Weight is Not a Behaviour with Dr. Michael Vallis

– Hello, and welcome to “Scale Up Your Practice,” the podcast brought to you by Obesity Canada. I’m Dr. Roshan Abraham, a family physician and associate professor in the Department of Family Medicine at the University of Alberta. Obesity is a complex chronic disease, not a simple matter of willpower or behavior. Every day I see the challenges it presents for both patients and our healthcare system.

 

– And I’m Michelle McMillan, a lived experience expert with Obesity Canada and your co-host. Obesity management takes collaboration, understanding and evidence-based care. That’s why we bring together diverse voices to explore practical strategies that can help you provide better care.

 

– Today’s episode is not sponsored. In today’s episode, we’re thrilled to welcome back global obesity expert, Dr. Michael Vallis. So Dr. Vallis, we know obesity management is not a straight path, yet many patients feel discouraged when they don’t see immediate results. We also know that many people compare their weight loss or health journeys to others, which can lead to frustration and demotivation. How can we help patients focus on their own progress and redefine what success looks like for them individually?

 

– That’s a really, really great question. And there are actually two things that you’ve raised there, Roshan, that I really think need to be taken apart. And one of them is how we judge our own progress. So you say obesity management’s not a straight path, people feel discouraged when they don’t see immediate results. And this is a critically important issue because psychologically, the way behavior would operate is you’d put effort into something and you would want to see an outcome. And so effort and outcome in some way should match. If you put a little effort, you should expect a little outcome. Moderate effort, a moderate outcome. A lot of effort, a lot of outcome. This is where the nightmare begins because when we talk about weight management and we talk about effort and outcome, the outcome cannot be the scale. The outcome cannot be biology. The outcome has to be behavior. Don’t confuse behavior with biology. Human nature is such that if you work hard, you should get a result. And so if you count the number of calories you eat in a day, you should expect control over that. Whether it’s summer, winter, whether it’s raining or snowing, whether you’re tired or not tired, you should expect that you can have a relationship between how much effort you put into counting calories and how many calories you consume, how many steps you walk and your outcomes, how much sleep you get. So what we need to really understand is how important it is to support patients in setting goals that they can control. If they can’t control, you have the potential to harm your patient. And let me describe to you how you can unwittingly harm your patient. You can set up a paradigm with them, a learning paradigm in which they try hard and they get a result. I work and I get an outcome. Work and I get an outcome. I work and I get an outcome. And if that doesn’t make sense to them, if they feel that they’re not getting the return on investment, something will happen. I try, doesn’t work. I try, it doesn’t work. I try, it doesn’t work. I don’t keep trying forever. This is called learned helplessness. I’ve learned that I can’t do it. Whenever you put a non-behavioral goal, where you’re saying, we want you to work on this and here’s the outcomes we want. If it’s not a outcome that’s under the person’s control, then you’re likely gonna set up learned health. And weight is not a behavior. And it is so important for us because not only is weight not a behavior, we have no idea what weight outcomes were. And so I sometimes say it, this sounds kind of funny, but I sometimes say to people, citizens have three questions for us as health professionals. And those three questions are, how much weight am I going to lose? How much weight am I going to lose? How much weight am I going to lose? Those are the three questions. And there are two answers. And those answers are, I don’t know and it’s not what I care about most. Now I think we understand the importance of the expectations, the importance of this relationship. So we have to help people put effort into the behaviors that they can count and measure. Because if you can show them that they have power, if you can show them that they have agency, and this links to a behavioral strategy in which we always look for what the person’s next step goal is. And that next step should be doable by the patient’s judgment and worthwhile by our judgment. We collaborate with people. And so I’m suggesting that this is a behavioral pathway that is the antidote for learned helplessness. It’s called self-efficacy. And so it’s actually really, really important when we witness this in patients, we see this all of the time. I don’t get the results I’m expecting. Okay, something’s going wrong there. And we have to preserve the behavioral effort that our patients put into play because this one is super, super important. And the second point that you raised Roshan, which is equally important for us to be wary of, and that’s the social environment in which we live. And this is where we’re really witnessing the traumatic kind of aspects of the false narrative. The false narrative that we’ve exposed, which is you can achieve your ideal weight by eating less, moving more, using willpower, has been part of our society since Twiggy in the early 1960s. Prior to Twiggy, the sort of contemporary view of a female body was a Marilyn Monroe, Gina Lollobrigida, shapely female body with adipose tissue. And then along in the ’60s comes Twiggy, and then the social fabric from then to now has been thin is better, the thinner you are. So social comparison, because we’re social animals, we do make social comparisons. And so when I hear these questions, to me, this is where we come in as clinicians. We have to protect the vulnerable person living with obesity to establish a learning paradigm where they put effort and see an outcome, and they feel good about themselves. It’s more important that they establish this relationship between effort and outcome. And if you see disconnects between effort and outcome, well, then we have to work to sort of set that straight. And the second component, and this is where people like Michelle have been incredibly helpful to this profession because the lived experience voice is where we will get alternatives to that social comparison, alternatives to that sort of the more weight you lose, the better off you are, the lower your body weight, the better you are. So those two issues are actually really, really important. And again, justifies why we want to make the claim that obesity management is a team sport. It’s a collaboration of multiple health professionals with the person supporting them in a journey towards success rather than what many of our patients would say, which is they’re doing their best to try to follow the recommendations that have been made to them, but they’re finding it really difficult to do that over time, which by the way, makes them 100% normal human beings.

 

– That is so powerful. As a patient, living with obesity, that statement that weight is not a behavior is a thing that I think most people living with obesity struggle with, right? Because we’ve lived most of our lives in a society, and you brought this up as well, a society where the problem, the reason you have obesity is that you lack willpower, you don’t move enough, you eat bad foods, and so then you assume the solution is, well, if I move more and I eat better foods, then I shall be Twiggy. Yeah, that’s so powerful, so amazingly powerful. So if we move from that point of weight is not a behavior, you’re fighting a lot of things, like you’re fighting your own patients, right? To get them to understand this brand new concept, which is different from what the environment that they live in is. What would be your recommendations for clinicians? How do you best communicate that and get, you can communicate it, but get what I would say, get your patients to believe it when you say it. So what would be your recommendations around that?

 

– I think that’s a great, great point. And I guess I’d like to maybe put a little plugin for our 2020 Canadian clinical practice guidelines. I know that they’re five years on now and we started doing the research behind the guidelines a couple of years before we published them. But I think our heart was in the right place when we created those guidelines. And we really tried to create those guidelines as a way of amplifying or welcoming the patient voice and really establishing sort of a framework of collaboration. And I think that when I think about how do we use some of this, to me, I just see that it’s kind of coming together incredibly well. So we’re starting to see the reframing of obesity from a personal failure to a chronic disease, just like 25 years ago, we did in type two diabetes. So in type two diabetes for a long time, this was kind of considered to be a minor behavioral problem and our patients just had to get themselves together. And now that’s not the case whatsoever. It’s a chronic disease and we have multiple therapies. And so now we have pharmacotherapies that can address the appetite system. And so where we’re going to go with this, I think is incredible because this frees up. See, remember the psychological behavioral pillar of obesity management, the nutritional management piece, medical nutrition therapy pillar, have always in the past been responsible supposedly for creating and maintaining a calorie deficit. That’s who we send our patients to. We send our patients to the dieticians and to the psychologist to try to get them on a diet, get them on an activity pattern, 500 calorie deficit, keep them going forever. And it’s been a waste of time because of the biological imperative to maintain one’s highest weight because of all that goes on in the appetite system. That we understand so well. So I just have a lot of optimism and you’re starting to begin to see it. Now that we have medical therapies that may be able to address the drive to eat. So this calorie deficit kind of can get addressed from a medical perspective, operating biologically on the appetite system. Now, all of a sudden our dieticians can help people learn how to eat, learn how to have relationships with food in which they can enjoy food. They can eat mindfully. They can love food that loves them back. And the psychologist can now look at body image. Look in the mirror, that is your body. You’ve had that body your whole life. It doesn’t matter how much you would want to look like Twiggy or anybody else. The reality is it’s your body. Can we help you connect to it and establish body acceptance, the acceptance of body diversity, the promotion of health at any size and helping people really claim their own dignity. Because this is the thing that I think I get so upset at as a psychologist is how the social narrative of thinner is better is somehow just woven into our society in such a way that it’s exposed just so much turmoil and literally trauma. A trauma informed approach to people living in a larger body is a very valuable approach in my opinion because it helps us understand the level. And it’s death by a thousand cuts. Do you know what I mean by that? It’s that kind of Chinese water torture that’s dripping on your head. It’s not a tsunami. It’s not an earthquake, but it’s this constant, it’s like being raised by an abusive parent who’s psychologically kind of criticizing everything you do as a child. And so we have this incredible history behind this. And I think where I’m really excited about now is that as we really take this chronic disease perspective, especially since the voice of the citizen is going to keep us honest. That is the patient voice as part of the obesity initiative I think is gonna be really critical for us to move forward. So I’m really excited about how we can kind of move forward because it’ll be collaborative. We’ll need a lot of people rowing in the same direction and it’ll be critically involving the person with lived experience, which is exactly what it should be.

 

– And for our listeners, I’d like to say that for someone who’s, I mean, I’ve been in practice now for about eight years and the shift for me in this approach, this integration with biological therapies alongside nutrition and psychological support, this is exactly what I see in my very much everyday practice in family medicine is that the biological therapies that we have now can actually enhance. There’s a synergy to the treatment options that are available through nutrition, psychological support, even some of our exercise support that we have as part of our primary care networks in Alberta, I think is just vastly sort of improved over what we had before. And it gives patients hope because they know that there is an integrated approach now. It’s not something that where you’re just sending patients off to sort of say, hey, go see somebody else, go see somebody else, go see somebody else. This is for you to figure out. This is a team effort. We’re gonna coordinate it as the clinician, as a family doctor, especially primary care professional. I think it’s so valuable. There’s so much potential here. And I love to hear that enthusiasm from you because I see it every day in my practice. I don’t even have a specialized obesity practice. I have a very general practice in family medicine and there’s so much hope for so many of my patients.

 

– Absolutely.

 

– I do think though, kind of what you were talking about, about the social narrative that equates weight with personal worth, because I do see this, even though, I mean, there are ups and downs to any treatment plan. And for my patients who are living with obesity, there’s ups and downs. And the personal worth and the changes in how they feel about their personal worth with weight is something that I see time and time again after they have found some success. And then, you know, don’t find that success a little bit afterwards. That sort of up and down that’s going to ebb and flow with diabetes or with high blood pressure. And a lot of the other chronic diseases where patients have a different perspective, obviously. I mean, some people do get quite concerned about that. How can we as clinicians help shift that perspective? Again, both at an individual level and within the broader healthcare system.

 

– As clinicians, we tend to have an evaluation system, right? We have to, we have to be measuring what we’re treating and such. And so we sort of start to look and have these metrics that we use. And I think that’s kind of what we have to really abandon. We really need to listen to the voice. We need to sort of create what the important outcomes are for the person in the moment. And if you just think about, is it doable? Is it worthwhile? Those two questions you just say, is this something that if we had you, you know, if we asked you to do it, like, could you do it, you know, for the next week, two weeks, five weeks, 10 weeks, 12 weeks? What do you think? Let’s find something that you think that if you were going to commit to that whether it’s rainy or sunny, whether it’s cold or warm, that you could do it. Don’t take on something that you think, you know, if all the stars are aligned, I could probably do this behavior. Now that’s how people are going to orient, right? We live in a society where there’s a cultural sort of implicit belief, go big or go home, right? We only promote the huge, huge stories, right? This is really poor. You know, these, you know, ultra marathoners, they’re terrible role models. They’re really bad role models because they’re made of different stuff. The role model is what we call, they’re called mastery models. The role model that’s helpful is what’s called a coping model. A regular person doing regular things, you know, the dignity of getting through the day. And so if we can start sort of looking at these metrics that we’d love to use and find the co-creation of metrics that are based on the person’s experience, because I would like to make the following point from a behavioral perspective, that if a person has the following experience, so you’re a clinician working with your patient, please know this, something magical will happen with your patient, with the person, somewhere between the fifth and the seventh consecutive success experience. So when you’re working with a goal with your patient, if you can set it up so that the patient doesn’t have one success, but one, two, three, four, five, something’s happening. Something happens in the human brain when this pattern happens. And somewhere between the fifth and the seventh consecutive success experience, something clicks in the brain and the person has the sense of, I can do this. And not because you’re telling me doctor that I can do this, not because I wanna do this doctor, but because if I did all these steps, then the next step is just kind of like the step before. And this is called self-efficacy and our ability to work with people. And so the key here isn’t, here’s what the protocol says, you’ve go to follow the protocol. It’s kind of, what can you do? And then how do we help you develop the confidence to insert that behavior and then build on that behavior? Incredibly effective behavioral strategy. And anybody who’s ever run a 10K, a half marathon, a marathon, any of these endurance events, how do you swim five kilometers for a charity in a lake or something like that? Well, you build up very slowly. And how successful is that? And go to any running event and you’ll see all kinds of people in larger bodies. The last marathon I ran was the New York marathon. And I wanted to figure out, there were 46,000 finishers. And so my question was, who’s in the middle of the pack? So I went on the site and I found out who finished in the position 26,000 or 23,000, right? There’s 23,000 in front of them and 23,000 behind them. Four hours and 50 minutes. So at four hours and 50 minutes, half of the course of the New York marathon was out on the course. These are not thin runners. These are larger people who are accomplishing a tremendous amount. And so I love that, that sort of running community is a great example of just demonstrating the sort of behavioral power of behavior shaping. And it really does. I am exactly the same size I was when I was around 15 years old. My body actually hasn’t changed. I ran my first marathon in 1979 and I was considered to be a big runner. And I’m actually not a very large person. And I’m the same size now as I was then. I was big as a runner back then. I’m now considered to be a small runner, but I haven’t changed. I love that story because you see, it’s not me. It’s the environment is supporting body diversity. You go to any running event, you will not see shame over people living in larger bodies. As a matter of fact, you will see the fast runners engaging the slower runners at the end of an event. It’s awesome. The fast runners or the slower runners go, “Oh, I’m so I admire how fast you can run.” And do you know what? The fast runners turn around and they look at this person and they say, “I admire how long you can run. I don’t think I could ever be on the course as long as you.” There’s two hour marathoners, five hours would be too much for them.

 

– Yeah, that’s so great that we can see things are changing too. And I bring this up ’cause it’s a good contrast for our listeners if they ever see some pictures. So I’m a runner as well. I often say, “I don’t run very far and I don’t run very fast, but I enjoy it a great deal.” And yeah, just to see the diversity ’cause if Michael and I stood next to each other, I’m short and kind of square and he’s tall and by runner’s standards, somewhat thinner. So I think it speaks to a change in society as well, right? And I’m so thrilled that the world is moving that direction. So yeah.

 

– I would have one comment for you, Michelle, just to, and this one is a pickup on what you said. This is a challenge to us all. We cannot rest on our laurels. I think we’ve made some good strides, but let’s not get in an echo chamber. And what I mean by this is that we all now, I think as professionals, as individuals living in larger bodies, as people interested in this from whatever the perspective is, we now have to confront inequities, confront bias when we see it. And this is not going to be easy. How do we change the medical training system? How do we change the training system for other health professionals? How do we get the policymakers engaged, et cetera? So I kind of think you’re right, Michelle. I think things have changed dramatically, but I think we’re now in a position where our field requires some social action to really highlight these issues, especially if you think that we are privileged people. And so we need to be, I think, responsible with that privilege in some degree of social action. It’s not okay to witness obesity bias any longer and be silent.

 

– Yeah, that’s so true. And I think that somewhat leads us into, every week we like to do a little, what we call a bias break. And it’s not, we’re not tackling the world of every bias and stigma out there, but we try to ask our guests one, maybe discrete or small event that’s happened, maybe in the past couple of weeks or something that you could bring forward to other health professionals that highlights the bias that perhaps you’ve observed. So they can learn from it.

 

– Yeah, so thank you. I think my story will relate really directly to just what I said. So I’m a psychologist, so I actually like to study people. I mean, it’s just what I do, right? Very interested in human behavior. And what I find really challenging, and it happened just recently, is watching what happens to a person in a larger body when they’ve been just, you know, looked at or react to or pulled away from. And I’m thinking about, you know, being in a grocery store and having somebody walk by their cart and look in the inside. You could see the, you know what I mean? Just this nonspecifics that are going on. And then just observing how damaging that is to the person. And what I’m talking here to the audience about is internalized weight bias. And that because the societal, the false narrative is so ubiquitous, and it’s been with us for such a long time, that individuals living with obesity are as biased against people with obesity as those without obesity. And so this is really, and it’s incredibly dangerous. So for me, I’m always really sensitive to that. And that’s why I think if we can take action, you know, the Rudd Center has a website where you can do the implicit attitudes test around obesity. And I really recommend that people do it and keep doing it until the test shows you that you got no bias. And because we’re all going to start out and it’s going to help us to see what our biases are. And I think if we could do that, because this is where the vulnerability comes in. Remember, right? If, you know, part of being traumatized is you internalize the trauma. And so this is what’s happened to people living in larger bodies. So I’m really hopeful that this internalized weight bias will become critically important. We do need to call more light on it. So I was part of the ICHOMS International Outcome Measurement Group who just published the outcomes for obesity. And we wanted to include internalized weight bias, but the data didn’t support it yet. So I think we really need to sort of, as an obesity community, really sort of rally around internalized weight bias. Anyone who’s working on PhDs, I mean, your students, you know, encourage this area of post-BMI, what are we going to measure? And internalized weight bias. I think those are two directions that we can really go in.

 

– I really wish we could spend even more time talking about, I mean, the last two points you had there. I think there’s so much to unpack. I probably, or hopefully for another time, I can’t thank you enough for joining us today, Dr. Vallis. To our listeners, we hope our discussion has been informative and has opened your mind again to be curious about the evolving science in the fast moving field of obesity.

 

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– Until next time, keep scaling up your practice. This podcast is intended for informational and educational purposes only and does not constitute medical advice. The content shared in this podcast should never be used as a substitute for professional medical advice, diagnosis, or treatment. Always seek the guidance of a qualified healthcare professional with any questions you may have regarding your health or a medical condition. The information and treatments discussed in this podcast are based on Canadian guidelines and approved practices as of the time of recording. If you are listening from outside of Canada, please consult your local healthcare professional to ensure compliance with your region’s medical standards, guidelines, and recommendations. The creators of this podcast disclaim all liability for any decisions or actions taken based on the content discussed. Listening to this podcast does not establish a professional or patient-client relationship.