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The behavior and psychology of weight management
Katherine T. Kelly, PhD, MSPH
Dr. Kelly is Director of Behavioral Science, Department of Family and Community
Medicine, Wake Forest University School of Medicine, Winston-Salem, NC. The
author has indicated no relationships to disclose relating to the content of
this article.
Clinicians who know the multiple
factors involved in achieving behavioral change can better assess a patient's
true readiness for a major lifestyle adjustment.
Many overweight or obese patients who fail to lose weight, or use diet and
exercise to lose weight but then regain it, do so in part for emotional or psychological
reasons or because of a poor understanding of the need for behavioral change.
Educating overweight patients about nutrition and exercise is simply not enough;
in many such persons, behavioral and psychological factors must be addressed
or these factors will prevent them from permanently changing behavior.
This article discusses behavioral change models that can be used to assess
and treat overweight and obese patients and to address the psychological comorbidities
that can affect long-term success.
Ready, or willing?
Researchers have identified six stages of change: precontemplation, contemplation,
preparation and determination, action, maintenance, and termination (see Table
1).1 The behavioral change required in weight management is multifactorial
and complex; it involves multiple changes in exercise, nutrition, and responses
to stimuli, and it affects many aspects of a person's daily life. A patient
who indicates being "ready to change" may in fact be at different stages of
readiness for each of the different behaviors involved in overall change. These
multiple stages of readiness are what need to be assessed rather than simply
the person's general willingness to lose weight.
TABLE 1
Applying the stages of change model to weight management
|
| Stage |
Characteristics |
Provider's role |
| Precontemplation |
Patient may be unaware that the problem exists, see no need for diet*
or exercise changes, and not be interested in discussing the behavior |
Raise patient’s self-awareness about weight behavior,† alert
patient to health implications of excess weight, and encourage expression
of feelings about weight |
| Contemplation |
Patient is considering the risks and benefits of changing weight behavior,
is waiting for the right moment to begin diet and exercise, and wishes the
problem behavior would solve itself |
Identify and discuss patient’s concerns, beliefs, and perceived barriers
toward weight behavior change, explain the benefits of change compared to
no change, clarify any ambivalence felt toward changing weight behavior,
and provide or suggest resources for learning more about healthy weight
behavior |
| Preparation and determination |
Patient plans to initiate weight behavior change and is motivated and
ready to learn about diet and exercise |
Help develop a plan for change in weight behavior, teach specific skills
related to weight loss, and help patient to build self-confidence and access
educational resources for change |
| Action |
Patient has achieved consistency with changed weight behavior, weight
loss is visible, and the patient believes that maintenance is possible |
Help to reinforce the weight-loss decision, provide emotional support,
and explain the difference between lapse and relapse in weight behavior |
| Maintenance |
The patient has incorporated new weight behavior in daily life, avoids
backsliding, and is confident about maintaining the change |
Offer ideas to maintain the weight behavior change, help the patient build
a supportive environment to maintain the change, continue to teach relapse
prevention techniques, and reinforce the rationale for behavior change |
| Termination |
Patient has maintained new weight behavior for >1 yr, avoids relapses,
and is confident about maintaining lifestyle and behavior |
Address lapses in weight behavior and reinforce healthful lifestyle behavior |
*Healthful nutrition.
†Any health-related behavior (eg, healthful nutrition, exercise) that
affects weight. |
| Source: Prochaska and
DiClemente.1 |
In addition to assessing the patient's stages of readiness, the patient's
attitudes and beliefs related to weight should be evaluated. For example, emotional
barriers to some or all aspects of weight loss may jeopardize success (see "Weighty
issues"). The Health Belief Model is a tool that can be used to determine a
patient's general health-related thoughts concerning personal prevention strategies.
In this model, health-related change occurs when patients have interest in and
concern about their personal health and when they perceive both a personal vulnerability
to a particular health threat and potential negative consequences if change
does not occur (see Table 2).2 A patient whose health beliefs oppose
those that support management of overweight and obesity is less likely to achieve
long-term weight loss and management.
Weighty issues
The following case reports describe overweight and obese patients who
were treated in a medically supervised weight-management and lifestyle
change program. The treatment team included a PA, a clinical nutritionist,
a clinical psychologist, and an exercise specialist. Before starting the
program, each patient underwent an initial assessment to identify barriers
to success, and each case illustrates the effects of unresolved psychological
comorbidity on initial weight loss and long-term success.
All three patients reported multiple weight loss attempts using various
methods, including personal diets, fad diets, and popular commercial programs.
The missing component in all these weight-loss methods, however, was the
effect of psychological influences on eating behavior. Although each of
these patients reported using an antidepressant to manage depression,
none received appropriate counseling to identify and resolve the concerns
that contributed to clinical depression.
Dysthymic disorder Ms. C., a 38-year-old woman
with a body mass index (BMI) of 35 kg/m2 at the initial assessment
for the weight-management program, hoped to lose 60 to 70 lb. She had
changed jobs 16 months before the assessment but continued to have difficulty
adjusting to new responsibilities. The assessment revealed dysthymic disorder,
a low-grade form of depression that does not meet criteria for major depressive
disorder but has persisted in interfering with a patient's life for at
least 2 years.1
Dysthymic disorder is characterized by flat affect, low energy and motivation,
fluctuations in overall mood, and chronic pessimism. Although patients
with this disorder may acknowledge the presence of symptoms, they typically
do not realize the impact these symptoms have on daily life. Although
Ms. C. continued in the weight-management program, her low motivation
prevented her from exercising and changing her eating patterns. In addition,
Ms. C.'s pessimism was evident through her frequent comments about her
perceived inability to make positive change; she believed herself to have
almost no self-efficacy.
Ms. C. also displayed characteristics of avoidant personality disorder—she
desired close connection with others, but she avoided intimacy because
of feelings of inadequacy.1 Even in the treatment group, Ms.
C. remained silent to avoid embarrassment. Despite multiple attempts to
include her in paired exercise sessions, Ms. C. continued to avoid contact
with other group members. At the initial psychological assessment session,
she was strongly encouraged to seek therapy, but she did not do so because
of a fear of embarrassment. These psychological comorbidities will likely
prevent Ms. C. from reaching her goal weight, which could further deepen
her depressive symptoms and create a vicious cycle for both her mental
and physical health.
Depression Ms. H., a 39-year-old married emergency department
nurse with a BMI of 53 kg/m2, reported a long history of weight
problems that developed after sexual abuse during childhood. Like many
women with a history of abuse, she had a history of depression, a disturbed
body image, and feelings of vulnerability. Although she was highly motivated
to lose weight, she admitted that her emotional difficulties, including
her pattern of emotional eating, were obstacles to weight loss. During
the initial assessment before joining the weight-loss program, she was
encouraged to seek behavioral and psychological help. By doing so, she
gained insight into her emotional eating patterns. She sought further
therapy to manage her body image disturbance and depressive symptoms.
She successfully managed to lose some of the weight.
Codependency Mr. B., a 56-year-old married retired minister
with a BMI of 42.2 kg/m2 at the initial assessment, reported
a long history of codependent behavior, depression, low self-esteem, and
overall general dissatisfaction with life. He also described an alcoholic
father who verbally and physically abused him as a child. He admitted
using food for comfort and often chose foods high in fats and carbohydrates
to soothe his emotions. Mr. B. was strongly encouraged to seek psychotherapy
in addition to attending the weight-management program in order to fully
address emotional and behavioral patterns that stemmed from his childhood.
Although Mr. B. did not achieve his goal weight, he did lose weight and
improve his cholesterol and blood glucose levels.
1. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR). Washington, DC: American Psychiatric Assoc; 2000.
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TABLE 2
Applying the key components of the Health Belief Model to an overweight
patient
|
| Component |
Ask the patient |
| Perceived susceptibility |
What health risks do you think your weight poses for you? |
| Perceived seriousness |
What do you think will happen if you don’t lose weight? |
| Perceived benefits of action |
How do you think you will benefit by losing the weight? |
| Barriers to action |
What prevents you from losing weight? |
| Cues to action |
What will motivate you to lose weight? |
| Source: Rosenstock.2 |
Understanding the psychology of weight
Although obesity has long been considered a medical condition,3
growing evidence suggests that obese patients often also have comorbid psychopathology,4
such as destructive eating behaviors, difficulty with body image, and
general emotional instability related to past attempts at weight loss.5
In examining the lifetime incidence of psychiatric diagnoses, researchers
found that patients in a bariatric clinic were more likely than those in a control
group to have received a diagnosis of major depression, agoraphobia, simple
phobia, posttraumatic stress disorder (PTSD), bulimia nervosa, and histrionic,
borderline, avoidant, and passive-aggressive personality disorders.6
More recent research also showed an association between obesity and depression.7
Bipolar disorder has also been linked to an increased risk for obesity, with
approximately 35% of bipolar patients meeting the diagnostic criteria for obesity.8
PTSD, particularly that related to sexual abuse or assault, has been strongly
correlated with obesity as well. Researchers found that obese women had a higher
lifetime prevalence of PTSD related to a history of sexual trauma than did women
of normal weight.9 Some overweight patients who have been sexually
assaulted or abused feel vulnerable to further assault or abuse after losing
weight. These patients often use food as a coping mechanism to reduce stress.
Binge eating disorder (BED) is closely associated with obesity and is characterized
by episodes of uncontrolled eating behavior for at least 2 days each month for
6 months.10 Patients with BED are typically distressed by their behavior,
and nearly all have symptoms of depression.11 Patients with BED are
usually severely obese and have a higher lifetime prevalence of major depression,
panic disorder, bulimia nervosa, and borderline or avoidant personality disorder.12
Although research has indicated strong associations between obesity and psychopathology,
assigning direct causality is difficult. The research does, however, confirm
the psychological complexity of overweight and obesity.
Mind over matter: Helpful strategies
Learn it and live it A patient is more likely to follow advice
about healthful lifestyle from health care providers who practice what they
teach. Providers who read and understand nutritional labels, learn appropriate
exercise techniques, have identified their own triggers for emotional eating
(stress, boredom, reward), are physically active, and eat a variety of healthful
foods are good role models for patients who need to lose weight.
Know when to call in help A patient who has been unable to achieve
an ideal body weight after 5 years of trying has a better chance of success
working with a team trained to manage obese patients. The team should include
a nutritionist, a mental health professional, and a physical trainer. Patients
often benefit significantly from the reinforcement provided by each team member.
Think of overweight as a symptom The statistics related to psychological
comorbidity in overweight and obesity suggest that many patients' severe weight
problems arise from emotional problems, attitudes, or beliefs that are unshakable
without psychotherapy. These patients will not lose weight and maintain the
loss over the long term if their emotional weight is not addressed and resolved.
In the author's experience, patients are more successful with weight loss once
they identify and resolve underlying psychological issues.
Assess readiness As discussed, a patient who declares readiness
to lose weight may balk at engaging in the key components of actually losing
it. It is important to assess readiness to address specific aspects—not
just diet and exercise, but also the behavioral and emotional factors. Working
with patients to establish incremental change is much more likely to result
in success than a general recommendation to lose 30 lb by the next appointment.
Identify beliefs about weight Identifying a patient's beliefs
about weight loss by using the Health Belief Model assists the provider in understanding
the patient's perspective. Additionally, the assessment itself acts as an intervention.
Asking about the benefits and barriers of losing weight can move patients along
the change continuum simply by getting them to think about change.
Conclusion
Although primary care providers are the first to intervene for many health
concerns, including obesity, the complexity of overweight and obesity often
warrants a team approach. Such a strategy may produce optimal success as various
specialists each reinforce changes in obesity-related behavior.
KEY POINTS in this article
- The behavioral changes required for successful weight loss and maintenance
are multifactorial and complex.
- A patient's success may be jeopardized by emotional barriers
to some or all aspects of weight loss.
- Research has shown an association between obesity and depression
and other psychiatric disorders, which may also preclude successful
weight management.
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Katherine Kelly. The behavior and psychology of weight management. JAAPA April 2004;17:29-32.
Copyright © 2004, Advanstar Medical Economics Healthcare Communications at Montvale, NJ 07645-1742. All rights reserved.
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