FACILITATING BEHAVIOR CHANGE
Changing patients’ long-term behavior to increase energy expenditure and decrease energy intake is one of the biggest challenges facing primary care physicians. Other health care professionals can be of great assistance in this effort. Dietitians can help patients reduce energy intake by providing instruction on portion size, energy values of foods, and menu planning. Exercise therapists and trainers can tailor exercise programs to the patient and encourage long-term compliance. Behavioral therapists can help actualize the principles discussed subsequently in this article. Principles drawn from behavioral psychology can help primary care professionals counsel their patients more effectively.
Behavior change requires the ability to self-regulate. A series of studies has demonstrated that this ability is limited. Resisting temptation makes it harder to resist temptation a second time, as does performing complex cognitive tasks, dealing with difficult emotional situations, and suppressing thoughts and emotions. Conversely, exercise and sleep enhance self-regulatory ability (indeed, self-regulatory ability declines during the course of a normal day). Thus, the correlation of obesity with chronic sleep deprivation is not surprising.
A common misconception among patients and clinicians is that weight loss is simply a matter of willpower. Many obese patients regard themselves as failures (no will-power), but sound data indicate that the ability to delay gratification involves more than willpower. Rather than thinking of resisting temptation as willpower, it should be considered a matter of managing where one focuses one’s attention. Mischel et al conducted a series of experiments in children spanning more than 30 years. On the basis of this research, they suggest 3 strategies for managing one’s attention: avoidance, distraction, and reframing. Young children given a reward for delayed gratification are best able to avoid giving in prematurely when the reward is not visible (avoidance). When the reward is visible, distraction (such as singing a song) is much more effective than focusing on the reward. Another effective technique is to reframe the meaning of the stimulus (eg, shifting attention from a tempting aspect of the stimulus to its long-term consequences). Many obese patients break their diet regimen just before dinner or before bedtime. By using distractions such as going for a walk before dinner or working on an interesting hobby before bedtime, patients may avoid dietary indiscretions. Focusing on the temptation and trying to fight it (“I won’t have that donut!”) is ineffective. Similarly, telling someone not to think about something often makes the situation worse.
A recent systematic review showed that behavioral therapy facilitated weight loss in comparison to placebo (2.5 kg) and when added to diet and exercise (5 kg). Successful aspects of behavioral therapy include self-monitoring, environmental modification, self-efficacy, and social support.
An important component of behavior change is self-monitoring of that behavior. Several studies have documented impressive weight loss in patients who monitor their energy intake carefully. The difference in weight loss attained by patients who monitor their energy intake and those who do not can be 10 kg or more. Programs for handheld calculating devices make the process of self-monitoring less time-consuming and offer the potential to facilitate weight loss.
Modifying the Physical Environment. Tips for modifying the physical environment are shown in Table 2. Patients should ensure that high-calorie foods that tempt them to eat too much are not readily available. Resisting temptation for an hour a week in the grocery store is much easier than ignoring the ice cream sitting in one’s freezer all week long. Patients who have a tendency to binge on a certain food (eg, chips) should avoid that particular food altogether. Increasing evidence suggests that increased consumption of fast food is partially responsible for the current obesity epidemic. Borushek reported that converting a medium-sized value meal to a supersized meal at McDonald’s costs 64 cents and 1512 extra calories (6326.2 J). Supersized meals have since been phased out, but a Big Mac, large order of fries, and 16-oz (448-g) milk shake have a combined energy value of 7112.8 J (1700 kcal), a day’s worth of energy intake in 1 meal.
Modifying Thinking Patterns. Part of modifying the cognitive environment involves developing short-term goals that are specific, reasonable, and proximate. “I will walk 20 minutes 5 days a week for the next 2 weeks” is a specific, reasonable, and proximate goal. These goals should be viewed as something to be learned rather than something to be performed. In this way, lack of success indicates that more learning is necessary rather than denoting failure. One should specify when, where, and how goals will be achieved. For example, “I will arise 30 minutes earlier to walk 2 miles in my neighborhood every morning 5 days a week [specify days], and I will record my walking on a chart that will be posted on my refrigerator in the kitchen.” Potential obstacles to goal achievement should be considered, followed by the development of “if-then” scenarios—“If obstacle x arises, then I will do y.” For example, dining at a restaurant can be an obstacle to healthy eating. Planning to share a meal, asking that foods be grilled rather than fried, having sauces and salad dressings served on the side, and skipping dessert are healthy ways to respond to this circumstance. Planning in this fashion increases the likelihood that effective behaviors will become automatic (part of the patient’s new lifestyle) so that one does not have to expend energy resisting temptation.
Bandura has shown the importance of self-efficacy in altering behavior. Self-efficacy is crucial to changing eating and exercising behavior. Although counseling patients to lose weight can be discouraging, an optimistic and positive approach is important because patients who feel positive about themselves are more willing to work on their perceived weaknesses and are more likely to be successful.
Both family and social support have been shown to enhance exercise patterns and facilitate weight loss. For example, a patient might explain to his or her family why it is necessary to have only healthy foods in the home. Finding a partner to walk with can increase activity and weight loss, and a confidant can provide support on challenging days. People eat more in groups because they are strongly and unconsciously influenced by how much others around them eat. Several studies have demonstrated that ongoing contact between the patient and the practitioner results in less weight regain. When feasible, follow-up with dietitians, trainers, and behavioral therapists is also helpful. The optimal frequency of follow-up varies according to patient characteristics and the availability of other team members. Patients should be cautioned to avoid unduly optimistic expectations about weight loss because they can undermine continuing behavior changes.