A guest post by Catherine W. Britell, M.D.
Every health condition has a number of components that work together in a complex way to determine the balance between wellness and sickness in each individual. They include:
Genes – These are the traits that we inherit from our parents, handed down over centuries and honed by evolution to help us survive.
Cellular Environment – The environment of our cells is a result of many things, including the foods we eat, the medications, pollutants and other substances that enter our bodies, the exercise we do, and the chemicals and hormones our body produces.
Knowledge – The information we have about how to remain safe and healthy is obviously vital to achieving and maintaining wellness.
Emotions – When we are sick, it has a negative emotional effect on us, and conversely, our emotions can powerfully affect our health and health behaviors.
Social Milieu – Having adequate food, shelter and clothing, access to health care, social support and intimacy are all obvious and important determinants of wellness. And of course, when we are not healthy we become unable to provide for our basic needs, and also often become socially isolated and vocationally challenged.
Obesity is a condition where these multiple factors work particularly closely together. People who live with this condition are often painfully aware of each one of these factors as it relates to their overall well-being, and how they work together to diminish physical health, happiness, and social and vocational effectiveness. Almost everyone who is overweight or obese would very much like the situation to be otherwise. And most have spent many years, much energy and often many dollars on the quest for a “normal” healthy body.
Almost everyone who is overweight or obese would very much like the situation to be otherwise. And most have spent many years, much energy and often many dollars on the quest for a “normal” healthy body.
For many, this quest starts in childhood, when siblings or playmates or classmates often tease, bully, or just exclude the obese child (1,2). The child may be admonished by loving parents or a caring doctor to “cut down on the sweets and run around more”. From that point on, there are no more candy bars or after-school trips with friends to the A&W or the Dairy Queen. So, they go home alone and read a book. And at home, a “healthy” breakfast starts with a big glass of orange juice, followed by a bowl of Cheerios or granola and a banana and a lot of skim milk, while Mom lovingly packs a peanut butter sandwich on soft white bread and a big sweet apple for a healthy lunch. But no cookies like the other kids! And despite eating less than his/her thin friends (3) the child becomes more overweight, participates less in sports and games because of inability to keep up with peers, and perhaps becomes more socially withdrawn, hating being “different”, doing what s/he is told, but seeing the condition simply worsen.
A “healthy” breakfast starts with a big glass of orange juice, followed by a bowl of Cheerios or granola and a banana and a lot of skim milk, while Mom lovingly packs a peanut butter sandwich on soft white bread and a big sweet apple for a healthy lunch. But no cookies like the other kids!
Then comes puberty, where overweight children become overweight teens, or because of hormonal changes obesity first rears its ugly head. The emotional and social toll escalates many fold. Teens react to being overweight or obese in different ways. A few develop clinical eating disorders (4). Many become afraid to eat sweet or fatty foods, and fill up instead on low-fat starch, which quickly accelerates obesity. Many experience chronic low-level depression (5,) finding that a sweet soda or bag of chips or a candy bar will make them feel a bit better for a short time. Social isolation becomes the norm, with inability to take part in sports, recreational exercise, or other rewarding activities. Well-meaning parents and physicians offer advice that the teen has heard and often followed before to no avail, adding to feelings of inadequacy and failure. A few compensate with high academic achievement, while many others spiral into low self-esteem, and begin failing in school (6). Those who do well and apply to college may be passed over in favor of their normal weight poorer-achieving classmates (7).
Social isolation becomes the norm, with inability to take part in sports, recreational exercise, or other rewarding activities.
Fast-forward to adulthood, where the individual is likely a veteran of many a weight-loss program. The results always look promising at first; but after a few months, the weight creeps back up, despite compulsive adherence to whatever program s/he is doing at the time (8). As blood lipids and glucose and blood pressure gradually become more elevated, most follow their doctors’ advice to “eat less and exercise more”; while a few just give up. Many will make dieting a way of life, often reinforced by hunger, thinking that they are being “good” when they feel hungry. Many will end up and also spending many hours per week on cardio activities trying to burn off what few calories they take in. They may lose a few pounds temporarily, but as time goes on find themselves not only still overweight, but hypertensive, perhaps pre-diabetic, and dysphoric.
They may lose a few pounds temporarily, but as time goes on find themselves not only still overweight, but hypertensive, perhaps pre-diabetic, and dysphoric.
Many keep at the diet and exercise programs even though they don’t seem to work, because there doesn’t seem to be an alternative. Some fear that if they stop dieting they will balloon up to fatal, morbid obesity. Oftentimes, people who are chronically obese try adapt to their obesity, accept themselves as they are (9), and find attractive “plus-size” clothing. They push themselves to over-achieve and compensate for the social and job discrimination they may likely experience (10,11). They may develop other stress-related conditions as a result. They hunker down and power through, taking their antihypertensive and lipid-lowering and anti-diabetic medications as prescribed, trying to make the best of a difficult situation.
There is a constellation of psychological, behavioral and biochemical changes that result from trying with all one’s might to change one’s condition for the better, but in the end, not being to exert any effective control over the situation. It is often termed “learned helplessness”. This term was coined by psychologist Martin Seligman. In 1967, he performed a number of experiments with dogs (12). In Part 1 of the experiment, three groups of dogs were immobilized in harnesses. The first group (the “control group) were simply put in the harnesses for a specific time and then released. Groups 2 and 3 were the “study groups” and were in “yoked pairs.” If the dog was in Group 2 he would be given electric shocks that he could end by pressing a lever. Each Group 3 dog was wired in series with a Group 2 dog, and his lever had no effect, so he would receive shocks of identical intensity and duration as the group 2 dogs; but he could not control them. To a dog in Group 3, it seemed that the shocks were random and inescapable. Group 1 and Group 2 dogs quickly recovered from the experience, but Group 3 dogs learned that they were helpless, and exhibited symptoms similar to chronic clinical depression.
There is a constellation of psychological, behavioral and biochemical changes that result from trying with all one’s might to change one’s condition for the better, but in the end, not being to exert any effective control over the situation.
In Part 2 of the experiment, these three groups of dogs were put into a box where the dogs could escape electric shocks by jumping over a low partition. The dogs in the first two groups quickly learned to jump away from the shocks. The dogs in Group 3, who had previously learned that nothing they did had any effect on the shocks, would lie down passively and whine. Even though they could have easily jumped into the other half of the box to escape shocks, they didn’t even try. It is interesting to note that animals subjected to conditions that produce learned helplessness show marked differences in various pain and mood-mediating neurochemicals in their brain (13,14).
Now, being very interested not only in characterizing psychopathology but finding ways to cure it, Seligman did another experiment (15). He took the dogs in Group 3, who had learned helplessness, and put them back into the divided box, where they would get shocks in one-half of the box, but could escape by jumping over into the other half. At first, the dogs just stayed where they were, whined, shook, hunkered down, and endured the shocks as with the previous experiment. Then the experimenters tried calling the dogs to come to the “safe” shock-free side of the box. Still, they wouldn’t move. Finally, they put leashes on them and physically dragged the dogs to the shock-free side. After forcing the dogs to “escape” on the average of 25 times, the dogs finally became able to decide on their own to take control, jump over and escape the shocks. So, the only way to “cure” the learned helpless in the dogs was to force them to do an activity to avoid the shocks, again and again, until they finally learned that they were able to take control of the situation.
In humans, learned helplessness has been implicated in dietary behaviors; (16) and as a causative factor in the persistence of obesity in both adolescents and adults (16).
In humans, learned helplessness has been implicated in dietary behaviors; (16) and as a causative factor in the persistence of obesity in both adolescents and adults (16). This condition extends to health care providers as well. In one study of primary physicians, a majority believed that dealing with obesity and weight loss is frustrating, treatment for obesity is ineffective, and they felt that patients are not motivated to lose weight (17).
SANE offers a new level of control to a group of people, who, as described above, have likely developed a form of “learned helplessness” around their health, well-being and body composition. More than just a diet book, it is a program of “eating more and exercising less” in a particular way that has proven to be uniquely effective in turning around the metabolic conditions that conspire to maintain overweight and obesity. In many ways it is counter-intuitive and in many more ways counter to what physicians and their patients have been and are still being taught about the “calories in/calories out” theory of weight management. It promotes a significant behavior/lifestyle change that is simple, yet often challenging for many overweight individuals to make.
Importantly, it is not a “diet”; but rather a way of thinking about nutrition and exercise that results in lifetime behaviors that bring about dramatic changes in metabolism and body composition.
Importantly, it is not a “diet”; but rather a way of thinking about nutrition and exercise that results in lifetime behaviors that bring about dramatic changes in metabolism and body composition. At issue significantly is cognitive restructuring, so that the individual can move beyond old habits and wisely use the simple tools of basic, nutritious food and accessible exercise to achieve and maintain healthy functional goals.
In many ways, the SSoS program persistently and powerfully drags its participants toward appropriate lifestyle decisions, somewhat like Seligman’s dogs who learned that they could take control only after being dragged over and over again to safety. The book lays out the information in a straightforward way, then re-iterates it from a different angle, and repeats it in graphs and charts and diagrams, and then again in examples. Then the reader is brought to a rich website, with inspirational trailers, reader resources, book summaries, more charts and graphs, exercise videos, an overview, a 7-day diet plan, recipes, and a blog. There is a weekly webcast that re-iterates and expands the principles of the program in a conversational way, and a forum, where people have a chance to ask questions and share success stores. They are drawn in not only as consumers, but as valued members of a mutually supportive information-sharing team.
What is unique about this program is that it does not tell the individual what to do. Rather, it lays out information that allows people to make informed lifestyle decisions and empowers them to move forward and reap the multiple benefits of that change.
What is unique about this program is that it does not tell the individual what to do. Rather, it lays out information that allows people to make informed lifestyle decisions and empowers them to move forward and reap the multiple benefits of that change. And because the program works, the participant gains steady strong reinforcement for sticking with it. The thing that initially attracted me to this program both as a physician and as a participant, and keeps me involved and recommending it to others, is that aspect of empowerment and control backed up by an impressive body of knowledge. This, I think is potentially the very best antidote to the “learned helplessness” of chronic overweight and obesity.
About the author: Dr. Britell is a specialist in Physical Medicine and Rehabilitation who works as a health consultant and teacher. She is Associate Clinical Professor of Rehabilitation Medicine at the University of Washington.