In reading the discussion of obesity in the May issue of Canadian Family Physician,1,2 we were astonished and disappointed, both as clinicians and researchers, to discover strong attitudes suggesting that obesity should not be treated. We found it particularly alarming that doctors should feel so hopeless; they are no doubt transmitting this frustration to their patients. Thus, we are concerned that numerous obese individuals will be discouraged from taking better care of themselves. This letter examines the basis for hopefulness in obesity treatment research, considering the results of our own research program.
In thinking about whether obesity should be treated, we considered the effect of the well-documented negative bias among health professionals—physicians, nurses, psychologists, dietitians, and others—against obese people and the negative attitudes toward the subject of weight management. The obese individual is blamed for the problem and is thought to be perhaps less deserving of care. Such biases, implicit and explicit, have been shown time and again.3
It is our opinion that those offering far-reaching conclusions about whether obesity “should” be treated1,2 need to recognize the possibility of their own negative biases toward the obese patient and the weight management process. Negative attitudes in practitioners might be linked to their feeling ill-equipped to conduct this type of counseling.4 It is unknown to what extent practitioners are conscious of such feelings of low self-efficacy.
Doctors very frequently prescribe healthy behaviour like better eating, exercise, and stress reduction.5,6 In fact, these are the fundamentals of weight management. Are doctors more effective at influencing health behaviour than they are at influencing weight management? There is a paradox in which doctors recognize and support the practice of healthy behaviour (in regard to eating, exercise, substance use, stress, mood, and sleep), but dismiss the likelihood of successful weight management. If an obese person improves on these health behaviour dimensions, isn’t it a virtual certainty that he or she will lose weight?
Developing a better theory
Most of the available obesity treatment research has looked at outcomes primarily in terms of weight change, with insufficient attention to concurrent changes in behaviour, attitudes, and emotions, and there is almost no consideration of the treatment process. A theory-based account of how processes lead to weight control outcomes over time is needed. If we observe a negative outcome, there is no way to engineer better treatments without a strong theory. Our research is an example of a more theory-based approach—an analysis of process and outcome in weight management based on a reliable set of measures of psychological variables and the therapeutic alliance, as well as body mass index and other physiologic variables.
If the outcome of obesity treatment is very poor, as some believe, then we must try harder to understand why results are so poor and develop a better theory that will predict more successful outcomes. This is not the time for hopelessness. To develop and test such a theory, we need studies with multiple observations over time and under different conditions. This type of research design is a perfect fit for obesity treatment, which involves ongoing treatment visits and assessments over a long period. In recent years we have used this type of repeated-measures design with a multilevel modeling analysis to show the following.
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Early (approximately 1 month) improvements in both weight and eating habits (less uncontrolled eating) predict better later weight changes (at up to 9 months).7 This indicates that we must pay very close attention to early treatment results.
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Changes in “negative” weight control motivation (feelings of resentment, regret, doubt, and effort) are related to changes in weight and improvements in eating behaviour and mood. “Positive” weight control motivation (beliefs that weight is causing physical or emotional suffering, and expectations that better weight control will have physical or emotional benefits) is not associated with weight or psychological changes.8 It is clear that the negative motivation dimension must be a focus of treatment research.
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Improvements in psychological variables (eating, depression, stress, perfectionism, negative motivation) are related to improvements in the therapeutic alliance between clinician and patient; the alliance is related to weight loss outcomes, but this effect is fully mediated by changes in psychological variables. Thus, the alliance directly influences the patient’s mood and behaviour, which are directly related to weight change (C. Larocque et al, unpublished data).
Commitment and optimism
Our combined body of research leads us to conclude that the outcomes of weight control treatment are more predictable than previously believed.9 This research brings needed optimism for practitioners deciding to venture into the field of helping people with their weight. Patients often feel hopeless about weight control and seek support from their doctors and therapists. We must practice hope, as we continue to conduct theory-driven research to try to better understand the processes of weight control failure and success. We were motivated to write this response to counter what we saw as a particularly negative viewpoint that some, but not all,10 professionals seem to have about obesity treatment. We believe it is important to promote a stronger commitment to treating this problem.
Our research shows that some of the causes of success and failure are controllable, such as helping patients to address their negative attitudes about the weight control process and establishing a good working alliance. Our research shows it is not the initial levels of psychological variables (eg, depressed mood, emotional eating) or the alliance that predict outcome, but changes in these variables. Patients improve (and backslide) in all of these dimensions simultaneously, which shows that practitioners must be sensitive to such changes. If we accept the premise that lifestyle change is possible—although a difficult, variable, and long-term process—we are likely to achieve better outcomes. Surely we must not stop trying to better understand weight control, as we work to develop better ways to help individuals improve their health behaviour.
Footnotes
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Competing interests
None declared
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