Outline

• Introduction
• Physical Effects of Restrictive Dieting
• Psychological Effects of Restrictive Dieting
• A LifeStyle Approach
• Become An Effective Agent of Change
• Counseling Strategies
• Five Strategies For Patients
• In Conclusion
• References

I. Introduction

MICHELLE MAY, MD, is the founder and director of Am I Hungry? a weight management program in Phoenix, Ariz. This program received the 2005 Patient Care Excellence in Patient Education Innovation Award at the Fall Patient Education Conference, Society of Teachers of Family Medicine. Dr May is also the award-winning author of "Am I Hungry? What to Do When Diets Don't Work" and coauthor of "H is for Healthy . . . Weight Management for Kids."

On the surface, weight management is straightforward—decrease the number of calories consumed and increase the number of calories burned, and weight loss will result. However, while more is known now than ever before about the complex genetic, metabolic, physiological, cultural, social, and behavioral determinants, the incidence of overweight and obesity has continued to rise in all 50 states, across all age-groups, educational levels, and major racial and ethnic groups, and in both sexes. 1-3

This burgeoning problem correlates with a host of factors—readily available calorically dense foods, increased portion sizes, decreased physical activity, and an increase in sedentary lifestyles, for example. 4 The recent attention directed at these factors has had a negligible impact on the obesity epidemic, however.

Though studies have shown that even a 5% weight loss can produce significant health benefits, few patients are able to achieve or maintain significant decreases in their body weight. 5,6 Nearly one half of US women and more than one third of men report that they are trying to lose weight at any given moment in time. Accurate statistics are hard to come by, but it is widely quoted that 90% to 95% of dieters regain their lost weight. 7 Desperate, dieters become easy targets for the billion-dollar weight-loss industry.

Many of these patients will be seen in their doctor's office for problems directly or indirectly related to their weight or for advice on weight loss. It is common for patients to report that they have already tried numerous diets ranging from popular books and meal replacements to commercial and physician supervised programs. The epidemic of overweight and obesity is evidence not only of excess dietary intake and inadequate activity, but also of the failure of diets to effectively address this problem. 8

Despite the increasing prevalence of obesity, the proportion of obese persons who report being counseled by a health care professional has declined. However, patients who report that their health care professional talked with them about losing weight were more likely to attempt to lose weight than those who did not receive any advice. 9

II. PHYSICAL EFFECTS OF RESTRICTIVE DIETING

Primitive adaptive mechanisms for survival kick in under restrictive diet conditions. Ancient hunter-gatherers worked strenuously for food. When food was plentiful and they could eat whenever they were hungry, their bodies burned fuel freely and stored excess calories as fat. During a famine, their bodies burned the fat for fuel and became more fuel efficient to conserve energy and increase the likelihood of survival. When food was plentiful again, their lowered metabolism allowed them to quickly replace their fat stores in preparation for the next famine. 10

Very-low-calorie restrictive dieting has the same effect as a famine. The dieter's body goes into starvation mode, burning fat and muscle, which, over time, can result in a decrease in the metabolic rate and a significant increase in the body's ability to store and conserve fat. 11,12 When people lose weight, their bodies require fewer calories, particularly if they are not exercising regularly.

This adaptive response may result in a weight-loss plateau and decreased energy and motivation. If people return to their former eating patterns, they regain some or all of the weight, and sometimes more.

Unfortunately, when overweight patients regain weight, they regain fat, but, without exercise, they do not regain any lost muscle. The result is a less healthy, higher body-fat percentage. This is typically a cyclical process, resulting in further weight gain with each attempt at dieting. Studies have shown that those with a history of weight cycling gain more weight than their peers during a given time.

III. PSYCHOLOGICAL EFFECTS OF RESTRICTIVE DIETING

There are also important possible psychological effects of restrictive dieting. 13-15 Initially, the weight-loss process may be empowering and motivating. However, most popular diets are based on some external method of limiting caloric intake, such as counting calories, decreasing fat, or restricting certain foods (eg, carbohydrates). While these are logical approaches from an energy balance perspective, the restrictive approach requires the dieter to maintain willpower indefinitely in order to comply with the rules. Dieters exhibit an increased preoccupation with food and feelings of deprivation, as well as a sense of guilt and resignation if they fall off their diet. Consequently, they develop feelings of failure, lowered self-esteem, and decreased self-efficacy—which often leads to more overeating.

Another significant problem is that people who are overweight often eat in response to environmental and emotional cues rather than in response to cues of hunger and satiety. 10,16,17 However, diets focus on what and how much people should eat without addressing why they are eating in the first place. As a result, dieters usually do not learn to recognize and effectively cope with their eating triggers or meet their true biopsychosocial needs. 18 These triggers and underlying unmet needs will continue to drive overeating.

According to a growing antidiet movement, diets are an "external authority" that teaches dieters to disregard their "internal authority." 19 The latest expert defines what is "fattening" and since nearly every food has been labeled "bad" at least once, patients often report ambivalence and confusion about what to eat.

Furthermore, dieters are usually advised to exercise to burn off fat or earn the right to eat. In essence, exercise becomes a punishment for eating. As a result of this negative association between eating and exercise, dieters quit exercising when they quit dieting.

The psychological constructs of "locus of control" and "self-efficacy" partially explain why diets often do not result in long-term behavioral change. When people perceive that they are unable to control their own eating and therefore must follow an externally determined set of rules (in psychological terms, an "external locus of control"), they will believe that they lack the ability to manage their own weight outside of those strict boundaries. In other words, they will have a low "self-efficacy." Since willpower and compliance are difficult to maintain indefinitely, the dieter's fears become a self-fulfilling prophecy.

IV. A LIFESTYLE APPROACH

A lifestyle approach that shifts the paradigm away from stringent, sometimes arbitrary dietary rules and rigid exercise regimens may be helpful in patients who have demonstrated a poor response to traditional dieting. The focus should be on normalizing eating while teaching patients to distinguish emotional or environmental cues that trigger an urge to eat from their biological need for food as indicated by physical hunger.

V. Become an Effective Agent Of Change

Physicians and other health care providers often have long-term therapeutic relationships with their patients so they are in a unique position to assist and support their efforts to make sustainable lifestyle changes. When patients express frustration about their attempts to lose weight, clinicians should demonstrate that they are willing to partner with them to explore avenues for making healthy lifestyle changes.

The office environment should accommodate patients of all sizes and should encourage dialogue about healthy lifestyles. The physical environment should be welcoming, including, for example, appropriate-sized chairs and gowns, privacy during weighing and history taking, and sturdy, stable exam tables. Posters and reading materials that invite discussion about nutrition and physical activity let patients know that these are legitimate topics and give the provider a visual reminder to address lifestyle issues. 20

It is important to evaluate the patient for causes and consequences of obesity, medical and physical obstacles such as injury or pain that limit physical activity, and other complicating conditions such as anxiety or depression. It is also important to be aware of psychosocial factors that affect weight management, including relationship or career problems, coping styles, economic constraints, and cultural preferences.

Reimbursement for obesity and weight management can be problematic and varies from one health care plan to another. However, since lifestyle changes are a critical part of the prevention and treatment of many chronic diseases, counseling in the context of a covered wellness exam or a problem-oriented visit for a related comorbidity is a common and accepted practice.

Time limitations are a potential barrier. However, most clinicians will find that addressing lifestyle issues consistently builds a mutually satisfying and effective therapeutic relationship with the patient. This kind of communication with patients is likely to result in improved efficiency and better outcomes.

VI. Counseling Strategies

The following counseling strategies support an office-based weight-management approach.

TABLE 1. "Stages of change" model

Assess readiness to change Rather than just telling your patients what they need to do to lose weight—a common but rarely effective strategy—first assess their stage of change (see Table 1). 21 Your role is to guide and support patients to make changes based on their readiness and assist them in moving from one stage to the next. For example, a physician might ask a patient in "contemplation" whether there are any barriers to making a change in his or her diet. If the patient acknowledges that there is a problem, the physician can encourage the patient to face the difficulties, and the patient and the doctor together can explore possible strategies for overcoming the perceived barrier. A patient in the "preparation" stage of starting an exercise program may benefit from a discussion about practical strategies for fitting exercise into his or her schedule.

Guide patients who are exploring their motivation Ask open-ended questions about your patients' current patterns and beliefs. You can help them understand their motivation and point out opportunities for improving their eating and physical activity habits. 22 Examples of such questions are, "You mentioned that you thought you'd feel better if you lost weight. How do you think you would feel better?" and "So you're thinking about joining a gym. What do you hope will happen as a result?"

Focus on the health benefits of a change, not weight loss Keep in mind that patients should be making dietary changes and increasing their physical activity to improve their health, not just to lose weight. Improved nutrition and increased exercise are beneficial even without any concomitant decrease in weight. Encourage patients to focus on long-term lifestyle changes rather than short-term weight loss and evaluate their progress in terms of increased energy levels, improved cholesterol and blood glucose levels, and a greater sense of well-being.

Encourage small steps When weight-loss advice is complicated, requiring numerous simultaneous changes, the patient may become overwhelmed and make no changes at all. Attempts to make small, incremental changes are more likely to be successful. 23 For example, patients might first increase the amounts of fruits and vegetables they eat, add just 10 minutes of walking daily, and decrease the number of foods high in saturated fats. When patients experience small successes, their self-efficacy improves and they become motivated to make additional lifestyle modifications.

Identify obstacles Encourage patients to identify potential challenges and obstacles to carrying out their plan. Practice problem solving by brainstorming possible solutions with them. The clinician's role is to facilitate the process, not to tell the patient what to do. For example, the physician might say, "It sounds like you have a good plan for losing weight. It is often helpful to think ahead of time about how you will handle the inevitable challenges that will come up. What might get in the way of your plan?" If the patient says he or she does not have time to go to a gym, the physician could say, "Exercise doesn't just happen in a gym or in 30-minute blocks of time. What other ways could you be more physically active in your daily life?"

Provide acceptance and support Change takes place in a nonjudgmental climate. Encourage patients to share their challenges as well as their successes. Remind patients that they do not need to be perfect. They should view their mistakes and relapses as a normal part of the process. Encourage patients to tell you when things go wrong so you can help them understand why they made certain choices. Then when they run into problems again, they may be able to make better choices.

Identify a team of community resources. Some patients will require more intensive intervention and ongoing support than is practical or available in most medical settings. Professionals skilled in lifestyle approaches and programs that integrate the psychological, behavioral, fitness, and nutritional aspects of weight management should be identified so that appropriate referrals can be made when necessary. 24-26

VII. FIVE STRATEGIES FOR PATIENTS

Guide patients to make sustainable adjustments to their lifestyle in small, focused changes rather than in an all-or-nothing approach. 23,27 Your objective is to help patients develop an internal locus of control so they can self-regulate their caloric intake in an environment where tempting foods are abundant and sedentary lifestyles are common. Recommend the following strategies—based on these considerations—to your patients:

1. Recognize and respond appropriately to hunger and satiety Hunger is a primitive yet reliable way of signaling a need for fuel and, therefore, regulating dietary intake. Normal-weight individuals are more likely to eat in response to an internal cue of hunger. People who are overweight tend to eat in response to other cues. Environmental and emotional cues can trigger an urge to eat (or to continue eating) whether there is a physical need for fuel or not. When patients try to control their weight by using diet guidelines to tell them when, what, and how much to eat, they may move even further from recognizing and responding in a natural way to hunger. 28

For long-term weight management without chronic dieting, patients must reestablish hunger as their primary cue for eating. A useful approach is to encourage patients to ask themselves if they are hungry before they eat. 18 Coach patients to identify hunger by physical symptoms including growling stomach, lightheadedness, and irritability, in addition to other signs that their stomach is empty and their blood sugar is dropping. By understanding the basics of hunger—what it feels like and how it differs from other sensations and urges to eat (such as stress or appetite)—they will begin to differentiate the need for fuel from their environmental or emotional triggers.

Once patients can accurately identify hunger, they can fine-tune their awareness by determining just how hungry they are. Through trial and error they usually discover that waiting to eat until they are sufficiently hungry increases satisfaction, while waiting too long often leads to overeating.

With this increased awareness of their physical cues, patients will also begin to identify satiety and can learn to stop eating before they become too full. Avoidance of the physical discomfort of fullness becomes an internalized mechanism of portion control. The objective is to help patients restore satisfaction and enjoyment from eating an appropriate amount of food.

2. Eliminate rigid food and nutrition rules Humans are motivated more by pleasure than by pain, so most people cannot maintain the willpower to avoid pleasurable foods indefinitely—even when threatened by negative health consequences. Even healthy-weight patients have difficulty following stringent dietary restrictions, such as very-low-cholesterol diets.

In a lifestyle approach there are no rigid food or nutrition rules. Any food can be eaten within the limits of hunger. This premise is based on the observation that most thin people do not eat perfectly or rigidly and that a normal diet consists of a variety of foods, including foods eaten for pleasure.

When pleasurable foods are not forbidden and can be eaten without guilt, there is less drive to overeat them. When deprivation is no longer a factor, people will begin to recognize that they are hungry for a variety of foods, including healthy foods. Their desire for healthier foods will increase further through education and experience about the effects that different foods have on their body. How different types of foods affect their body will reinforce lifestyle changes. They may gradually modify their diet as they learn about nutrition that will help them feel better and improve their health.

A simple yet effective way to communicate these concepts to patients is to point out that all foods can fit into a healthy diet. Explain that it is just a matter of using the principles of balance, variety, and moderation. 29 This flexible approach to eating can be applied in any situation and is particularly effective when patients are provided with education about nutrition, shopping, cooking, dining out, and social eating strategies.

3. Reduce responses to environmental triggers Environmental triggers not only affect the decision to eat, but also affect what and how much is eaten. 30 People are more likely to choose tempting, less healthy foods and overeat them than if they were eating in response to hunger. If physical hunger does not trigger the urge to start eating, then physical satisfaction cannot signal when to stop, so people will eat until the plate is clean, the package is empty, or they become physically uncomfortable.

Examples of environmental triggers include appetizing food, meal times, holidays, advertising, and large portion sizes. 31 There are hundreds of specific examples, and the availability of calorically dense, appealing foods in increasingly larger portion sizes is a problem on both an individual and a societal level. 32

To decrease eating in response to environmental triggers, patients must first become aware of their associations. Whenever possible, patients should try to remove themselves for a few moments from the food and situations that they associate with eating, so that they can determine whether they are actually hungry before they eat. When they recognize that an urge to eat was triggered by something in their environment, they can choose to distract themselves until the urge passes, reminding themselves that they eat when hungry. People can prepare for these situations by having a variety of appealing alternative activities available to distract themselves, such as reading, letter writing, journaling, or woodworking.

They can also decrease some of environmental triggers by putting food out of sight, avoiding the break room, and ordering half-portions or sharing meals. With practice, this process will help patients break the habitual association between certain activities, people, and places, and overeating. Over time, they are likely to find themselves eating less often when they are not hungry.

4. Develop effective emotional coping strategies All people eat for emotional reasons, including celebrating, expressing love, or finding comfort in Grandma's apple pie. Cross-culturally, social events often revolve around eating, and emotional connections to food are part of normal eating.

Emotional eating becomes maladaptive when it is the primary way that a person copes with emotions. Weight problems often result, and they can become more and more difficult to resolve. This does not imply that all overweight people have major psychological problems; it simply means that they tend to use food for purposes other than energy and nutrition.

Emotional triggers include boredom, stress, sadness, anger, loneliness, and even happiness. Eating can be a way for people to comfort themselves, avoid other issues, and numb or distract themselves from emotions. If someone has been using food to help cope with stress and other emotions, dieting will disrupt the primary coping strategy. If the person does not learn alternative coping mechanisms, distress will increase and overeating will eventually return. Addressing emotional eating is a significant challenge for many people and is probably the most common reason that diets fail. 33,34

Alternatively, when people are able to gain insight into their emotional triggers, they can improve their ability to identify feelings and expand their range of coping mechanisms. Examples of strategies that work for people include stress management, positive thinking, and setting boundaries in relationships. Often, new skills and tools are needed, so it is best to approach this issue as an ongoing process and refer patients for counseling when necessary.

When patients learn more effective strategies for coping with their emotions and use food less often for comfort or to avoid dealing with feelings, 2 things happen. First, their desire to overeat diminishes. Second, and most important, they begin to find fulfillment in experiences other than eating and meet their true needs more effectively.

5. Increase physical activity Exercise has numerous well-documented health and psychological benefits. 35 It is also essential for weight loss and maintenance by increasing caloric output and improving metabolism. 36,37 Studies have shown that 91% of people who successfully maintain their weight loss exercise regularly. 38 But exercise improves health and decreases morbidity, even without weight loss. 39 Overweight individuals who exercise are healthier than normal-weight individuals who are sedentary. 40 Exercise also helps people reconnect with their body and improves their sense of well-being and quality of life. 41 Therefore, exercise should be viewed not as a means to an end, but as an end in and of itself.

Exercise is uncomfortable for many overweight and deconditioned people, who may also have negative associations with exercise. Clinicians should elicit patients' feelings about exercise and then work with them to write a physical activity prescription tailored to their preferences and level of fitness. If patients are not ready to begin exercising, they can be coached to come up with ideas for ways to increase their lifestyle activity—parking farther from the building and walking to the mailbox, for example. They can increase their activity as their tolerance increases, always keeping in mind that exercise must be comfortable, convenient, fun, and rewarding if it is to become a long-term habit.

VIII. IN CONCLUSION

Health care professionals are in the best possible position to help their patients make meaningful changes that will lead to a healthier weight. They should discourage strict and fad dieting and help their patients set realistic, attainable health goals. Encouraging small, incremental changes and maintaining a supportive environment are crucial. The goal is to guide the patient toward developing a healthy, satisfying, sustainable approach to eating and physical activity.

This article was contributed by Dr May and edited by Deborah Kaplan.

Dr May discloses that she is the owner of Am I Hungry?

IX. REFERENCES

1. Ogden CL, Carroll MD, Curtin LR, et al. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549-1555.

2. Hedley AA, Ogden CL, Johnson CL, et al. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004;291:2847-2850.

3. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults, 1999-2000. JAMA. 2002;288:1724-1727.

4. Ness-Abramof R, Apovian CM. Diet modification for treatment and prevention of obesity. Endocrine. 2006;29:5-9.

5. Cummings S, Parham ES, Strain GW. Position of the American Dietetic Association: weight management. J Am Diet Assn. 2002;102:1145-1155.

6. Field AE, Wing RR, Manson JE, et al. Relationship of a large weight loss to long-term weight change among young and middle-aged US women. Intl J Obes. 2001;25:1113-1121.

7. Dohm FA, Beattie JA, Aibel C, et al. Factors differing women and men who successfully maintain weight loss from women and men who do not. J Clin Psych. 2001:57:105-117.

8. Miller WC. How effective are traditional dietary and exercise interventions for weight loss? Med Sci Sports Exerc. 1999;31:1129-1134.

9. Abid A, Galuska D, Khan LK, et al. Are healthcare professionals advising obese patients to lose weight? A trend analysis. MedGenMed. 2005;7:10.

10. Mela DJ, Rogers PJ. Food, Eating and Obesity: The Psychobiological Basis of Appetite and Weight Control. London; New York: Chapman & Hall; 1998.

11. American College of Sports Medicine's Resource Manual for Guidelines for Exercise Testing and Prescription. 4th ed. Baltimore, Md: Lippincott Williams & Wilkins; 2001.

12. Connolly J, Romano T, Patruno M. Selections from current literature: effects of dieting and exercise on resting metabolic rate and implications for weight management. Fam Pract. 1999;16:196-201.

13. Polivy J, Coleman J, Herman CP. The effect of deprivation on food cravings and eating behavior in restrained and unrestrained eaters. Int J Eat Disord. 2005;38:301-309.

14. Lowe MR, Foster GD, Kerzhnerman I, et al. Restrictive dieting vs. "undieting" effects on eating regulation in obese clinic attenders. Addict Behav. 2001;26:253-266.

15. Polivy J. Psychological consequences of food restriction. J Am Diet Assoc. 1996;96:589-592.

16. Woods SC, Seeley RJ, Porte DJ, et al. Signals that regulate food intake and energy homeostasis. Science. 1998;280:1378-1383.

17. Magnen JL. Hunger. Great Britain: Press Syndicate of the University of Cambridge; 1985.

18. May ML, Galper LS, Carr J. Am I Hungry? What to Do When Diets Don't Work. Phoenix, Ariz: Nourish Publishing; 2005.

19. Miller WC, Robinson MS. HAES around the world. Health at Every Size. 2006;19:193-194.

20. Aim to Change: Family Physician Primer. Leawood, Kan: American Academy of Family Physicians; 2005.

21. Zimmerman GL, Olsen CG, Bosworth MF. A 'stages of change' approach to helping patients change behavior. Am Fam Phys. 2000;61:1409-1416.

22. Miller WR, Rollnick S. Motivational Interviewing. Available at: http:// www.motivationalinterviewing.org . Accessed July 28, 2006.

23. Jacobs AV. Translating theory into practice: self-efficacy and weight management. Healthy Weight J. 2002:86-88.

24. Shaw K, O'Rourke P, Del Mar C, et al. Psychological interventions for overweight or obesity. Cochrane Database Syst Rev. 2005;(2):CD003818.

25. Wadden TA, Butryn ML. Behavioral treatment of obesity. Endocrinol Metab Clin North Am. 2003;32:981-1003,x.

26. Riebe D, Blissmer B, Greene G, et al. Long-term maintenance of exercise and healthy eating behaviors in overweight adults. Prev Med. 2005;40:769-778.

27. Bacon L, Stern JS, Van Loan MD, et al. Size acceptance and intuitive eating improve health for obese, female chronic dieters. J Am Diet Assoc. 2005;105:929-936.

28. Tribole E, Resch E. Intuitive Eating. New York, NY: St Martin's Press; 1995.

29. Freeland-Graves J, Nitzke S. Total diet approach to communicating food and nutrition: position of the American Dietetic Association. J Am Diet Assn. 2002;102:100-108.

30. Herman CP, Polivy J. Normative influences on food intake. Physiol Behav. 2005;86:762-772.

31. Wansink B. Environmental factors that increase the food intake and consumption volume of unknowing consumers. Annu Rev Nutr. 2004;24:455-479.

32. Rolls BJ. The supersizing of America: portion size and the obesity epidemic. Nutr Today. 2003;38:42-53.

33. Byrne S, Cooper Z, Fairburn C. Weight maintenance and relapse in obesity: a qualitative study. Int J Obes Relat Metab Disord. 2003;27:955-962.

34. Elfhag K, Rossner S. Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain [review]. Obes Rev. 2005;6:67-85.

35. Bensimhon DR, Kraus WE, Donahue MP. Obesity and physical activity: a review. Am Heart J. 2006;141:598-603.

36. Wing RR. Physical activity in the treatment of the adulthood overweight and obesity: current evidence and research issues (Roundtable Consensus Statement). Med Sci Sports Exerc. 1999;31:S547-S552.

37. Stiegler P, Cunliffe A. The role of diet and exercise for the maintenance of fat-free mass and resting metabolic rate during weight loss. Sports Med. 2006;36:249-262.

38. Hill J, Wing R. The National Weight Control Registry. 2003. Available at: http:// xnet.kp.org/permanentejournal/sum03/registry.html . Accessed July 28, 2006.

39. Poirier P, Despres JP. Exercise in weight management of obesity. Cardiol Clin. 2001;19:459-470.

40. Carroll S, Dudfield M. What is the relationship between exercise and metabolic abnormalities? A review of the metabolic syndrome. Sports Med. 2004;34:371-418.

41. Kruger J, Bowles HR, Jones DA, et al. Health-related quality of life, BMI and physical activity among US adults (>18 years): National Physical Activity and Weight Loss Survey, 2002. Int J Obes. Advance online publication 16 May 2006; doi: 10.1038/sj.ijo.0803386.