Relapse Is My Middle Name

Those who remember my technical blatherings about the Stages of Change Model describing how people voluntarily change behaviors know that I have tried to relate my journey from merely thinking about eating healthy, to seriously planning, to acting on the set of behaviors, and then integrating the mechanisms (processes) of change to help me keep going. (Fifty-word sentence, good grief.)

Relapse is one of the stages, and I am in it. “Don’t despair,” I tell myself because this is normal. There is always something to be learned from a setback. And, recycling to a later stage of change means not starting all over. I do not need to build motivation. I do need to re-establish my ability to shun certain trigger foods. Regain my self-efficacy/confidence. This is especially hard given that I have a binge eating disorder. Yep, depression, anxiety, PTSD, BED. One wonders how I ever functioned so successfully in academia. Here’s a secret. I almost ate myself to death. I gained 150-pounds and no one talked to me about it. If I had reeked of alcohol think someone might have initiated an intervention? Yep? Do I harbor some anger at those charged with my training during medical residency, those who supposedly valued behavioral sciences yet ignored my tremendous weight gain during my residency? You bet. Time to let that go.

I have returned to the world of the present by being open with my family about what has been going on. Sought support from key friends and loved ones. Agreed to not eat in private. Talked with my long distance shrink who is an incredible sounding board. Finally, I stepped into my tightest jeans and found they were almost too tight to wear. Reality check.

Losing weight and maintenance are difficult enough without adding a binge problem. I don’t expect sympathy. It’s a real disorder that I magically thought had disappeared. Nope.

Ever vigilant without obsessing is a fine line. I’m back in the saddle and wearing my tight jeans.

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♪♫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.

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.)

Update on (Drowning) Gym Rat

Eleven months and 85 pounds into my weight loss journey, I feel pretty comfortable that I have mastered techniques and behaviors around eating that will keep me going to my final goal weight and even into maintenance. Now that I am embarking on a similar path to changing physical activity, I am hitting a wall. I have an exercise plan developed with a personal trainer (that I might need to modify given the amount of knee swelling after the first workout); got my workout music on the iTouch; picked aquatic classes for my level of fitness; after experimenting with the so-called non-weight bearing elliptical (ha!) decided that the treadmill and recumbent bike will be my cardio machines of choice; even have a schedule – OK, a kinda schedule. But, I am not following through. What the heck is going on? Why can’t I apply the same internal motivation to change around eating to exercise?

I looked at a post from January to help answer my question (partially). I used a model of behavior change called the Stages of Change (proven to show how people change successfully on their own or with help) and applied techniques that matched the Stage (action) that I was in to changing how I ate.

Now I’m going to do the same thing with physical activity and see if I can’t generate some more internal motivation and confidence to stick with my exercise plan. First, the behaviors that I want to accomplish have to be very specific. So here they are (don’t laugh, I’m starting out slowly because of my damn knee and to make these initial goals achievable):

  • Exercise in some form 6 days a week
  • Aquatics class M,W,F – if the aquatics class I chose doesn’t work out, there are 3 others to select from
  • Gym workout T,Th,Sat or 60 minutes of outdoor walking or 60 minutes on home recumbent bike or 60 minutes of walking/bike
  • Check off activities on trainer’s worksheet in the gym

OK, there it is in writing. I can do that. I can. I think.

I am in the action stage for exercising. I need to remind myself of why I am doing this. These new behaviors are very important to me. I want to reclaim my self (body) as an active person, believe life long physical activity is crucial to successful weight loss maintenance and health, and know once I get started that I will feel so much better about my body and reap emotional benefit. I am, however, not so confident that I can carry out this routine even though I just said that I could. Building my self-confidence (not the same as an ego boost) is important now and for the long-term. I worry about my knee flaring up; I reflect back on past failed efforts to exercise; I wonder what to do when family and vacations get in the way (walk maybe?); I know that the very recent death of my mother and my raw grief reaction are probably impacting my ability to act. I need more confidence. So here are things that should help:

  • I have set realistic goals and know that I can modify the goals as needed based on how my body reacts (not on how my brain does)
  • Seek positive support for efforts – spouse, family, close friends, fellow bloggers. All negativity will be booted out the door. My spouse has not been as supportive with the gym. “Why do you need to spend the money? Why can’t you just walk?” Negotiations in progress.
  • Reward myself for small changes – something I didn’t do with my dietary changes. So I’m going to have to think about this. What can I give myself for staying 100% on track for one week?
  • Continue reading/watching the successful exercise experiences of others like myself. “Hey, if she can do it, so can I!”

Those of you who have been successful in becoming a regular exerciser, feel free to let me know how you did it. I’m open to any suggestions on the how to do – not necessarily the what to do. Really, I’m drowning here.

Sarah Harford's "To Save a Drowning Rat"

Changes I Have Made (this time)

I have lost hundreds of pounds since I become overweight around age 26, which means I have regained hundreds of pounds also. Now at the age of 55 and through menopause, the ease of weight loss just isn’t so easy any more. Perhaps that’s “a good thing” as Martha Stewart would comment.

One of the most ironic aspects of my life is that my years in health research focused on health behavior, so I know exactly what one should do for successful health behavior change and maintenance. Ah, but the knowing and the doing and the feeling somehow just aren’t the same are they? Or, no one would smoke; we would all wear seat belts; there would be no fire arm accidents, etc.

Back on track… I finally reached the stage of commitment to weight loss and maintenance (after years of dejection from repeated regaining) and, spurned on by a surgery unrelated to weight problems, found the self-confidence that I could act on life-style changes. [Those interested in the Stages of Change Model for voluntary behavior change can read here a brief and very elementary intro about how people successfully modify their behaviors.]

First, I had to identify which behaviors I wanted to change. Weight loss is a goal – not a behavior. There are no less one than gazillion behaviors tied into losing weight.  That’s right, exactly one gazillion. One must identify which behaviors are specific for you before springing into action.  For me, the starting behavior changes are:

  • restricting my calories to 1500kcal/day on average in a week
  • aiming for a balance between protein, fat and carbs
  • spreading out my food intake throughout the day, which means eating breakfast
  • no food after 7pm
  • no red meat
  • no ice cream (the ultimate trigger food for my binging)
  • minimal refined grains and grain products
  • adding at least 3 fresh fruits/vegetables per day
  • shopping only for fresh produce
  • limiting what is in the cupboard/frig to what is acceptable to eat
  • no artificial sweeteners or drinks with artificial sweeteners – sweet stimulates me to eat more sweets
  • monitoring everything calorie that goes into my mouth (I use the Livestrong.com site)
  • charting my weight twice a week
  • being physically active 30 minutes a day, beyond job and household activities

To help me do these things, I enlisted the support of my partner (too many negotiations to go into here) and got her to agree to help in ways that are acceptable to both.  I announced to family and close friends my plans and asked for their support – mainly by not offering me food.  I joined a support group. We rearranged the kitchen and threw out or gave away everything we would not eat. I found substitute behaviors for my late night eating, e.g. drinking hot tea (bought new mugs, fancy water kettle, special teas), made the bath more spa-like for reading in the tub rather than eating in front of the TV. I chose rewards for certain goals reached. Started this silly blog. I also gave myself permission to go off plan for special occasions – to prevent me from  binging because I had “blown it” by eating chocolate or dessert or had a 5 course dinner including red meat for Christmas eve. LIFE GOES ON!

I will continue to revisit my behavior change list, expecting to change caloric intake and activity levels. If something doesn’t work, I will throw it out. I will continue to seek wisdom from those who have succeeded in maintaining weight loss and from those who are on the same journey.

What are your behavior changes and mechanisms for keeping them going?

Peace.