When it comes to weight loss, it’s not as simple as eating right and working out. It’s really about a complicated combination of biology, personality, and lifestyle, and the right approach might be unique to each one of us. We spoke with Robert Kushner, clinical director of Northwestern’s Comprehensive Center on Obesity and author of numerous book and articles on weight management, about the obesity epidemic in the US, and an individualized way to fight it.
In your book, you talk about using an "ecological approach" to understand the obesity epidemic. What do you mean by this?
Ecology is the blending of the organism – the animal or person – with their environment. A perfect example is the animal that starts to change the color of its coat or its skin to blend in with the foliage.
When it comes to obesity, individuals have actually adapted very nicely to the changing culture of our society in an ecological way. Some examples of this are taking a car to work, taking an escalator/elevator up to your office, having a remote control, a gas or electric-motored lawn mower, and so on. [You have] all of these things, [so you] really don’t need to walk or do a lot of activity to do very nicely in our society. We have ecologically adapted to the way that the current lifestyle is in America.
On the eating side, with the availability of easy prep, convenient foods and increased eating out or home delivery, you don’t need to spend a lot of time cooking with fresh ingredients. And you’re now dependent on someone else doing the cooking for you, which is typically higher in calories and larger in portion. This is what I would call a perfect storm: not getting as much physical activity as you should and not watching or limiting the amount of calories as you should. What that leads to is the development of an obese society. And that’s a perfectly understandable ecological change that’s occurring now.
You developed the "lifestyle patterns approach" for weight loss and maintenance, which identifies individualized problem patterns for eating, exercise and coping. What do you mean by "coping," and why is that piece so important?
Most counseling for weight management will come down to “this is what I want you to eat” or “ I want you to be more physically active or start an exercise program.” Those are specific and discreet counseling recommendations, and two behaviors that individuals understand. But what is typically missing in a lifestyle change is the context in which the individual approaches their behaviors or their goals, and that’s what I mean by coping.
For example, an individual who is under a great deal of stress will often tend to procrastinate making these changes because they have other things going on, or they’re too stressed. Or another individual, just because of her personality or life experiences, always puts herself last on her own to-do list. So it’s always the children or the church group or carpooling or the husband that comes before them.
Another example would be people who know what to eat and know to be physically active, but their emotions, whether it’s anxiety or boredom or frustration, impacts their ability to follow those recommendations, and they continue to turn to food to cope. Coping is that gap, the in-between area that will either hinder or influence the successful changes in the recommendations of diet or physical activity. It’s the one area that clinicians often don’t spend enough time probing in providing treatment.
How do these coping patterns vary by gender?
[From our study], we have data on half a million individuals who took the pattern questionnaire online. We found very distinct differences in all of the seven coping patterns between males and females, such that for every coping pattern, females expressed a higher number of these than males. And that was distinctly different from the eating and physical activity patterns in which there was not a major gender difference. It’s very important to highlight that when you’re working with men or women regarding weight control, having a higher attention to these coping patterns – how individuals respond to behavior and what gets in the way of making these behavior changes – may be even more important in females than males.
Have you found that, once patients identify these coping patterns, they’re better able to overcome them?
They are. The treatments that we introduce are evidence-based. They’re not new; they’re types of treatments that other researchers or clinicians have used all the time. What this approach does is provide for the clinician and the individual a very quick assessment of what they need to focus on to be successful. If, after taking this questionnaire, one can identify very quickly that they have a body image disparagement – where they are strongly influenced by their body shape or weight and are embarrassed to be in front of others – that is something to identify very early and up front, to address and include in the treatment. The reason that may be important is, if someone is very unhappy with their body shape or weight, that may inhibit them from going to the gym or exercising in public, which is the very thing they need to do in order to get in shape. So you have to address both of these at the same time.
In developing a weight-loss strategy for a patient, what biological factors do you also consider?
Gaining weight and being overweight is actually quite complex. There are multiple factors that can lead to one’s body weight, and it’s important to make that assessment up front. Some of these factors can be modified. Examples of these factors would be medications that cause weight gain. These are typically in the categories of diabetes drugs, antidepressants, or drugs for other mental illness. Others would be drugs for arthritis or asthma, which are steroids. These are things that could be changed or addressed.
Sometimes there are medical causes for weight gain, not very common but could potentially occur, such as hypothyroidism. Others are biological, and knowing that they are about to occur can influence your outcome. A perfect example of that is pregnancy. Some women gain excessively large amounts of weight during pregnancy, and maintain that weight after pregnancy, which sets them up for a second pregnancy with even more weight gain. Attention to critical times in life – pregnancy being an example and another being menopause – and implementing changes proactively during that time can influence the individual’s total weight gain.
How prevalent is individualized care for obesity patients in our healthcare system?
It’s not individualized. I’d even step back and say that weight control is, unfortunately, infrequently done in the physician’s office. There are multiple [reasons] for that.
The first thing we need to do before we even start individualized care is to get all healthcare providers to assess and evaluate patients’ weights and their weight gain over time. And start providing more recommendations that are good for everyone – be more cognizant of your eating, reduce high-calorie foods, increase foods that are lower in calories like fruits and vegetables, get physical activity on a daily basis, etc. These are general recommendations that I think would go a long way in putting obesity on the radar screen for treatment between the patient and the healthcare provider.
Once that is done – and that’s a major goal; if that were done I’d be satisfied – but for those for whom that isn’t enough, then we need to individualize treatment so it resonates specifically with the patient. That’s a tall order, because clinicians often don’t have the time and the reimbursement to spend a lot of time with patients regarding weight control. So easy, quick messages that are meaningful would be the first step.