*NOTE - The following paper by Dr. Gordon Cochrane was published in the medical journal, The Canadian Family Physician, April, 2008 (pgs 543-547).

Canadian Family Physician
April, 2008, 543-547

A Role for Self-Worth in Weight Loss Treatments:
Helping Patients Develop Self-Efficacy

By Dr. Gordon Cochrane

ABSTRACT

OBJECTIVE To summarize the literature on weight-loss treatments and recommend strategies for self-worth and self-efficacy enhancement that will help patients more effectively make healthy choices.

SOURCES OF INFORMATION PsycINFO, Google Scholar and APA journals on-line were searched for original research articles on treatment models and review articles. I also drew upon my own 22 years of clinical work with overweight patients and the APA research published during those years.

MAIN MESSAGE In spite of extensive research, we have failed to stem the tide of weight-gain in North America. The focus has been on physiological, behavioral and cultural explanations for this relatively recent phenomenon while the internal dynamics of overweight individuals has been overlooked. Professional treatments are cognitive-behavioral in nature and rest on the premise that overweight patients will effectively apply the CBT principals. Commercial programs sell the dream but, in the long-run, professional and commercial programs are equally ineffective. We need treatments that include strategies to repair ego-damage, enhance self-worth and develop self-efficacy so that overweight patients can become the agents of their own well-being.

CONCLUSION Self-efficacy correlates positively with success in all realms of personal endeavor and we can help our overweight patients become more self-reliant.

North Americans are increasingly overweight^1,2,3 and the risk factors of excess weight for numerous health problems have been confirmed^4,5 as has the financial burden on our health system.⁴ Weight-loss treatment models ranging from the familiar cognitive behavioral (CBT) model, which consists of recommendations for a healthy diet and regular exercise, to commercial programs, books and products all share consistently disappointing outcomes.^1,2,3,6,7 and have remained fundamentally the same for the past 30 years.⁶ Research also shows that the genetic, metabolic and hormonal contributions to this relatively recent and culturally specific weight phenomenon are comparatively minimal^8,9,10,11 and overweight people continue their search for an external solution to a problem that primarily arises from their decision-making.⁸

In an American Dietetics Association poll in 2000, 40% of the overweight people polled said that they didn't want to give up their unhealthy lifestyle in order to be healthy. Most overweight people however, do want to lose weight. Unfortunately, their search for an external solution makes the dream marketed by commercial weight-loss programs very appealing.^2,7 We can help our willing patients by giving them the tools and support to make the shift from an external to an internal locus of control. As far back as 1960 Feinstein¹² found that personal initiative and a positive relationship with the physician are more important than the treatment model. Though it is not an easy undertaking, family physicians can help receptive overweight patients take appropriate steps to develop the attitudes and commitment to self-care that are evident among people who consistently take care of their physical and emotional well-being.^{13,14,15,16,17,18,19,20} Fast food outlets, junk food, nutritional food and fitness centers are available to everyone. Overweight people interact with them differently than do fit people.

Case introduction

Ms. R., a 43-year old married woman with sons of seven and nine years old, works full time as a nurse in a local hospital. She is five feet four inches tall and weighs 212 pounds. She tearfully describes to her family physician the distress and frustration that she feels about her perceived inability to lose weight. She says that she feels defeated and ashamed. Ms. R. has tried many diets and diet products over the years and now feels that nothing works. It is evident that she has a persistent desire to lose weight. It is equally evident that she is expressing her version of the must-but-cannot dilemma familiar to millions of overweight people. This dilemma manifests when sincere intelligent people express an enduring desire to achieve an achievable goal but repeatedly undermine their efforts to do so. The internal struggle between the patient's desire to be healthy and her lack of faith in self to do what it takes is reflected in the well-documented pattern of short-term weight-loss followed by relapse that is independent of treatment models. The must-but-cannot dilemma is recognized and treated in endeavors such as sports, education, business and personal relationships^13,21 but has been overlooked in the weight-reduction realm. Ms. R. is an educated woman and may be receptive to an approach that gives her tools to improve her self-efficacy. Diet, discipline and exercise, the three pillars of the extensively studied cognitive-behavioral model, are clearly necessary for success but they are not sufficient for success. The individual who is undertaking this endeavor must have the self-efficacy to utilize, over time, these cognitive behavioral principles.

Sources of information

PsycINFO and Google Scholar were searched for original weight-loss research articles and treatment reviews. The APA journals on-line and the International Journal of Obesity on-line were extensively reviewed. There are numerous original articles on weight-loss treatments from the past 45 years and there are a number of reviews (1960, 1979, 1994, 2005) on short-term and long-term outcomes arising from these treatments. Since the publication of my own weight-loss research in the early eighties, I have built an extensive dossier of Level I and Level II research on treatment models, the search for genetic causes and the role played by psycho-emotional issues. The 2007 review paper on the role of self in life by Swann et al¹³ provides a wealth of research on the value of programs for the enhancement of self-worth and self-efficacy.

Main message

Basic information for patients

Family physicians know that some overweight patients have little or no interest in losing weight and some who want help are reluctant to accept the primary role in their weight-loss. However, some are willing to learn how they can take control of their own health and they will value accurate weight-reduction information, tools for personal change and supportive encouragement from their physician. A trust-based relationship with the patient gives the family physician an opportunity to respectfully challenge the patient's weight-loss myths and avoidance strategies with information, analogies and friendly humor.¹⁶ Most overweight patients have tried numerous diets and are therefore reasonably knowledgeable about nutrition though they don't apply their knowledge with consistency. These patients can be given a one-page summary of nutrition guidelines from the ongoing work of Drs. Frank Hu and Walter Willett of the Harvard School of Public Health. They recommend a Mediterranean style of eating that is rich in vegetables, fruits, whole grains, nuts, unsaturated vegetable oils and protein derived from fish, beans and chicken but not red meat. They also recommend that consumption of animal fats be minimized and trans fats be reduced to near zero. This is sufficient for most as extensive information about diet and nutrition is not a predictor of positive outcome.²

Whereas these nutrition guidelines are familiar to most patients, the nature and frequency of exercise required for lasting weight-loss^17,18 will initially be an unacceptable shock to many. Fit people work out rigorously and regularly. Overweight patients often insist that they would like to do the same but they don't have time. This is a self-efficacy issue and represents a critical moment in patient care. If the family physician is too forceful about the realities of exercise, the patient may withdraw. If, on the other hand, the physician softens the message, the patient may revert to little or no meaningful exercise.

Additionally, overweight patients should be informed of the inaccuracies in media articles that suggest a biological cause for the pattern of weight gain. This model, the disease model, is described by D.F. Klien of Columbia University, New York State Psychiatric Institute⁷ as a model wherein an individual suffers from an involuntary affliction that exempts him or her from personal responsibility for the affliction. The person cannot help being ill and cannot get well by taking some form of action. This model validates the beliefs of overweight patients who see themselves as victims of their biology. It may also be helpful to mention that Goel et al ⁸ found that 8% of immigrants arriving in the United States are overweight and 15 years later, 38% of them are overweight.

Clinicians and researchers who work from the disease model focus on obesity while minimizing the role of the persons who become obese. This perspective restricts the range of research questions and excludes consideration of other potentially mediating variables such as the decision-making of overweight people. For example, Philip Geenland et al⁹ studied the life-styles and heart problems of 400,000 people over a 30-year period and found that unhealthy choices, including excessive food consumption and insufficient physical activity were evident in 90% of the participants.

Weight-loss researchers have overlooked the decision-makers who overeat unhealthy food, who exercise rarely, insufficiently and inconsistently^17,18 and who enmesh their emotions with food,^20,21. The research on treatment models has given insufficient attention to the decision-makers who must apply the directives from the cognitive-behavioral models².

Most patients have read that diets don't work but they usually find this message in commercials for a new weight-loss product and should therefore be given a brief factual summary of diets, all of which are based on the cognitive-behavioral model. This model has dominated the weight-loss literature for decades even though it repeatedly shows a pattern of moderate short-term success followed by relapse.^2,9,22 In its most basic form it provides detailed nutrition guidelines and guidelines for cognitive and behavioral changes that, if applied consistently over time, will bring about weight-loss. The model is easy to understand, it can be readily taught, it is research-compatible and it lends itself to standardization of treatment but, it has not provided meaningful benefit to the vast majority of overweight people.²³

Self-worth and self-efficacy

We are creative, active-information-processing beings for whom reality is unique. Our felt-sense of self, which is part of our reality, is a subjective, emotion-laden ongoing self-evaluation of our worthiness, competence and social acceptability and it functions as the perceptual screen through which we experience life. Our self-evaluations begin in childhood and are solidified over time through our selective attending and meaning attributions. Many overweight patients came from ego-damaging families^24,25,26,27 wherein they learned a felt-sense of inadequacy. Many learned to put the needs of others ahead of their own leaving little time to attend to their own health. Their subsequent weight-gain is then perceived as confirmation of their inadequacy.

Self-efficacy arises from self-worth. It is the faith in self that gives rise to personal initiative, persistence, self-confidence and optimism.^13,15,28,29 Changes to patterns of thinking and behavior (CBT) are fundamental to all psychotherapy treatments but self-worth, which is a perceived and felt sense of self, cannot be meaningfully altered with CBT alone. When people perceive themselves as attractive or unattractive, intelligent or unintelligent or, more globally, adequate or inadequate, they live accordingly.^{14,15,28,29,33,35} Their self-perception is experienced as reality and a negative sense-of-self robs overweight patients of the faith-in-self to do what it takes to be healthy.

The enhancement of self

Family physicians can teach willing patients such as Ms.R, how to identify and therapeutically respond to their problematic self-perceptions.^20,28,29 These patients can also be taught how to self-monitor so they can identify the specifics of their emotional relationship with food.^{20,21,24,27,28,31,35} They can be shown how to use simple imagery activities ²⁹ wherein they close their eyes, relax, picture their goal and then, using a simple device such as an imagined photo album containing photos of the most influential experiences of their life, they bring to awareness the origins of their emotion-laden self-critical conclusions.^{10,11,12,14,24} When patients are reminded that their self-negating conclusions were derived by the younger, less independent and less experienced person that they were at the time, they can be encouraged to view themselves now as a compassionate, wiser and supportive provider of therapeutic guidance for the person they were in the past. This is the committed relationship with self that is the cornerstone of self-worth enhancement.²⁹ The patient's growing sense of worthiness and faith in self enables him or her to experiment with the attitudes and behaviors familiar to people who live healthy self-respecting lives^{13,14,15, 24,35} and they will increasingly understand and accept what it takes to maintain good health. Most patients like Ms. R. can do this therapeutic work at home if they supplement it with regular visits with their family physician.

The pace of change will vary with the nature of the ego-damage experienced by each patient. Some patients will decline this opportunity but many will welcome it. Those with more severe psychological damage²⁷ may, if it seems necessary, be referred to a psychologist or psychiatrist. Repairing ego-damage, dealing with ongoing emotions and building self-worth are challenging tasks for anyone but weight-loss treatment models that do not include these undertakings are ineffective.^1,2,3,5,9,23

Case conclusion

Ms. R. accepted, with some initial reluctance, personal responsibility for the care of her own health. Over time she adopted a Mediterranean style of eating, joined a fitness center, hired a trainer for six sessions and committed to work out a minimum of four times a week. She scheduled bi-weekly appointments with her family physician where she received support, guidance and clarification of her imagery-facilitated work on self-worth enhancement. After two years of dedicated effort, including setbacks and frustrations, Ms. R. brought her weight down to 148 pounds while greatly improving her fitness level. When asked how she accomplished this outcome, she said that she learned to think of herself as a competitive swimmer with a good coach and a clear understanding that it is her body in the water doing the swimming.

Conclusion

Weight-reduction is a daunting endeavor for our overweight patients but it is an achievable endeavor for those who will accept support, guidance and tools for self-worth enhancement from their family physician.

References

1. Flegal K, Carroll M, Kuezmarski R, Johnson C. Overweight and obesity in the United States: Prevalence and trends, 1960-1994. Int J Obes 1998; 22: 39-47.
2. Pittler, MH. & Ernst, E. Complementary therapies for reducing body weight: A systematic review. Int J of Obes 2005;Vol. 29, 9, 1011-1029.
3. Moore, BA. & Bowers, A. Weight loss. In J.E. Fisher & W.T. O'Donohue (Eds.), Practitioner's guide to evidence-based psychotherapy. 2006; New York: Springer. 734-743.
4. Birmingham CL, Muller JL, Palepu A, Spinelli JJ, Anis AH. The cost of obesity in Canada. JAMC 1999; 160 (4) 483-488.
5. Peeters A, Barendregt JJ, Willekins, F, Mackenbach, JP, Mamun AA, Bonneux L. Obesity in adulthood and its consequences for life expectancy: A life-table analysis. Annals of Internal Medicine 2003; Vol. 138; No.1; 24-32.
6. Wilson GT. Behavioral treatment of obesity: Thirty years and counting. Advances in Behavior Reaserch and Therapy 1994; 16 (1): 31-75.
7. Wadden TA, Tsai AG. Systematic review: An evaluation of major commercial weight loss programs in the United States. Annals of Internal Medicine January 04, 2005; 142: 56-66.
8. Klien DF. Harmful dysfunction, disorder, disease, illness and evolution. J Ab Psych 1999; Vol. 108, No.3, 421-429.
9. Goel MS, McCarthy EP, Phillips RS & Wee CC. Obesity among US immigrant subgroups by duration of residence. JAMA 2004; 292: 2860 - 2867.
10. Davies, K.M., Heany, R.P., Recker, R.R., Barger-Lux, M.J. & Lappe, J.M. Hormones, weight change and menopause. International Journal of Obesity 2001; 25, 874-879.
11. Corica, F., Corsonello, A., Luchetti, M., Malara, A., DeDomenico, D., Cannavo, L., Foti, S., Valenti, A., Ientile, R. & Saitta, A. Relationship between metabolic syndrome and platelet responsiveness to lepitin in overweight and obese patients. International Journal of Obesity, 31, 842-849.
12. Feinstein A. Obesity treatments: a literature review. J Chronic Disorders 1960; 11: 349-357.
13. Swann, W.B., Chang-Schneider, C., & McCarty, K.L. Do people's self-views matter? Self-concept and self-esteem in everyday life. Am Psych 2007; 62, 2, 84-94.
14. Smith LM, Fouad NA. Subject-matter specificity of self-efficacy, outcome expectancies, interests and goals: Implications for the social-cognitive model. J Consult Psych 1999; 46, 4, 461-471.
15. Bennet P, Moore L, Smith A, Murphy S Smith C. Health locus of control and value for health as predictors of dietary behavior. Psych Health 1994; 10, 1, 41-54.
16. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development and well-being. Am Psych 2000; 55, 1, 68-78.
17. Stajkovic AD, Luthans F. Self-efficacy and work related performance: A meta-analysis. Psych Bull 1998; 124(2): 240-261.
18. DuBois DL, Flay BR. The healthy pursuit of self-esteem: Comment on alternative to Crocker and Park (2004). Psych Bull 2004; 130(3): 415-420.
19. Bandura A. Human agency in cognitive theory. Am Psych 1989; 44(9): 1175-1184.
20. Martin DJ, Garske JP, Davis MK. Relation of therapeutic alliance with outcome and other variables. J Consult Psych 2000; 68, 3, 438-450.
21. Cochrane, GJ. The Self-Worth Odyssey 2008. Devon Productions, Vancouver.
22. Jeffery RJ, Wing RR, Thorson C, et al. Use of personal trainers and financial incentives to increase exercise in a behavioral weight-loss program. J Consult Clin Psych 1998; 66 (5): 777-778.
23. Wadden TA, Vogt RA, Foster GD et al. Exercise and the maintenance of weight-loss: A one-year follow-up. J Consult Clin Psychol 1998;66(2);429-433.
24. Greenland P, Knoll MD, Stamler J, Neaton JD, Dyer AR, Garside DB, Wilson PW. Major risk factors as antecedents of fatal and non fatal coronary heart disease events. JAMA 2003; 290: 898-904.
25. Polivy J, Herman CP, McFarlane T. Effects of anxiety on eating: Does palatability moderate distress induced overeating in dieters? J Abnorm Psych 1994; 103: 505-510.
26. Heatherton TF, Baumiester RF. Binge-eating as an escape from self-awareness. Psych Bull 1991; 110 (10):86-106.
27. 22.Wing R, Jeffery, RW. Outpatient treatments of obesity: A comparison of methodology and clinical results. Int J Ob 1979; 3: 261-279.
28. Harvey EL, Glenny AM, Kirk SFL, Summerbelt CD. A systematic review of interventions to improve health professionals' management of obesity. Int J Obes 1999; Vol 23(12)1213-1222.
29. Cochrane GJ, Friesen J. Hypnotherapy in weight loss treatment. J Consult Clin Psychol 1986; 54(4): 489-492.
30. Matz, PE, Foster GD, Faith MS & Wadden TA. Correlates of body image dissatisfaction among overweight women seeking weight loss. J Consult Clin Psychol 2002; 70(4): 1040-1044.
31. Pike KM, Rodin J. Mothers daughters and disordered eating. J Abnorm Psychol 1991; 100(2): 198-204.
32. Johnson JG, Cohen P, Brook JS, Kotler L, Kasen S. Psychiatric disorders associated with risk for the development of eating disorders during adolescence and early adulthood. J Consul Clin Psychol 2002; 70, 5, 1119-1128.
33. Baumeister RF, Scher SJ. Self-defeating behavior patterns among normal individuals: A review and analysis of common self-destructive tendencies. Psych Bull 1988; 104(1): 3-22.
34. Cochrane, G.J. How to Build Your Self-Worth, Self-Esteem, Self-Confidence & Optimism: What Works and What Dosn't. 2008.
35. Parsons TJ, Power C, Logan S, Summerbell CD. Childhood predictors of adult obesity: a systematic review. Int J Obes 1999; 23: Supp 8, S1-S35
36. Greeno CG, Wing R.R., Shiffman S. Binge antecedents in obese women with and without binge eating disorder. J Consul Cl Psych 2000; 68, 1, 95-102.
37. Dominy NL, Johnson WB, Koch C. Perception of parental acceptance in women with binge eating disorder. J Psych 2000; 134, 1, 23-36.
38. Taylor SE, Kemeny ME, Reed GM, Bower JE, Greunewald TL. Psychological resources, positive illusions and health. Am Psych 2000; 55, 1, 99-109.
39. Carels RA, Douglas OM, Cacciapaglia HM, O'Brien WH. An ecological momentary assessment of relapse crisis in dieting. J Consult Clin Psych 2004; 72, 2, 341-348.
40. Salovey P, Rothman AJ, Detweiler JB, Steward WT. Emotional states and physical health. Am Psych 2000; 55, 1, 110-119.