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Well-being and morbid obesity in women Tanco, Sheryl Anne 1995

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WELL-BEING AND MORB]D OBESITY IN WOMENbySHERYL ANNE TANCOB.A., The University of British Columbia, 1987M.A., The University of British Columbia, 1991A THESIS SUBMITTED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFDOCTOR OF PHiLOSOPHYinTHE FACULTY OF GRADUATE STUDIES(Department of Psychology)We accept this thesis as conformingto the required standardTHE UNWERSITY OF BRITISH COLUMBIAMarch 1995© Sheryl Anne Tanco, 1995In presenting this thesis in partial fulfillment of therequirements for an advanced degree at the University of BritishColumbia, I agree that the Library shall make it freely availablefor reference and study. I further agree that permission forextensive copying of this thesis for scholarly purposes may begranted by the head of my department or by his or herrepresentatives. It is understood that copying or publication ofthis thesis for financial gain shall not be allowed without mywritten permission.(Signature)Department of_________________The University of British ColumbiaVancouver, CanadaDate c?AbstractObesity is a prevalent disorder associated with myriad psychological and physiologicalproblems. Dietary restraint alone is ineffective in treating obesity and can instead exacerbate theproblem. Regular physical exercise is fundamental to successful management of weight problemsas well as to generalized physical and psychological well-being. In Study 1, demographic andpsychometric variables from obese women, referred over an eight year period to a hospitalpsychology department for weight management, were reviewed. Findings suggest that suchobese women are mildly depressed, anxious, perceive themselves as lacking in self-control andhave elevated levels of eating-related psychopathology. In addition to such psychologicaldistress, morbidly obese women are also at risk physiologically. As morbidly obese individualsare unlikely to maintain weights at normative levels, goals and treatments aimed at alleviatingthese problems, independent of attempts at significant weight loss, seem appropriate. A grouptreatment programme (CT), based, in part, on the principals of cognitive therapy was developed.The programme incorporated a nondieting approach, encouraged nonchaotic eating and regularexercise, and promoted the use of alternative coping skills; weight loss per se was not a focus ofthe intervention. Study 2 presents pre- and post-treatment results from a group of 15 morbidlyobese women completing this programme. Following treatment, these women were significantlyless depressed and anxious and showed lower levels of eating-related psychopathology. By theend of treatment, significantly more of the women were exercising regularly. Given thepromising nature of these results, a controlled, comparative treatment outcome study (Study 3)was embarked upon. Sixty-two women, each with a body mass index of at least 30 kg/m2,were randomly assigned to either the above-described CT programme, a behaviour therapyweight loss programme (BT) or a wait-list control group. Women in both active treatmentgroups lost significant amounts of weight, while members of the control group had anonsignificant increase in weight. For CT participants, depression, anxiety, and eating-relatedpsychopathology decreased significantly over the course of treatment while perceptions of selfcontrol increased significantly. In contrast, BT and control subjects showed no significantchanges in these psychological variables. Relative to control subjects, significantly greater11proportions of CT and BT subjects were exercising regularly by the end of treatment. At sixmonth follow-up, data from approximately half the original CT and BT participants wereobtained. Statistically, these subjects did not show significant changes across time in terms ofweight or psychometric variables. Variables possibly mediating the differential effects of the twotreatments are discussed, as are limitations to the current work and directions for futureresearch.111TABLE OF CONTENTSAbstract page ii.Table of Contents page iv.List of Tables page vii.List of Figures page viii.Acknowledgments page ix,Dedication page ix,Introduction page 1.Effects of Dietary Restriction page 2.The Nondieting Approach page 3.Effects of Physical Exercise page 4.Self-Efficacy page 6.Self-Efficacy and Exercise page 7.Self-Efficacy and Diet page 7.Stages of Change page 8.Cognitive Distortions and Eating Disorders page 9.Summary page 11.Study 1Rationale page 12.Methods page 13.Results and Discussion page 14.Study 2Rationale page 16.Methods page 17.Results and Discussion page 18.ivStudy 3Rationale.page 21.Methods page 24.Subjects page 24.Procedures page 26.Analytic Strategies page 27.Results page 28.Pre-treatment page 28.Drop-outs page 28.Treatment Findings page 30.Depression, Anxiety & Self-Control page 30.Eating Disorder Inventory page 32.Exercise, Eating & Self-Efficacy page 37.Body Mass page 40.Correlations with Weight Loss page 41.Self-Efficacy Correlations page 42.Depression by Treatment Interactions page 44.Post-treatment Follow-up page 47.Discussion of Findings from Studies 1-3 page 49.Psychological Variables page 54.Exercise page 58.Body Mass page 59.Limitations page 62.Clinical Observations, Implications and Future Directions page 64.VSummary and Conclusion.page 67.Appendix I page 69.Appendix II page 102.References page 119.viLIST OF TABLESTable 1. Study I: Eating Disorder Inventory Subscale Scores page 15.Table 2. Study 2: Variables Pre- and Post-treatment page 19.Table 3. Differences between Cognitive & Behavioural Treatments page 23.Table 4. Study 3: Subject Variables Prior to Treatment page 29.Table 5. Study 3: Psychometric Scores page 31.Table 6, Study 3: Change Scores for Subjects Showing Deterioration page 33.Table 7. Study 3: Eating Disorder Inventory Scores page 35.Table 8. Study 3: Eating, Exercise and Self-Efficacy Scores page 38.Table 9. Study 3: Weight and Body Mass page 40.Table 10. Study 3: Weight and Depression Correlation Coefficients page 42.Table 11.1 Study 3: Pre-treatment Self-Efficacy Correlation Coefficients page 43.Table 11.2 Study 3: Post-treatment Self-Efficacy Correlation Coefficients page 43.Table 12 Study 3: Pre-treatment EDT Scores for Completers andNoncompleters page 48.Table 13.1 Study 3: Pre, Post and Six Month Follow-up Scores page 50.Table 13.2 Study 3: Pre-, Post and Six Month Follow-up EDT Scores page 51.viiLIST OF FIGURESFigure 1. Psychometric Change Scores page 32.Figure 2. Eating Disorder Inventory Change Scores page 34.Figure 3.1 Psychometric Change Scores for Exercisers and Nonexercisers page 39.Figure 3.2 Eating Disorder inventory Change Scoresfor Exercisers and Nonexercisers page 39.Figure 4. Body Mass Index page 41.Figure 5.1 Changes in Depression Scores page 45.Figure 5.2 Changes in State Anxiety Scores page 45.Figure 5.3 Changes in Trait Anxiety Scores page 46.Figure 5.4 Changes in Self-Control Schedule Scores page 46.vu’AcknowledgmentsI wish to acknowledge my deepest appreciation to my research supervisor, Dr. WolfgangLinden, for his support, patience and enthusiasm, In addition, I am grateful to the othermembers of my committee, Dr. Ray Corteen and Dr. Boris Gorzalka, for their contributions. Iam indebted also to Dr. Carol Solyom, who first introduced me to this area and generouslyshared with me her expertise and support. My thanks as well to Dr. Darrin Lehman and Dr.Susan Butt who made valuable comments on an earlier version of this work. The assistanceprovided by Trina McClure in countless ways throughout this project is acknowledged withgratitude and thanks. To Jeff Maurice and Carmen Stossel, two very fine people, who make it apleasure to spend time in the lab, my appreciation for exceptional patience, organizational skillsand time generously shared. To Tracey Earle, friend and co-therapist, for her many long hoursand help in myriads of ways, I am most deeply indebted; without her, this work would not havecome to fruition. The many women who have participated in the therapy groups have been aconstant source of inspiration. They have provided me with many insights and suggestions andit has been a privilege to work with them. Despite countless adversities which face them in theirlives, they endeavour in the hardest of work, share the deepest of secrets and through it allmaintain a place for joy and laughter in their hearts. My deepest thanks to them all: they arewhat has made writing a thesis a true labour of love. Finally, a heartfelt thank you to mypartner, Dean Smith, for his incredible insights and encouragement, his irrepressible laughter,unending patience and most of all, his love.DedicationThis thesis is dedicated with appreciation and love to my parents:To the Memory of my Mother, Elaine Tanco and to my Father, George Tanco,wonderful parents who taught me early to tbe comfortable in my own skin.ixWithin western society a pervasive obsession with obtaining the body ideal exists.Women in particular are inundated with unrealistic and unrelenting social pressures to altertheir appearances; for most, body shape and weight are special foci of concern (e.g.Brownell, 1991). Women not conforming to the aesthetic ideal are often penalized and,for seriously overweight women, the social and economic consequences are great(Gortmaker, Must, Perrin, Sobol & Dietz, 1993). Ironically, even the likelihood of beingperceived as overweight by others is greater for females than males (e.g. White, Schliecker&Dayan, 1991).Unfortunately, despite an estimated annual expenditure in excess of 29 biffiondollars on weight-loss products and services in the USA alone (What’s ahead?, 1989),obesity remains a prevalent and refractory disorder (Brownell & Wadden, 1992). Indeed,it is now estimated that 27% of the female population is obese (Kuczmarski, 1992). Thereis increasing recognition that dietary restraint alone does not provide a satisfactorysolution to the problems associated with obesity and may instead contribute causally tosuch problems (e.g. Brownell & Wadden, 1992; Garner & Wooley, 1991). This realizationhas promoted examination of the role of physical activity. Despite acceptance that regularexercise confers a myriad of beneficial psychological and physiological effects (e.g.Dubbert, 1992), assisting obese individuals to adopt and maintain regular exercise regimesremains a significant therapeutic challenge.Associated with obesity are a host of psychosocial and physiological problems.According to Stunkard and Wadden (1992), persons seeking professional treatment forweight problems evidence increased rates of depression, binge eating, purgativebehaviours, body image disparagement and social isolation. Western society activelydiscriminates against overweight individuals; for example, overweight persons are treatedprejudicially with respect to employment and college admission (Stunkard & Wadden,1992). Obese individuals have also been reported to be at increased risk for a variety ofmedical problems such as coronary heart disease (Anderson & Kaniel, 1992),1hypertension (Eliahou, Shechter & Blau, 1992), respiratory impairment (Kopelman, 1992),diabetes (Bonadonna & Defronzo, 1992), and arthritis (Bollet, 1992).The presumed causal nature of the relationship between obesity and healthproblems is increasingly being questioned. For example, during the past two decades,there has been growing acceptance that the psychopathology often observed in associationwith obesity is not etiological, but is instead due to “living in a society that derogatesobesity and obese persons” (Stunkard & Wadden, 1992; p. 352). Furthermore, as obeseindividuals are less physically active than normal weight persons (e.g. Stern, 1983), andbecause many epidemiological studies fail to control for this, the reported relationshipbetween obesity and physiological morbidity may be somewhat spurious: physicalinactivity rather than obesity per se may be responsible for at least some of the increasedrisk to overweight individuals.Effects ofDietary RestrictionRegardless of whether or not obesity is causally related to various psychologicaland physiological problems, the demand for treatment remains great. Indeed, a plethora ofpotentially dangerous weight-reduction ploys awaits individuals seeking solutions to theproblems of obesity. As Lebow (1989; page 10) states, “The foolishness is theretantalizing the desperate - the vulnerable”. Moreover, even traditional, relatively sensible,approaches to weight loss may not be without risk. Although dietary restriction has longbeen the treatment of choice, in recent years, the inadequacy of this approach has becomeall too apparent (for review see Garner & Wooley, 1991). Evidence is mounting thatfrequent fluctuations in body weight due to dieting may actually convey greater healthrisks than does obesity itself (Lissner, Odell, D’Agostino, Stokes, Kreger, Belanger &Brownell, 1991). In addition, considerable evidence demonstrating that manifold negativeeffects are associated with restrictive eating has emerged. Dieting has been found to beassociated with depression, irritability and obsessive thoughts in both normal weight2individuals (Keys, Brozek, Henschel, Mickelsen, & Taylor, 1950) and in obese individuals(e.g. Stunkard, 1957). Although obese individuals may not eat more than theirnonoverweight counterparts when in public (e.g. LeBow, Chipperfield & Magnusson,1985), many obese persons report episodes of chaotic overeating while in private. Itappears that dieting may contribute in a causal fashion to the development of binge eating,bulimia, and subsequent weight gain (Polivy & Herman, 1985). Indeed, for individualsattempting to restrict their dietary intake, the mere perception of transgression, whichoften follows the consumption of ‘forbidden foods’ can lead to subsequent over-eating(e.g. Knight & Boland, 1989).In addition, dieting has significant metabolic consequences. The observedreduction in metabolic rate, which occurs in response to decreased caloric intake, isgreater than that predicted by the accompanying weight loss alone (Stern, 1983).Similarly, both animal (Coscina & Dixon, 1983) and human (e.g. Stordy, Marks, Kalucy &Crisp, 1977) studies provide evidence that weight gain following termination of restrictedintake is at a rate greater than that predicted by caloric consumption alone. Brownell andWadden (1992) note that, for seriously obese persons, attempts to reduce body weight towithin normative ranges may not be appropriate, as their adiposity is generally the functionof both cellular hypertrophy and hyperplasia, the later of which is not reversible.The Nondieting ApproachRecognizing the risks associated with dieting, the futility of the approach in termsof successful long-term weight loss, some clinicians (Hirschmann & Munter, 1988) andresearchers (Polivy & Herman, 1992; Roughan, Seddon & Vernon-Roberts, 1990) havebegun promoting “nondieting”. Polivy and Herman (1992) report results from a 10-weeknondieting treatment programme aimed at raising participants’ awareness regarding theeffects of dieting and substituting such eating behaviour with normal eating habits. Theauthors emphasize that their programme was not intended as a weight loss group or group3therapy. Participants showed significant improvement post-treatment in terms ofreduction in dieting behaviour and eating-related psychopathology as well as in reducedfeelings of ineffectiveness and depression and enhanced self-esteem. Weight showed anonsignificant increase from 235 pounds pre-treatment to 243 pounds post-treatment. Nocontrol group was included in the study. Roughan and colleagues (1990) present findingsfrom a similar 10 week programme implemented in Australia. Again, the treatmentprogramme resulted in significant improvements in self-esteem, depression and eating-related psychopathology. Fifty-six of the 80 women completing the programme werereassessed two years following completion of the group. In addition to maintainingimprovements in psychological function, these women also evidenced a significant meandecrease (3.1 kg) in body weight relative to their weight pre-treatment. Again however,no control group was included.Whereas treatment goals for obese patients (e.g. weight loss per se, decreases inbinge eating and weight fluctuations etc.) remain controversial, clearly, successful long-term management of obesity requires treatment modalities in addition to, or perhaps inplace of, dietary restriction.Effects ofPhysical ExercisePhysical exercise regimes can play an important role in the treatment of obeseindividuals. Independent of weight loss or fat reduction, exercise contributes topsychological and physiological well being (Dubbert, 1992). An eight year prospectivestudy revealed that among a group of healthy individuals, physically inactive women weretwice as likely as their active counterparts to become depressed (Farmer et al., 1988).Similarly, in the absence of weight reduction, regular physical exercise appears to protectagainst development of noninsulin-dependent diabetes meffitus (Helmrich, Ragland, Leung& Paffenbarger, 1991), coronary heart disease (Dubbert, 1992) and cancer (Blair et al.,1989). Indeed, it has been cogently argued that overweight women should be exposed to4the benefits of regular exercise in the absence of any attempts at weight loss (Packer,1989).As the above findings indicate, regular physical exercise is an important componentof healthy living; moreover, it appears to play an important role with respect to weightmanagement. In a review article on obesity and exercise, Thompson, Jarvie, Lahey andCureton (1982) report that in five treatment outcome studies, exercise was found toproduce weight losses equivalent (1 study) or superior (4 studies) to those obtained withdietary interventions. These authors also note a tendency for exercise to appear superiorwhen longer term follow-up assessments are made. Since this time, several further studieshave appeared in the literature. The congruity in findings is exceptional: physical exerciseclearly contributes to weight reduction (Colvin & Olson, 1983; Craighead & Blum, 1989;Foreyt & Goodrick, 1991, Hill et al., 1989; Hoiberg, Bernard, Watten, & Caine, 1984;Kayman, Bruvold & Stern, 1990; Marston & Criss, 1984; Pavlou, Krey & Steffee, 1989;Perri, McAdoo, McAllister, Lauer, & Yancey, 1986; Sikand, Kondo, Koreyt, Jones &Gotto, 1988; Segal & Pi-Sunyer, 1989) and maintenance (Colvin & Olson, 1983; Epstein,Wing, Koeske & Valoski, 1984; Gormally, Rardin & Black, 1980; Hoiberg et al., 1984;Marston & Criss, 1984; Stern & Lowney, 1986). As Brownell and Wadden (1992; p.507)conclude, there is consistent agreement that regular physical exercise “plays a critical rolein long-term weight management.”Physical exercise may promote and maintain weight loss via several differentpathways. Although the energy expenditure associated with a single bout of exercise is notclinically important in and of itself, chronic exercise can help to create an overall negativeenergy balance (Calles-Escandón & Horton, 1992). Similarly, the enhanced thermic effectof food and increase in resting metabolism, which are observed in response to acuteexercise, are of clinical significance, in terms of weight loss, only when exercise isundertaken on a chronic basis (Calles-Escandón & Horton, 1992). Exercise can also helpto restore diet-attenuated metabolic rates (Donahoe, Lin, Kirschenbaum & Keesey, 1984).5In addition, it has been suggested that exercise may affect food consumption, although thenature of this effect awaits clarification as exercise has been reported to increase, decreaseand, fail to, influence food intake (Stern, 1983). Finally, some data suggest that exercise isassociated with enhanced attendance at behaviour modification sessions aimed at weightreduction (Hill et al., 1989; Sikand et al., 1988).Despite the plethora of known benefits, only about 20% of people engage inphysical exercise at a frequency and duration sufficient to procure the beneficial effects(Dubbert, 1992). This problem is accentuated amongst obese women, one of thepopulations most in need of the benefits conferred by regular exercise (Packer, 1989). Anumber of factors have been proposed to account for why overweight women fail toexercise: fear of physical harm and ridicule, unavailability of facilities such as appropriateclasses and clothing (Packer, 1989). Unfortunately, data suggest that even whenindividuals do begin exercise programs they are unlikely to continue in the long term(Dubbert, 1992). Indeed, attrition rates within the first six months approximate 50%(Dishman, 1982). Understandably, there has been an increasing call for studiesinvestigating factors promoting adoption and maintenance of regular physical exercise.SefEfficacySocial Learning Theory, as put forth by Bandura (1977), attempts to explain avariety of behaviours. Self-efficacy, a construct fundamental to Social Learning Theory,appears to play a particularly important role with respect to health-related behaviours.Self-efficacy refers to the belief that one is capable of engaging in a particular set ofrequired behaviours (Bandura, 1977). Contrasted with this are outcome expectancieswhich pertain to beliefs that particular behaviours will produce desired outcomes. Selfefficacy expectations are independent of actual skill level and instead refer to beliefs aboutcapabilities in specific situations. Thus, contextual factors influence perceptions of selfefficacy (Bandura, 1977). While research suggests that ratings of self-efficacy can predict6various health-related behaviours (Strecher et al., 1986), it is necessary to note that suchrelationships are not unidirectional but instead are a function of reciprocal determinism(Bandura, 1977).In keeping with Bandura’s original theorizing, the vast majority of empirical self-efficacy studies have focused on domain-specific self-efficacy. Recently, however, it hasbeen suggested that general self-efficacy is also an important construct (Shelton, 1990).General self-efficacy is posited to be a composite of all past successes and failures and toreflect one’s belief about her or his ability to achieve goals and overcome obstacles in dailyliving. General self-efficacy is assumed to affect a person’s mastery expectations (i.e.Bandurian self-efficacy) in new contexts; thus a correlation between measures of generaland domain-specific seif-efficacies is anticipated.Sef-Efficacy and ExerciseAmongst community samples, a small but consistent body of data indicates theexistence of a relationship between ratings of self-efficacy and exercise behaviour (e.g.Desharnais, Bouillon & Godin, 1986; McAuley, 1992; McAuley & Courneya, 1992;McAuley & Jacobson, 1991; Sallis, Haskell, Fortmann, Vranizan, Taylor & Solomon,1986). While these studies produced fmdings consistent with a reciprocal relationshipbetween perceived self-efficacy and exercise, it must be noted that all involved nonclinicalsamples. Although there is empirical support for the importance of exercise self-efficacy inpatients with chronic obstructive pulmonary disease (Kaplan, Atkins & Reinsch, 1984) andcardiac problems (Ewart, Taylor, Reese & Debusk, 1984), no published studiesinvestigating the role of exercise self-efficacy in seriously obese patients appear to exist.Self-Efficacy and DietStudies investigating eating/dieting self-efficacy in obese subjects support thecontention that self-efficacy is an influential construct in obese persons. In a group of7people, at least 50 pounds overweight, Edell, Edington, Herd, O’Brien and Witkin, (1987)found that self-efficacy accounted for a significant amount of the variance in actual weightlost, Bernier and Avard (1986) found pre-treatment levels of eating-related self-efficacywere significantly correlated with weight loss during treatment and that efficacy wassignificantly related to weight loss six weeks post-treatment. Similarly, Bemier and Poser(1984) report that in overweight women, self-efficacy at termination of treatment predictssubsequent weight loss at six weeks and six months. Dropouts from a Weight Watchersprogramme were significantly more likely to report low self-efficacy at treatment onsetthan individuals remaining in the programme (Mitchell & Stuart, 1984; see also, Bemier &Avard, 1986). Taken together, these results indicate an important role for self-efficacy inmediating at least some behaviours in obese persons.Stages of ChangeThe work of James Prochaska and colleagues provides evidence that individualsattempting to alter health-related behaviours progress through a series of readiness tochange stages: precontemplation, contemplation, planning, action and maintenance (e.g.Prochaska, DiClemente & Norcross, 1992). These stages characterize attempts atbehaviour changes such as smoking cessation (Prochaska & DiClemente, 1983), exerciseadoption and adherence (Marcus & Owen, 1992) and weight loss (Prochaska, Norcross,Fowler, Follick & Abrams, 1992). Of importance, from a therapeutic perspective, is thefinding from these studies that individuals at the action stage consistently show greatersuccess than do persons at the contemplative or planning stages. Furthermore, whetherembarking on a new exercise programme (e.g. Marcus & Owen, 1992; McAuley, 1992),or attending a weight loss programme (Prochaska, Norcross et al. 1992), individualsevidence increasing amounts of self-efficacy as they progress through the stages ofreadiness to change from precontemplation to maintenance.8Taken together, these findings indicate that successful alteration of dysfunctionaleating and exercise behaviours requires high levels of self-efficacy and readiness tochange. Despite a possible lack of conscious awareness and/or a refusal to acknowledgeit, the physical and/or emotional correlates of obesity frequently come to serve positivefunctions for the individuals afflicted. For example, the physical distance created byobesity can form a safety barrier for some women (e.g. Orbach, 1978). Likewise, bingeeating may help to diminish feelings of anxiety (e.g., Heatherton & Baumeister, 1991).That obesity and the behaviours associated with it may confer benefits for some peopleraises the possibility that, in such individuals, readiness to change may be compromised(DiClemente, 1991). Similarly, for many obese women, years of not exercising and/oreating chaotically, make it improbable that they perceive themselves as highly efficaciousin terms of ability to exercise regularly and eat nonchaotically. Thus, the majority of obesewomen presenting for treatment are unlikely to possess high levels of self-efficacy andreadiness for change, qualities seemingly essential for successful alteration of dysfunctionaleating and exercise behaviours.Cognitive Distortions and Eating DisordersCognitive theories posit that, as with depression, eating disorders are characterizedby faulty cognitions. Although empirical studies of anorexic and bulimic women exist,investigations of cognitive processes in obese persons are limited. Throughout much of thetreatment literature, obesity is distinguished from anorexia and bulimia and is treated assimply a weight-related disorder devoid of emotional or cognitive components.Nonetheless, King, Polivy and Herman (1991) have suggested that overweight people maydiffer in memory for food/weight related stimuli. King et al. found that subsequent toreading a paragraph concerning a ficticious woman, obese women remember moreweight/food related variables than other items; in contrast, memory fornonfood/nonweight related items is superior to recall of food/weight related variables in9unrestrained, university women (King, Polivy, & Herman, 1991). These findings suggestthat cognitive processes may differ between obese persons and nonobese, unrestrainedwomen. (It should be noted that all the obese subjects in their sample evidenced elevatedrestraint scores, making a distinction between restraint and obesity impossible). In contrasthowever, other researchers have failed to find evidence of such alterations in memoryprocesses in obese persons (e.g. Conforto & Gershman, 1985; Rodin & Slochower, 1974).Although clinical experience suggests that obese persons also evidence higher thanaverage rates of cognitive distortions not specifically related to eating and/or weightsimilar to the sort manifested by depressed and/or anxious individuals, this has yet to beempirically confirmed. No published studies investigating this issue appear to exist in theliterature. Nonetheless, given the higher rates of depression seen iii obese peoplepresenting for treatment and the increase in cognitive distortions seen amongst depressedpersons (Beck, Shaw, Rush & Emery, 1979), this hypothesis appears tenable.Furthermore, at least one study provides evidence that perceptual differences betweenobese and nonobese persons may exist. Specifically, under conditions of stress, obeseindividuals were found to perceive time as passing more slowly than did nonobese people(Faulkner & Duecker, 1989). Furthermore, they tended to maintain this perceptualdistortion after the external stress had been removed. In turn, it is possible that suchperceptual distortions may contribute to more widespread, integrated distortions inthinking. Depressive and anxiety disorders respond very favourably to cognitivetreatments. Thus, if obese persons do exhibit dysfunctional cognitive distortions, eitherbecause of concomitant psychological problems or directly as a result of the obesity, itmakes sense to directly target cognitive variables in treatment. Heatherton andBaumeister (1991) posit that binge eating, such as that which occurs in both bulimics andchronic dieters, reflects an attempt to reduce/avoid self-awareness. Moreover, theyconclude that, “Treatment must therefore focus on the cognitive processes and causes that10set the escapist pattern m motion, rather than focusing on the binge behavior per Se.”(Heatherton & Baumeister, 1991; page 102).SummaryObesity is a prevalent disorder associated with myriad psychological andphysiological problems. Dietary restraint alone is ineffective in treating obesity and is nowfirmly held to exacerbate the problem. Regular physical exercise appears fundamental tosuccessful management of weight problems as well as to generalized physical andpsychological well being. Relationships between self-efficacy and exercise and dietingbehaviour have been found, although no specific findings regarding exercise-related self-efficacy in obese persons have been reported. That alterations in cognitive processing maycontribute to the problems experienced by some obese individuals suggests that treatmentaimed at ameliorating cognitive distortions may be beneficial. In addition to being at riskphysiologically, morbidly obese women who seek psychological treatment for their weightproblems are also distressed emotionally. For example, such individuals show elevatedlevels of depression, as well as body image disparagement (e.g. Stunkard & Wadden,1992). As it is unlikely that morbidly obese individuals will maintain body weights withinnormal ranges, goals and treatments aimed directly at alleviating psychological problemsand enhancing physical fitness, independent of attempts at significant weight loss, seemappropriate. The purpose of the current programme of research is to increaseunderstanding of the psychological components of severe obesity in women in order thattreatment may be refined and enhanced. Study 1 provides a description of thepsychological characteristics of a group of women seeking psychological treatment formorbid obesity. Study 2 describes a pilot cognitive group treatment programme for obesewomen which was developed on the basis of the needs identified in Study 1, and presentspre- and post-treatment scores on several psychological indices. Finally, in Study 3, acontrolled, randomized, clinical trial is used to assess the efficacy of the treatment11programme implemented in Study 2 and compare it with results obtained from two controlgroups: a standard behaviour therapy weight loss programme and a no-treatment wait-listcontrol group.Study 1RationalePsychological profiles of women seeking treatment for morbid obesity may not berepresentative of obese women in general. Whereas population studies have failed to fmdevidence of increased levels of psychopathology in obese as compared with nonobesepersons (Wadden & Stunkard, 1987), studies utilizing clinical samples suggest that, incomparison with normal control subjects, seriously obese persons presenting for treatmentshow elevated levels of psychopathology. Like their anorexic and bulimic counterparts,obese women display evidence of excessive body image disparagement (e.g. Stunkard &Wadden, 1992). Stunkard and Wadden (1992) also report that ten studies utilizing theMinnesota Multiphasic Personality Inventory found evidence of at least mild elevations indepression scores for obese individuals seeking treatment; also, elevations on scores forhysteria, hypochondriasis and impulsivity were often found. Of importance, wheninterpreting these findings, are studies showing that people with various other types ofchronic medical problems such as arthritis, diabetes, chronic pain syndromes etc., alsohave elevated levels of psychopathology (Stunkard & Wadden, 1992). Thus, elevatedpsychopathology is not specific to the obese, but is instead characteristically associatedwith various forms of physiological pathology. The dissimilarity between clinical andnonclinical samples notwithstanding, accurate characterization of obese women whopresent for treatment remains important; greater understanding of their psychologicalprofiles wifi help to facilitate the development of specifically tailored treatmentprogrammes. Indeed, attention to the psychological needs of such individuals isparticularly important given the unlikelihood that these women wifi ever achieve weightswithin normative ranges (e.g. Brownell & Wadden, 1992).12MethodPsychometric data from the files of 147 women referred by family physicians to thepsychology department at University Hospital, Shaughnessy site from 1985 to 1993,inclusive, were examined. These represent the records of all the women referred, acceptedto, and agreeing to participate in, behavioural group treatment programmes for obesityduring this time. Upon presentation for treatment, patients were required to complete thefollowing tests: The Beck Depression Inventory (BDI; Beck et al., 1961), The RosenbaumSelf-Control Schedule (SCS; Rosenbaum, 1980), The Eating Disorders Inventory (EDI;Garner, Olmstead & Polivy, 1983) and The State Trait Anxiety Inventory (STAT;Speilberger, Gorsuch, Lushene, Vagg & Jacobs, 1983). The BDI is a widely usedinstrument which assesses current affective status. The SCS assesses use of cognitivestrategies to control emotions, use of problem-solving strategies, ability to delaygratification and perceived self-efficacy regarding self-control (Mizes, 1988). Scores onthe SCS were linearly transformed to yield a non-negative metric; i.e. all SCS scores weretransformed from an original possible range of -108- +108, to a new range of 0 - 216.The EDT is comprised of eight subscales: Drive for Thinness (DT), Bulimia (B), BodyDissatisfaction (BD), Inefficacy (I), Perfectionism (P), Interpersonal Distrust (ID),Interoceptive Awareness (A) and Maturity Fears (MF). The Interoceptive Awarenesssubscale is perhaps more accurately labeled interoceptive unawareness, as higher scorescorrespond to less internal awareness. These subscales tap eating-specific behaviours aswell as more generalized cognitions and behaviours. EDI profiles accurately distinguishnoneating disordered individuals from subjects having eating disorders (Garner et al.,1983). The STAT is widely used for both research and clinical purposes. It assesses bothcharacterologic (i.e. trait) anxiety and context-dependent (state) anxiety.13The purpose of this study was simply to provide a description of the psychologicalcharacteristics of women seeking treatment for obesity. No attempt was made to includean appropriate control group and thus no inferential statistical analyses were conducted.Results and DiscussionSubjects had an average age of 40 years (SD=12) and had a mean body massindex (BMI) of 39 kg/rn2 (SD=6), indicating they were extremely obese and at risk formedical complications. BDI scores ranged from 0 to 45 with a mean score of 18 (SD=10).Thus, the average patient was mildly depressed. The average score on the SCS was 114(SD=29), with a range of 49-175. Published norms (Rosenbaum, 1980) transformed asdescribed above, indicate an average score for women to be approximately 135 (SD=25),thus suggesting that the average woman in the cunent group felt a relative lack ofgeneralized, cognitive self-control.Mean EDI scores are presented iii Table 1. Not surprisingly, obese patientsshowed an extreme elevation on the Body Dissatisfaction subscale. In contrast, scores onthe Maturity Fears and Interpersonal Distrust subscales were not elevated. This likelyreflects, at least in part, a difference in the mean age of women presenting with obesity andthose presenting with other eating disorders, In general, other EDT subscale scores wereapproximately midway between those observed in female college students and womenwith anorexia nervosa.Scores on the state component of the STAT ranged from 21 to 94, with a mean of44.6 (SD=14.3). On the trait component, scores ranged from 23 to 76 and the mean was47.4 (SD=l 1.9). Mean scores for normal working adult women, according to previouslypublished normative data (Spielberger et a!., 1983), are 35.7 (SD=10.4) and 34.9(SD=9.2) for state and trait anxiety respectively.Together, the current findings indicate that these obese women presenting fortreatment are somewhat depressed and anxious, and perceive themselves as lacking in14cognitive self-control. Furthermore, they are excessively dissatisfied with their bodies,preoccupied with becoming thin, feel inefficacious, engage in bulimic behaviour and have alack of interoceptive awareness.Table 1. Study 1: Eating Disorder Inventory subscale scores (mean j standarddeviation) for women referred by family physicians for psychological treatment of obesityfrom 1985-1993.DriveforThinness 9.38 ± 5.74Bulirm 6.66 ± 5.29Body Dissatisfaction 22.14 ± 5.78Inefficacy 7.35 ± 5.93Perfectionism 7.02 ± 4.63Interpersonal Distrust 3.56 ± 3.91Interoceptive Awareness 6.61 ± 5.81Maturity Fears 2.23 ± 2.81Such findings were not unanticipated; as noted above, chronic medical patientstypically show elevated levels of psychopathology on psychometric testing (Stunkard &Wadden, 1992). The mechanisms whereby different chronic illnesses lead to increaseddepression and anxiety etc. may differ. For example, the physical sensations associatedwith uncontrollable, chronic pain may directly lead to depression, whereas, heighteneddepression in obese individuals may be more a function of the social response to physicalappearance. Conversely, factors such as decreased mobility and social interaction maycontribute to the increase in depression experienced by both obese and nonobeseindividuals who have chronic medical problems. Irrespective of the specific mechanismsinvolved, the findings from Study 1 suggest that numerous variables in addition to body15weight require consideration when treating morbidly obese women. As noted above,attention to such problems is particularly germane since it is unlikely that most of thesewomen will succeed at reducing and maintaining their weights at socially sanctionedlevels.Study 2RationaleThe above findings indicate that, in addition to their physiological health problems,obese women presenting for treatment have a range of psychological problems. Whereasweight loss programmes may be associated with psychological improvements, thesechanges may not be long standing. For example, Wadden, Stunkard, and Liebschutz(1988) report that whereas decrements in depression and improvements in body image andself-confidence, etc. occurred in conjunction with weight loss, three years post-treatment,in the face of subsequent weight gain, these improvements were not maintained. Incontrast, a nondieting programme which promoted nonchaotic eating and enhancement ofbody image and self-esteem was associated with significant improvements in terms ofpsychological functioning and weight loss, two years post-treatment (Roughan et al.,1990). Taken together, these findings suggest that, irrespective of attempts at weight loss,treatments aimed directly at enhancing psychological well- being may be beneficial forobese persons.Recent data indicate that decrements in weight as small as 10% confer signfficanthealth benefits (Goldstein, 1992) and that, independent of weight loss, exercise enhancesboth physical and mental health (Dubbert, 1992). Therefore, even if weight were to remainessentially unchanged, improvements in psychological status and physical fitness areworthy therapeutic goals, in and of themselves.With the above considerations in mind, a treatment programme was designedwhich emphasized emotional health (e.g. by decreasing anxiety and dysfunctional16cognitions) and long-term healthful life style practices, (e.g. engaging in regular exerciseand eating nonchaotically). The programme was eclectic in nature and contained elementsof feminist, dynamic, cognitive-behavioural and systemic theories. A nondieting approachwas adopted; weight loss per se was not a focus of the intervention. The initialimplementation and evaluation of the programme, herein presented, was undertaken as apilot study upon which to base a subsequent randomized clinical trial.MethodPatients, referred by their family physicians for psychological treatment of obesity,were assessed individually pre- and post-treatment, at which times they were interviewed,completed the above psychometric tests and were weighed. The programme was 10 weeksin duration and was comprised of the following topics:Week 1 Introduction, the effects of dieting on metabolism, cognitionsWeek 2 The importance of exercise, how to begin exercising, choosing anactivityWeek 3 The concept of nondieting, awareness of physical hungerWeek 4 Nutrition, decreasing fat intake and increasing intake of complexcarbohydratesWeek 5 Nonhunger reasons for eatingWeek 6 Relaxation: Progressive muscle relaxation, deep breathingWeek 7 Depression, anxiety and faulty cognitionsWeek 8 Self-esteem, efficacy and assertivenessWeek 9 Developing a healthy relationship with one’s bodyWeek 10 Review of Weeks 1- 9, Reasons to Recover, Barriers to Recovery,Relapse Prevention17Weekly meetings were 1.5 hours in duration. At each session, homework wasreviewed and the women discussed events which occurred in their Lives during theprevious week. Didactic material was presented and homework assigned. Homeworkincluded readings such as The New Fit or Fat by Covert Bailey (1991) and OvercomingOver Eating by Jane Hirschmann and Carol Munter (1988). The women were encouragedto discuss experiences and feelings regarding obesity and other problems in their lives.Social influences were discussed in terms of power, inappropriate body ideals etc. to helpthem externalize part of the source of their problems and encourage them to take controlwhen possible. A revised version of the treatment manual, comprised of handouts forparticipants, is provided in Appendix I.Results and DiscussionTwo consecutive treatment groups were conducted with eleven women in the firstand six in the second. Two women dropped out of the first group. One had unstablediabetes mellitus which necessitated her hospitalization after the second week of thegroup. A second woman, with a long history of manic depressive illness, ceased attendingsessions and did not respond to repeated telephone messages, There were no drop-outsfrom the second group.Fifteen women thus completed the programme. One subject presented in a verydistraught state for the fmal assessment as her mother had unexpectedly died a few dayspreviously and was unable to provide reliable psychometric data. Two other subjects failedto complete all psychometric data and could not be contacted. Thus, findings for the EDIsubscales are based on data from 14 subjects, while means for the remaining psychometricvariables are based on n’s of 13. Pre- and post-treatment data are presented in Table 2.18Table 2. Study 2: Pre- and post-treatment scores (mean ± standard deviation) forwomen completing a 10 week cognitive treatment programme.Pre-treatment Post-treatmentProportion exercising 3 Xs/wk .13 .87Body Mass Index (kg/rn2) 40.3 ± 4.6 39.6 ± 5.0BeckDepressionLnventory 19.9 ± 11.1 10.4 ± 10.7State Anxiety Inventory 46.1 ± 16.1 37.4 ± 16.7Trait Anxiety Inventory 50.0 ± 15.5 40.6 ± 15.1Self Control Schedule 90.5 ± 34.3 106.7 ± 33.8Eating Disorder InventoryDriveforThinness 10.3 ± 5,6 2.7 + 2.6Bulimia 7.8 ± 5.7 1.7 ± 2.4Body Dissatisfaction 23.3 ± 6.0 17.3 ± 6.9Inefficacy 9.9 ± 7.2 5.4 ± 4.8Perfectionism 6.9 ± 4.8 5.2 ± 4.5Interpersonal Distrust 2.7 ± 4.2 2.1 ± 2.5Interoceptive Awareness 8.8 ± 7.9 3.0 ± 4.3Maturity Fears 2.7 ± 3.0 1.8 ± 2.8The proportion of individuals exercising regularly was significantly increasedfollowing treatment (sign test; p<.OO1). Statistical constraints dictated that data from theeight EDI subtests be analyzed m two separate analyses so that the number of dependentvariables (i.e. pre and post scores for each subscale) did not surpass the number of19subjects (n= 14). Multivariate analysis of variance (MANOVA) revealed significant overalleffects for the first four subscales (F(8,6)=35.97; p<.OO1) and the last four subscales(F(8,6)=4.66; p=.O38). Univariate tests indicated that scores on the Drive for Thinness(t=4.1O; p=.OO1), Bulimia (t=4.22; p=.OO1), Body Dissatisfaction (t=2.99; p=.Ol),Inefficacy (t=2.34; p=.O4.), Perfectionism (t=3.12; p=.OO1) and Interoceptive Awareness(t=4.07; =.OOl) subscales were significantly reduced following treatment. Scores on theInterpersonal Distrust and Maturity Fears subscales were not significantly different preand post-treatment. Scores on the Beck Depression Inventory, State Trait AnxietyInventory and Self-Control Schedule were also subjected to a MANOVA which revealed asignificant overall effect (F(8,4)=23.7; p=.OO4.). This analysis was based on data from the12 subjects who completed all four of these tests pre- and post-treatment. Univariatetesting indicated that Beck Depression Inventory (t=3.73; p=.003), State AnxietyInventory (t=2.16; p=.O5) and Trait Anxiety Inventory (t=2.55; p=.O2) scores weresignificantly reduced post-treatment. Although movement in the desired directionoccurred, scores on the Self-Control Schedule were not significantly reduced posttreatment. A t-test for related samples indicated that Body Mass Index was significantlydecreased post-treatment (t=3.Ol; p=.O2). It should be noted, however, that this is basedon a sample size of only nine, as several patients declined to be weighed, a requestconsidered commensurate with the philosophy of the programme.Post-treatment the majority of women were exercising regularly. Depression andanxiety scores were significantly reduced, as were scores on six of the eight EatingDisorder Inventory subscales. These findings indicate that the women irì the programme20were less depressed and anxious and exhibited less eating/weight-related psychopathologyfollowing treatment. These pre/post changes suggest that the treatment was influentialand, as such, are consistent with recent reports indicating that women who are notnecessarily morbidly obese benefit from programmes aimed at decreasing dietingbehaviour and preoccupation with weight and food (e.g. Polivy & Herman, 1992;Roughan et al., 1990). It should be noted, however, that whereas the women in thesetwo previous studies were self-selected in terms of feeling preoccupied with their weightand wanting to stop dieting, the current sample consisted of a group of women whopresented with the intent of embarking on a weight loss programme. Nonetheless, theyappeared to derive both psychological and physiological benefits from the programme.Clearly, however, in the absence, of an appropriate control group, the effectsobserved, subsequent to treatment, may have been due to placebo effects or any of a hostof contributing factors. Nonetheless, given the promising nature of the data from this pilotstudy, further investigation of a more rigorous nature appeared warranted.Study 3RationaleWhile the data from Study 2 suggest that obese women receive multiple benefitsfrom treatment not directly aimed at weight loss, it has yet to be determined whether thistype of treatment is any more effective than standard behavioural treatments which focusdirectly on, and are generally effective in, promoting weight loss (e.g. Wing, 1993). Asweight loss can be very reinforcing for obese individuals, it can be hypothesized thatweight loss per se may enhance psychological well-being by reducing depression, anxiety,21inefficacy etc. Conversely, it can be argued that small amounts of weight loss alone dolittle to alter many of the life conditions which obese people report as aversive, e.g., socialstigmatization and isolation, and thus should not be anticipated to improve psychologicalhealth. The results from Study 2 suggest that the nondieting programme produces modestweight loss. However, this finding is difficult to interpret since subjects agreeing to beweighed were self-selected and their number was limited. Interpretation is further hinderedby the fact that obese individuals not undergoing treatment often gain weight and anappropriate comparison group was lacking.In addition to examining comparative treatment outcome, Study 3 was designed toaddress a number of questions regarding perceived self-efficacy iii obesity. It was designedto (1) assess whether exercise self-efficacy cognitions are associated with exerciseadoption and initial adherence in this population. This study was also intended toinvestigate whether (2) post-treatment changes in physical exercise and exercise self-efficacy are associated with alterations in generalized self-efficacy/self-control. Previouswork suggests that alterations in health-related behaviours progress through stagescharacterized by changes in self-efficacy; therefore, the current research was also designedto examine (3) whether similar changes iii self-efficacy occur in the processes of affectenhancement and exercise adoption in obese women.Thus, Study 3 investigates the efficacy of the treatment programme described inStudy 2 in a controlled manner. It was designed to permit evaluation of the programme’sefficacy with respect to exercise adoption, weight loss, nonchaotic eating and generalpsychological well-being. Behavioural treatment programmes aimed at changing eatingbehaviour, reducing caloric intake and increasing exercise are currently the gold standardfor psychological weight management programmes. Thus, to facilitate evaluation of therelative efficacy of the above-described programme, in Study 3 a standard behavioralweight loss treatment programme was included, in addition to a no-treatment wait listcontrol group. The principle differences between the two treatments are highlighted in22Table 3. Study 3 was also designed to investigate the constructs of general and domain-specific (i.e. exercise and eating) self-efficacy in obese women undergoing treatment.Table 3. Principal differences between the Cognitive Therapy (CT) programme andthe Behavioural Therapy (BT) programme.CT BTPsychoeducational;Didactic presentations;group problem solving re:overeating, underexercising;Weekly weigh-ins;It was hypothesized that members of the BT group would lose significantly moreweight than CT members since intake restriction is generally efficacious in promotingweight loss in the short term. Also, subjects in the CT group were not anticipated to loseas much weight since they were going to be ‘given permission’ to eat previously forbiddenfoods and instructed not to attempt active restriction. In contrast, we expected that CTmembers would show enhanced self-efficacy and self-control post-treatment relative to theBT individuals as they learned to rely on signals of hunger and satiety from their ownbodies rather than forcing themselves to use cognitive mechanisms to refrain from eating.TheoreticalFoundationsFocusFormatPrimarily Behavioural, someCognitive;Weight loss via increasedexercise & decreased food(especially fat) intake;Cognitive, Feminist, Systemic,Dynamic, some Behavioural;Alteration in psychologicaldistress; increased awarenessof body, the purposes servedby overeating, the role of earlyexperiences; promotion of regularexercise & nonchaotic eating;Therapeutic;Group discussions, personaldisclosures, didactic presentations;23It was also anticipated that depression would be significantly reduced in both groups. Inthe BT group, reduction in depression was predicted to be positively correlated with theamount of weight lost as weight loss is typically reinforcing for overweight individuals. Incontrast, no such relationship was anticipated in CT group members, since minimalweight loss was expected and since they were involved in treatment directly aimed atreducing depression independent of attempts at weight loss.MethodSubjectsSubjects were recruited via radio announcements, newspaper articles arid referralsfrom the Eating Disorders Resource Centre of British Columbia. Subjects were screenedover the telephone to ensure they met the following criteria: female, legal age, i.e., 19years of age or older, no medical condition precluding participation in an exerciseprogramme, BMI of at least 30 kg/rn2, a minimum 10 year history of obesity, and, atleast, three prior unsuccessful attempts at weight loss/maintenance. These criteria wereemployed in an attempt to recruit a sample of women resembling those who had beenreferred for treatment in Studies 1 and 2. In addition, subjects were required to obtainreferral letters from their family physicians.Subjects meeting the above criteria were sent a questionnaire package in the mailand were scheduled for an individual assessment appointment. Subjects were interviewedto check for other psychopathology (e.g., psychosis) which would have precludedparticipation. Each subject had her weight and height measured and was assessed for the24following: depression (BDT), anxiety (STAT), eating-related psychopathology (EDT) andself-control (SCS). Each participant indicated her sense of exercise self-efficacy (I believeI can exercise for at least 20 minutes five times per week) and nonchaotic eating self-efficacy (1 believe I can eat when I am hungry and not engage in binge eating) on twoseparate visual analogue scales. In addition, participants were required to indicate thenumber of times they exercised and the number of binges in which they engaged, duringthe preceding week. Assessments were repeated at Weeks 4 and 8, resulting in a 3 (typeof treatment) X 3 (time) between-within design. Follow-up data were obtained 6 monthsfollowing treatment and will be collected again in a further six months (i.e. 12 monthspost-treatment) and annually thereafter.Subsequent to giving informed consent, subjects meeting the above criteria wererandomly assigned to one of three groups: 1) a standard behavioural weight managementprogramme (BT), directly aimed at weight reduction; 2) a cognitive treatment programme(CT) aimed at enhancing emotional well-being and promoting regular physical exerciseand nondisordered eating in the absence of any attempt at weight reduction; 3) a wait-listcontrol group. The CT and BT groups were comprised of eight, 2 hour weekly meetingsconducted by experienced clinical psychology graduate students.Sixty-two women were originally accepted for, and agreed to participate in, thestudy. Initially, twenty-one subjects were assigned to both the CT and BT groups andtwenty to the control group. However one control subject and one CT subject failed tocomplete all required psychometric measures. When contacted, they indicated they nolonger wished to participate in the study. As group treatments had begun these subjects25were not replaced, thus resulting m n’s of 20, 21 and 19 for the CT, BT and controlgroups respectively. Two groups of the CT programme, each initially having 10participants, and two BT groups, one with 10 and one with 11 participants, wereconducted simultaneously over an eight week period.ProceduresMembers of the BT group were weighed weekly and were required to chart theirweight. They were also required to keep daily records of their food intake and exercise,which were reviewed weekly. They were given a standard diabetic exchange dietproviding 1200-1500 kcal/day (British Columbia Dietitians’ & Nutritionists’ Association,1992) to follow. A psychoeducational format was employed: group meetings weredidactic and personal disclosures were not encouraged. A standardized treatment manualfor each week was developed (see Appendix II). Weekly topics were as follows:1. Introduction, Contracts, Goal Setting2. The Exchange Diet3. Exercise4. Stimulus Control5. Shaping and rewards6. Nutrition7. Relapse prevention8. ReviewCT group members were weighed at Weeks 1, 4 and 8. Individuals were informedof their weight only if they so desired. Social and political influences regarding bodilyideals and appearance were discussed and participants were always encouraged to sharetheir personal experiences and feelings. Readings concerning the nondieting approach andexercise were assigned. Subjects were encouraged to allow themselves previouslyforbidden foods and to consciously recognize psychological and physiological hunger and26satiety cues. The standardized manual for the CT programme is presented in Appendix I.Weekly topics for the CT group were as follows:1. Introduction, Exercise and Exercise Self-Efficacy2. The Nondieting Approach and Nutrition3. Nonhunger Reasons for Eating and Problem Solving Techniques4. Depression/Cognitive Distortions5. Assertiveness and Relaxation Training6. Developing a Healthy Relationship with One’s Body7. Relapse Prevention8. ReviewAnalytic StrategiesData were analyzed via separate 3 (treatment group) X 3 (time) X J (outcomemeasure) repeated measures multivariate analyses of variance (MANOVAs). Body MassIndex scores constituted one MANOVA. Data from the Eating Disorder Inventorycomprised another and scores on the Beck Depression Inventory, State Trait AnxietyInventory, and Self-Control Schedule constituted a third. Eating and exercise behaviours(i.e. the number of binges and exercise episodes during the preceding week) and ratings ofeating and exercise self-efficacy made up a fourth MANOVA. Where appropriate,multivariate tests were followed up with univariate tests and Tukey’s tests for pairwisecomparisons. Pre, post, and follow-up data for those subjects providing data six monthssubsequent to treatment were similarly analyzed via multivariate methods.As multivariate procedures may not be robust to violations of the assumption ofhomogeneity of variance when cell sizes are unequal, Box’s M test was used to test allMANOVA data for homogeneity of variance. In all cases, the hypothesis that the datawere homogeneous remained tenable. As repeated measures analyses may not be robust toviolations of sphericity, Mauchly’s test was used to assess repeated measures data for27sphericity. For nonspherical data, the Huynh-Feldt Epsilon was used to adjust degrees offreedom for critical Fs used to establish significance levels. When using Tukey’s tests forpairwise comparisons on nonspherical data, residual mean squares based on individualscores (rather than the overall mean square within from the ANOVA) were used.To gain further understanding of the construct of self-efficacy in obese women,Pearson product-moment correlation coefficients were calculated to examine the relationof nonchaotic eating self-efficacy, number of binges, ratings of exercise self-efficacy andexercise frequency. In addition, correlations between measures of general self-efficacy (i.e.SCS and I scores) and measures of domain-specific self-efficacy were also examined.ResultsPre-treatmentMean pre-treatment scores and standard deviations for the original 60 subjects arepresented in Table 4. MANOVA indicated that whereas, prior to treatment, no significantdifferences existed between the three groups in terms of age and BMI (F(4,l 12)=.37;p=.&3); depression, anxiety and self-control (F(8,108)=.53); p=.&3); or EDI scores(F(16,l00)=.49; p=.95); eating and exercise frequencies and efficacies (F(8,108)=2.49;p=.O2) did differ. Specifically, eating (F(2,57)=3.30; p=.O4.) and exercise (F(2,57)=5.52;p=.Ol) self-efficacies differed, with CT subjects reporting significantly higher pretreatment levels of eating and exercise self-efficacy than BT subjects. Similarly, prior totreatment, exercise self-efficacy was significantly higher for control than for BT subjects.Drop-outsTen subjects, two CT and BT members and six control subjects dropped out oftreatment, resulting in final n’s of 18, 19 and 13 for the CT, BT and control groups,28Table 4. Study 3: Subject variables (mean ± standard deviation) prior to treatment.Age (years) 46.3 9.4Weight (kg) 108.8 ± 19.9Body Mass Index (kg/rn2) 39.4 6.2Beck Depression Inventory 17.4 ± 8.8State Anxiety Inventory 42.0 ± 13.2Trait Anxiety Inventory 46.3 ± 11.8Self-Control Schedule 121.6 ± 27.5Eating Disorder InventoryDrive for Thinness 6.8 ± 4.9Bulimi 53 ± 4.4BodyDissatisfaction 21.0 ± 6.0Inefficacy 6.4 ± 5.4Perfectionisrn 6.2 ± 4.4Interpersonal Distrust 3.5 ± 3.5Interoceptive Awareness 5.7 5.1Maturity Fears 2.7 2.7Binges/pastweek 1.2 ± 1.7Eating Efficacy 91.2 ±37.6Exercise / past week 2,6 ± 2.5Exercise Efficacy 101.4 ±26.629respectively, MANOVA failed to reveal any significant differences between subjects whodropped out of and those who completed the programme (F(18,41)= 1.65; p=.O93).Treatment FindingsOver the course of treatment, CT group members showed improvement indepression, anxiety and self-control scores while individuals in the BT and control groupsdid not. Similarly, CT subjects evidenced a reduction in eating-related psychopathologywhereas individuals in the BT and control groups did not. Over the eight weeks of thestudy there was an increase in the proportion of CT and BT participants who reportedexercising regularly (i.e., at least three times per week); in contrast, during this sameperiod, there was an nonsignificant decrease in the proportion of control group memberswho reported exercising regularly. Likewise, subjects in both the CT and BT groupsshowed modest, but significant, weight losses while members of the control group showeda nonsignificant increase in mean weight.Depression, Anxiety and Seif-Contro1Mean Beck Depression Inventory, State and Trait Anxiety Inventories and Self-Control Schedule scores for the three groups at pre-treatment, mid-treatment and post-treatment are presented in Table 5. These data were subjected to MANOVA whichrevealed a significant group by time interaction (F(16,279)=2.12; p<z.O5). No main effectswere found. Simple effects analysis revealed that whereas scores for the CT groupchanged across time (F(8,182)=4.2l; cz.Ol), those for the BT and Control groups did not.Univariate analysis indicated that within the CT group, depression scores improvedsignfficantly over time (F(2,34)=6.04; p<.O25), as did state anxiety scores (F(2,34)=5. 12;p=.Oll), trait anxiety scores (F(2,34)=5.18; p=.O1 1), and self-control scores(F(2,34)=8.42; p=.OO1). Whereas scores on the Self-Control Schedule were significantly30improved by mid-treatment, depression and anxiety scores did not show statisticallysignificant improvement (relative to pre-treatment) until post-treatment.Table 5. Study 3: Psychometric scores (mean ± standard deviation) for cognitivetherapy (CT), behaviour therapy (BT) and control subjects.Pre-treatment Mid-treatment Post-treatmentCT (n=18) 17.9 ± 10.5 12.7 -- 6.0 10.0.5.8Beck DepressionInventory BT(n=19) 15.8± 8.4 11.7± 8.2 11.0± 8.5Control(n=13) 19.6÷ 7.8 19.9÷ 11.3 14.5± 7.5CT(n=18) 45.2÷ 12.8 43.9± 13.1 36.3± 12.2State AnxietyInventory BT(n=19) 36.8± 12.9 37.1± 11.9 37.8± 13.3Control(n=13) 45.2± 13.8 44.2± 12.9 41.8± 9.8CT(n=18) 49.9± 11.5 46.0± 10.5 42.6± 10.9Trait AnxietyInventory BT(n=19) 43.0± 11.6 41.7± 12.0 41.6± 13.2Control(n=13) 48,3± 10.5 48,9± 11.8 45.9± 11.5CT(n=18) 109.2± 21.3 124.1± 20.4 129.1± 24.0Self-ControlSchedule BT(n=19) 128.2÷ 33.5 123.6± 37.7 135.2± 35.1Control (n=13) 122.8 ± 26.2 117.2 ±27.4 117.6 ± 26.7Pre-/post-treatment change scores for depression, anxiety and self-control arepresented in Figure 1. A consistent pattern is present with the CT group showing thegreatest amount of change, always in the desired direction.31Psychometric Change ScoresImprovement_______ci cr• BT• CONTROL—LState Trait Self-5 Depression Anxiety Anxiety ControInventory Inventory Inventory ScheduleWorseningFigure 1. The cognitive therapy (CT) group improved significantly over the course oftreatment on Beck Depression Inventory (BDI), State Anxiety Inventory (SAT), TraitAnxiety Inventory (TAT) and Self-Control Schedule (SCS) scores. Scores for thebehaviour therapy (BT) and Control groups did not change significantly over time.Change scores for individuals showing psychological deterioration are presented inTable 6. Examination of these scores reveals an interesting pattern. Although thedifference is not statistically significant, due, at least in part, to the very small n’s, the BTgroup consistently shows the greatest deterioration.Eating Disorder InventoryMean EDI subscale scores are presented in Table 7. Consistent with previousresults, scores for Maturity Fears and Interpersonal Distrust were not elevated prior totreatment and thus were not included in the subsequent analyses, The remaining sixsubscale scores were subjected to MANOVA which revealed a significant effect of time(F(12,178)=3.05; p<.O25) but not group. A marginally significant group by timeinteraction F(24,31 l)=l .58; p=.lO) was found. (Statistical significance for the group by32Table 6. Study 3: Change scores (mean ± standard deviation) for cognitivetherapy (CT), behaviour therapy (BT) and control subjects who show deterioration oneither Beck Depression Inventory, State Trait Anxiety Inventory or Self-Control Schedulescores. On the Self-Control Schedule, positive change scores reflect clinical worsening; onall other measures, negative change scores correspond to clinical deterioration.CT (n=4) -2.8 ± 1.0BECK DEPRESSIONINVENTORY BT (n=3) -4.3 ± 3.2Control (n=4) -1.3 ± 0.5CT (n=5) -4.0 ± 4.8STATE ANXIETYINVENTORY BT (n=8) -8.3 ± 5.8Control (n=7) -5.6 + 2.8CT(n=4)-3.0± 3.4TRAIT ANXIETYINVENTORY BT (n=6) -4.2 ± 2.7Control (n=6) -2.5 ± 2.8CT (n=3) 6.7 ± 4.2SELF-CONTROLSCHEDULE BT (n=2) 47.0 ±52.3Control (n=5) 18.2±11.0time interaction was reduced from p=.04-4. due to correction for nonsphericity). Simpleeffects analysis indicated that while scores for the CT group improved significantly across33time (F(12,178)=4.96; <.OO1) those for the BT and Control groups did not. Furtheranalyses for CT scores showed significant reductions (i.e. improvement) across time forthe following subscale scores: Drive for Thinness (F(2,34)=8.OO; =.OO1); Bulimia(F(2,34)= 11.12; <.O 1); Body Dissatisfaction (F(2,34)=6.28; p<.O25); Inefficacy(F(2,34)=5.59; p<.O5); and Interoceptive Awareness (F(2,34)6.5O; <.O25).Perfectionism did not change significantly. Interoceptive Awareness scores showedsignificant improvement by mid-treatment; other EDI subscale scores did not showsignificant improvement until post-treatment. Pre- /post-treatment change scores for theEating Disorder Inventory subscales are presented in Figure 2. Again, a consistent patternis present with the CT group showing the greatest improvement.Eating Disorder Inventory Change Scores\Figure 2. Study 3: Cognitive therapy (CT) subjects improved significantly over thecourse of treatment on the following Eating Disorder Inventory subscale scores: Drive forThinness, Bulimia, Body Dissatisfaction , Inefficacy and Interoceptive Awareness. Theydid not show significant changes in Perfectionism. Behaviour therapy (BT) and controlsubjects did not change significantly over time on any of the subscales.-:1:clcrBT• CONTROL34Table 7. Study 3: Scores (mean ± standard deviation) on subscales of the EatingDisorder Inventory for cognitive therapy (CT), behaviour therapy (BT) and controlsubjects pre-, mid- and post-treatment.Pre Mid PostCT(n=18) 7.9± 6.2 6.9± 6,0 3.8± 4.4Drive forThinness BT(n=19) 6,1± 3.9 6.5± 5.1 5.3± 4.6Control (n=13) 7.2 ± 4.7 6.0 ± 4.5 6.5 ± 4.6CT(n=18) 5.9± 5.4 2.2± 2.7 1.3± 1.8BulimiaBT(n=19) 5.0+ 3.7 3.5± 3.4 3.5+ 4.1Control (n=13) 5.0 + 4.5 4.5 ± 5.8 4.1 -F 5.0CT(n=18) 22.2± 5.4 20.3± 7.3 16.5± 8.9BodyDissatisfaction BT(n=19) 18.6± 6.7 18.4± 7.1 18.1± 7.8Control(n=13) 21.2± 6.3 19.4± 6.9 20.3± 6.0CT(n=18) 7.9± 6.4 5.7± 4.3 3.9± 5.1InefficacyBT(n=19) 5.2± 4.2 3.6± 4.3 4.2± 4.6Control(n=13) 7.9± 5.1 6.5± 5.8 6.0± 5.635Table 7. Continued...Pre Mid PostCT(n=18) 6,8± 4.1 6,3± 4.1 6.3± 3.8PerfectionismBT (n=19) 6.0 ± 3.8 5.3 ± 4.2 5.2 ± 4.7Control (n=13) 5.2 ± 4.5 4.5 ± 4.1 4.8 ± 4,5CT (n=18) 3.4 ± 3.9 3.3 ± 3.8 3.1 ± 4.4InterpersonalDistrust BT(n=19) 3.6± 3.3 1.6± 2.0 2.1 ± 2.7Control(n=13) 2.9± 2.9 3.4± 3.3 2.5± 3.3CT (n=18) 7.6 ± 6.9 4.6 ± 4.9 3.6 ± 3.7InteroceptiveAwareness BT(n=19) 4.8± 4.3 3.3± 3.4 4.4± 4.5Control (n=13) 5.6 ± 3.8 5.4 ± 5.3 4.2 ± 4.8CT(n=18) 2.3± 2.3 1.8± 1.9 1.9± 2.0MaturityFears BT(n=19) 2.1± 2.6 1.6± 1.8 1.9± 1.8Control(n=13) 2.9± 3.1 3.0± 2.9 2.2± 2.836Exercise, Eating and Self-EfficacyPrior to treatment, 33%, 50% and 31% of CT, BT and control subjects,respectively, reported exercising regularly (i.e. at least three times per week). Post-treatment, 83% of CT, 79% of BT and 23% of control subjects were exercising regularly.Kruskal-Wallis ANOVA revealed that prior to treatment no differences between the threegroups existed with respect to these proportions (X2=.76, p=.684); following treatmenthowever, significant differences between the groups emerged (2=12,88, p=.0O2).Pairwise comparisons (Mann-Whitney U Tests) revealed that the proportions of regularexercisers were greater in the CT (U=46.5; p=.004.) and BT (U= 61.0; p=.Ol6) groupsthan in the control group and that the proportion of regular exercises did not differsignificantly between the two active treatment groups. Sign tests revealed that theproportion of individuals in the CT group exercising regularly increased significantly overthe course of treatment (p=.0O4-); the increase for BT subjects was marginally significant(p=.O65) During this same time there was a nonsignificant decrease in the proportion ofindividuals in the control group who reported exercising regularly.Mean number of binges and exercise bouts, together with ratings of eating- andexercise- self-efficacy are presented in Table 8. MANOVA of these data revealed asignificant group effect (F(4,44)=372,70; p<.OO1). However, no time, or group by timeeffects were found and thus follow-up analyses were not conducted.Although there were no statistically significant differences between subjectswho reported exercising regularly (n=33) and those who did not (n=17), certain patternsdid emerge as can be seen in Figures 3.1 and 3.2. Subjects who reported exercisingregularly by the end of treatment showed greater improvement in depression, anxiety, selfcontrol and eating-related psychopathology. Subjects exercising regularly lost an averageof 2.4 kg while subjects not exercising regularly gained an average of .25 kg.37Table 8. Study 3: Scores (mean ± standard deviation) for eating and exercisebehaviours and ratings of self-efficacy for cognitive therapy (CT), behaviour therapy (BT)and control subjects.Pre-treatment Mid-treatment Post-treatmentCT(n=18) 1.2± 2,0 0.6± 0.8 0.4± 0.6BINGES BT(n=19) 1.5± 1.6 1.3± 2.2 1.0± 1.3Control (n=13) 0.9± 1.5 1.0± 1.5 0.5± 0.7CT (n=18) 102.1 ± 29.8 108.1 ± 20.5 106.7± 30.2EATINGEFFICACY BT (n=19) 77.0 ± 40.2 78.8 ± 37.8 91.7 ± 30.6Control (n=13) 101.7 ± 24.8 92.7 ± 25.6 99.9 ± 29.3CT (n=18) 2.1 ± 2.1 4.3 ± 2.3 3.7 ± 1.7EXERCISE BT(n=19) 3.1 ± 3.1 5.3± 3.7 4.6± 3.2Control(n=13) 2.5± 1.9 1.5± 2.1 1.6± 2.0CT(n=18) 110.1± 20.2 109.4± 26.0 112.4± 24.9EXERCISEEFFICACY BT (n=19) 89.5 ± 34.5 89.2 ± 40.3 94.3 ± 39.2Control(n=13) 108.9± 17.7 111.4± 12.3 111.8± 13.438Changes in Psychometric Scores for Exercisers and NonexercisersWorseningFigure 3.1 Changes in Beck Depression Inventory, State Anxiety Inventory, TraitAnxiety Inventory and Self-Control Schedule scores for individuals exercising regularly(EX) and for nonexercisers (NONEX) across all three treatment groups.Changes in ED! Subscales for Exercisers and Nonexercisers3d’.\\Figure 3.2 Changes in Eating Disorder Inventory (EDI) subscales for regularexercisers (EX) and for nonexercisers (NONEX) across all three treatment groups.Improvement15 D EXNONEXl050-5.Beck Depression State Anxiety Trait Anxiety Self-ControlInventory Inventory Inventory Schedule42ImprovementI EXC NONEX0)o v’. AJ39Body MassMean Body Mass Index scores and weights from subjects completing all threeassessments are presented in Table 9.Table 9. Study 3: Weight and body mass index (BMI; mean ± standard deviation)for cognitive therapy (CT), behavior therapy (BT) and control subjects in Study 3.Pre-treatment Mid-treatment Post-treatmentCT(n=l8) 112.9± 19.0 112.1± 18.9 111.1± 18.4WEIGHT(kg) BT (n=l8) 104.4 ± 15.6 102.6 ± 14.9 101.8 ± 14,8Control(n=12) 111.7± 20.2 111.8± 19.9 112.5± 20.1CT(n=18) 39.4± 5.2 39.2± 5.2 38.8± 5.1BMI(kg/rn2) BT (n=18) 38.7 ± 5.8 38.1 ± 5.8 37.8 ± 5.9Control (n=12) 40.7 ± 5.5 40.8 ± 5.5 41.0 ± 5.5Two subjects, one BT member and one control group member failed to attend finalsessions iii person and were not weighed; however, they did submit questionnaire data bymail. Thus, weight-related data for these groups are based on n’s of 18 and 12,respectively. Mean losses in weight were 1.76 ± 2.29 kg and 2.60 ± 4.15 kg for the CTand BT groups respectively; members of the Control group gained an average of .75 ±2.20 kg. MANOVA of body weight data revealed a significant group by time interaction(F(4,90)=4.12; p<.OS), such that CT (F(2,90)=5.34; p<.O5) and BT (F(2,90)=1 1.95;p<.Ol) but not control (F(2,90)=.83; p>.44) subjects lost significant amounts of weightduring the course of treatment.Body mass data, which are presented in Figure 4, were subjected to MANOVA.This revealed a significant main effect of time F(2,90)=6.00; p<.O25) but not group. A40significant group by time interaction (F(4,90=4. 11; p<.O25) was also found. Simpleeffects analysis revealed that body mass decreased with time in both the CT(F(2,90)=4.70; p<.O25) and BT (F(2,90)=l1.57; <.O1) groups. Relative to pretreatment Body Mass Indices, mean Body Mass Indices at mid- and post-treatment weresignificantly reduced in both BT and CT subjects. In contrast to both active treatmentgroups, the control group showed a nonsignificant increase in body mass (F(2,90)= .91p>.41).Body Mass Index—4--cr42——— BT—A—— CONTROL::3983736 I IPRE- MID- POST-TREATMENT TREATMENT TREATMENTFigure 4. Study 3: Body Mass Index (BMI; kg/rn2) decreased significantly over thecourse of treatment for both cognitive therapy (CT) and behaviour therapy (BT)participants. Control subjects showed a nonsignificant increase in BMI during the eightweeks of the study.Correlations with Weight LossContrary to expectations, no significant correlations between weight loss and posttreatment depression scores or change scores were found for either subjects as a whole(Le., n=50) or for BT subjects alone. In contrast, for CT subjects, a negative correlationbetween weight loss and depression post-treatment (r=-. 63; p<.Ol), but not between41weight loss and change in depression, was found. The correlation coefficients arepresented in Table 10.Table 10. Pearson product-moment correlation coefficients between weight changeand Beck Depression Inventory scores post-treatment and depression change scores for allsubjects (n=50) and for cognitive therapy (CT) and behaviour therapy (BT) subjects.ALL SUBJECTS CT SUBJECTS BT SUBJECTSWt Change Wt Change Wt ChangeBeck DepressionPost-treatment -.29 -.63 -.04Beck DepressionChange Score .03 -.13 .10Sef-Efficacy CorrelationsCorrelation coefficients for self-efficacy ratings and exercise and eating behavioursprior to treatment and following treatment are presented in Tables 11.1 and 11.2,respectively. No consistent and significant correlations between number of exercise boutsand exercise self-efficacy or number of binges and eating self-efficacy were found.Likewise, eating self-efficacy was not related to changes in weight. Furthermore, at notime were Inefficacy or Self-Control Schedule scores significantly related to either eatingor exercise self-efficacy.42Table 11.1 Pearson product-moment correlation coefficients for all subjects prior totreatment, for the number of binges during the preceding week (Binge Freq), rating ofnonchaotic eating self-efficacy (Eating Efficacy), number of exercise bouts duringpreceding week (Ex Freq), rating of exercise self-efficacy (Ex Efficacy), Self-ControlSchedule score (Self-Control) and score on the Inefficacy subscale of the Eating DisorderInventory.Binge Freq Eating Efficacy Ex Freq Ex Efficacy Self-Control InefficacyBingeFreq 1.00 -.26 .09 -.24 .11 25Eating Efficacy 1.00 .03 .48 -.02 -.11Ex Freq 1.00 .44 .07 -.05Ex Efficacy 1.00 -.01 -.09Self-Control 1.00 -.36Inefficacy 1.00Table 11.2 Pearson product-moment correlation coefficients for all subjects post-treatment, for the number of binges during the preceding week (Binge Freq), rating ofnonchaotic eating self-efficacy (Eating Efficacy), number of exercise bouts duringpreceding week (Ex Freq), rating of exercise self-efficacy (Ex Efficacy), Self-ControlSchedule score (Self-Control) and score on the Inefficacy subscale of the Eating DisorderInventory.Binges Freq Eating Efficacy Ex Freq Ex Efficacy Self-Control InefficacyBingeFreq 1.00 -.46 -.08 -.31 -.03 .14Eating Efficacy 1.00 .09 .41 .28 -.10Ex Freq 1.00 .27 .38 -.13Ex Efficacy 1.00 .32 .01Self-Control 1.00 -.45Inefficacy 1.0043Depression by Treatment InteractionsTo examine a possible differential impact of treatment on depressed andnondepressed subjects, participants were divided according to whether or not they hadevidence of serious depression (operationalized as pre-treatment BDI scores of greaterand less than 30 respectively). Three individuals in the CT group, two iii the BT and twoin the Control group had BDI scores greater than 30, while 15, 17 and 11 subjects in theCT, BT and Control groups respectively had BDI scores less than 30. These data arepresented in Figures 5.1, 5.2, 5.3 and 5.4. MANOVA of depression, anxiety and self-control change scores revealed a significant treatment group by depression effect(F(8,82)=7.2; p<.OO1). Univariate tests revealed significant effects for change indepression (F(5,44)=12.l; p<.0001); state anxiety (F(5,44)=7.2; p<.0001); trait anxiety(F(5,44)=1 1.9; p<.0001) and self-control (F(5,44)=8.5; p<.0001). Whereas the CT andBT treatments produced similar effects for the group of individuals who were not highlydepressed, the group of severely depressed CT subjects showed greater benefits fromtreatment than did severely depressed BT subjects. Tukey pairwise comparisons revealedthat severely depressed CT, but not BT, subjects showed statistically greater improvementin depression than depressed control subject. Depressed CT subjects also showed greaterimprovements iii state anxiety, trait anxiety and self-control than either depressed BT orcontrol subjects. A similar group by depression interaction was also found for EDI scores(F(6,39)=5.05; p=.OO1).44353025BDI 20151050Changes in Beck Depression Inventory ScoresFor Depressed SubjectsFigure 5.1. Changes in Beck Depression Inventory (BDI) scores for severely depressed(pre-treatment BDI 30) Cognitive Therapy (CT; n=3), Behaviour Therapy (BT; n=2) andControl (n=2) subjects.Changes in State Anxiety Inventory ScoresFor Depressed SubjectsD Pro• PostFigure 5.2 Changes in State Anxiety Inventory (SAT) scores for severely depressed(pre-treatment BDI 30) Cognitive Therapy (CT; n=3), Behaviour Therapy (BT; n=2)and Control (n=2) subjects. Depressed CT subjects show greater improvement thandepressed BT or control subjects.40o Pro• Post605040SAl 3020100CT BT Control45Changes in Trait Anxiety Inventory ScoresFor Depressed SubjectsFigure 5.3 Changes in Trait Anxiety Inventory (TAI) scores for severely depressed(pre-treatment BDI 30) Cognitive Therapy (CT; n=3), Behaviour Therapy (BT; n=2)and Control (n=2) subjects. Depressed CT subjects show greater improvement thandepressed BT or control subjects.160140120100SCS 806040200Changes in Self-Control Schedule ScoresFor Depressed SubjectsFigure 5.4 Changes in Self-Control Schedule (SCS) scores for severely depressed(pre-treatment BDI 30) Cognitive Therapy (CT; n=3), Behaviour Therapy (BT; n=2)and Control (n=2) subjects. Depressed CT subjects show greater improvement thandepressed BT or control subjects.70605040TAI3020100D Pre• PostCT BT ControlD Pre• PostCT ST Control46Post-treatmentfollow-upGiven the improvement in psychological well-being evidenced by CT subjectsfollowing the initial eight weeks of treatment, BT subjects were offered an additional fourweeks of treatment, during which time, topics covered previously in the CT, but not theBT group, were presented. To maintain consistency in the number of sessions received,CT subjects were also offered an additional four weeks of treatment at this time. For CTsubjects, these sessions involved discussions of previously presented materials. Followingthe initial eight weeks of the study, the wait-list control subjects received a combination ofthe CT and BT programmes. These groups were led by two therapists, i.e. both theoriginal CT and BT therapist. Thus, these groups differed in terms of both delivery andcontent from the original treatment protocols. Therefore, treatment outcome data from thewait-list control subjects are not presented here.Follow-up data were collected six months post-treatment. Although all subjectshad agreed to provide post-treatment data, and its importance to the study had beenrepeatedly stressed, only 12 of the original 18 CT and 9 of the original 19 BT subjectsprovided follow-up information when contacted. As detailed above, the original wait-listcontrol subjects received treatment which differed in content, delivery and time ofadministration; they are therefore being followed-up independent of the current study.Statistically, subjects who completed the six month follow-up did not differ from thosewho failed to, in terms of pre-treatment depression, anxiety and self-control (F(4,32)=.89;p=.4’79); binge and exercise frequencies and self-efficacies (F(4,32)=1,22; p=L32l) orage and body mass (F(2,34)=l,14; p=.33l). Subjects who completed the six month47follow-up did differ from individuals who failed to, in terms of pre-treatment EDT scores(F(8,28)=3.05; =.0l4). These data are presented in Table 12. Specifically, the meanMaturity Fears subscale score was greater for noncompleters than for completers(F( 1 ,35)= 4.30; p=.046). In addition, there was a trend for noncompleters to score higheron the Drive for Thinness (F(1,35)=3.04; p=.O90) and Bulimia (F(1,35)=4.04; p=.052)subscales.Table 12. Pre-treatment Eating Disorder Inventory scores (mean ± standarddeviation) for CT and BT subjects who provided 6 month follow-up data (Completers;n=21) and for those who did not (Noncompleters; n=16). Only scores on the MaturityFears subscale are significantly different between the two groups (p=.O46).Noncompleters CompletersDrive for Thinness 8.6 ± 5.1 5.7 ± 5.0Bulimia 7.1 + 4.6 4.2 ± 4.3Body Dissatisfaction 20 .1 ± 7.1 20.6 ± 5.8Inefficacy 6.7 ± 4.3 6.4 ± 6.3Perfectionism 6.1 ± 3.8 6.6 ± 4.1Interpersonal Distrust 3.8 3.6 3.3 ± 3.5Interoceptive Awareness 7.9 ± 4.8 4.9 ± 6.2Maturity Fears 3.1 ± 3.1 1.5 ± 1.5Follow-up data obtained from the CT and BT subjects six months subsequent totreatment are presented in Tables 13.1 and 13.2, together with the corresponding pre- and48post-treatment data for these subjects. Nonparametric analyses failed to reveal anysignificant differences in the proportion of individuals exercsing regularly (i.e. three ormore times per week) either between the two groups or across time. MANOVA of BDI,STAI and SCS data failed to reveal any statistically significant effect of group(F(4,16)=.157; p=.957), time (F(8,72)= 1.064; p>.398) or group by time interaction(F(8,72)=l.624; p>.l33). Likewise, no significant group (F(8,12)=.910; =.539), time(F(16, 64)=.903; p>.569) or group by time (F(16, 64)=.903; p>.569) effects for EDI datawere found. MANOVA of eating and exercise behaviours and seif-efficacies failed toreveal a significant effect of group (F(4,16)=l,69; p=.2O2) or group by time interaction(F(8,72)=.584; p>.788). A significant main effect of time was found (F(8,72)= 3.15;p<.O5); however, simple effects analyses failed to reveal significant changes across timefor CT (F(8,72)=1.9l7; p>.O7) or BT (F(8,72)=0.518; >.ll4) subjects. A main effect oftime (F(2,38)=4.91; p<.O5) was also present for BMI data although no group (F(1,19)=0;=.976) or group by time (F(2,38)=.60; p=.557) effects were found, Again, simple effectsanalyses failed to reveal significant changes in BMI across time for BT (F(2,38)=3.89;or CT (F(2,38)=1.24; p>.3Ol) subjects.Discussion of Findings from Studies 1- 3Consistent with findings from Studies 1 and 2, the results from Study 3 suggestthat women seeking psychological treatment for obesity are somewhat depressed andanxious and have higher than average levels of eating-related psychopathology, especiallywith respect to body dissatisfaction. in addition, it appears that these women feel a relative49Table 13.1. Study 3: Pre-treatment, post-treatment and follow-up scores (mean ÷standard deviation) for those cognitive therapy (CT; n=12) and behaviour therapy (BT;n=9) subjects who completed 6 month follow-up data.Pre-treatment Post-treatment 6 Month Follow-upProportion CT .42 .83 .58Exercising Reg. BT .44 .67 .44Weight CT 244.7 34.6 239.9 ± 32.7 233.9 ± 29.8BT 234.2± 43.9 226.9± 40.2 214.8± 39.9BodyMasslndex CT 39.2± 5.2 38.4± 5.1 37.5± 4.9BT 39.9 ± 6.8 38.7 ± 6.7 36.6 ± 6.4Beck Depression CT 15.2 10.6 10.4 ± 6.4 8.0 ± 6.8Inventory BT 13.9± 9.3 9.8± 9.4 11.3± 11.1StateAnxiety CT 41.8± 14.2 35.4± 13.0 34.8± 11.9Inventory BT 36.3 ± 16.7 34.7 ± 14.3 35.4 9.3Trait Anxiety CT 47.0± 11.9 42.9± 11.8 36.5± 11.4Inventory BT 40.4± 14.1 38.9± 16.0 41.8± 16.2Self-Control CT 109.1 ± 23.3 122.2 ± 29.8 130.3 ± 26.3Schedule BT 128.0 ± 46.1 132.1 ± 46.0 124.7 ± 48.9Binges CT 1.0± 2.2 0.4± 0.7 0.1 ± 0.3BT 0.7± 1.0 0.1 ± 0.3 0.5± 0.7Eating Efficacy CT 104.8± 23.2 101.0± 35.4 85.0± 37.3BT 87.9± 36.7 102.4± 24.3 74.4± 38.7Exercise Freq. CT 2.7± 2.1 3.6± 1.8 2.7± 2.1BT 2.8 ± 3.0 4.9 ± 3.0 3.4 ± 3.2Exercise Efficacy CT 112.5± 19.2 108.3± 29.7 104.2± 31.8BT 99.1 ± 20.7 104.3 ± 34.3 83.7 ± 41.350Table 13.2. Study 3: Pre-treatment, post-treatment and follow-up Eating DisorderInventory scores (mean ± standard deviation) for those cognitive therapy (CT; n=12) andbehaviour therapy (BT; n=9) subjects who completed 6 month follow-up data.Pre-treatment Post-treatment 6 Month Follow-upDrive for CT 5.8 ± 5.9 3.4 ± 3.9 4.4 ± 3.9Thinness BT 5.7 ± 3.7 5.7 ± 5.5 7.1 ± 5.2Bulimia CT 4.9± 5,4 1.0-i- 1.5 1.4± 1.5BT 3.2-i- 1.7 1.9± 2.3 4.0± 4.3Body CT 20.6± 6.0 16.3± 8.5 18.6± 7.0Dissatisfaction BT 20.6-i- 5.9 19.1+ 7.4 18.4± 6.0Inefficacy CT 7.3± 7.4 4.5± 6.0 3.4± 4.1BT 5.2 4.8 5.0 ± 5.9 5.9 ± 6.2Perfectionism CT 7.9 -I- 4.3 7.6 ± 3.5 8.0 ± 4.2BT 4.8± 3.1 5.6± 5.1 4.8± 5.0Interpersonal CT 3.9 ± 4.0 4.1 ± 5.0 3.6 ± 4.7Distrust BT 2.4± 2.8 1.6± 1.8 2.2± 2.8Interoceptive CT 6.1± 7.4 2.9± 3.6 2,8± 2.6Awareness BT 3.2± 4.1 2.9± 3.1 1.8± 3.5Maturity CT 1.4± 1.7 1.8± 1.8 1.3± 1.8Fears BT 1,6± 1.3 2.0± 1.4 1.0± 1.8lack of cognitive self-control. These findings are fri keeping with previous reportssuggesting that people seeking treatment for obesity have elevated levels ofpsychopathology (e.g. Stunkard & Wadden, 1992).51The results also suggest that women receiving a broad-based treatment approach(CT) benefit considerably in terms of reduced psychopathology and enhanced cognitiveself-control. In contrast, women participating in a standard BT group focusing on diet andexercise did not show significant changes in these psychological variables. These findingssupport the idea that treatment tailored to the psychological needs of obese womenprovides specific benefits in terms of enhanced emotional well-being. In contrast to controlsubjects who received no form of treatment and who showed a slight increase in weight,women in both forms of active treatment experienced significant decreases in weight.The potential importance of these findings notwithstanding, cognizance of thedistinction between clinically significant changes and statistically significant changesremains necessary. For treatment effects to be of true clinical significance, they must notonly be of sufficient magnitude, but must also be maintained over some meaningful periodof time. In terms of magnitude, not all of the current treatment effects, found to bestatistically significant, can also be considered clinically significant. For example, althoughbody weight was statistically reduced post-treatment, the mean changes were not ofimmediate clinical relevance. It is possible however that, over time, continued modestreductions in weight may eventually result in levels of weight change which are of clinicalsignificance. In contrast to such observed changes in weight, many of the post-treatmentchanges in psychopathology were of clinical, as well as statistical, significance. Forexample, the reduction in BDI score for the average CT subject reflected movement froma moderate level of depression to a non-depressed state, a change which is certainly ofclinical importance. Nonetheless, determination of the extent to which such effects are of52true clinical significance, in terms of both their magnitude and maintenance over time,awaits longer term follow-up.The current findings extend the research literature in several important ways. First,they confirm previous reports that women can benefit psychologically and physiologicallyfrom a nondieting programme (Polivy & Herman, 1992; Roughan et a!., 1990). Secondly,in contrast to these previous studies wherein no control groups were employed, thecurrent study included two control groups, additions which greatly facilitate theinterpretation of results. Finally, whereas the prior studies had recruited subjects based ontheir desire to stop dieting, the current study used a sample of women who soughttreatment for obesity and expressed a desire to lose weight. Thus, this work extends theknown utility and generalizability of nondieting programmes to include seriously obesewomen presenting for treatment.Surprisingly, eating self-efficacy was not consistently related to eating behaviour(i.e., number of binges in the preceding week) or amount of weight lost. This contrastswith previous studies reporting a strong relation between ratings of eating efficacy andamount of weight lost during treatment (e.g. Bemier & Avard, 1986; Edell et al., 1987).Likewise, exercise self-efficacy was not related to the number of bouts of exerciseengaged in during the preceding week. This differs from findings with other populationswherein significant correlations between exercise behaviour and self-efficacy ratings exist(e.g. Desharnais et al., 1986; McAuley, 1992; McAuley & Courneya, 1992; McAuley &Jacobson, 1991; Sallis et al., 1986). In addition, no correlations between measures ofgeneral self-efficacy (Inefficacy subscale of the EDT or the SCS) and specific eating or53exercise self-efficacy were found. The method of assessment likely contributed to thesefindings. The visual analogue scale used to assess eating and exercise efficacy appearedconfusing to many individuals. For example, people often circled the end anchor pointsrather than placing a cross on the scale. The fact that scores on the inefficacy scale of theEDI and the SCS did not correlate with either eating or exercise efficacy supportsBandura’s original contention that self-efficacy is domain specific and may not bemeasurable as a generalized construct.Psychological VariablesCT subjects showed improvement over the course of treatment in terms of scoresfor depression, anxiety, self-control and specific eating-related pathology; BT and controlsubjects did not. Given the similarity between the CT and BT groups in terms of meanweight loss, this difference in treatment outcome is potentially important as it suggeststhat improvement in overall psychological well-being need not be at the expense of weightloss. The results obtained provide evidence for treatment specificity: the BT programme iseffective in helping individuals reduce body weight but is not particularly useful as a meansof enhancing psychological health. In contrast, the CT programme produces decrements inboth weight and psychopathology. The differential effects of the CT and BT treatmentsmay be mediated by psychological constructs such as readiness to change, depression, anduse of eating as a means of affect regulation.The pattern of results is entirely consistent with Prochaska’s theorizing andresearch regarding readiness to change (e.g., Prochaska, DiClemente et al., 1992). Perhapspeople who have not yet reached the action stage do better in the CT programme andwomen with repeated dieting failures are predictably ambivalent about the usefulness ofaction strategies. The CT programme may help to prepare individuals for change, e.g. by54talking about advantages to remaining fat, disadvantages to being thin, ways their Lives willchange in terms of relationships with others and with food. Perhaps such work can beconceptualized along the Motivational Interviewing method (DiClemente, 1991) and helpsto move people into readiness for action. If so, then individuals in the contemplation andpreparation stages could be anticipated to specifically benefit from the programme. Such acontention is consistent with research showing that treatments mismatched to anindividual’s stage of readiness to change do not produce favourable results. For individualsat the precontemplative and contemplative stages of change, action-oriented treatmentsmay be ineffective or detrimental (Prochaska, DiClemente et al., 1992). As an example,Prochaska and colleagues discuss findings from a special self-help smoking cessationprogramme for pregnant women (Ershoff, Mullen & Quin, 1987, cited in Prochaska,DiQemente et al., 1992). For women prepared for action, the special care programmeproduced significantly greater success (38% not smoking by the end of pregnancy) thandid the regular care programme of advice and fact sheets (12% success rate). However,for women at the precontemplative and contemplative stages, the two treatments failed toproduce differential effects. By the end of pregnancy, only six percent of the women in thespecial care programme, as well as six percent of women in the regular care programme,were not smoking. Such findings are consistent with the idea that individuals not yetprepared for action regarding weight loss may have obtained greater benefits from the CTprogramme than from the action-oriented BT programme.While the CT programme may be particularly beneficial for individuals at preaction stages, it also contains therapeutic elements which are clearly action-oriented.Although the rationale given is for reasons of well-being, rather than for reasons of weightloss per Se, exercise and nonchaotic, low fat eating are discussed and encouraged in theCT group (albeit, to a lesser extent than in the BT group). Therefore, at leasttheoretically, individuals already at the action stage can be anticipated to benefit from theCT programme as well. In contrast to the wide applicability of the CT programme, the BT55programme, with its exclusive focus on weight-related behaviours, i.e., diet and exercise,would be beneficial only for individuals already at the action stage. if people present fortreatment at various stages of readiness for change, from contemplation through to action,the BT programme would be expected to be of benefit for fewer morbidly obeseindividuals seeking treatment than would the CT programme. That the BT group had lessconsistent effects, even in terms of weight loss alone, is suggested by the higher standarddeviations observed for this group (4.15 kg) than for the CT group (2.29 kg). However,for persons truly at the action stage with respect to weight loss, the BT programme withits directed focus may offer greater benefits.The presence of a significant treatment group by depression interaction, in terms ofimprovement in depression, anxiety, self-control and eating-related psychopathology,suggests that depression is also contributing to the differential effects of the CT and BTprogrammes. Whereas the CT and BT treatments produced similar effects for individualswho were not highly depressed, severely depressed CT subjects showed greater benefitfrom treatment than did severely depressed BT subjects (see Figures 5.1-5.4). Indeed, forseverely depressed BT subjects, state anxiety and self-control scores worsened during thecourse of treatment. While part of the effect observed iii the depressed CT subjects mayreflect the regression of extreme scores towards their means, the data also suggest that theCT and BT treatments have a differential impact on depressed individuals.Consistent with the observed difference in treatment impact are affect regulationmodels which posit that eating disorder symptomatology can reflect an attempt to copewith or regulate negative affect (Grilo, Levy, Becker, Edell & McGlashan, 1994;Heatherton & Baumeister, 1991). Normal weight children show a preference for nonfoodrewards and activities (as opposed to food-related items and activities) whereasoverweight children show no such preference (Bonato & Boland, 1983). Moreover, thesesame authors report that when an edible reward is offered, relative to normal weightindividuals, obese subjects show an inability to delay gratification. Considered together,56these findings are Consistent with the idea that food may have greater significance forpeople with eating/weight-related problems and that such individuals may preferentiallyuse food to modulate mood. For individuals who are using food as a means of affectregulation, removing this method of coping (i.e., by limiting intake) may result in apararloxical effect and exacerbate feelings of depression and anxiety, and diminishperceptions of self-control. It is possible that this occurred for some individuals in the BTgroup as these participants were strongly encouraged to restrict intake (i.e., their currentmeans of affect regulation may have been eliminated) and no replacement copingstrategies were provided. In contrast, no emphasis to reduce intake was placed on CTgroup members. Moreover, replacement affect regulation skills such as muscle relaxation,alteration of depressogenic cognitions, assertiveness skills etc. were taught to CTparticipants. Researchers such as Heatherton and Baumeister (1991), who posit affect-regulation motives to persons who overeat, assert that individuals who use food to avoidself-awareness do so because they evaluate themselves negatively. Focus on a negativelyevaluated self is assumed to produce an aversive internal state, In contrast, focus on a selfwho is positively evaluated does not produce an aversive state and thus does not need tobe avoided. Therefore, it is reasonable to assume that the increase in self-likingexperienced by CT subjects (e.g., as evidenced by decreased body dissatisfaction scores)makes self-awareness less aversive. And, if the underlying motive for escape, and thus forbingeing behaviour, is removed, it logically follows that overeating may decline withoutaccompanying increments in anxiety, depression or perceptions that one is lacking in self-control. Although the present data do not permit identification and analysis of scoresbelonging to individuals using food as a means of affect regulation, the pattern of negativeoutcomes is consistent with this idea. Although not statistically different (most likely dueto the small n), mean BDI, STAI and SCS scores of individuals showing deteriorationover the course of treatment (see Table 6) support this idea. Within this group of subjects,deterioration in each of the above scores is greater for BT than for CT or Control57subjects. In terms of the numbers of subjects for whom treatment produced negativeeffects, no differences appear to exist between the groups. Also consistent with the ideathat some BT subjects may have perceived themselves as losing an important means ofaffect regulation, is the deterioration during treatment in state anxiety and self-control forBT subjects who were seriously depressed at treatment onset (and thus, presumably, inneed of affect regulation).Thus, for a plethora of possible reasons, treatment impacts differentially acrosssubjects. Neither the clients who seek help for problems of obesity, nor the treatmentmethods available, are homogeneous. Treatment is most apt to be successful when itaddresses the particular needs of the individual. It appears that the CT and BT treatmentsproduce differential effects as a function of depression and possibly also as a function ofreadiness to change. Accurate identification of those variables which predict positiveresponse to specific treatment programmes will facilitate the matching of client totreatment and enhance therapeutic outcomes. For example, DiClemente (1991) notes thatpeople seeking treatment are often not aware of the positive functions which theiraddictive behaviours serve. As such, they may lack conscious awareness regarding theirown ambiguity towards change. hi such cases, individuals are most likely to benefit fromtreatment when they can be specifically assigned to programmes which commensuratewith their degree of readiness to change. Indeed, White and White (1988) state that therelatively disappointing results of behavioural weight-reducing programmes is, in part, dueto the inability to identify individuals for whom behaviour therapy is the treatment ofchoice.ExerciseThe proportion of CT subjects exercising regularly (i.e., at least three times perweek) increased significantly over the eight weeks of the study, an important behaviourchange, given the benefits (emotional and physical) conferred by regular exercise. There58was a marginally significant increase in the proportion of BT subjects exercising (p=.O63)An interesting comment was volunteered by one of the CT participants who had embarkedupon regular exercise for the first time in her life. She noted that when she beganexercising at the beginning of the programme, she did so only because she had been told toand she found it most unpleasant. By the end of the eight weeks, she reported that, muchto her surprise, exercise was now an important and enjoyable part of her life. Moreover,she noted that nowhere amongst the forms which she had completed, had there been aquestion which addressed this issue. This was indeed true and something which definitelyneeds investigating as such a perceptual change may be an important marker for long-termadherence to exercise in these women.Previous reports indicate that regular exercise confers many benefits, bothpsychological and physiological (e.g. Dubbert, 1992). The current findings show aconsistent, but statistically nonsignificant, pattern wherein women who reported exercisingregularly tended to show greater psychological improvement and weight loss. Ofparticular interest is the improvement fri body satisfaction for women who were exercisingregularly. This is consistent with spontaneously offered reports from some women thatwhereas in the past they had evaluated their bodies in terms of comparison with aparticular aesthetic ideal, they had now begun to evaluate their bodies in terms of its abilityto perform for them (e.g. enable them to walk, swim etc.).Body MassCT and BT subjects lost a significant amount of weight from pre- to posttreatment. Such findings are consistent with reports from the literature indicating thatbehavioural treatments are effective in promoting weight loss (e.g., Wing, 1993).Although the average amount of weight lost by CT and BT subjects was notstatistically different, there did appear to be a different pattern of weight loss between thetwo groups. BT subjects lost an average of 2.6 kg. However, the range of weight change59was substantial: from a gain of 3.4 kg to a loss of 10.0 kg. In contrast, while the meanweight loss was similar overall for the CT group (1.8 kg), the range did not show suchgreat variation. The greatest gain for a CT member was 2.3 kg and the greatest loss, 5.0kg. The variation in weight loss in the BT group is consistent with the therapist’s report ofsubstantial individual difference in initial subjective response to the type of treatment.Some individuals refused to be “put on” a diet (“that’s die with a t”). Interestingly, whilethey continued to attend the group, their compliance with homework exercises was verypoor. It appeared that their initial displeasure with the treatment regime resulted in overallapathy/antipathy for the treatment. It is possible that this type of resistance to treatmentreflects a lack of readiness to change. BT participants not yet at the action stage ofchange, may have refused to engage in behaviours apt to bring about decrements in weightuntil they were sufficiently prepared for such changes.While exercise may have contributed to weight loss in both CT and BT subjects,other mechanisms may also be responsible for bringing about changes in weight.Moreover, these mechanisms may differ between the two groups. It is interesting that theCT programme, which was not directly aimed at weight loss, nonetheless produceddecrements in weight. This is likely due, at least in part, to increased interoceptiveawareness, i.e., people in the CT group learned to identify appetitive and satiety cues.Consistent with this hypothesis is a post-treatment improvement on the interoceptiveawareness scale of the EDT. Likewise, a decrease on the bulimia subscale of the EDT forCT subjects suggests diminished bingeing. If subjects were overeating in response toother problems such as depression and anxiety, then reductions in psychological distresscan be hypothesized to contribute to weight loss, via reductions in overeating. Such acontention is consistent with the idea that pathological eating may act as a form of affectregulation for some people (e.g. Heatherton & Baumeister, 1991). Thus, it is reasonableto expect decrements in eating pathology and weight when distressed individuals receive60psychological treatment aimed at reduction of depression and anxiety, since some of theunderlying reasons why they are overeating are being removed.BT subjects lost significantly more weight than control subjects. Clearly, as withCT subjects, exercise may have contributed to the weight loss observed m BT subjects.Enhanced Interoceptive Awareness scores for CT subjects suggests the possibility thatthese subjects may be recognizing the difference between physiological and emotionalhunger and may simply be choosing not to eat when they do not feel physically hungry. Incontrast, it does not appear that such a change contributed to the weight loss observed inBT subjects, as they did not show significant improvement in Interoceptive Awareness.Likewise, although BT subjects did show a nonsignificant trend toward lower depression,overall, they evidenced very little in the way of enhanced psychological well-being. Thus,while generalized psychological improvement may, in part, be responsible for a decrementin overeating and subsequent weight loss in CT subjects, it is unlikely to be making amajor contribution to the weight loss evidenced by BT subjects. By post-hoc process ofelimination, one is left with the interpretation that BT subjects may have achieved themajority of their weight loss by active intake restriction. It is reasonable to contend thathypervigalence regarding food, especially in conjunction with perceptions of low self-control, may account for the increase in state-anxiety observed in BT subjects.As noted previously, no relation between amount of weight lost and depressionwere found for either the group of subjects as a whole or for BT subjects alone. For BTsubjects, whose treatment focused on weight loss, the lack of correlation between weightloss and depression is somewhat surprising as weight loss is reportedly very rewarding formost overweight individuals. Perhaps individuals did not consider their relatively smalllosses in weight as rewarding since (1) in their previous experiences these losses wereoften of short duration and (2) a five pound weight loss does not translate into visuallysalient change. A significant correlation between weight loss and post-treatmentdepression score, but not between weight loss and change in depression, was found for CT61subjects. This suggests that it is not the actual decrease in weight which brings about thechange in depression. It may be that in the context of the CT programme, a third variable(e.g., exercise or enhanced self-control) contributes to both the level of depression post-treatment and to weight loss.LimitationsFinally, limitations to the current work must be considered. Internal validity inStudy 3 is limited by the fact that treatment type was confounded with therapist. That is,one therapist conducted the BT groups while another conducted the CT groups. Theinfluence of individual therapist styles was, in part, controlled for by the fact that thetherapist for the BT programme followed a prewritten agenda and used apsychoeducational format which did not encourage self-disclosure and group discussion.While this situation was unavoidable in the current study, i.e., there was a lack of funds topay independent therapists, and the writer was not impartial enough to deliver the BTprogramme, the confounding of therapist with treatment is a concern. Future research withother therapists will be necessary to ensure that the differential results obtained were notattributable solely to therapist variables.External validity or generalizability is also subject to certain constraints. This studywas conducted in a university research setting which may have enhanced the participants’belief in treatment efficacy in a manner which might not have occurred had the programmebeen conducted in a private setting. This argument is mitigated somewhat by findings fromStudy 2. Although Study 2 was conducted in a hospital setting as a clinical (vis a vis aresearch) programme, participants showed substantial improvements post-treatment,which were similar to those observed for participants in Study 3. That results from Study2, as well as the results of both CT and BT groups in Study 3, are based on data from twoseparate therapy groups helps to increase the generalizability.62The lack of long-term follow-up data represents another limitation of the currentstudy. Obesity is clearly a chronic condition and as such requires long-term monitoring.While data from the subjects in this study wifi continue to be collected, the availablefollow-up data, i.e., those obtained six months post-treatment, are difficult to interpret.Only just over half of the subjects completing treatment provided follow-up data, Overall,analyses of the pre, post and follow-up data, from subjects who completed the six monthfollow-up, revealed very few statistically significant changes. However, these subjectsrepresent a self-selected subgroup; they differ from the group as a whole in terms of pretreatment eating-related psychopathology and possibly in other ways as well. Thus,extrapolation of the findings from this subgroup to subjects in general is not justified.Furthermore, reduction in statistical power, due to the fewer number of subjects, may alsohave contributed to the lack of statistically significant findings.While follow-up with clinical populations is generally problematic, the particularfactors accounting for the current low response are not known. It is impossible to know towhat extent a systematic bias is operating in terms of which subjects are complying withrequests for follow-up data. One possible difference between individuals who did and didnot provide follow-up data concerns continued group support. Nine of the CT and threeof the BT subjects providing follow-up data reported continuing to meet with theiroriginal group members. Whether or not individuals not complying with follow-up are alsoa part of these groups is unknown. While it can be hypothesized that subjects whoperceive themselves as doing well are more likely to respond to follow-up, since thinkingabout, and reporting on, eating/weight-related issues is presumably less distressing forsuch individuals, it can also be argued that subjects who perceive themselves as doing lesswell, may be more apt to comply in hopes of reestablishing a therapeutic connection.Subjects in Studies 2 and 3 did not pay for the therapy they received and thus maydiffer from individuals paying for treatment. While individuals paying for therapy aremore likely to feel invested in their treatment and thus, perhaps, to work harder, it is also63conceivable that some clients would not have continued with a treatment, for which theywere paying, which was not producing the desired effect (i.e., weight loss). However,anonymous treatment evaluation forms completed by BT and CT participants indicated ahigh degree of satisfaction with both types of treatment and thus lessens this possibility.The other limitation to generalizabifity concerns the client population. This studyselected women with a minimum 10 year history of obesity who had engaged in at leastthree prior, serious attempts at weight loss. It is conceivable that similar results would nothave been obtained had the clients not had such histories. For example, a woman who haslost and regained weight multiple times may not respond to an initial weight loss with adiminution in depression. For a woman who is only 10 kgs overweight and who has neverbefore managed to lose weight, an initial drop in weight might well enhance her affectivestatus. Similarly, women who have struggled with their body images and deteriorations inphysical health for many years are apt to be more motivated, ready to give up the dietmyth and perhaps, prepared to work harder. On the other hand, they may also be evenmore resistant to treatment.The subjects in this programme of research have been exclusively female. Howmen would respond to such a programme is not known. The issues facing men who areoverweight differ from those facing women. White and colleagues (1991) report that,amongst a sample of adolescents having high relative weights, 90% of females, but only49% of males, were rated by judges as being overweight based on visual inspection. Suchperceptual discrepancy may in turn influence whether an individual is treated prejudiciallyand thus may result in excess weight having a differential impact on men and women.Indeed, the social and economic consequences of excess adiposity are greater for womenthan for men (Gortmaker et al., 1992). Conversely, as obese men are typically at greaterrisk for cardiovascular diseases than are obese women (Bjorntrop, 1992) their obesity mayresult in increased anxiety regarding physical health or death. Regardless of the specifics,64given the differential effects of excess weight on men and women, extrapolation of thecurrent findings to men is not justified.Clinical Observations, Implications and Future DirectionsTo protect against threats to internal validity, subjects in Study 3 were randomlyassigned to treatment condition. While random assignment is perhaps a necessary firststep in a programme of research, it is not without its price, for the cost of such controlcomes at the expense of external validity. In clinical settings, individuals seek outtherapists and treatments which are compatible with their beliefs, previous experiences etc.In this area of research, many individuals have spent lifetimes dieting and the meresuggestion of this strategy can create a resistance so strong that it makes further work orprogress very difficult. For other individuals, the nondieting approach lacks structure.They feel deeply uncomfortable without a framework to guide their eating. The success ofany type of psychotherapy is highly dependent upon client characteristics; the recipient ofpsychotherapy is not a passive player in the process (Bradley, 1993). Thus, an importantfuture step will be to investigate the influence of client preference and treatment selection.One way to examine this would be to allow one group of subjects to self-select either theBT or CT type of treatment programme. A second group of subjects could be randomlyassigned to the two groups. Comparisons between assigned and self-selected subjects onoutcome variables such as depression, amount of weight lost, treatment satisfaction,number of drop outs etc. could prove enlightening, and help to identify the types of clientswho respond most favourably to each type of treatment. It is quite possible that arandomized, controlled trial such as that employed in Study 3 systematicallyunderestimates potential benefits. That is, appropriate matching of client to treatment mayenhance apparent treatment efficacy. The question needs to be what treatment for whatclient under what circumstances? It is foolhardy to think that an unqualified statementsuch as Treatment X is superior to Treatment Y is any longer sufficient in the realm of65psychotherapy. Psychotherapy differs m too many important ways from the double blind,placebo controlled drug trials upon which we have largely modeled our earlier outcomestudies, It is simply not possible, nor particularly desirable, to have therapists and clientsunaware of the treatments they are implementing and receiving.Specific client variables suggested by the current work as predictive of differentialresponse to the BT and CT programmes should be empirically assessed in future studies.As noted above, the presence of significant depression may predict a poor response to aBT type programme. In contrast, depressed indlividuals appear to do better in the CTprogramme. Despite presenting themselves for treatment aimed at weight loss, many obesewomen actually manifest ambiguous feelings regarding weight. For example, issuessurrounding sexual abuse, incest as a child, stranger rape as an adult, and physical abusewithin a marriage were repeatedly brought up for discussion in the CT programme. Thewomen for whom these were issues, felt them to be a significant part of their weightproblem. While the current data certainly do not speak adequately to such issues, it isinteresting to note that many of these women felt it “unsafe” to lose weight as this would,in some ways, increase their vulnerability. Yet, they recognized that a part of them wantedto lose the weight, usually for both health and appearance reasons. It seems likely that forindividuals still grappling with such indecision, a CT type programme which addressesthem directly would be more beneficial. This is but one of the many client characteristicswhose influence awaits empirical examination.Although the current programme of research focussed on the psychosocial factorsinvolved in obesity, there is great need for research which integrates psychosocial factorsand biological variables. One such area of particular interest involves interactions betweenpharmacological and psychological treatment modalities. Selective serotonin (5-HT)reuptake inhibitors (SSRI’s) such as fluoxetine (Prozac), which increase synaptic serotoninare effective in alleviating depression (e.g. Pande & Sayler, 1993) and decreasingovereating and promoting weight loss (Nathan, 1992). Furthermore, such drugs are also66purported to enhance social interactions and decrease interpersonal timidity and rejectionsensitivity (Kramer, 1993). In monkeys, changes in behaviour, such as increasedassertiveness, are associated with increases in 5-HT (e.g. Raleigh & McGuire, 1991).Perhaps certain behavioural changes encouraged in the CT group (e.g. increased activityand assertiveness) altered serotonergic transmission which in turn had an impact on eatingand mood. That monkeys given 5-HT-enhancing drugs and 5-HT-depleting drugs showincreased dominance and submissive behaviours, respectively (Raleigh & McGuire, 1991),suggests that alterations in 5-HT transmission, (perhaps due to factors such as increasedacceptance and the interpersonal interactions experienced in the treatment group), acted tomoderate eating and assertiveness behaviours. But, irrespective of the direction ofcausality (and most realistically, it appears to be bidirectional [e.g. McGuire & Raleigh,1986]), investigations of interactions between the effects of SSRIs and psychologicalmodes of treatment are needed. Do persons stabilized on drugs such as Prozac showsuperior response to treatments such as the CT programme or are the effects of suchprogrammes washed out by drug effects? Are gains made by persons completing apsychological programme while on SSRI’s lost when medication is terminated? SSRI’s,unlike their tricyclic predecessors, are not associated with weight gain. Consequently, theavailability of these compounds has made pharmacological management of depression inobese women a feasible, and frequently elected, treatment option. Thus, questionsconcerning interactions between SSRI’s and psychological treatment modalities areparticularly germane.Summary and ConclusionsThe above three studies indicate that women seeking psychological treatment formorbid obesity tend to manifest problems such as depression, anxiety, perceptions ofdeficits in self-control and elevated levels of eating-related psychopathology. Results fromStudies 2 and 3 indicate that a nondieting programme aimed at improving emotional well67being and adopting healthful lifestyle behaviours such as exercising regularly and eatingnonchaotically is effective in promoting exercise adoption and significantly reducingpsychological distress as well as body weight. Unfortunately, the available data do notpermit conclusions to be drawn regarding long-term outcome.Given the myriad difficulties which face seriously overweight women and researchfindings which suggest that the majority of morbidly obese women will not maintainnormative weights, it is important that such women learn to live healthily in the present,enjoying their lives in the here and now, rather than waiting indefinitely for the thin futureof their dreams. As Freedman (1988) so aptly states in her book Bodylove, ‘tYou have aright-and a responsibility-to judge yourself according to realistic standards, a right to feelcomfortable in your own skin”. Even if these women are never to lose substantialamounts of weight, there is simply no reason why they must also remain unhappy andphysically unfit for the remainder of their lives.68Appendix ICognitive Therapy Treatment ManualParticipant Handouts69WEEK ONEWelcome, tonight we will be discussing the following:The goals and structure of the programme;The importance of group support and how best to obtain it;The need for homework;Required readings:The New Fit or Fat by Covert BaileyBreaking Free from Compulsive Eating by Geneen Roth.Overcoming Overeating by Jane Hirschmann & Carol Munter.Optional reading:Your Perfect Right: A Guide to Assertive Behavior by Robert Alberti & MichaelEmmonsWhen Food is Love by Geneen RothExercise.ExerciseWhy? To burn calories and alter metabolism; for overall health and a generalized sense of wellbeing.What? Decide on two forms of aerobic exercise, preferably, one of which can bedone indoors; e.g. walking, running, rowing, biking, aquasize, stairclimbing, swimmingetc.When? Ideally you should engage in at least 20 minutes of aerobic exercise daily.As a minimum, you should be doing some aerobic exercise at least five times a week.How? Slowly, gradually. Be gentle with yourself, think positively and work hard.Suggest some ways to increase the likelihood of your success. For example, makingarrangements to exercise with someone else who is at about your fitness level.Exercise Self-EfficacyMany people, especially those who are overweight, believe in their heart of hearts that they cannot be “exercisers”. Nothing could be further from the truth. Unfortunately, that attitude alonecan be detrimental. Studies have shown that among people who are equal in terms of weight,physical fitness etc. those that “believe” they can successfully exercise, are much more likely tobe successful in adopting a new physical activity regime, than those who are very uncertain thatthey can do this. What I want you to know, is that many other women, equally overweight,equally fit or unfit have successfully begun exercising. It takes planning, dedication and70perseverance. Start trying to think of yourself as someone who is physically active, imagineyourself walking around the block, riding a bike etc. Have frequent conversations with yourself.Tell yourself that you can exercise regularly. Try to be specific e.g. I can walk briskly around theblock for 10 minutes every day this week at 3 o’clock.To begin: First of all warm up your muscles with slow to moderate walking, biking etc. Thenstretch - no bouncing - for about 5 minutes. Your goal is to engage in 20 minutes of aerobicexercise, i.e. activity during which your heart rate is in its target zone (65 to 85% of itsmaximum). Its best to stay at the low end, at least initially. When you have completed youraerobic workout, spend a few minutes cooling down. Do some light exercise, e.g. slow walkingetc. and stretching.Target heart rate per minute:.65 X (220 - your age) to .85 X (220-your age).Target heart rate per 10 seconds (the above two numbers divided by 6)The level at which you begin wifi depend upon your current level of fitness, The most importantthing is to begin doing some physical activity. The “no pain, no gain” school of exercise ismasochistic and perpetuated by jocks; it results in injuries and abandonment of planned exercise.If you can do only 2 minutes of walking at a time, that’s fine. Do it 4 times a day and add 30seconds to each session every day. A little sweat is fine, but no agony or crutches please!Perseverance is the key. According to most people, it takes between two and six months tobecome “hooked” on exercise. The idea is that regular exercise will become a way of life foryou. If this is to happen, it is important that the activities you choose are enjoyable, or at leastpotentially enjoyable for you. Try to think of ways you can increase the enjoyment associatedwith exercising. For example, working out with a friend, buying a new pair of running shoes etc.It will require hard work and dedication to get yourself “over the hump” to the point whereexercise is intrinsically rewarding, but it does happen.Insensible Exercise - This refers to small amounts of physical exercise which are obtained duringthe course of the day but are not primarily intended as such, e.g. taking the stairs instead of theelevator, parking further from your destination and walking, standing instead of sitting etc. Thistype of exercise burns calories, but does not significantly improve cardiovascular fitness.71HOMEWORKRecord all food intake during the coming week and include a brief description of thesituation, whether you are alone or with others, any associated emotions and thoughts.Towards the end of the week examine your record and try to discern whether particularpatterns to your eating exist: e.g. overeating following fights with your partner or alwayssnacking from 2:00 to 3:00 before the children get home from school. Bring your recordwith you to next week’s meeting.2. Read Fit or Fat.3. Think about an exercise programme for you. Choose 2 aerobic activities that you thinkyou could do and enjoy, e.g. bike riding, walking, swimming. In choosing your activities,consider whether you would prefer to exercise alone or with someone. Think about yourdaily routine carefully and decide on a time or times when you can exercise, Write thesedown. Next spend some time thinking about things which are likely to hinder yourexercise success, e.g., sleeping in late if you planned to exercise in the morning beforework. Write these down on the left hand half of a piece of paper. Next to these, on theright hand side write down ways of overcoming each potential obstacle you identified.For example, if you slept in, perhaps you could plan to exercise on your lunch hour orafter work. Bring your list with you next week.4. Purchase any equipment necessary for your chosen activities, e.g. a swimming suit orrunning shoes.5. Exercise at least once during the week.72WEEK TWOReview Homework:Questions, problems with Fit or FatExercise: successes, problems, comments...Food diaries - what patterns of eating emerged?Nondieting ApproachTonight we’ll talk about the rationale for this approach and some ideas about how to implementit. We’ll also talk a bit about actual nutritional requirements, food preparation etc.Dieting does not work!The current success rate for weight loss maintenance after five years is approximately 5%. Thereis clearly little in the diet industry for people needing to lose weight. There is however a lot ofmoney for those involved in the industry. They have a vested interested in making sure we usetheir services over and over...The Minnesota StudyIn the 1940’s a classic study of the effects of food deprivation was conducted at The Universityof Minnesota. Healthy men ate half their usual intake for six months. These men becamepreoccupied with food. They began reading cookbooks, collecting recipes. Some entered intofood-related occupations. This deprivation also resulted in bingeing, impaired concentration andmemory, loss of interest and motivation to engage in previously engaged activities, depression,mood swings, irritability, anxiety, apathy, sleep disturbance, The metabolic rates of these mendecreased by an average of 40%. Their metabolic rates improved when they were refed. Thebiggest increases in metabolism were observed in those eating the most.Nondieters regulate their food intake differently than dieters. When given the opportunity to eatwhatever amount she wants, a nondieter will eat less if she has just had a carbohydrate load(e.g. a milkshake) than if she has had nothing to eat before. In contrast, a dieter will eat morewhen given the opportunity if she has just had a carbohydrate load than if she has had nothing.Furthermore, depression, anxiety, and alcohol intake all increase eating in dieters.Bingeing is precipitated by physical (i.e. nutritional) and emotional deprivation. The way toavoid nutritional deprivation is to feed yourself regularly. Emotional deprivation is avoided bynot forcing yourself to give up foods you love. Instead, choose to eat anything in moderation.Nutritional deprivation can be habit forming. It is the process (dieting) not the substance (food)that is addictive. You tend to lose control because you are deprived and not because you areaddicted to a particular food.I hope I’ve convinced you that in the long run dieting doesn’t work. You’re here because yourpast attempts to lower your weight have not been successful. Be a risk taker. This time trysomething different. Look at this as an experiment, if it doesn’t work out after a reasonableperiod, you can always go back to your previous methods.73The nondieting approach takes time (months, years). Your weight problem didn’t developovernight. Unfortunately, the solution will also take time, Be patient with yourself. Try toremember that what you are doing is implementing life style changes that will hopefully stay withyou for the next twenty, fifty years.We eat for so many reasons other than physical hunger, that it is often very difficult for us todetermine when we are truly hungry and require food. Part of nondieting is relearning how toidentify when you are physically hungry and how to eat appropriately. Because this takes time, itis best to begin eating in a mechanical fashion. Have breakfast no later than an hour after youawaken. Eat lunch 3-4 hours after your first meal and dinner in the early evening. Meals shouldbe treated like medicine and given the highest priority in your day. Do not skip meals: this setsyou up for bingeing. Would you fail to give your best friend, child or partner the medicine theyneeded three times a day if it meant their recovery from a “disorder” that made them unhealthyand unhappy. If not, why should you treat yourself any less well? Plan snacks for in betweenmeals.Sometimes those we love the most and who love us the most contribute significantly to ourproblems. This often happens because they recognize there is a problem but do not know howto help. Thus, they resort to doing things that are anything but helpful. Be frank with people inyour life. Tell them that you are trying a “scientifically based” approach and that the mosthelpful thing they can do is to “butt out”. This includes not making comments about what foodsyou are eating, your weight etc. If there are concrete ways in which they can help you, e.g.watching the children while you are exercising, joining you in an exercise programme etc. tellthem.Rebelliousness arises when we perceive our choices as being limited, i.e. we start to feel backedinto a corner. This can happen when we have rules imposed upon us, either by ourselves or byothers. Therefore, it is imperative that you and others quit dictating rules. Setting up strict rulessimply makes us want to break them.As you learn to listen to your body you can eat in response to cues of physical hunger. For now,control overeating by using the following techniques:1. Eat regularly.2. Do not forbid yourself any foods.3. Have a prescribed eating place. Keep and eat food only in this area. Try not to do otherthings in this area. This is known as stimulus control. Frequently we “learn” to eat whenconfronted with situations in which we have eaten in the past, e.g. in front of the T.V.Therefore try to break these associations or habits, but limiting the cues associated witheating. Eat only in this area, not in the car, bedroom etc.4. When eating in your prescribed eating place, set a place, put your fork down betweeneach bite and pause for a few seconds, enjoy your food, take a 3 minute break in themiddle of your meal.745. Remove serving bowls from the table.6. Leave the eating area when finished meal.7. Distract yourself after a meal, e.g. call a friend, take a walk.8. Give yourself other pleasures. What things are pleasurable for you? A long bath, amovie, writing in a journal, listening to music? Make up a list of activities that youenjoy.9. Treat each meal as an independent event. You choose to ‘start fresh” at the beginning ofa new week or a new day. You can just as easily choose to start fresh each time you eat.Don’t let how you eat now be influenced by how you ate earlier in the day.10. Use coping phrases such as the following to talk to yourself*:“The urge to eat is strong now, but I know it will decrease to a tolerable level in a littlewhile so I can just ride it out.”“One reason I want to keep eating is because my stomach is not yet signaffing to me thatI am full. In an hour or so I will feel full and satisfied; so, I don’t have to continue eatingnow.”“I know I get confused between real emotions and urges to binge eat. The urge I feelnow is not physical because I have nourished myself with regular nondieting meals.*Taken from The Road to Recovery: A Manual for Participants in the Psychoeducation Groupfor Bulimia Nervosa by Ron Davis et al.75NutritionThere are three basic “chemical” components which make up our diets:1) Carbohydrates - These include simple sugars such asglucose and complex carbohydrates such as apples and breads. Carbohydrates areused as fuel by the body. Under normal circumstances, glucose is the brain’s onlysource of energy.2) Proteins - are comprised of amino acids. These are the body’s building blocks.We require protein for hair growth, muscle development, tissue repair etc.3) Fats - or lipids. These are used by the body for making cell membranes andinsulation. Each gram of fat contains 9 calories, approximately double the amountcontained in proteins or carbohydrates.We frequently talk about the food groups from which we derive the above nutrients. The fourfood groups include:1) Fruits and vegetables2) Dairy products3) Meats, fish, poultry4) Breads and grainsWe need products from each of the above groups to be healthy. I have attachedrecommendations from the Canada food guide to give you some idea of nutritionalrequirements. Even when one is attempting to lose weight, nutritional requirements should bemet. This is important because when the body is nutritionally deprived, one begins to experiencecravings for the missing substances. Also one risks breaking down protein (i.e. muscles) tosupply the needed nutrients.CARBOHYDRATESIt is important to eat an adequate amount of complex carbohydrates. Complex carbohydrates, asopposed to simple sugars, take longer to digest and do not result in such extreme swings friblood glucose levels. In addition, the guide recommends increasing your intake of fibre.PROTEIN REQUIREMENTS AND VEGETARIANISMWe require approximately 60 grams (2 ounces) of protein a day. Most North Americansconsume an excessive amount of protein. It is however important to eat an adequate amount ofprotein to permit muscle development. Proteins are made up of amino acids. There are 9“essential amino acids”. These are amino acids which the body is unable to make and which musttherefore be obtained in the diet. Dietary amino acids are necessary for protein synthesis andsubsequent muscle growth. Meats, poultry, fish, eggs and dairy products contain all 9 essentialamino acids. In contrast, plant products (legumes; cereals - rice, wheat, corn; and roots) aremissing one or more of the essential amino acids. People who choose not to eat animal productsneed to ensure that they obtain sufficient protein from these other sources. Because the bodycan not store large quantities of amino acids, the different essential amino acids need to be76consumed together to enable the body to synthesize proteins. A combination of cereals andlegumes wifi ensure that you are obtaining the essential amino acids. For example, lentils andrice or baked beans on toast.DIETARY FATThe one specific dietary recommendation I would make is to decrease your intake of fats. This isfor a number of reasons. First of all excessive dietary fat can increase your cholesterol. Increasesin blood cholesterol levels increase your risk of heart attack and stroke. Secondly, fats containdouble the amount of calories as do carbohydrates and proteins. Thirdly, dietary fats areconverted to bodily fat with 25% greater efficiency than carbohydrates. Therefore, you wifi gainmore weight when you eat an equal number of calories from fats than when you consume thesame number of calories from carbohydrates. Furthermore, people who decrease fat intake tendnot to compensate completely in their caloric intake and thus lose weight.At present the average Canadian obtains 40% of her calories from fat. The National Academyof Sciences recommends that calories derived from fats constitute only 20- 30% of our totalcaloric intake. There are 4 main types of dietary fat:1. Saturated fats- are obtained mainly from animal products such as meat, millcbutter and cheese. Coconut and palm oils are also high in saturated fats.Saturated fats increase blood cholesterol. Therefore you want to limit your intakeof these fats.2. Polyunsaturated fats - these fats come primarily from fish; nuts like almonds,pecans and walnuts; vegetable oils like safflower, sunflower and corn oil.Polyunsaturated fats help to decrease blood cholesterol.3. Omega-3 fats - these help to lower triglycerides, a type of blood fat involved inthe development of heart disease. Omega-3 fats are a type of polyunsaturated fatand are found in fish oil and canola oil. Therefore increasing your intake of fishcan be very healthy.4. Monounsaturated fats - help to lower blood cholesterol. These fats are found inolive, canola, peanut and soya oils.The first step to decreasing fat intake is being aware of where/how you consume fats. Fats canbe found in almost all types of prepared food. If eating high fat content foods is normal for youit wifi take time, planning and effort to change this. As always, it is easy to slip back to oldhabits unless alternatives are readily available. Therefore, it is important that you examine youruse and intake of fats and make arrangements to adopt new ways. This involves making aconscious choice, buying alternatives and learning to cook in new ways etc.77The following are a few ways to decrease fat use:1. Buy a low fat cookbook. Books recommended by the Heart and Stroke Foundationinclude: The Light-hearted Cookbook by Anne Lindsay (Toronto: Key Porter Books,1988) and Light-hearted Everyday Cooking by Anne Lindsay (MacMifian Canada,1991).2. Prepare foods in ways other than frying: steaming, microwave, broiling. For everyteaspoon of butter, oil or margarine you eliminate you save 4 grams of fat.3. Buy a nonstick frying pan, so you dont need to add extra oil or butter.4. Consider using a wok and cooking oriental style foods.5. Use spices or condiments such as soya sauce to flavour foods instead of gravies and richsauces.6. Use a small amount of jam instead of butter on toast.7. Skip the mayonnaise or butter on sandwiches; you may not even notice it is missing.8. Whip butter or margarine so that it spreads further.9. Use skim or 2% milk instead of whole milk or cream.10. Use yogurt instead of sour cream.11. Choose “light” products with less oil e.g. mayonnaise, salad dressings etc.12. Watch your use of cheese which can be very high in fat. Use skim milk cheese wheneverpossible.13. Choose tomato sauces instead of cream sauces on pasta.14. If you eat meat, choose lean cuts. Consider decreasing the amount of meat you use.15. Remove skin from chicken.16. Choose sherbet or frozen yogurt instead of ice cream.17. Have a whole wheat bun instead of a croissant.18. Try alternate foods. For example, if potatoes seem unpalatable without 3 Thsp of buttertry eating rice.19. Try some new foods: Do you eat lentils or dal? What new vegetables would you like totry? Plant protein is generally lower in fat than protein from animal products. Trydecreasing the amount of meat you eat. Be adventuresome! Talk to friends who arehealthy and eat well. Ask for their ideas, recipes etc.20. Keep low fat foods readily available. For example, keep cut vegetable sticks in the fridgeso that when you’re hungry it is as easy to eat them as it is to eat a bag of potato chips.21. Prepare your own foods. Decrease oil called for in recipes and replace with othermoisture e.g. yogurt or apple sauce in muffins.22. If you are eating out, choose menu items with the smart heart symbol.Other ideas for decreasing fat intake78What obstacles stand in your way to consuming less fat? Does your partner refuse to eatanything that is not deep fried? Will it be difficult for you to fmd the time necessary to preparenew foods in different ways? Do you eat out frequently? Consider the things that may foibleyour attempts to decrease fat intake. Plan how you can overcome these. Once you have a plan ofaction, implement it. For example, make sure you have appropriate foods in your home.Delegate tasks so that you have the extra time necessary to cook in a new way.HOMEWORK1. Finishing reading The New Fit or Fat2. Read Overcoming Overeating3. Make a list of how you know when you are physically hungry. Make another list of howyou know when you are emotionally hungry” and likely to eat- eg. bored, lonely, afterfight with partner or children. Bring it next week.4. Plan your meals/snacks in advance. Eat the equivalent of at least three meals per day.Use the techniques discussed above, Enjoy your food.5. Make a list of how you obtain your fats e.g. butter on toast, deep frying and try to cutdown on your fat intake. Try the strategies we discussed this week. Which ones workfor you? Why? Bring your list with you next week.6. Exercise and record your activity. Try to exercise a minimum of five times per week.Feel free to exercise more frequently! Remember long periods at lower intensity levels(e.g. 70% of your maximum heart rate) will be of greater benefit than short bursts at veryhigh intensities.79WEEK THREEReview Homework:Please hand in your exercise chart. How is exercising?Has everyone finished Overcoming Overeating’? Any thoughts, questions?Have people been managing to eat regularly’? Anybody having problems with overeating, thatthey feel they can’t get a handle on’?Did anyone come up with sources of fat that we missed last week or any new ideas on how todecrease fat intake?Reasons (Besides Physical Hunger) for EatingHow do you know when you are physically hungry? Possible cues:Length of time since you last ate.Sensations in your stomach, aching, growlingMental fuzziness, cloudingHeadache, Dizziness, blurred visionOthersFor what reasons other than physical hunger do you eat? For example:BoredomLonelinessAs a rewardWhen you are feeling sad, anxious etc.As a diversion, to help you not to feelDoes eating permit you to procrastinate about doing an unpleasant task a little longer?As a form of relaxationHabit (I’m walking by the fridge...)Do you eat when you think about particular things, e.g. an unhappy relationship, pastabuse etc.OthersHow can you identify when you are eating for the above type of reasons? For example:Do you eat in an uncontrolled fashion,Are you less aware than usual of what you are eatingCertain foods which you don’t normally consumeOthers80Problem SolvingEffective problem solving involves several steps. These steps are applicable to all sorts ofproblems. These are the type of techniques taught in management courses, time managementcourses etc. There are two main reasons for you to try diligently to become proficient with this.One, you can use the steps to directly change your eating or exercise behaviours. Two, if youregularly use the steps so that you effectively solve problems not related to eating or weight inyour day to day life, you will decrease the chances that you binge because of stress,unmanageable problems etc.1. Identify the Problem(s)It is imperative that you become aware of why you are overeating (or not exercising etc.). It isone of the initial steps in changing your eating behaviours. Write these down on separate piecesof paper, Remember, the real problem is not always what it first appears to be. For example,excessive eating may more accurately be described in terms of anxiety or procrastination aboutwork, changing relationships etc. Look carefully for what the real problem is.2. Generate as many solutions as possible.Below the identified problem, write down all the solutions to the particular problem you canthink of. Do NOT be concerned about the feasibility of your possible solutions. Include thoselikely to be successful and those less likely to result in the desired outcome. The important thingis to generate lots of ideas. Be creative, take a break, new ideas may come to mind. Look at howother people have solved similar problems. Don’t stick exclusively to old solutions. If they’d beencompletely successful, you wouldn’t have to be solving the problem at present. Look for newand different ways of thinking about the problem.3. Order and choose the solutions which you are going to implement.First of all decide which solutions you are going to use. You may eliminate some because theyare simply to difficult to implement, other solutions may have a very low probability of success.Once you’ve decided what solutions you are going to try, rank them. Consider how difficult interms of time, cost, energy etc. they will be to implement and also how effective you think theyare going to be.4. Plan and implementPlan how you can implement your chosen solutions. Do you need to make any purchases? setaside time? talk to other people? Whatever you need to do, PLAN, PLAN, PLAN. I know thissounds like a broken record, but this drastically increases the likelihood of success when you aretrying to change behaviours. We all have a tendency to slip back to the path of least resistance(i.e. to engage in old behaviours and old, ineffective solutions like over eating) when ourattempts to make changes are thwarted. The best guard against this is to have a solid plan inplace. A plan and proper preparation tends to make difference in difficulty between the old andnew solutions not seem as great. Thus, you will be more likely to persist with the new and81hopefully more effective solution. Do everything you can to enhance the possibility you willsucceed with the new plan.5. EvaluateAfter you have implemented your new strategy, sit down and consider the results. Was itefficacious, did you get the results you wanted? If so, what wifi these new results change in yourlife, wifi you need a plan for dealing with these changes. For example, someone who was usingfood as friend, decided to try the human variety instead. She planned ways in which she couldmeet some new people and was quite successful in this regard. She was then faced with theproblem that her new social activities required more time. She therefore tried to reorganize someof her duties (e.g. doing household chores in the morning before work) so that she had time inthe evenings to spend with her new friends. When you have achieved success, its easy not tobother with the evaluative phase of problem solving. To ensure your continued success, itsimportant that you take the time to do this. Also, spend some time deciding why you weresuccessful. What factors contributed? This wifi help you to problem solve effectively in otherareas.If your attempt was not successful, try to determine the reasons for this. Was it because theidentified problem was not the “real” problem? Was it because the strategy was notappropriate? Because the plan and/or preparations were not successful? When you have someidea of why you were not as successful as you had hoped, make some modifications and tryagain. Be sure to reevaluate. Use these opportunities to learn about yourself. Your new selfknowledge will be invaluable in helping you to create new strategies and plans in the future.Try not to evaluate your success in “all or none” terms. Perhaps you were a bit successful,moderately successful etc. Try to talk to yourself as you would to a friend. Imagine a friend toldyou that she started knitting so that she would not be as tempted to eat out of boredom. If sheshowed you the sweater she had made, replete with holes, dropped stitches etc. what would yousay? You could frame the experience as a failure because the sweater was less than perfect andwas not likely to be worn. Or, you could frame it as a success because she learned a new skill(albeit imperfectly), was able to decrease her eating and now knows that she prefers sewing overknitting. Whatever the results of your efforts, try to evaluate them fairly and realistically. Lookat things from more than one angle...As you become proficient with this method of problem solving, your sense of overall controlshould increase. Believing that you can do something is often as important as learning the actualtechnique. Talk to your self, reinforce yourself for your success.82Possible Solutions for Binge EatingThe particular reasons why you over eat will determine which strategies you choose. Here aresome common ones.Alternative methods to “zone out” or procrastinate:Watch TVListen (and/or dance) to a favourite albumPlay video games on the computerAlternatives to eating when you are bored (remember to pick ones you are likely to use, even ifthey seem less desirable than other solutions):Make a telephone callGo out with a friendRead a book, (always have a couple readily available books m your home, a “no mind”one, for when you are bored but really just want to zone out, and a more involved onefor when you need a little more stimulation).Subscribing to a magazine can ensure that you have a constant source of new readingmaterialGo for a walk, exerciseWork in the garden, organize your sock drawerDo a simple task. Not only do you occupy yourself and hopeful prevent yourself fromeating out of boredom, but you also accomplish something which needs doing and thusget to feel good about your accomplishment. Make a list of simple tasks whichfrequently need doing. E.g. paying the bills, balancing your cheque book, dusting,painting your nails...Alternatives to using food as a reward:Identify other ways you could reward yourself: buy yourself flowers, a new piece ofclothing, have a long soak in the bathtub with your favourite bath oil; try rewardingyourself with time alone, taking up a new hobby such as painting or writing which hasalways interested you. Remember a new hobby need only be enjoyable, you do not haveto be a Rembrandt; learn to enjoy the process not just the end goal or product.HOMEWORKRecord (and bring) the ways you know when you are eating for reasons other thanhunger.2. Develop a list of personal “rewards” or reinforcers.3. Continue with the eating strategies you have been using (eating regularly, in a set area,sitting down etc.). How does it feel not to have forbidden foods? Are you eating more,less? Have you been able to decrease your fat intake. BE AWARE of your eating.834. Continue exercising five times per week. If you are having difficulty with this, if it stillfeels like a complete chore, continue to keep an exercise diary and talk to me. It’s veryimportant that exercise become something enjoyable for you, so you will WANT tocontinue with it...5. Finish reading Fit or Fat and Overcoming Overeating.84WEEK FOURReview HomeworkDid you discover nonhunger reasons why you are eating? How do you know when you areeating for reasons other than hunger? What personal “rewards” or reinforcers could you useinstead of eating?Eating - Are you able to eat at your prescribed area? Any problems with bingeing? Are youeating regularly? Are you able to tell when you are physically hungry? Are you able to usereinforcers other than food to reward yourself?Exercise - Are you exercising at least five times per week? Are you able to get back on track iffor some reason you miss a session’? Is exercise becoming enjoyable’? Do you notice anychanges in how you feel about your body or how it is responding?Readings - Has everyone finished reading Fit or Fat and Overcoming Overeating’?DISORDERED EATING, COGNITIVE ERRORS & DEPRESSIONPeople with disordered eating often have depressed moods; this frequently involves self-deprecating thoughts and actions.Depression negatively affects areas of personality and interpersonal functioning, influencing theway we feel, think and act.Common signs of depression are:-overwhelming feelings of sadness or being blue, down in the dumps;-loss of interest in most things previously considered pleasurable;-feelings of guilt, helplessness and hopelessness about the future;-social withdrawal;-thoughts of self-harm;-diminished level of energy;-inability to concentrate;-sleep difficulties.Typically, when dieters are feeling depressed or anxious, they tend to overeat. In contrast, whennondieters are depressed, they often lose weight. A number of factors may contribute to this.Dieters and depressed people tend to be less aware of and/or ignore internal cues. Also, somepeople report that they are able to “stuff down” emotions by eating.DepressionA variety of factors, including heredity, biochemistry, behaviour, thoughts and socialcircumstances contribute to the development of depression. Drugs (antidepressants) aresometimes used to combat depression biochemically. It is also possible to alter feelings ofdepression by changing one’s behaviours and thoughts. As some of you have attested, exercise85is often beneficial in lifting one’s mood. Engaging in enjoyable activities (i.e. rewarding oneself)can also help. It is important to know what activities are enjoyable for you. And, it is equallyimportant that you permit yourself access to such activities. While people often complain thatthey haven’t the time to engage in such activities, it should be noted that when a person isdepressed, her or his ability to concentrate and function effectively is impaired. If you take thetime to take care of yourself, eat well, exercise regularly and do enjoyable things, you are apt tobe more productive and accomplish more work in less time. This in turn tends to help elevateone’s mood.Friends and SocializingPeople who are depressed and/or overweight often feel very isolated socially. Although differentpeople prefer different amounts of social contact, interpersonal relationships are important foreveryone. Many individuals feel they are using food as a friend. If you are not socializing orspending as much time with friends as you would like, why not? As you are no doubt aware, thisbehaviour like all others can be changed. It is not easy and initially will require hard work.Try using the problem solving template we talked about last week. Why aren’t you socializingenough? Is it because of time constraints, lack of opportunities, social discomfort, inhibitionbecause of appearance? What possible solutions can you come up with? Improving your timemanagement and organizational skills can increase time for socializing. Changing priorities canalso help, as can delegating tasks. Could you join a club, community centre, take a course?Think about ways you can gain exposure to people with whom you would be able to developfriendships. Does your physical appearance hinder you from socializing? WHY?? Remember,you are far more concerned about your appearance than are other people. Is it really yourphysical appearance that is stopping you or are there other factors involved? Be honest withyourself. Consider using some of the cognitive methods discussed below. (We will talk aboutassertive behaviour next week and hopefully come up with methods for dealing with obnoxiouspeople whose comments etc. make you uncomfortable). Would you tell an overweight friend sheshould not be seen in public because of how she looks? What about someone who had lost herhair because of chemotherapy... Why are you so hard on yourself?Faulty Cognitions and Dysfunctional ThoughtsPeople, especially those who are depressed, often have “dysfunctional thoughts”. People whoare emotionally healthy tend to have a favourable bias about themselves. Distressed individualson the other hand, tend to see and remember negative things about themselves and the worldaround them. Researchers have identified a number of types of cognitions or thoughts whichplagued depressed and anxious people. Often we are not aware of these types of thoughts. It isimportant that when you are feeling upset you take the time to look inwards and try tounderstand why you are upset. Try to ascertain whether you engage in the types of thoughtsifiustrated on the attached page. These thoughts are often so automatic that we aren’t aware oftheir presence. When you feel upset, take the time to look inwards and see if any such thoughtsare there. This will take time, effort and practice.86Once you learn to identify faulty cognitions you can set about changing them. Initially it wifi behelpful to write down the dysfunctional thought and construct rational, accurate responses. Onceyou have written the best response possible, beginning saying it to yourself either silently oraloud. Look for similar situations and assess whether similar faulty cognitions are involved. Asyou become more experienced in talking back to yourself, you will be able to directly counteryour dysfunctional thoughts.Dieters and overweight people often become involved in vicious cycles, They break a self-imposed rule such as no bread, no chocolate, or only 1200 calories a day and then beratethemselves for doing this. As a result they feel bad; then in an attempt to feel better, they againeat. People frequently translate problems which are very hard to deal with into the language offood, eating, weight etc. Thus instead of admitting to oneself (and/or others) that she is in anunhappy relationship, would like to work outside the home, is lonely, or has yet to deal with pastabuse etc., a person will often talk about her weight problem. This is very much accepted bysociety: everyone is allowed to complain about their body, their diet etc. regardless of whetheror not they are overweight. Unfortunately, translating nonfood, nonweight problems into thelanguage of food and weight tends to prevent one from dealing with the real problem, whateverit is. Berating oneself about one’s appearance, breaking rules etc. serves to make one moreunhappy, more likely to overeat and less likely to work on and eventually solve the real problem.When you begin to yell at yourself, quietly ask yourself what it is you are really unhappy about.Regardless of the answer, remember: berating yourself will not help.Our society promises that thinness will bring with it many rewards: romance, happiness, wealthetc. This is a fairy tale. Thin people still have unhappy marriages, careers which fail etc.Although we all say that we know rationally that being thin is not the answer to all ourproblems, there is a very strong tendency to think in terms of “When I am thin: he will love me, Iwon’t feel insecure..”.People who are overweight and/or depressed often have low self esteem. As we have discussedpreviously, people who are overweight are often subject to negative biases. Accepting yourpresent self as you are is a prerequisite for change. This does not mean that you can’t worktowards change and growth. Rather, it implies valuing and respecting yourself right now. Whenyou accept yourself as you are, other people are more likely to also accept you. When you act inways which suggest you are not happy with yourself, others often sense this and respondsimilarly.Some therapists suggest that when you are overly critical of yourself and put yourself down, thehealthy part of you, who loves yourself will tend to rebel by telling you that you are fine just asyou are and sabotaging any attempt on your part to change. If you learn to accept yourself asyou are, identify your problems accurately, and deal with them to the best of your ability withoutdenigrating yourself, you will feel better and be more likely to make successful changes (weightand otherwise) in the future.The Feeling Good Handbook by Dr. David Burns is an excellent book which deals with thesubject of how thoughts can effect our moods and behaviours. It contains many “exercises”designed to increase your awareness of self berating and faulty cognitions and help you replacethese with more useful thoughts. It is available in paperback. Cognitive therapy as described by87Bums is widely used m the clinical treatment of depression and anxiety disorders. It can be verypowerful and developing some facility with the techniques involved is highly recommended.HOMEWORK1. Read Breaking Free from Compulsive Eating.2. Continue with regular exercise and eating. Note any problems you are having so we candiscuss them next week.3. Think about your mood. Do you feel up or down most of the time’? Why’? Whatbehaviours are contributing to your moods e.g. lack of sleep, lack of socializing,overworking’? What faulty cognitions are involved? Write down situations in which youhave faulty cognitions. Identify the type of thought and write a more accurate, rationalresponse. Practice using this type of self talk when you experience dysfunctionalthoughts.4. When you feel upset and think it is because you are overweight or because you have justovereaten or have failed to exercise etc., check in with yourself to see if this is reallywhat the problem is about. Try hard to accurately identify the things which upset youwithout always “blaming” your eating, appearance etc.5. Complete the questionnaire package and BRING IT WITH YOU NEXT WEEK!!88WEEK FIVEReview HomeworkTurn in questionnairesHow are people finding their exercise programmes? Problems? Suggestions?Eating Behaviours? Are people able to eat regularly all the time? Have you been able to feedyourself when you are hungry? What problems are you having? Can you make adequate time toprepare and appropriate foods?Identifying dysfunctional thoughts and creating rational responses:Have you been able to identify problems which you have been attributing to weight, appearanceetc. Have you been able to establish ways of dealing with the real problems?ASSERTIVENESSSelf EsteemSelf esteem is determined by how closely ones actual self approximates ones ideal self. If thetwo are very similar self esteem is high; if the two are quite disparate, then self esteem is low.As we have discussed previously, there is a societal prejudice against overweight persons inNorth American. Being the recipient of negative biases can contribute to the low self esteemfrequently seen in overweight people. There is an erroneous belief that if one is overweight it isbecause she or he is lazy, weak or out of control. Indeed, health practitioners such as physiciansoften fall prey to telling their chronically overweight patients that they are not trying hardenough or must not truly want to change. More importantly, people with weight problems mayend up internalizing such negative beliefs. That is, they may come to believe they are lazy, out ofcontrol etc. It is important that you develop and maintain a sense of self efficacy.You may feel guilty and confused about your weight, embarrassed or ashamed of chaotic eatinghabits, You may feel that the ttyou” the rest of the world sees is simply a front, portrayingsomeone who is confident and in control. You may temporarily feel elated when you aresuccessful at restricting your intake. However, breaking any of your rules around food andweight may upset you, cause you to diet more strenuously and, as we discussed earlier, this isoften the beginning of a vicious cycle of overeating and feeling badly.Indeed, women often describe a sense of shame and failure from cycles of losing and regainingweight. In fact, it has been suggested that this may account for the higher rates of depressionseen in women as compared to men, In support of this idea, are findings that, in countries nothaving an inappropriately thin ideal for women, eating disorders are not a problem and rates ofdepression are not higher in women, In contrast, in countries where there is an unrealisticly thinideal, eating disorders are also prevalent and depression rates are higher in women than men.89It is essential to understand that in the long term, weight control will not solve all life’s problemsand that thinness is not a prerequisite for a sense of self worth and happiness. Focusing on foodand weight issues as a way of dealing with unhappiness will only perpetuate your weightproblem and distract you from addressing the underlying issues. Ultimately, we all need to learnto anchor self esteem in self awareness and acceptance and not on weight control. Inherent inpermanently raising self esteem, is learning to live in the here and now (and not in the “thinfuture” of your dreams) and accepting yourself as you are, right now.AssertivenessWomen frequently find it difficult to be assertive. When one is unable to be assertive, she placesherself in the likely position of feeling abused and not having her needs met. Furthermore, whenself esteem is low, people often feel they do not deserve to have their needs met. In turn, whenone’s needs not met, self esteem becomes lower, creating yet another vicious cycle. By beingappropriately assertive and having needs met, this cycle can be broken.Assertiveness consists of being aware of one’s own needs and expressing these appropriatelywithout impinging on the rights of others. (Remember there is a difference between otherpeople’s rights and their desires). Fundamental to being assertive is learning to ask directly forthings and being able to refuse the requests of others when they are inconvenient orinappropriate. First of all, it is imperative that what you want is clear in your own mind. Thisdoes not mean you can not remain flexible and negotiate with someone, but you do need to beaware of what it is you are needing or wanting. Certain behaviours help to ensure that one’sneeds will be met:-Consider in advance in what situations difficulties tend to arise, so that you can beprepared.-Speak in a firm tone of voice, at a volume clearly audible (careful not to raise the pitchof your voice at the end of a statement thus giving it a question-like quality).-Maintain eye contact.-State your desires in a clear and unambiguous fashion;-Suggest alternatives which would be acceptable to you (this enables others to feel thatthey also have some control and choice in the situation).-Remember: you are not obligated to justify your decisions or wishes to others. In fact,this may prompt them to question your decisions.-Try practising with an audio or video tape; better yet do some role playing withsomeone else: this can be invaluable.While everyone has particular situations she finds difficult, people who are overweight typicallyreport having difficulty in situations involving food. People with weight problems often feelguilty and ashamed if they eat in front of others, or if they eat anything other than the ‘good’foods. No one else has the right to tell you what to eat or not to eat. Learning to eat previouslyforbidden foods such as deserts in front of others helps to eliminate the secretive aspect ofeating. When it feels acceptable for you to eat what you want, in front of whomever, your urgeto binge when alone will likely decrease.90When eating fri restaurants, remember you are paying for a service. Do not hesitate to makerequests, if they are unable to comply you are still no worse off. With friends and family, learn toexpress appreciation and love via means other than food. For example, tell your friend youwould love to get together, but would prefer that this no longer entail having lunch together atyour favourite French Restaurant. When a host or hostess is insisting that you eat food whichyou would rather not, be firm and clear. Do not offer unnecessary explanations. Remember,food has come to serve many other purposes than simply providing fuel for a physically hungrybody and it is quite possible that you will strike a chord of insecurity in your host when yourefuse a second helping or desert etc. Rather than entering into an arguing match about whetheror not you truly want something, try complimenting your host and assuring him or her that youare having a good time and simply restating that you do not wish the ‘whatever’. Whenpossible, it often helps to have a chat with your host beforehand. If she is aware of your attemptto alter your eating habits, she is more apt to respect your stated wishes and may even berelieved to learn that preparing an elaborate meal will not be necessary.While being assertive in eating-related situations is certainly important, learning to be assertive innonfood-related situations can be equally as important. Being assertive in situations not directlyinvolving food can help to ensure that you do not end up eating as a means of compensating forfeeling overwhelmed, deprived, that life is unfair, that you are being used etc.RELAXATION STRATEGIESThere are many different ways to relieve tension. Eating may be one of the coping strategies youare presently using. By exploring and learning some alternative methods, you will have copingstrategies (other than eating) from which to choose when you are under stress. Hopefully havingmore choices will help you not to over eat; ideally, you will discover new techniques which aresuperior methods for reducing tension.Deep BreathingWhen concentrating mentally or straining physically, humans have a tendency to hold theirbreath. This is detrimental for several reasons, It can increase the pressure in your abdomen,chest and head. It prevents you from acquiring needed oxygen to nourish your brain andmuscles. Holding your breath also prevents you from blowing off carbon dioxide (C02). This inturn results iii a change in your pH. Another possibility when you are under tension is that youbegin to breathe very rapidly and shallowly. This causes you to blow off excessive amounts ofCO2 and your pH rises. This in turns leads to symptoms such as tingling (pins & needles),dizziness and sometimes panic.Learning to control your breathing is perhaps the most simple and effective way a person canreduce her sense of tension or anxiety. This initially requires effort and practice. However, likedriving a car it can become second nature and be implemented whenever you find yourself in astressful situation. Ideally, you can sit in a reclining chair or lay with your head slightly elevated.Place one hand on your chest, one on your abdomen. Breathe in normally; notice your hand onchest move. Now breathe in slowly and very deeply; notice the hand on your abdomen rise.Count in to four (or 3 or 5) as you breathe in. Make sure you breathe all the way in to your91stomach. Hold it for just a second and then blow out to the same Count of four (or 3 or 5).Concentrate on all the sensations associated with breathing.Progressive Muscle RelaxationThis is a technique which is very popular. It is used “prophylactically” as well as prescriptivelyfor problems such as chronic pain and insomnia. The method involves tensing and then relaxingvarious groups of muscles and concentrating on the differences in sensations when the musclesare tensed versus relaxed. In this way you can learn to become aware of when there is excessivetension iii your muscles and how to release it. Pick a quiet place and time when you will not bedisturbed. Sit in a comfortable recliner or lie on your bed. You may want to play some relaxingmusic (new age music, sounds of nature etc. can be quite helpful).The following are the major groups of muscles and the ways in which they can be tensed.1. Hands-makeafist2. Lower arms- press your arms downwards (e.g. onto the arms of a chair or onto a bed).3, Upper arms- flex your biceps4. Forehead- raise your eyebrows5. Mid face - wrinkle your nose and squint your eyes6. Lower face / jaw - bite together with your teeth and pull the edges of your lips back7. Neck - press your chin towards your chest but use the muscles in the back of your neckto prevent it from actually reaching your chest8. Upper back, shoulders- press your shoulder blades together9. Abdomen - harden your stomach as though you were protecting yourse]f from beingpunched10. Thighs - press downwards with the large muscles on the top of your thighs; use themuscles on the back of your legs to counterpoise11. Calves - point your toes upwards12. Feet - turn your feet inwards and gently curl your toes underHOMEWORK1. Finish reading Breaking Free from Compulsive Eating2. Continue exercising and using the eating strategies as discussed previously. Be aware ofwhen you are physically hungry and be sure to feed yourself.3. Identify at least two situations in which you need to be more assertive. Remember theimportance of delegation. Devise and write a plan of action. if possible implement thisand evaluate its efficacy. Examine what happened to see what aspects were helpful andwhat aspects will require modification for next time.924. Set aside 20 minutes per day. Ideally, this should be the same time each day to help youincorporate this into your routine. Practice deep breathing and progressive musclerelaxation every day. It is important that you practice it frequently at first to ensure thatyou acquire the skill to relax at will. Afterwards such frequency may not be necessary foryou.5. Be aware of times when you a) feel stressed; b) breathe rapidly and/or shallowly and c)hold your breathe. Note the types of situations under which these behaviours tend toreoccur. When you are aware that you are engaging iii these behaviours, begin deepbreathing. Notice any changes you feel, either physically or mentally.6. Use these techniques when you find yourself in stressful situations. When you want toeat and know that you are not physically hungry, try to take a few minutes out. Do somerelaxation exercises. Remind yourself that after the exercises if you still want to eat, youcan. You may, however, find that the urge for food wifi have passed by the time youhave completed the relaxation exercises.93WEEK SIXReview HomeworkFinished reading Breaking Free from Compulsive Eating?Any problems re: eating or exercising?Are you able to identify dysfunctional thoughts and create rational responses.Have you been able to identify problems which you have been attributing to weight, appearanceetc. Have you been able to establish ways of dealing with the real problems?Have you practiced/used progressive muscle relaxation and deep breathing?Have you been able to identify and act assertively in a problematic situation during the pastweek?DEVELOPING A HEALTHY RELATIONSHIP WITH YOUR BODYAccepting your body is an important part of self acceptance. It is difficult for people in oursociety to feel good about their bodies because the body which is considered to be the ideal andthe only one acceptable, is not a healthy, adult body. Images portrayed in the media haveresulted in body image dissatisfaction on an epidemic scale.While you may actually feel uncomfortable with your body, it is also true that bodydissatisfaction is often a clue to deeper feelings of personal distress. As we discussed earlier,there is frequently a tendency to use displacement as a means of coping. Instead of dealing withthe real problem and working towards its resolution, one works at changing her body. However,because it is not really her body alone about which she is unhappy, fixing it only provides atemporary sense of relief.For example, a person who feels dejected, unwanted, unloveable because of a failed relationship,may project their feelings onto their body. Instead of feeling that you, as a person, are notloveable, your displacement enables you to feel that it is your body that is not desirable. Peopleoften try to change their body in an attempt to make themselves feel more loveable. The problemis that altering your body won’t make you feel that you are truly loveable or valuable etc. andthere will always be something else that you believe requires “fixing” on your body.Displacement as a means of coping provides certain benefits, at least initially. It allows you tolocalize the problem (e.g. its not all of me, its just my body and this can be changed). This inturn may diminish the intensity of the painful feelings. Displacement may allow you to avoid aproblem which you feel is too painful to confront. Also, displacement of one’s problems ontotheir body allows them to believe that they know how to deal with their problems.94Because fatness is (erroneously) associated with being inadequate and out of control, it is easyfor people to displace their other problems onto their fatness. You may try to feel moreefficacious and in control by attempting to change your body. Since this is dealing with, at most,only one aspect of the problem, it is doomed to fail and may result in you entering into adetrimental cycle of:-disliking your body,-losing some weight,-feeling a bit better for a while-then feeling badly because you again gain weight and feel out of control etc.,-feeling badly means you are more likely to abuse your body by overeating and failing toexercise...-then attempting to feel better again, but using drastic measures to try to lose weightTo help escape from this cycle:1. Get to know yourself- what things do you like / dislike about yourself as a person?Make a list of the things you dislike and examine it carefully. What things on this list arereasonable? What things would other people think are ridiculous? Would you laugh atsome items were they on another’s list? When you have a list of the significant aspects ofyourself which you find distressing, take the time to plan how to deal with theseproblems. It is very important that you deal with such problems directly and not try tosolve them via changes to your body, as this wifi increase the likelihood of overeating,not exercising etc. Not to mention the fact that the true problem will remain unresolved.2. Get to know and appreciate your body - we often have a tendency to dissect andcompare our bodies with those of others. Instead of appreciating all our bodies do for us,enabling us to walk, pick flowers, hug our friends, our children etc., we feel disappointedthat our bodies do not resemble the airbrushed photographs of anorexic, prepubescentgirls in magazines. One’s body should be the place from which she acts as a whole andintegrated person.a) Make up a sentence which describes how you would like to move through theworld, (e.g. I move confidently, easily and calmly); say it over to yourself.b) Look at your body in a full length mirror. Notice the usual judgements youmake. Acknowledge each of these judgements until no more criticisms arise.Then just look at your body as a whole, just being there. See if you can just lookat yourself with nothing good or bad to say. Try describing your body to yourselfwithout prejudice, i.e. just how it looks without any value judgements.953. Break the connection between how you feel regarding your body and how you act.When you imagine yourself as being very large, is the way you envision yourself acting,different from the way you see yourself acting when you imagine yourself as small. Why?Your size does not have to determine how you act. You can choose to act in what evermanner you wish. This includes acting confidently, eating in front of others, wearing’bright clothes, flirting, engaging in desired activities and anticipating (yes, even insistingupon) an acceptable level of respect from others.HOMEWORKContinue with regular exercise and eating. Continue practising progressive musclerelaxation and deep breathing. Use these techniques when you find yourself in stressfulsituations.2, Be aware of when you are berating yourself, using faulty cognitions etc. Create and userational responses.3. Be on the look out for situations in your every day life in which acting more assertivelywould be beneficially. Learn to regularly develop plans for how to act more assertivelyand try these out. Assertiveness is like any other skill: it takes time and practice tobecome proficient.4. Do the body self-awareness exercises described above.5. Towards the end of the week, take some time to review your current eating andexercising behaviours. I would like each of you to write and turn in a written paragraphor two about how you are managing with your eating and exercising, how you arefeeling etc. In particular, I’d like to know about areas which you are finding problematic.Try to be as specific as possible so that we can try to come up with some answers. Also,please mention any topics which we have not covered which you would like to haveaddressed.96WEEK SEVENReview HomeworkAble to eat and exercise regularly?Can you do the muscle relaxation exercises and deep breathing? Is this useful?Are you identifying faulty cognitions and replacing them with rational responses’?Have you tried acting assertively? What happens?How did you find the body self-awareness exercises?Could you identify aspects of yourself with which you are dissatisfied? Did you learn anythingabout yourself?Please turn in your paragraphs and I’ll read them during the week.RELAPSE PREVENTIONMaking lifestyle changes, including loosing weight is difficult work. Regardless of the degree ofyour initial success, it is natural to expect that you wifi have periods of difficulty. This does notmean that your accomplishments to date have been for naught. In the same vein, if you have notachieved what you initially hoped for, remember you have been exposed to ideas which you canchoose to implement now and in the future. Because slips are to be expected, it is important toconsider them in advance and plan for their occurrence. Remember, most people can manage tolose weight, it is the maintenance phase in which most people fail.1, Making Changes Takes Time. Try to view your new behaviours as simply an ongoingprocess and anticipate slips along the way. If you start thinking in black and white terms(i.e. all or none thinking) and applying unrealistic standards you will interpret anydeviation in your behaviour as failure. In turn this will increase the possibility that youwill eat to compensate for feeling like a failure.In contrast, you can view slips as isolated events which are to be expected and thus arenot out of the ordinary. This type of perception allows you to view the situation as alearning experience and part of the natural path of the journey. Try not to overgeneralize.A binge now says nothing about this evening, nor does it say anything about tomorrow.When you do have a lapse with eating or you fail to exercise, don’t try to compensate forit by restricting your subsequent food intake or over exercising. This will only increasethe chances that you will again binge. Instead, take time to learn from the situation, whatfactors contributed to the binge or to not exercising? How can these be overcome in thefuture?972. Plan. Plan. Plan. What situations or factors have been problematic for you to date? Whendo you fail to exercise? Under what circumstances do you tend to over eat? Take thetime to write down the situations in which you anticipating having difficulty in the future.Then try to generate methods for avoiding these pitfalls. Do not expect all of yourattempts to avoid slips to be successful.if lapses are to be expected it makes sense to plan for them in advance. Use the thingsyou have learned about yourself over the past ten weeks to help you generate a plan toensure that a lapse does not turn into a relapse. For example, you may decide that if youmiss two scheduled exercise sessions, you wifi make plans to exercise with someone elsefor the next couple sessions as a means of encouragement and ensuring that you get backon track. If you overeat, perhaps you can plan to treat yourself to a movie to get yourselfaway from the food or source of stress etc.3. When a lapse seems to be becoming a relapse. If you recognize that your exercise andeating behaviours are returning to their old patterns (e.g. bingeing frequently, notexercising), then return to the methods suggested early on. Schedule and eat regularmeals. Start monitoring your eating again. Write down when and what you eat. Scheduleexercise times. Chart or graph your exercise. Make arrangements with someone,perhaps someone in the group to call regularly and check up.4. Positive Reinforcement. We all know the value in rewarding children and pets when weare trying to teach them something new. The same thing applies for you. Evaluate yourprogress on a regular basis. Pick a time and each week examine how you have done.Measure your success iii terms of your own progress: are your binges down from fivetimes per week to once a week? Are you going to functions you once would haveavoided because you felt fat? Are you walking regularly now where as six months agoyou were not? These are all indicators of progress. Evaluate yourself over a reasonableperiod of time. If you have just binged, don’t evaluate/berate yourself on your behavioursof the past few hours. Instead view these behaviours in context. How have you doneover the past two weeks’? Remember where you were two months ago. Change is a slowbusiness. Take credit for your accomplishments.Ongoing ContactOne of the things which has been shown to help people make changes is contact with othersupportive people. I will be leaving Vancouver, so continuing with the group is not possible.What I would like to encourage you to do, is to meet amongst yourselves. Running a supportgroup can be difficult, onerous, fun, or exciting; it really is up to you. if this seems likesomething you would like to pursue, I would suggest deciding upon two people to be in chargefor the first month. Think about this during the coming week, and if you want we can talk aboutsetting up/running such a group next week. if this is not possible, two or three of you might stillwant to meet regularly on a more informal basis.98HOMEWORK1. Decide on a time for your weekly self evaluation.2. Decide exactly what it is you wifi be evaluating each week (e.g. if you’ve exercised fivetimes, if you have decreased the frequency of self berating comments etc.)3. Look back over your diary, itemize the places/situations which seem to be risky for you.They may be risky b/c they increase the likelihood of a binge or decrease the likelihoodof exercising; they may be risky b/c they make you feel badly about yourself,4. Develop very specific game plans for either avoiding the risky situations you’ve identifiedor for coping successfully with them.5. Decide exactly what will constitute a relapse (rather than just a lapse) for you. Is it 7days without exercising; two days of staying home alone crying? Have a game planprepared in advance for a relapse. Try to make this plan a comprehensive one (i.e. itshould be specific and detailed and should involve many different aspects of yourbehaviour: exercise, emotional well being, socializing, nonchaotic eating etc.). BRINGTHIS WITH YOU NEXT WEEK.99WEEK EIGHTReview HomeworkHow are you managing with eating, exercise and relaxation behaviours?Are you able to routinely identify cognitive distortions and identify the ‘real’ problems in yourlife?Did you identify a regular self evaluation time?Did you identify risky situations and how to cope with them?Turn in your paragraph about coping with a relapse. I’ll read them and we can discuss them atyour individual session.Do you want to continue getting together?SUMMARYOver the past weeks you have been given many suggestions for overcoming your weightproblem and making lifestyle changes. Hopefully, you have acquired some new skills andinsights which you will find useful. The basic areas we covered were:-Eating: taking a nondieting approach, learning not to deprive yourself and insteadrecognizing when you are hungry and feeding yourself appropriately wifi help to preventbinges. Identifying nonhunger reasons for eating and learning to cope by means otherthan food will help to reduce your caloric intake without feelings of deprivation.-Exercise: regular aerobic exercise is an important component of a healthy lifestyle. Inaddition to enhancing your sense of mental well being, exercise is a necessary componentfor weight loss. Remember, exercise needs to be enjoyable if you are going to continuewith it for the rest of your life, Persevere over the difficult initial phases till you reach thepoint where exercise is just a part of your life, like brushing your teeth.-Depression, low self esteem: remember to be on the look out for dysfunctionalthoughts. Replace these with more useful and accurate statements. Strive towardsidentifying areas of your life with which you are not satisfied instead of assuming that allyour unhappiness is the result of your weight problem. Live in the here and now.-Assertiveness: you have rights: the right to the healthiest body you can achieve, selfrespect, the right to feel comfortable in your own skin. Being assertive can help you tomeet needs in a healthy manner. Others lii your life may also feel relieved when you actstraightforward and direct. They know where they stand and what is expected of them. Itmay however, take time for them to adjust to your changes. Be patient and consistent.100-A Healthy Relationship with Your Body: take the time to get to know your body.Appreciate what it does for you. Try to stay in touch with your body and take good careof it. This means exercising regularly, providing it with nutritious food and not berating itunnecessarily.These are lifestyle changes. They won’t happen overnight, but they wifi happen. It is soimportant for you not to become overly discouraged. There wifi be days when it is very difficult,but remind yourself that you have the rest of your life and you can take it one day at a time.Adopt and maintain a long term perspective. The short term outlook wifi only result in shortterm solutions, e.g. quickly regained weight losses. The hardest part is at the beginning. Takeheart, you won’t always have to work this hard. Be kind to yourself and encourage yourself asyou would a friend. Base evaluation on your own progress and not on comparisons with otherpeople.We all need measures of success, goalposts etc. Unfortunately, we often use measures of weightas indicators about personal success. How ridiculous! Perhaps it is to someone’s advantage tokeep us using such measures but it is surely not to ours. Is a 100 lb. body really the answer tolife’s problems? Be aware of society’s strong arm in our beliefs about what constitutes a healthyand attractive body. An inappropriately thin ideal is so widely accepted in western culture thatyou will often find yourself having to accept and/or present what will seem like counterrevolutionary ideas. Be brave in your thoughts and actions. Adopt new standards, ones that arebeneficial for you. Self knowledge is the key to change. Be a risk-taker, try new things, workhard, take credit for accomplishments. Accept and respect yourself, all of yourself, includingyour body, today. Allow yourself to feel contentment and happiness. Remember real lastingcontrol comes from making choices.BARRIERS AND REASONS TO RECOVERAs a group, we will generate lists of the barriers to and the reasons for recovery. I would likeyou each to make a copy of the lists and keep it somewhere handy for future reference.FINAL ASSESSMENTSPlease complete the questionnaire package as you have done previously and we’ll scheduleindividual times.NOTE: Many of the ideas and sections in the handouts of the last eight weeks have been takenfrom “The Road to Recovery”, a Manual for Participants in the Bulimia Treatment Program byRon Davis et al.101Appendix IIBehaviour Therapy Treatment ManualParticipant Handouts102WEEK ONEWelcome. Tonight we will be covering the following:Format of the programme;Introductions;Contracts;Weigh-ins.HomeworkKeep a food diary during the coming week.2. The evening before group, review your diary carefully to discover any patterns to youreating. Eg. always eating when stressed, overeating if alone, consistently having a snackwith the 11 o’clock news even though you are not hungry, etc. Write your discoveriesdown, bring these together with your food diary to group next week.103WEEK TWOGoal SettingThe process of goal setting is an important one. One needs to consider both long-term andshort-term goals. When goals are unrealistic, one is apt to become discouraged and cease to tryas hard to obtain the goal. Thus, setting goals which are too high may contribute to failure. Ofcourse, if one never sets high goals, then one is unlikely to strive and realize ones potential. Thepoint is that a mixture of goals is needed.One, one and a half pounds of weight loss per week is a realistic expectation, although of coursethis will vary with the individual. It is likely that weight loss will fluctuate somewhat; this is to beanticipated and should not be a cause for alarm. Generally, weight loss is more rapid wheninitially embarking on a weight loss programme. It is clear now that periods of starvation,excessive dieting etc. can wreak havoc with one’s metabolism. Therefore, it is essential to set agoal which can be achieved while still maintaining a healthy intake. If one drastically reducesone’s food consumption, weight will certainly be lost, but at a slower and slower pace until it isalmost impossible not to gain weight.Achieving a goal is, in many ways, like receiving a reward: it makes us feel good and spurs us onto reach our next goal. Failing to reach a goal can feel like punishment, it can erode our self-esteem and make us feel like giving up. During the coming week, I want you to think carefullyabout what your goals are. Try to come up with some short-term and some long-term goals. Iexpect for many of you these goals will be weight related, e.g. to lose one pound per week, or toweigh X pounds by next Christmas. Try to be realistic and specific in the goals you set. Better toaim a little low; remember, your goal can always be adjusted. I would encourage each of you toalso set some goals which are not directly related to weight, but to the behaviours whichinfluence weight. For example, a goal for the next week, might be “I will eat a piece of fruitrather than a chocolate bar when I crave something sweet”. Perhaps you can try to create goalsbased around patterns you discovered about your eating habits. For example, if you found thatevery time you had a fight with your partner you ate a bag of chips, a goal might be somethinglike “If Fred and I have a fight, rather than devouring a bag of chips, I wifi instead spend half anhour reading a book”. (Remember to be successful with such goals, planning is necessary: itshard to avoid the chips and read a book, when you do not have anything you are interested inreading in the house...) Try to be creative, specific and realistic in setting and planning how toreach these goals.104Exchange DietThe exchange diet is fairly well explained in the handout. This diet is based on food groups anddoes not involve calorie counting.The food groups are dairy products, meat and meat substitutes, bread products, fruits andvegetables, and fats.What is important to remember is to follow the plan and eat regularly. Evidence veryconsistently shows that when people over-restrict their eating, they are much more likely tobinge. Therefore, even though one feels as though she can forgo a particular meal (and thus savecalories), she is apt to pay more for it in the long run.One consistent recommendation from doctors, Nutrition Canada etc. is to decrease fats in yourdiet. This is important both for weight loss and for health reasons such as decreasing your risk ofheart disease. It is recommended that you limit yourself to between 20 and 30 grams of fat perday. One of the hardest parts of decreasing fats is knowing where your fats are coming from.Frequently, prepared foods are very high in fats, so start reading labels very carefully.Remember, ounce for ounce, fats have twice as many calories as do other kinds of foods (i.e.proteins and carbohydrates). Be creative with cooking, avoid frying foods. Oils can add flavourto foods, so remember to make your foods that are steamed, broiled etc. flavourful by usingspices. Remember, it takes time to change old habits. Giving up high fat “fast foods”, usuallyrequires one to spend some extra time preparing food. Be prepared for this, give yourselfenough time to prepare interesting, enjoyable low fat foods. Rushing yourself wifi only set youup for failure. Remember to keep low fat “fast foods” e.g. fruits, veggie sticks etc. in readysupply. Keeping such food in stock requires advanced planning. Think about it before you’refamished and are reaching for the bag of chips in your cupboard. We’ll be talking more about fatreduction in a couple weeks. For now, I hope you’ll be able to get started on the exchange diet.HOMEWORK1. Write your long-term and short-term goals down. Try to come up with goals which aredirectly-related to weight and with goals which relate to behaviours rather than to weightper se. Keep these in your folders, read through them each day. Bring them to groupnext week.2. Begin the Exchange Diet. Take time to plan, to shop so that you have appropriate foodin your house. Be aware of what you are eating, especially fats. Any problems? Writethem down and bring them to group. Remember don’t skip any meals.3. Continue to keep a daily food diary; don’t cheat yourself by falling to do this. I know it isonerous, but it is also very useful. Again, review it at the end of the week. See what youcan learn. Bring it with you next week.105WEEK THREEExerciseWhy? To burn calories and alter metabolism; for overall health and a generalized sense ofwell being.What? Decide on two forms of aerobic exercise, preferably, one of which can beaccomplished in doors; e.g. walking, running, rowing, biking, aquasize, swimming etc.When? Ideally you should engage in at least 20 minutes of aerobic exercise daily. As aminimum, you should be doing some aerobic exercise at least five times a week.How’? Slowly, gradually. Think positively and work hard. Suggest some ways to increasethe likelihood of your success. For example, making arrangements to exercise withsomeone else who is at about your fitness level.To begin: First of all warm up your muscles with slow to moderate walking, biking etc.Then stretch - no bouncing - for about 5 minutes. Your goal is to engage in 20 minutesof aerobic exercise, i.e. activity during which your heart rate is in its target zone (65 to80% of its maximum). Its best to stay at the low end, at least initially. When you havecompleted your aerobic workout, spend a few minutes cooling down. Do some lightexercise, e.g. slow walking etc. and stretching.Target heart rate per minute:.60 X (220 - your age) to .85 X (220-your age).Target heart rate per 10 seconds (the above two numbers divided by 6)106The level at which you begin wifi depend upon your current level of fitness. The most importantthing is to begin doing some physical activity, if you can do only 2 minutes of walking at a time,that’s fine. Do it 4 times a day and add 1 minute to each session every day. A little sweat is fine,but no agony or crutches please!Perseverance is the key. According to most people, it takes between two and six months tobecome “hooked” on exercise. The idea is that regular exercise wifi become a way of life foryou. If this is to happen, it is important that the activities you choose are enjoyable, or at leastpotentially enjoyable for you. Try to think of ways you can increase the enjoyment associatedwith exercising. For example, working out with a friend, buying a new pair of running shoes etc.It wifi require hard work and dedication to get yourself “over the hump” to the point whereexercise is intrinsically rewarding, but it does happen.It is imperative that you plan how, when, where and at what you will exercise. Initially, whenexercise feels like a burden, you wifi frequently be tempted not to bother or to just skip, just fortoday... It is so important that you stack the deck in favour of overcoming this type oftemptation. Set a regular time when the kids are cared for etc. and you can have some time toyourself.Insensible Exercise — This type of exercise won’t improve cardiovascular status a great deal but itwiil help to burn calories. Insensible exercise includes: taking the stairs instead of the elevator,parking further away from your destination and walking part of the distance. Try to look foropportunities to increase your activity level. View them as good fortune instead of asannoyances.HOMEWORK1. Read Fit or Fat by Covert Baily; Fit or Fat for Women is also a good book. (It’s availableat most libraries and at the Book Warehouse).2. Decide on at least two types of exercise, Purchase any necessary equipment, e.g. runningshoes, community centre membership etc.3. By mid week, you should be exercising regularly. Keep track of your exercise on thechart. Remember to take your pulse.4. Continue with the exchange diet and continue recording what you are eating.107WEEK FOURStimulus Control1. Have a prescribed eating place. Keep and eat food only in this area. Try not to do otherthings in this area. This is known as stimulus control. Frequently we learn” to eat whenconfronted with situations in which we have eaten in the past, e.g. in front of the T.V.Therefore try to break these associations or habits, by limiting the cues associated witheating. Eat only in this area, not in the car, bedroom etc.2, When eating in your prescribed eating place, set a place, put your fork down betweeneach bite and pause for a few seconds, enjoy your food, take a 3 minute break m themiddle of your meal.3. Remove serving bowls from the table.4. Leave the eating area when finished meal.5. Distract yourself after a meal, e.g. call a friend, take a walk.6. Use coping phrases such as the following to talk to yourself*:“The urge to eat is strong now, but I know it will decrease to a tolerable level in a littlewhile so I can just ride it out.”“One reason I want to keep eating is because my stomach is not yet signaffing to me thatI am full. In an hour or so I will feel full and satisfied; so, I don’t have to continue eatingnow.”“I know I get confused between real emotions and urges to binge eat. The urge I feelnow is not physical because I have nourished myself with regular nondieting meals.HOMEWORK1. Continue with the exchange diet.2. Exercise at least 5 times per week.3. Use your past food diaries to help you make a list of situations which stimulate you toeat.4. For each of the situations you identified above, write at least two ways you can decreasethe likelihood that you will over eat.5. Eat all your meals and snacks in one place, sit when you eat, take time, put your forkdown between bites, pause for five minutes when you are midway through your meal.*Taken from The Road to Recovery: A Manual for Participants in the Psychoeducation Groupfor Bulimia Nervosa by Ron Davis et al.108WEEK FIVEShaping and RewardsShaping is a term used for purposeful, gradual change in a behaviour. For example, teaching achild to swim can be thought of as a shaping procedure. Now your ideal for the child might be toswim 200 laps of the pooi, however, you probably start out by getting the child into the pooi andplaying. (This tends to produce an association between something fun and the pool, helping thechild to like the pool). You might then progress to having the child submerge her/his face andblow bubbles. If the child finds this difficult, it might takes several attempts and require thepromise of some type of reward, e.g. going to a friend’s house. You might then try having thechild float on her/his back. Following this you might demonstrate the front crawl, have the childpractice this on land and then in the pool. Next you might have the child swim the width of thepool in the shallow end, then the deep end and finally you will have him/her try to swim thelength of the pool. To get to this point, you have probably offer all kinds of verbal praise andencouragement (which is often very reinforcing for a child), if the child is not paying attention orputting in any effort, you might have resorted to punishment, e.g. not being allowed to go to afriend’s house. Following the time when the child can swim a length of the pooi, i.e. now has thetechnical ability, it wifi stifi take months of practice to build up sufficient endurance to swim 200laps. During this time remaining motivated maybe difficult. Progress doesn’t seem as quick. It isreinforcing when a child can say to herself, half an hour ago, I couldn’t swim across the pooi,now I can swim a width by myself. In contrast being able to swim 150 laps instead of 145 maynot seem like such a great accomplishment. Whereas intrinsic rewards (e.g. recognizing her ownprogress, enjoying being in the water) may have been sufficient to keep the child motivated mostof the time. There will no doubt be times when more external rewards, e.g. visiting a friend, atrip to the local video store etc. are required for inducement, if however, the child appeared tohave no internal motivation and it took constant “bribery” of this form to get the child to swim200 laps, you might decide that swimming was not the sport for this child or that 200 laps wasnot a reasonable goal etc.Now I have gone on at some length about shaping and rewards in teaching a child toswim because they have, what I hope are some obvious parallels, in attempting to lose weight.The first week we talked about goals. Goals are an important part of the process of shaping. Ifthe goals you set are appropriately spaced they wifi facilitate weight loss if not, they wifi tend toimpede it. Imagine putting a four year old child in one end of a pool and saying, O.K. swim acouple hundred laps and walking away. The child simply has no idea how to get from one end tothe other (let alone how to do it 200 times); furthermore, s/he has seen their sister do it, so s/hefeels foolish for not being able to accomplish the same thing.Now, when you are losing weight, this, and things directly associated with it such as looserclothes etc., are probably sufficient rewards to induce you to keep trying. However, whenweight loss slows or you gain weight, keeping your motivation up can be very difficult. Whatyou need is an arsenal of tools to use when this occurs, as it no doubt will somewhere along theroad. What one uses as rewards is extremely individual. You also have to be clear about whenyou will get these rewards (remember the behavioural goals that were not directly related toweight loss??). So decide now what your rewards wifi be: a night at the movies, some flowers.109You also need to determine other methods for helping you to stay or get back on track duringtimes when you are not successful m losing weight. For example, one woman told me shearranged a daily call in with her sister who quizzed her about her eating and exercise behavioursduring the day. Others have said planning exercise times in advance with a friend helped toensure that they continued exercising.HOMEWORK1. Work on a list of rewards for the goals you identified earlier. Remember, there’s no senseplanning a week in Hawaii, if there’s no money in the bank, i.e. make the rewardsfeasible.2. Decide on at least six different ways of ensuring that you continue to exercise andmodify your eating even though you might not be losing weight. Bring this list with younext week.3. Continue with the exchange diet; be aware of when your problem times are. Try to comeup with plans for overcoming these. If you are having difficulty, bring a list of problemtimes/situations with you next week.4. Continue with exercising at least five times per week. Remember, this is a slow process.Aiy problems let me know.5. Finish reading Fit or Fat.110WEEK SIXThere are three basic “chemical’ components which make up our diets:1) Carbohydrates - These include simple sugars such asglucose and complex carbohydrates such as apples and breads. Carbohydrates areused as fuel by the body. Under normal circumstances, glucose is the brain’s onlysource of energy.2) Proteins - are comprised of amino acids. These are the body’s building blocks.We require protein for hair growth, muscle development, tissue repair etc.3) Fats - or lipids. These are used by the body for making cell membranes aridinsulation. Each gram of fat contains 9 calories, approximately double the amountcontained in proteins or carbohydrates.We frequently talk about the four food groups from which we derive the above nutrients. Thefour food groups include:1) Fruits and vegetables2) Dairy products3) Meats, fish, poultry4) Breads and grainsWe need products from each of the above groups to be healthy. I have attachedrecommendations from the Canada food guide to give you some idea of nutritionalrequirements. Even when one is attempting to loose weight, nutritional requirements should bemet. This is important because when the body is nutritionally deprived, one begins to experiencecravings for the missing substances. Also one risks breaking down protein (i.e. muscles) tosupply the needed nutrients.CARBOHYDRATESIt is important to eat an adequate amount of complex carbohydrates. Complex carbohydrates, asopposed to simple sugars, take longer to digest and do not result in such extreme swings inblood glucose levels. In addition, the guide recommends increasing your intake of fibre.PROTEIN REQUIREMENTS AND VEGETARIANISMWe require approximately 60 grams (2 ounces) of protein a day. Most North Americansconsume an excessive amount of protein. It is however important to eat an adequate amount ofprotein to permit muscle development. Proteins are made up of amino acids. There are 9“essential amino acids”. These are amino acids which the body is unable to make and which musttherefore be obtained in the diet. Dietary amino acids are necessary for protein synthesis andsubsequent muscle growth. Meats, poultry, fish, eggs and dairy products contain all 9 essentialamino acids. hi contrast, plant products (legumes; cereals - rice, wheat, corn; and roots) aremissing one or more of the essential amino acids. People who choose not to eat animal productsneed to ensure that they obtain sufficient protein from other these other sources. Because thebody can not store large quantities of amino acids, the different essential amino acids need to be111consumed together to enable the body to synthesize proteins. A combination of cereals andlegumes will ensure that you are obtaining the essential amino acids. For example, lentils andrice or baked beans on toast.DIETARY FATOne specific dietary recommendation which is now being consistently made is to decrease yourintake of fats. This is for a number of reasons. First of all excessive dietary fat can increase yourcholesterol. Increases in blood cholesterol levels increase your risk of heart attack and stroke.Secondly, fats contain double the amount of calories as do carbohydrates and proteins. Thirdly,dietary fats are converted to bodily fat with 25% greater efficiency than carbohydrates.Therefore, you will gain more weight when you eat an equal number of calories from fats thanwhen you consume the same number of calories from carbohydrates. Furthermore, people whodecrease fat intake tend not to compensate completely in their caloric intake and thus loseweight.At present the average Canadian obtains 40% of her calories from fat. The National Academyof Sciences recommends that calories derived from fats constitute only 20 - 30% of our totalcaloric intake. There are 4 main types of dietary fat:1. Saturated fats - are obtained mainly from animal products such as meat, millçbutter and cheese. Coconut and palm oils are also high in saturated fats.Saturated fats increase blood cholesterol. Therefore you want to limit your intakeof these fats.2. Polyunsaturated fats - these fats come primarily from fish; nuts like almonds,pecans and walnuts; vegetable oils like safflower, sunflower and corn oil.Polyunsaturated fats help to decrease blood cholesterol.3. Omega-3 fats - these help to lower triglycerides, a type of blood fat involved inthe development of heart disease. Omega-3 fats are a type of polyunsaturated fatand are found in fish oil and canola oil. Therefore increasing your intake of fishcan be very healthy.4. Monounsaturated fats - help to lower blood cholesterol, These fats are found inolive, canola, peanut and soya oils.The first step to decreasing fat intake is being aware of where/how you consume fats. Fats canbe found in almost all types of prepared food. If eating high fat content foods is normal for youit will take time, planning and effort to change this, As always, it is easy to slip back to oldhabits unless alternatives are readily available. Therefore, it is important that you examine youruse and intake of fats and make arrangements to adopt new ways. This involves making aconscious choice, buying alternatives and learning to cook in new ways etc.112The following are a few ways to decrease fat use:1. Buy a low fat cookbook. Books recommended by the Heart and Stroke Foundationinclude: The Light-hearted Cookbook by Anne Lindsay (Toronto: Key Porter Books,1988) and Light-hearted Everyday Cooking by Anne Lindsay (MacMillan Canada,1991).2. Prepare foods in ways other than frying: steaming, microwave, broiling. For everyteaspoon of butter, oil or margarine you eliminate you save 4 grams of fat.3. Buy a nonstick frying pan, so you don’t need to add extra oil or butter.4. Consider using a wok and cooking oriental style foods.5. Use spices or condiments such as soya sauce to flavour foods instead of gravies and richsauces.6. Use a small amount of jam instead of butter on toast.7. Skip the mayonnaise or butter on sandwiches; you may not even notice it is missing.8. Whip butter or margarine so that it spreads further.9. Use skim or 2% milk instead of whole milk or cream.10. Use yogurt instead of sour cream.11. Choose “light” products with less oil e.g. mayonnaise, salad dressings etc.12. Watch your use of cheese which can be very high in fat. Use skim milk cheese wheneverpossible.13. Choose tomato sauces instead of cream sauces on pasta.14. If you eat meat, choose lean cuts. Consider decreasing the amount of meat you use.15. Remove skin from chicken.16. Choose sherbet or frozen yogurt instead of ice cream.17. Have a whole wheat bun instead of a croissant,18, Try alternate foods. For example, if potatoes seem unpalatable without 3 Thsp of buttertry eating rice.19. Try some new foods: Do you eat lentils or dahl? What new vegetables would you like totry? Plant protein is generally lower in fat than protein from animal products. Trydecreasing the amount of meat you eat. Be adventuresome! Talk to friends who arehealthy and eat well. Ask for their ideas, recipes etc.20. Keep low fat foods readily available. For example, keep cut vegetable sticks in the fridgeso that when you’re hungry it is as easy to eat them as it is to eat a bag of potato chips.21. Prepare your own foods. Decrease oil called for in recipes and replace with othermoisture e.g. yogurt or apple sauce in muffins.22. If you are eating out, choose menu items with the smart heart symbol.113HOMEWORK1. Continue exercising a minimum of five times per week. Feel free to exercise more frequently!Remember long periods at lower intensity levels (e.g. 70% of your maximum heart rate) will beof greater benefit than short bursts at very high intensities.2. Keep following the exchange diet. Continue using the eating strategies we discussedpreviously: keep a specific eating area, eat slowly, pause frequently, use self-talk copingstrategies.3. If you are having difficulty following the exchange diet, or find you are not losing weight,make a list of how you obtain your fats e.g. butter on toast, deep frying and try to cut down onyour fat intake. Try the strategies in the handout.4. If you have not yet finished FIT OR FAT, be sure to finish it this week.114WEEK SEVENRELAPSE PREVENTIONLosing weight is difficult work and must be viewed as part of an ongoing process. Regardless ofthe degree of your initial success, it is natural to expect that you will have periods of difficulty.This does not mean that your accomplishments to date have been for naught. In the same vein, ifyou have not achieved what you initially hoped for, remember you have been exposed to ideaswhich you can choose to implement now and in the future. Because slips are to be expected, itis important to consider them in advance and plan for their occurrence, Remember, most peoplecan manage to loose weight, it is the maintenance phase in which most people fail.1. The changes you have implemented in terms of eating and exercise are part of anongoing, long-term process. As such you can anticipate slips along the way. If you can,view slips as isolated events which are to be expected and thus are not out of theordinary. This type of perception allows you to use the situation as a learning experience.A binge now says nothing about this evening, nor does it say anything about tomorrow.When you do have a lapse with eating or you fail to exercise, don’t try to compensate forit by restricting your subsequent food intake or over exercising. This will only increasethe chances that you will again binge. Instead, take time to learn from the situation, whatfactors contributed to the binge or to not exercising? How can these be overcome in thefuture? Try to write down what you learn as this wifi help you to remember and besuccessful in the long term.2. Plan. Plan. Plan. Make sure you have appropriate food in the house, “equipment” toexercise etc. What situations or factors have been problematic for you to date? When doyou fail to exercise? Under what circumstances do you tend to over eat? Take the timeto write down the situations in which you anticipate having difficulty in the future. Thentry to generate methods for avoiding these pitfalls. Do not expect all of your attempts toavoid slips to be successful. By planning in advance for situations which are likely to bedifficult or risky for you, you the likelihood of long-term success.3. When a lapse seems to be becoming a relapse. If you recognize that your weight issteadily increasing, your exercise and eating behaviours are returning to their old patterns(e.g. bingeing frequently, consistently not exercising) etc., use what you have learnedduring the past couple months. Attempt more rigorous planning and scheduling. Keeptrack of your weight and/or body measurements. Write down when and what you eat.Schedule exercise times and chart or graph your exercise. One thing which is importantfor most everyone, is being able to identify a relapse early on. This way you avoidredeveloping old habits, gaining large amounts of weight etc. Thus, you need to be ableto identify clearly when you have begun to relapse. This is something which you wiilhave to figure out for you. What is most helpful in terms of actually overcoming arelapse varies from person to person. What we do know is that having an advance plan isbeneficial, Therefore, it is important that you come up with an individualized game planthat will work for you.1154. Evaluation and Positive Reinforcement. We all know the value in rewarding children andpets when we are trying to teach them something new. The same thing applies for you.Evaluate your progress on a regular basis, Pick a time and each week examine how youhave done. Measure your success in terms of your own progress. Are you progressingtowards your goals: has your weight decreased since you started the programme, areyour binges down from five times per week to once a week, are you walking regularlynow where as six months ago you were not? Evaluate yourself over a reasonable periodof time. If you have just binged, don’t evaluate/berate yourself on your behaviours of thepast few hours. Instead view these behaviours in context. How have you done over thepast two weeks? Remember where you were two months ago. Remember to rewardyourself.HOMEWORKContinue exercising and following the exchange diet.For each of the risky situations you identified in group, generate specific methods of coping.Write down very specific ways of knowing when you have ‘relapsed”, e.g. have not exercisedfor X number of days; have had X episodes of overeating alone in bedroom.Construct a game plan which will be ready to put into action if you recognize a relapse isoccurring. Back to square one: planning, scheduling, monitoring etc. Write out how you aregoing to reinstigate appropriate behaviours, (include exactly what those appropriate behavioursare), how you will evaluate your success with getting back on track, and what you will do if youfeel as though you are not getting back on track. Try to be as specific as possible. Bring thiswith you next week.116WEEK EIGHTREVIEW HOMEWORKOver the past eight weeks you have been given a lot of information regarding ways ofovercoming your weight problem. Hopefully, you have acquired some new skills andinformation which you will find useful. The basic areas we covered were:-Eating: Eating regularly and healthfully is necessary if you are to be successful in losingweight. By now most of you should be feeling comfortable with the exchange diet andshould be able to eat enough not to be feeling hungry. At the same time, your caloricintake, especially in the form of fats should now be low enough to permit you to beregularly losing weight.-Exercise: Regular aerobic exercise is an important component of a healthy lifestyle anda necessary component for weight loss. Remember, exercise needs to be enjoyable if youare going to continue with it for the rest of your life. Persevere over the difficult initialphases till you reach the point where exercise is just a part of your life, like brushing yourteeth.-Methods for changing eating and exercise behaviours: We discussed the ideas ofstimulus control (e.g. keeping food out of sight, limiting eating to the kitchen table etc.)and shaping (working gradually towards goals which more and more closely approximateyour ultimate goal). We talked about the importance of rewarding yourself when tryingto change your behaviour.-Relapse Prevention: Last week we talked about relapse prevention. Because you willhave to continue with the changes in your eating and exercise behaviours for the rest ofyour life, relapse prevention is incredibly important for success. Remember to planregular time for self-evaluation, determine how you are making out, what you can do toimprove progress etc.These are lifestyle changes. They won’t happen overnight, but they will happen. It is soimportant for you not to become overly discouraged. There will be days when it is very difficult,but remind yourself that you have the rest of your life and you can take it one day at a time.Adopt and maintain a long term perspective. The short term outlook wifi only result in shortterm solutions, e.g. quickly regained weight losses. The hardest part is at the beginning. Takeheart, you wont always have to work this hard. Be kind to yourself and encourage yourself asyou would a friend. Base evaluation on your own progress and not on comparisons with otherpeople.We all need measures of success, goalposts etc. Unfortunately, we often use measures of weightas indicators about personal success. How ridiculous! Perhaps it is to someone’s advantage tokeep us using such measures but it is surely not to ours. Is a 100 lb. body really the answer tolife’s problems’? Be aware of society’s strong arm in our beliefs about what constitutes a healthy117and attractive body. An inappropriately thin ideal is so widely accepted in western culture thatyou will often find yourself having to accept and/or present what will seem like counterrevolutionary ideas. Be brave in your thoughts and actions. Adopt new standards, ones that arebeneficial for you. Self knowledge is the key to change. Be a risk-taker, try new things, workhard, take credit for accomplishments. Accept and respect yourself, all of yourself, includingyour body, today. Allow yourself to feel contentment and happiness. Remember real lastingcontrol comes from making choices.NOTE: Many of the ideas and sections in the handouts of the last 8 weeks have been taken from‘The Road to Recovery”, a Manual for Participants in the Bulimia Treatment Program by RonDavis et al.118ReferencesAnderson, K.M. & Kannel, W.B. (1992). Obesity and disease. In: P. Bjömtrop & B.N. Brodoff(Eds.), Obesity, (pp. 465-473). Philadelphia: J.B. Lippincott Company.Bailey, C. (1991). The New Fit or Fat. 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