Role for a sense of self-worth in weight-loss treatments

Case description

Ms R., a 43-year-old married woman with sons who are 7 and 9 years old, works full-time as a nurse in a hospital. She is 5 feet 4 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 is evident when sincere, intelligent people express an enduring desire to achieve an achievable goal but repeatedly undermine their own efforts to do so. The internal struggle between the patient’s desire to be healthy and her lack of faith in herself 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 endeavours such as sports and education, as well as in business and personal relationships,13,21 but has been overlooked in the weight-reduction realm. Ms R. is an educated woman and might be receptive to an approach that gives her tools to improve her self-efficacy. Diet, discipline, and exercise are 3 pillars of the extensively studied CBT model and are clearly necessary for success, but they are not sufficient by themselves.6 The fourth pillar is the self-efficacy that patients need in order to consistently apply the diet, discipline, and exercise principles.

Sources of information

PubMed, PsycINFO, and Google Scholar were searched for original weight-loss research articles and treatment reviews. Key search terms were weight loss, weight-loss treatments, diets and weight loss, psychology and obesity, physiology and obesity, and exercise and weight loss. The American Psychological Association Journals Online and the International Journal of Obesity were also extensively reviewed. Over the past 20 years, 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 psychoemotional issues. The 2007 review paper on the role of self in life by Swann et al14 provides a wealth of research on the value of programs for the enhancement of the sense of self-worth and self-efficacy.

Exercise

Whereas these nutrition guidelines are familiar to most patients, the nature and frequency of exercise required for lasting weight loss2,23,24 will initially be an unacceptable shock to many. Overweight patients often insist that they would like to exercise but do not 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 might withdraw. If, on the other hand, the physician softens the message, the patient might revert to little or no meaningful exercise.*

Disease model

Overweight patients should be informed of the inaccuracies in media articles that suggest that biological causes are largely to blame for weight gain. This model, the disease model, is described by D.F. Klein of Columbia University and the New York State Psychiatric Institute8 as a model wherein an individual suffers from an affliction that exempts him or her from personal responsibility. The person cannot help being ill and cannot get well by taking any form of action. This model validates the beliefs of those overweight patients who see themselves as victims of their biology. It might also be helpful to mention that Goel et al9 found that 8% of immigrants arriving in the United States were overweight and, 15 years later, 38% of them were overweight.

Clinicians and researchers who work from the disease model focus on obesity while minimizing the role of the patients in becoming 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, Geenland et al25 studied the lifestyles 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.

Some weight-loss researchers have overlooked the decision makers who overeat unhealthy food, who exercise rarely, insufficiently, and inconsistently,23,24 and who enmesh their emotions with food.26–28 When some do lose weight but regain it after 1 or 2 years, biology is often blamed. The research on treatment models has given insufficient attention to the decision makers who must apply the directives from the CBT model.6

Cognitive-behavioural model

Most patients have read that diets usually do not work, but they tend to find this message in commercials for new weight-loss products. They should, therefore, be given a brief factual summary of diets, all or most of which are based on the CBT 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.6,13,29 In its most basic form, it provides detailed nutrition guidelines along with cognitive and behavioural changes that will bring about weight loss if applied consistently over time. The model is easy to understand, it can be readily taught, it is compatible with the available research, and it lends itself to standardization of treatment. Unfortunately, however, it has not provided meaningful benefit to the vast majority of overweight people.6,30

Self-worth and self-efficacy

We are creative, active beings and each of us has our own reality. Our sense of self, which is part of our reality, is a subjective, emotion-laden, ongoing self-evaluation of worthiness, competence, and social acceptability. 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.

Ego damage is harm to one’s sense of self-worth, and many overweight patients come from ego-damaging families28,33–35 in which they developed a 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.28

Self-efficacy arises from a sense of self-worth. It is the faith in self that gives rise to personal initiative, persistence, self-confidence, and optimism.14,20,36,37 Positive changes in thinking and behaviour are fundamental to all psychotherapy treatments, but a sense of 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 adequate or inadequate, they live accordingly.14–17,36–39 Perception of self is experienced as reality and a negative self-perception robs many overweight patients of the faith in self to do what it takes to be healthy.

Enhancement of self

In their recent review paper, Swann and colleagues14 confirm that self-perceptions do influence our decision making, our resolve, and our actions. They therefore recommend the development of programs to improve these self-perceptions. Family physicians can teach willing patients, such as Ms R., how to identify and therapeutically respond to their problematic perceptions of self.26,36,37

Areas of controversy

There are 3 primary areas of controversy in the weight-loss realm. The first can be illustrated by a quote by Will Rogers: “Often it’s not what we don’t know that causes problems, it’s what we know that isn’t so.” When we view the culturally specific and relatively recent pattern of weight gain among North Americans as a disease, we research it as a disease and we treat it as a disease. This approach has not been effective. When we view it as a predictable result of the self-perception, attitudes, decision making, and behaviour of the decision makers, we can focus on programs for the enhancement of their self-worth and self-efficacy so our patients make healthier decisions.

The second area of controversy has focused on the uncertain value and practicality of self-worth enhancement. After thoroughly reviewing this controversy in their recent paper, Swann et al14 endorse self-worth enhancement for improved functioning in a range of personal endeavours.

The third area of controversy is the concern that patients will not participate in programs for self-worth enhancement. This is an unfamiliar approach to weight loss and some will not participate. Many others will not at first, but most smokers were also initially reluctant to exchange their addiction for their health, yet many have done so.

Levels of evidence

Level I: At least one properly conducted randomized controlled trial, systematic review, or meta-analysis

Level II: Other comparison trials, non-randomized, cohort, case-control, or epidemiologic studies, and preferably more than one study

Level III: Expert opinion or consensus statements