Backed by an abundance of medical research, the Motivate approach has emerged from 35 years of scientific study. For more information and a more detailed examination of the science behind the philosophy of Motivate, we invite you to peruse our many resources including studies, media and articles about and by our team.
1Neurocognitive and Hormonal Correlates of Voluntary Weight Loss in Humans
Insufficient responses to hypocaloric diets have been attributed to hormonal adaptations that override self- control of food intake. We tested this hypothesis by measuring circulating energy-balance hormones and brain functional magnetic resonance imaging reactivity to food cues in 24 overweight/obese participants before, and 1 and 3 months after starting a calorie restriction diet. Increased activity and functional connectivity in prefrontal regions at month 1 correlated with weight loss at months 1 and 3. Weight loss was also correlated with increased plasma ghrelin and decreased leptin, and these changes were associated with food cue reactivity in reward-related brain regions. However, the reduction in leptin did not counteract weight loss; indeed, it was correlated with further weight loss at month 3. Activation in prefrontal regions associated with self-control could contribute to successful weight loss and maintenance. This work supports the role of higher-level cognitive brain function in body-weight regulation in humans. contact us for the full research at firstname.lastname@example.org
2The Role of Motivation in Weight Management: New Findings
We have made what we think is a major breakthrough in research on weight management, in our finding that there are two kinds of weight control motivation. “Positive” motivation comes from the perception of the benefits of weight control and the pain from one’s current weight. “Negative” motivation comes from the perception that weight control involves a loss of pleasure and freedom, takes a great deal of effort, and has a low probability of success. These two kinds of motivation may play different roles in weight management at different time points. For example, overweight people who have no intention and who are making no effort to lose weight will have a relatively low level of Positive motivation. Those with a high level of Positive motivation are more likely to have definite weight loss goals and intentions (e.g. to lose 10 pounds in the next month). Thus, Positive motivation may be an important determinant in the “initiation” of weight loss efforts. Positive motivation is what makes you want to do something. On the other hand, the level of Negative motivation should be related to the strength and persistence of weight loss efforts. Someone with a low level of Negative motivation will be less frustrated and more satisfied with the process of weight control. Therefore, Negative motivation should be a good predictor of weight loss. Negative motivation is what makes you not want to do something. This is what we have learned about Positive and Negative motivation in our recent analysis: We found that the perceived benefits of weight control increase slightly over the first 5 weeks of treatment. At the same time, physical and psychological pain associated with weight decrease significantly. The net result is that Positive motivation stays about the same. Negative motivation decreased significantly over 5 weeks, with consistent decreases in feelings of “resentment,” “regret,” “doubt,” and “perceived effort.” The results for Positive and Negative motivation at Time 1 and Time 2 are presented in Figure 1. The decrease in Negative motivation over 5 weeks was related to improvements in weight, eating habits (decrease in “uncontrolled eating”), depression and stress. However, we did not see any relationship between changes in Positive motivation and these other changes (see Table 1). It seems that a key effect of treatment on motivation is to decrease Negative Motivation. Improvements in negative motivation are not only due to weight loss, but are primarily related to improvements in eating habits and emotional state. Weight loss treatment is not just about following a diet, but about improving psychological risk factors and maintaining a strong motivation. How do we decrease Negative motivation? We learn to see the process of weight control in a more positive light. Instead of thinking about what you can’t have, think about the advantages and pleasures associated with what you can have. If you come to value eating small portions of tasty and healthy food, then it won’t seem like such a burden and there will be less negative thinking. Similarly, if you discover that exercise is fun and feels good your thoughts about exercise will be positive. Motivation is an automatic emotional response (something that we feel) and in order to keep it strong, we have to work on our thoughts and perceptions. Daily, you should continue to think about the benefits of being at your healthy weight and making the right choices, and put a STOP to negative thoughts that are always unrealistic. Switch negative interpretations to positive ones, as follows: Instead of “It is too much of an effort to lose weight,” think “it’s too much effort to carry the extra weight”. Instead of “I resent having to follow a diet and change my eating habits,” think “I resent having to deprive myself of health, energy, youth, and a nice silhouette.” Rather than thinking “I regret not having the food I love,” think “I regret not being the human being I want to be” . Successful long-term weight management (losing the weight and keeping it off) is not just about trying to stick to a diet but learning to think and feel in less negative and more positive ways. This can easily be accomplished with the therapy tools that you have available to you, which you only need to do for a few minutes per day. Stephen Stotland, Ph.D. & Maurice Larocque, M.D. August 2009
3Prediction of weight loss
RESEARCH UPDATE: Prediction of weight loss We have recently analyzed results from 344 female patients during the first 9 months of their treatment. The following are factors which we found to predict the amount of weight lost during this period: (1) choosing a VLCD rather than a LCD, (2) early weight loss, (3) the number of assessments, and most importantly, (4) early improvement in eating behavior. Together, they make a very substantial difference in the treatment outcome! In the best case scenario there is a reduction of 7.4 BMI points, while the worst case scenario shows a gain of 1.3 BMI points.
4PROLONGED REFEEDING IMPROVES MAINTENANCE
Abstract The aim of this study was to test the hypothesis that a prolonged re-feeding duration after successful VLED-induced weight loss beneficially affects weight development and eating behaviour. 269 patients were recruited to a one-year obesity treatment program with 12 weeks of initial very-low-energy diet (VLED). After VLED, patients with ≥10% weight loss were randomly allocated to one week (Group 1) or six weeks (Group 6) of re-feeding to an ordinary, energy-reduced diet, and thereafter followed and actively treated for an additional 40 weeks. Eating behaviour was measured with the revised Three-Factor Eating Questionnaire (TFEQ-R21) at baseline, during and after re-feeding, and at week 52. Weight change over time in the two treatment groups was tested by repeated measures analysis in completers and by intention-to-treat (ITT). 169 patients (109 women and 60 men) lost ≥10% during VLED and were randomised. At randomization, weight loss was −16.5 ± 3.7% in Group 1 and −16.7 ± 4.3% in Group 6 (P = 0.73). Between week 12 and 52, completers in Group 6 regained significantly less weight (3.9 ± 9.1%) as compared to Group 1 (8.2 ± 8.3%), (P = 0.006), (ITT, P = 0.05). Patients with six weeks of re-feeding maintained a higher level of dietary restraint after re-feeding was completed but eating behaviour did not differ significantly between the two groups at week 52. The results suggest that longer re-feeding duration after successful weight loss with VLED improves weight maintenance in a one-year perspective.
5Selfregulation of weight: Basic processes and treatment implications
In Anne. E. Prescott (Ed.), The concept of self in medicine and health care. Nova Science Publishers, Hauppauge NY, 2006. Selfregulation of weight: Basic processes and treatment implications S C Stotland1, 2, M Larocque2, & I Kronick1 1Department of Psychology, McGill University, Montreal, Canada 2MLA Nutrition Clinics, Montreal, Canada Address: Dr. Stephen Stotland 1310 Greene Avenue, Suite 230 Westmount, Quebec H3Z 2B2 (514) 7373360 email@example.com SELFREGULATION OF WEIGHT 1 SELFREGULATION OF WEIGHT 2 Abstract The regulation of bodyweight is a complex process, with multiple biological, environmental and psychological factors playing a role. The primary treatment for obesity is modification of eating and exercise behavior, the success of which depends on the patient’s adherence to the behavior change plan, and therefore represents a problem of selfregulation. The failure of a large percentage of individuals to achieve their weight loss goals has led a number of authors to question whether or not bodyweight is amenable to effective selfregulation. However, psychological approaches to obesity have not integrated recent theoretical developments concerning selfregulation. The present paper will present a new model of weight control, which considers weight regulation as a broadly applicable, carefully sequenced, selfregulatory process occurring in the context of other goals and challenges, in particular the management of mood states and interpersonal relations. Data relevant to our model is presented, derived from a large sample of individuals in treatment for obesity. Introduction Obesity has received a great deal of scientific and popular attention in recent years. The detrimental physical and emotional effects of obesity have been well documented (Fontaine, Redden, Wang, Westfall, & Allison, 2003; World Health Organization, 1998). However, while weight loss efforts are very common among overweight individuals (Meltzer & Everhart, 1996; Serdula, Mokhad, Williamson, Galuska, Mendlein, & Heath, 1999), only a small percentage reach or maintain a healthy weight (Jeffery, Drewnowski, Epstein, Stunkard, Wilson, Wing, & Hill, 2000; Wadden, Foster, & Brownell, 2002). Nevertheless, where successful, intentional weight loss appears to have positive effects in reducing disease and mortality (Gregg & Williamson, 2002). In view of the urgent need to develop more effective treatment methods, research designed to elucidate factors responsible for successful or unsuccessful weight loss outcomes is extremely important. The present chapter addresses this issue from a “self regulation” perspective. Weight Regulation When we talk about the selfregulation of weight, how difficult is the task one is up against? How controllable is weight? As evidenced by the multitudes of perspectives and the huge amount of current research, it is clear that weight regulation is an extremely complex biopsychosocial process. Genetic factors appear to exert a large effect, estimated to predict anywhere between 25% and 40% of actual weight (Bouchard, 1994; Price, 2002). Physiological processes influence eating by altering hunger and satiety mechanisms (Badman & Flier, 2005; Hellstrom, Geliebter, Näslund, Schmidt, Yahav, Hashim, & Yeomans, 2004). Environmental factors, including the available food and SELFREGULATION OF WEIGHT 3 features of the social situation, are also powerful influences on eating (de Castro, 2004; Wansink, 2004). It is apparent that genetic and environmental variables interact, such that genetic predisposition combines with an “obesogenic” environment to determine obesity prevalence (Tremblay, Perusse, & Bouchard, 2004). However, such views appear overly “deterministic” when the role of selfregulation is ignored. An understanding of weight selfregulation requires an analysis of eating and exercise selfregulation. This is so because weight can only be controlled, or “self regulated,” by controlling eating and exercise. Of course, one could theoretically take a medication that would result in a lower weight without a change in eating and exercise, but that would not be illustrative of “self” regulation, but a direct biological manipulation. Other drugs might cause weight reduction by altering eating or exercise, but this too would not be evidence of selfregulation, but a biological change. Certainly, such a change could have an effect on selfregulation, by making the task easier (i.e. by reducing hunger, increasing satiety, or increasing the drive and ability to move and engage in activity). As physiological and socialpsychological research demonstrates, not all self regulation is created equal – it may be more or less difficult, depending on biology and circumstances. In any case, selfregulation appears to require a certain amount of energy, or psychological resources, that may be “used up,” which can lead to selfregulatory failure (Baumeister, Bratslavsky, Muraven, & Tice, 1998). In fact, several authors have declared the task of weight selfregulation so difficult that it should be abandoned as a target of obesity treatment; it has been suggested that efforts to reduce the prevalence of obesity should focus exclusively on environmental and pharmacological intervention SELFREGULATION OF WEIGHT 4 (Herman & Polivy, 2004; Jeffery, 2004; Lowe, 2003; Swinburn, Egger, & Raza, 1999; Wansink, 2004). In rejecting the feasibility of individualfocused intervention, these authors appear to reject the importance of selfregulation of eating, exercise and weight. Lowe (2003) concludes that selfregulation is not up to the task of effective weight control, but rather that some of the answer to the obesity problem lies in helping people make changes in what he calls the “personal food environment.” Such changes might include reducing the “energy density” of the diet (increasing fiber and water content) and reducing the amount of contact with food and the number of eating choices one has to make by relying on prepackaged meals (meal replacements and prepared meals). However, although making changes in the food that one encounters and interacts with seems like an important strategy for weight control, it should be recognized that the implementation of the strategy is dependent on selfregulation. One of the ways that effective weight controllers accomplish weight selfregulation is by making changes in their environments to facilitate selfregulation. This is good problem solving, which is of course an important part of selfregulation as well. The pessimistic tone of recent papers about individual change efforts is not characteristic of the attitudes of clinicians more generally, however, and treatment of the obese individual is still a very important target of medical and psychological intervention. Furthermore, overweight individuals continue to purchase and utilize a huge amount of commercial weight loss products, plans and programs – people evidently believe that weight can be selfregulated (i.e. they display an “internal” weight locus of control – Stotland & Zuroff, 1990). In fact, people generally possess a mixture of internal and external weight locus of control beliefs (Stotland & Zuroff, 1990). Thus, people tend to SELFREGULATION OF WEIGHT 5 think that they have some degree of control over their weight, but that uncontrollable factors like genetics and luck also play a role. This kind of attitude means that the individual is very open to “treatments” that promise to increase selfcontrol, or to make selfcontrol less necessary. The paradox is that one looks to an external agent to supply internal control (see also, Polivy & Herman, 2002). The popularity of weight control treatments indicates that individuals often do not feel they understand the problem or know how to solve it. They are reaching out for commercial or professional help to supply the answer, as well as needed support. However, recent analyses indicate that results for commercial (Tsai & Wadden, 2005) and professional (Wadden et al., 2002) treatment have been disappointing. The average weight loss over a number of years in studies that include longterm followup approaches zero (Wadden et al., 2002). The implications of such failures for psychological theories of obesity treatment have not been fully or adequately examined. Early behavior therapy approaches towards obesity treatment (Stuart, 1967) were based on classical and operant conditioning principles and they attempted to modify behaviour by changing the environmental stimuli associated with maladaptive behaviour. Current behavioural programs utilize a variety of techniques derived from conditioning as well as cognitive theories (Foster, Makris, & Bailer, 2005). There is a growing consensus (Byrne, Cooper, & Fairburn, 2004; Jeffery et al., 2000) that psychological research has so far failed to provide an adequate explanation for why most people fail to maintain weight loss – this being the crucial problem in obesity treatment. The present chapter offers a selfregulation model of weight control as a framework for research and as a guide for the treatment of obesity. SELFREGULATION OF WEIGHT 6 SelfRegulation Selfregulation theories have become increasingly popular in health psychology research (Maes & Karoly, 2005), but have not been well developed in relation to weight and eating. Selfregulation theories vary in emphasis, but generally include: goal-setting, planning, self-monitoring of outcomes, self-evaluation of progress relative to expectations, emotional response to outcomes, problem-solving when progress does not meet expectations, and emotion-control strategies (see Figure 1). Selfregulation theories begin with the concept of “goal”. The goal is the reference point from which efforts and outcomes can be judged. Of course, there are a great variety of types of goals – goals may be easy or challenging, shortterm or longterm, selfchosen or given to one, important or trivial, realistic or unlikely, stressful or relaxing, supported or alone, and perhaps even conscious or unconscious (Little, 1999). Weight selfregulation occurs in the context of other goals that the individual is pursuing simultaneously. Consequently, the goals of maintaining emotional wellbeing or managing interpersonal relationships may at times conflict with weight goals. This may be for two reasons, (1) focusing on other goals may interfere with weight selfregulation, and (2) eating may serve emotional or interpersonal selfregulation functions that may conflict with weight selfregulation. Thus, when an individual is depressed, eating self regulation may be altered, as the individual is engaged in the high priority project of trying to feel better, and may choose to eat (or even overeat) as a means of doing so. To adequately understand eating and weight selfregulation, we need to identify how they fit into the bigger picture of selfregulation. This requires a “molar” level analysis of goals, such as the analysis of “personal action constructs” like personal projects (Little, 1999) SELFREGULATION OF WEIGHT 7 and current concerns (Klinger, 1975). There has not yet been a comprehensive analysis of goal constructs in relation to eating and weight selfregulation. The weight selfregulation sequence Weight goals may include weight maintenance, weight loss or weight gain. Research indicates that participants in weight loss programs typically have unrealistic goals – while weight loss in such programs rarely exceeds 10% (considered a good outcome from the point of view of improving health), the average weight loss goal tends to be in the range of 20 – 35 % of starting weight (Foster, Wadden, Vogt, & Brewer, 1997). Several authors have suggested that helping patients adopt more realistic weight loss goals may improve maintenance (Byrne et al., 2004), although a recent test of this hypothesis produced equivocal results (Foster, Phelan, Wadden, Gill, Ermold, & Didie, 2004). The process of goalsetting is addressed by a number of cognitivebehaviour theories. The motivation to pursue a goal is considered to be a function of its “value” (compared to alternatives), and the “expectancy” of being able to reach it (Feather, 1982). A variety of motivational variables relevant to goalsetting have been assessed in relation to weight control, including locus of control, outcome expectancy, selfefficacy and self determination (for a review, see Baranowski, Cullen, Nicklas, Thompson, & Baranowski, 2003). Once a goal is established, selfregulation proceeds to a planning phase. The act of planning in weight selfregulation consists of deciding when and what to eat and where and when to exercise. Without plans, one is more likely to be influenced by situational factors, such as the kind of food that is available. For example, if one does not bring SELFREGULATION OF WEIGHT 8 lunch to work and suddenly, at noon, is offered a share in the alldressed pizza that work colleagues have ordered and that will arrive in moments, the probability of eating pizza is increased. One can learn to respond to such temptations with effective planned strategies. For instance, one could determine never to partake in fast food lunches at work, and when offered to do so, to politely decline, and to go take a walk in search of some more balanced meal. Having a specific plan, or “implementation intention” (Gollwitzer, 1993), appears to increase the probability of healthy eating behaviour (Verplanken & Faes, 1999). The most common weight loss plan is some form of structured diet. An obvious difference between various diet plans is in the rate of weight loss. For example, we found that “very low” calorie (e.g. 600 – 800 calories per day) diets resulted in greater short term (up to 9 months) weight loss compared to “low” calorie (e.g. 1000 – 1200) diets (Stotland & Larocque, 2005). Therefore, we were not surprised to find that when given a free choice of diets, a majority of participants chose very low calorie (60%) rather than low calorie diets (40%) (Stotland & Larocque, 2002), reflecting dieters’ desire for rapid weight loss. Goal attainment may be monitored with various methods of self-monitoring, such as calorie counting, following a menu plan, or more subjective judgments (“I feel like I’m following the plan”), as well as weight change. Most weight loss programs teach participants some method of monitoring eating and exercise. A number of studies have shown that better adherence to behavioural selfmonitoring predicts better weight loss outcomes (Boutelle & Kirschenbaum, 1998). However, although it is a helpful strategy, most people are not very diligent in monitoring eating (Womble, Wadden, McGuckin, SELFREGULATION OF WEIGHT 9 Sargent, Rothman, & KrauthamerEwing, 2004), and quite inaccurate in reporting what they have eaten (Lichtman, Pisarska, Berman, Pestone, Dowling, Offenbacher, et al., 1992; Weber, Reid, Greaves, De Lany, Stanford, Going, Howell, & Houtkooper, 2001). So how do people selfmonitor their eating and exercise behaviour? How do we selfmonitor states of hunger and fullness? How much awareness is there of “daily” consumption (i.e. not only what I’ve just eaten and how full I feel right now, but how much I’ve eaten for the day, how balanced my eating has been). Little information is currently available about how much attention people typically give to their eating, or about how such attention influences actual food intake. The self-evaluation of dieting outcomes influences the motivation to continue. Weight change is the most important feedback for a dieter. Weight loss is highly rewarding and therefore rapid weight loss is a strong motivator to adhere to a diet. However, people on diets generally stop losing weight between 3 and 6 months from starting (Jeffery et al., 2000), and consequently very few reach their original weight loss goal (Foster et al., 1997). Given the undeniable logic of the energybalance equation (Bray, 2002), it would appear that the primary reason that people stop losing weight is that they stop adhering to the diet plan, otherwise they would eventually reach (or come much closer to) their desired weight. If one is still dissatisfied with one’s weight, why do continued weight loss efforts seem to have a diminishing reward value? Why do people slip back to old habits? The more dissatisfied one is with the weight loss result the more one should be motivated to achieve the lower weight goal, yet dissatisfaction with weight loss is associated with poorer weight loss maintenance (Foster et al., 2004). Perhaps it is because, as Bandura SELFREGULATION OF WEIGHT 10 and Cervone (1982) showed quite some time ago, dissatisfaction is only motivating in combination with high selfefficacy. Only when one believes the goal can be achieved will one be motivated by feedback that the goal has not yet been reached. The tendency appears to be for dieters to blame themselves, attributing the poor result to a lack of effort and willpower (Polivy & Herman, 2002), which contributes to guilt feelings and a loss of selfefficacy. Depending on the results of the earlier steps of the weight selfregulation sequence, the individual then engages in problem solving. Behaviour therapy programs typically include strategies for more adaptive problem solving (Foster et al., 2005). Here, one tries to figure out how to increase the probability of attaining the weight goal, and then whether the required effort is worth it. Little information is available concerning dieters’ problem solving. Anecdotally, the problem solving appears to consist of a vow to “be better tomorrow,” or worse, “start again on Monday.” Thus, there does not seem to be an adequate analysis of the cause of dietary failure. The simple admonition to “try harder,” is unlikely to produce better results. If one feels that progress towards an important goal is too slow but success is judged to be still possible, one may feel frustrated but still motivated. On the other hand, if progress is slow and prospects are doubtful, then frustration will be mixed with anxiety, and if the poor results persist will lead to feelings of disappointment, sadness and eventually hopelessness (Carver, 2004; Vieth, Strauman, Kolden, Woods, Michels, & Klein, 2003). Dieting can have quite dramatic positive or negative effects on emotional state, depending on the weight loss outcome. Generally, problemsolving is enhanced by positive affect and disrupted by negative affect (Frederickson, 2001). Furthermore, SELFREGULATION OF WEIGHT 11 numerous studies have demonstrated a link between negative affect and overeating tendencies (Canetti, Bachar, & Berry, 2002; Stotland & Larocque, 2004). Thus, the need for dieters to manage emotional states is evident. Dieting vs. lifestyle modification The expected longterm outcome of dieting (although the dieter may not acknowledge it consciously) is “stopping the diet” – no one plans to stay on a diet forever. There is an assumption that after the diet a change will have taken place in eating and exercise habits, so that maintenance of weight loss will be assured. Yet most dieters have less confidence in maintenance than they do in the achievement of the initial weight loss (Stotland & Larocque, 2005). Weak confidence in maintenance unfortunately is an accurate reflection of the typical outcome. Problems in maintaining weight lost may be due to the lack of effort put into meaningful behaviour change during a strict diet program. At a minimum, dieters need to understand that maintenance is a separate goal from weight loss. Weight maintenance requires that one learn how to balance energy intake and output, which requires a modification of one’s former eating and activity patterns – this kind of behaviour change is often referred to as “lifestyle modification.” Diets represent a very different type of selfregulation than lifestyle modification – in lifestyle modification the goal is “healthy eating and exercise behaviour” which is expected to result in the eventual attainment and maintenance of a “healthy weight.” An example of a specific behavioural goal in a lifestyle modification approach is learning to stop eating at a lower threshold of fullness, a goal that requires self monitoring and learning a new standard of fullness. If we look closely at the experience SELFREGULATION OF WEIGHT 12 of eating less we see that the immediate result is simply feeling less full – the link with weight loss is delayed and must be taken on faith. Yet one can learn to appreciate feeling less full as a goal in of itself – this is a glass half full or half empty scenario; one may see eating less as a loss of pleasure, or feel good about eating “just the right amount.” A study of weight control motivation We measured weight loss goals and related motivational variables in 450 women and 60 men who were participating in a medicallysupervised diet program (Stotland & Larocque, 2005). A subset of these subjects (N=276) were assessed again after one month of treatment. We determined the weight loss goal by calculating the difference between current weight and desired weight, as a percentage of current weight. We then asked a series of 22 questions assessing weight control motivation (Table 1). We defined weight control motivation as the sum of attitudes about current weight, desired weight and weight control. These attitudes reflect positive and negative outcome expectancies, selfefficacy, and response expectancy, which are central concepts in cognitive social learning theories of weight control motivation (Baranowski et al., 2003). Our objective was to create a brief scale that would be appropriate for clinical settings and research requiring repeated measures analysis, where the issue of “user friendliness” is paramount, and the length of the scale is a primary consideration. We considered various factor analytic solutions and concluded that a 3factor model was the most meaningful, accounting for 40.3% of the variance in the items. Factor 1 items appeared to measure selfefficacy and response expectancy, and was labeled confidence & acceptability. Factor 2 included items related to attitudes about current weight and expected benefits of weight loss, and was labeled importance. Factor SELFREGULATION OF WEIGHT 13 3 included items reflecting the frequency of thoughts about the goal, and was labeled positive goal activation. Examination of Table 2 indicates that several motivation items showed somewhat limited variance. In particular, items related to the value of weight loss had means close to the maximum possible score. This is not surprising considering that the sample included only patients in weight loss treatment. As a consequence of the restricted range, the importance subscale had a somewhat low internal consistency. We would expect that evaluation of this scale in the general population, or in a nontreatment seeking obese sample would reveal more variability and higher reliability. The three motivation scales showed an interesting pattern of correlations with other variables (Table 3). Our current research is exploring a number of unanswered questions, including changes in motivation over longer periods of time during treatment and outside of a treatment context, influences of treatment variables (e.g. therapeutic alliance measures) on motivation, and the causal relationship between motivation, other psychological variables (e.g. depression, stress) and weight changes. Do only dieters engage in eating selfregulation? In research on dietary restraint (Herman & Polivy, 1984; 2004; Ruderman, 1986), people are often grouped into “restrained” and “unrestrained” eaters, a categorization which is sometimes used interchangeably with “dieters” and “nondieters.” Studies have tended to focus on mapping the cognitive structure of the high restraint group (the “dieters”) while ignoring those who are low on restraint (the “nondieters”). The assumption has been that unrestrained eaters regulate their eating in a much less cognitive SELFREGULATION OF WEIGHT 14 manner, eating in accord with hunger and taste considerations and are therefore not thought to engage in eating selfregulation. We investigated the cognitive processes underlying the decision to eat or not eat (Stotland & Kronick, 2005) in restrained and unrestrained college females. We used a trait measure of eating restraint, the Restraint Scale (Polivy, Herman, & Warsh, 1978) to measure general attitudes towards dieting, and we developed the Eating Thoughts Inventory to measure thoughts that one might have while deciding whether or not to eat some available food. The scale includes items measuring “restraint” thoughts (“No, I don’t want the cookies; I shouldn’t), “disinhibition” thoughts (“Yes, I want the cookies, what the hell”), and “appetitive” thoughts (“No, I don’t want the cookies, they don’t appeal to me”). We found that eating thoughts were a better predictor than Restraint Scale scores of the decision whether or not to eat. Regardless of level of trait restraint, it was the combination of appetitive thoughts and restraint thoughts that predicted eating/not eating behavior. Even the unrestrained eaters reported a significant number of restraint thoughts and an even greater number of disinhibitive thoughts (which, by definition must firstly involve some level of dietary inhibition). From these results, it may be concluded that what determines whether or not individuals eat is not ultimately their everyday (trait) level of restraint, but rather the actual restrained and appetitive (and disinhibitive) thoughts they are having with regards to the food placed in front of them. We believe that such eating thoughts constitute a form of active selfregulation – one that seems to be taking place in both restrained and unrestrained eaters alike. Indeed, a robust decision making process involving caloric, dietabiding and tasterelated factors SELFREGULATION OF WEIGHT 15 seems to be at play, mediating food intake in all eaters. Our study thus shows that unrestrained eaters do selfregulate their eating, and are not purely driven by physical needs and desires. Obesity treatment based on selfregulation theory In our view, many obese patients would benefit from a better understanding of selfregulation in weight control. Individuals may need help at various stages of goal pursuit, from the decision making stage in which the pros and cons of beginning a weight loss attempt are evaluated and a specific weight loss goal is determined, the planning stage in which diet and exercise strategies are chosen, the action stage in which the plan is enacted, evaluated and modified, and during which one must persist despite stress and frustration, and the maintenance stage, with the ultimate goal of fully integrating the eating and exercise changes. The selfregulation model describes the processes that guide the weight control process. Failure to achieve the goal may reflect problems in selfregulatory processes, or may be due to other factors interfering with selfregulation (see Figure 1). For example, metabolic adaptations to weight loss may make further weight loss more difficult (Weyer, Proatley, Salbe, Bogardus, Ravussin, & Tataranni, 2000). Negative affective states may reduce weight control selfefficacy and increase emotional eating tendencies (Stotland & Larocque, 2005). Social influences may make selfcontrol more or less likely (Wansink, 2004). Clinicians should appreciate both the complexities of weight selfregulation and the larger context of the individual’s life. The therapeutic attitude described as “autonomy supportive” (Williams, Deci, & Ryan, 1998) encourages the patient to make her own decisions about goals and strategies. SELFREGULATION OF WEIGHT 16 Motivation is enhanced by emphasizing patients’ awareness of their goals and encouraging discussion of the consequences of their current behavioral choices, along with optimistic collaboration in the development of plans (Rollnick & Miller, 1995). As treatment progresses, selfefficacy is strengthened by helping the patient recognize incremental progress towards the goal or the success of a plan (Bandura, 2004). This is crucial, given the tendencies for dieters to feel dissatisfied and frustrated with their rate of weight loss and to focus on weight rather than behaviour change goals. All of these strategies are important in obesity treatment, because patients often have a significant amount of negative emotional expectancies about the process (Stotland & Larocque, 2005) and treatment dropout rates are notoriously high (Davis & Addis, 1999). In addition to therapeutic support, there is growing interest in the use of interactive technology as selfregulation tools (Bandura, 2004), which are seen as methods to make treatment available to a much larger number of people, and add a new dimension to treatment in settings where patientclinician contact is at a premium (e.g. primary care). In our own research we have been evaluating the usefulness of Internet based psychological assessment in the treatment of obesity (Stotland & Larocque, 2003). The Larocque Obesity Questionnaire (LOQ; Stotland & Larocque, 2004) is an online questionnaire which includes subscales measuring Uncontrolled Eating, Stress Responses, Depression, Perfectionism, and the recently added motivation scales. The questionnaire is brief (requiring 10 – 15 minutes) and is immediately scored, with visual, quantitative and textbased feedback provided. Patients are strongly urged to complete the test on a monthly basis, to evaluate changes and areas of difficulty. SELFREGULATION OF WEIGHT 17 We believe that an online assessment and feedback system such as the LOQ should enhance effective selfregulation, and may therefore have value in improving treatment outcome. We liken this tool to the blood sugar measurements required for effective diabetes selfmanagement – without some sort of objective feedback it is extremely difficult for patient and clinician to guide longterm weight control efforts. Although we have not yet tested it in a controlled experiment we have found that more frequent use of the system was associated with a lower treatment dropout rate during the first 4 1⁄2 months of treatment (Stotland & Larocque, 2003). The potential for online assessment and treatment in obesity is still largely untapped (see Womble et al., 2004). Conclusion According to a selfregulation model, individuals who try to reduce their weight require effective goal setting, planning, selfmonitoring, selfevaluation, emotional coping and problemsolving. In previous accounts of the behavioural treatment of obesity, many of these elements have been included in treatment plans (Foster et al., 2005), but there has been a lack of theoretical integration or a model that can be used to guide efforts to improve treatment outcome. Our model places the selfregulation of weight, eating and exercise within a broader selfregulatory perspective, considering other goals that the individual is pursuing, and also recognizing the influence that physiological and environmental variables can have on selfregulation. A number of theories have stressed the importance of stages, or phases, or periods, in selfregulation (e.g. Schwarzer, 1999). This is nowhere more necessary than in weight control. The management of obesity is a lifelong concern, and longterm studies are SELFREGULATION OF WEIGHT 18 required to even begin to appreciate the changes that occur over time in behaviour, motivation and weight. The study of obesity and its treatment require a means of measuring and tracking selfregulation processes. This is an interesting situation in which the means for one group (the patients) to improve selfregulation of weight, by providing them with information relevant to their goals, is the same means for another group (the researchers) to evaluate the causes and effects of weight selfregulation processes. Interactive technology is a means of expanding the scope and access of research and clinical intervention. Yet again, weight selfregulation can never be totally predictable, because it is influenced by other ongoing selfregulation projects. However, as we map out the self regulatory strategies of people showing different courses of weight change, response to diets, and adherence to treatment, we may be able to design a blueprint for more successful outcomes. A treatment model based on selfregulation maximizes patient responsibility and facilitates the doctorpatient relationship. 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SELFREGULATION OF WEIGHT 27 SELFREGULATION OF WEIGHT 28 Outcome expectancy Selfefficacy, acceptability Goal Accesibility, activation Planning Self-monitoring Socio environmental Facilitators & impediments Physiology Emotional state Problem-solving Self-evaluation & emotional response Personality traits Figure 1 – The selfregulation sequence and influences Table 1 – Weight Control Motivation Questionnaire 1. RIGHT NOW, how important is it for you to succeed in weight control? 1234567 It’s not that Important compared To other goals in my Life It’s the most Important. Goal in my Life 2. RIGHT NOW, how much physical pain is caused by your weight? 1234567 None A great deal 3. RIGHT NOW, how much emotional pain is caused by your weight? 1234567 None A great deal 4. RIGHT NOW, do you believe you will be healthier if you lose weight? 1234567 I do not Believe I Will be any healthier I believe I Will be much Healthier 5. RIGHT NOW, do you believe you will be happier if you lose weight? 1234567 I do not Believe I Will be any happier I believe I Will be much Happier 6. RIGHT NOW, how do you feel about having to deal with weight control and trying to maintain healthy (eating and exercise) habits? 1234567 I don’t mind I totally It at all Resent it 7. RIGHT NOW, how much effort do you feel it will take to succeed in weight control? 1234567 A little effort A huge effort 8. RIGHT NOW, how much effort are you willing to make in order to reach your desired weight? 1234567 Hardly any Whatever it takes SELFREGULATION OF WEIGHT 29 9. RIGHT NOW, how confident are you that you will reach your desired weight? 1234567 I’m afraid I I’m sure I Will fail Will succeed 10. RIGHT NOW, how confident are you that you will maintain the weight you lose? 1234567 I’m afraid I Will regain All of it I’m sure I Will maintain All of it DURING THE PAST WEEK, how often did you do each of the following: 11. 12. 13. 14. 15. 16. Imagined myself at my desired weight. 123456 never once or a few times every day a few times many times twice per day per day per day Told myself that life is short and I deserve to please myself by eating whatever I want. 123456 never once or a few times every day a few times many times twice per day per day per day Felt doubtful about succeeding in weight control. 123456 never once or a few times every day a few times many times twice per day per day per day Talked to someone who made me feel discouraged about losing weight. 123456 never once or a few times every day a few times many times twice per day per day per day Thought about the benefits of losing weight. 123456 never once or a few times every day a few times many times twice per day per day per day Felt regretful about all the things I must give up in order to lose weight (e.g., foods I like, old and comfortable habits, favorite restaurants, parties, etc.). 123456 never once or a few times every day a few times many times twice per day per day per day SELFREGULATION OF WEIGHT 30 17. Read or listened (TV, radio, tapes, books and Internet) to inspiring material about weight loss. 123456 never once or a few times every day a few times many times twice per day per day per day 18. Reminded myself that I will reach my weight loss goals if I am persistent. 123456 never once or a few times every day a few times many times twice per day per day per day 19. Felt guilty about my weight (or my overeating). 123456 never once or a few times every day a few times many times twice per day per day per day 20. Read or listened to something that made me feel discouraged about losing weight. 123456 never once or a few times every day a few times many times twice per day per day per day 21. Talked about weight loss strategies with a supportive person (friend, advisor, doctor). 123456 never once or a few times every day a few times many times twice per day per day per day 22. Thought that trying to lose weight was too big of an effort. 123456 never once or a few times every day a few times many times twice per day per day per day SELFREGULATION OF WEIGHT 31 Table 2 – Weight Control Motivation Questionnaire means, standard deviations and reliabilities at time 1 (pretreatment) and time 2 (1 month after start of treatment) SELFREGULATION OF WEIGHT 32 Scale & Items Time 1 Time 2 t275 Mean SD ! Mean SD ! Confidence & Acceptability 56.5 8.8 .79 64.2 7.8 .82 15.3*** 61 5.0 1.7 5.6 1.4 6.3*** 9 5.2 1.8 6.0 1.4 7.8*** 10 4.2 1.9 5.3 1.5 10.3*** 121 5.0 1.1 5.6 0.7 7.9*** 131 4.3 1.2 5.0 0.9 9.9*** 141 5.6 0.8 5.8 0.5 4.9*** 161 4.3 1.2 5.0 0.9 11.7*** 191 3.5 1.6 4.7 1.4 11.0*** 201 5.5 0.9 5.8 0.5 4.9*** 221 5.1 1.0 5.7 0.7 8.1*** Importance 38.6 5.4 .69 35.6 5.4 .60 3.7*** 1 5.8 1.1 5.7 1.1 0.6 2 3.0 2.0 2.5 1.6 4.6*** 3 5.0 1.8 3.9 1.9 9.6*** 4 6.6 0.9 6.4 1.2 2.1* 5 6.3 1.1 6.2 1.2 1.4 7 5.6 1.5 4.6 1.7 9.6*** 8 6.3 0.9 6.3 1.0 0.1 Positive Goal Activation 15.4 4.2 .65 17.0 4.4 .76 6.4*** 11 3.2 1.4 3.7 1.3 6.1*** 15 4.3 1.2 4.3 1.2 0.2 17 2.1 1.2 2.4 1.1 3.6** 18 3.2 1.5 3.9 1.3 7.6*** 21 2.6 1.0 2.7 1.1 1.1 *p< .05 **p< .001 ***p< .0001 Note – 276 of the original sample of 510 patients completed a second psychological assessment 1 item is reverse scored Table 3 – Correlations between weight control motivation scales and age, body mass index and psychological variables SELFREGULATION OF WEIGHT 33 Variable Confidence & Acceptability Importance Positive Goal Activation Age .19*** .03 .06 Body Mass Index .18*** .36*** .03 Weight Loss Goal1 .24*** .36*** .09 Uncontrolled Eating2 .58*** .25*** .08 Stress Responses2 .37*** .35*** .01 Depression2 .43*** .29*** .01 Perfectionism2 .35*** .22*** .06 Autonomous Motivation3 .15 .28* .22* Controlled Motivation3 .43*** .33*** .03 Perceived Health Threat4 .30** .34*** .05 Outcome Expectancy4 .09 .13 .06 Action Self Efficacy4 .44*** .09 .21* Coping Self Efficacy4 .34*** .19* .13 Intention4 .25** .19* .32** *p< .05 **p< .001 ***p< .0001 1 – Represents desired weight loss as a percentage of starting weight 2 – Larocque Obesity Questionnaire (Stotland & Larocque, 2004) subscale 3 – Treatment SelfRegulation Questionnaire subscale (Williams, Grow, Freedman, Ryan, & Deci, 1996) 4 – from Schwarzer & Renner (2000)
6Larocque Obesity Questionnaire (LOQ): comment évaluer les facteurs psychologiques dans le contrôle du poids.
Article publié dans "The American Journal of Bariatric Medicine", Automne 2000,Vol.15, N.3. Par Maurice Larocque, MD et Stephen Stotland, Ph D . Note de l'éditeur : Dr Larocque, membre de l'ASBP, dirige une clinique d'obésité à Montréal. Dr Stotland fait partie du Service de thérapie cognitive et comportementale de l'Hôpital Général de Montréal. Introduction Le traitement de l'obésité passe par un changement des comportements sous-jacents, notamment l'apport excessif de nourriture et un niveau d'activité insuffisant. L'efficacité des approches nutritionnelles et comportementales dans le traitement de l'obésité demeure limitée. Un pourcentage alarmant de patients abandonnent leur traitement dès les premières semaines, n'atteignent jamais leur poids santé ou encore, reprennent tout le poids perdu.1,2 Pour que le traitement de l'obésité soit efficace, il doit nécessairement viser les mécanismes psycho-biologiques responsables du manque d'auto-discipline.3,4 Cependant, à ce jour, la recherche n'a pas réussi à mettre en lumière toutes les variables psychologiques généralement associées à l'obésité5 même si de toute évidence les patients montrent toujours, au cours des périodes de perte de poids et de maintien, des changements d'humeur8 et de personnalité qui peuvent avoir une signification6,7 clinique. De plus, la plupart des médecins pensent que les facteurs émotionnels jouent un rôle capital dans le contrôle du poids et jouent un rôle déterminant dans le maintien à long terme et le retour des comportements indésirables. Cet article présente un nouveau questionnaire servant à mesurer le nombre de variables comportementales et psychologiques qui peuvent jouer un rôle important dans le contrôle du poids. Le LOQ a été conçu pour des applications cliniques - il est complet, bref et facile à administrer sur ordinateur. Ces aspects sont très importants dans des applications cliniques, particulièrement en médecine générale, domaine dans lequel les médecins voient de nombreuses personnes souffrant d'obésité mais n'ont ni le temps ni les ressources nécessaires pour intervenir. Le LOQ permet d'évaluer efficacement et à faible coût les attitudes et les comportements problématiques qui peuvent entraver les efforts de contrôle du poids. Le questionnaire fournit également un rapport personnalisé indiquant les attitudes qui posent problème et des conseils pour les modifier. Ce questionnaire a été utilisé durant la dernière décennie dans un certain nombre de cliniques auprès d'environ 300 000 patients, mais, à ce jour, aucune analyse de fiabilité et de validité n'a été présentée. Nous nous penchons ici sur une étude qui examine les propriétés statistiques du LOQ et son rapport avec d'autres mesures psychologiques. Méthode Sujets Soixante-dix-huit femmes, toutes âgées de 18 ans et plus, qui suivaient une cure amaigrissante prescrite par des médecins spécialisés dans le traitement de l'obésité, ont participé à cette étude. Le traitement comportait un régime basses-calories et des exercices physiques ainsi que des visites périodiques à des spécialistes traitant des problèmes médicaux ou psychologiques relatifs au contrôle du poids. Le sujet moyen était âgé de 37 ans (+/- 8,7) et pesait 183,4 livres (+/- 37,8). Seuls les patients présentant un IMC supérieur à 25 étaient acceptés pour l'étude. Procédure Les sujets ont rempli le LOQ ainsi que divers autres questionnaires d'auto-vérification à différents stades de leur traitement. Certains ont rempli le questionnaire avant de suivre leur premier traitement, alors que d'autres l'ont rempli à un stade ultérieur du traitement. Le LOQ est un questionnaire d'auto-vérification en 52 points, administré et corrigé par ordinateur, qui peut être rempli en 10 minutes. Ces points mesurent diverses variables liées au comportement, aux émotions et à la personnalité et susceptibles d'être associées à des problèmes de contrôle du poids. Les variables ont été choisies en fonction de l'expérience clinique des auteurs dans le traitement de l'obésité. Le questionnaire permet d'évaluer les habitudes alimentaires problématiques, la nourriture-émotion, la nourriture-récompense, les objectifs de perte de poids, le sentiment de dépression, l'ennui et la culpabilité, les réponses au stress et différents traits de caractère, comme l'agressivité, la passivité et la paranoïa. Une analyse factorielle antérieure menée auprès de 680 femmes obèses (Larocque et Stotland, 1992, données non publiées) montrait que le LOQ peut être divisé en quatre sous-échelles appelées Habitudes, Motivation à la perte de poids, Réactions physiques au stress et Émotions négatives. Des exemples de points de ces quatre sous-échelles sont présentés au Tableau 1. Tableau 1 Exemple des points du LOQ Sous-échelle Exemple de points Habitudes 1. En repensant aux derniers repas que vous avez pris, essayez d'estimer le temps que vous avez pris pour manger: A. Moins de 5 minutes B.Entre 5 et 10 minutes C. Entre 10 et 20 minutes D. Entre 20 et 30 minutes D. Plus de 30 minutes. 2. Lorsque vous passez devant une corbeille de fruits, de nourriture ou de sucreries, vous servez-vous souvent? A. Toujours B. Assez souvent C. A l'occasion D. Jamais. Motivation à la Perte de Poids 1. Au plus profond de vous-même, vous croyez-vous capable d'atteindre le poids désiré et de le maintenir par la suite? A. Pas du tout B. Peut-être C. Probablement D. Certainement. 2. Si vous perdez seulement la moitié du poids prévu dans le mois à venir, prévoyez-vous poursuivre votre régime? A. Pas du tout B. Peut-être C. Probablement D. Certainement. Réactions physiques au stress 1. Au cours du dernier mois, alors que vous étiez au repos, avez-vous ressenti un des symptômes suivants : accélération des battements de cœur, gorge nouée ou souffle court. A. Jamais B. A l'occasion C. Souvent (une fois par semaine en moyenne) D. Très souvent (plusieurs fois par semaine). 2. Au cours du dernier mois, avez-vous ressenti un des symptômes suivants qui ne sont pas imputables à une maladie quelconque : maux de tête, maux de dos, douleur au cou. A. Jamais B. A l'occasion C.Une fois par semaine en moyenne D. Plus d'une fois par semaine. Émotions négatives 1. J'ai l'impression que ma vie ne mène nulle part et n'a aucune valeur. A. C'est tout à fait moi B. Je pense souvent ainsi C. Je pense parfois ainsi D.Je ne pense jamais ainsi. 2. Je ne m'engage généralement dans des activités que si je suis certain de réussir. A. Oui, absolument B. J'ai souvent cette attitude C.J'ai parfois cette attitude D. Non, cela ne me ressemble pas du tout. Le Questionnaire sur la personnalité de Eysenck9 est fondé sur une échelle de 90 points mesurant les Traits névrotiques, l'Extraversion et les Traits psychotiques. Cette échelle a été largement utilisée et a affiché un niveau élevé de consistance interne et de fiabilité test-retest. Les échelles de Traits névrotiques et d'Extraversion ont été utilisées dans la présente étude. Les Traits névrotiques sont définis comme la mesure d'une tendance à l'inquiétude, aux sautes d'humeur et à la dépression ainsi qu'aux plaintes psychomotrices. L'Extraversion est censée traduire la sociabilité, le besoin d'émotions et de changement ainsi que la décontraction. L'Inventaire de la dépression de Beck comprend 13 points d'étude et mesure les symptômes et signes de dépression. La corrélation entre le BDI-13 et le BDI intégral varie de 0,89 à 0,97, et les coefficients de cohérence dépassent généralement 0,85. L'Échelle d'estime corporelle11 mesure trois dimensions modérément intercorrélées liées à l'auto-évaluation de l'Attirance sexuelle, la Préoccupation du poids et la Condition physique. Une note totale pour l'Estime corporelle globale a été utilisée dans la présente étude. L'Échelle de comportement alimentaire hollandaise12 a été largement utilisée pour évaluer les tendances à suivre des régimes (Restriction cognitive) et la suralimentation en réponse à des états émotionnels (Nourriture-émotion). Les deux échelles présentent des niveaux élevés de consistance interne et montrent les relations prévues entre des variables telles que l'apport calorique et la frénésie alimentaire. Afin d'examiner la validité d'une fonction discriminante des échelles du LOQ, nous avons comparé les 1intercorrélations entre les sous-échelles du LOQ et les 2relations entre les sous-échelles du LOQ et d'autres variables. Résultats On a mesuré la fiabilité des sous-échelles du LOQ en utilisant le coefficient de Cronbach, qui fournit une indication sur la consistance interne des points des sous-échelles. La sous-échelle des Habitudes mesure en 17 points une large gamme de comportements face à la nourriture et à l'activité physique; on attendait donc un coefficient de consistance de 0,67. La sous-échelle en neuf points des Réactions physiques au stress présentait un coefficient de consistance de 0,68, ce qui reflète le vaste champ d'observation des symptômes liés au stress. La sous-échelle en 19 points des Émotions négatives affichait un niveau de consistance de 0,85, ce qui indique qu'elle mesure un construct relativement cohérent. La sous-échelle en 5 points de la Motivation à la perte de poids présentait un coefficient de consistance d'à peine 0,46, qui pourrait être imputable au nombre limité de points utilisés ou au caractère multidimensionnel de cette variable. Cependant, la somme des points de motivation a été considérée comme une mesure utile de la motivation globale à la perte de poids, et a été retenue pour des analyses ultérieures. Les corrélations entre les sous-échelles du LOQ sont présentées au Tableau 2. La sous-échelle des Habitudes présentait une corrélation significative avec la Motivation à la perte de poids (r = 0,37, p.01), ce qui indique que les patients ayant des habitudes plus saines sont plus motivés à perdre du poids, ainsi qu'avec les Émotions négatives (r= 0,29, p.01), ce qui donne à penser que de meilleures habitudes sont associées à de plus faibles niveaux d'affects négatifs. La corrélation la plus significative a été établie entre les Émotions négatives et les Réactions physiques au stress (r= 0,57, p.001), ce qui coïncide avec les résultats des questionnaires d'auto-évaluation sur les affects négatifs et les réactions au stress. Dans l'ensemble, les sous-échelles du LOQ étaient faiblement ou modérément corrélées, sauf pour ce qui est de l'association émotions/stress mentionnée ci-dessus. Il semble donc que les sous-échelles du LOQ représentent des constructs psychologiques différents. Cet aspect a été étudié plus avant lors de l'analyse des relations entre les échelles du LOQ et d'autres mesures psychologiques. Tableau 2 Intercorrélations entre les sous-échelles du LOQ Habitudes Motivation à la perte de poids Réactions physiques au stress Émotions négatives Habitudes --- .37*** -.10 -.29** Motivation à la perte de poids --- -.1 .19 Réactions physiques au stress --- .57*** Émotions négatives --- * p<.05 ** p<.01 ***p<.001 La sous-échelle des Habitudes présentait une corrélation significative avec différentes variables psychologiques, dont l'estime du corps (r= 0,31, p.01), la restriction alimentaire cognitive (r=0,46, p.001), la nourriture-émotion (r=-0,41, p.001) et les résultats BDI (r=-0,32, p.01). Ces données indiquent que les sujets qui ont des résultats élevés dans la sous-échelle des Habitudes tendent à avoir une meilleure estime de leur corps et un degré plus élevé de restriction alimentaire cognitive et des tendances moins marquées à la nourriture-émotion et à la dépression. La Motivation à la perte de poids était corrélée avec les résultats BDI (r=-0,26, p.01) et au poids (r=-0,26, p.01), indiquant qu'un degré élevé de motivation à la perte de poids était associé à des niveaux de dépression plus faibles et à un poids moins élevé. Les Réactions physiques au stress étaient corrélées avec à l'estime du corps (r=-0,39, p.001), les résultats BDI (r=0,63, p.001) et les traits névrotiques (r=0,62, p.001), ce qui semble indiquer que les réactions au stress étaient étroitement liées à une affectivité négative et à une autoperception négative. Enfin, les Émotions négatives montraient à peu près les mêmes modes d'associations que la sous-échelle des Réactions physiques au stress, avec des corrélations significatives avec l'estime du corps (r=-0,27, p.01), les résultats BDI (0,66, p.001) et les traits névrotiques (r=0,76, p.001). Les Émotions négatives étaient également associées à des résultats plus élevés dans la sous-échelle de la Nourriture-émotion (r=0,42, p.001). Tableau 3 Relations entre les sous-échelles du LOQ et d'autres mesures Habitudes Motivation à la perte de poids Réactions physiques au stress Émotions négatives Estime du corps .31** .08 -.39*** -.27** Restriction alimentaire cognitive .46*** .20* .14 .01 Nourriture-émotion -.41*** -.19 .19 .42*** BDI -.32** -.26** .63*** .66*** Extraversion .14 .27** .17 .01 Traits névrotiques -.18 -.13 .62*** .76*** Poids (livres) -.19 -.26** .17 .01 * p<.05 ** p<.01 ***p<.001 Discussion Le LOQ semble un instrument fiable permettant de mesurer plusieurs variables psychologiques et comportementales associées à l'obésité. Cette conclusion est corroborée par la consistance interne et les résultats convergents des analyses de validité. Les résultats suggèrent que le LOQ mesure un certain nombre de variables cohérentes et dont le caractère distinct peut être établi par une fonction discriminante, et donne des associations prévisibles avec d'autres mesures. Une étude continue13 permettra de déterminer si les variables mesurées par le LOQ sont liées à des résultats cliniques importants (c'est-à-dire perte de poids ou maintien). Un des facteurs du LOQ, la sous-échelle Motivation à la perte de poids, semble présenter un degré de consistance interne assez faible. Comme il a été mentionné précédemment, ce résultat pourrait être interprété comme découlant de l'ampleur du construct de la motivation à perdre du poids, étant donné que chacun a ses propres raisons de vouloir perdre du poids et qu'il n'est pas démontré que les diverses sources de motivation sont additives. Quoi qu'il en soit, d'autres travaux doivent être rapidement entrepris pour explorer et mesurer cette variable, étant donné son importance théorique et son potentiel pratique. Les variables mesurées par le LOQ ne sont pas nouvelles. Il existe déjà des mesures validées de la plupart de ces facteurs.6 Cependant, la valeur réelle de ce LOQ est qu'il permet de mesurer facilement ces facteurs psychologiques et dans un format accessible dans les applications cliniques. Étant donné les conséquences de l'obésité sur la santé et l'inefficacité des traitements actuels, il est impératif d'étudier les processus qui interviennent dans le maintien à long terme du poids. Même si les obstacles à un contrôle du poids efficace sont certainement complexes et mettent en jeu diverses variables biopsychosociales, il est clair que les facteurs psychologiques tiennent une place prépondérante dans l'équation. Les résultats de cette étude montrent que le Questionnaire sur l'obésité du Dr Larocque peut se révéler un outil précieux pour comprendre les processus psychologiques qui interviennent dans le contrôle du poids. Références 1. French S, Jeffery R, Murray D. Is dieting good for you? Prevalence, duration and associated weight and behavior changes for specific weight loss strategies over four years in US adults. Int J Obes. 1999;23:320-327. 2. Wing R. Behavioral approaches to the treatment of obesity. In G. Bray, C. Bouchard, & P. James (Eds.), Handbook of Obesity. 1997; New York: Marcel Dekker. 3. Foster, G., Wadden, T., Swain, R., Stunkard, A., Platte, P., & Vogt, R. The eating inventory in obese women: Clinical correlates and relationship to weight loss. Int J of Obes and Rel Metab Dis. 1998;22, 778-785. 4. McGuire M, Wing R, Klem, Lang W, Hill J. What predicts weight regain in a group of successful weight losers? J of Consult and Clin Psych . 1999;67, 177-185. 5. Friedman M, Brownell K. Psychological correlates of obesity: Moving to the next research generation. Psych Bulletin . 1995;17, 3-20. 6. Wadden T, Foster G. Behavioral assessment and treatment of markedly obese patients. In T. Wadden & T. VanItallie (Eds.) Treatment of the seriously obese patient. 1992; New York: Guilford. 7. Williams P, Surwit R, Babyak M, McCaskill C. Personality predictors of mood related to dieting. J of Consult and Clin Psych. 1998;66, 994-1004. 8. Brownell K. Relapse and the treatment of obesity. In T. Wadden & T. VanItallie (Eds.) Treatment of the seriously obese patient. 1992. New York: Guilford. 9. Eysenck H, Eysenck S. Manual of the Eysenck Personality Questionnaire. 1975, San Diego: EdITS. 10. Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch of Gen Psychiat.1961;4, 561-571. 11. Franzoi S, Shields J. The body esteem scale: Multidimensional structure and gender differences in a college population. J of Personality Assessment.1984 12. Van Strein T, Frijters J, Bergers G, & Defares P. (1986). Dutch eating behavior questionnaire for the assessment of restrained, emotional and external eating behavior. Int J of Eat Dis. 1986;5, 295-315. 13. Larocque M, Gougeon R. (1999). Primary care treatment of obesity: Strategy for long-term weight maintenance. American Journal of Bariatric Medicine, 1999;14, 16-20.
7BARIATRIC SURGERY VS LIFESTYLE CHANGE
Abstract Background Few studies have looked at non-surgical alternatives for morbid obese patients. This study aims to compare 1-year weight loss and changes in risk factors and comorbidities after bariatric surgery and three conservative treatments. Methods Patients with morbid obesity (BMI>40 or BMI> 35 kg/m2 plus comorbidities) on waiting list for bariatric surgery, were non-randomly allocated to (A) bariatric surgery or to one of three conservative treatments; (B) residential intermittent program; (C) commercial weight loss camp and (D) hospital outpatient program. Body weight, risk factors and comorbidities were assessed at baseline and 1 year.
8Should obesity be treated?
Response to debate in Canadian Family Physician, May 2012 Should obesity be treated? Stephen Stotland, Ph.D. & Maurice Larocque, M.D. In reading the debate in the recent issue of Canadian Family Physician, we were astonished and disappointed, both as clinicians and researchers, to discover strong attitudes suggesting that obesity should not be treated. We found it particularly alarming that doctors should feel so hopeless and no doubt transmitting this frustration to their patients. Thus, we are concerned that numerous obese individuals will be discouraged from taking better care of themselves. This essay examines the basis for hopefulness in obesity treatment research, considering the results of our own research program. In thinking about whether or not obesity should be treated we considered the impact of the well-documented negative bias among health professionals, including physicians, nurses, psychologists, dietitians and others, against obese people and negative attitudes toward the subject of weight management. The obese individual is blamed for the problem and is thought to be perhaps less deserving of care. Such biases, implicit and explicit, have been shown time and again.1 It is our opinion that those offering far-reaching conclusions about whether obesity “should” be treated2, 3 need to recognize the possibility of their own negative bias towards the obese patient and the weight management process. Negative attitudes in practitioners may be linked to their feeling ill-equipped to conduct this type of counseling.4 It is unknown to what extent practitioners are conscious of such feelings of low self-efficacy. Doctors very frequently prescribe healthy behavior like better eating, exercise and stress reduction.5, 6 In fact these are the fundamentals of weight management. Do doctors have greater self-efficacy for influencing health behaviour than they have for influencing weight management? There is a paradox if doctors recognize and support the practice of healthy behavior (eating, exercise, substance use, stress, mood, sleep), but dismiss the likelihood of successful weight management, because if an obese person improves on these health behavior dimensions isn’t it a virtual certainty that they will lose weight? Most of the available obesity treatment research has looked at outcomes primarily in terms of weight change, with insufficient attention to concurrent changes in behavior, attitudes and emotions, and there is almost no consideration of treatment “process.” What is needed is a theory-based account of how processes lead to weight control outcomes, over time. Without a strong theory, if we observe a negative outcome there is no way to use this information to engineer better treatments. Our research is an example of a more theoretically-based approach, an analysis of process and outcome in weight management based on a reliable set of measures of Should obesity be treated? 1 psychological variables and the therapeutic alliance, as well as BMI and other physiological variables. If the outcome of obesity treatment is very poor, as some believe, then we must try harder to understand why results are as they are, and develop a better theory that will predict more successful outcomes. This is not the time for hopelessness. In order to develop and test such a theory, we need studies with multiple observations over time and conditions. This type of research design is a perfect fit for obesity treatment, which involves ongoing treatment visits and assessments over a long period of time. In recent years we have used this type of repeated measures design, employing a multi-level modeling analysis to show: (1) early (approximately one month) improvements in both weight and eating habits (less uncontrolled eating) predict better later weight changes (up to 9 months).7 This indicates we must pay very close attention to the early treatment results; (2) changes in “negative” weight control motivation (feelings of resentment, regret, doubt and effort) are related to changes in weight and improvements in eating behavior and mood, while “positive” weight control motivation (beliefs that weight is causing physical or emotional suffering, and expectations that better weight control will have physical or emotional benefits) is not associated with weight or psychological changes.8 It is clear that the negative motivation dimension must be a focus of treatment research; (3) improvements in psychological variables (eating, depression, stress, perfectionism, negative motivation) are related to improvements in the therapeutic alliance between clinician and patient; the alliance is related to weight loss outcomes, but this effect is fully mediated by changes in psychological variables. Thus, the alliance directly influences the patient’s mood and behaviour, which is then directly related to weight change.9 Our combined body of research leads us to conclude that the outcomes of weight control treatment are more predictable than previously believed (see also10). This research brings needed optimism for practitioners deciding to venture into the field of helping people with their weight. Patients often feel hopeless about weight control and are seeking support from their doctors and therapists. We must practice hope, as we continue to do theory-driven research to try to better understand the processes of weight control failure and success. We were motivated to write this response to counter what we saw as a particularly negative viewpoint that some (but not all11) professionals seem to have about obesity treatment. We believe it is important to promote a stronger commitment to treat this problem. Our research shows that some of the causes of success and failure are controllable, such as helping patients to address their negative attitudes about the weight control process and working to establish a good working alliance. In this regard we would point at that our research shows it is not the initial levels of psychological variables (e.g. depressed mood, emotional eating) or the alliance that predicts outcome, but “changes” in these variables. Patients improve (and backslide) in all of Should obesity be treated? 2 these dimensions simultaneously, which shows that practitioners must be sensitive to such changes. If we accept the premise that lifestyle change is possible, although a difficult, variable and long-term process, we are likely to achieve better outcomes. Surely we must not stop trying to better understand weight control, as we work to develop better ways to help individuals improve all of their health behaviour. Should obesity be treated? 3 References 1. Puhl, R.M., & Heuer, C.A. The stigma of obesity: A review and update. Obesity 2009, doi:10.1038/oby.2008.636. 2. Ladouceur, R. Should we stop telling obese patients to lose weight? Canadian Family Physician 2012, 58, 499. 3. Havrankova, J. Is the treatment of obesity futile? Canadian Family Physician 2012, 58, 508- 510. 4. Greenwood, J.I.J. The complexity of weight loss counseling. J Am Board Fam Med 2009, doi: 10.3122/jabfm.2009.02.080256. 5. Foster, G.D.,Wadden, T.A., Makris, A.P., Davidson, D., Swain Sanderson, R., Allison, D., & Kessler, A. Primary care physicians’ attitudes about obesity and its treatment. Obes Res 2003, 11, 1168-1177. 6. Phelan, S., Nallari, M., Darroch, F.E., & Wing, R.R. What do physicians recommend to their overweight and obese patients? J Am Board Fam Med 2009, 22:115–122. 7. Stotland, S., & Larocque, M. Early treatment response as a predictor of ongoing weight loss in obesity treatment. British J of Health Psych, 2005, 10, 601–614. 8. Stotland, S., Larocque, M., & Sadikaj, G. Positive and negative dimensions of weight control motivation. Eating Behaviors 2012, 13, 20–26. 9. Larocque, C., Stotland, S., Larocque, M., Lecomte, C., Savard, R., & Sadikaj, G. Therapeutic alliance, psychological variables and outcome in obesity treatment. (In preparation). 10. Stubbs, J., Whybrow , S., Teixeira, P., Blundell, J., Lawton, C., Westenhoefer, J., ...& Raats, M. implications for weight control therapies based on behaviour change. Obesity Reviews Should obesity be treated? Problems in identifying predictors and correlates of weight loss and maintenance: 2011, 12, 688-708. 11. Moyer, V.A. Screening for and Management of Obesity in Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Int Med 2012, 157, 1-6. 4
9Positive and negative dimensions of weight control motivation
Abstract This study examined weight control motivation among patients (N = 5460 females and 547 males) who sought weight loss treatment with family physicians. An eight-item measure assessed the frequency of thoughts and feelings related to weight control “outcome” (e.g. expected physical and psychological benefits) and “process” (e.g. resentment and doubt). Factor analysis supported the existence of two factors, labeled Positive and Negative motivation. Positive motivation was high (average frequency of thoughts about benefits was ‘every day’) and stable throughout treatment, while Negative motivation declined rapidly and then stabilized. The determinants of changes in the Positive and Negative dimensions during treatment were examined within 3 time frames: first month, months 2–6, and 6–12. Maintenance of high scores on Positive motivation was associated with higher BMI and more disturbed eating habits. Early reductions in Negative motivation were greater for those starting treatment with higher weight and more disturbed eating habits, but less depression and stress, while later reductions in Negative motivation were predicted by improvements in eating habits, weight, stress and perfectionism. Clinicians treating obesity should be sensitive to fluctuations in both motivational dimensions, as they are likely to play a central role in determining long-term behavior and weight change. Highlights ► We identified two relatively independent dimensions of weight control motivation. ► The value of weight control fluctuates with recent weight change and depression. ► Negative motivation fluctuates with changes in eating habits, weight, and stress. ► Motivation should be assessed repeatedly during weight control treatment.