and Birgit Hannikainen.
To our supportive and patient friends, Wally Arnold, Nan Bidlack, Per Eriksson, Joan Goodwin, Ingrid Linde, Gudrun Persson, Margareta Lundgren, Margit Lundqvist, Anna-Lena and Loffe Undén Elofsson, and Ulla Vedda, we also owe a heartfelt acknowledgment.
To Bernt Lindahl and Chris Wallin, for their interest in obesity treatment and their support for working with the problem-solving model and lifestyle change, we thank them for their insight.
We thank our colleagues with the Obesity Unit and Clinic of Metabolism and Endocrinology at the Karolinska University Hospital, Stockholm, and with the Michigan Diabetes Research and Training Center at the University of Michigan, Ann Arbor.
We are indebted to the wisdom of Robin Nwankwo, Betty Brackenridge, and Rachel Trevathon, dietitians whose professional practice remains consistent with their understanding that prefabricated solutions rarely fit anyone’s personal food habits or style.
Betty Brackenridge is owed further thanks, as is Chris Swensen. They documented that significant improvement in outcome measures are possible when patients receive the information and support they need to make informed decisions about their care.
This book would not exist were it not for the interest, questions, and feedback provided by students, health care providers, and other participants in seminars, lectures, and workshops.
Acknowledgment must be given to all those who helped us appreciate that living with a chronic disease is difficult, that there is always more to the story than is told, and that our professional challenge is to control our comments, not their behavior.
For our colleagues, family, friends, and patients who have demonstrated with their lives the effectiveness of the problem-solving model, who make it clear that they are in charge of their lives, and who demonstrated the power of personal goals in propelling change, we thank them for their inspiration.
To Stig Lundquist, whose feedback on the first version of the manuscript was invaluable, and to our reviewers, who shared their time, effort, expertise, insight, and suggestions to improve the text, we owe a gracious thanks.
To Victor Van Beuren, Christine Charlip, Greg Guthrie, Abe Ogden, and others at the American Diabetes Association, we owe our thanks for their support of the idea of this book and for guiding it through to this finished product.
Finally, we must acknowledge and dedicate this book to our patients, for whom this book is written. Without their trust, courage, and willingness to share their stories, we would not be where we are today in the realm of supporting behavior change. We must thank our patients for the privilege of watching resistance to behavior change dissolve when they realized that no one was pushing.
Birgitta Adolfsson, PhD
Marilynn S. Arnold, MS, RD, LD, CDE
February 2006
Why This Book?
“Watch your weight.” How many of you have told a patient that at one time or another? “Your blood sugar is just a little bit out of range, but if you watch your weight, it will be okay.” “Your blood pressure should be fine if you just watch your weight.” “You know your knee wouldn’t bother you so much if you would just watch your weight.”
But what does it mean to “watch your weight”? Is it handing out a flyer with a 1,500-calorie meal plan, recommending the South Beach Diet, or suggesting joining Weight Watchers? These suggestions provide advice that is a bit more specific. Many obese people hear admonitions to consume no sweets, no alcohol, no potatoes, and little fat, but have no clue as to what they should eat. What is helpful? What does no harm?
The recent increase in obesity is a serious global problem, but it is not anyone’s fault any more than is a flu epidemic. It is a problem we must solve. We can’t choose the effectiveness of our metabolism. We also didn’t choose to live in the 21st century, when food that could fill up a polar bear is conveniently available year-round and when desk jobs are prevalent. Although we are not responsible for all of these problems, we can decide how to respond to the situation in which we find ourselves.
Changing how we respond means changing our lifestyle. It means changing the usual behavior patterns (of eating and activity) for those who want to lose weight. It may also mean changing the behavior patterns of those professionals who are interested in helping others lose weight. Usual health care responds well when treating severe and short-term problems (such as the flu or a broken leg), but it is often at a disadvantage when advocating lifestyle change. This is because overweight and obesity are chronic rather than acute conditions and the direct health consequences arise over time. When a person is ill or has a broken leg, the consequences are immediate and felt. Similarly, the solutions are clear cut and directive (e.g., take this medicine, immobilize the leg). People with a chronic condition face the challenge of adjusting to that condition over the long term. They can benefit from the information and support of their health care providers, but effective treatment requires their investment in making changes in the way they live.
Therefore, to support lifestyle change, we must ask ourselves how lifestyle change actually happens. Here are just some thoughts for a discussion on facilitating change.
• Can health care providers diagnose and treat another person’s lifestyle?
• Who owns the problem?
• Who lives with the consequences?
• Who does most of the work to solve the problem?
• Where do people get help?
• What kind of help is useful?
Obesity is a chronic condition. Health care planners ascribe a different health care model or paradigm for treating those problems that evolve slowly over time. Chronic conditions cannot be resolved with pills, diets, support groups, counseling, or supplements. The person with the condition must participate. Any or all of the above tools and strategies may prove helpful, but only to the extent that the person with the condition decides to use them.
Assume that a new health care group in town, “The Chronic Care Experiment (TCCE),” approached you about employment. In TCCE, patients are responsible for making all of the decisions about their care, and your role as a health care provider will be to prepare them for that responsibility. This is frequently called the empowerment model for chronic illness, and in such a chronic-care model, you will be a consultant, not the decision maker. Would you decline the position immediately or consider it? How might that job be different from your current one? Would you have to change how you relate to patients or learn new skills?
This book is not a comprehensive obesity text or a new way to lose weight. It is not a bag of tricks and tips to get people to shed pounds. It is an invitation to view the obesity problem from a perspective that we think opens up treatment possibilities. We are a dietitian and psychologist, persuaded by our beloved colleagues, Bob Anderson, Marti Funnell, and the late Anita Carlson, that in chronic care, patients do make all of the decisions. From the findings of experts and the teaching of our patients, we offer ideas for applying this philosophy of care to people struggling with obesity.
Part I
Assessing the Problem
Chapter 1
The Global Challenge of Obesity
Obesity is a problem. Excess body fat, also known as adipose tissue, is a prominent risk factor for many chronic health problems, including diabetes, heart disease, stroke, cancer, joint problems, and psychosocial stress. Increases in weight drive a similar rise in chronic disease (WHO 2009). Reducing excess fat is a challenge for those who carry it, those who attempt to treat it, and those who pay for its multiple consequences.
We are all likely aware that the rates of obesity have increased dramatically (15 to 34%) in the past 30 years (CDC 2010), despite an ever-expanding array of products, programs, and treatments promoted as remedies. Efforts to reduce the number of people with obesity and to lessen the extent to which they suffer from it present a complex global challenge.
Genetics