Obesity, defined as a body mass index (BMI) greater than 30 kg/m2 (Centers for Disease Control and Prevention [CDC], 2016), is an epidemic problem in the United States. Figure 1 shows obesity rates, revealing a higher prevalence in Midwest and Southern states. Overweight is defined as a BMI greater than 25 kg/m2. In 1991, the prevalence of obesity in the United States was 12% and approximately 25 years later, the rate rose to greater than 38%. Now, 70% of the adult population in the U.S. is either overweight or obese (CDC).
Many health risks are associated with obesity: diabetes, hypertension, coronary artery disease, infertility, cancer of the breast and colon, menstrual irregularities, negative perinatal outcomes, and dyslipidemia. However, the risk of complications can be reduced through diet modification, weight control, and increased physical activity, all of which improve BMI measurements (Fitzpatrick et al., 2016).
Early screening and diagnosis have always been essential components of care for those with weight issues, but obesity is a highly stigmatized issue that can be associated with bias and shame (Forhan & Salas, 2013; Swift, Choi, Puhl, & Glazebrook, 2013). An obese individual may feel less self-esteem or depression, and hesitate to ask for assistance with weight loss. Individuals may perceive their weight as appropriate or think they do not have a problem if their healthcare provider does not address weight. The idea that one is normally weighted may be reinforced in the faith community, if much of the congregation is overweight or obese. Food and eating behaviors are essential parts of church life, and norms for eating are reinforced in church settings.
Healthcare providers may be unsure how to initiate weight loss discussions (Swift et al., 2013). Lifestyle modification requires significant changes that are difficult to address (Swift et al.). In addition, people who have weight issues often know they need to make behavioral changes but struggle with or do not know how to incorporate a healthy diet and exercise into their life (Sherson, Yakes Jimenez, & Katalanos, 2014).
Permanent lifestyle changes are difficult. However, faithfulness to God and to a vigorous and nourishing existence calls one to consistency, surrender to God, and deliberate healthier decisions. Faithfulness is a consistent, regular choice to do something. It is a routine that demonstrates what people ultimately depend on and value in family and friends. Faithfulness is revealed in daily habits. Individual and community faith commitments and actions make significant contributions toward living a Christian life, which includes a life full of health.
Nurses provide care in multiple roles and are ideal professionals to aid people in making lifestyle changes. Faith community nurses (FCNs), who specialize in health promotion and disease prevention, with an emphasis on spiritual care, are in a perfect position to support lifestyle modification (American Nurses Association & Health Ministries Association, 2017). FCNs can promote healthy lifestyle changes and offer spiritual support to those who are obese. In addition to FCN practice, other nurses and primary care providers need to address this epidemic in a loving manner, and all need tools to work effectively with weight loss.
ADDRESSING LIFESTYLE MODIFICATIONS
Habits are formed by consistently repeating behaviors. The frequency of a chosen behavior creates deeper neural links within the brain (Lazaridou & Pentaris, 2016). The responses become automatic, uncontrollable, and frequent enough that the individual feels guilty after the unwanted behavior, such as between-meal snacking, overeating, or being sedentary (Lazaridou & Pentaris). The self-perception of obesity is influenced by what is learned, observed, and experienced (Sherson et al., 2014). These choices, whether healthy or unhealthy, are influenced by peers, family, and cultural norms. Lifetime behavior change and continued motivation require substantial enthusiasm and focus to achieve and maintain an ideal body weight. This behavior change may begin as a need to lose weight, but the motivation to continue lies deep within an individual. People need to believe they have the ability to change in order to achieve a goal (Sherson et al.). This takes faith and trust that change can elicit desired outcomes.
What is the role of Christian faith in behavior change? Learning to physically and spiritually walk with God should be a goal of all Christ-followers because faith and faithfulness are interwoven (Matthew 25:21). Jesus calls us to have faith and be faithful servants. Faithfulness emphasizes the inside self, and faith focuses outside the self upon an object that is believed or trusted in. Faithfulness is how reliable or trustworthy I am; faith is how reliable and trustworthy the object is that I am believing in, and is usually not visualized (Rasco, 2012).
According to 1 Corinthians 5:6-7, one should learn to walk in faith, believing God will lead down the right path. One should be faithful to the God who never falters or leaves, having faith that he will provide strength and endurance to achieve the desired habits and goals. Hebrews 10:38 mentions living by faith in God's Word and promises. Each of us should try to learn to walk in the Spirit by displaying a spiritual life every day. To be changed physically and spiritually, one must show enthusiasm and possess motivation and faith that God can help. Trust is essential to faith and obedience. When we trust God, we acknowledge that God knows what is best (Rasco, 2012). Colossians 3:10 states, "Put on the new self, which is being renewed in knowledge in the image of its Creator" (NIV).
WHAT IS BIBLICAL FAITH?
Like people facing significant weight loss, Noah's story in Genesis 6-9 reveals God's plan of success when faced with unsurmountable odds. Noah believed he was doing God's work, which allowed him to withstand intensive labor and challenges. God called Noah to an enormous task because he saw the faithfulness of Noah (Genesis 6:14). The ark is literal, yet, could symbolically be a monument of faith.
As Noah physically hammered to build the ark, he built on the foundation of his daily walk with God. He saw the confirmation of God's faithfulness, as he chose to go against his generation (Rasco, 2012). Hebrews 11:7 mentions how Noah built the ark in holy fear because he was "warned of things not yet seen." Noah had many doubters but had faith that God told him the way to prepare and achieve the overwhelming task. It took Noah's faith, motivation, and enthusiasm to guide him building the ark, then in the water with no land in sight. Noah's family was affected by his decisions, and he was affected by their support.
Noah's story reveals it takes strength of mind and character to make decisions that have a lifelong impact. He began God's journey by taking 100 years to build an ark with his family, piece-by-piece, day-by-day. It took commitment and faith. In struggles with obesity, it takes commitment to change negative health behaviors and maintain positive ones. Family and friends can assist in weight loss like Noah's family committed to him and God to build the ark.
Another faith exemplar is the story of Elijah in 1 Kings. Elijah consistently chose faith by being steady, dependable, regular, deliberate, and faithful to God in the obstacles he faced. The obstacles were seemingly impossible for Elijah, including the prophets of Baal and rebuilding the altar of the LORD (1 Kings 18). However, he had an unwavering trust in God to remain true and steadfast.
Elijah was a servant of God, deliberate in his obedience to God's commands. Some days, making a conscious effort to live for God is easy; other days, we find ourselves, like Elijah, alone. Elijah's story inspires Christians today to consistently make better choices and allow God to mold us into what he wants us to be (Rasco, 2012). Hebrews 11 highlights other ordinary people who were heroes of faith, painting a variety of pictures that illustrate what it means to walk by faith-inspiring people to walk with God, listen to his voice, and surrender to his will for our life.
CHALLENGES TO CHANGE
Learning to control and modify formed habits can seem like an impossible task. Significant change affects people on all levels: physically, psychologically, and spiritually. Physically, obesity must be controlled for the body systems to function properly. To make changes in diet and increase physical activity, a person needs a mindset focusing on the end result. Lifestyle changes require learning how to self-manage a new lifestyle and have faith that the desired effect can be possible. Psychologically, individuals may feel guilty for the history of overeating frustrated with the repeated circle of dieting and weight gain. Spiritually, individuals may ask God questions such as: Why am I fat? Why can't I manage my life better? What is the purpose of my life?
Those who rely on God can pray for personal strength and build on their assets. By focusing on areas of strength and visualizing past success, a person can identify areas of weakness and ask FCNs or other providers for assistance in developing a health plan conducive to weight loss. As in Noah's and other stories of faith, all had faith in God to lead them safely through what was to come. Those with faith can trust that God has a plan and ask for help to make lifestyle changes.
Exploring how overweight and obese individuals feel about their spiritual life can aid weight management. Faith does not need to hinder believers into thinking about their worthiness to stand before God, but help them realize God's love will strengthen them to grow. His love is not dependent on whether the goal is reached. Rather, God lovingly approves of the mind's acceptance of the need to change (Romans 12:1-2; 1 Peter 2:5). Over time, others will view the steps as directed by a focused, faithful individual, whose actions are governed by a consistent call, and a life that reflects the Holy One.
Lifestyle choices come at least partially from formed habits. A circle of events including a cue, a routine, and a reward occurs when a habit begins (Duhigg, 2012). A habit begins with a cue or sensory prompt from the brain. A routine involves an action from the cue to achieve a desired effect. The reward is the accomplishment of the desired effect. In obesity, the brain seeks to reward the body for smells, hunger pangs, and emotional issues. A continuum of overeating is created. To change this unhealthy habit, self-awareness and choices must be controlled to reach the desired healthy outcome. It requires a substantial commitment to modify habits. FCNs can help individuals identify cues, routines, and rewards, to change unhealthy eating habits to those conducive to weight loss.
The mind is a powerful contributor to the habits of eating and weight loss. Failure to modify negative habits of overeating and/or lack of exercise likely mirrors past responses, rather than a lack of knowledge or willpower (Shaw, Caughey, & Edelman, 2012). An FCN can use Scripture to reinforce this principle. The apostle Paul understood the difficulty of changing habits. In Romans 7, Paul said he acted automatically in some instances, even though he desired a different action, affirming that repetitive habits are difficult to change. Habits are multifaceted and include spirituality, individual health beliefs, and cultural norms (Sridhar, 2013).
Changing how a person conforms to the world is another obstacle contributing to habit formation. Choices are influenced by family, friends, acquaintances, and other outside sources, such as media. Over time, choices become habits, and habits become ingrained into daily existence. Habits turn into hardly recognized automatic responses because they have become instinctive.
Changing habits requires determination to alter the way one sees him- or herself. Romans 12:2 instructs, "Do not conform to the pattern of this world, but be transformed by the renewing of your mind" (NIV). Negative confirmation comes from unhealthy influences that aid in creating bad habits. Overweight and obese individuals need to learn new ways to control and adjust that confirmation to produce lasting positive transformations. This can be accomplished with seeking help from healthcare professionals who believe and trust in God's Word. FCNs are first-line providers in recognizing and addressing this need for help.
Weight bias, discrimination, and stigma are other challenges to managing obesity. Matthew 7 teaches not to judge; yet, some hold the individual solely responsible for obesity. Jesus mentions not to look at the speck in another's eye because the judging person may have much bigger issues (Mathew 7; Luke 6). We should first judge ourselves and recognize our own problems, then approach others with love and humility. Clinical judgment of weight bias has been shown to bring about shorter annual health visits, less nutritional counseling, providing fewer or no specifications on interventions, and offering fewer health screenings (Forhan & Salas, 2013). All healthcare providers should identify obesity, and without judgment, offer counseling and support in love and humility to individuals who seek to live a healthier life.
5 A'S MODEL FOR BEHAVIOR CHANGE
The 5 A's Model is a newer tool that can be used to encourage behavior change, the first step in managing weight loss. This patient-centered, holistic model was developed to be used during clinic visits and implemented in 5 to 10 minutes. The 5 A's are for Assess, Advise, Agree, Assist, and Arrange (Fitzpatrick et al., 2016; Sherson et al., 2014).
Because weight is a multifaceted and sensitive issue, discussions about weight can be perplexing for healthcare providers. Many do not know how to communicate about weight while supporting patients in an empowering, nonjudgmental, and encouraging way. Moreover, conversations about weight will influence patient engagement in weight loss efforts. Many obese patients are not informed that they are overweight or obese. Patients who are informed (Assess) are almost nine times more likely to concede their weight is detrimental to their health, than those who are not informed (Sherson et al., 2014).
Providers who Assess a patient's weight and Advise the patient on how to lose weight can have a substantial impact. Counseling should begin after assessment of weight, height, and BMI. Counseling can begin with the first visit when obesity is diagnosed and can be simply stated that the patient needs to decrease total caloric intake and participate in a regular exercise regimen. Once the patient Agrees there is a weight problem that needs to be addressed, the provider can follow up with Assisting and Arranging weight loss visits. A mutually agreed upon timeline for attaining a specific goal aids in motivation and enthusiasm.
After the initial visit, schedule follow-up visits to offer more detail about calorie reduction and amount of exercise needed to produce the desired weight goal (Assisting). Typically, a net reduction of 500 calories daily, plus 30 minutes of cardiovascular activity, such as walking, 3 to 4 days per week, is a beginning goal for weight loss (Rogge & Merrill, 2013). Encourage daily water consumption of one half of the patient's bodyweight in ounces (Popkin, D'Anci, & Rosenberg, 2010). For example, a patient who weighs 200 lb should drink 100 oz of water daily for effective weight loss.
Patients occasionally need medication to aid in weight loss. This should be mutually agreed on between patient and provider (Agree). Medications approved by the Food and Drug Administration (FDA) for weight loss can be considered, based on the patient's medical history (Table 1). Weight loss medications are for use in those with BMIs of 27 or greater, when there is at least one other risk factor (such as diabetes or high cholesterol) present, or in patients with no other risk factors who have BMIs of 30 or greater. Typically, medications are only for short-term use.
Arrange stands for the consistent monthly follow-up visits, where the provider and the patient evaluate habit change and reset goals, thus increasing accountability. In follow-up visits, providers should assess the patient's progress, review self-monitoring records, help the patient problem-solve any barriers encountered since the last visit, and review progress on habits changed. The pace of weight loss differs, with some losing 1 to 2 pounds every week, and others experience up and down weight fluctuations. Patients with slow or minor weight loss in the first few months can be referred for more intensive counseling with behavioral health or nutrition providers (Fitzpatrick et al., 2016).
It is not difficult to see how this model could apply to the faith community setting and help FCNs organize their practice. Using the principles in one-on-one, health-oriented conversations is a direct application. The FCN also can design a comprehensive program to address obesity in the congregation, using the 5 A's as a framework. A 5-week set of small group meetings, one for each A, can be offered. This provides a progressive and incremental approach to walk a group of congregants through an obesity intervention. Additionally, the group can provide support and accountability to each other, and even lead to the formation of a permanent health promotion support group. For those who need more assistance, the FCN can make referrals to outside support groups, dietitians, and primary care providers. Sidebar 1 makes application from one FCN to herself and her faith community. Sidebar 2, offered online as supplemental digital content at http://links.lww.com/NCF-JCN/A57, discusses using a writing assignment and research project to teach faith community nursing and weight management to undergraduate nursing students.
CONCLUSION
Many challenges present themselves in helping those living with obesity. Obesity necessitates lifestyle modifications and stimulation to reevaluate lifestyle and habits. Christian faith can help provide a sense of hope in changing unhealthy habits. Individuals need help believing they can change, faith that God can give strength and endurance, and be given support from family, friends, the faith community, and healthcare providers. Making habitual change requires awareness of the cues, cravings, behaviors, and rewards that initiate choices. These choices can be viewed as decisions to take deliberate steps with God.
FCNs are in an excellent position to empower individuals to change by understanding the multifaceted areas of life that shape decisions. The FCN can provide a new perspective of negative triggers, how to view the world, and what is pleasing to God. Managing weight loss can be aided by using the 5 A's tool, which considers the whole person-physically, mentally, and spiritually. The tool provides one way that FCNs can inspire and encourage others to remain faithful and committed to a plan to be a better self. This tool encourages all providers to act on the obesity epidemic through counseling in a nonbiased, nonjudgmental way, and reassuring desired outcomes through trust in a healthier lifestyle. FCNs can encourage the integration of faith without judgment for those seeking to adopt healthy lifestyle modifications.
SIDEBAR 1 I Want to Be Overweight! A personal testimony from an FCN
My BMI hovers between 30 and 31-the obese category. It is my goal to achieve overweightness-a BMI less than 30. If I could be overweight, smack dab in the middle of the 25-30 range, I would be so happy. I have struggled with weight for years, felt guilty about being "the fat nurse," wondering how I could teach students and establish an FCN practice when I myself was not a role model for health.
I first gained weight during my 40s, gaining 5 pounds a year over 8 years. Then suddenly I was 40-pounds overweight. I saw it happening but didn't know what to do. No provider pointed it out to me. Now I have a provider who listens to my vigorous and substantial exercise regimen of dance and water aerobics and says, "Your exercise is great; you just eat too much." This is true but not helpful.
I relocated to Jackson, Mississippi, in 2015 to help start a new baccalaureate nursing program at Belhaven University. Jackson is known for having the highest obesity rate in the U.S. and the least number of elderly people (because people do not live to old age). When I moved, it took months to find a church that was the right fit for me and my husband. We looked for a racially diverse congregation in a denomination that ordained women. We are now partners in a church plant in West Jackson, in a safe and welcoming place that espouses racial reconciliation, community development, and gender equality.
These priority issues at my church resonate with my priorities. However, the behaviors around food and congregational norms for weight and eating are daunting. The weight of our congregation mirrors or exceeds that of the city of Jackson. A church event usually has food attached, consisting of typical Southern fare: fried chicken, sweet tea, glistening cornbread dipped in pot likker, buttery ears of corn, slow-smoked ribs dripping with fat, macaroni and cheese, greens and green beans stewed with bacon and pork fat. After church treats are sugary sweet cookies, muffins, and breakfast items. Often, the lead elder shares one of his grandmother's dessert recipes or makes a restaurant recommendation during his welcome to visitors.
One of the strangest things that happens around food is the Daniel fast in January. We returned from our first Christmas holiday and found that the entire church was eating vegan: yeast, and sugar free. This continued for the entire month and happens every year. The Daniel fast is a common practice in local African American congregations to start the new year. The rest of the year, food and eating reverts to the norm, described previously.
How do I, a person from away, a non-Southerner, obese myself, and just beginning the health ministry, begin to address obesity in this congregation? How has this article helped me?
1. I need to begin using the 5 A's. It starts with self-reflection and a commitment to lifestyle changes. I need to take care of business at home.
2. I will look for allies in the congregation to work with me. Are there any normally weighted individuals, or those who have lost significant amounts of weight, who can partner with me in my personal journey? Can they serve as models and champions for addressing obesity and developing healthier lifestyles?
3. With my husband, a licensed psychologist and codirector of the health ministry, I need to establish relationships of mutual trust. In Jackson, well-meaning people who want to help come and go. Trust takes time and a track record to develop. I want the pastor and leadership team to know we are committed for the long haul.
4. Congregants need to know they are loved by God and as a church member. I need to be a conduit of God's love. My love and support of this congregation, accepting all the way they are, where they are, must be the starting point-before confronting norms and suggesting change is needed.
5. Use the Scriptures provided in the article to educate.
6. Make small, doable, incremental changes around health, food options, nutrition, and exercise.
7. Build on the Daniel fast tradition. Encourage carry-over of lessons learned and the experience of extreme eating behaviors. Bridge into new, healthier lifestyle behaviors with education and encouragement. February would be a great time to start our 5-week 5 A's group!
I hope to be able to report to you next New Year that my church and I have made significant progress in addressing the obesity epidemic.
Amy Rex Smith, PhD, RN
Professor of Nursing, Belhaven University
Faith Community Nurse
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