Learning Objectives

This is an Intermediate Level course. After completing this course, mental health professionals will be able to:

• Discuss the biological and environmental determinants of obesity.
• Describe the controversy regarding food addiction.
• Differentiate between three types of bariatric surgery.
• Explain how you would sensitively discuss weight concerns with a defensive client.
• List three components of a cognitive-behavioral treatment program.

This course is intended to provide the mental health professional with an overview of the measurement, etiology, and treatment of people with obesity and weight concerns. It is based on currently available research along with clinical observations of the author. Psychological and medical approaches to understanding and treating people with obesity and weight concerns change and grow daily, and new information may emerge that supersedes some content in this course.

Outline

• Introduction
• Stigma
  • Why Is Obesity Shameful?
  • Understanding Body Mass Index
  • Apples vs. Pears
  • Health at Every Size?
• Why Gaining Is Easy but Losing Is Hard
  • Is The Fat in Your Genes?
  • Nature vs. Nurture
  • Environment and Choice: Not All the Fat Is in Your Genes
• Is Your Client a Food Addict?
• Help May Be on the Way
• Diets, Drugs, Supplements and Surgery: What Works?
• Getting Off the Diet Roller Coaster
  • The Revised Restraint Scale
  • Understanding Food Choice and Weight
  • Portion Size Guide
  • Intermittent Fasting
  • Meal Replacements
• Diet-Based Programs
• Intermittent Fasting
• Nonprofit Group Methods
• Web-Based Methods
• Supplements
• Medication
• Surgery
• Cognitive-Behavioral Treatment
  • Talking About Weight
  • Assessing Readiness
  • Goal Setting
  • Components of Cognitive-Behavioral Treatment
  • Eating Behaviors
  • Emotional Eating
  • Restaurants and Social Events
  • Adding Technology to Treatment
  • Maintenance and Relapse Prevention
  • Additional Methods
• Childhood Obesity
  • Helping Parents Walk the Weight Tightrope
  • Helping Parents Concerned About Their Children’s Weight
  • Healthy Eating
  • Physical Activity
  • Body Image
  • School Programs
• Final Thoughts
• References

Introduction

You know the stats: two thirds of all Americans are overweight or have obesity. You’re probably aware that the obesity epidemic presents serious problems – everything from increased risk of diabetes and cardiovascular disease to the estimated quarter of a billion dollars it costs for the extra jet fuel airlines need to carry their overweight passengers.

What is less obvious is that, if you’re a health professional, many of your clients, regardless of their diagnoses or presenting problems, are concerned about their weight. Even if they aren’t in a formal weight loss program or consulting you regarding an eating disorder, their weight concerns may play a critical role in their treatment. Medical problems ranging from sleep apnea to back pain to stroke may be affected by excess weight. Psychological difficulties including depression, marital conflict, and self-esteem issues frequently include a weight component. Issues such as body dissatisfaction, health risks associated with obesity, or concerns about their children’s weight and eating habits may emerge in your work with your clients.

It’s hard for your clients to ignore all the conflicting information they are exposed to about diets, weight, and exercise. The media is full of confusing reports revolving around these issues. TV programs show extreme methods for losing weight. Magazines, websites, and talk shows are full of stories highlighting one diet or another. Even if your clients limit themselves to more serious media, there’s a never-ending stream of articles reporting findings from university and medical center studies. So how do they keep up?

Unfortunately, while there’s no easy answer, your clients may ask your opinion about Ozempic or Wegovy, the latest diet or something they read or saw on TV. Even if they don’t ask your opinion, their beliefs about diet and weight may affect how they approach the medical or psychological issues you are treating.

It’s not uncommon for clients to want to know THE cause of their weight gain. But there rarely is a single cause. Diets, supplements, and programs often oversimplify and claim to have the solution to your clients’ weight concerns. Although it would be easier if there were a single determinant of weight, everything from genetics, to brain function, physiology, emotions, relationships, culture, economics, politics, and even urban planning play a role in how much anyone will weigh. Given this complexity, how are you going to address your client’s concerns? How can you help them resolve, or at least understand, their weight issues?

This course, based on my book, Weight, Diet, and Body Image: What Every Therapist Needs to Know (2016, PESI Publishing & Media), is designed to do just that. It offers an overview of the processes that determine weight without delving too deeply in the technical aspects or methodology of the research findings. It will provide the basic information you need in order to offer realistic help to your clients. You can refer to my book for additional information about eating in response to physical hunger, external cues, emotions and relationships.

Stigma

Whenever I’m giving a workshop and use the word fat, someone in the audience will cringe visibly. The stigma and shame associated with the word is sufficient to elicit a physical response. As we’ll see, the word fat doesn’t just connote adipose tissue (the technical term for fat) but rather a constellation of personal and moral failings that have resulted in a body that is considered shameful and unattractive.

Unfortunately, the shame associated with fat is counterproductive – it makes it more difficult to effectively control weight. One of the first goals in working with weight-conscious clients is to decrease the shame associated with obesity. Becoming comfortable with the word fat is a good starting point.

Let’s look at the terminology we’ve been accustomed to using. When I was a child, husky was a euphemism for fat boys. Husky has gone out of fashion but we have dozens of other terms to describe people who have bodies that are considered to be large. Words such as full-figured, big-boned, heavyset, Rubenesque, etc. enable us to avoid using the term, fat. Parts of the body in which fat tissue accumulates are frequently described as bubble butts, love handles, beer bellies, thunder thighs or other supposedly humorous terms. Some of these terms are nonsensical. For example, big-boned suggests that an individual’s weight is a result of their bone structure, yet bones account for less than 10 percent of body weight. Even if the bones were huge, it wouldn’t explain anyone’s having obesity. Why is it necessary to come up with all these terms that have the sole purpose of allowing us to avoid saying fat?

Why is Obesity Shameful?

If you’re going to be working with clients who’ve been struggling with their weight, it’s important to understand the effects of the shame and stigma they’ve experienced. For example, at work, overweight people earn less than normal weight people in comparable positions, get fewer promotions, and are viewed by their co-workers as lazy, less competent, and lacking in self-discipline. In schools, teachers view overweight students as untidy, more emotional, and less likely to succeed in their studies.

The anti-obesity stigma can also affect close interpersonal relationships. One study found that men were more likely to respond to a personal ad for a woman with a history of drug problems than to an ad for a woman with obesity (Sitton & Blanchard, 1995). Another study of more than 2,000 women with obesity or overweight found that 72 percent reported that family members teased them, called them pejorative names, and made negative comments about their weight (Puhl & Brownell, 2006).

Even when they seek medical care, individuals with obesity are viewed as lazy, lacking in self-control, weak-willed, sloppy, and dishonest. Interestingly, the negative view of obesity in healthcare settings goes both ways. A recent study found that patients were less inclined to follow medical advice and more likely change providers if the doctor had obesity or overweight (Puhl et al., 2013). Weight bias in healthcare isn’t limited to physicians. One study of nurses found that 24 percent were “repulsed” by patients with obesity (Maroney & Golub, 1992). In another study, psychologists were found to attribute more pathology, more severe symptoms, and a worse prognosis to patients with obesity compared with thinner patients presenting similar profiles (Friedman & Puhl, 2012).

If you harbor negative feelings about overweight people, you’ve got plenty of company. Even a noted humanistic psychiatrist wasn’t immune to fat phobia. In his best-selling book, Love’s Executioner (1989), Dr. Irvin Yalom described his feelings about a patient with obesity thusly:

I have always been repelled by fat women. I find them disgusting: their absurd sidewise waddle, their absence of body contour – breasts, laps, buttocks, shoulders, jawlines, cheekbones, everything, everything I like to see in a woman, obscured in an avalanche of flesh…How dare they impose that body on the rest of us (pp. 87-88)?

Despite these feelings, Dr. Yalom was able to get past his initial revulsion and work with this patient. He developed a therapeutic relationship and helped her, while becoming more compassionate and understanding of people with eating and weight issues. Toward the end of therapy Dr. Yalom’s patient revealed that she knew from the start that he had been repelled by her looks. There’s a lesson for everyone who works with this population; it’s important to examine your own feelings about fat. Can you get past the stigma of obesity so that you can be helpful to your client?

Given the negative characteristics ascribed to overweight individuals and the rejection they encounter in various settings they may react to stigma by internalizing the harmful characteristics attributed to them. Since it is widely believed that weight loss is merely a matter of will power, many overweight people will assume that they are deficient because they’ve failed at dieting. This is not only counterproductive, but it’s also irrational since will power is only one of the many determinants of weight, and dieting might not be their best strategy for weight loss.

The medical and psychological consequences of internalizing weight stigma are profound and may include:

• Depression
• Binge eating
• Lowered self-esteem
• Body dissatisfaction
• Avoidance of physical activity

In addition, the psychological stress brought on by weight stigma may result in higher blood pressure and increased cardiovascular reactivity resulting in negative health consequences.

Understanding Body Mass Index

When should someone be concerned about their weight? For many years, the standard was the height-weight tables originally developed by a life insurance company in the 1920s. While they have been updated, the tables are difficult to use and probably not representative of the total population.

Currently, the most widely used method to determine if someone is too heavy is the Body Mass Index (BMI). It’s used as a simple measure of how much an individual’s weight deviates from what is considered normal or desirable for their height. It is calculated by dividing weight in kilos by height in meters squared. You don’t need to do the arithmetic; an online BMI calculator is available at nhlbi.nih.gov or you can use the chart below to determine your BMI.

BMI	19	20	21	22	23	24	25	26	27	28	29	30	31	32	33	34	35
Height (inches)	Body Weight (pounds)
58	91	96	100	105	110	115	119	124	129	134	138	143	148	153	158	162	167
59	94	99	104	109	114	119	124	128	133	138	143	148	153	158	163	168	173
60	97	102	107	112	118	123	128	133	138	143	148	153	158	163	168	174	179
61	100	106	111	116	122	127	132	137	143	148	153	158	164	169	174	180	185
62	104	109	115	120	126	131	136	142	147	153	158	164	169	175	180	186	191
63	107	113	118	124	130	135	141	146	152	158	163	169	175	180	186	191	197
64	110	116	122	128	134	140	145	151	157	163	169	174	180	186	192	197	204
65	114	120	126	132	138	144	150	156	162	168	174	180	186	192	198	204	210
66	118	124	130	136	142	148	155	161	167	173	179	186	192	198	204	210	216
67	121	127	134	140	146	153	159	166	172	178	185	191	198	204	211	217	223
68	125	131	138	144	151	158	164	171	177	184	190	197	203	210	216	223	230
69	128	135	142	149	155	162	169	176	182	189	196	203	209	216	223	230	236
70	132	139	146	153	160	167	174	181	188	195	202	209	216	222	229	236	243
71	136	143	150	157	165	172	179	186	193	200	208	215	222	229	236	243	250
72	140	147	154	162	169	177	184	191	199	206	213	221	228	235	242	250	258
73	144	151	159	166	174	182	189	197	204	212	219	227	235	242	250	257	265
74	148	155	163	171	179	186	194	202	210	218	225	233	241	249	256	264	272
75	152	160	168	176	184	192	200	208	216	224	232	240	248	256	264	272	279
76	156	164	172	180	189	197	205	213	221	230	238	246	254	263	271	279	287

Using this formula the World Health Organization (WHO) and the National Institutes of Health (NIH) classified a BMI of 18.5 to 25 as optimal, 25 to 30 as overweight, while a BMI greater than 30 would indicate obesity. The BMI ranges were based on WHO data suggesting increased health risks for people with BMIs above 25.

While BMI has been useful in research, especially when comparing large groups of people, it can be misleading for any one individual. For example, Arnold Schwarzeneggar, in his younger days as a body builder, had a BMI of 33, while Tom Cruise, another movie star, had a BMI of 31. Based on these numbers, both would be categorized as having obesity even though neither had excessive fat accumulations. The simple explanation for these discrepancies is that muscle is heavier than fat tissue, so a muscular person will have an elevated BMI even if they have little fat on their body.

Another problem with using BMI as an indicator of desirable weight is that the health risks associated with BMI are not the same for all ethnic groups. There’s evidence that people of Asian ancestry would have increased risks at lower BMIs, so a BMI of 23 to 27.5 would be overweight and 27.5 or higher would indicate having obesity for someone of Asian ancestry. Likewise, there is some evidence that, for African-American females, the health risks increase at higher BMIs, so the usual cutoffs for overweight and obesity might not make sense for this population (Carroll et al., 2008).

Understanding the limitations of the BMI is helpful when working with clients who set their weight loss goals based on a BMI score. Methods for helping your client develop reasonable goals that aren’t based on their BMI will be described later in this course.

Apples vs. Pears

There are several other methods for determining obesity. Perhaps the most accurate, but least practical is hydrostatic weighing, or more simply, weighing under water. This procedure yields the body’s density, which then allows for a calculation of percentage of body fat. Measuring waist circumference is more practical and doesn’t require any fancy equipment, just a simple tape measure. Waist circumference may not be the same as your belt size. To get your waist circumference, position the tape mid-way between the top of your hip bone and the bottom of your rib cage. Then, while taking the measurement, your abdomen should be relaxed and you should breathe out.

Compared to BMI, waist circumference may be a better measure of health risks because all fat is not created equal. Most of the negative health consequences attributed to obesity, including diabetes, cardiovascular disease, and some types of cancer, are more accurately attributed to visceral fat. Visceral fat is the deep abdominal fat that surrounds your organs, while peripheral fat lies outside the abdominal wall, just under the skin.

Unlike fat in the buttocks, arms, and thighs, abdominal fat, particularly internal visceral fat is associated with cardiovascular disease, type 2 diabetes and stroke (Bjornstorp, 2002). While we tend to think of fat tissue as an inert blob just sitting inside our skin, this is not accurate. Belly fat is metabolically active, secreting a variety of hormones. This fat is wrapped around vital organs such as the heart, lungs, and liver. It can contribute to inflammation and insulin resistance that can promote diabetes and the other illnesses that have been associated with obesity (Lustig, 2013).

The World Health Organization suggests that health risks increase when waist circumference reaches the following levels:

	MEN	WOMEN
Increased Risk	37”	31.5”
Substantially Increased Risk	40”	34.5”

People who tend to accumulate excess fat in their abdominal area can be described as having an apple shaped body while others who accumulate fat in their butt and thighs have a pear-shaped body. As a rule, when men gain weight they tend to be apples, while women are more often pears. People with pear fat have increased risk for varicose veins, but that is much less dangerous than apple fat. While peripheral fat is more benign than visceral fat, it is more difficult to lose. If you’re a typical pear-shaped female, you may find it difficult to reduce the size of your butt and thighs, while your husband has an easier time losing his belly fat.

One final point about apples and pears: the location of fat on the body is determined by genetics. You have some control over how much fat will be on your body. If you eat less and exercise more you’ll probably lose fat, but you can’t control where the weight loss will come from. Unfortunately some of your clients will judge the success of their weight loss efforts based on changes (or lack of changes) in the body part they find most troubling. A client could lose weight and improve their health risks but be dissatisfied because they think that their thighs are still too big. Understanding the genetic determinants of fat distribution will help prevent clients from getting discouraged and giving up on their behavior changes.

Like most men, I’m apple-shaped, so when I joined a gym several years ago I immediately started on abdominal exercises using the crunch machine. Over several months, I did this exercise hoping that it would reduce the size of my midsection. While I was successful in increasing the amount of weight I could pull with my crunches, the exercise had no effect on my visceral fat; I just developed strong abdominal muscles around the visceral fat. This experience taught me that regardless of whether it’s a realistic exercise or some pie-in-the-sky miracle cream or belt, there’s nothing that will work as a “spot reducer.”

Understanding the genetic determinants of fat distribution and body shape can be helpful when working with your clients so they won’t have unrealistic goals based on their dissatisfaction with a specific area of their body.

Health at Every Size?

It’s hard to ignore newspaper articles and media reports about “the obesity epidemic.” We’re bombarded with reports about the health risks and economic costs of obesity; $1.72 trillion according to one estimate. More recently, there’s been a movement arguing that the war on obesity is misguided. According to the Health at Every Size website^® (https://asdah.org/haes), this view “… is based on the simple premise that the best way to improve health is to honor your body…Health at Every Size encourages: Accepting and respecting the natural diversity of body sizes and shapes.” The basic idea is that the focus on weight as a health risk is ill-advised; you can be heavy and still be healthy. The medical consequences attributed to obesity are not the result of obesity per se, but rather the effects of unhealthy yo-yo dieting. They encourage increasing physical activity not to lose weight but rather to improve health.

The view that you can have obesity and be healthy was supported by the 2013 publication of a study that was widely quoted in the popular media. The New York Times ran an Op-Ed piece about “Our Absurd Fear of Fat.” The study was a meta-analysis (a method of combining data from several studies) of almost three million individuals and more than 270,000 deaths. It found that compared to normal-weight individuals, being overweight (BMI 25-30) was “…associated with significantly lower all-cause mortality,” while Grade 1 obesity (BMI 30-35) did not have a greater risk of mortality. Only with BMIs above 35 did the risk of death increase (Flegal et al., 2013). While this doesn’t support the idea that you can be healthy at any weight, it does suggest that being overweight is beneficial and that health risks don’t increase until the BMI is above 35.

Given the obvious appeal of the counter-intuitive findings that obesity isn’t a health risk – and may even be protective – your clients might question the need to lose weight. This could put you in the difficult position of conveying the disappointing news that, despite being published in a highly respected journal, the conclusions are questionable. The methodology of the study has been criticized. For example, the effects of smoking or being ill were not adequately controlled and the study didn’t account for the relationship between age and weight gain or loss. Also, modern medicine has increased lifespan but living longer with a chronic obesity-related disease might not be a desirable outcome.

Other studies have supported the view that obesity is unhealthy. For example, an earlier meta-analysis of 1.46 million white men and women between the ages of 19 and 84 found individuals with obesity to be two and a half times as likely to die young (Barrington et al., 2010). Canadian researchers compared mortality data for normal-weight people who were metabolically healthy with metabolically healthy individuals with obesity in a meta-analysis involving 60,000 adults followed for 10 years or more. They concluded that there is no healthy pattern of obesity (Kramer et al., 2013). Another study examined weight and age concluding, “…young adults who are obese have more than a 50% lifetime risk of diabetes and cardiovascular disease, and those with severe obesity might expect to spend a third of their remaining life with a major chronic disorder” (Grover et al., 2014). These findings are important because they show that the effect of obesity on the number of healthy years lost is greater than its effect on life expectancy. In other words, even if obesity doesn’t shorten the lifespan, it increases the likelihood of a chronic illness.

One of the goals of the Health at Every Size movement is to remove the stigma attached to obesity. While this is a worthwhile goal, and lessening the stigma should make weight loss easier, the bulk of the evidence doesn’t support the idea that you can be both healthy and have significant obesity.

Why Gaining Is Easy but Losing Is Hard

If you live in the U.S., it’s quite likely that if you just go about your normal business you’ll gain weight. It won’t be because you have any of the shameful personal characteristics described earlier, but rather because you live in an environment that makes it easy to gain weight and hard to lose it. In this section, we’ll examine many of the variables that make it so easy to gain weight, and distinguish between those that you can control vs. the others that you can’t.

Clients typically are confused or may hold erroneous beliefs about the source of their weight difficulties. They may attribute their weight gain to anything ranging from the Freshman 15, a myth, (Zagorsky & Smith, 2011) to food allergies or an unhappy childhood. By helping clients understand how weight is determined, they’ll likely be relieved to learn that it’s not just a matter of will power or a vague medical or psychological condition, but rather a complex interaction of many genetic, physiological, and environmental variables. Knowing which of the variables are under your client’s control and which aren’t will help reduce self-stigmatization. With less guilt and recrimination, their motivation to make the behavioral changes needed for weight control will increase. They’ll be able to establish realistic weight goals, and make permanent lifestyle changes that will avoid the disappointment that comes with repeated dieting failures.

Is the Fat In Your Genes?

Unfortunately, regardless of their efforts, clients cannot control one of the most powerful determinants of weight: their genes. In a now classic study, Dr. Claude Bouchard and colleagues (1990) overfed 12 pairs of male twins. For 12 weeks, in a controlled environment, they consumed 1,000 more calories than they needed each day. Although each twin gained about the same amount as his brother, the amount of weight the different twin pairs gained varied. With the same overfeeding, some of the subjects gained 9.5 lbs. while others gained as much as 29.3 lbs. The discouraging truth is that some people inherit a tendency to gain weight easily.

The thrifty gene hypothesis (Prentice, 2005) is one possible explanation for the heritability of weight. Basically, our prehistoric ancestors had to cope with a variable food supply. When there was a famine due to drought, a harsh winter, or war with a neighboring tribe, many people, especially children, died. The folks who were more efficient in storing energy (fat is stored energy) during times of plenty were more likely to survive during the lean years, and then reproduce. Their children inherited the ability to efficiently store energy so after numerous generations, many of us easily gain weight when food is available even though it’s unlikely that we’ll experience famine.

Most of your clients live near a supermarket stocked with calorically dense foods that are easily affordable, and there’s a McDonald’s or other fast-food dispensary within driving distance. We live in an environment sometimes referred to as obesegenetic; our environment helps us get fat because it’s just not suited to our genetic makeup.

David Katz, MD, Director of the Yale-Griffin Prevention Research Center, draws an illustrative analogy: Over many thousands of years, polar bears have evolved overlapping mechanisms to conserve heat so that they can survive in their harsh, frigid environment. They soak up and retain heat but if you put them in the desert, where it’s hot, they would continue to soak up heat, get overheated and have difficulty surviving. They are ill-suited to life in the desert. Similarly, humans evolved in an environment where food was scarce and there was a constant need to soak up and retain energy. But in our current environment, where food is plentiful, we get fat.

Although there is clear evidence that genes help to determine weight, it isn’t as simple as identifying THE obesity gene. A recent review suggests that there are hundreds of genes that contribute to determining an individual’s weight  (Rankinen et al., 2006). It’s possible that there are one or more genes that determine basal metabolism, another set of genes that determine the length of time it takes to get hungry, different genes that control how much food is needed to feel full, and so on. Given that so many genes are involved in weight regulation, it’s unlikely that in the foreseeable future there will be any way of modifying our genetic makeup to lessen the likelihood of obesity.

While genes clearly influence weight, recent research suggests that the environment can influence the expression of the gene. Researchers have found that a variant of the FTO gene is associated with obesity. One copy of the gene results in an average of an extra 3.5 lbs., while two copies increase the risk of having obesity by 50 percent. A recent study (Rosenquist et al., 2014) reviewed FTO data collected over 60 years and found that people born before the 1940s with the risky gene were less likely to have obesity compared with people with the same gene but born more recently. These findings suggest that environmental influences, perhaps the modern diet and all the labor-saving devices that reduce the need to be physically active, have altered the expression of the FTO gene. In other words, the environment can impact the effect of one of the genes contributing to obesity. While this research needs to be replicated, and it only deals with one of the many genes involved with obesity, it has profound implications that are important for your clients.

If your client has other family members who have obesity, they may have inherited a tendency to easily gain weight, but their destiny is not fixed. They won’t be able to change their genetics, but by making behavioral changes they may be able to reduce the effect of the genes contributing to obesity.

Nature vs. Nurture

Although we know that genetics can play an important role in determining weight, there’s no way of knowing how much of an individual’s weight is inherited, versus being a result of their behavior. To examine the role of heritability in determining weight there have been many studies comparing the similarity of the weights of twins (identical vs. fraternal twins), or the weight of adopted children compared with their adoptive vs. biological parents, or similarity of weights within families. The studies yield greatly variable results suggesting that anywhere between 30 to 70 percent of BMI is determined by genetics (Bouchard, 2002). Even if we knew what percent of weight was determined by heredity the resulting figure would be an estimate for the population as a whole. We still wouldn’t know the genetic components of any individual’s weight.

Your client might assume that they are programmed to get fat because everyone in their family has obesity but family members typically have similar environments and developmental histories so genetics might not be the primary determinant of their obesity. Furthermore, it probably wouldn’t be helpful for your client to know their genetic predisposition to be fat or thin. If they knew that they were genetically predisposed to gain weight they might get discouraged and give up on any attempt to control their eating (“What’s the use, I’m going to be fat anyway. I might as well…”) and as a result, they would gain more weight.

What would be helpful for your clients is knowing where they are genetically predisposed to accumulate fat tissue. Recall from the discussion of apples and pears that the location of fat on the body is determined by genetics. While there’s no applicable genetic test available today, your clients can make a good guess by looking at their parents and siblings to see which part of their bodies tend to collect fat. Often, successful weight loss still leaves the client feeling dissatisfied because they still don’t have their ideal shape. Understanding the genetic basis of fat distribution will help avoid discouragement when their weight control efforts don’t result in a “perfect” figure.

Environment and Choice: Not All the Fat Is in Your Genes

Although we may have evolved to efficiently store energy, our genetic predisposition isn’t sufficient to explain the current obesity epidemic. As recently as 1980, about 20 percent of us were overweight while now the number is closer to 33 percent and the number of individuals with morbid obesity (100 lbs. or more overweight) has quadrupled. In the same time period, the rate of juvenile obesity has tripled (King, 2013). Clearly, evolution doesn’t take place over 30 or 40 years. Our genetic makeup hasn’t changed in this time period, so we need to consider something else: the effects of the environment on weight.

It’s important for clients to know that eating habits and the environment have a lot to do with weight. Cross-cultural comparisons demonstrate the effects of the environment on weight. For example, the Pima Indians of Arizona have tremendous problems with obesity and the highest prevalence of type 2 diabetes of all Americans. If you compare them with their genetically similar Pima cousins in the Sierra Madre Mountains of Mexico, you’ll find that obesity is 10 times more frequent in the American Pima men and three times as likely in American Pima women (Schultz et al., 2006). It’s likely that the shift from the traditional agriculturally based diet to a typical American diet with a greater proportion of processed foods is responsible for the greater prevalence of obesity and diabetes in the Arizona Pimas.

Another example of the effects of culture and environment can be found in Qatar, the tiny oil-rich sheikdom on the Arabian Peninsula. Qataris have the highest per capita income and, according to some estimates, the Qataris – not Americans – are the fattest humans on the planet. Seventy-three percent of Qatari men and 70 percent of Qatari women are overweight or have obesity. But it wasn’t always so. In two generations, the Qataris went from a traditional tribal lifestyle to living in air-conditioned villas, loving fast food, and delegating any physical labor to servants (Edwards, 2011). Regardless if it’s Arizona, the Middle East, or anywhere else in the world, when a culture transitions from a traditional lifestyle to an American pattern of eating and activity, weight gain follows regardless of genetics.

Perhaps the most dramatic example of the effects of the environment on weight is the increase in the sugar content of the foods we eat. Sugar consumption has doubled in the last 30 years. Americans consume an average of 6.5 ounces per day, or about 130 pounds of sugar each year. Sugar now comprises between 20 to 25 percent of daily caloric consumption. For many clients, the simplest way of reducing their sugar intake is to avoid soda and other sugary beverages.

Dr. George Bray, one of the most influential obesity researchers, nicely summarized the research on genetics and the environment. He said, “Genes load the gun; the environment pulls the trigger.”

Is Your Client a Food Addict?

The notion that obesity is a result of addiction to carbohydrate-laden, high-fat foods has been popular for many years. Traditionally, food addiction has been conceptualized using a 12-step model similar to Alcoholics Anonymous (Overeaters Anonymous, 1998). Although it remains controversial, recent research with animals and humans has lent support to the idea that food can be addicting. Proponents of this view include Nora Volkow, MD, Director of the National Institute on Drug Abuse (Volkow et al., 2013). She said,

The data is so overwhelming the field has to accept it. We are finding tremendous overlap between drugs in the brain and food in the brain (Quoted in Langreth & Stanford, 2011).

Other scientists disagree, pointing out that the biological consequences of food don’t make it an addictive substance (Ziauddeen & Fletcher, 2012). Activities such as sex and sleep also have biological consequences, but that doesn’t make them physiologically addicting.

In discussing food addiction, it’s necessary to distinguish between true physiological addiction in which the substance affects brain function (e.g., addiction to alcohol or opiates) and a process addiction that doesn’t involve taking brain-affecting substances. Compulsive shopping or computer game-playing would be examples of process addictions.

Proponents of food as an addictive substance point to studies of brain function to support the view that it is a true physiological addiction, not a process addiction. Opponents point to behavioral differences. For example, a heroin addict deprived of his drug for eight hours would readily use the drug if given the opportunity. In contrast, many self-identified food addicts claim they’re not hungry and refuse to eat breakfast despite not having had anything to eat for eight hours while they slept.

While the scientific validity of the concept of food addiction is still unsettled, some of your clients will self-identify as “chocoholics,” “food addicts,” or use similar terminology to explain their eating difficulties. They might make reference to self-scoring questionnaires offered by 12-step programs (e.g., Food Addicts in Recovery Anonymous) as evidence of their addiction. These questionnaires have not been scientifically validated and, with overly inclusive questions, (e.g., “Do you eat when you’re not hungry?”) the questionnaire is likely to yield false positives.

The 12-step programs advocate abstinence. Since you can’t completely abstain from eating, defining abstinence for eating problems is more problematic than defining abstinence from alcohol or drugs. For example, Food Addicts in Recovery defines abstinence as “weighed and measured meals with nothing in between, no flour, no sugar and the avoidance of any individual binge foods.” This approach, which eliminates specific foods or food groups, is consistent with rigid dieting. Some of the pitfalls of dieting are discussed in an upcoming section.

If your client reports that they are a food addict, instead of directly challenging your client’s self-identification, you can discourage rigid dieting while not challenging their belief that they’re addicted to sugar, carbs, chocolate, or any specific food or food group. For example, Robert Lustig, M.D. (2013) notes that sugar is found in most processed foods. If your client reports that they’re addicted to sugar, you could suggest that it’s unlikely that they could completely eliminate it from their diet. Instead you could encourage them to reduce sugar consumption and follow Dr. Lustig’s suggestion to increase fiber in their diet to mitigate the effects of sugar.

Help May Be on the Way

The next section will include a review of the current medical and surgical methods for weight loss, but new research may yield novel methods in the near future. While it’s unlikely that anything will modify the genetic basis of obesity, it may be possible to alter how food is processed inside the body.

Even when you’re all by yourself, you’re not alone. It’s been estimated that the human gut is home to about 100 trillion microorganisms. All together, they probably weigh as much as the human brain. These little bugs play a role in extracting energy during the digestion of food. A recent study showed that gut bacteria could contribute to obesity. Researchers found pairs of human twins where one had obesity and the other didn’t. They transferred gut bacteria from the humans to mice. The mice receiving bacteria from the human twins with obesity got fat, mice getting bacteria from thin twins didn’t (Ridaura et al., 2013). If researchers can isolate the types of microorganism that alter digestion so that fewer calories were absorbed, it might be possible to develop supplements containing good bacteria that would promote weight loss. Despite the future possibility of helpful bacteria, there aren’t any probiotics currently available that can reliably produce weight loss.

While our genetics, combined with an obesigenetic environment make it easy to gain weight and hard to lose it, all is not lost. Your clients cannot modify their genetic codes, nor change their surrounding culture, but with your help, your clients can learn to modify their individual environment to reduce the cues that promote unnecessary eating and alter the expression of genes that would produce weight gain.

Diets, Drugs, Supplements and Surgery: What Works?

According to one estimate, 55 percent of women and 29 percent of men have been dieting in the past year. If any of your clients are heavy or simply weight-conscious, they’re probably included in these statistics. Unfortunately, they probably weren’t successful in losing, or if they did lose, they probably were unable to maintain their weight loss. Your client’s discouraging experience is consistent with the oft-cited gloomy conclusion, ''Most obese persons will not stay in treatment, most will not lose weight, and of those who do lose weight, most will regain it.'' Although following a typical diet is a flawed strategy, the 95 percent failure statistic is unrealistically pessimistic. It comes from a 1950s study in which 100 participants were just given a printed diet and sent on their way (Stunkard & McLaren-Hume, 1959).

Even more recent studies may not provide an accurate picture of weight-loss outcomes since most studies were conducted with participants in weight-loss programs. This may contribute to a negative bias since many people who lost weight on their own, without participating in a formal program, would not have been included in the outcome data. Although weight loss is still a challenge, the currently available methods are far superior to just offering a printed diet; your overweight clients shouldn’t abandon all efforts.

Getting Off the Diet Roller Coaster

One client told me, “I’ve lost 100 pounds, but it was the same 10 pounds ten times.”

Yo-Yo dieting occurs when a diet results in weight loss that is followed by weight gain, often with a few additional pounds, followed by a period of discouragement, followed by yet another diet. Like many of their peers, your dieting client may be discouraged but still holds out hope that the new diet they saw on the best-seller list or touted on a TV program will finally be the diet that actually works. You can help your client stop yo-yoing by providing accurate information about caloric restriction and offering practical, non-dieting suggestions for weight loss.

A good place to start is to measure your clients’ dietary restraint (attempts to restrict food intake to lose weight). The Revised Restraint Scale has been used in dozens of studies that have yielded important findings about the effects of habitual dieting. To measure your clients’ dietary restraint have them circle the best response to the ten questions below:

The Revised Restraint Scale

Revised Restraint Scale
1. How often are you dieting?
Never	Rarely	Sometimes	Usually	Always
2. What is the maximum amount of weight (in pounds) you have ever lost within one month?
0 - 4	5 - 9	10 - 14	15 - 19	20+
3. What is your maximum weight gain within a week?
0 - 1	1.1 - 2	2.1 - 3	3.1 - 5	5.1+
4. In a typical week, how much does your weight fluctuate?
0 -1	1.1 - 2	2.1 - 3	3.1 - 5	5.1+
5. Would a weight fluctuation of five pounds affect the way you live your life?
Not at all	Slightly	Moderately	Extremely
6. Do you eat sensibly in front of others and splurge when alone?
Never	Rarely	Often	Always
7. Do you give too much time and thought to food?
Never	Rarely	Often	Always
8. Do you have feelings of guilt after overeating?
Never	Rarely	Often	Always
9. How conscious are you of what you’re eating?
Not at all	Slightly	Moderately	Extremely
10. How many pounds over your desired weight were you at your maximum weight?
0 - 1	1 - 5	6 - 10	11 - 20	21+

To score the scale, give each response in the first column on the left (e.g., Never, Not at all) a 0, each response in the second column (e.g., Rarely, Slightly) a 1, each response in the third column (e.g., Sometimes, Often) a 2, and so on. Then add the numbers to get the Restraint Score. For women a score of 16 or above is considered indicative of dietary restraint, while for men 12 or higher indicates restrained eating.

Many studies have demonstrated that high restraint scores are associated with weight-loss failure. In a classic study, psychologists Herman and Mack gave subjects a milkshake (the preload) and then offered them ice cream. After consuming the milkshake, the restrained eaters ate more ice cream than the unrestrained eaters who’d had the same milkshakes (Herman & Mack, 1975). Along with other studies, these findings suggest that when dietary restraint is broken, subsequent eating increases. Thus, having a milkshake, which isn’t on the diet, caused the restrained eaters to give up control and eat more ice cream. Other studies have demonstrated that an emotional upset, drinking alcoholic beverages, or anything else that would disrupt a rigid diet is likely to result in increased eating or may precipitate binge eating.

Dieting promotes black-or-white, all-or-nothing thinking. Once a dieter has had a forbidden food, they’re “off the diet.” They see themselves as failures and feel demoralized so there’s no point in reducing eating until it’s time to start the next diet. It’s also likely that with a history of restraint, eventually the habitual dieter will learn to override the signals of hunger and satiety that normally regulate eating. As a result, once the diet is abandoned, they don’t have guidelines to help control eating.

If chronic dieting is counter-productive, should you encourage your clients to just give up and accept the health and psychological consequences of being overweight? Despite the failure of most diets, your clients can learn that while some slip-ups are inevitable, there are changes they can make that will promote a healthy weight.

Understanding Food Choice and Weight

Your client is probably confused – low carb vs. low fat, eat like a caveman (Paleo) or eat like an Italian (Mediterranean), avoid gluten, avoid sugar, or go vegan? Despite all the hype and the never-ending controversy, in terms of weight loss, it probably doesn’t matter. A Kansas State University professor lost 27 pounds in just 10 weeks by eating junk (Oreos, Doritos, Twinkies, etc.) but limiting his consumption to 1,800 calories per day, although he did “cheat” by having a protein shake, a can of green beans, and four celery stalks every day (Medical News Today, 2010). Although it didn’t include junk food diets, a recent meta-analysis combining the results from 59 different studies found that, “Weight loss differences between individual named diets were small” (Johnston et al., 2014).

Ask your client, “Have you ever had a meal, felt full so you refused seconds of the main course, but then found room in your stomach when the hostess brought out the dessert?” This is an example of sensory-specific satiety. As you eat more of a food, the appeal of that food declines, but your appetite is revived when there’s a new food. This is the “secret ingredient” in virtually all diets; they limit food choices so you’ll eat less. Studies with both animals and humans show that there’s more eating and increased weight when there’s more variety in the diet and less eating when there are fewer choices  (Raynor & Epstein, 2001).

To gain weight, eat at an all-you-can-eat buffet with dozens of choices available. To lose weight, limit your consumption to cabbage soup or grapefruit or rice or any of the other fad diet foods. Even more reasonable diets will restrict food choices. For example, if your client is on a low-fat diet they won’t have bacon or burgers, while if they’re on a low-carb diet they can’t have pasta and pizza; most diets forbid some foods. This approach works for as long as the dieter can maintain the restraint, but invariably, the appeal and cravings for the forbidden foods will increase until there’s an emotional upset, a little too much alcohol, or anything else breaking the restraint causing the diet to be abandoned. After consuming or perhaps bingeing on the forbidden foods the failed dieter will have feelings of guilt and self-recrimination.

Unfortunately, all the attention devoted to dieting controversies obscures what may be a more significant contributor to the obesity epidemic: portion size. Numerous studies have demonstrated that average portion sizes have increased in both restaurant meals (“Supersize it?”) and meals made at home. Not so long ago, bagels were two ounces with 160 calories, but now they’re likely to weigh as much as 10 ounces and supply 800 calories not including cream cheese or anything else. One study found that between 1977 and 1994-1996, increases in portion size of homemade food accounted for an additional 93 calories for snacks, 49 calories for soft drinks, 97 calories for hamburgers, and 133 calories for Mexican dishes (Division of Nutrition and Physical Activity, 2006). Americans consume an average of 3,600 calories each day according to a recent estimate compared with 2,075 calories per day in 1970 (Liebman, 2013) whether it’s at a restaurant or a meal at home, people have just become accustomed to eating more than they need.

Eating too much is easy to do because most people aren’t accurate when judging the amount that they eat. Education level, age, body weight, and gender don’t seem to make any difference; most people don’t correctly assess the amount that they’re eating (Young & Nestle, 1998). Judging the appropriate serving size isn’t easy, since clients don’t usually have measuring cups or scales handy to measure the portion they’re taking. The chart below should help.

Portion Size Guide

1 cup	baseball
1/2 cup	lightbulb
1 oz or 2 tbsp	golf ball
1 tbsp	poker chip
3 oz chicken or meat	deck of cards
3 oz fish	checkbook
1 oz lunch meat	compact disk
3 oz muffin or biscuit	hockey puck
1 1/2 oz cheese	3 dice
1 slice of bread	cassette tape

Intermittent Fasting

Recently several bestsellers have recently touted intermittent fasting to “lose weight effortlessly,” or “supercharge fat loss.” A review of 21 outcome studies (Varady et al., 2022) looked at the results of three types of intermittent fasts:

• Alternative Day Fasting: a fast day when you consume 1-500 calories followed by a day when you can eat whatever you’d like
• 5:2 Diet: on two fast days you consume 500-1,000 calories while on the other five days you’re free to eat normally
• Time Restricted Eating: although the specifics vary, the general ideas is that you only eat during a 4 – 8 hour period. You’re limited to water or non-caloric beverages (but not artificially sweetened beverages) the rest of the day.

The results were mostly favorable: fasting resulted in mild weight loss, usually between 3 to 8 percent over the course of the 8 – 12 week programs. Comparing the strategies, Time Restricted Eating was the least effective with reported weight loss of 3 to 4 percent. Only Alternate Day Fasting and the 5:2 Diet resulted in significant visceral fat loss.

The research suggests that the mild weight loss from Intermittent Fasting resulted from a reduction in total caloric intake. On fast days participants consumed fewer calories without increased food consumption on non-fast days. Likewise, there were no differences in usual food choices on non-fast days.

While they shouldn’t expect dramatic results, some of your clients might find the structure of an intermittent fast to be easier compared with a more typical diet requiring calorie counting or keeping track and limiting food choices.

Meal Replacements

There are many options in the marketplace for weight loss, from meal replacements to social-supported diet programs. It can be helpful to be familiar with these options, many of which will be known to your clients. One strategy to reduce caloric intake and portion size is to use prepackaged meals and meal replacements that are shipped directly to the customer. The companies (e.g., HMR, Medifast) vary in the frequency and amount of outside foods allowed. For example, HMR provides all the food except for five one-cup servings of fruit and vegetables, while Medifast provides the food for five meals each day supplemented by one meal of five ounces of lean protein and three servings of non-starchy vegetables. One study funded by Medifast (Shikany et al., 2013) compared Medifast dieters with dieters given advice on how to meet a 1,000-calorie per day goal. While there were dropouts in both groups, people in the Medifast group lost 16.5 pounds after six months while regular dieters lost 8.4 pounds. At the end of a year, members of both groups had regained weight, but the Medifast group still had superior results, maintaining a ten pound loss vs. four pounds for the control group.

SlimFast shake mixes and snack bars are widely available in grocery stores and on-line. They are intended to replace breakfast, lunch, and snacks and – combined with a 500-calorie dinner – total 1,200 calories daily. A German study (Ditschuneit & Fletchner-Mors, 2001) compared a 1,200-calorie diet with SlimFast liquid meal replacements for two of the three daily meals. After three months, the diet group lost 3.3 pounds while the SlimFast group lost 17 pounds. The participants were then told to use the SlimFast to replace one meal. After four years, participants maintained an average 18.5-pound weight loss.

Diet-Based Programs

Many of your overweight clients will have tried, or be curious about, commercial weight-loss programs. Perhaps you’ve been asked what you think about Weight Watchers vs. Jenny Craig or Nutrisystem. In addition to the widely advertised commercial programs there are on-line programs, self-help organizations, and medical-modified fasts.

The commercial programs such as Weight Watchers and Jenny Craig typically advocate diets that are neither low-carb nor low-fat. The programs differ in how the recommended diet is delivered and the type of social support provided. Thus, Weight Watchers doesn’t forbid any food but uses a point system to provide choices while restricting caloric intake. The point values favor foods that are nutritionally dense, thereby promoting satiety. In contrast, Jenny Craig and Nutrisystem provide calorie-controlled packaged foods. Jenny Craig participants eat the packaged meals until they’re halfway to their weight loss goals, then prepare their own meals twice a week until they reach their goal, at which time they transition to all home-prepared meals. Nutrisystem is similar, although they claim that a five-pound weight loss is possible in the first week, followed by one- to two-pound weekly weight losses.

Traditionally, Weight Watchers participants attend weekly group meetings in which there is a private weigh-in and discussion conducted by a non-professional group leader. Recently they’ve added phone and on-line coaching in lieu of the group meetings. Jenny Craig also has a weekly weigh-in but instead of group meetings there are individual sessions with a non-professional counselor. In contrast, Nutrisystem has neither group nor individual sessions, although online or phone consultations are available.

US News & World Report rated weight-loss diets and programs and concluded that:

Weight Watchers bested all other ranked diets for both short-term and long-term weight loss. That doesn’t guarantee it will work for everyone, of course. Its average rating of “moderately effective” for long-term weight loss reflects the difficulty dieters have in staying on the wagon, even when using the best weight-loss diet available.

Their conclusions were based on several studies that have demonstrated significant weight loss with Weight Watchers. For example one 48-week study found an average weight loss of 13.2 pounds Pinto et al., 2013). Another study comparing Weight Watchers with Jenny Craig and three medications (Qsymia, Belviq, and Orlistat) found that Weight Watchers was the most cost-effective, with an average expense of $70.50 per pound lost (Finkelstein & Kruger, 2014).

Nonprofit Group Methods

One problem with commercial programs is that the expense can be prohibitive. Two widely available nonprofit programs are Take off Pounds Sensibly (TOPS) and Overeaters Anonymous. Unlike Weight Watchers, volunteers who are elected by the chapter members lead the TOPS meetings. A recent study (Mitchell et al., 2011) found that TOPS members who remained in the program for at least one year lost about six percent of their initial weight. The researchers noted the average loss was comparable to the results of Weight Watchers.

Overeaters Anonymous (OA) is a 12-step program similar to Alcoholics Anonymous that is open to anyone with eating issues, including people with bulimia nervosa, anorexia nervosa, and binge-eating disorder. There’s no specified diet and no religious beliefs are propounded although the program does include a spiritual component. The program advocates abstinence from compulsive eating, but does not provide a definition of abstinence other than avoiding individual trigger foods and behaviors. An OA survey reported on their website (Overeaters Anonymous, 1998, p. 404) claims that 69 percent of their members have lost an average of 45 pounds and 51 percent are maintaining a “healthy weight.” An independently conducted survey (Westphal & Smith, 1996) found that participants who had been in the program for an average of 5.7 years lost an average of 21.8 pounds. While many weight conscious individuals would have difficulty subscribing to the OA ideology e.g., “…a Power greater than ourselves could restore us to sanity,” there is evidence that the program does benefit a subset of primarily white overweight females.

Web-Based Methods

While the web offers endless posts on diet and weight – much of it inaccurate – the most promising applications make use of smartphones or wearable activity-and-diet trackers. One of the most widely used applications is myfitnesspal.com. It includes an extensive listing of the caloric value of more than four million foods, including brand names and restaurant selections so that your client can self-monitor food intake. Instead of writing down everything, clients can use their smartphone to check the foods consumed and the app tallies the total number of calories. Over time, it “learns” the typical foods that the user eats so there’s less need to scroll through long lists of foods when making an entry. The app also allows detailed tracking of physical activity and calculates the caloric expenditure based on the user’s weight. For example, an hour of sitting in a boat fishing burns 170 calories for a 150-pound person, versus 238 calories used when fishing while standing on the shore. Users can also share their progress on Facebook and other social media websites.

Studies of the effects of web-based methods are inconclusive. A recent study of MyFitnessPal used in a primary care medical setting found no difference in weight loss after six months compared with a control group (Liang et al., 2014). The researchers noted that logins to MyFitnessPal decreased sharply after the first month, suggesting that it’s only useful so long as people are willing to self-monitor. In contrast, a study of participants in a VA outpatient clinic found that adding mobile technology to biweekly group meetings resulted in an additional 8.5 pounds lost after six months (Spring et al., 2013). A meta-analysis of web-based programs found statistically significant but minimal additional weight loss compared with a control group (Kodama et al., 2012). The authors concluded that the effect of internet programs was inconsistent and depended on the type of usage and the period of use.

There are several wearable devices that will transmit activity data to a smartphone app that will generate charts and graphs. For example, a Fitbit that is worn on the wrist will monitor steps, distance walked, stairs climbed, calories burned, and sleep patterns. The Apple Watch also provides feedback including how often you stand up to take a break from sitting, delivers reminders, and suggests personal fitness goals. These devices measure caloric expenditure only, but the data collected can be downloaded into one of the web applications.

Noom is a widely advertised online weight loss program based on cognitive-behavioral therapy (CBT) principles which will be described in a later section. They claim to have helped over three million people lose weight by focusing on habit change rather than dieting (May et al., 2023). They report that participants who lost at least 10 percent of their body weight had maintained 57 percent of the loss after two years. If this finding can be replicated it would demonstrate that habit change is more enduring than yo-yo dieting.

Supplements

If your clients have watched Dr. Oz on TV, they may have heard him claim:

“You may think magic is make believe but this little bean has scientists saying they’ve found the magic weight loss cure for every body type – it’s green coffee extract.”

or

“I’ve got the No. 1 miracle in a bottle to burn your fat. It’s raspberry ketones.”

or

“Garcinia Cambogia. It may be the simple solution you’ve been looking for to bust your body fat for good.”

Despite Dr. Oz’s impressive medical credentials and the huge audience for his program, these exaggerated claims have no basis in fact. Green coffee, raspberry ketones, and the dozens of other supplements sold for weight loss either have not been subjected to controlled outcome studies or, when they have been studied produce little or no more weight loss than placebos. For example, garcinia cambogia, a supplement derived from the rind of a fruit found in India, is claimed to burn fat. A meta-analysis of clinical trials found no evidence for weight loss (Pittler & Ernst, 2004). If your client is determined to try an unregulated supplement, you can point out that, despite Dr. Oz’s endorsement, the Federal Trade Commission banned deceptive advertising by marketers of green coffee bean supplements. You can help your client make realistic decisions about using supplements and avoid the disappointment when the anticipated weight loss isn’t accomplished.

Medication

If your clients are frustrated dieters, they may be considering weight-loss medication or possibly surgery. It would be helpful to know the options that are currently available. While the client should make the decision in consultation with their physician, you can help in the decision process by providing accurate information.

In 2012, the FDA approved Belviq (lorcaserin), the first new weight loss drug in 13 years. In prior years, fen-phen was withdrawn after reports of fatal heart-valve problems, Meridia (sibutramine) was withdrawn after being linked to heart problems, and Acomplia (rimonabant) – which was never approved in the U.S. – was withdrawn in Europe. The only weight-loss drugs that were available were Xenical (orlistat), Alli – a lower dose of orlistat available without a prescription – and phentermine, a controlled substance that was approved only for short-term use.

Both orlistat and phentermine are still available, but have significant disadvantages. Orlistat reduces caloric intake by inhibiting an enzyme necessary for digesting fat so that the fat passes through the digestive system and is eliminated. Although it results in modest weight loss (4.4-6.6 pounds after one year), the possible side effects include flatulence, oily spotting, and fecal urgency. One of my clients jokingly asked, “Is it true that if you take Xenical you should wear brown pants?”

Phentermine, the benign component of fen-phen, is FDA-approved for short-term use (three months) because of possible risks including elevation in blood pressure, tachycardia, insomnia, and addiction. It works as an appetite suppressant but is a controlled substance because of its potential for abuse. Since phentermine is off-patent and inexpensive (less than $20 per month) none of the pharmaceutical companies have sponsored carefully controlled long-term studies. A recent study found no evidence of abuse or addiction in 269 clinic patients who had been taking the drug for up to 21 years  (Hendricks et al., 2014). Perhaps the three-month limitation is overly cautious. Many physicians have been prescribing the drug long-term, ignoring the FDA guidelines.

Given the fatalities associated with fen-phen, the FDA has been cautious in approving new drugs. Belviq which is generally well tolerated, is a serotonin receptor agonist (probably not the best choice for a client on an SSRI) resulting in an average weight loss of 12.75 pounds over one year. Later in 2012, the FDA approved Qsymia (phentermine/topiramate). This drug combines phentermine with topiramate, an anti-seizure medication. Patients receiving the recommended higher dose lost 22.5 pounds with some reported side effects including dry mouth, constipation, and insomnia.

Contrave, a combination of naltrexone, an anti-addiction medication, with Wellbutrin (bupripion), an antidepressant, was approved in 2014. According to the manufacturer, weight loss averaged 25 pounds, but about a third of the patients in the clinical trial experienced nausea. Later that year, Saxenda (liraglutide), a once-daily injectable drug developed for the treatment of type 2 diabetes, was approved for treating individuals with obesity with at least one comorbid disorder.

Recently there’s been a lot of media attention focused on Ozempic (technically semaglutide). It’s a weekly injection for adults with type 2 diabetes that has weight loss as a side effect. Wegovy, a larger dose of semaglutide, was approved by the FDA specifically for weight loss. Mounjaro (tirzepatide) is a similar diabetes drug that also has weight loss as a side effect. Zepbound, a larger dose of tirzepatide, is approved for weight loss. Along with dramatic weight loss there are reports of users of these drugs losing their continual thoughts about eating (“food noise”).

Ozempic, Wegovy, Mounjaro, and Zepbound work by curbing appetite and making the stomach empty more slowly. They lower blood sugar levels and act like glucagon-like peptite-1 (GLP-1), a hormone produced in the intestines which signals fullness and allows the stomach to empty more slowly. As a result, appetite and eating decrease. Participants in one study of semaglutide lost 14.9 percent of their body weight after 68 weeks of treatment (Wilding et al., 2021). An added benefit was demonstrated in a recent study of patients with obesity and preexisting cardiovascular disease. It found that, in addition to weight loss, semaglutide reduced the incidence of death from cardiovascular causes. Also, there are clinical reports that semaglutide produces reductions in emotional eating, food cravings as well as cravings for alcohol. Possible side effects include nausea, dehydration, fatigue, constipation, muscle loss, and the possibility of malnourishment resulting from extreme loss of appetite.

Weight loss with these medications will plateau so, despite significant weight loss, clients might not reach their goal weight. Also, exercise will be necessary to preserve lean muscle mass needed to maintain weight loss.

After reviewing outcome literature a task force of experts concluded (Lincoff et al., 2023):

Unfortunately, while they may be helpful, none of the drugs are “miracle cures.” The Practice Guidelines (Apovian et al., 2015) offered by The Endocrine Society and co-sponsored by the European Society of Endocrinology and The Obesity Society states, “Although all of these medications and others have been shown to be effective as adjunctive treatment, none have been shown to be effective on their own.” (p. 8) The Guidelines also caution that, “Patients should be made aware that lifestyle changes are needed when using a weight loss medication…” (p. 8)

You may need to remind your clients that weight is usually regained after going off medications so ultimately lifestyle change is necessary even if they decide to try the medications.

Surgery

It’s estimated that 14.5 percent of the adult population in the US have a BMI of 35 or more. In addition to the health risks and behavioral problems it’s estimated that the health-care expenses of individuals with severe obesity are almost twice that of their normal weight peers (Arterburn & Fisher, 2014). Given the modest weight losses resulting from pharmacological and lifestyle interventions, bariatric surgery is the most effective current treatment for severe obesity, with over 200,000 procedures performed each year. Awareness of bariatric surgery increased as celebrities including Roseanne Barr and Al Roker have publicly discussed their experiences with this surgery.

Many of your clients with severe obesity who have made repeated unsuccessful attempts to lose weight may have considered surgery, even if they can’t afford it (typical cost is between $18,000 and $35,000) or have ambivalent feelings about it. You can help by providing information and clarifying some of the psychological issues that emerge with these procedures.

Currently, three bariatric procedures are widely used: adjustable gastric band (Lap Band), Roux-en-Y gastric bypass (RYGB), and vertical sleeve gastrectomy.

The laparoscopic adjustable gastric band procedure is the least invasive. The stomach and intestines remain intact but an adjustable silicone band is placed around the upper part of the stomach creating a pouch about the size of a golf ball. A thin tube connects the band to a port placed under the skin. Adding or removing saline through the port can adjust the band. Weight is lost gradually over two to three years since the smaller stomach pouch holds less food and there is delayed gastric emptying of partially digested food. A ten-year follow-up study of 714 patients found a 47 percent excess weight loss with no mortality associated with the procedure, although 40 percent needed some revision of the procedure and five percent had the band removed (O’Brien et al., 2013). Frequent follow-up visits are typically required for adjustments, and other studies have reported less favorable outcomes. As a result, the use of the gastric band procedure has decreased markedly in recent years.

With the Roux-en-Y procedure, a small stomach pouch, also about the size of a golf ball, is created and part of the small intestine is attached to the pouch. Food intake is limited by the small size of the pouch and less is absorbed because of the shortened intestine that bypasses most of the stomach. Typically, patients lose 60-70 percent of their excess weight.

Although Roux-en-Y is a major surgical procedure with possible complications a ten-year follow-up found that 6.5 per cent of the surgery patients had died, compared with 13 percent mortality for matched patients with obesity who did not have surgery (Guidry et al., in press).

The vertical sleeve gastrectomy is a newer surgery that has become the most popular bariatric procedure. About 75 percent of the stomach is removed, with the vertical sleeve gastrectomy leaving a banana-shaped stomach. No intestines are removed or bypassed. In addition to limiting the amount of food that can be consumed, appetite is reduced because there is less ghrelin, the hormone associated with hunger that is produced in the stomach. Typically, there is less weight loss compared to the Roux-en-Y and the weight comes off more slowly, but this procedure may be preferred for patients who have severe heart or lung disease because the surgery has fewer risks than the Roux-en-Y procedure.

Despite the perception that these are dangerous procedures, a meta-analysis found a mortality of less than one percent, with weight losses of 44 to 66 pounds maintained for up to ten years (Maggard et al., 2005). A Swedish 15-year follow-up study found a 53 percent reduction in cardiovascular mortality and a 33 percent reduction in heart disease and stroke with the 20 percent post-surgical weight reduction. While the weight loss and reduction in mortality was beneficial, about 13 percent of the patients had postoperative complications (Sjostrom et al., 2012). Also, a significant number of patients had trouble maintaining their weight losses, possibly as a result of psychological issues revolving around body weight.

In 2015, the FDA approved two balloon devices that are less invasive than surgery. Under mild sedation, the physician deposits a balloon in the stomach via the mouth and then fills it with saline so it expands, creating a feeling of satiety. The balloon is used in conjunction with a diet and exercise program and is removed after six months. In one study, patients receiving the balloon lost an average of 14.3 pounds after six months and had an average weight loss of 9.9 pounds after a year, although there were some reports of vomiting, nausea, and indigestion (Lowes, 2015).

Several years ago, I was confronted with an example of psychological issues that can affect the outcome of surgery. I gave a talk about emotional eating to an aftercare group for patients who’d had bariatric surgery. Afterward, a young woman confided to me that she’d been regaining weight after her procedure. Surprisingly, she wasn’t upset but rather seemed pleased with the weight gain. It was a brief conversation, so I don’t know what the weight loss represented to her, but it illustrates that psychological issues involving weight might not be resolved by surgery. Even when the procedure has been successful, it can easily be defeated if the preexisting psychological issues have not been resolved. For example, the stomach pouch can be stretched by gradually increasing meal size. Frequent drinking of calorically dense liquids such as milkshakes will also result in weight gain despite the small stomach.

If any of your patients are seriously considering any bariatric procedure, it’s important that their expectations are realistic and they understand the post-surgical hazards and changes that will be necessary. Most bariatric programs require a psychological evaluation prior to surgery. Even if you are not doing the evaluation, you should be aware of some of the possible contraindications.

Preexisting psychopathology, especially disordered eating, would predict poor postoperative outcomes. For example, about five percent of bariatric surgery candidates suffer from binge-eating disorder. This has been associated with smaller post-surgical weight losses and possible gastrointestinal complications. While depressive symptoms often improve after surgery there is some evidence that depression and suicide may increase over time, especially for patients with a history of mood disorders. Also while research findings are mixed, there are clinical reports of increased alcohol abuse following bariatric surgery (Sarwer, 2014). Likewise, pre-existing marital conflict may not improve or could get worse after surgery.

Although it’s not intended to be a bariatric procedure, some clients may be curious about liposuction for weight loss. While the idea of removing fat may be appealing, liposuction only affects subcutaneous fat. The procedure may improve the body’s contours but it won’t alter the visceral fat that is responsible for much of your client’s excess weight and the health risks associated with obesity.

Bariatric surgery is not a magical procedure that will effortlessly remedy all weight troubles. One successful patient described it as “a tool, not a cure.” If she hadn’t made behavioral changes, been more active, and sought support from family and a therapist, she would have regained at least some of the weight. All surgery candidates should be informed about the post-operative changes that will be required. Patients will need to eat small meals, chew foods well and may feel the need to vomit when feeling full. They will need to avoid sugars and fats to prevent dumping syndrome, which includes lightheadedness, nausea, sweating, cramping, and diarrhea. After surgery, they will need to take vitamins and engage in regular physical activity to maintain their weight loss.

Regardless of whether your client continues to diet, joins a structured program, tries one of the medications, or considers surgery, lifestyle changes will be necessary to maintain any weight loss. You can help your client by using the methods described in the next sections.

Cognitive-Behavioral Treatment

This section will present the components of cognitive-behavioral treatment enabling you to plan a treatment tailored to your client. In contrast to the typical diet that prescribes foods to be eaten and foods to be avoided, the cognitive-behavioral approach focuses on changing your client’s thinking and environment to make unnecessary eating less likely.

You can describe for your clients the differences between your plan and their previous attempts to lose weight. If they attribute their previous dieting failures to a lack of will power, you can explain that will power is a limited resource that can easily be depleted. Making decisions, controlling emotions, resisting impulses, staying awake when sleepy, and many other daily occurrences drain will power so that when an attractive food is nearby, it will be difficult to resist. If your client does succeed in resisting, that will use up some will power, making it more likely that they will give in when they see the next yummy food. Rather than trying to develop more will power, the goal of treatment is to change the environment to reduce your client’s need for will power to lose weight.

Talking About Weight

For many people, their weight is a sensitive topic. Recall that many people, including health professionals, hold stigmatizing negative beliefs about obesity. Depending on your relationship with your client, they may feel ashamed about their weight, avoid discussing the topic, and might get defensive if you bring it up directly. Instead, you can open communication by asking, “Is it okay to talk about your weight?” You’ll be distinguishing yourself from others who have made disparaging comments, jokes, or given unhelpful advice. If your client doesn’t want to talk about weight you can let the subject drop without having harmed your relationship. If your client responds with a humorous or defensive statement, you can say, “I know this is a difficult topic to talk about, but I have some information that you might find useful,” and then check to see if it’s okay to discuss.

When you start the conversation, you’ll probably find that your client, having failed at previous diets may doubt their ability to lose weight. Your client may quote the oft-cited statistic that 95 percent of dieters won’t lose weight, and of the few who do succeed most will regain the weight. You can explain that this data comes from a 1950s study in which participants were given a printed diet and told to go home and follow it. More recent studies of current methods of weight control have yielded much better results. For example, an eight-year study of more than five thousand adults with obesity and type 2 diabetes compared an intensive behavioral lifestyle intervention with a typical diabetes education and support program. The participants in the behavioral program lost an average of five percent of their starting weight and 27 percent of the participants lost more than ten percent of their starting weight (The Look AHEAD Research Group 2014). While your client might be disappointed with “only” a five percent weight loss, there are significant improvements in health risks even if the loss doesn’t result in the ideal physique.

You can remind your clients that weight-loss outcome studies report the results of people in treatment programs. It’s likely that the outcome studies underestimate overall success at weight loss because the participants wouldn’t be in treatment unless they had already failed at previous attempts to lose weight on their own. Several studies suggest that many people can lose weight without participating in any program. One study of 500 randomly dialed adults found that the success rate for long-term weight loss was about 20 percent (McGuire et al., 1999). Another study of 4,021 adults with obesity found that 63 percent tried to lose weight in the previous year and 40 percent of them lost more than five percent of their body weight (Nicklas et al., 2012). A Consumer Reports survey (The truth about dieting, 2002) found that about 13 percent of the respondents were able to maintain an average weight loss of 37 pounds for five or more years with “self-directed lifestyle changes.” Adding the people who lost weight on their own to those who were successful in a program would yield a figure significantly higher than the oft-cited five percent success rate. Despite previous failures at dieting, if your client meets readiness prerequisites, it’s likely that they can lose weight.

Assessing Readiness

Notwithstanding advertisements for miracle diets that promise easy weight loss without restricting eating or exercising, permanent weight control is effortful. Even bariatric surgery isn’t magic; it requires changes in eating and activity habits. Before starting to work on weight issues, it’s helpful to assess readiness to change since there’s no point in offering treatment to someone who is unwilling or unable to implement your suggestions. Here are some guidelines to help you determine your client’s readiness:

1. Are they going through any major life transitions? If they’re moving to a new city, starting a new job, going through a divorce, or recovering from surgery they may not be able to devote the attention and energy required for habit change. While major disruptions would make weight loss difficult, few clients report that they are leading perfect, trouble-free lives. The ordinary hassles of living shouldn’t prevent a client from using the strategies you suggest.
2. Are there drug or alcohol problems? Despite sincere efforts, any treatment progress may be undone following an episode of substance use. Encourage your client to get treatment for their substance use. Weight loss can be postponed until drug and alcohol problems have been managed.
3. Are there recurrent depressive, manic, or psychotic episodes? Psychiatric treatment may be required before tackling weight loss. As with substance use, these mental disorders may make it difficult to consistently change eating and activity behaviors.

4. Are they willing to commit to becoming more active? Physical activity is necessary for weight loss maintenance. Although a client’s physical limitations may make exercise difficult or impractical, with a medical clearance they should be willing to find activities that they can do. A trainer at a local gym could be a useful resource.

Goal Setting

Your client may have fond memories of how they looked when they were 18, but that shouldn’t provide the basis for their weight-loss goals. Their genetic, metabolic, and hormonal determinants may put a limit on the amount of weight loss that is possible. Nonetheless, there is ample evidence that smaller weight losses can decrease health risks and have surprisingly positive psychological benefits.

In a Pennsylvania study, 60 women with obesity were asked to define their dream weight, their happy weight (not as ideal as the dream weight, but they’d be happy to achieve this weight), acceptable weight (not happy, but less than current weight) and disappointed weight (less than current weight, but they’d view the loss as unsuccessful), before their treatment started. After 48 weeks of treatment, the average weight loss was 38 lbs. Almost half of the participants had losses higher than their disappointed weight. Participants attaining their disappointed weight were surprised to find that achieving this weight still had positive psychological effects. Even though they still wanted to lose more, they felt more attractive, more comfortable in social situations, and had increased self-confidence. Also, the authors note that participants who began with a better body image and self-esteem set more realistic weight loss goals (Foster et al., 1997). These findings suggest that improving body image is helpful and attaining a reasonable weight loss has unexpected benefits even if the ideal goals weren’t met. For a discussion of methods for improving body image in clients who are overweight, see Weight, Diet, and Body Image: What Every Therapist Needs to Know.

It may help to have your client reformulate their goals based on what they hope to accomplish rather than on a specific number on the scale. Although the primary goal might be to improve their appearance, you can remind them that they can improve their appearance even if they don’t reach their ideal weight and that there are other benefits to weight loss. If you probe deeper you’ll find some of the other benefits. Your client might agree that they’d like to:

• Decrease their risk of diabetes, cardiovascular disease, and other health problems
• Be able to walk and climb stairs without becoming out-of-breath
• Feel comfortable dancing, swimming, or doing other activities that had been avoided
• Play with children or grandchildren
• Wear more fashionable clothes
• Resume a favorite sporting activity such as bicycling, bowling, tennis, or golf

Success could be defined as attaining any of the identified goals.

Components of Cognitive-Behavioral Treatment

Instead of relying on willpower to make drastic changes, cognitive-behavioral treatment involves learning specific behavioral skills, typically in small steps. Unhelpful eating and exercise behaviors are examined to determine the cues and events that lead to the behavior. Then changes in thinking and in the environment are suggested to promote weight loss.

SELF-MONITORING: The most important, and possibly essential, component is self-monitoring (Baker & Kirschenbaum, 1993). Recording eating and activity can be done with smartphone apps (e.g., myfitnesspal.com), wearable activity monitors (e.g., Fitbit), or the old fashioned pencil and 3x5 card. Self-monitoring of eating requires a more comprehensive and detailed daily recording of food intake (type and amount), along with the circumstances in which it occurs. Your client may be reluctant to record their food intake or just “forget” to do it. You will need to reassure them that you won’t be judging them, just collecting information. You can suggest that they try it for one day, or even one meal, to see that it isn’t as difficult as they had imagined.

Recording physical activity is especially important for weight-loss maintenance. If your client doesn’t use a wearable activity monitor, they can buy an inexpensive pedometer to count their steps or use a smartphone app such Pacer (available from the Apple App Store or Google Play). Clients can add friends to their app to provide social support to encourage increased activity.

STIMULUS CONTROL: Another component of treatment is stimulus control, or changing the environment to make eating less likely. For example, one study found that individuals with obesity were more likely to have food available in locations throughout the house rather than just in their kitchen (Emery et al., 2015). You can explain stimulus control by describing several common instances when an external stimulus prompted eating without hunger. For example, ask your client,

Have you ever been watching a TV program when a commercial for a dessert (e.g., chocolate chip cookies) came on, and you found yourself in the kitchen looking for a similar snack?

or

Have you ever walked by a bakery or the cookie stand in a mall, smelled the baked goods and felt the urge to buy some?

or

You’ve had dinner and aren’t hungry, but when you are visiting friends who are having dessert and they offer you some, you go ahead and indulge.

These are examples of how visual and olfactory cues can trigger unnecessary eating. Most likely, your client will be able to identify similar instances, but often the external cues prompting eating are not as obvious. As you explain stimulus control to your client, you can emphasize the need to carefully self-monitor eating. Reviewing your client’s self-monitoring will usually suggest environmental changes that will reduce external cues. Here are several interventions you can suggest to your client:

1. Keep all food in the kitchen or pantry (no snacks in the living room, no candies in the dresser drawer, or munchies in the glove compartment in the car).
2. Store calorically dense foods in opaque containers and keep them in the back of the refrigerator, freezer, or pantry.
3. Serve the food onto plates in the kitchen. Don’t put serving bowls or platters on the table where you’ll be eating.
4. Increase the effort required to snack but make healthy snacks easy to get (e.g., keep apple sauce or small, washed carrots in clear wrap toward the front of the refrigerator).
5. Buy calorically dense snacks and treats in single serving packages (e.g., buy ice cream sandwiches instead of one quart tubs of ice cream).

Eating Behaviors

Often eating is done rapidly, sometimes without awareness. You can help your client slow the pace of eating by becoming mindful of their eating behaviors. A review of 19 studies of interventions designed to increase mindfulness found significant weight loss reported in 13 of the studies (Olson & Emery, 2015). Several interventions can help your client slow the pace and give full attention to the act of eating so that they will be satisfied with less food.

1. Never eat standing up. When at home, do all eating sitting down either in the kitchen or dining room.
2. Structure eating (e.g., three meals and one or two snacks per day).
3. Resign from the clean plate club. Leave a small amount of food on your plate at the end of a meal.
4. Make eating a singular activity. Conversation is okay, but turn off the TV, don’t read, text, talk on the phone, etc.
5. To slow the pace of eating and establish a sense of control, put your knife and fork down in the middle of a meal, continue conversing without eating for 60 seconds, then resume eating.
6. Use the non-dominant hand to eat for part of the meal.
7. Put your knife and fork down after each swallow. Pause to take a breath before resuming eating.
8. During a meal, stop and focus on the taste (sweet, sour, bitter), texture (soft, crunchy, chewy) and temperature of the food.
9. Brush and floss your teeth after dinner to reduce the likelihood of later snacking.

You can have your client practice some of these eating behaviors in your session. For example, you could have your client bring in a favorite food. After a brief meditation or relaxation exercise, have them take a small bite, savor the food and then describe the sensations that the food provides. For example, if the food is a chocolate bar, have your client notice the color and then take a small bite. Have them experience the crunch as they bite into it, then notice the sensations as it melts on their tongue before swallowing the chocolate. In addition to the sweet taste, direct their attention to the mouth feel or smoothness of the chocolate. Encourage your client to do a similar exercise at home. Additional mindfulness exercises can be found in several books including Eating Mindfully (Albers, 2003) and The Self-Compassion Diet (Fain, 2011).

Emotional Eating

It’s likely that many of your clients, even those who aren’t overweight, can relate to eating, in response to emotional arousal. Depending on the frequency and intensity of the emotional eating you may want to address the underlying emotional issues as well as the unnecessary eating. If your client has an anxiety disorder, depression, or other mental health problem, it may become the focus of treatment, but here are some suggestions for addressing the eating issues:

1. Identify the emotion(s) most likely to trigger eating. When and where are they likely to occur?
2. Plan alternative methods of dealing with the emotion (e.g., meditation or relaxation exercises, journaling, physical activity, or getting social support).
3. Develop methods of self-nurturing (e.g., take a warm bath, read a trashy novel, play an on-line game, play with a pet, etc.) to use instead of eating.
4. Do boring tasks in food-free environments. For example, study in the library or do ironing someplace other than in the kitchen.

Restaurants and Social Events

From 1977 to 2000, there was a 42 percent decrease in foods consumed at home (Johnson, 2003). According to the Department of Agriculture, meals at fast-food and sit down restaurants accounted for 20 percent of the calories Americans consumed in the years 2005 to 2008. Eating in restaurants or at social events will present a challenge to your clients since they will be tempted by calorically dense foods while they have little control over their immediate environment. Here are some strategies your clients can use to minimize unnecessary eating when away from home.

1. Plan your menu before going out to eat or to a party. Avoid all-you-can-eat buffets.
2. Restaurants serve large portions. Consider sharing the entree with your companion and ordering an extra salad.
3. Ask the waiter for a doggie bag and before starting to eat, divide the food into the portion you’ll eat and the portion you’ll take home.
4. At cocktail parties and buffets, stand on the opposite side of the room with your back to the food table.
5. At a party, carry a glass of sparking water with ice cubes while you socialize.

Adding Technology to Treatment

Computers and smartphones can be a useful adjunct to treatment and may be helpful when in-person treatment isn’t available. A review of 23 studies concluded that using the Internet as an adjunct was effective, but the effects were inconsistent, depending on the type of usage and the duration of use (Kodama et al., 2012). Often clients are enthusiastic about apps such as myfitnesspal.com, but usage typically decreases after the novelty wears off. If your client does use a weight-loss app it would be good to plan on frequent follow-ups to encourage continued use of the app.

Maintenance and Relapse Prevention

Virtually all forms of obesity treatment, whether surgical, medical, or behavioral, report that a significant number of participants will regain weight after successfully completing treatment. You can use several methods to help your clients maintain their weight loss.

ACCEPTANCE AND COMMITMENT THERAPY (ACT): An approach that integrates cognitive and behavioral change with mindfulness. This may help improve long-term outcomes of treatment (Lillis & Kendra, 2014). ACT places emphasis on private thoughts, feelings, and body sensations rather than on overt behavior. Many unhelpful thoughts and feelings, such as cravings or feeling fat contribute to relapse, but rather than trying to suppress or control them, ACT encourages tolerating these internal states. The goal is to observe from a distance but not act on these thoughts and feelings; they are transient experiences and the unpleasantness will end without having to do anything. ACT is described in more detail by Hayes, et al. (Hayes et al., 1999).

Before the end of treatment, it’s helpful to explain the difference between a lapse or slip and a relapse. A temporary abandonment of the new eating and exercise behaviors is a lapse. Lapses are inevitable; everyone has a bad day and no one is perfect. In contrast, a relapse is when the client gives up their weight loss efforts and reverts to pre-treatment behaviors. Unfortunately, a perfectly normal lapse can become a relapse but with planning, you can help your client avoid this outcome. Here are several predictable situations that can cause lapses:

1. Holidays and special events: From Halloween through Thanksgiving, Christmas, New Years, and even Super Bowl, there are many opportunities to overeat, so lapses are common. Birthdays, weddings, and other special occasions also present challenges. Help your client anticipate specific situations and problem-solve to help them minimize their effects.
2. Vacations: Going on vacation typically includes freedom from usual responsibilities. This may include abandoning eating rules. If the vacation is a cruise or an all-inclusive resort, eating opulent meals may be a focus of the trip. You can encourage your client to discuss eating with their travel companion to agree on less food-centric vacations or if necessary, strategies for minimizing unnecessary eating.
3. Life changes: Moving to a new town, getting a new job, getting sick, or being in a hospital can disrupt well-established habits and routines. After a period of change, it will take intensified effort to reestablish the healthier behaviors. While your client may not be able to anticipate these events, you can encourage them to call you for a “tune-up” if they find that changes in their circumstances have resulted in a lapse.

Additional Methods

Treatment programs often include methods that complement cognitive-behavioral techniques. For example, several studies have found that reducing food choices either by providing portion-controlled packaged foods (e.g., Medifast) or specified menus resulted in greater weight loss than standard cognitive-behavioral treatment (Shikany et al., 2013). Dietitians might make specific recommendations such as eating a protein-rich breakfast to retain fullness throughout the day or drinking water before meals to reduce eating (Dennis et al., 2010). Sports trainers and other health professionals could also be helpful when dealing with your client’s specific eating and exercise issues.

Childhood Obesity

Childhood and adolescent obesity is a serious problem. A 2003-2004 study showed that the prevalence in the U.S. had gone from five percent to more than 17 percent, although the rate has remained stable since then (Ogden et al., 2014). The health risks associated with childhood obesity are well established. For example, one study found that children with obesity are twice as likely to die before age 55 compared children who don't have obesity (Franks et al., 2010). A study published in The New England Journal of Medicine concluded that for the first time, the current generation of children might have a shorter lifespan than their parents (Olshansky et al., 2005). Given the health risks associated with childhood obesity, you may be able to help parents concerned about their children’s weight.

While many of the health consequences of childhood obesity, including diabetes, kidney failure, and heart disease, are likely to occur later in life, the negative psychological effects are more immediate. Children as young as three attribute negative characteristics such as lazy, ugly, dirty, and stupid to their overweight peers (Haines & Neumark-Sztainer, 2009). There are significant effects of this stigmatization. Studies of adolescents found that being teased about weight was associated with lower self-esteem, depressive symptoms, suicidal ideation, and suicide attempts (Eisenberg et al,. 2006).

Despite the seriousness of the problem, a review of 69 studies found that 50 percent of the parents of children who were overweight or had obesity underestimated their child’s weight (Lundahl et al., 2014). When should a parent become concerned about their child’s weight? How should health professionals address this topic with parents when they’re not acknowledging the problem?

It’s not obvious when a child stops having cute baby fat and starts being overweight or having obesity. While the BMI for an adult isn’t a perfect measure, calculating adult BMI is straightforward. Using BMI as a measure of obesity for children is not as simple because kids are still growing and they don’t all develop at the same rate. One possible solution is to calculate a child’s BMI and then compare the result with norms for children of the same age. This would yield a BMI percentile score for the child. Doing this manually would be quite a chore, but fortunately the Centers for Disease Control (CDC) has an online calculator that will do it for you. You just need to know the child’s birth date, sex, height (to the nearest eighth of an inch) and weight (to the nearest quarter pound). The calculator can be accessed at cdc.gov/healthyweight/bmi/calculator.html.

By using BMI for age percentiles, you can help your clients decide if they should be concerned about their child’s weight. Typically, the 95^th or above percentiles indicate obesity and the 85th to 95^th percentiles are considered overweight.

Helping Parents Walk the Weight Tightrope

Parents who are concerned about their child’s weight are in a difficult position. If they recognize the health risks and psychological problems caused by childhood obesity, most parents will want to help their child maintain a healthy weight. They might not be aware that, even with the best intentions, they could cause their child to gain weight or possibly develop an eating disorder. When you are working with parents, you will need to be careful in discussing this topic. Although the weight-control advice you give can be straightforward recommendations, it requires a more nuanced judgment to assess the parent’s attitude about their child’s weight.

Parents often believe many of the stigmatizing myths about obesity. They may attribute their child having obesity to being lazy or some other personality defect and communicate disappointment and disapproval to their child. Your client may feel that their child having obesity is a poor reflection of their parenting skills and be annoyed or embarrassed by the child’s appearance. The result is likely to be harsh or punitive measures such as nagging, overly restricting the child’s food choices, or enforced dieting. Kelly R. is an example of one of the possible unfortunate results of excessive parental involvement in their child’s weight issues.

Kelly was a 230-lb. 26-year-old convalescent hospital aide who appeared mildly depressed. She had a lengthy history of struggling with her weight. She recalled that in first grade, her mother, who was overweight, was concerned about Kelly’s baby fat and forbade her to eat desserts and snacks (especially Oreos, Kelly’s favorite). Over the years, Kelly’s mother increased her efforts to control Kelly’s eating. She put Kelly on a diet, lectured her whenever she ate forbidden foods, took her to Weight Watchers meetings, and frequently expressed dissatisfaction with Kelly’s eating and weight. Kelly continued to disappoint her parents by dropping out of college, taking a job that they felt was beneath their social standing, failing to lose weight, and continuing to eat Oreos.

Kelly’s eating and weight difficulties might have represented an attempt to rebel against her mother’s heavy-handed tactics. Excessive parental concern about weight doesn’t always result in a child having obesity; it can have a more dangerous outcome. Fear of gaining weight in childhood is a risk factor for the development of an eating disorder (Killen et al., 1996) or subclinical eating problems such as overly strict dieting, excessive exercising, and having a negative body image. Often it’s a mother who, with the best of intentions, transmits her own weight concerns to her daughter resulting in problematic eating behaviors (Francis & Birch, 2005). This can be exacerbated when parents have difficulty dealing with the challenges of adolescence. The inevitable conflict with a teenager may be channeled into battles over eating, weight, and appearance.

In contrast, eating disorders may result from relationships that family therapists describe as “enmeshed.” Like Kelly, Debra’s mom was a continual dieter. Debra, a 19-year-old college freshman who binged and purged, was distant from her father. She reported that he had lost interest when Debra was in high school after she dropped out of the swimming team. In contrast, Debra was very close to her mother, telling me, “My mother is my best friend.” She reported that, with one exception, she could tell her mother everything. While they shared confidences about their dating and sexual experiences, Debra didn’t discuss her bulimia because she “didn’t want to disappoint” her mother.

Parents are in a difficult position. If they have a laissez-faire attitude about their child’s weight, the intrinsic appeal of calorically dense foods along with TV and media influences can result in obesity. Conversely, if they are overly involved in their child’s eating and weight they may increase the risk of obesity or an eating disorder.

Helping Parents Concerned About Their Children’s Weight

Parents who are concerned about their children’s weight often use methods that are unhelpful. Unlike adults, kids are still growing, so they don’t need to lose weight; they just need to maintain their weight while they continue to grow. Regardless of any other intervention, parents should be discouraged from putting their child on a diet. Several studies have demonstrated that for adolescents, dieting results in weight GAIN rather than weight loss (Stice et al., 1999). A Finnish study used identical twins to control for the influence of heredity and still found that dieting was associated with weight gain (Pietilainen et al., 2012). Dieting is clearly counterproductive, so when discussing food choices and exercise, it’s better to advocate for healthy eating and getting fit rather than going on a diet. In addition to avoiding diets, parents should be discouraged from “playful” teasing, forbidding any food, and using dessert as a reward for finishing vegetables.

Individual therapy with the overweight child is also unlikely to be successful (Epstein et al., 1998). You can show parents how to create conditions to help their child get to a healthy weight without dieting or having individual sessions with the child. There are decades of research demonstrating that family-based behavioral interventions can be effective (Faith et al., 2009). Helping a parent of an overweight child doesn’t require intensive training or sophisticated techniques. A study from 42 pediatric practices found that motivational interviewing – a communication style that includes shared decision-making and reflective listening – resulted in significantly lower BMI percentiles compared with routine care after two years (Nierengarten, 2015). These findings suggest that in primary care settings, rather than just giving admonitions and advice to parents, clinicians will be more effective if they are warm, empathic, and help the client to access their motivation to change. You can encourage parents to consider the pros and cons of changing versus not changing. Motivational interviewing: Helping people change (Miller & Rollnick, 2012) more fully describes this method of communicating.

Several books, including my It’s NOT Just Baby Fat: 10 Steps to Help Your Child to a Healthy Weight (Abramson, 2011), offer parents practical ideas for helping overweight kids. In addition to suggesting readings, you can use some of the methods described below to help your clients create a home environment that promotes healthy eating, appropriate physical activity, and a healthy body image for their child.

Healthy Eating

Until children go off to school, their parents have control over their diet. Your clients can promote healthy habits that should influence their children’s eating as they are exposed to friends, school, and the larger world. Many of the suggestions for children are equally useful for parents who are trying to control their weight. Reducing external cues, self-monitoring, and stimulus control will also benefit children. Here are a few more suggestions that you can offer to your client:

• Minimize fast food meals, sugary drinks, calorically dense snacks and desserts.
• Don’t use treats as a reward or to soothe an upset child. Parents can celebrate a good report card or soccer victory with an extra privilege instead of ice cream.
• Encourage sit-down family meals; discourage unstructured eating and snacking on the run.
• Serve a healthy breakfast; avoid sugary cereals.

Parents should avoid critical or punitive comments when the child eats unhealthy foods. Instead offer recognition and praise when the child succeeds in making positive behavioral changes.

Getting kids to eat vegetables can be a special challenge. It’s helpful for parents to realize that their children’s preference for sweets is innate; they’re not just being stubborn. Kids are born liking sweet tastes (mother’s milk is sweet) and have to learn to like other tastes, so it’s best to start with sweeter veggies such as carrots and peas rather than broccoli or asparagus. If the child refuses to try the vegetables, parents shouldn’t discuss, bribe, cajole, or nag the child. Instead, let the matter drop and try again at another meal. Sometimes it takes 15 or 20 repetitions before the child will try a new food. While they’re waiting, parents should be sure that their child sees them eating and enjoying the vegetables. They can also have the child help prepare the veggies in the kitchen or plant them in a garden. It’s unlikely that a child would refuse a food that they grew and helped prepare.

When working with parents, ask about their child’s sleeping, since sleep can affect eating and weight. A review of 36 publications found that short sleep is associated with childhood obesity (Patel & Hu, 2008). Here are recommended guidelines you can use when discussing their child’s sleep:

• Infants (3-11 months): 9-12 hours at night and 1-4 naps during the day
• Toddlers (1-3 years): 12-14 hours including one daytime nap
• Preschoolers (3-5 years): 11-13 hours
• School-aged (5-12 years): 10-11 hours
• Teens: 8-9 hours

Often it’s hard for teens to get enough sleep since they typically stay up late while their school day may start at 8 a.m. Although it’s easier to establish a regular bedtime routine for younger children, parents can encourage an earlier bedtime for teens.

Physical Activity

Parents of overweight children may be ready to make changes in the child’s diet but less willing to consider the child’s physical activity (Rhee et al., 2014). Discussing a child’s physical activity with a parent will require sensitivity because of possible defensiveness about their own sedentary behavior. Nonetheless, the best way of getting children to be active is to get the parent involved in the activity. Would Mom enjoy going on a bike ride with her child? Or, how about tossing a ball in the back yard, dancing in the living room to a disco song, or even just raking leaves? One study found that kids who have two active parents were six times more likely to be active compared with their peers who had sedentary parents (Moore et al., 1991). You could also suggest that the whole family use pedometers, smartphones, or activity trackers to record daily step counts.

Even with parental encouragement, the overweight child may resist physical activities because of possible embarrassment. For example, playing baseball or soccer could expose them to teasing and feelings of failure if they are not able to keep up with their peers. It might be better to suggest increasing movement in daily activities such as walking to school, playing outside with the dog, or helping to wash the car.

Since many overweight children are sedentary and spend considerable time watching TV an intervention that might elicit less parental defensiveness is to suggest limiting screen time. A recent study found that children ages 8 to 18 spent an average of 4 hours and 29 minutes watching TV and 2 hours and 42 minutes using the computer and playing video games (Rideout et al., 2010). It’s been estimated that there are an average of 10 food advertisements per hour on children’s TV programs and about a third of the ads are for candy, sweets, and soft drinks (Harrison & Marske, 2005). Television viewing is associated with various undesirable outcomes ranging from decreased fruit and vegetable consumption (Boynton-Jarrett et al., 2003) to reduced life expectancy (Veerman et al., 2012). There’s ample evidence demonstrating that reducing television viewing results in weight loss (Epstein et al, 2000). The American Academy of Pediatrics recommends a maximum of two hours of viewing per day.

You can start the conversation by asking if there’s a TV in the child’s bedroom. Having a TV in the bedroom was associated with obesity in younger children (Dennison et al., 2002) and poorer dietary habits, less physical activity, fewer family meals, and poorer school performance in adolescents (Barr-Anderson et el., 2008). Unless they are bedridden with an illness there really is no reason for a child to have a TV in their bedroom. Likewise, you can suggest that computer use and video games be limited to common areas in the house.

Body Image

Although toddlers like their bodies, a significant number of children – some as young as six – are dissatisfied with their bodies and are concerned about their weight (Smolak & Levine, 2001). For girls, the dissatisfaction increases as they get older. By the time they get to school, children are aware of the stigma attached to obesity, and often have internalized the negative view of fatness. While there are limits to what your clients can do to protect their teens from media stereotypes about obesity and peer pressures they experience at school, parents can help their younger children to develop a positive body image.

For both kids and grown-ups, hating the way you look is demoralizing. How can you feel good about yourself if you hate your physical being? Not liking the way you look rarely provides motivation to change. It is depressing and saps the energy required to try new behaviors. You can help your clients promote a positive body image for their kids. Parents should:

• Focus on nice features of the child’s appearance instead of commenting on their weight or heavy body parts. Does she have nice eyes, a pretty smile, or fashionable hair? Is he handsome, or strong?

• Avoid negative comments or seeking reassurance about their bodies. For example, daughters don’t need to hear Mom ask, “Does this make my butt look big?”

• Develop media literacy. On occasion, parents should watch TV, YouTube, TikToc, or other media with their child and discuss unrealistic depictions of the ideal body form.

• Discuss the changes that come with puberty. Girls, especially when they mature early, may interpret their newly rounded shape as getting fat.

• Explain the inherited aspects of body shape and size to help the child accept genetically determined features.

School Programs

Kids consume between 35 to 50 percent of their daily calories at school. If you work in or consult with schools, or even if you’re just a concerned parent, you can advocate for school-based programs to help prevent childhood obesity. For example, one study reported increased vegetable consumption and decreases in sweetened beverages and chips after the implementation of a statewide nutrition policy for middle schools (Cullen et al., 2008). Fortunately, school-based obesity programs don’t appear to increase teasing about weight (Krukowski et al., 2008). Targeted interventions on a local level can also be beneficial. School vending machines could include fruits instead of candy and milk instead of soda. A program in Ireland significantly increased fruit and vegetable consumption by showing six short episodes in which the “Food Dudes” gain “life force” from eating fruits and vegetables (fooddudes.ie/main.html). In a study conducted in upstate New York, elementary school children were given a choice between a cookie and an apple. Apples were chosen twice as often when the apple had a sticker with a cartoon character (Elmo) on it (Wansink et al., 2012).

Former First Lady Michele Obama’s Let’s Move initiative suggests that children should get 60 minutes a day of physical activity. It’s estimated that only four percent of elementary schools provide even 30 minutes per day of physical education and not all of that time is spent exercising. A review of 26 studies of school-based interventions to increase physical activity did not find significant reductions in BMI (Dobbins et al., 2013). But one innovative school program, Dance for Health, resulted in significantly greater reductions in BMI when compared with the usual PE class (Flores, 1995). While a CDC review concluded that there wasn’t sufficient evidence to determine the effectiveness of school based programs (CDC, 2005), it’s clear that more needs to be done to increase children’s physical activity in school.

Final Thoughts

I hope you’ve found this course to be helpful in your work with clients. For a more detailed discussion of physical hunger, environmental and emotional triggers to eating, exercise, body image, and the role that relationships play in eating and weight problems, please consult Weight, Diet and Body Image: What Every Therapist Needs to Know.

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