Issue: 2015, Vol 1, No 2, Pages 41–79

Obesity: All in the mind?

Jen Nash

Jen Nash
Jen Nash is a Chartered Clinical Psychologist and Associate Fellow of the British Psychological Society, London.

Whilst current health education is focused on the “eat less and move more” message (Haslam, 2010), we know that for every person who can implement this advice there are many who struggle. This leads to a sense of failure and hopelessness for both the obese individual and the healthcare professional (Hörnsten et al, 2008).

Traditional medical and dietary advice treats weight loss as if it is a logical, rational process. There is an assumption that education alone leads to behaviour change. However, education does not always lead to the desired change, as the prevalence of overweight and obesity in the NHS workforce demonstrates (Press Association, 2014). Health messages concerning alcohol intake, food choices, exercise and smoking behaviours are clear, yet how often do clinicians take their own advice? Readers are invited to acknowledge that they too may be the “patient” when it comes to being able to implement lifestyle change.

What is the missing link? Our patients often know what they need to do to care for their health, but something “gets in the way” when they leave us. Is it motivation? Motivation is a hugely complex phenomenon, yet the term is used as if it is something that can simply be summoned up at will. However, when considering weight change, the term motivation can be a red herring. Our patients are motivated; they are motivated to do the things that are important to them. If you consider your own life, you (generally!) do not have to “motivate” yourself to get dressed in the morning, clean your teeth or kiss your child goodbye. You probably do not use the term “motivation” in relation to these tasks of daily living. Why? Because these activities are in line with your identity, self-esteem and values. You value your children feeling loved as they go to school, so you organise yourself to wave them off in the morning. You value having fresh breath, so you make time to brush your teeth in the morning. Likewise, our patients are motivated to do exactly the right thing for themselves, given the following two aspects:

- Knowledge and information.
- Emotions and values.

Traditional medical and health education models are excellent at catering to the first of these, but conversations about the latter are absent from our healthcare settings. This is where psychology plays a part, and it is perhaps the missing link in our understanding of people with obesity. Psychology is all about understanding our identities, self-esteem, values and emotions. These are the bridge between knowledge and behaviour, and they are the key to motivation (Leventhal, 2003). They guide our decision making, including decisions about our health and what to eat. Food in particular is intimately connected with emotions, and the association starts in infancy, when hunger and distress are soothed by the caregiver’s milk (Carnell et al, 2012). Psychological models address emotions; however, access to a registered practitioner psychologist for people with obesity, although recommended by NICE (2014a) and an integral part of Tier 3 weight management services, is extremely limited within current service provision.

A novel psychological self-help tool: The Eating Blueprint

Cognitive behavioural therapy (CBT) is the treatment of choice for “atypical” eating behaviour such as binge eating disorder (NICE, 2004); however, some of the techniques and jargon of CBT are not user-friendly for the people we work with or non-psychologists. The EatingBlueprint is a new tool that attempts to address this. It is an everyday approach to techniques drawn from numerous psychological models that address the human capacity to change (e.g. solution-focussed, compassionate, mindfulness-based, dialectical and attachmentbased approaches). It is an online, video-based tool designed to develop the emotional and mindset skills that that are required as the foundations to implement weight loss advice. The author is prompted by the McKinsey Global Institute’s economic analysis of obesity (Dobbs et al, 2014), which urges clinicians towards a “bias for action” in implementing new initiatives and programmes to tackle obesity, especially where risks are low.

The tools used in the EatingBlueprint are grounded in the theories they are drawn from, and audit data demonstrate an average weight loss of 5 kg over 12 weeks in people who complete the programme (n=162 to date). Work is underway to establish a robust evidence base. The eight areas of the blueprint are provided below.

1. Forgiveness

The blueprint begins by normalising the idea that it is difficult to lose and maintain a healthy weight. We are fighting a biological, psychological and social world that is set up to promote weight gain, and the person is not “wrong” or “bad” for being overweight. This step is designed to provide relief from shame and stigma.

2. Focus

This area aims to encourage noticing and overcoming “mindless” eating. Whilst it is usual to eat mindlessly for non-hunger reasons occasionally (Waller and Osman, 1998), people need strategies to help themselves interrupt frequent mindless eating. We encourage them to do this using a simple question: “WHY am I eating?” or, simply, the acronym “WHY?” This stands for:

- Wait

Remembering to wait is challenging so, in the short term, participants are invited to use a reminder (e.g. a charity band) on their dominant hand/wrist. This is just a very short-term strategy, until the automatic nature of eating becomes interrupted.

- Hungry?

Inviting participants to ask themselves, “Am I really hungry? How physically hungry am I, on a scale of 0–10? If I’m not hungry, what AM I hungry for?” (e.g. for a break, as a reward, as a distraction, to cheer myself up or to bond with someone).

- Yes

The final stage is to say “yes” to food or whatever the person is truly hungry for. If the person is physically hungry, say “yes” to food and eat. If the person is not truly hungry and still eats, that’s ok too. Change takes time and the simple act of pausing brings awareness to what was an unconscious process.

The power in this area is to help people figure out what they are truly “hungry” for and ask themselves whether they can meet their hunger with something other than food. The areas of the blueprint that follow are designed to help increase the flexibility to choose between a range of responses to food.

3. Fun

Eating is pleasurable and entertaining, and it can become “a friend.” People may need help to look for ways to increase their non-food sources of pleasure and entertainment when they feel the urge to eat for non-hunger reasons, particularly in environments where food is a ready and available source of pleasure and distraction.

4. Feelings

It is common to use food to “stuff down” emotions that are not easy to express. It is a skill to be able to express emotions authentically to both ourselves and others, and we often need strategies to express emotions rather than dull them with food. The EatingBlueprint provides a template for identifying and expressing feelings in ways other than through food.

5. Fables

These are the family stories and rules about food, spoken and unspoken. Phrases like “eat your vegetables before having dessert” and postrationing narratives such as “don’t waste food” and “finish your plate” have value, but we need to question the modern-day utility of these fables, and create more helpful narratives that serve us.

6. Foresight

To continue to maintain a healthy weight, people need to learn from previous life experiences and manage their thinking styles relating to food. This step encourages people to plan ahead and learn from the “predictability of life” (e.g. Christmas and meals out) and to learn how to experiment with trying out new behaviours. It also invites them to challenge the “good/bad” paradigms of diets (e.g. “I’ve eaten something ‘bad,’ I’ll give up trying for today and start again tomorrow”) using CBT techniques.

7. Framework

Weight loss is not a solo journey. The impact of family influence, the obesogenic environment and social events are all crucial. People need to develop assertiveness skills to be able to say no to the “feeders” in their lives, and to spot the signs of sabotage, often by well-meaning but threatened loved ones. The blueprint provides these skills.

8. Future

Weight loss is a skill, yet we don’t treat it as one. Like learning to drive a car, it is a process that requires coaching and facilitation, and “mistakes” and “slip-ups” are an integral part of the journey that need to be welcomed. The blueprint teaches people how to “update the default” and stay solution-focussed on their weight loss journey.

The role of the psychologist

Obesity is currently treated as a medical or educational problem, not an emotional, psychological or skills-development one. Clinical psychologists are generally limited to using structured CBT, in a one-to-one or small-group format, so these ideas are not particularly available for the multidisciplinary team to utilise.

Do all obese people need a clinical psychologist? Controversially, some would argue that, for many people who have received education and are still struggling, yes they do (British Psychological Society, 2011). There is a substantial body of evidence showing that many people who routinely use food for emotional regulation have a history of psychological issues (Felitti, 2003; Bidgood and Buckroyd, 2005). The prevalence of trauma, childhood abuse, sexual abuse, low self-esteem and depression is high among people who are obese and those presenting for bariatric surgery (Gustafson et al, 2006).

Despite this, access to psychological services for obese people has been, in the main, limited to screening for psychiatric disorders in preparation for bariatric surgery (NICE, 2014b). Tier 3 weight management services provide much more scope for psychological intervention, and online tools of this nature may provide a useful and cost-effective support to interventions in these contexts.

Many clinicians report a sense of hopelessness that surrounds the obesity issue (Brotons et al, 2003). This hopelessness may exist because we need to shift our focus. The “what” and “how much” of eating is of key importance, but to be able to intervene at this level we need to first shift the focus onto the “why” of our eating behaviour – and to be creative in taking a macro- and microlevel approach to the obesity challenge. There are reasons for optimism if we learn lessons from the changes we have seen in the area of smoking cessation. In the last decades, widespread change in tobacco use has occurred, but it required the coordination of government legislation, industry responsibility and effective public health campaigns. The same integrated approach will be required for the obesity challenge (Dobbs et al, 2014).

Conclusion

In our food-abundant environment, for many people, weight management is not simply an educational endeavour; it is a skill. Achieving and maintaining a healthy weight requires the skills of emotional regulation, the ability to tolerate distress and the assertiveness to say no. In other words, it takes a highly developed person. We need to widen the scope of interventions for obesity to include these skills of emotional regulation. We need to empower people with skills and strategies to make choices other than eating so that the person, not the food, is in control.

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NICE (2014a) Managing Overweight and Obesity in Adults – Lifestyle Weight Management Services (PH53). NICE, London. Available at: http://www.nice.org.uk/guidance/ph53 (accessed 23.03.15)

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Waller G, Osman S (1998) Emotional eating and eating psychopathology among non-eating-disordered women. Int J Eat Disord 23: 419–24