What’s Eating You? The Psychology of Obesity Is About Triggering Behavioral Change

It’s called a moment of clarity, or MOC.

For anyone with an addiction, it’s that moment when the root problem for the overuse of some substance or action is identified, physically and/or emotionally. It’s an ‘a-ha’ moment that, sadly, is not a switch that a doctor can turn on in a patient.

“Consistently, my successful patients who have lost weight will say, ‘I just decided to do it,’ but from a health provider point of view, that is really frustrating because we really want policies, protocols, and formulas to help people,” said Dr. Christopher Keroack, medical director of the Pioneer Valley Weight Loss Centers in Springfield.

Keroack is a bariatrician, a physician who helps patients gain control of their emotional stress and physical weight, while uncovering the root cause of their eating addiction to make positive behavioral changes to achieve a healthier mental state and also a lower body mass. Once MOC has been achieved within each customized process — or, rather, if it has — patients hopefully progress to the point of decision, or POD, the next important step to behavioral change that leads to actually doing something about what’s causing an addiction. Keroack then helps them determine their best weight-loss solution, whether through nutrition, exercise, one of the different bariatric surgeries, or, most often, a combination of these options.

“There is no pill, potion, lotion, cream, or procedure that can substitute for behavioral change,” Keroack went on. “There are things that everybody does that, taken to extreme, can lead to our destruction, and very few of us understand why we do what we do.”

And everyone’s trigger is based on so many things that “we just don’t know why one person gravitates toward food and the other gravitates toward gambling, for instance,” noted Brenda Temblador, Ph.D., a clinical supervisor for Adult Behavioral Health at Baystate Health, who helps patients through the psychological process prior to being approved for bariatric surgery.

Healthcare managers like Temblador and Keroack are, sadly, more necessary now than ever before.

Indeed, statistics regarding obesity in America over the past half-century constitute a tough pill to swallow. According to the Centers for Disease Control and Prevention, only 13{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of adults and 7{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of children in the mid-1960s were obese, quantified by a body-mass index (BMI) of 25 or higher. In 2012, 17{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of children and 68{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of adults in all racial and ethnic groups were overweight or obese, with a BMI of 30 or higher.

Both Keroack and Temblador agree that the billions of dollars of saturation advertising and the easy availability of fast-food drive-thrus, restaurant chain meal deals, and ready-to-eat grocery dinners has exploded since the ’60’s, but the availability of unhealthy food is just one of many hurdles that patients have to overcome.

Overeating is quite possibly one of the most overwhelming forms of addiction when compared to others, said those HCN spoke with, because a person addicted to gambling, alcohol, pornography, or shopping doesn’t physically need to continue those activities to actually live, but everyone has to eat to survive. In essence, those eating too much food, or the wrong foods, regardless of the reason, will forever have their obsession staring them in the face.

Getting to the MOC and the POD, said Keroack, are still the keys to changing one’s eating habits.

“It just comes down to the psychology of change,” he said, adding that the method for affecting change varies with the individual.

For this issue and its focus on the epidemic of obesity in this country, HCN talked with two experts who help obese patients change their behavior by focusing not necessarily on what they’re eating, but on what’s eating them.

It Takes a Village

Because bariatric surgery has become so mainstream (see related story, page 14), Temblador is seeing a variety of patients from all income levels. Part of that is due, she admitted, to insurance companies realizing that caring for patients down the line who are obese and experiencing a host of critical and costly healthcare issues — like diabetes, stroke, and heart failure — is far more expensive than covering much of the cost of intervention through bariatric surgery.

But to get a patient to understand that bariatric surgery is not the cure-all, they must understand the reasons behind their overeating.

“When I do my evaluations with folks, they’ve already met with the dietitian who says they want to them to do X,Y, and Z, and my job is to say, ‘what’s it like to do X,Y, and Z?’” said Temblador, adding that she helps patients identify ‘triggers’ that prompt them to eat the wrong types of foods (usually simple carbohydrates and fatty foods) that, for individual reasons, are linked to memories, bad or good, and offer a soothing effect. She works with them to find what she calls “diversionary activities” to get them away from the trigger, such as walking or calling a friend.

Keroack has found, through nearly 20 years assisting thousands of patients, that both love and pain inspire decisions when it comes to behavioral change. But pain will only get someone to a certain point to lessen or alleviate issues — the minimum requirements, so to speak. But love and acceptance will help people reach self-actualization to go beyond their own expectations.

Temblador also sees a significant amount of her obese patients who seek help because they are in physical pain, but that doesn’t mean they are emotionally ready to make significant behavioral changes.

“The impact of their obesity on their physical health has reached such a level that they finally feel like they can’t avoid it anymore and it’s worth really working on themselves,” added Temblador, who helped to institute the Weight Management Program at Baystate. She said surgery probably won’t be successful without a lifestyle change.

The key to that change, Keroack told HCN, is understanding “substitutionary thinking” and replacing the destructive element — certain types of food or too much food — with something that is a greater reward, which is different for everyone.

It could be envisioning a cruise, or a new outfit, or a day at the spa, once the behavioral change is accomplished. But it can’t be — as Keroack said he often initially finds with his patients — another food product.

“They’ll say, ‘I’ll go on a diet for a month, and then I’ll have cake,’” he noted, “which is elevating the wrong food to a reward, and it’s still got a handle on you.”

And starting on a Monday, or using the word ‘start’ in any context, is not reality. “Because it’s a continuum, there is no stopping; it’s a change of behavior and a lifestyle change.”

Weighty Issues

Part of Temblador’s and Keroack’s work with obese patients involves the concept of delayed gratification — that time of sacrifice before reward — and overcoming it.

Keroack explained that many of the simplest actions in life are quantified by how fast we can get what we want, like information off the Internet (download speed), the ability to get dinner quickly (fast food), and losing weight (pill and shakes).

Keroack asks questions like, “what is the design of certain foods?”; “if food is designed to give nourishment and fuel, is what you’re eating the best choice?”; and “if a certain sweet, like cake or ice cream, is a trigger or a weakness, should the design of that food be for celebratory moments, not just the typical Tuesday evening, or every evening?” And by answering them honestly, people can start down the road that will lead to changed behavior.

The same questions can be used for other addictions, like sex, money, even extreme exercising, he continued. “When you understand how something is designed, you can use it to the greater good. Once they find that food really isn’t fulfilling what they need in their lives, then we can find out what is missing and what honestly fulfills them.”

To back up this contention, he offered some examples of work he’s done with his patients, individuals who now understand the design of food and have reached both MOC and POD.

One was a young woman debating gastric-bypass surgery, a popular but dramatic operation with many side effects, who, during the initial process, found that her job was causing so much stress that she had become literally unable to care for herself. Rather than just completely disconnect from her position, which she needed financially, Keroack worked with her on her time management, negotiation, and stress- management techniques, and put into place the modified Mediterranean diet, a nutritionally sound eating plan. Over the course of 18 months, the patient lost 120 pounds and recently had body-contouring surgery to regain her youthful figure.

Keroack feels his biggest success story was one that started off quite rocky.

It involved a woman in her mid-40s, weighing more than 400 pounds. Over the course of six months — what he calls the social-engaging stage — she was just not advancing as she should in the behavioral process. With open, neutral, and receptive patience, Keroack came to find out why; as a child, she’d been abandoned by her parents and raped by her uncle.

“She had major trust issues, psychological and physical abuse, that she had finally started to discuss with us, but had not explored, and she had built a wall of protection around her,” explained Keroack. “I honestly think she was trying to determine if this was a safe environment or not, and based on her previous psychological history, she had no reason to believe that anything is a safe environment.”

As the process focused on the underlying issues, and then the slow repair and healing of her psychology, she built the natural momentum to bring about behavioral change in her life, he went on, adding that she has now lost half her weight, more than 200 pounds, and is continuing on her way to a new healthy state, both physically and mentally.

External Influences

Summing up the process his patients undertake, Keroak described it as a journey that starts in the head, goes to the heart, and ends up in the hands.

“You have the information that leads to application,” he said, “and that leads to transformation.”

He recalled the formerly 400-pound woman who is still in the healing process, losing weight, and gaining self-esteem, who repeatedly thanks him and his staff for helping her reclaim her life. To that, Keroack said he responds, “we only showed you the door; you walked through.”

With support and patience, she realized her own MOC and made her POD, and is now achieving an appetite for a healthy lifestyle — and there are many others who are successfully making the same journey.