Manuel had a problem with weight. He loved chocolate, donuts and potato chips, but he didn't like the effects that came with them. He hated being shunned by his peers, especially girls, but he felt that he couldn't stop eating the foods that were so unhealthy for him. He was not aware that he had an ongoing choice to eat or not to eat, and he felt out of control. His father, George, was overweight and kept a lot of junk food around the house. George had grown up with an abusive dad and took some of his anger out on Manuel. This left Manuel starving emotionally as the years went by. Manuel's mother, Jennifer, was also overweight. She loved to cook and always offered Manuel extra servings of food, and somehow this made her feel valued.
Other kids would tease Manuel and call him names like "gingerbread dough boy," especially when he was younger. He often felt hurt by these jabs, but he learned to hide his pain with a sense of humor. He might shoot back some half-hearted joke to let his classmates think their jokes rolled off his back, but he could not dismiss the pain that slowly grew inside of him.
When he was 13 years old, Manuel began to isolate himself in his room, gobbling down sweets while he did his homework and spent time on Facebook. Not only was he lonely, but he was starting to feel depressed. He longed for a girlfriend as he moved into his later teens and imagined that this would make everything better and brighter. Sadly, he was getting rejected when he reached out toward girls, and he knew it was due to his weight. He was almost 6 feet tall, but he weighed 300 pounds. As the teasing, staring and rejections triggered more pain, his caloric intake kept going up, and his self-esteem plummeted. His closest friend from school, Maria, was also overweight, although her problem stemmed from a different issue.
Maria's Weight Issues
Maria's mother was a CPA at a large accounting firm, and her father was an international pilot who was often away from home. They both worked long hours, leaving Maria home without adult supervision. Maria returned home from school around 4 p.m., and on most days she would spend the next five hours alone. To stave off the boredom that set in afterabout two hours, Maria turned to television. She sat on the sofa for hours on end watching movies and reality shows. During the commercials, Maria would go to the kitchen and find leftovers, cupcakes, crackers and chips to keep her busy munching while she watched television. Her walk to the kitchen was the most exercise she got after school. Recent studies show that there is a link between sedentary television time and childhood weight-gain problems, and aggressive junk-food advertising only adds to the dilemma.
Maria wasted a lot of precious time daydreaming that she would wake up one day and be slim, but that day never came. Many obese people are 5-star procrastinators who put off new diets "until tomorrow or next week." Getting fit takes action, and Maria was content to sit. Those long, sedentary hours were beginning to take a toll on her health as she gained weight from her chronic inactivity. She tried to motivate herself to begin exercising, but she quickly reverted to the comfort of watching television.
Some Facts about Obesity
For adults, obesity is defined as a body mass index (BMI) of 30 or greater. BMI is calculated from a person's weight and height and can indicate risk factors that may lead to health problems such as cardiovascular disease, certain types of cancer, diabetes and depression. Children are measured differently than adults, and according to the growth charts (2000 edition) from the Centers for Disease Control and Prevention, children are classified as obese when their BMI-for-age percentiles are at or above the 95th percentile. Children who are in the 85th to 95th percentiles are classified as overweight.
Maria and Manuel are not alone in their struggles to control their weight. Their cases reveal a disturbing trend among today's youth. Childhood obesity and the number of overweight children nearly doubled from the late 1970s to 2000, rising from 8 percent to 15.3 percent. The numbers are similarly stark among adolescents as evidenced by an increase from 5 percent in the late 1970s to 15 percent in 2000. Obesity rates in the U.S. are among the highest in the world, and California ranks high at about 41 in the state rankings. Estimates have steadily increased from about 15 percent in 2000 to 26 percent in 2007. Recently, some research indicates that the trend is leveling off, but we have a national problem with increasing American waistlines. Furthermore, studies indicate that African-Americans had a 51 percent higher prevalence of obesity, and Hispanics had a 21 percent higher obesity prevalence compared with whites. All of these trends could be greatly improved with healthy commercials, better jobs and positive parent involvement.
A study by the Centers for Disease Control and Prevention indicates these important facts:
- More than 75 percent of high school students do not eat the recommended servings of fruit and vegetables each day.
- About 30 percent of U.S. children do not exercise three times a week or more. People in poorer areas have less access to places where they can be physically active.
- An estimated 61 percent of obese young people have at least one additional health risk factor such as high blood pressure or high cholesterol.
Additional research shows that a large percentage of obese kids are depressed, although we do not know if obesity causes depression or vice versa. Experts are concerned that this growing trend will have a highly negative impact on the health and longevity of the next generation, and the healthcare costs will be astronomical.
Manuel's Visits to the Doctor
For Manuel, going to the doctor's office was becoming very unpleasant because all he heard there were lectures about diets and health risks.His father was also overweight, and his family had a history of heart disease. His physician, Dr. Bennett, said that his total cholesterol was seriously high at 350, and his glucose was in the diabetic range of 130. His HDL (high-density lipoprotein), also known as "good cholesterol," was about 35 and showed his lack of exercise. Additionally, Manuel had high triglycerides at about 110. His LDL (low-density lipoprotein) cholesterol was of serious concern at about 200, and Dr. Bennett brought up the subject of medication. Manuel was opposed to this and promised to start exercising. Dr. Bennett said that Manuel had a high BMI and was obese.Because of this, he was 30 times more likely to be diagnosed with coronary heart disease, stroke, gout, osteoarthritis, hypertension, asthma and/or even some types of cancer.
The doctor was trying to scare Manuel -- he figured Manuel could turn things around by joining a gym, but like many overeaters, Manuel was a procrastinator. He was headed for trouble and feeling pressured by his family when he decided to meet with me. His first girlfriend had left him for an athletic guy, and he felt devastated. I learned in the first session that Manuel was handling his pain by turning to his only source of comfort: sweets. At the time we met, Manuel was 17 years old and gaining more weight each month.
Manuel's Struggle with Food
After a couple of sessions, I learned that Manuel had good intentions, but he found it very difficult to stay with a diet. He would experience cravings and repeatedly give in to them because he didn't have any effective coping strategies to contain his cravings. When he experienced even a slight pang of hunger, he would almost automatically head to the kitchen, saying to himself "Oh, I'll have just one scoop of Rocky Road," but once he started, he ended up finishing the entire half-gallon. Manuel could easily forget about the ice cream after he had eaten it, which typically sent his parents into an uproar. His mother screamed at him, "You have absolutely no willpower and never think of the rest of the family." His father was also harsh and said, "You are going to be one of the fattest kids in the state." Relationship therapy could help Manuel and his parents establish a better relationship based on healthy communication and nurturing. Manuel was growing increasingly depressed, and told himself things like "See, you are just a loser, and no one will ever like you" and "You can't even stay on a diet for a day, and you'll never have any willpower." This is the typical distorted thinking of depressed people, and Manuel was starting to develop serious symptoms of depression. Research suggests that obese people experience major discrimination, and Manuel noticed how people avoided him or stared at him at school.
The Relationship between Obesity and Mental Health
Recent research indicates that obesity may trigger psychological disorders such as depression, distorted body image, low self-esteem, and eating disorders. David Kats, M.D., and his colleagues at the University of Wisconsin-Madison assessed the quality of life for 2,931 patients with chronic health conditions, including obesity. They found that clinical depression was highest in very obese participants. Evidence from the Swedish Obese Subjects study indicates that clinically significant depression is three to four times more likely for severely obese individuals than in similar, non-obese individuals. As the study suggests, many obese people are depressed and struggling with the following:
- a lack of motivation
- fatigue
- a lack of interest in normal activities
- hopelessness
- thoughts of suicide
- difficulty sleeping
- sadness and feeling blue
In my second interview with Manuel, I learned that his father had been overweight for years. When Manuel was growing up, his parents would remind him not to take third servings, but his father consistently did so. Manuel rebelled by sneaking downstairs at night and raiding the refrigerator. First, he would eat ice cream, and then he would search for chocolate. Manuel craved chocolate, which researchers now know improves mood. This "chocolate habit" began when Manuel was about 5 years old when he would sneak food into his bedroom and gobble it down.
Maria's parents, like Manuel's, also set poor examples at home. Neither of her parents exercised,and her mother would come home exhausted from work and simply plop down in front of the television to watch the nightly news. Of course her mother was only reinforcing the role-model status that television had gained over her daughter. Maria really missed her father because he was often gone for 10 days at a time, and she felt wounded by his lack of appreciation and understanding. Maria could not remember one loving thing that her dad ever said to her, and deep inside she felt unlovable. Her weight was ballooning, and like Manuel, she felt powerless to do anything about it. But Manuel learned about a new possibility that pulled him out of his depression.
Could Liposuction Be the Answer?
When he was 17, Manuel found a reason to feel hopeful: a new procedure called liposuction. He felt that this was the cure he had been waiting for, and he wouldn't need to exercise or cut back his calories. The doctor said Manuel was a good candidate for liposuction because he was very obese. Manuel believed that this would help him get another girlfriend, and that he wouldn't have to change his eating habits. Like many overweight Americans, he didn't really want to change, but he wanted the benefits of change.
A 2010 study in Journal Pediatrics found that about 590 teenagers between the ages of 13 and 20 underwent obesity surgery from 2005 to 2007 in California. The study revealed that the complications for teenagers were about the same as for adults. These included bleeding, infection, lung problems (post operative) and kidney failure while in the hospital. These procedures supposedly result in permanent weight loss; however, we do not know where these young people will be in 30 years. Manuel wanted the procedure, his mother had mixed feelings, and his father was strongly opposed thinking that Manual needed "to start working out and quit eating so darn much."
In order for Manuel to have the liposuction procedure, the doctor wanted an evaluation from a psychologist to determine if Manuel had realistic expectations about this procedure. In my opinion, Manuel's expectations were unrealistic because he believed that the surgery would magically take care of all his problems. It was my professional opinion that he needed to spend at least six months in an exercise program to gain some positive lifelong habits. I knew Manuel loved music, and research indicates that pulsating, high-beats-per-minute songs motivate people to move faster. Fortunately, Manuel was willing to commit to the seven-week program that would make a marvelous difference in his life. I only expected him to cut back on his calories after 8 p.m. and to work out four days per week for 30 minutes. Manuel needed to cut back on eating in the evening because he consumed a lot of calories late at night. Here are the five steps of my "Get Fit for Life" walking program that helped him get fit and feel good:
- Set aside 30 minutes to walk. I asked Manuel to decide on a time where he could set aside 30 minutes to walk. It could be in the morning, afternoon or evening, although I usually encourage people to exercise in the morning. Some research indicates that people are more likely to continue with an exercise program if they work out in the morning.Manuel decided to walk before he went to school, so he could get it out of the way.
- Decide on the distance. Manuel would determine how long his walks would be. He and I decided that 10 blocks around his neighborhood was a good start, and possibly 12 if he felt up to it. It was crucial to the program's success for Manuel to commit to walking at whatever pace he wanted. If he wanted to go faster he could, but when he felt like slowing down it was important to do so. Speed-walking and running were fine, too. The key was not to rush things, but to enjoy the walk. We were aiming to develop a positive addiction rather than overexertion burnout.
- Listen to upbeat music. During his 30-minute workout, Manuel would often listen to music on his iPod. Again, we were aiming to make the experience pleasurable. He decided he wanted to listen to upbeat music, which would drive away his pessimistic thoughts and help him move faster.One of Manuel's favorite CDs was "Black Star" by Mos Def and Talib Kwelli. He loved Lupe Fiasco and memorized the words to "Kick Push," and he especially enjoyed Zumba music like Shakira's song "Waka Waka" on the "Loca" CD.
- Continue for seven weeks then decide whether to go on. Manuel was to continue the walking program for seven weeks (49 days), and then decide whether he wanted to go on or quit. If Manuel decided he wanted to continue, he could commit to another seven weeks. After that time, he was free to decide what he wanted to do regarding exercise. This program increases the probability that many kids will stick with exercise because it supports a positive addiction.
- Don't beat yourself up for a missed day. Manuel did not beat himself up when he skipped a day of walking, but instead reminded himself that "everyone misses here and there." He and I then used therapy time to go over the ways that he sabotaged himself so he could understand himself better and really get with the program. Occasionally, he would start postponing his exercise and say, "Oh, it won't hurt to skip a day -- I'll just go longer tomorrow," so we nipped that habit with a change of thinking and behavior. Manuel was to get up at 7 a.m., no matter what he felt, put on his shoes and start walking. He could crawl out the door as long as he got moving and went the distance. He encouraged himself by saying "I can do this, walking is easy, and I can do things other people can't do."
The combination of relationship therapy, music, the guidelines for the "Get Fit for Life" walking program, and positive encouragement resulted in Manuel staying with his walking program. He often asked Maria to join him on his walks, and they would spend almost an hour walking while talking about their respective issues at home and school. Manuel reported feeling better, and he wasn't as hungry during the day. Although he was still obese, his clothes were getting baggy as his body got firmer, and he felt good about his change. Manuel had found a new habit that led him to sign up for a five-mile hike. As he became more fit, Manuel's self-esteem began to improve, and he felt better about himself. Teachers and classmates started to reach out and support him in his mission to get fit.
Some people say it takes 21 days to change a habit, but when it comes to developing lifelong exercise habits, I recommend seven weeks, or 49 days. Adding weightlifting to his daily routine helped Manuel become more fit, and he later decided to join a gym. He still had a long way to go, but he had made significant progress: he had lost 25 pounds and was more toned, he knew he could achieve goals he had never thought possible, and he seemed to have a new lease on life. Manuel was in relationship therapy for about six months building a stronger relationship with himself and later with his parents. When I last saw him, he had a steady girlfriend and had lost 90 pounds. Most importantly, he had personal health goals and a commitment to achieve them based on his success.
