Behavior Modification: A Patient and Physician’s Perspective
This article, co-authored by a patient affected by obesity and an obesity medicine specialist, discusses the patient’s experience of living with the disease and using many different weight loss approaches until finding a lifestyle program that was appropriate for her metabolism. The physician discusses the scientific basis of insulin resistance, and why the chosen lifestyle program worked so well for this individual.
KeywordsBehavior modification Obesity Weight loss
Pain was my initial motivation for losing weight, this time. At 240 lb and 5′4″ tall, I was in the morbidly obese category on the BMI scale. I was fairly active, regardless, with hiking, walking my dogs, yardwork, and physical volunteer work. However, it was putting a strain on my energy, breathing, joints, and bones. At age 52, I had zero self-esteem, I was ashamed of myself and my appearance. I was depressed, felt unloved, invisible, and under an incredible amount of emotional anxiety. I would sneak out for fast food daily, sometimes twice a day; burritos, nachos, tacos, fried chicken, burgers, fries, breakfast sandwiches, eating until I couldn’t take another bite. Every night, I drank alcohol mixed with juice to dull the emotional pain. Personally destructive eating behaviors, either subconsciously or consciously, had been practiced for probably over half of my life. I told myself that I couldn’t lose weight because of my age or my slowed metabolism. I told myself that nothing worked anyway, that no matter what I did, I could never keep more than a pound or two off. I had basically stopped caring, and given up.
Only one doctor ever suggested that I lose weight, and that was 25 years ago. Current doctors would just laugh along with me when I joked at the weigh-in scale, “Just write down ‘a lot’ for my weight”. The BMI chart was right on the wall in front of the scale. No implication was ever made that I should lose weight. Six months ago, after excruciating pain from scrubbing tile floors on hands and knees, X-rays and MRIs revealed that my knees had a bone spur, advanced arthritis, and torn meniscus. “Surgery” was the implied fix; when I asked questions, the specialist’s attitude was “Do it or don’t, I don’t care. Schedule an appointment or don’t”. I wasn’t thrilled. I went home and started researching arthritis on the computer. I would not spend the rest of my life with an impaired activity level. Finding one particular piece of information on the Johns Hopkins Arthritis Center website, “Being only 10 lb overweight increases the force on the knee by 30–60 lb with each step”, I knew my current eating behaviors had to stop immediately . I called my general physician to ask for recommendations for a “serious” weight loss program. I specifically chose a specialty center which is overseen by board-certified medical doctors, does not use or promote the use of human chorionic gonadotropin or human growth hormone, uses nutritionally complete protein shakes, and uses behavior modification classes as a major component of its structure.
An integral part of the weight loss journey at this center is a series of 20 behavior modification classes, led by five different professionals who are doctors of psychology, and registered dietitians. Each class targets a particular topic, ranging from motivation, planning, setting goals, the psychology of weight loss, fitness/activity, nutrition, shopping, cooking, eating out to name a few. Classes are between 1 and 1.5 h, and rotate continually every month, giving many opportunities for those with busy schedules. Saturday and evening classes are available, so there are no excuses! Each one causes you to reflect on yourself, your behaviors, and your lifestyle. Each class challenges you to make modifications to your eating patterns, your daily habits, your activity level, and your routines.
The class series helps you to retrain your brain about your eating habits. With handouts full of useful tips and information, and class sizes small enough to feel like you are getting 1:1 attention with the instructors, the classes help you to stay on track during your journey. When you begin, you are given a binder to retain your information. This binder is like your own personal tool box, and each class is like adding a new tool. These tools are there for you to read, reference, and go back to, whenever you need some motivation.
My previous weight loss attempts included “meetings” with the group that were just a weigh-in, where you’d stand in line and publicly step on the scale, and a weak attempt to offer structure and tools to the attendees. Or, there would be sessions that were like group therapy, where tearful stories were told. There were no materials to take home, and the meetings were not held by professionals in the field, rather by a colleague who had been successful at losing weight. That is not a solid foundation for success.
My favorite saying, obtained from Dr. Primack’s office, is “What you do today is important, because you are exchanging a day of your life for it”. So make it count, and learn how to be the best you that you can be.
This patient’s story is quite common. The average person who comes to our clinic has been on 8–12 formal “diets” before we see them. Eight to 12 times they believed that they were doing what was right and correct to lose weight, and therefore to treat their obesity. Unfortunately, these “diets” were just that, just diets. They focused on the “what” people were eating and not the “why”. Their prior plans were lacking in multiple areas.
There are four keys or pillars of medical weight loss management. The pillars are:
Activity or exercise
A recent study showed the magnitude of adding behavior modification to medications to improve weight loss . Many patients who are not seeing physicians for weight loss choose diets that unfortunately are incomplete and only focus on one or two of the necessary pillars. These patients often do lose weight, but do not keep it off nor are they likely lose enough weight to achieve their goal. This is because, amazingly, the body has developed systems over generations that are designed to defend against weight loss; to be successful, we have to find several synergistic methods to override these compensatory mechanisms .
Physicians who are certified in obesity medicine by the American Board of Obesity Medicine (ABOM.org) have undergone further clinical obesity treatment training often provided by the Obesity Medicine Association (ObesityMedicine.org). These physicians dedicate all or part of their practice to help patients in all four aspects of a complete medical weight loss program.
Visualize a chair with four legs. If you lean back and try to balance on two of the legs, you can likely do it for a while. Soon enough, you will fall. On a chair with three legs, you may stay balanced longer. However, the more stress you put on the chair, the more you notice it rocking and eventually you will also fall. With a complete program (four legs on your chair), you can put a lot more stress on the system and remain seated much better than you can on less than four legs.
When we started my clinic, we made a commitment to all four aspects of a comprehensive weight loss program. For behavior modification, we designed a 20-week class series program taught by PhD-level psychologists and registered dieticians, each with an exercise background.
Patients in the program are asked to come to regular physician visits during the active part of their weight loss program as well as the classes. Of the 20 classes, 11 of them are behavior-based. The behavior class topics include “eliminating negativity in your life”, “eat mindfully… live mindfully”, and “managing plateaus and weight regain”. The remaining nine classes are either dietary education-based or exercise-based. The dietary classes range from “grocery shopping and food labels” to “food, fact or fiction classes one and two”. Exercise-based classes include “taking exercise to the next level” and “exercise for the non-exerciser”.
One of the common themes that I see in weight management is that it is not what the patients are eating per se; it is “why” they are eating. When we figure out the why, we can durably change behaviors. When we have a defined goal and a reason to attain our weight loss goal, it makes it easier to achieve those goals. The more structured and comprehensive behavior modification classes are, the better the weight loss . Our classes generally provide three additional aspects: didactic learning, group troubleshooting, and a place for social support .
The authors would like to thank the Obesity Treatment Foundation for facilitating the publication of this article. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval for the version to be published. The opinions expressed in the manuscript are those of the authors. No funding was received for publication of this article.
Elizabeth Swanson and Craig Primack have nothing to disclose with regards to the publication of this article.
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This article does not contain any new studies with human or animal subjects performed by any of the authors.
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- 1.Bartlett S. Role of body weight in osteoarthritis. John Hopkins Arthritis Center. 2012. https://www.hopkinsarthritis.org/patient-corner/disease-management/role-of-body-weight-in-osteoarthritis/. Accessed 4 Jan 2017.