Christy, Adelle & Helen

A short article about a famous super-model seems such an unlikely trigger for my recent dilemma over my professional focus. Christy Turlington is well-known for her perfect features and glamorous, lithe body more than she is known for her intellect, depth or public health work. So it is odd that reading the Beauty and Soul column about Christy's second career, during a casual flick through an old Vogue magazine, soon had me scrambling for the words to articulate my own passion for working in the field of obesity and weight management.

Christy's perspective about her new career in public health, focusing specifically in maternal health in developing countries, was intriguing. She mentioned the tipping point for her new focus being the complicated birth of her daughter. When she learned that the same complication would've been fatal in a developing country, Christy became committed to improving maternal health world-wide. She became passionate about the endless complexities of public health --"Maternal deaths mean there are very serious things going on under the radar about women's status". Along with obtaining her master's degree in public health, Christy is leading a film project following mothers and the people who care for them in Bangladesh, Tanzania and Guatemala.

Knowing that if I was similarly interviewed I would likely be at a loss to articulate why I've been working for the past 20 years in weight management and obesity was a little depressing. Looking back, my own tipping point was probably reading Adelle Davis' book "Let's Eat Right to Keep Fit" when I was 16. Adelle was clear: our choices can either optimize or be detrimental to health and well-being. And these choices are not usually big and momentous decisions but the culmination of many small, frequent daily decisions. Good health is not bestowed on us but something that we can impact ourselves. Over the years, I've become more fascinated by the endless complexities of food choice decisions and eating routines, as well as their interplay with good health. When talking about focusing on the fundamentals -- birth and death --Christy states "I am fascinated by those transitions that are so important and that we completely numb ourselves to" . I believe we are also chronically numbed to the day-to-day fundamentals of eating routines, food choices and our relationship to food.

So if Vogue magazine comes calling for an exclusive, in-depth interview with me, maybe I will have something to say about my professional focus. Obesity rates are reflective of our daily routines and choices. Unraveling the complexities controlling those choices and routines is the most satisfying aspect of my work. Of course, I might just have to do something interview-worthy while waiting for the call.

Food and Table Rules

Michael Pollan, of "In Defense of Food" fame, has started a new project. In his last book he cautioned us to "Eat food. Not too much. Mostly plants". For his new book project he is soliciting our input on rules for eating. He believes that it is important to preserve the cultural wisdom around choosing, preparing and eating food. Sayings such as the Japanese "hara hachi bu" (eat until you are four-fifths full) and the German "tie off the sack before it is full" are examples of traditional ethnic advice to stop eating before becoming completely full. Some of the funnier ones people have quoted include "No white food after Labor Day... or ever", "No dumpster cheese" or Miss Piggy's "Never eat more than you can lift" rule.

His request reminded me of a strategy I've used with parents when we discuss healthful eating. Originally an ice-breaker activity, I uncovered some interesting obstacles to enjoyable family meals with the question "what table rules did you grow up with?". As an example, I would share that in our family we had a "no singing at the table" rule thanks to a sister with her sudden off-key, raucous opera-like singing outbursts that clearly needed to be stopped. One father shared his boarding school experience of the "clean plate" rule which included his fear of a teacher who stood over him till the last bite was downed. Another parent shared a "no talking" rule while another admitted to frequently breaking the "no talking with your mouth full" rule.

It is fascinating to talk with parents about their childhood table rules because they now set the table rules for a new generation. Some steadfastly maintain their childhood rules - I know my mother would appreciate that I mandate the "no elbows on the table" rule - while others have rebelled completely and refuse to set any rules. Many times, I've had to explore the origin of table rules or lack of table rules to help parents build useful boundaries for their child's eating habits and to set the stage for more enjoyable meals.

As we encourage our patients to have family meals as a strategy to increase healthful eating, it might be important to also discuss table rules. If nothing else you might uncover some amusing rules and anecdotes. I know my son will enjoy telling folks the story behind his mother having to mandate the "no naked people at the table" rule.

Reflection - a radical concept?

courtesy iStockPhotos
Last week I was part of an interviewing panel for a new first grade teacher at my daughter's school. I love to participate in things like these as I get a first hand view of another manager's interviewing process which inevitably helps my own hiring strategies.

First, we spent time bringing clarity to the job role and determining the questions that would uncover the right person, right fit for the job. Always time well-spent and very insightful to hear different stakeholders' perspectives. Then after the interviews we discussed our interpretations of the candidates' answers and body language and debated merits and drawbacks. Again, another insightful activity.

There was one point in the lively post-interview debate that caught my attention. It was pointed out that a candidate might be too entrenched in her ways and may not be sufficiently reflective to notice when curriculum changes are necessary to enhance student learning. Apparently, teachers in this school are expected to be self-reflective. It is seen as a valued and critical skill necessary for effective teaching.

What a concept! How often do we, as health care professionals, spend time reflecting how we are conversing with our patients? We are teachers too yet do we give sufficient thought to our "curriculum" or typical education points? Just how well are our current strategies working for us? Yes, we might lament that patient X just doesn't get it or that patient Y is resistant to change. But that isn't self-reflection about the things that we are doing or the things we can change.

Just remember when reflecting on your own teaching style, information-sharing techniques, and patient skill-building strategies it is necessary to do it from a results-perspective: how well are your patients doing under your current education strategy? As one of my colleagues would always say when working with a resistant patient spending lots of time justifying inaction "and just how well is that working for you?"

Mapping a conversation

Whether the disease is diabetes, heart failure, asthma or obesity, there is a lot of information that we think is necessary to share with our patients. Unfortunately, none of us have truly perfected the art of sharing that information in a way that universally makes sense to our patients. Maeve Binchy, in her latest book Heart and Soul, eloquently highlights the stories heart disease patients might tell themselves when faced with the doom and gloom of their disease diagnosis. The wise healthcare provider will hear these stories before engaging in any dialog about diets, medications and other disease-based to dos.

Fortunately, disease management organizations are looking for ways to improve the dialog between healthcare provider and patient. Many are embracing the health coaching model and enhancing their use of motivational interviewing or change talk. Lately I've seen reference to conversation mapping in the education arsenal. Medication manufacturer, Merck, has funded work on conversation mapping. Building on this work and in partnership with the American Diabetes Association, Healthy Interactions has developed the U.S. Diabetes Conversation Map Tool (R). This tool has most recently been incorporated into Kaiser Permanente Mid-Atlantic region's diabetes education curriculum. The tool (a 3 x 5 foot table-top visual display) acts as a conversation enhancer allowing a trained facilitator to use the patients' perspectives to guide the discussion and help lead participants to make sustainable lifestyle change to better manage their disease.

Conversation mapping has been around for awhile and is used frequently in organization, research and social media fields. It is a modeling process used to explore complex and ill-defined issues. It can help frame key perceptions that prevent consensus and action-oriented work in a certain area. Conversation mapping can explore the inherent tensions and problems related to changes. Better yet it can frame the various elements of the ‘root definition' of a problem.

Just imagine having the perspectives of policy makers, scientists, physicians, medication and/or surgical device manufacturers, psychologists, dietitians, nurses, town planners, food manufacturers and patients all around the table discussing the future action to take to stem the obesity epidemic? Imagine a conversation mapping tool helping these folks, with many different and divergent perspectives, navigate the complexity of the obesity epidemic to come to a unifying approach for action? What would that conversation LOOK like?

As it turns out, visualizing a conversation isn't that hard anymore. Wordle makes it very easy to "see" a conversation by creating word clouds - the larger a word is in a word cloud the more often it has been repeated. People have been using it to map email threads and Twitter feeds. Possibly we should be using this tool more often. Perhaps evaluating the effectiveness of our conversations or uncovering the focus of our beliefs. Is what we are saying aligning with what we think we are saying? And if we were to "word cloud" the text of our portion of a conversation with that of our patient's portion of the conversation - would it look divergent or similar?


Please note that the word cloud above is from this blog post and was made at http://www.wordle.net/.

Rational Conversations

The other day, Seth Godin, top marketing guru, wrote a post about rationality in marketing. He could just as easily have written about rationality in obesity conversations. Certainly the frustration level is the same. The marketer has done the research, refined the product, gathered the testimonials, made the brochures and yet the customer (acting "irrational") ignores the sales pitch and buys from another company.

Switch "health care provider" (e.g. physician, nurse, dietitian) for "marketer" and you can see the similarities between the 2 scenarios. The healthcare provider has collated the patient's information (e.g. BMI > 30, labs look like pre-diabetes, blood pressure risky), provided the health assessment and suggested next steps (i.e. lose weight sensibly, join this program, consider surgery etc.). And yet, the patient ignores the "sales pitch" and goes with the other company. In this scenario, the "other company" might be trying some risky quick diet regimen, drug or ignoring the advice altogether.

The marketer's frustrations is very similar to the healthcare provider's frustrations and leads both to consider the rationality of the customer/patient. Afterall, how could a person not make changes in light of all the convincing evidence presented? As Seth Godin puts it:

The problem is that your prospect doesn't care about any of those things. He cares about his boss or the story you're telling or the risk or the hassle of making a change. He cares about who you know and what other people will think when he tells them what he's done after he buys from you.

The opportunity, then, is not to insist that your customers get more rational, but instead to embrace just how irrational they are. Give them what they need. Help them satisfy their needs at the same time they get the measurable, rational results your product can give them in the long run.

The obesity-related conversation can switch to one based on developing understanding and rapport. It might be an opportunity to explore ambivalence to change or eliciting change talk. Getting frustrated or even worse blaming the patient likely will lead to a stalemate. Your patients need you to help them change not to challenge their rationality.

Are we having the right conversations?

Recently I've been thinking a lot about conversations or more specifically how frequently we have the wrong conversations about obesity. This really hit home to me when I attended an obesity forum at the Democratic National Convention last August. The Obesity Society sponsored the event and there was an impressive panel of both policymakers and obesity scientists. Given the role that the obesity epidemic plays in this nation's healthcare woes, the forum was very timely.

However, timeliness and relevancy weren't enough to carry the conversation to a useful outcome. Very quickly, it was obvious that although a conversation was taking place, no one was listening. Strange nuances occurred: the scientists spoke about the potential impact of the obesity "tsunami" and the policy makers spoke about their personal experiences with food and weight issues. The policy makers were concerned that people aren't cooking any more and kids have nowhere to play. The scientists spoke of complicated webs and cautioned that there are no easy answers. No one had an adequate answer for the intrepid journalist from the Congressional Quarterly who asked about the opportunity for taxation on junk foods. There was definitely an air of defeat at least among the some of the scientists.

Since August, I've paid closer attention to how we are discussing obesity issues at all levels - global, national, local and personal. What is the right conversation for scientists to have with policymakers? What has to happen for both sides to listen and collaborate with each other for a useful outcome? What are the markers that will really inform us that actual change is taking place?

A couple of organizations working on ensuring the obesity conversation is kept alive - Strategies to Overcome and Prevent (STOP) Obesity Alliance and the National Campaign to End Obesity. Check out their web sites and see what you think about whether the conversations are the right ones to have.

What does "Everything in moderation" really mean?

As I have mentioned before, weight management "tips" annoy me. I'm especially annoyed when a tip is repeated so often that it takes on a mantra-like quality. Take "Everything in moderation" for example or even the American Dietetic Association's mantra "All foods can fit". How often have you heard this type of advice? More importantly, how useful has it been for you?

"Everything in moderation" implies that you do not have to give up your favorite foods but you should be careful about how much you eat. The evidence comes from the energy-balance equation: if you take in fewer calories than your body needs then the body dips into its own energy stores (often fat stores) and over time, the scale shows a sustainable weight loss. Therefore, you can eat any food as long as you don't eat more calories than you burn. The evidence is that weight loss follows a reduction in calories, i.e. the tip's evidence is based on physiological rather than behavioral evidence.

However, if by trying to be moderate, you commit to serving yourself just one handful of potato chips AND you can't stop at one handful then you have exposed yourself to more calories than you needed and your weight loss goal just slipped further away. The "Everything in moderation" mantra just backfired: Your behavioral tendencies ruled the day. You may have been better off not trying to be moderate with the potato chips.

Gretchen Rubin, at the Happiness Project blog, talks about the usefulness in knowing whether you are a "moderator" or an "abstainer". According to Gretchen, some people just do better if they go cold turkey when trying to make a key behavior change. For example, an "abstainer" might be more successful by not having any potato chips at all. A "moderator" might feel deprived going without potato chips so just having a 1-handful portion might be a more successful strategy. Knowing whether you are a "moderator" or an "abstainer" might just help you figure out why your calorie reduction strategies haven't worked in the past and develop the right strategy for the future.

Or even better, as an "abstainer" you can smugly feel confident and guilt-free when your "moderator" friend admonishes you with "Everything in moderation".