key: cord-1050297-ihjos8z6
authors: Chua, Wei Jie Marvin
title: Managing patients with obesity in the post COVID-19 world: time to sharpen the saw
date: 2020-12-03
journal: Obes Res Clin Pract
DOI: 10.1016/j.orcp.2020.11.008
sha: 2350ec37753cf737afd6cd32edb27c56f938a1c6
doc_id: 1050297
cord_uid: ihjos8z6

The clash of the dual pandemics – COVID-19 and obesity (Chua et al., 2020) [1], threatens to exponentially increase the rates of obesity, which is a risk factor for severe COVID-19 and death (Garg et al., 2020; Peng et al., 2020; Wu et al., 2020; Kass et al., 2020) [[2], [3], [4], [5]]. We need to urgently find solutions to halt this vicious circle. Where do we begin? Our patients – who are often our best teachers. In my clinical practice, I have observed disparate responses among my patients in response to the pandemic. This highlighted the importance of understanding the factors underlying motivation and provided important clues on what clinicians can do to help our patients create a virtuous circle towards positive health outcomes.

There is probably no single medical condition which leads to more complications and is associated with greater morbidity and mortality than obesity. Obesity is linked to a multitude of co-morbidities including but not limited to cardiovascular disease, diabetes mellitus, obstructive sleep apnea and non-alcoholic fatty liver disease 6 . With the huge numbers of people with obesity worldwide and its progressively increasing incidence, it is hardly surprising that obesity has been termed a "pandemic" 1, 7 .

From early this year when the COVID-19 pandemic struck, it became clear that we were facing the "clash of the dual pandemics" 1 . Obesity increases the risk of severe and death, including in young patients [2] [3] [4] 8, 9 . As pandemics go, above and beyond its direct effect as evidenced by massive infection rates and fatalities, COVID-19 stands out in its profound and far-reaching impacthow it has changed the way we live for good. The various measures implemented to curb viral transmission, collectively termed "lockdown" (or "circuit breaker" in Singapore), threaten to lead to sky-rocketing rates of obesity and its associated complications through two main mechanisms 10 . Firstly, COVID-19 has led to a socio-economic crisis which increases the risk of obesity, contributed by the preferential reliance on processed, energy-rich food 10 . Secondly, there is an observed significant deterioration of mental healthit is with good reason that the United Nations had called the pandemic "a major mental health crisis" 10 . To begin with, patients with obesity have increased psycho-social distress 11 . The pandemic stokes this fire through disruption of lifestyles and livelihoods, increased anxiety which is often fuelled by misinformation and fake news 11 , as well as home confinement which might increase feelings of abandonment and isolation 11 . These factors often lead to depression, anxiety and eating disorders such as binge J o u r n a l P r e -p r o o f eating, all of which culminate in weight gain 12, 13 . It is clear that COVID-19 and obesity reinforce each other in a vicious circle which needs to be urgently nipped in the bud.

As an Endocrinologist managing patients with obesity, I felt a sense of personal responsibility to take action to stop this vicious circle from reaching a point of no return. The "new normal" is here to stay, and it is evident that strategies with a lasting effect are required if we were to have any chance of successfully coping with the impending avalanche of obesity and its associated complications.

What can be done? Weight management and bariatric surgery services should resume with immediate effectwe need to be prepared for a surge in patient numbers due to the "backlog" contributed by postponement of clinic appointments and surgeries to conserve resources and reduce risk of viral transmission at the height of the pandemic 14 , coupled with the growing rates of obesity. The common pathogenic mechanisms in obesity and COVID-19, both of which are pro-inflammatory states in which there is increased production of cytokines such as tumour necrosis factor (TNF) α and IL-6 15,16 , lends to the potential role of immunotherapy. For example, monoclonal antibodies directed to IL-6, which is elevated in both COVID-19 and obesity, can alleviate cytokine-related symptoms in severe COVID-19 15 .

As important as they are, these are system-level or future interventions respectively, which may not be directly or immediately applicable to the patient sitting before us in the clinic. As This turned out to be an important clue which set me on a quest to not only uncover the reasons for this observation, but also how we can "sharpen the saw". In this journey, I looked beyond the medical field to complementary disciplines which offered invaluable wisdom.

Let us begin by looking at two of my clinic patients. Patient A is a 33-year-old male who had undergone sleeve gastrectomy two years ago. Following surgery, he maintained strict dietary restrictions and a daily exercise regime, and had achieved excellent weight loss which was sustained till Feb 2020. However, during his last clinic review in June 2020, he had a sudden weight gain (4% of body weight) which was cause for concern, given that he had till then been one of my "best performing" patients. During my consult with him, he revealed that his carefully curated routine over the past two years had been upset by the circumstances forced upon him during the COVID-19 pandemic. Whereas he would previously meet his family members only at the end of the day, since the start of the "circuit breaker", there was a steep increase in contact and consequently increased friction, due to the patient and his family members all working from home. A major subject of disagreement was food. Previously, the patient would carefully prepare his own meals and bring them to work. However, with everybody consuming meals together "under one roof", the patient often felt what was on the table was too oily, salty or sweet. Voicing out his objections and refusal to have the same meals was met with antagonism. He felt a sense of "loss of freedom" and "isolation", despite in the apparent company of many others. The resultant mental turmoil led him to paradoxically resort to "comfort" food and snacks.

We now turn our attention to Patient B, a 28-year-old female with obesity and Type 2

Diabetes Mellitus (DM) on insulin. During follow-up over the last one year, she did not lose any weight and glycemic control remained poor (HbA1c 10 -12%). She often gave the J o u r n a l P r e -p r o o f reason that she worked 14 -16 hours every day and thus had inadequate time for any form of exercise or even sleep. When I saw her again after 6 months in Jul 2020, she was a changed person! She had lost 6% of her body weight and experienced significant improvement in glycaemic control (HbA1c 8.4%). Most importantly, she appeared more self-confident and self-assured than I had ever seen her. What was her success story like? Patient B shared that when the pandemic struck, she found herself retrenched and felt distraught in the initial weeks. However, with encouragement from family and friends, she made a resolution to turn the crisis into an opportunity and changed her lifestyle. She did daily brisk walking for up to 2 hours, which was supplemented by online Zumba classes. She eschewed her previous "staples" of takeaways and fast food, and started preparing healthy meals.

These two patients which I have illustrated were by no means the only patients whose health outcomes took on vastly different trajectories during the COVID-19 pandemic. What could account for such disparate effects? If clinicians are able to uncover the underlying factors that influence patients' daily decisions and actions, we could stop this looming vicious circle from snowballing and help to nurture a healthier community, in spite of the COVID-19 pandemic.

Conversely, if we are unable to do so, we would likely find ourselves struggling to cope with the influx of patients with obesity in the very near future, and witness a new generation of individuals with worsening health outcomes.

The self-determination theory (SDT) offers a useful framework to explain the underlying motivational factors which could account for these observed disparate effects 17, 18 . This theory posits that motivation can be divided into autonomous or intrinsic motivation, which is the extent to which actions are self-endorsed and performed with free choice; and controlled or extrinsic motivation, which is the extent to which external pressure influences behaviour 19 .

Motivation is in turn determined by three basic needs: autonomy, competence and relatedness 17, 18 . Autonomy refers to a sense of ownership in one's actions, which is supported by experiences of interest and value and undermined by being externally controlled 17 .

Competence refers to the sense of personal mastery, which is supported by optimal challenges, positive feedback and opportunities for growth 17 . Relatedness refers to a sense of belonging and connection, which is supported by a nurturing and caring environment 17 .

Thwarting any of these three basic needs undermines motivation 17 .

Applying this to the cases described above, Patient A experienced a loss of autonomy due to a sense of "loss of freedom" with regard to preparation and choice of his meals. At the same time, there was a loss of relatedness due to frequent conflicts with his family members. The resultant decrease in motivation led to the adoption of unhealthy lifestyle habits and consequently, weight gain. In contrast, while Patient B initially suffered from a "set-back", she actually enjoyed increased autonomy during the pandemic with new-found time with which she could choose her activities, whereas previously she had little time for herself due to work commitments. Patient B also benefited from increase in relatedness with support from her friends and family. As can be seen, the contrasting effects on autonomy and relatedness, and therefore motivation, led to a marked difference in the outcome of weight.

Increased autonomous motivation is associated with long-lasting behavioural changes such as increased duration and intensity of exercise and improved weight loss at up to 3 years 20-22 . It is my firm belief that SDT and its principles have significant potential to combat obesity in this post COVID-19 world which we are living in and is here to stay.

It would be appropriate at this juncture to consider the transtheoretical model (TTM). In contrast to the emphasis on the quality of motivation in SDT, the TTM focuses on the J o u r n a l P r e -p r o o f quantitative aspect of motivation, and is therefore complementary to SDT 23 . According to the TTM, change is a process that progresses through five stages: precontemplation, contemplation, preparation, action and maintenance 23 . The key clinical value in this model is to recognize that patients are all at various stages of change, and to tailor specific interventions according to their respective stage so as to be most effective 24, 25 . For example, patients in the precontemplation stage require strategies to increase motivation and awareness, while action-based strategies such as stimulus control and reinforcement management may be more suitable for patients in the preparation and action stages 24 . This model recognizes that a "one size fits all" model of clinical practice may be counterproductive: imposing action on a patient who is in the precontemplation stage and clearly not ready for behavioural change risks early termination.

How then, do we apply the SDT and TTM theories in clinical practice to help our patients?

Motivational interviewing (MI) is a patient-centred, directive counselling approach focused on exploring and resolving ambivalence towards change 26, 27 . Ambivalence refers to the gap between knowledge and behaviour 27 . As an example, most of our patients with obesity know that they should change their lifestyle, but when faced with various barriers such as conflicting pressures and perception that the change is too big, the personal or financial costs of change are too high and so on, behavioural change does not occur 27 . In MI, patients are guided to find their own solutions to barriers which are preventing change. At the same time, the individual has every right to make no changethe healthcare worker embraces rather than combats the ambivalence 28 . By giving patients the freedom to change on their own terms while providing constant support in their journey, MI supports both autonomy and relatedness and increases autonomous motivation 28 . Thus, it is hardly surprising that MI has significant overlap with SDT, and has in fact been seen as a practical application of the theory 28 . SDT and MI share the same basic assumption that humans are naturally oriented towards health and growth, and that the individual must want to change of his/her own accord 28, 29 . By closing the gap between knowledge and behaviour, it is evident that MI also has an overlap with TTM and is useful in the precontemplation and contemplation stages to "nudge" patients towards action 29 .

Program and the LOOK AHEAD trial, both of which had a goal of 7% weight loss 30, 31 . MI has been shown to lead to sustained lifestyle changes and weight loss in patients with obesity, whether performed in an individual or group setting [26] [27] [28] . A TTM-based motivational interviewing method has been shown to improve the health behaviour stages and metabolic control of patients with Type 2 DM 32 .

How is MI performed? The four main principles of MI can be summarized as "RULE": "R" for resisting the righting reflex, which is the natural tendency of healthcare professionals to "fix" whatever is wrong, "U" for understanding the patient's motivations, "L" for listening to the patient empathically and "E" for empowering the patient 28 . Some questions which might be relevant in a dialogue with a patient with obesity include "Would it be all right to talk about your weight today?" (agenda setting), "Tell me about your concerns related to exercising more" (open-ended questions), "Is there any behaviour that you are currently doing which may get in the way of these goals?" (developing discrepancy between actual and desired behaviour) and "Could you share with me a previous experience in which you tried to lose weight and succeeded?" (supporting self-efficacy) 29 . Although a detailed review of the technique of MI is beyond the scope of this report, we propose that physicians and healthcare J o u r n a l P r e -p r o o f workers, including nurses and dieticians, learn this invaluable skill. In the same vein, is there any other skill which we should equip ourselves with?

Mindfulnesswhich can be defined as "paying attention in a particular way, on purpose, in the present moment, and non-judgementally" 35 . Our thoughts, emotions and actions are closely linked: our thoughts and emotions influence our actions, often in a subconscious manner 36, 37 . Mindfulness helps us to be more aware of our thoughts and emotions and how they influence our behaviour.

Why is mindfulness worthy of specific mention? Mindfulness, through decreasing stress, anxiety and depression while increasing resilience 37, 38 , is an invaluable tool in battling this "major mental health crisis". Mindfulness has been demonstrated to be effective in weight reduction and improving obesity-related eating behaviours, including emotional, impulsive and binge eating 36, 39, 40 . It would be apt to describe a study in which the first group of subjects were given soup in special bowls which, unknown to them, self-refilled as their contents were consumed; while the second group was given soup in normal bowls 41 . The subjects in the first group ate 73% more than the second group; however, they did not believe they had consumed more, nor did they report increased satiety 41 . This study clearly illustrates the importance of mindfulness and the perils of "mindlessness".

As with MI, an overlap exists between mindfulness and SDT. Ryan and Deci et al had previously proposed that mindfulness is an important factor which supports autonomous engagement in activities and decreases susceptibility to controlled motives 42 . This was supported by a meta-analysis, which found that mindfulness is positively associated with autonomous motivation and negatively associated with controlled motivation 43 Of particular relevance in today's world, telehealth and telemedicine are useful tools which transcend physical boundaries and increase access to care while maintaining social distancing 45 . MI delivered via telephone has been found to be effective for weight loss 33 , while MI delivered via text messaging is another promising option 34 . Although mindfulnessbased interventions delivered via telemedicine have been shown to reduce psychological distress 46 , their application in weight loss remains to be studied.

J o u r n a l P r e -p r o o f As Winston Churchill said, "never let a good crisis go to waste"so we physicians should recognize that our environment has changed, learn from our experiences during the pandemic and think about how we could rebuild our clinical pathways for the future to manage the post COVID-19 fallout. The "new normal" makes these lessons all the more important. In our armamentarium lies two tools which are somewhat related to each other, neither of which are novel but nonetheless deserving of specific attention: MI and mindfulness. As Viktor E.

Frankl said, "Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom"so it is our duty to help influence this response. The author declares that there is no conflict of interest.

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