In January 2006 I wrote an editorial called "Whatever Happened to Rubenesque?" about our country's obesity epidemic and noted, "I am, technically speaking, obese." I love good food, don't love vigorous exercise, and have a "genetic predisposition to gaining weight." I mentioned changes I'd made, including quitting smoking, getting a dog to walk, and following a nearly vegetarian diet. My lungs and lipid profile were in good shape. So, I asked, if I'm living a healthier life, why should I expose myself to the risks of bariatric surgery, diet pills, or purging? Isn't healthful living more important than being thin?
I received several letters in response, but one stood out. The writer argued that I was making excuses, that I just needed to eat less and exercise more. I wrote back, reminding her that I can devote no more time than the 30 to 60 minutes I already walk on most days and I eat healthfully, if sometimes too much. She maintained that I simply lacked the discipline to do better.
I responded again; eating less is not always easy, I said. Hunger and satiety are complex, particularly in light of genetics. She said again that I was making excuses. I was by now tired of the exchange, but it made me realize that nurses often believe that information is all patients need to change their behavior. If information were all I needed, I'd be skinny as a rail.
So I asked my primary care provider to send me to a nutritionist who focuses on behavioral change. She referred me to a nutritional coach, who's helped me lose more than 30 lbs. since May 2007.
What does she do? She uses motivational interviewing techniques (see "Motivational Interviewing," October 2007) and frames behavior in the transtheoretical model of change (see "Weight Loss and Diet Plans," June 2006). She's taught me about hidden calories (those pumpkin seeds that I thought were low calorie are roasted in oil, upping the calories). I'm not on a diet plan; instead, I focus on reducing calories and choosing good foods like low-fat sources of proteins, fruits, and vegetables. A study by Sacks and colleagues in the February 26 New England Journal of Medicine confirms that reducing caloric intake matters more than adhering to a specific type of diet.
I e-mail my coach every day with an estimate of the calories I've eaten and notes about my struggles. She writes back, "What do you think you could have done differently to get down to a reduction level?" or "Great day!!" She has me weigh myself daily and is teaching me to cope when higher numbers unexpectedly (but inevitably) appear. I see or talk with her every week or two. I'm losing slowly, and that's okay.
Nurses tend to weigh more than the general population. Does that affect patients' confidence in us as health advisors? And what does it do to the quality of our own lives? In the May 2008 Journal of the American Academy of Nurse Practitioners, Miller and colleagues report on a random survey of U.S. nurses. Of the 15% who responded, only 22% said they counsel patients about "healthy diet practices"; of those, 21% were obese and 31% were overweight.
How can we help patients lose weight if it's not working for us?
Nurses should be health coaches and educated for that role. But patient-teaching time is being reduced in many settings, so we'll have to fight for adequate time to do it if we're committed to promoting health. With our nation now considering how to improve the accessibility and cost-effectiveness of health care, we have the perfect opportunity to advocate interventions that work.
The nurse who wrote to me didn't understand how coaching can help, but she did move me to think about what else I might do to reduce my weight. It's just a shame that I had to go to a practitioner who isn't a nurse to find the solution.