It is possible to plan environments in which residents can increase activity without thinking about it too much. Environments that support activity could include safe parks and biking trails near homes, building layouts that encourage the use of stairs, and walking (or pedestrian) malls. Several organizations and numerous websites offer information about how to build communities that encourage walking and biking. Among them are the Partnership for a Walkable America (PWA) (www.walkableamerica.org), the Pedestrian and Bicycle Information Center (PBIC) (www.pedbikeinfo.org), and International Walk to School (www.iwalktoschool.org). Information alone will not guarantee behavior change, but by offering environmental support, communities can encourage healthy living by making better choices easier.
Modifying lifestyle is changing usual routines. Change requires time as well as effort. Specifically, to accomplish a lifestyle change, someone must make time for it in his or her usual schedule. Consider two women equally motivated to incorporate a 30-minute walking session three days a week into their lifestyles. The first woman drives to her gym for a 30-minute walk around an indoor track, a drive that takes 15 minutes each way. By the time she’s done, she’s spent at least 60 minutes on her “exercise session.” The second woman lives in a neighborhood where she can simply step out her front door and walk for 30 minutes. Which woman is more likely to stick with her exercise routine and actually increase the number of days she works out in the future?
Hill (2006) proposes that personal responsibility that can be supported by even small changes in the environment offers the most realistic hope for progress.
Lifestyle
Regardless of genetic background or the medical treatments used, lifestyle choices about food and activity influence body weight. There are multiple physiological pathways in the human species that influence energy balance, and there are even more behavior patterns that influence energy balance in individuals. To make the task of supporting lifestyle change even more difficult, the mechanisms that drive behavior patterns are often not evident and more or less invisible to the person with the behavior. We hope that the difficulty in facilitating behavior change will not dissuade us from pursuing it as a viable (and effective) treatment option. If someone enters a clinic with an infection, do we just treat it or do we look for what is causing the infection? We look for the source of the problem. It is at least as important to look for the source of problematic behavior patterns before considering treatment options.
There are many reasons that prompt people to eat more than they need. Eating more than the body requires is “excessive eating” whether the food portions are large or the caloric content is high. For most people, an appropriate intake at 20 years of age becomes excessive at 40 due to changes in physical activity. Today, hunger is rarely the only reason for eating. Frequently, people eat because they are prompted by habit, because they feel pressured by social circumstances, or because they use it as a way to cope with discomfort.
An iceberg is a useful metaphor to describe the factors that influence obesity (see Fig. 2, below). We often only interact with the tip of the obesity iceberg—its physical components. Below the waterline are the true obstacles, the behavioral and genetic factors that drive obesity. We are able to make effective, sustained change at the tip of this iceberg if we can trace and address the underlying factors. Health care providers have the opportunity to help patients identify, address, and change the behavioral patterns that encourage excessive eating. The following sections describe reasons obese people report for accumulating excess pounds.
Figure 2—The Iceberg
Food Habits
Daily food habits often contribute to excessive eating and obesity. Much like a person’s genetic makeup, dietary patterns can be passed on from one generation to the next. Children who grow up with high-fat meals, routine snacking in front of the TV, and a well-stocked cookie jar are likely to continue those habits in their own homes, thus perpetuating excess weight regardless of genetics. Habits such as skipping meals, eating while driving, eating take-out meals, and drinking high-calorie beverages can all easily develop in response to tight schedules, family demands, fatigue, poor planning, or social pressure. Awareness, information, and support can help committed individuals change these habits. However, cravings complicate this process.
Cravings
One of the most common weight-loss questions is why is it so hard to stick with healthy behaviors, even when we know exactly how to eat well and know when we make poor choices? Eating is often affiliated with feelings and needs rather than with what we know to be healthy habits. When excessive eating satisfies underlying needs, those needs must be addressed during weight-reduction treatment or they will obstruct weight loss and interfere with sustained efforts to lose weight.
Figure 3 organizes motives for excessive eating from the iceberg (Fig. 2), similar to Maslow’s motivational hierarchy of needs, where a need motivates behavior (Maslow 1968).
Figure 3—Excessive Eating and Maslow’s Motivational Hierarchy
Craving, which often leads to excessive eating, is associated with “faulty” hunger awareness, which arises from different biological and psychosocial needs. The biological function of eating—to provide energy for life—has changed. We expect food to satisfy other human needs. People eat to build a sense of security, affinity, or self-actualization. Thus, to alter the reasons for excessive eating, an obese or overweight person has to discover what function excessive eating serves. There may be a way to make these cravings unnecessary or to create a sense of satisfaction with something other than eating. Emotional reasons for cravings sometimes overlap. The following categories of cravings are arbitrary, but may be helpful in identifying possible sources of cravings. You can find practical approaches to helping the patient solve these issues in chapter 17.
Stress
Many people eat in response to stress. According to the psychological definition, stress arises from an imbalance between a person’s perceived resources and perceived demands (Lazarus 1984). People look for coping skills that help them adapt to and manage that imbalance and may respond to stress with active or passive coping strategies (de Ridder 1997).
Henry (1977) describes active, problem-focused coping as a “fight-or-flight” strategy and passive coping as a “defeat reaction” or loss of control. Eating for comfort is a passive coping strategy (Popkess-Vawter 1998). Reports suggest that these cravings are due to the energizing power of sweets and the calming effect of fats (Wells 1998). Some evidence points to a relationship between the passive coping style and obesity (Hörchner 2002) and with the release of the cortisol hormone (Bob 2008), which is associated with central obesity, type 2 diabetes, and other components of the metabolic syndrome (Ljung 2001, Phillips 2010).
Research shows that obese people use passive coping more often than active, problem-focused coping (Rydén 2003). Hunger has been associated with feelings of hopelessness (Chilton 2007). Eating may offer a way to escape problems that are perceived as too difficult or impossible to solve (Popkess-Vawter 1998). Obese women particularly describe eating as a way to feel better in stressful situations (Laitinen 2002). Due to the significant association between passive coping and central obesity, some researchers interpret abdominal fat as an indicator of hopelessness (Björntorp 1999).
Symptoms of stress can be physiological and psychological. If a person has coped with stress through excessive eating and then stops that eating without addressing the initiating stressors, other stress symptoms may emerge. Feelings of anger, irritation, isolation, and depression, along