The obesity epidemic: Are emotions the “elephant in the room”?

We are in the midst of a dual obesity and type 2 diabetes epidemic (Abdullah et al, 2010). Current health education messages are focused on “eat less and move more” (Haslam, 2010), yet we know that for every person who can implement this advice there are many who struggle. This can lead to a sense of failure and increased hopelessness, for both the person and the health professional (Hornsten 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 desired change – the evidence for this exists within our NHS employee workforce (Press Association, 2014). Health messages concerning alcohol intake, food choices, exercise and smoking behaviours are clear, yet how often do we as clinicians take our own advice? An invitation to readers is to consider that they too may be the “patient” when it comes to being able to implement lifestyle change.

So what is the missing link? The people we see 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 and is a term that gets used as if it is something we can simply summon up at will. However, when we are considering weight change, the term motivation can be a “red herring”.

The people we see 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 and clean your teeth. You probably do not use the term “motivation” in relation to these tasks of life. Why? Because these activities are in line with your identity, self-esteem and values (you value having fresh breath, so your organise yourself to make time to brush your teeth in the morning). Similarly, the people we see are motivated to do exactly the right thing for them, given two aspects of themselves:

1. Knowledge and information.
2. Emotions and values.

Traditional medical and health education models are excellent at the first of these, but conversations about the latter are generally absent from our healthcare settings. This is where psychology plays a part, and it is arguably the missing link in our understanding of people with obesity.

Psychology is all about understanding our identities, our self-esteem, our values and emotions. These form the bridge between knowledge and behaviour, and the key to motivation (Leventhal et al, 2003). They guide our decision-making on things relating to our health and on what to eat. Food, in particular, is intimately connected with emotions – from infancy when hunger and distress is soothed by the caregiver’s milk (Carnell et al, 2012). Psychological models address emotions, but access to a clinical psychologist for people with obesity, while recommended (NICE, 2014), is extremely limited within current service provision.

A novel psychological self-help tool: the EatingBlueprint
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 one attempt to address this. Its aim is to take an everyday approach to the techniques drawn from a variety of psychological models that address the human capacity to change (e.g. cognitive, solution-focussed, compassionate, mindfulness, dialectical and attachment approaches). It is an online video-based tool designed to develop the emotional and mindset skills that are required as the foundations to implement weight loss advice. A brief description of the eight areas of the EatingBlueprint is provided in Box 1.

The author is prompted by McKinsey’s global 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 within the EatingBlueprint are grounded within the theories they are drawn from, and work is underway to establish an evidence base for the programme. For further details, see Box 2.

Advice for the time-limited clinician
If you would like to move beyond the “eat less, move more” approach within your time-limited consultations (in line with the NHS’s Making Every Contact Count initiative [e.g. East Midlands Health Trainer Hub, 2012]), some suggested “conversations starters” are presented below for you to adapt to your own style and language. Tone of voice can be as important as what you say – using a soft, friendly tone and making eye-contact is helpful.

If you only have 15 seconds…
Begin with the approach below:

“May we talk about your weight for a moment? Don’t worry, I’m not here to give you a lecture.”

Pause for a moment to allow them to say “no” if they would rather not. Then, if proceeding, continue with:

“We know that weight loss isn’t as simple as “eat less, move more” – life can be difficult, and eating can be a way of coping with feelings, stress and boredom, for all of us. Are you aware you ever eat in this way?”

If the person says “no”, just respond “okay” and carry on with your consultation as usual. The person may genuinely not identify with using food in this way or perhaps does not want to talk about it. If this is the case, you have still provided an intervention, by sowing a seed that the conversation is available if the person would like to have it at another point.

If the person says “yes” but you do not have any more time to talk about it, you could respond with: “It’s really common. I can point you in the direction of some self-help information, if you would like?” (see Boxes 2 and 3).

If you have 30 seconds…
Following on from the above, if the person indicates a “yes” response, and seems open to talking, continue with:

“Is this something you’d like to think about? We may not have time to explore this much today, but many people I see tell me they eat more when they are feeling down or at a loose end, or are alone, or stressed, or nervous… This is very normal. Do you ever eat in these ways?”

Pause and wait for the answer. Then, if you do not have any more time to talk about it, you can point the individual towards some self-help resources as above.

If you have 1 minute…
Begin in the same way as above and if the person seems open to talking continue with the following:

“Can I invite you to try something a bit different with me? Perhaps we could think about the times you tend to eat when you’re not hungry and think about what else you may be able to do instead of eating? Sometimes only food will hit the spot, in which case don’t beat yourself up if you eat. But often just having a few ideas in mind of different things you can experiment with doing when you’re feeling this way can be useful. It’s likely there are some times when your brain is telling you to eat, but you can choose whether or not to listen, and try and do something else instead.”

If you have 2 minutes…
Following on from above, if the person seems open to talking continue with:

“Would it be useful if we thought of some ideas together now? We could come up with a few, and you could give one or more of them a go next time you’re feeling the urge to eat when you’re not really hungry. Perhaps you can try it out, and see how you get on? Remember, it won’t ‘work’ every time – that’s okay. It’s just helpful to see that just because your brain is giving you the instruction to eat, you don’t always have to follow it if you’re not really hungry. It will likely get easier with practice, like most things.”

Possible ideas to suggest for alternative responses to an eating urge (tailored to the age, gender and your knowledge of the person) include: stroke your pet, go online, have a lie-down, text or call a friend, paint your nails, read, do a Sudoku puzzle, mend something, write a letter, organise a drawer or wardrobe or make a shopping list.

If you have 3 minutes…
If the person seems engaged with the conversation above, continue with:

“Can I invite you to write these ideas down or make a note of them in your phone?”

Pause here and wait for a “yes” response. Some people may be uncomfortable with this for literacy and other reasons. If agreed, proceed with:

“You could put the list in your kitchen, so you’ll be reminded, or if you don’t want others at home to know, you could try something like moving an object in your kitchen counter to a slightly different location to remind you that you’re trying something different.”

Write the ideas down for the person if that is preferred (you could refer to it as a “prescription” in a light-hearted tone if you think the person might like that style). Then, continue with:

“Remember, don’t worry if it doesn’t work, just trying it out is useful. We can talk about how you found it next time we meet if you’d like, or I can point you in the direction of a self-help resource?”

The future
None of this advice is “rocket science”, yet why aren’t we doing it? It may be because we’re in a medical paradigm that treats obesity as a medical or educational problem, not an emotional, psychological or skills-development one.

Do all obese people need a clinical psychologist? Controversially, I would argue that for many who have received education and are still struggling, the answer is perhaps yes. There is a substantial body of evidence that demonstrates many who routinely use food for emotional regulation have a history of psychological issues (Felitti, 2003; Bidgood and Buckroyd, 2005). The incidence 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 is limited to screening for psychiatric disorders in preparation for bariatric surgery (NICE, 2014).

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 the level of “what” and “how much” we need to first shift the focus onto the “why” of our eating behaviour – and to be creative in taking a macro- and micro-level 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 recent decades, widespread change in tobacco use has occurred, but it required the co-ordination 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)

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