By Louise Adams MAPS, Principal Clinical Psychologist, Self Essentials
I ncreased rates of overweight and obesity are viewed as major health concerns in Australia and the developed world, and people are typically advised to lose weight in order to alleviate associated metabolic problems. As a consequence, the diet industry is booming, and we are bombarded with increasingly urgent messages to lose weight in order to improve our health. But how effective is dieting in terms of lasting weight loss?
It appears that long-term weight loss is unachievable for most people, as demonstrated in a review of 31 studies with greater than two-year follow up periods that found no evidence to support significant weight loss through dieting (Mann et al., 2007). In fact, two thirds of people weighed more after the diet than they did at baseline. Generally, weight loss through dieting peaks at around six months, after which weight regain begins. The more restrictive the diet, the quicker the weight regain (Cooper et al., 2003). Weight regain occurs even if people adhere to calorie controlled diets and exercise regimes. Pharmaceutical interventions and weight loss surgery slow weight regain, but the pattern remains. It is clear that long-term weight loss is no more than a pipe dream for most people.
In response to the failure of dieting, defendants locate the problem as one of individual 'willpower'. This attitude is endemic in the nutrition industry and the obesity field, and, not surprisingly, even amongst the clients who may present to psychologists for help. But the willpower explanation fails to take into account a myriad of factors known to influence weight.
Research over the past twenty years has painted a more complex picture than any simple idea of 'calories in/calories out'. The regulation of human body weight includes genetic predisposition, as well as sophisticated biofeedback mechanisms designed to maintain homeostasis. In short, our bodies fight to maintain stable body weight and react to decreasing fat cells as a threat to survival. In response to such a threat, metabolism slows down, and a range of hormonal changes occur, invoking powerful messages to eat and regain fat cell mass (Friedman, 2009).
The psychologically harmful effects of dieting are well established. Dieting is a known risk factor for developing eating disorders, particularly amongst young people. When people diet, they are essentially given a set of 'food rules'. The specific rules differ from diet to diet, and variously involve attention to the 'points' value of a given food, or eating pre-prepared meals, or adhering to specific carbohydrate/protein/fat/sugar rules, or abstaining from eating whole food groups (or even not eating at all, as in liquid diets).
Dieting creates disordered eating and restrained eating patterns. People are directed to ignore their bodies and eat according to certain rules, as depicted by ‘head eating’ in Figure 1.
Having food rules makes people feel deprived, and sets up a preoccupation with the very foods they are trying to avoid. Food becomes 'good' or 'bad', and the bad food is so very seductive. Before long most people break the rules in some manner, and this can lead to over-eating the bad food.
When people have broken their food rules, they blame themselves for their lack of willpower, and feelings of guilt and shame arise. The more often people have been through the cycle of restriction/blow out, the more hopeless and out of control they feel. This negative self evaluation further undermines self esteem, motivation and self confidence.
Dieting also evokes a range of negative physical side effects. Concerns have been raised regarding the risks of 'yo-yo' dieting, in which people lose and regain weight over time.
Because virtually everyone will regain weight after dieting, the effects of weight cycling on health has become an important area of research. Although firm conclusions are yet to be drawn, well controlled studies indicate a link between weight cycling and mortality risk (Andres et al., 1993; Pamuk et al., 1993). From the perspective of staying alive, it may well be more beneficial to health to maintain body weight rather than cycle up and down.
Given the serious physical and psychological consequences of dieting, and its ultimate ineffectiveness at achieving long-term change in weight, an increasing number of commentators are expressing concern about continuing to pursue dieting as a reasonable solution to the problem of increasing weight.
Most of the current approaches to weight management focus on weight loss as the primary outcome, but there is ample evidence that metabolic health may be achieved even in the absence of weight loss. Many of the reported changes in key metabolic areas (such as blood insulin levels) observed during weight loss interventions occur in the early stages, before significant weight loss is observed (Bacon & Aphramor, 2011). This suggests that changes in lifestyle, such as physical activity and eating habits, may be more important factors in metabolic health than weight loss itself.
A growing non-dieting movement – exemplified in books such as If not dieting, then what (Kausman, 1998) and the Health at every size (HAES) approach (see www.haescommunity.org/) – is challenging traditional weight focused interventions. The non-dieting approach shifts focus from body weight and conceptualises metabolic health as the desired outcome. The non-dieting movement emphasises body acceptance and diversity of body size rather than viewing anyone with a Body Mass Index (BMI) over 25 as 'unacceptable'.
A recent review of non-dieting approaches examined six randomised controlled trials and reported statistically significant and clinically relevant improvements in physiological measures such as blood pressure and lipids, as well as improvements in behaviours related to health, such as increased physical activity and reduced eating disorder pathology (Bacon & Aphramor, 2011). In addition to this, the non-dieting interventions resulted in improved self esteem and body image. It seems that a non-dieting approach can offer meaningful and sustainable health benefits without the damaging effects observed in dieting approaches.
Psychologists are strongly positioned to play an important role in helping clients struggling with their weight to change their focus from weight to health. Clients presenting for weight issues are typically disempowered, demotivated and worried, and tend to have poor body image and low self efficacy (i.e., they don't think they can change). The overarching aim of working with such clients is to improve their sense of self efficacy and motivation to take care of themselves – in short, to become empowered to look after their health.
PSYCHOLOGICAL TREATMENT PLAN FOR WEIGHT MANAGEMENT USING A NON-DIETING APPROACH
Those of us who treat eating disordered clients know that central to the eating disorder is an unhealthy fascination with body weight, with weighing and measuring food intake and in counting calories. Psychological recovery from the eating disorder requires clients to reduce this focus and learn a more relaxed attitude towards food. It seems odd, then, that when people present with weight concerns, we would suddenly advise them to become more vigilant and aware of things such as body weight, calorie counting, or weighing and measuring food. Yet this type of focus is just what is advised in many cognitive behavioural treatment manuals for obesity.
The last thing psychologists want as an outcome is to create an eating disordered client. These people have been bombarded with 'food rules', often without this advice leading to lifestyle change. Reiterating such messages will simply serve to demotivate the client further. Rather than reinforcing diet thinking to clients, the focus of treatment from a non-dieting perspective is to encourage them to let go of food rules and learn the principles of mindful eating, as illustrated in Figure 1.
An effective non-dieting psychological approach to weight management, using cognitive behavioural principles alongside mindfulness and values-based strategies from acceptance and commitment therapy, is presented in the boxed information. This approach is currently the subject of outcome research at our practice to determine its effectiveness in changing lifestyle habits, health indicators and measures of psychological wellbeing. Anecdotally, the approach has been described by clients as 'liberating' and 'empowering', with people beginning to live their lives in a more engaged manner without waiting to lose weight. As a result of this, they take better care of their bodies. In sum, the non-dieting approach seems to provide the elusive ingredient missing in dieting approaches – lasting motivation to engage in self-care.
The author can be contacted at firstname.lastname@example.org.