Psychology of Health Behavior Change in Obesity

Hi, I'm Lissa McGerty. I'm an associate professor and clinical psychologist at the University of Utah. And my specialty is psychological health for patients with severe obesity. And I'd like to today just share a few thoughts about health behavior change really from a psychological perspective.

One thing that I always tell my trainees is that understandably every discipline tends to look at obesity through their own lens. So a dietician is going to think about the specific nutrition changes that are most likely to optimize health. A physician who say is treating diabetes is going to think about the medications that will be most helpful to the patient or the lab values or the amount of carbs per meal for diabetes management. An exercise physiologist will think about the amount of physical activity that's associated with the greatest kind of cardiometabolic benefit. And all of those perspectives are absolutely important and they matter.

My role as a clinical psychologist is to think about something a little bit different. And that is in this case, can this patient actually do the things we are asking them to do? And maybe more importantly, can they keep doing it and keep doing it really long term? Because health recommendations only improve health if they actually become part of someone's life over the long term. So from a psychological perspective, behavior change is really less about identifying like what would be the ideal recommendation for this patient and more can we help patients to find meaningful changes that they can realistically sustain.

One challenge in doing that is that the typical patient we see with severe obesity has often spent many years, sometimes decades, trying to lose weight. Many have tried restrictive diets, intense exercise programs, may have done commercial weight loss, and they've often lost substantial amounts of weight before. This is usually not the first attempt, and they've experienced that really common cycle of what we call the yo-yo diet or weight recurrence over time. And over time, many patients have internalized a pretty specific message. The idea that I failed. That message often comes from close loved ones, family members. It comes from the media, social media, healthcare experiences, and eventually internalized or from themselves.

So when a patient walks into your office, they may come with years of discouragement, self-blame, and reduced confidence that change is even possible. And it turns out that's not the best starting point for behavior change.

So one question I like to ask, especially when meeting patients for the first time and beginning to discuss this, is help me understand, help me understand your journey with weight and health over time. Very open-ended, the answer is often much more complicated than people expect. And sometimes you'll hear about pain or stress or depression, caregiving responsibilities, maybe financial constraints. Understanding those barriers allows you to then work on a tailored plan for that patient that really addresses their needs.

And that brings me to kind of a second point. As healthcare providers, including clinical psychologists, we spend a lot of time identifying risk factors and pathology. But we really should spend just as much time identifying resilience and patient and family strengths. And one thing I've learned from working with this population over the years is that many patients with severe obesity are remarkably resilient. And that flies in the face of some of the common stereotypes that I think we sometimes see. These patients have spent years managing health challenges, stigma, setbacks, yet they continue showing up and trying again.

Research from my team supports this. We've actually found in our studies that levels of resilience for patients with severe obesity are comparable to primary care norms. And higher levels of resilience are not surprisingly associated with better psychological functioning, improved health behaviors, and quality of life. So I often ask patients, what has helped you get through difficult situations before? Or what supports you, or who supports you when things get hard — asking about the support system, asking about resources and strengths already available to them. These answers frequently then become that foundation for behavior change.

And many patients with obesity don't need more education about what healthy behaviors look like or what they're doing wrong. Some do, but many have heard this many times before. What they do need is help translating your recommendations into sustainable action within the realities of their own lives.

So one of my favorite questions when we think about getting at bigger picture values for patients that drive behavior change is if you could achieve the goals that we're talking about here today, what would look different for you in your life 5 years from now? That again really gets at underlying
motivation, intrinsic motivation, and anything that we can do to help patients remind themselves of those bigger picture values supports the likelihood that they will make sustainable behavior changes.

The third point I'd like to make is highlighting weight stigma. It's been a major focus of my research where my team has identified that improvements in weight stigma from before surgery, bariatric surgery to about two years after surgery was actually a stronger predictor of many psychological outcomes than the amount of weight that people lost. In other words, the change in stigma was more strongly associated with psychological distress, dysregulated eating, some of the things that we hope to change for patients than anything about the change on the scale. And I think that is a powerful finding because it really suggests that when we reduce the stigma patients experience or anticipate or internalize, we're not simply being kind to them. Reducing weight stigma is in itself a clinical intervention.

So sometimes that starts with small changes in how we communicate. Instead of just being one more provider to tell the patient to just eat less and exercise more, we can be a provider who acknowledges complexity and chronicity of obesity. We can validate their experiences and feelings. We can highlight their unique strengths and that allows us to engage in truly patient centered care.

And finally, when I talk with patients, I try not to focus primarily on weight, which may sound a little odd when what we're talking about is weight management. Most patients have already spent years focusing on weight. So at every possible opportunity where you can focus instead on function, quality of life, sustainable behaviors, you're more likely to get that momentum with patients. So I might ask, how can we help your body and mind function at their best? Or what change could realistically fit into your life this week? The goal is not about perfection. It really is helping patients identify those changes they can realistically sustain. A modest change that they maintain consistently will almost always have that greater impact on long-term health than any perfect plan that a patient abandons 2 weeks later.

And with that, thank you so much for your time and for the work you do supporting your patients living with obesity. If you want more information, check out resources through RheumNow.