patients recognized obesity as a disease, more than 80% believed weight loss was completely their own responsibility. The results also showed inadequate communication between patients and HCPs about weight, with less than one-quarter of patients with obesity offered follow-up care after a weight-management conversation with their HCP.  And while nearly three-quarters of employers believed their wellness programs supported weight management, only 17% of people with obesity agreed.  These and other findings from the ACTION study highlight important areas that need to be addressed for patients to receive adequate obesity care.

These are the specific questions we will discuss during the chat (Sunday, 11/12/17 at 9 pm EST):

1. What is the impact of weight bias internalization? How can clinics and providers help minimize this?
2. What is the most effective use of social media for patients? For providers?
3. What are practical tips gleaned from The Biggest Loser experience?
4. How can we encourage patients to seek treatment for obesity just like they would for any other chronic disease?
5. What topics and issues would you like to hear about at Obesity Week 2018?

The Psychology of Obesity: Working together to eliminate shame and stigma

This month's blog post is written by psychologist, Robyn Osborn Pashby, PhD

Our healthcare system is failing people with obesity. Yet rather than viewing the obesity epidemic as a failure of the system, failed weight loss interventions are too often attributed to failure of will. Sadly weight bias on the part of society as a whole, and health practitioners specifically, feeds into this stigma and prevents healthy psychological support for weight loss. For patients, this weight bias and stigma fuels a sense of self as a failure, and repeated perceived failures can lead to a belief that something is wrong with oneself as a person – shame. Shame isolates people from one another at a time when support could be beneficial. Depletion of energy from this sense of failure and shame creates a cycle that can interfere with healthy cognitive, emotional, and behavioral changes.

Mired in self-blame, shame, and humiliation, people with obesity often recount failed interventions and list the ways in which they are not strong enough, good enough, or determined enough to lose weight. The same people who run businesses, care for families, serve community organizations, and make our country’s policies, laws, and regulations believe they are failures because of the number on the scale. The belief that obesity is a failure of will can cause or exacerbate eating and mood struggles, interfering with health behavior change. The constant barrage of negative self-talk results in emotional and intellectual exhaustion. This is problematic because energy for behavior change is a finite resource. The more of it that is allocated to negative self-talk criticizing oneself for a “lack of self-control,” or berating oneself for “failing” the latest diet plan, the less energy available for self-care and maintenance of healthy lifestyle changes.

Shame also interferes with a person’s likelihood of accessing support. Weight management requires support from numerous disciplines (often medical, psychological, nutrition, and/or movement) as well as from loved ones, friends, families, and coworkers. Thoughts like, “I should lose weight before I go back to my doctor,” is just one example of how shame can interfere with a person accessing the very support that is most helpful. Shame can lead a person with obesity to believe that support is something reserved for others…those who are worthy of the support. Thus, reducing shame, identifying and disempowering the shame-based beliefs, and building a core sense of worthiness are all critical in helping individuals embrace autonomy and maintain energy for long term health behavior change.

In our next Twitter chat we will discuss the psychology of obesity. Specifically, we will be addressing the following questions:

What types and sources of psychological support are most helpful for persons with #obesity?
How do stigma and shame affect eating, exercise, and even accessing treatments such as #bariatricsurgery?
In what ways can self-talk be used for making positive changes rather than reinforcing shame and stigma?
Can a goal of feeling good (rather than # on the scale) have a meaningful impact on weight management?
In what ways can health practitioners lessen the burden of stigma and shame for patients with #obesity?

We hope you will join the discussion 9:00p EST Sunday, October 8!

~The #obsm chat leadership: Arghavan Salles, MD, PhD; Heather Logghe, MD; Neil Floch, MD; Amir Ghaferi, MD, MS; and Babak Moein, MD