Not All Obese People Die From Fatness. Well, Duh

Aside

Most of us know how inaccurate the BMI is as a measure of fat & health. A 16-year prospective study just released shows that obesity alone does not determine mortality down the road.The study followed 29,533 volunteers from the Cooper Clinic in Dallas over an average of 16.2 years; 6,224 were considered obese; the obese folks were categorized into a 4 point classification system based on fatness-related illnesses – Edmonton Obesity Staging System (EOSS) levels 0-3.

One of the things I did in my former life was to critique scientific articles. I won’t do that in detail here but will point out a few limitations and summarize. Plus, I encourage you to read the results in the abstract plus look at Table 1 to see the EOSS classification system of health that they used rather than BMI and Table 2 to see the characteristics of the participants.

Bottom line: the more obesity-related diseases at the start (for example, diabetes, heart disease, hypertension, sleep apnea, limitations in daily activities, even mental health issues), the higher risk of mortality over follow-up in  EOSS groups 2 & 3. Those in the EOSS classes 0 or 1 actually had lower risk for heart deaths. All EOSS categories had higher risk of cancer. (See Figure 1 from the article below for a picture of risk of death at the end of the study.)

The participants were highly educated, White men (sigh), which means this is not representative of most of us. Not all participants were available for follow-up over the entire study, and the length of time the participants were followed varied by group. (For example the normal weight people were followed for an average of 17.6 years, EOSS 0 and 1 for 18.4, EOSS 2 10.2, and EOSS 3 11.9) I don’t see that the authors attempted to account for this statistically. (But I didn’t read it that closely in my attempt to get this on the blog quickly.) Weight or fat measure was not analyzed over time, so fluctuations could have occurred differentially among the groups.

This doesn’t mean stay fat. This lends credence to the saying, “fat and fit” (If you are a wealthy, educated White male living in Texas…) But the cancer risk is hard to ignore. More importantly it provides a measure for other studies to use rather than BMI for measuring risk in fat folks. Also, if I were a practicing doc, I would start incorporating this scale to assess risk and advise patients. (Because BMI sucks so badly.)

A final caveat. Although this study shows increased risk of death among those with more fat-related (my words) conditions, it does not prove that treatment of fatness or the related conditions will decrease the risk of dying or dying from cancer or heart disease. This study does not address that question. But it is always tempting to extrapolate…

HR=hazard ratio. How much more at risk than the normal weight group. NW=normal weight. CVD=cardiovascular disease

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Physician Blog Referral

A very quick post to let folks know that my favorite “diet doctor” will be writing daily posts for the next month about transformative eating – getting to successful maintenance. I appreciate Dr. Berkeley’s writing, scientific approach, and years of clinical experience working with obese patients and following maintainers. She clearly states when something comes from science and when something is based on her opinions or experience.

Here is a quote from the first post in the series that really hit home, “You will have made the quantum leap when you go from wanting to stay away from unhealthy foods to really not wanting to eat them anymore in some visceral way.”

Dr. Berkeley

Barbara Berkeley, M.D.

♪♫The Sound of Music♪♫ and Confidence

This is really going to date me (and show my sappy love of musicals). I can still hear the soaring French horns in the opening scene of “The Sound of Music”,  the camera’s sweeping movement over the Austrian Alps combined with glorious music burned into a 13-year old’s brain.

Julie Andrews in The Sound of MusicWhen Maria left the abbey singing, “What will this day be like? I wonder. What will my future be?“, I was whisked into her adventure and eventually knew the entire score and lyrics. That song ends with the amazingly uplifting statement:  “I have confidence in confidence alone. Besides which you see I have confidence in me!”

From my parents and teachers and Julie Andrews, I developed a strong confidence in my ability to succeed in life. This became manifest in whatever I chose to “do”, meaning my work and when I was younger, my athletic endeavors into college. Somehow that same confidence just didn’t carry over to maintaining weight loss. Sure when I made up my mind to get started losing weight, it was full steam ahead, but staying there… nope.

What happened during all those regains? I lost my ability to resist temptation, and once I went over the edge – being an all or nothing kinda gal – I was gone; it was gone. Belief in my core self was shaken.

Fast forward 20 years from my last large weight loss (90 pounds) and regain (165). I have learned so much about behavior change through my transition from a family medicine doctor to a preventive medicine/public health physician and researcher. My career shift led me to work with one of the pioneering experts in the field of behavior change (Carlo DiClemente) and find a best friend and future colleague (Mary Marden Velasquez) who happens now to be an international expert in the research and teaching of Motivational Interviewing.

So what, Jan – you had an epiphany in your work life and met cool people. Why did it take so long for you to lose weight again? I became a chronic contemplator – my failures to keep weight off left me in a state of, “I’ll start dieting again some other day.” God knows I knew what to do. (Most fat people do.)

My story of getting going this time is chronicled elsewhere. Here I am 547 days later and 109 pounds less fat with 46 pounds and the rest of my life to go. According to the Transtheoretical Model, I have left the action stage and am in maintenance for eating healthy (more than 6 months of the new behavior and having made it part of my routine life), and my biggest task now is to work on my CONFIDENCE – cue Julie Andrews. Actually this type of confidence is called self-efficacy because it is more specific than confidence to stay on plan. Self-efficacy is my belief to stay on plan in various situations. Like when my mother-in-law leaves chocolate laying all over the house. When I pass one of my former binge foods in the grocery store. When grief for my mother hits unexpectedly. When I get bored late at night.

Since, self-efficacy is such a vital part of success for those in the later stages of change, how does one get or increase self-efficacy?

  • One of the easiest ways is to review your successes: OMG I have lost 1/3 of me! If I can do that, how much power can a silly cookie hold? I made it through the hardest grieving, I can make it through a few moments of sadness without resorting to food to soothe my feelings. Success breeds success. Every day of staying on plan should be a little star in your brain to boost your self-efficacy. Pay special attention to when you overcame tough or tempting circumstances and remember your ability to do that!
  • Another way is to look at others like yourself (NOT OPRAH – no one is like Oprah) or those who face even harder circumstances and see their successes: Gosh, if someone with 4 kids, a husband, and a job can lose 100 pounds and keep it off – so can I! That’s why I read so many maintenance blogs. I want to remind myself a 150-pound weight loss can be maintained for years. I read the medical literature and find blogs of docs who write about their patients who are maintaining. At this point, I don’t shy away from those who are having trouble, but if you are early in the process, I encourage you to put those blogs on hold and deal with your own plans, seek your own support.
  • Don’t shy away from positive feedback. Embrace it! One reason I comment on blogs is to give others positive responses during their hard work to eat healthy. It’s amazing how much positive feedback can help bolster one’s new way of eating. (This is a double-edged sword for those of us who are sensitive about our bodies and get positive “body talk” from people.)

In summary, self-efficacy is not the same thing as self-confidence. Self-efficacy in the belief in one’s ability to do a given behavior under various situations. Self-efficacy is most important for those in the action and maintenance stages of change. Self-efficacy can be increased, in fact fairly easily (much more so than self-confidence), but it does take work. Two days ago I passed some cookies the grocery store that I hadn’t seen since my binge days. I gasped audibly then walked by without another thought. Last night when my in-laws were driving my crazy, those cookies started calling me like the Sirens of ancient mythology. I tied myself to the mast of my self-efficacy, refusing to let an 84-year old, crazy mother-in-law and my feelings of whatever-the-hell-they-were sabotage so much success. Today I could no more eat one of those cookies than I could eat liver. Another notch in the belt for my self-efficacy

How can you build your self-efficacy? How can you help others who are working hard to change or who are working hard to maintain?

No Excuses? Part II

In the previous post I said “no excuses”/tough love (might) work for those already motivated to change. Now I want to talk with those struggling to get started or to stay consistent with a their eating plan. People who are actively working hard to eat healthy can review this for grins or use as a reference for others.*

Almost everyone just starting out with a behavior change feels ambivalent. Yes, we do. There are many reasons why we want to change and there are reasons why we have not changed (the pros and cons). Early on before we are ready to change our way of eating or are just thinking about changing (the precontemplation and contemplation stages of change) the cons of change outweigh the pros. Folks really do consider the importance to change in a logical manner, even if it isn’t explicit.

For example, we consider the impact eating better will have:

  1. on ourselves (my health, appearance, and mobility will improve)
  2. the benefits to others (my kids will have their mom around longer; my friends can take me more places; my health bills will go down)
  3. on approval from others (my partner, family, doctor want me to eat healthier and be thinner)
  4. and our own self-approval (I would feel so much better about myself if I ate healthy and lost weight)

We balance the pros with the cons of changing our eating behavior:

  1. on us (I will have to give up foods like, I eat to relieve stress; I couldn’t go out to eat with my friends at our favorite restaurant)
  2. on significant others (all my friends eat this way and won’t like to see me eat different from them; my spouse is a feeder)
  3. on disapproval from others for changing (my partner is fat and wouldn’t want me to get skinny)
  4. on self-disapproval (I cannot see me as thin; I’m not strong enough to change how I eat; I will just fail again).

Across many types of voluntary behavior change, from dieting to quitting smoking to teens using contraception, a standard pattern of pros and cons of changing looks like this:

pros and cons of behavior change

Until the Pros of adopting a new way of eating are greater than Cons of continuing to eat as usual, we will stay stuck.

So what? For those in the early stages (not planning to change your eating in the next month) and for those who are having trouble staying with a diet plan, you can motivate yourself by listing your unique pros and cons, think about them, revisit & revise as needed. Take a few days. When you feel comfortable with your list, put it where you can see it to remind yourself why you want to eat healthy and why you don’t want to change. Will something magical happen? NO. But, this will help you clarify your ambivalence; where there are discrepancies between how you see yourself and where you are now. The process alone can get you motivated to start making a plan that works for you.  Only you know what is getting in the way of your change. Only you understand if you have depression that needs addressed (most of us do not). Only you know if your spouse is going to be a support or hindrance (usually some of both). Only you can make this list!

To summarize, if you still haven’t changed your way of eating or are struggling to maintain it, try the pros and cons activity listed above. Begin to appreciate your normal ambivalence about a new diet and what your benefits and barriers are to change. Share your list and the feelings generated only with someone who is willing to be supportive. Once you are in the midst of change and working hard, put the list away. You won’t need it. You will require something else to keep going. That something is called self-efficacy, meaning your belief to succeed under various situations. This is where I am now. I’m in the action stage and focusing on building my self-efficacy. More in the next post (if I haven’t lost you in the wall of words).

cartoon

*My comments are based on: Motivational Interviewing; the Transtheoretical Model; my own experiences as a diet and exercise yo-yo’er; and as a physician who worked with many patients – some who needed/wanted to lose weight, quit smoking, adhere with medications, stop abusing substances. This is a scientific approach backed up with human research and years of clinical and personal experience, which is what evidence-based practice is all about.

No Excuses? Bah!

Have you ever posted a negative comment on a blog site? (I don’t mean a political site, newspaper, or other types of public so-called “blogs”.)

I have done so twice recently. One was in response to a nutritionist-to-be who was using her “personal” blog to shill for food companies. Giving outrageously positive reviews for sugar-laden products without divulging if she had a conflict of interest or mentioning the downside of such products. This is not unlike physicians who promote drugs for Big Pharma on talk circuits (we call them conferences or grand rounds), but at least ethics dictate that doctors reveal any financial or other gains they have tied to any product they discuss.

The other negative comment was in response to an article posted titled “Excusitis” – no doubt meant to be motivating, a tough love approach. Maybe this can be just what some people need – although not many. Who needs to be told to just “do it” unless they are ready to do whatever it is and have plenty of resources to move ahead? I called bullshit on this article (not using that term).

When we pressure ourselves, or worse when others pressure us, to change what does any reasonable, independent thinking adult do? We dig in our heels and become resistant. Admit it. The more you thought about how much you needed to lose X number of pounds, the harder it became to get started. The more you hear about insurance companies threatening to cut off benefits for being too fat, the harder it is to lose weight. You get discouraged. The more airlines that throw fat people off of planes, the angrier you get. The more you see fat men starring in movie roles while emaciated actresses are the ones representing women… Really motivating, uh?

BUT, if we begin to believe that our current behavior(s)  is not leading to some important future goal, we just might become motivated to make a change.

I want to provide an alternative to the “no excuses” mantra for those who are trying to start a behavior change or who are having trouble maintaining one. Because I won’t drag this post on, if you want to read more about motivating yourself  or even help others to get motivated early in the process of change, please follow along in the next post.

gary larson cartoon

In My Former Life…

I was an academic primary care & preventive medicine physician who focused teaching and research efforts on behavior change. (Ironic, eh?) Since beginning this weight loss journey in September of 2009, I have often thought about how I  progressed along these behavior changes. This involved consciously using a model (The Transtheoretical Model or TTM) that predicts how people successfully change and maintain voluntary behavior change over a wide variety of behaviors. Bear with me while I reflect on how I have used the TTM and continue to use it to help me stay on course with eating (and hopefully with physical activity.)

Many people are aware of the Stages of Change that come from the TTM:

  • Precontemplation – little or no intention to change in the near future
  • Contemplation – thinking about changing soon. Often ambivalent and can be stuck here for a while. The pros and cons of changing and not changing should be considered. Many of us who have lost and regained repeatedly become chronic contemplators, discouraged by our prior regains.
  • Preparation – ready to start taking action, make a commitment, and might be taking baby steps such as cutting down on certain foods. People in this stage need to create a realistic plan. I jumped in here right after my cholecystectomy in 2009. I couldn’t eat anyway, so why not start the weight loss I had been putting off?
  • Action – actively changed the behavior in last 6 months; implementing chosen strategies, revising as needed (I just did this the last 2 months when I cut sugar/starch/grains),  and working hard to keep it going even in the face of difficulties
  • Maintenance – YAY! Doing the new behavior as a part of our routine existence. Weight loss folks tend to think of maintenance as having reached goal. The TTM conceptualizes this as having been in action for at least 6 months. I suppose this is where I am. BUT, for those of us with weight issues, maintenance is forever. Trust me, after 539 days, it’s finally becoming a part of who I am.
  • Relapse/recycling – not exactly a stage, but a normal part of change. We yo-yo’ers are familiar with this. The good thing is that most of the time we have learned something from our experiences and recycle back to a later stage of change. Rarely do we go back to precontemplation.
  • Termination –  moving out of cycle of stages. For behaviors that involve quitting a “bad” behavior such as substance abuse (smoking, for example), this means finally having conquered the behavior change, being no longer tempted, feeling confident to stay on course. I don’t see this as applicable to acquisition of a healthy behavior like eating or physical activity – unless you want to reframe it as something like quitting sugar intake, for example.

The Stages only identify where people are in relationship to readiness to change a behavior. More importantly is HOW we change and how we can move forward. Since I am in the action stage and moving toward maintenance (and it’s my blog 😉  ),  I want to focus on some of the Processes of Change – the engines that drive movement through the stages.

There are 10 Processes, which are divided into experiential (thinking, feeling kind of activities) and behavioral processes. In action and maintenance, it is much more important to focus on the action-oriented behavioral processes – this makes sense as I am actively working to keep on my plan and incorporate my new eating changes into my life forever. So, here are things I should be doing now:

  • Reinforcement management – Reward positive change. Manicures and pedicures have been on Mrs. Brightside’s recent list. I don’t do this much, although I am considering a small tattoo when I hit goal. OK, I dream about having my boobs tacked up…
  • Helping relationships – One can never have enough support, especially from those closest to us. The blogging community has boomed with weight loss and fitness blogs and forums because we are in need of such support and this is an incredibly important process to stay in action. WW, OA and other groups can be instrumental for many folks.
  • Counterconditioning – substituting positive behaviors and thoughts for the problem behavior. I drink a lot of warm tea at night in the cool season as a ritual to distract me. Blogging is probably another positive behavior that takes up time that I would have otherwise spent obsessing about food. You probably have your own examples.
  • Stimulus control – I remember when even commercials were intolerable. Now, it’s “Get that food out of here!” I demand that ice cream NEVER be allowed in the house. All candy must be kept hidden. No food is allowed on the counters. At restaurants, I politely shove bread out of reach. (A friend of mine pours salt on food she doesn’t want to eat.) It is, however, getting easier to tolerate triggering and tempting foods as time goes on.
  • Self-liberation – this process actually is important in preparation and in action. This means accepting responsibility for and committing (or maintaining the commitment) to the behavior change. For me this has meant viewing myself as a healthy eater for life; realizing that I can eat off plan if I choose and jump right back on; understanding that no one controls what goes in my mouth but me! Wow, that really is liberating.

There are other aspects that support one’s ability to change behavior and fit well with the TTM:  motivation and confidence (also referred to as self-efficacy). I’ll discuss those in another post because they are so important both for getting started and for keeping going, and I need to keep my confidence high at this point with 50 pounds and the rest of my life to go!

Do any of these processes resonant with you? What stage are you in? What suggestions would you give others for moving forward?

(Those of you interested in a more detailed explanation with references can check out this link, which is from one of the developers of the TTM.)

Lady Killer

February is always “Heart Month” as designated by the American Heart Association. This year there is a special emphasis on women and heart disease. None too soon as heart disease is the number 1 killer of adult women, symptoms of heart attacks in women are different from men and are often misdiagnosed, and for years women were intentionally left out of medical research investigating heart disease – yes, the very same #1 killer of women.

Today bloggers are sharing their sites with heart-health information and links to help fight this killer of women because many risk factors are preventable. The strongest, preventable risk factor for heart attacks in women in smoking. You might not smoke, but over 20% of American women (highly dependent on ethnicity) still smoke. Between 10-15% of pregnant women smoke.

Quitting is hard, very hard. Everyone knows smoking is bad – so why does anyone continue to smoke? I am not an apologist for smokers. I don’t smoke, but I worked with smokers in practice and in public health & medical research (non-pharmaceutical) to develop methods to help those who wanted to quit. Nicotine is highly addictive. Women who smoke often are surrounded by others who smoke, and the pressure to continue smoking can be tremendous. Women especially are concerned about weight gain if they quit. Many girls and young women start smoking in attempts to help control their weight. Smoking is used as a stress reducer. (Did you know that nicotine has anti-depressant properties?) Although smoking is being seen at higher levels on college campuses, women who smoke tend to have lower educational levels (they are NOT less smart) and probably are less likely to read blogs or even be on the Internet.

So, why am I blathering on about smoking to those of you who are probably among the most health conscious? Tobacco is a killer of women. You probably know women who smoke or use tobacco products. You also have faced your own battles with food or struggled to exercise and thus have a good understanding of how hard it is to change behaviors. If you have a chance to reach out to a smoker, do so in productive ways. Sure the best method to quit  is medication combined with brief counseling (by a doc, pharmacist, nurse, or phone advice). BUT, many people are not ready to quit. Telling them to go buy some Nicorette just turns them off. They know they shouldn’t smoke – just like we know that we should eat better and keep our weight in a healthy range. They need motivation and confidence. How can you help? Here is a list of excellent tips to help you help your friends and family members stop smoking.  These are very familiar to us who are trying to change our relationship with food: respect the smoker/quitter while letting her know you are there to help, don’t nag, help them reduce stress, celebrate small steps, don’t offer advice but ask how you can help with whatever plan they are using, keep you own home smoke free, don’t nag (did I mention that?), understand that most quitters take 6-10 serious attempts before becoming successful. You can suggest this site specifically geared toward women, even those not yet ready to quit. This motivational approach is evidence-based and works.

For those of you who have quit, I applaud you for stopping a substance that is as addicting as heroin and causes more damage to pregnancies than cocaine.

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