What COVID‐19 is Teaching Us About Counseling for Weight Management

The coronavirus disease (COVID‐19) pandemic has been a seismic event for those of us who provide obesity care for two reasons: it profoundly altered our patients’ living environment, and it fundamentally changed the practice of how we deliver counseling. The convergence of these two unique experiences has brought insight to patients and providers alike and it will most certainly lead to transformational changes in health care. Oftentimes, anomalies lead to deeper understanding. We are at such a time in our history.

Behavioral counseling for obesity emphasizes the interactions between the person and his or her environment. Behavior, therefore, is a function of aspects of both the environment and the person, all of which are in constant reciprocal interaction (1). The behavioral choices we make regarding what we eat or what we do are determined, in part, by accessibility, affordability, and available resources. Ecological models expand our definition of environmental influences to include interpersonal relationships, family, community, and city. The built environment, meaning the environment that humans built, influences physical activity and diet by either enhancing or hindering healthy behaviors.

COVID‐19 abruptly and radically altered our environment and daily routines, a condition that is akin to a clinical experimental design. Overnight, stay‐at‐home orders eliminated restaurant dining, the enticement of workplace snacks, and impulse shopping for savory foods. With parks, playgrounds, and fitness facilities closed, we were no longer able to take walks, access exercise equipment, or attend workout classes. Being forced to become socially distanced from family, friends, and colleagues, we lost an important support structure that gives us an emotional connection and meaning to our lives. These sudden and dramatic changes shed light on the impact of an obesogenic environment on our behavior along with our psychological capacity for coping, adaptability, and resilience.

COVID‐19 has brought an unprecedented increase of stress for most people because of a loss of “normalcy” in our lives, financial insecurity, and social isolation (2). Without the benefit of being armed with a repertoire of healthy coping strategies, people are at risk for experiencing increased anxiety, depression, uncertainty, and sleep disturbance; feeling overwhelmed; and engaging in uncontrolled eating (3). Stress and sleep have recently been recognized as importance factors in weight management (4, 5) and even more so during the pandemic. Coping is a complex, multidimensional process that involves problem solving, positive adaptive emotional responses, and engagement (6). Staying connected and assessing patients for the impact of the pandemic on their lives, including enforced isolation, loneliness, and depression, along with providing tips and resources for stress reduction, are paramount during our “new normal” existence.

Yet despite the indisputable stress of the moment, I have been surprised and gratified by how many of my patients have responded to the precipitous environmental change. For those who dined in restaurants or consumed convenient foods regularly, the pandemic has forced them to be more self‐reliant and acquire new cooking and meal‐preparation skills. Furthermore, because visits to the grocery store are being minimized, most patients are making shopping lists and planning their weekly meals, an activity they had not performed prior to the pandemic.

Another unintended consequence of the pandemic has been a disruption of the daily social and emotional cues that led other patients to overeat. This resulted in a counseling opportunity to therapeutically intervene more effectively to help them understand their past triggers and develop new and healthier eating behaviors. For those still struggling, I emphasize the importance of implementing structure and planning into their day, the value of self‐monitoring, and the benefit of maintaining a healthy “microenvironment” at home, which aids positive decision‐making.

Patients have also benefited from accessing new digital and social media resources that support healthy eating, physical activity, and accountability. It has been remarkable to observe that the behavioral self‐care strategies that were often formidable for my patients before the pandemic have now been adopted and taken on new meaning and perspective, boosting self‐efficacy and confidence.

One factor that I have witnessed as a vital response to the COVID‐19 pandemic is resilience, or the capacity to adapt to or recover from difficult situations. It is not considered a personal trait but rather it involves behaviors, thoughts, and actions that can be learned (7). Resilience is strengthened by making connections with others, taking decisive action, maintaining a hopeful outlook, and gaining self‐control, also called learned resourcefulness. In addition to building resilience, I have shifted a considerable amount of my counseling from focusing on weight management to stressing the value of good health and well‐being, including establishing a daily schedule for self‐care, choosing nutritious foods, scheduling daily physical activity, getting adequate sleep, destressing, and virtually connecting with friends and family. In the midst of the pandemic, patients have been receptive to the importance of optimizing their health to align with their personal values.

The COVID‐19 pandemic has also altered the manner in which we all practice clinical care. In accordance with stay‐at home orders and physical distancing, in‐person office visits were replaced with telehealth visits overnight, fundamentally changing patient‐provider interaction (8). While telehealth is not new, rates of telehealth visits have dramatically increased since March 6, 2020, when the Centers for Medicare and Medicaid Services issued site restriction waivers for reimbursement. Although direct patient contact is forfeited, telehealth is more convenient for patients and it eliminates the financial and time burden of traveling to the medical office. For clinicians, telehealth increases efficiency of care, reduces no‐show rates, and allows for more resourceful use of office space (8). With good listening and communication skills, counseling can be delivered effectively, providing education, guidance, and accountability. Short‐term 12‐week trials using telemedicine‐based obesity counseling have demonstrated improved weight loss and adherence (9, 10), although larger and longer‐term studies are needed.

What will be the enduring lessons learned from the COVID‐19 pandemic for obesity care? We are reminded that our physical and social environments along with emotional health are significant drivers of our behavior and are subject to change. Stress is an anticipated and inevitable variable that impacts self‐care and decision‐making. Importantly, empowering our patients to develop healthy adaptive coping skills and building resilience are quintessential targets for counseling. Clinically, the catalyzed application of telehealth will likely have a permanent place in obesity care but will require building a sustainable infrastructure and long‐term reimbursement by payers.

In this Perspective, I strived to capture my impressions and how I have modified my behavioral counseling during the pandemic in trying to assist my patients. Others will reflect on their own experiences over the coming months and years. However, prior to fully transforming our paradigm of how we deliver obesity care, we ultimately will need a rigorous evaluation of all aspects of a newly proposed model, including randomized controlled trials to assess the value of and methods to build resilience, the clinical effectiveness of telemedicine, and resultant long‐term outcomes on body weight and other health metrics.

Disclosure

The author declared no conflict of interest.