During the first monthly monitoring appointment, after reviewing the top ten questions in Figure 11.1, the physician presents the five principles of long-term weight control (Figure 11.2). These principles are meant to help the patient remember the key steps of the program. Ultimately, the patient's long-term success is based on internalizing the evidence-based science in a way that the patient can use in any social or private situation. This goal is accomplished by teaching the patient the five principles.
1. Preference versus Passion. The first principle, Preference versus Passion, defines how serious the patient is in wanting to lose weight. Patients who exhibit wishful thinking, who expect someone or something else to be responsible for weight loss success, or who are not willing to focus daily on trying to achieve success will not lose weight long-term. On the other hand, patients who demonstrate passion for wanting to lose weight accept a realistic weight loss goal, hold themselves accountable for either success or failure, and are committed to focusing on developing health behavior changes over time. Patients who come to the clinic for their fourth appointment have shown they have passion and are to be encouraged for this. When this principle is described, patients typically comment on how in the past their efforts were half-hearted but that this time is different. They are determined to control their weight.
It is common after a weight loss of 10% or more for a patient to have friends or family members ask how the patient was able to lose weight. With workbook in hand, the patient can show the process step-by-step. A common result of this encounter is for some of the patient's acquaintances to lose weight, too. The physician should tell the patient that such encounters are likely to occur and that the friend or a family member will exhibit either a passion or a preference for losing weight. Telling the patient this ahead of time helps the patient to understand the difference between the two and to not be discouraged when others do not share the same desire.
2. Planning for Success. Patients choose their desired amount of weight loss based on many reasons. Even when a patient writes on the intake survey he or she want to lose over 100 lb, the physician should not say it cannot be done. Determined patients have accomplished amazing amounts of weight loss. How long it will take to lose that amount of weight is the key question for the patient.
1. Passion versus Preference - Do you have the staying power to make a health behavior change?
Preference: Wishful Thinking
(Someone else in control of my success)
(Not able to establish a reasonable goal and follow a plan) Passion: Realistic Goal
(Understand 10% / 6 months as reasonable)
(Accountable to self for success or failure)
(Daily commitment to a plan)
2. Planning For Success - Put-On and Take-Off Weight Gradually
A. Goal of 10% weight loss over 6 months
B. Self-monitoring - Complete a daily log for calories and physical activity
C. Preplanning disarms 'landmines to weight loss' - anniversaries, holidays, birthday, and vacations
3. Perfect Fit -The most important practical principle for long-term success.
A. The C.A.M.E.S. Approach empowers the individual to improve their dietary choices without deprivation.
B. The P.A.S.S. Behavioral Prescription creates a personalized behavioral approach to food.
4. Physical Activity -You were made for motion
A. To last a lifetime, the individual must "enjoy" the activity.
B. Pedometers provide feedback with regards to physical activity, and provide a safe way to increase that activity.
C. If approved by your physician, using light weights 2-3 times per week helps maintain muscle mass and increases your metabolism, which burns calories.
5. Personal Control - Regaining lost weight is always possible.
B. The asthma model (green-yellow-red) to control the disease provides a plan for timely intervention.
C. The individual develops a strategic plan for intervention called the Zones.
Figure 11.2. The five principles of long-term weight control (copyright © 2001 Dr Thomas McKnight).
Using the approach presented to Andrea, a large amount can be lost over 1 to 2 years. Losing 10% of a patient's weight over 6 months improves a patient's health and sets the stage for losing more weight over a longer period of time. All the patient has to do is to continue to follow the program.
Planning for success involves three steps. The first is to identify a goal that is attainable. The science says 10% in 6 months is an attainable goal. The second step is self-monitoring. If the patient does not know if his or her weight is staying the same, going up, or going down, then how can any adjustment in behavior occur in order to control weight? Pre-planning is the final, critical step if the patient is to avoid the barriers to weight loss. Both self-monitoring and preplanning are accomplished using the calorie and physical activity log.
3. Perfect Fit. The CAMES. approach and PASS prescription empower the patient to enjoy eating the foods he or she likes to eat and at the same time reasonably reduce calories so weight loss can occur. Like most patients, Andrea was surprised to learn she only had to eliminate a few foods or drinks from her diet and could still lose weight. She made these choices, not the physician or a dietician. This does not mean she chooses the most healthful foods or drinks. It does mean she can be around her friends and not feel frustrated because she is on a special diet and is trying to lose weight. Her long-term success with weight loss is far more likely if she learns how to control the caloric intake of her preferred foods than if she tries to adhere to a diet that is unnatural for her.
4. Physical Activity. For many patients the word exercise has negative connotations. But describing how to increase physical activity in a natural way with a plan to safely increase that activity is appealing to most patients. If Andrea initially tried to do much more than increase her walking, it is likely she would injure herself. This does not mean that at some point in the program she cannot expand into other areas her desire to be physically active. It does mean she needs to build up to a condition where this can be done with minimal risk of harm to herself.
5. Personal Control. By this time in the program, Andrea has heard several times that her obesity is a chronic disease that never goes away. Even after losing weight, her obesity can easily return through the gradual but cumulative process of ingestingmorecaloriesperdaythanherbodyneeds.Itisthetrendofpatients'eating habits that leads to obesity. Thoroughly understanding and embracing this principle empowers Andrea to apply the other four principles no matter where she is.
Finally, in each of the two remaining weight monitoring visits, the physician can quickly review all the basic components of the weight reduction program by using the questions in Figure 11.1 and reviewing the five principles in Figure 11.2. This process allows the primary care physician years later to make brief interventions that can have a powerful impact. For instance, a year from now if Andrea has gained weight, her physician can quickly ask about her barriers and if anything has changed. She may choose to focus on the barrier or ignore it, but at least her physician understands why she is regaining weight and can offer assistance in a way that will be most effective for the patient.
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