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Assessment

Assessment of the individual with dysmetabolic syndrome involves quantification of obesity, diets and dietary patterns, physical activity, emotional problems, and motivation [16]. Lifestyle modification strategies are typically most helpful for individuals with a body mass index of <40. For individuals with severe obesity, much more aggressive approaches, such as bariatric surgery, may be required. Registered dietitians are the best professionals for assessing diets and dietary patterns. Physical activity can be assessed by asking the number of minutes per day spent walking briskly or similar exercise. Emotional problems, which oftentimes make weight loss much more difficult, can be identified through the use of brief psychological questionnaires, such as the Beck Depression Inventory [17] or similar instruments. For individuals who do not appear motivated to change their diet or physical activity levels, personalizing each of the dysmetabolic syndrome risk factors and explaining how modest weight losses may improve them can sometimes be helpful. For individuals who do seem willing to make changes, encouragement from the physician can oftentimes help. Basic education about small steps which individuals can make in changing their lifestyles may help motivate them to begin a program. For individuals who are already motivated the lifestyle changes described next have been shown to be extremely useful.

Table 1. Components of a lifestyle modification intervention

Lifestyle Change Strategies

Diet and Physical Activity

The recognized diet for weight loss involves a balanced eating plan, including a deficit of about 500-1,000 kcal/day, resulting in a safe weight loss of 0.45-0.90kg/week (1-2 lb) [10, 18]. Physical activity recommendations typically include adding 30-60 min/day of brisk walking or the equivalent on most days of the week [10].

Behavior Modification

To help individuals make these dietary and physical activity changes, a number of behavior modification strategies have shown good efficacy. These strategies include a tailored problem-solving intervention, involving goalsetting, self-monitoring, stimulus control, cognitive restructuring, stress management, relapse prevention, social support, and contracting [19].

Goal-Setting

Many individuals with the dysmetabolic syndrome have unrealistic goals regarding their ability to lose weight. Obese individuals frequently express a desire to lose more than 30% of their weight [20], although research studies indicate that patients who participate in a lifestyle change intervention lose about 8-10%. It is important to remember that a modest loss of about 8% generally will lead to improvement in the constellation of risk factors of the dysmetabolic syndrome. The DPP and Finnish prevention study, for example, both showed that modest weight losses through lifestyle change significantly reduced the incidence of diabetes in individuals at high risk. Unfortunately, this amount of weight loss is disappointing to some individuals who still are overweight or obese. An emphasis on achieving small, short-term goals, such as walking an extra 20 min/day and then focusing on the increased psychological feelings of enhanced well-being can sometimes help individuals understand and appreciate the gains that they have made. Accomplishing modest dietary or physical activity goals oftentimes improves self-esteem and serves as encouragement to try new ones. Setting unrealistic goals, such as losing weight too quickly through fasting or severely depriving diets, or attempting strenuous exercise, frequently results in disappointment, discouragement, and ultimately failure. Reevaluation of goals should be done on a regular basis, with revisions made as needed.

Self-Monitoring

Research suggests that self-monitoring is the most important of all behavioral change strategies [21]. In the DPP study, for example, the frequency of self-monitoring was related to success at achieving both the physical activity goal and the weight loss goal [22]. Self-monitoring involves three aspects: self-observation, self-recording, and feedback. The primary purpose of self-monitoring is to raise awareness. If an individual is going to successfully change physical activity and diet, it is important to know one's activity level and what one is eating. The typical way to raise awareness of habits is through a diary in which individuals write down what they eat and the number of minutes that they are physically active. They then look up the number of calories they ate and calculate the number of calories burned through their brisk walking or other activity (calculating about 6cal burned/min of walking). Pedometers are also helpful for raising awareness, with about 100 cal expended for each 2,000 steps. Individuals typically do not like to keep diaries. They also tend to underestimate their intake by about one third, and overestimate their activity by about one half. It really does not matter. The primary purpose of monitoring is raising awareness, not accuracy of recording. Monitoring helps remind individuals of what they are trying to do, i.e. healthy eating and more exercise. Monitoring weight by weighing on a regular schedule, i.e. daily or once a week, is also important. Food and activity diaries, and monitoring weight on a regular schedule, are essential components of long-term habit change in individuals with the dysmetabolic syndrome. If an individual agrees to make a single lifestyle change strategy, self-monitoring should be the one chosen.

Stimulus Control

Stimulus control involves identifying and confronting the individual's idiosyncratic barriers to losing weight [23]. Frequently the food and activity diaries can help identify the problems that individuals are having when they stray from their healthy eating pattern or activity plan. Common problems include eating outside the home, traveling extensively, late night eating, or weather too hot, too rainy, or too cold to exercise. Using a problem-solving approach by encouraging the individual to come up with a realistic plan to the specific problem can oftentimes lead to a solution. A few ideas that individuals can be encouraged to come up with when they are confronted with barriers include: taking meals from home to the office rather than eating in the cafeteria; calling restaurants ahead of time and asking for low-fat, low-calorie meals; carrying calorie-controlled meals when on trips; planning sensible snacks in the home, or agreeing to exercise in a shopping mall during inclement weather.

Cognitive Restructuring

The belief that losing weight will improve all aspects of an obese individual's life and that somehow all problems will disappear is not unusual. Unfortunately, it usually is not true. Cognitive restructuring involves strategies to help individuals change the unrealistic beliefs they may think about themselves and replace them with more positive, realistic ones [24]. Individuals are taught to identify self-enhancing, self-affirming thoughts about themselves. Repeating healthy self-affirmations such as 'I will walk for 20 min before breakfast', 'small changes can make a big difference', 'I am no longer putting off my life until I reach some magic weight', and repeating them daily can be excellent motivators for lifestyle change.

Stress Management

Emotional factors frequently interfere with the development of healthy lifestyles. Stressful life events oftentimes lead to unwanted eating and subsequent weight gain. Recognizing stressors and learning strategies to deal with them can help individuals manage their eating patterns more effectively. Physical activity is an especially good strategy for reducing feelings of stress because it raises an individual's sense of well being. The regular practice of meditation or learning techniques like progressive muscle relaxation can be useful for managing everyday stresses [25].

Relapse Prevention

Lapses from one's diet or exercise program are common. Unplanned events, emergencies, boredom, and other factors interfere with well-intentioned plans. Life gets in the way. Understanding that lapses occur and are to be expected may help reduce the probability of a relapse (giving up), leading to weight regain. Learning strategies to deal with transgressions, such as those that likely occur during holidays, can help prevent a major collapse in one's long-term goals. Reviewing and understanding what happened and developing a strategy to deal with a situation if it occurs again can be extremely useful in preventing its recurrence [26].

Social Support

Family members who eat the same healthy food and exercise together can be a strong support system for individuals with the dysmetabolic syndrome. Good friends, colleagues at work, the individual's physician, and others can play a major role in keeping motivation high. Social support systems work because supportive individuals serve as excellent role models, provide assistance in confronting and dealing with obstacles to change, and encourage self-acceptance [20].

Contracting

Formalizing agreements to make specific behavioral changes can be useful for some individuals. Contracting involves having individuals agree to one or more specific behaviors that they will do over a short period of time. The agreed upon behaviors should be simple, achievable, and realistic. Agreeing 'to do better' or 'to be a better person' is not helpful. Agreeing to walk for 20 min on Monday, Wednesday, and Friday at 8:00 in the morning is hopefully simple, achievable, and realistic. Likewise, reducing the number of desserts from every night to three times a week may also be achievable. Writing down the agreements and signing the contract usually helps in achieving the goals. Contracting is particularly useful for motivating short-term behavioral change. Changing contracts frequently helps [20].

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