Q & A with Weight Management Expert Dr. Sheri Pruitt
For many, losing weight is pretty easy. The hard part is keeping it off. You can make a New Year's resolution and spend January in the gym, but can you keep it up until May? What about next December? Don't end up having to make the same resolution again in 2011. There are ways you can succeed in changing your lifestyle for the good — and for the long run.
Dr. Sheri Pruitt is a licensed clinical psychologist and the Director of Behavioral Science Integration for Kaiser Permanente in Sacramento, California. She has previously worked with the University of California, San Diego, School of Medicine and the World Health Organization (WHO) in Geneva, Switzerland. Dr. Pruitt is the principal writer for two WHO books that outline global strategies of care for chronic conditions, and she recently co-authored her second consumer-oriented book entitled Living SMART: Five Essential Skills to Change your Health Habits Forever.
Dr. Pruitt talked to us about how you can lose weight successfully and make permanent changes in your life.
Can you talk a little bit about your background and what you do?
I'm a clinical psychologist, and my area of expertise is in behavioral medicine, which is all about keeping people healthy, trying to prevent disease onset, and managing disease once it occurs. Basically, what I do is help people change behavior and maintain that change across time.
Kaiser's Medical Weight Management Program is designed using decades of scientific research about how people change their behavior and how they maintain those changes long-term. I don't want to imply that our program is without problems; the bottom line is that weight loss and maintenance is very difficult, no matter what program you use. What I want to emphasize is that although you often hear about people losing weight successfully and quickly by participating in this or that weight-loss program, what you don't hear is that most weight-loss programs don't work in the long run; most people gain all the weight back.
Why does that happen?
Because when you go off the initial restricted calorie intake and you go back to your former eating habits without making any real behavioral changes, you're going to regain your weight. Some people even gain weight beyond their baseline. The hardest thing is to maintain low weight across time.
What types of "behavioral skills" need to be taught in order to develop successful long-term eating and exercising habits?
To lose weight and maintain that weight loss over time, the only two things that lead to success are 1) consuming fewer calories and 2) exercising. There's no other answer; there's no magic solution. The question becomes, how do you help people develop a lifelong commitment to low-calorie intake and physical activity?
The acronym we use at Kaiser is S.M.A.R.T — Set goals. Monitor your progress. Arrange your environment. Recruit support. Treat yourself.
To learn more about S.M.A.R.T.; click here.
Does it help to diet in a group of peers?
There's a lot of data that shows group intervention for weight loss outperforms individual intervention. Even if people say that they prefer individual treatment, they do better in a group. The reasons seem to be that everybody is together in the same boat, so to speak. They all have the same mission and goals; they can support each other from beginning to end.
Is it more difficult to diet while living with someone who's still eating french fries?
In a household where one person needs to make serious lifestyle changes and the other person doesn't, it would be a little harder to stay on a diet. But not impossible. A spouse or family member who doesn't need to make the same dietary or exercise changes can still be supportive in other ways. The strategy is to arrange your world for success. So the cookies and ice cream that your husband buys, keep those things out of sight and out of mind. Have him put that stuff on a separate shelf that you don't open. Is it easier if your spouse diets with you? Yes. But if not, you can still have success. And you can find someone else to diet with you — someone at work, an aunt, a friend.
Do you think that regular engagement with a family doctor or general practitioner can be helpful?
Definitely. Your doctor is someone that you should look to for guidance with your health and should absolutely be a source of encouragement in the dieting process. What healthcare providers say is very influential, and I wish that more of them would talk about weight not so much from an appearance perspective, but in terms of how important it is for people's health — in minimizing the risk of developing a chronic illness. One of the aims of providers should be to help patients catch weight gain early and talk about prevention of weight gain. Do I expect a personal physician to develop a behavioral program for weight loss? No. But perhaps to refer a patient to a program that they can use to manage their weight.
How does one know when they are ready to start dieting?
It's different for every person. You have to make the decision to embark upon something that takes a lot of effort. There has to be some level of motivation to move beyond the negative patterns of overeating and not expending energy. Most of the time, people think that it takes an inordinate amount of motivation to make a change, but it really takes just enough motivation to start the new behavior and have some success. That success will build on itself because changing a negative behavior gives people a lot of pride. They start to feel good; they realize they can make these difficult changes. Friends start to recognize the change in them. These things perpetuate people staying on track. You do have to have some motivation to change, and I think everyone gets this from a different place.
Isn't there a tendency for dieters to go strong for a short while and then "fall off the wagon," so to speak?
When people are overweight, they've been practicing overeating and under exercising for a long time. For some people, it can be a lifetime of that. And when they try to lose weight, they are trying to create a whole new set of habits. They are up against what we call behavioral drift. They can start new behaviors, but there is a pull, like a strong magnet that pulls them back into old familiar patterns — a relapse. You're constantly working towards building a new path; you want to get in a new rut that is healthier than the one you were in before. And that's really the struggle, because sometimes it feels better to lie on the couch and eat high-calorie foods. I speak from experience. We're all human, and we all have similar experiences around this.
How can dieters stay motivated and stick to a diet and exercise plan?
Our goal is to get people to be independent and to learn the behavioral skills that they need to sustain long-term changes. I don't care about how much weight was lost in 30 weeks. What matters is how you're doing a year later, two years later, and so on. I really try to help our participants understand that they have to make a cognitive shift between the active weight loss phase [at the beginning of the diet] and the maintenance phase. At first, people are gung-ho; they're working hard, they're with their support group, and they're losing weight like crazy. But things will change. They will continue to be working just as hard — counting calories and exercising every day — but they won't be losing weight anymore. The goal then becomes to maintain a healthy weight. So they have to be mentally prepared for what life is going to be like after the weight is gone. People often fatigue during maintenance, and I think it's because they have expectations of continuing to lose weight indefinitely.
How can people make that shift from active weight loss to weight maintenance?
People think that once they get to their target weight, things will get easier. But it's not like that. I use the analogy of a wedding and marriage. You do all of this preparation for the wedding day — the dress, the invitations, the flowers, all the details. But really, marriage is for life, and it'll take continuous work to maintain. I think that people fail to really appreciate the effort, commitment, and nurturing necessary for long-term weight loss, just like we do with long-term relationships. It's not just getting to that weight goal; it's what you're going to do to maintain that weight in the long term.
What are some ways to prepare for long-term weight management?
One of my favorite strategies is having "personal rules." Everyone has rules that they live by. We brush our teeth every day. We wear a seatbelt. These are rules that govern our daily routines — a personal code of conduct. Making rules that govern exercise and eating can be incredibly effective. A personal rule that has worked really well for me: No fast food, ever. It's very simple, but it's a good example of a hard-and-fast rule that has been effective in helping me keep my weight in check.
Another effective strategy is to make a list of everything that could get you off track with eating or exercising and then develop a "Plan B" for each item on the list. Your exercise partner is sick. What's your Plan B? You're on vacation. Plan B. You sprain your ankle. Do you have a Plan B? The longer the list of scenarios you can come up with, the better. If you can plan for something, you have a much better opportunity to manage it. Think back in your past to things that have gotten in your way before. Thanksgiving, for example, is a very challenging time for people watching their weight. What are you going to do this Thanksgiving?
Does a New Year's resolution work in strengthening the possibilities of success?
Sure, if you're thoughtful about how to set your goal. You have to make it achievable. And be honest about what you can achieve. If you haven't exercised since high school, running five miles a day is probably not an achievable goal. A reasonable goal might be a ten-minute walk on Monday, Wednesday, and Friday. You don't want to set yourself up for failure. Set a goal you can achieve. Once you do, you can graduate and reset goals across time.
The other part is to make your goal observable. It has to be something that you can measure. Don't use "lose five pounds" as a goal. Instead, think about what you need to do to lose five pounds, and make those your goals. It's the same with calorie intake. Don't say "I'm going to fast for five days to lower my calories." It's not healthy, and it's certainly not going to last in the long run. A better, more observable goal might be to lower your calories by 500 per day. The more specific you can be, the more likely you are to achieve your goal.
How would you define "healthy weight loss" or "healthy dieting?"
Truly, losing weight and maintaining weight is all about calories. Some people absolutely abhor foods that are generally thought of as healthy — fruits and vegetables, for example. So it's a bit of a dilemma. You're not going to be successful if you're forcing yourself to eat foods you don't like. We tell people to select foods that they like that will also help them stay in their calorie allotment. It's much harder to change people's food preferences than it is to change their calorie intake. Everybody's a little bit different. Sure, there are guidelines, but forcing someone to reduce their calories while changing their food preference at the same time? I don't think it works very well.
There's no data that shows that any of the special diets that have different ratios of macro-nutrients — like the Atkin's Diet — outperform each other at the end of the day. So, you should eat what you like while still maintaining your ideal calorie intake over a long period of time. Again, everybody is different.
What are the most difficult aspects of dieting and/or exercising? How should these challenges be confronted?
There's something very interesting about exercise. We know that it's a great predictor of long-term weight loss maintenance. So people who are good at exercising over the long-term tend to be the people who are most successful at maintaining weight. But as I continue to read and think about this, I've become personally convinced that being consistent about your calorie intake is the most essential aspect of weight loss maintenance. We know that 1200 to 1500 kcal/day is the general recommendation for maintenance of weight loss and is the amount of calories consumed by people who successfully keep weight off for years. But the reason that calorie intake is such an issue is that most people underestimate the calories they consume and overestimate the calories they burn. Also, the availability of high-calorie, good-tasting, low-cost food added to the bombardment of food advertising in our culture makes it really difficult to keep your calorie intake within limits. All this adds up, I believe, to make calorie intake the slipperiest slope in weight loss. Exercise seems like the easier part of the equation
What is your number one piece of advice for someone considering beginning a diet and exercise plan to lose weight?
The most important piece of advice... it is ALL about behavior — the number of calories you consume and the amount of physical activity in which you engage. So you must know how to change and maintain your behavior in these two areas — eating and exercising. If you don't have the explicit behavioral skills to do this, you won't be successful.