Effective Psychological and Behavioural Interventions in Obesity Management
- These clinical guidelines were developed based on research with individuals living with less complicated obesity and lower body weights (body mass index (BMI) < 40 kg/m2 predominantly). Individuals living with more complicated obesity may require different or more specialist psychological interventions.
- All obesity-management interventions involve behaviour change on the part of the individual living with obesity (e.g., eating, activity, medication adherence), so behavioural-change supports should be incorporated into all obesity-management plans. This requires a shift in the patient-healthcare professional (HCP) relationship from the HCP as the expert (teach and tell) to that of the collaborator, sensitive to the psychology of the person.
- All clinicians working with people living with obesity can utilise behaviour change counselling, which includes:
- Communication skills,
- The spirit of the approach (respecting patient autonomy, empathy, non-judgemental approach), and
- Behavioural strategies (e.g., self-monitoring, goal setting, planning, relapse control).
- Obesity-management interventions should be evaluated based on how sustainable the behavioural components of the intervention are for the individual. Obesity-management plans that are sustainable for the individual should be prioritised over clinician- or
programme-led management plans.
- Individuals living with obesity should be encouraged to build self-esteem and self-efficacy (confidence to overcome barriers to the desired behaviour), based on
results that are achievable from behavioural efforts and not on idealised ideas of body weight and shape.
- Eating behaviours, medical adherence and physical activity are outcomes of psychological and behavioural interventions and not interventions in themselves. Behaviour-change strategies underlying dietary, medical and activity programmes should be identified (i.e., what are the change strategies by which sustainable changes to eating, medical adherence and activity are achieved?).
- Psychological interventions, such as cognitive behavioural therapy, acceptance and commitment therapies and compassion-focused therapies, should be carried out by psychologists (clinical, counselling or health psychologists) or other HCPs who are additionally accredited in the delivery of psychological therapy.
- CORU, the authority responsible for the regulation of health and HCPs in Ireland, are currently in the process of developing a registration process for psychologists. Once this process is complete, all psychologists working in clinical settings will be required to be CORU registered.
- Where mental health difficulties are present, untreated or are barriers to sustainable behaviour change, referral should be made to a GP (for medical management and possible referral to appropriate mental health services) and/or a clinical or counselling psychologist (for specialist psychological assessment and intervention).
- Where intellectual disability or learning difficulties are present (or suspected) and are barriers to engagement, referral for additional psychological assessment and/or specialist support services may be required.
- Adopt a collaborative relationship with the patient, and carer/support worker where applicable, using the principles of motivational interviewing, to encourage the patient to choose and commit to evidence-based, sustainable behaviours associated with obesity management.
- Consider the use of a brief intervention framework, such as the Health Service Executive Making Every Contact Count (HSE MECC), Talking About Weight 5 A’s (ask, advise, agree, assist, arrange) or Obesity Canada 5A’s of Obesity Management (ask, assess, advise, agree, assist). Disciplinespecific training may be available, but the HSE MECC modules provide a broad foundation in behaviour change theory and techniques and the underlying principles of a patient-centred approach for all healthcare professionals (HCPs).
- HCPs should share information about obesitymanagement success being related more to improved health, function and quality of life (QoL) resulting from achievable behavioural and psychological goals, not just on the amount of weight loss.
- Education should be focused on biology, bias and behaviour. Ask permission to discuss evidence regarding biological and environmental factors, including genetics (family history, the instinctual drive for food), neurohormonal functions that promote weight regain following weight loss and physical and social environments (i.e., built environment, food access/availability/security, sociocultural factors).
- Consider using the concept of “best weight” (i.e., the weight that a person can achieve and maintain while living their healthiest and happiest life). This education should be shared as a means of reducing self-bias, encouraging body acceptance and supporting appropriate goals that acknowledge that weight is not a behaviour.
- Success is related to setting achievable, sustainable goals that patients can follow, while developing confidence to overcome barriers and fostering an intrinsic motivation to maintain the plan. Goals should positively impact health, function and quality of life.
- Encourage the patient to:
- Set and sequence goals that are realistic and achievable.
- Self-monitor behaviour.
- Analyse setbacks using problem solving and cognitive reframing, including clarifying and reflecting on valuesbased
behaviours. See Figure 1 for an illustration of how to support the patient in their obesity-management journey.
For HCPs who function within teams (including obesity specialty services), at least one member of the team should develop competency in behavioural interventions, including selfmonitoring, goal setting and action planning, reinforcement management, social comparison (demonstrating/modelling behaviour), cognitive restructuring, motivational interviewing, and values-based counselling. Teams should include, or have access to, psychologists for the provision of psychological assessment and therapy. Psychological and behavioural interventions should focus on the impact of the interventions on adherence, self-efficacy, and autonomous motivation.
- Multi-component psychological interventions (combining behaviour modification, cognitive therapy (reframing) and values-based strategies to alter nutrition and physical activity) should be incorporated into care plans for obesity management and improved health status and quality of life (Level 1a, Grade A)1-8 in a manner that promotes adherence, confidence and intrinsic motivation (Level 1b, Grade A)9-13.
- Healthcare professionals (HCPs) should provide longitudinal care with consistent messaging to people living with obesity to support the development of confidence in overcoming barriers (self-efficacy) and intrinsic motivation (personal, meaningful reasons to change), to encourage the patient to set and sequence health goals that are realistic and achievable (Level 1a, Grade A)9-15, to selfmonitor behaviour (Level 1a, Grade A)9,13-15 and to analyse setbacks using problem-solving and adaptive thinking (cognitive reframing), including clarifying and reflecting on values-based behaviours (Level 1a, Grade A)9,13-15.
- HCPs should ask patients’ permission to share information that success in obesity management is related to improved health, function and quality of life resulting from achievable behavioural goals, and not on the amount of weight loss (Level 1a, Grade A)16,17.
- HCPs should provide follow-up sessions consistent with repetition and relevance to support the development of self-efficacy and intrinsic motivation9-15. Once an agreement to pursue a behavioural path has been established (health behaviour and/or medication and/or surgical pathways) follow-up sessions should repeat the above messages in a fashion consistent with repetition (the HCP role) and relevance (the patient role) to support the development of self-efficacy and intrinsic motivation (Level 1a, Grade A).
- The main goal of psychological and behavioural interventions is to help people living with obesity to make changes that are sustainable; promote positive self-esteem, self-compassion and confidence; and improve health, function and quality of life (QoL).
- There is no one size fits all. Goals should be individualised and be important to the individual living with obesity and not just the clinician or intervention.
- There are many psychological and behavioural strategies that can be helpful. The strategies that will suit an individual best will depend on the particular goals they have chosen, their individual way of thinking about things and their life circumstances. A clinician can be expected to work in a way that is collaborative, understanding and non-judgemental to enable the creation of a good working relationship.
- Obesity management may involve working around challenges such as finding time for appointments, planning food, getting medications on time, managing cravings, setting new routines for sleep or movement and managing social pressures. Sustainable changes are more beneficial if the options chosen by the individual are consistent with their core values and do not lead to adverse effects.
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