When behaviour meets biology: if obesity is a chronic medical disease what is obesity management?

Excess weight gain has become a pandemic in our contemporary societies and weight loss has long been an obsession. Until recently, there was very little attention paid to obesity as a disease in medicine and those seeking weight loss were inundated with a variety of unscientific messages. These messages varied from benevolent (commercial weight loss programmes supporting individuals to achieve ideal weight) to bizarre (every unusual vegetable/herb/elixir offered as the instant solution). All of these approaches have advanced what has become the dominant narrative regarding weight loss; that is, goal weight can be achieved by eating less and moving more through sustained willpower. Yet, the abject failure of successful sustained weight loss following this narrative is overwhelming. Most people are heavier after years of attempts at weight loss than when they began their weight loss pursuit, and their self-esteem tattered. Further, the eat less, move more narrative has been the fertile ground for the dominant bias and stigma towards those living with obesity, including internalized bias. The past decade has seen a tremendous shift in the understanding of excess weight, weight loss and obesity. Most of this research has emphasized the importance of biological (neurobiology and endocrine) factors indicating that weight loss is not strongly under behavioural control. Put simply, weight is not a behaviour! Behaviours can influence weight loss, but the specific weight loss achieved is a consequence of this non-conscious biological weight regulation system. This will challenge many individuals living with obesity because their dominant motivation to engage in obesity management is weight loss; the more the better. Further, a major reinforcer of continued weight management behaviour is continued weight loss (until ideal is reached). The current understanding of obesity may therefore remove both the motivation to start an intervention and the reinforcer to continue with an intervention. A reframing of what obesity management means to a person living with obesity is required. In this paper, such a reframe is presented, the goal of which is to engage a person in a weight management plan that is realistic, evidence based as well as motivating and reinforcing. A core driver of behaviour is reinforcement. If a behaviour results in positive outcomes (adding something positive or removing something negative; positive and negative reinforcement respectively) the action tendency of that behaviour is strengthened. If a behaviour results in negative outcomes (adding something negative or removing something positive; positive and negative punishment respectively) the action tendency of that behaviour is weakened. Cognition (interpretation of an event as positive or negative) plays a strong role in this process. In the eat less, move more narrative reaching the inevitable weight loss plateau is uniformly interpreted by the individual as negative; a punishment in the language of operant conditioning. This promotes learned helplessness (“whatever I do doesn't work”), demoralization (“why bother? ”) and internalized bias (“There must be something wrong with me”). Given what we now know about the neurobiology of weight loss, this negative evaluative narrative must change. How can we educate our patients about the neurobiology of obesity so they can change their expectations and interpretations of the weight loss plateau and reduce the internalized bias associated with repeated “failures”? The answer to the question “why is it so difficult to lose weight and keep it off? ” must be acceptable, even motivating to the person living with obesity. Unfortunately, the complex neurobiological explanation of why weight loss is resisted may challenge an individual's understanding, given the normative level of health literacy. We would like to propose a metaphor to use to educate individuals so that their expectations and self-evaluations of their efforts become reinforcing, not punishing. This begins by asking permission (the five As) to educate. The metaphor we offer, the Core Story, can Received: 14 September 2020 Revised: 7 December 2020 Accepted: 12 January 2021