Although Katherine used to enjoy hiking and skiing, if given a choice between elevators or stairs she now selects elevators. Katherine is 81 pounds overweight, has prescriptions for gastro-esophageal reflux and high blood pressure, and has avoided her primary care physician for 2 years. Katherine is 41 years old and struggling. She recently lost 11 pounds but then gained 13 in a month while completing a stressful work project. Every day her post-it note confronts her with the phone number for lap band surgery. She plans to call the clinic tomorrow.
Community prevalence data indicate men, women, and children have progressively lost personal control of their body weight over the last decade. Currently, more than two thirds of adults are considered overweight or obese in the United States. Additionally, more than one in six children and adolescents has a BMI indicative of obesity.
The notable effects of excess body weight include cardiovascular disease, Type II diabetes, cancer, osteoarthritis, liver and kidney disease, work disability, breathing difficulties, and depression. The healthcare costs for overweight people have doubled over the last decade. Specifically, treatment of excess body weight and related health problems costs approximately $93 billion annually (CDC). Accordingly, there is a keen interest in preventing excess body weight and identifying effective interventions.
Our Prescriptive Culture
Management strategies for excess weight vary depending on the physical condition and age of an individual, but fall along a continuum from non-intrusive to physically invasive. Treatment protocols include hypo-caloric diets, generic lifestyle changes, surgical procedures, and pharmacological treatments. Our culture embraces institutional-level interventions that are all-purpose, pre-designed, impersonal, and based on one-way transactions (i.e., the experts provide care). Commonly prescribed interventions do not emphasize self-determination, self-control, self-efficacy, or dynamic assessment and data-based decision making. Currently, people struggling with their body weight are prescribed interventions that are generically arranged, automated, or surgical. These interventions differ markedly from a strength-based and person-centered educational model. Accordingly, it is time for a revolution in how the professional community supports people with excess body weight.
Why a Strength-Based and Person-Centered Approach Matters
In contrast to generically arranged strategies for addressing weight control, contemporary ingestive behavior researchers study food and liquid intake systematically and emphasize individualized treatment plans. A strength-based and person-centered approach differs from the aforementioned methods in that it integrates practices focused on a person’s established strengths; personal preferences and choices; valued outcomes; participant and family collaboration; dynamic assessment; data collection on key health behaviors; and design and implementation of evidence-based interventions driven by knowledge of patients’ triggering variables, and motivations.
The approach guides development of a rich repertoire of essential health-promoting behaviors that will produce valued results and lasting health behavior change. We believe that obesity treatment requires a systematic, paced, and collaborative approach to produce permanent health transformation.
Ten Stages for Health Reclamation
Our program is built upon theory-based and evidence-based interventions typically applied to health promotion and disease prevention. The stages of the model are outlined below; the unique features of the program include one year commitments to help participants acclimate to new lifestyles; ongoing assessment, data collection, and data-driven decision making; a step-by-step syllabus outlining objectives; goals; knowledge, skills, and abilities to be acquired; and directed readings for discussion; weekly one-hour cohort meetings (five or six “matched” participants and a facilitator). Participation occurs exclusively via communications technology; and objective daily data reporting via: (a) Wi-Fi body scale (e.g., Smart Body Analyzer by Withings) that sends key measures (body weight, body fat percentage) to a secure account immediately available to program facilitators and co-participants, and (b) wireless devices to collect fitness and exercise adherence data online (e.g., Nike FuelBand). Uniform progress across key health indicators (body weight, body fat, cardiorespiratory health, muscle strength, flexibility) is emphasized. Interdisciplinary team support is given by various health professionals (nutritionists, MDs, psychologists, exercise physiologists) providing consultation to community members. The team is established to facilitate continuity of care, collaboration among key providers, and to address every human need centered on weight control. Creation of a complete record of participants’ comprehensive progress is delivered (with consent) to physicians monitoring their health.
These features of our model are the foundation for guiding participants through the 10-stage program. This program is technology-driven; every stage is coordinated through the internet.
Stage 1: Baseline. The initial baseline stage includes a thorough assessment of personal eating patterns and contextual factors (e.g., restaurants) contributing to food choices and overall ingestive behavior. The program is designed for far-reaching quality of life changes; therefore, data are gathered on key physical health and fitness indicators and lifestyle status. Self-monitoring begins after this stage is completed.
Stage 2: Self-Monitoring. Researchers found that self-monitoring food intake yields 64% more weight loss. Consequently, program participants log information (e.g., caloric intake, nutritional balance, exercise adherence) daily. Self-monitoring systems may involve “high” or “low” technology based on personal preferences. The data from personal “learning logs” are summarized, graphed, reviewed, and analyzed weekly. Understanding personal eating and movement patterns is emphasized.
Stage 3: The Motivational Interview. Motivational interviewing is non-judgmental. The approach attempts to increase participants’ awareness of the potential problems caused, consequences experienced, and risks faced as a result of suboptimal health choices. The motivational interview is a pivotal feature of the program scheduled after the requirements of the previous two stages are fulfilled. This is a participatory process whereby program members co-discover their own ingestive patterns and voice reasons for change. Participants also identify personal strengths, previous health-related successes, and personal preferences centered on food and physical movement.
Stage 4: Planning for Health. Planning is essential. The success of any health promotion program is related to the development of executive functioning skills, including planning, strategizing, organizing, setting goals, and attending to details that support healthy eating and exercise adherence. During this stage, participants schedule time for preparing grocery lists, shopping for a nutritionally balanced diet, preparing snacks and meals, and identifying a personal schedule for paced eating, exercise, and physical movement. Participants also set specific, measurable, attainable, relevant, and time-bound goals. Finally, participants write personal health mission statements to document their diverse and valued outcomes.
Stage 5: Telehealth Community and Virtual Guidance. Members join a telehealth community of five or six people working toward a common goal. The community meets weekly for one-hour teleconferences. Within the context of a community meeting, participants: (a) systematically advance through the information outlined in the syllabus, (b) review their personal data, (c) identify their areas of success and challenges, and (d) with their facilitator, troubleshoot and adjust their individualized programs. Participants also develop a Personal Information Management system wherein they document all strategies and adjustments that produce positive health changes.
Stage 6: The Easing Process. All participants are “eased” into changes centered on: (a) nutritional balance (i.e., consuming the right amounts of calories, water, macronutrients, micronutrients, and high satiety foods); (b) the frequency, duration, and intensity of movement and exercise; and (c) the development of a health network. All decisions regarding the easing schedule are based on individuals’ data.
Stage 7: Trigger Analysis. Participants must begin formally studying their responses to: stress, social circumstances, restaurants, dehydration, long durations between snacks and meals, high glycemic foods, nicotine usage, alcohol consumption, weekend schedules, vacations, and sleep deprivation. A trigger analysis reveals correlations every participant must understand and ultimately manage.
Stage 8: Exercise Intensity Adjustment. Recommendations from the CDC regarding exercise intensity are reviewed. The interdisciplinary team guides the optimization of exercise based on participants’ physical, medical, and orthotic conditions; pharmacological regimens; and ages. Emphasis is placed on exercise diversity; perceived enjoyableness; developing healthy networks; plans for home, workplace, and vacation sites; and episodic illness.
Stage 9: Relapse Prevention. Recent estimates indicate that only 5 to 10% of people successfully keep weight off long-term. Participants must understand long-term weight maintenance, particularly calculating calories and balancing calorie intake and output (e.g., through exercise) and, more specifically, metabolism, the digestive system, and transitioning to a weight-maintenance lifestyle.
Stage 10: Personal Relapse Recovery. A recovery plan must be established before such a plan is required (e.g., 5-pound gain or exercise non-adherence). This stage of the program helps participants discover and understand their personal relapse triggers and high-risk situations that cause relapses despite their commitment to healthy living.
The Person-Centered Revolution. Katherine’s story is not uncommon. Many people, like Katherine, need step-by-step guidance involving identification of personal strengths and preferences; knowledge of their personal patterns; interdisciplinary teams (nutritionists, physicians, psychologists); emphasis on self-control and self-efficacy within natural living conditions; telehealth, informatics, and a virtual community; skill building, nutrition and exercise planning; and a healthy network including family and friends.
We submit that the most compassionate treatment model involves a strength-based and person-centered approach. It is time for a revolution and paradigm shift through which individuals are the architects and co-creators of their own success and healthy lifestyles.
You can reach Dr. Cameron by email at: behavioralhealth.cameron@gmail.com or by phone at (818) 606-8229.
