Читать книгу Behavioral Approaches to Treating Obesity - Birgitta Adolfsson - Страница 7

Chapter 5

The Paradigm of Care

“If you want to build a ship,

Don’t drum up the people to collect wood and

Don’t assign them tasks and work,

But rather teach them to long for the end-less immensity of the sea.”

—Antoine de Saint-Exupery

Why Change It?

Obesity is a problem with adverse medical consequences, and lifestyle change is an essential part of the solution. A person living with excess weight must be engaged in and commit to changing his or her habits, and many require help in doing so.

Extensive documentation points to lifestyle as the first line of treatment to address the risk factors of metabolic syndrome (Nonas 2004). WHO states that the worldwide increase in obesity arises from lifestyle issues, such as unhealthy eating habits and decreased physical activity. The American Diabetes Association (ADA) and other experts recommend weight loss and increased physical activity as the safest, most effective, and preferred way to reduce insulin resistance in overweight and obese people. Randomized controlled studies show that even a weight loss of 3–5% of total body weight along with improved eating habits and increased physical activity decreases the prevalence of type 2 diabetes by 30–60% among obese people with impaired glucose tolerance (Knowler 2002, Tuomilehto 2001). Although a 5% loss of initial body weight will yield improvement, further benefits accompany a loss of 10% and may be necessary to achieve measurable benefits in those with an initial BMI >35 kg/m2 (SIGN 2010). Providers look for clinically useful changes, such as lowered blood pressure, improved lipids, and better control of diabetes (NCBI 1998, NICE 2006). Lifestyle changes work, but what does it take to make them work?

Much of our eating is informed by the culture in which we live. Society sends conflicting messages about food, health, and weight issues. Although being slim is valued as attractive and healthy by society, messages from advertising and other media undermine efforts to actually practice healthy behaviors. There is no identified connection between eating and slimness in commercial media. The implicit message seems to be that a person can be slim, yet not think about health. Too often, weight concerns are reduced to cosmetic issues. The end result of the contradictions in media messages is a generally unhealthy attitude toward eating and appearance.

Quick-fix diets lead consumers to visualize unrealistic, instant results and cast doubt on the less dramatic benefits of sustained healthy dietary management. There are many products and programs available that market themselves as solutions to the obesity problem. On the one hand, any diet that results in energy restriction and weight loss improves the metabolic profile of an individual (Sacks 2009). However, on the other hand, weight loss can be a marker of improved lifestyle habits or it can be the result of a short-term restricted diet or disordered eating. This ambiguity makes weight change itself an uncertain measure of progress. If the primary goal in treating obesity is to avoid adverse medical consequences, measures of changed behaviors will serve as more appropriate markers of progress than pounds lost. The real measure of success for weight-loss interventions is improved health (Dausch 2001).

Body weight is relatively easy to use to measure the results of change and provides an objective tool with which to measure change and compare individuals to population data. However, reliance on weight change as the only or primary measure of progress keeps the focus on the scale and cannot support long-term behavior change. When people hit a plateau or maintenance stage, weight loss will no longer provide positive reinforcement. This is when the importance of persisting with lifestyle change is crucial.

Facilitating behavior change requires a different approach to health care than the traditional acute care approach to medicine. The standard acute care visit addresses short-term problems with a specific recommendation. The provider makes treatment decisions with little need for input from the staff or the patient. Minimal follow-up is needed.

Obesity is a chronic condition. The Chronic Care Model provides a more effective structure for providing care (and reducing the costs) of chronic disease. This comprehensive model includes community, organizational, and clinical components to support its goals. It also emphasizes patient education, support, and access to resources as essential so that the person living with the problem can become an active participant in his or her own care (Blackburn 2005).

With a chronic disease approach, health care systems have the opportunity to advocate for the treatment of obesity as a complex biological/psychosocial problem that requires the tools of evidence-based medicine. By regularly assessing medical risk factors, offering treatment options based on scientific evidence, and providing long-term follow-up, health care providers may be able to refocus attention on health rather than weight. In doing this, the core of a treatment program focuses not on solving the “weight problem,” but on “increasing health.” Whether or not medications or surgery are included, the overall treatment plan requires behavior change to achieve long-term health goals.

Due to the strong association between cultural influences and obesity (e.g., “be thin, eat what you want, be healthy, but don’t do anything about it”), obesity simply cannot be treated with the familiar acute-care model. The habits and lifestyle choices that lead to obesity are closely tied to our modern environment, thus simply prescribing a regimen of physical activity and healthy eating will normally fail. If a patient presents with an infection, we treat with the proper antibiotic. That is the rationale behind the acute-care model. However, what if this patient’s infection briefly goes away and then comes back quickly? We begin to search for additional causes of this infection. There may be medical reasons, such as the need for a different antibiotic or the presence of another medical problem that reduces resistance.

Furthermore, the problem could be related to the patient’s lifestyle. Did the patient take all of his or her antibiotics? Is he or she susceptible to re-infection because he or she is fatigued from inadequate rest? Is the patient experiencing high stress due to unexpected bills? Is he or she smoking, which reduces resistance to infection? Has the patient experienced increased exposure to bacteria from crowds?

If the provider and patient discuss the problem, they could better identify possible causes. The patient may first require information about what may be a potential cause. If potential sources are identified, then the patient may require help knowing what might be done about them. Ultimately, the patient will have to decide what he or she is willing and able to do to reduce the risk of re-infection.

In the chronic-care model, patients do more than follow instructions. They partner in determining the problem and (because they are the ones making the changes) deciding what changes are worth making. This shift from physician-determined treatment to collaboration between the patient and provider defines the chronic-care model and a behavioral approach. Such a paradigm shift is necessary for the successful treatment of overweight and obesity in the modern world because (whether we as providers like it or not) the patient with chronic disease provides the majority of his or her own care.

Antoine de Saint-Exupery captured the essence of this paradigm shift. More explicitly it might read:

If you want optimal health for your patients

Don’t overload them with information

Don’t give them lists of dos and don’ts

But help them visualize the possibilities with confidence and discover the passions that energize their choices.