Every year it happens: people come to me telling of what they are going to be doing different in this fresh new year.  People are going to stop smoking, start exercising, and (especially) lose weight.  This year, I am among the resolvers. Every year, most people fail.

Which makes me wonder what it is about us humans that allows us to act against what we know is best.  Why is it that educating people is rarely enough to fix a problem?  Why should we have an obesity "epidemic" when very few people really want to be obese?

I wrote a post about the use of shame as a weapon in society and how it is used against obese people.  It is one of my all-time most read posts, and the one that first got me in the NY Times (aside from that incident with the llama and Silly String in the airport).  Our society - and us physicians especially - are very fond of telling people things they already know in patronizing ways.  "You need to loose some weight."  "Smoking is very bad for you, you know."  "You and your teenager need to communicate better."

These things aren't wrong, but they are so obvious that our saying them implies  a: the other person is really stupid, b: they are totally uneducated and out of touch, c: they are weak, or d: all of the above.  One of the performance measures physicians will likely be measured by in the future is counseling about obesity, smoking, etc.  The problem is, our counseling does as much good as the billion New Years resolutions done every year.  It brings focus on a problem that the person obviously has trouble solving without giving a solution.  It's like me seeing a person with depression and telling them: "you know, you should really stop being depressed."

Duh.

The problem is one of understanding the true underlying problem.  Quitting smoking is actually quite simple; you just stop smoking.  But the problem is not quitting, it is wanting to quit.  The problem with the obese person is even more complex, as there are huge societal, physiological, and psychological factors that are encouraging people to eat more than their bodies need.  To simply tell them to eat less and exercise more fails to address any of the reasons why the person is eating more and exercising less (if that's the reason for their obesity).  Ironically, it's the person who is lecturing the obese person who has the real gap in understanding.

Come on, folks! 1/3 of our population is struggling with this!  Shouldn't that suggest to us that the problem is a little deeper than just "poor self-control?"  It's not an epidemic of stupidity or moral weakness.

So what can we do about these obese smokers who don't exercise?  The reason I feel powerless when facing people in the exam room with this because I cant make people want to change.  I've struggled with my weight over the years, mainly because there are periods of time my want for eating overpowers my want for taking care of my health.  During those periods, I want to want to take care of myself, and  I want to not want to eat as much. The battle rages in the area of my wants.  This is why people employ guilt and shame to get others to change: we hope it changes their wants.  It usually fails.

Here are some things from personal experience that have been most effective in helping people keep their resolutions:

  1. Don't make people feel inferior. One of the greatest benefits from having my own personal struggles is that I come at people already knowing that I can be a moron, so I am less likely to look down on their moronic behavior.  I have told patients that one of the best things about doing my job is that I get to see that everyone else is just as screwed up as I am.  Smokers, obese people, and non-exercisers are what they are for one reason: they are humans.  Would I really be a non-smoker if I didn't grow up in a house where nobody smoked?
  2. Let them know you realize their struggle is hard. It is simple to stop smoking, but it is also very difficult.  When I am helping someone overcome an issue like this, I am joining in on a very difficult task.
  3. Don't promise magic fixes. It would be nice if a pill would make us thin.  It would be great if somehow I could suddenly want to exercise more.  I personally crave easy answers for my problems because I don't want to do the hard stuff.  But my life is defined far more by the hard things I accomplish than by easy ones.  I used to recommend the Atkin's diet and prescribe diet pills.  They worked only until people stopped using them, but 99% of the weight loss accomplished in this manner would be gone in a year.  Why?  Because changing wants is not done by magic; it is done by hard work (usually).
  4. Keep focus small. Weight loss is not a good resolution because it is not directly in a person's control.  Eating better is under control to some extent because people can choose to do it.  But the best goal is to eat a good dinner tonight.  Tonight is far more in our control than next week.  Advice should focus on this as well - keeping things practical.

OK, it sounds like I am a real expert.  Well, I am an expert at trying and failing.  I am an expert on knowing what doesn't work.  I can communicate with others, but those donuts still hold an amazing sway over me.  I still don't exercise much because getting up at 5:30 AM sounds like purgatory and I am too tired at the end of my day.

Well, I am resolving to do better.  I am resolving to take better care of myself and to be a better person.  But to fight and win these battles it will take a lot of time, a lot of failure, a lot of help, and a lot of resolve.

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