Posted on 03 October 2011.
Nick says he’s going to die if he doesn’t lose weight. he knows he should eat less. he knows he should move more. How do our minds sabotage us, in concert with our bodies? A probing look at the psychology of obesity.
Natasha Mitchell: If you’re overweight, majorly overweight, there comes a point for some when mind overtakes body. Nick is at that point.
Nick: I’m gonna die if I don’t and I’m going to die early, I want my life back, I want to go out and enjoy the sun, I want to walk a kilometre without having the severe pain that I have and I love children, and I love my wife and she loves children and one of the key motivators for myself is to start a family and at 222 kilos unfortunately it’s very hard to conceive, it’s very hard to do anything really.
Natasha Mitchell: But there’s a battle of wills going on here too, the will of a biology reconfigured by being obese, if you start shedding kilos your body in fact adjusts both metabolism and appetite to try to hang on to them. And then there are your thoughts, those beastly little things, doing their very best it seems to sabotage your efforts.
Which might explain why most folk end up where they started, or packing on even more kilos.
Hi Natasha Mitchell joining you for All in the Mind here on ABC Radio National – welcome. Forty years of public health efforts to fight obesity have failed. That’s the conclusion of last month’s landmark series of papers in the Lancet. This is despite Australians forking out millions of dollars on weight loss programs each year with billions more spent annually on obesity prevention.
It’s a paradox that’s long intrigued Corinne Podger, who’s been fighting the urge to live on chocolate since the 1980s. here she is to navigate the psycho culinary battleground of decision and desire.
Corinne Podger: I’ve just got home from work and I’m hungry. There’s rice in the cupboard, I’ve got some chicken and a bit of broccoli, I could do a stir fry. I fancy something sweet though. There’s some fruit including the world’s most expensive banana but at the back of the cupboard, right at the back, is a block of chocolate.
I know chocolate is not dinner, we all know because the healthy lifestyle message isn’t that complicated. Watch your calorie intake, get some exercise, don’t live on chocolate, job done, right? Wrong.
Marita McCabe: Their bodies become part of their whole persona and so it helps them to define themselves to be large and even it prevents them from confronting other issues like their sexuality if they’re large.
Corinne Podger: the flesh we occupy is in a very real sense who we are – fat, thin or in between. Psychologist Marita McCabe’s studies in the fields of obesity and sexuality have made some unexpected connections here.
Marita McCabe: And we found that with some of the women, as they started losing weight that was pretty terrifying for them to be now seen by their partners and other men as being sexual beings. that was pretty terrifying for them because that changed the balance of their interactions with other people and so instead they put their weight back on again.
Corinne Podger: because if you suddenly slim down presumably your partner might be frightened that you might run off with somebody else.
Marita McCabe: Absolutely, and with this very early study that we did 30 years ago on obese women, their partners got very concerned as the women started losing the weight. I mean the women started moving differently, they were dressing differently, moving differently, throwing their heads around differently and that was very threatening for the partners, and so they would be then getting rewards for their women for losing the weight and you know here’s a nice cake I got for you, or a block of chocolate I got for you because you were doing so well. And so weight is not just a simple ‘am I underweight, am I normal weight, am I overweight, am I obese’, it represents us and to change that means to change my being. You would think that’s a very clear process, reduce your calories, increase your physical activity and you will lose weight and you will be healthier, and you will be happier, your self-esteem will increase, you will have better levels of body satisfaction seems so straightforward.
Corinne Podger: But as we know, nothing in life is ever straightforward.
Leah Brennan: the challenge is that we’re trying to achieve those goals in an environment that is encouraging us, very strongly encouraging us, to be inactive and to eat more energy than we actually need.
Anna: there are biological factors that predispose people to being obese, but that was so in the past as well, and so why do we now have so much higher levels of obesity? And this is where the psycho-social factors come in.
Leah Brennan: There’s some really mixed messages out there culturally, so being thin is the cultural ideal and yet most of our social interactions involve food in some kind of way. so in the same sitting you can be talking to your friend about how you’re trying to control your weight and convincing each other to share a piece of chocolate cake.
Corinne Podger: Dr Leah Brennan at Monash University’s Centre for Obesity Research and Education. She’s also the psychology chair on the Australian and new Zealand Obesity Society (ANZOS) and before her Deakin University psychologist Professor Marita McCabe.
It’s bleak news. despite 40 years of prodigious effort and expense we’re getting fatter. According to Professor Sue Byrne, a psychologist at the University of WA, study after study has found 80 per cent of everyone who goes on a diet will lose less than 10 per cent of their body weight and within five years they’ll be back where they started or heavier.
Sue Byrne: It’s very, very difficult to not become overweight in our current environment and it’s even more difficult to lose weight and even more difficult again to maintain a new lower weight once you’ve lost weight.
Corinne Podger: What you’re suggesting, what you’re saying sounds as though it’s a battle that’s not even worth fighting.
Sue Byrne: well certainly that argument has been made, we do have a responsibility to give people a list of expectations of what’s the outcome of any treatment for obesity might look like. so medical people do that all the time. They say if you have lung cancer you’ve got a five per cent success rate, or a chance of remission or whatever, but with obesity I don’t think we do that very well. because most people who come in for treatment for obesity expect to lose a lot more weight than we know they are going to be able to lose.
And there’s that argument or the question that isn’t ethical to say to people that we have treatments for obesity that work when there’s actually no evidence that they actually do work, particularly in the long term.
At the moment the best treatment for overweight and obesity is surgery, it seems to be the only treatment where people can lose a significant amount of weight, a lot of weight, half their excess body weight or more and keep that off. But of course surgery comes with risks, and it’s not really a solution for the entire overweight population. only a few people can afford to have surgery for a start, and it wouldn’t be a viable treatment solution for everybody.
Corinne Podger: from Dr Leah Brennan’s office you can see the Melbourne suburb of Richmond, which is home to the company that runs Weigh it up, an online weight loss program. several members agreed to come in for a chat to explain why giving up isn’t an option for them.
Anna: five years ago I got injured and had to have numerous back surgeries. Throughout the course of that my weight just ballooned out as well. now that I’m getting back on track I needed to try and get my weight back down. it was hard to try and find clothes again to fit into and then when photos were taken you’d just kind of close your eyes, didn’t want to look at how you looked and so on.
Lyn: I’ve got a mild kidney issue and blood pressure and I’m going to see the specialist, she was saying to me we need to monitor you and you have to have a 24-hour blood pressure monitor. I’m actually a practised nurse so I knew what that meant, and I knew that if I continued putting on weight that was only just going to get worse.
Nick: because I really want to start a family and I really want to get up and go to a concert and go to the football and just watch a football match and be able to sit in the seat and not encroach on somebody else. And I just don’t want to die early.
Corinne Podger: Online dieters Nick, Anna and Lyn aren’t interested in the 80 per cent who fail; they want to hear about the others, the one in five who manage not just to lose weight but to keep it off. And it’s Dr Leah Brennan’s research focus too. She’s about to publish a literature review of dozens of weight loss programs, everything she could find in the English language looking at why people drop out with a view to encouraging more to stay the course.
Leah Brennan: we don’t know very much about why it is that people don’t complete a weight loss intervention. we do know that rates are very high, so up to about 30 per cent is sort of expected in terms of weight loss attrition. unfortunately to date the research has largely focussed on demographic factors and other really basic things like how old you are and what gender you are and to see whether they predict whether or not you’ll finish, and they are not particularly strong predictors. when we started looking at more complex predictors like psychological factors and social factors, we started to find there’s a little bit more information there. so the clearest predictors are around mental health issues and people who were dealing with mental illness such as depression or an eating disorder were more likely to drop out of a weight loss program. Other psychological distress, obviously if you’re distressed by a range of other issues it’s hard to maintain the motivation and be able to prioritise weight loss.
Corinne Podger: in fact it’s been suggested that the obesity epidemic that we have is partly a symptom of an underlying stress epidemic or depression epidemic. What was your view on that having carried out this literature review?
Leah Brennan: there certainly is growing interest and growing evidence in the relationship between mental health and weight, and so the two areas that the literature is really focussing on at the moment is stress and depression. We’re in the early stages, but so far what it’s showing us is there are some common physiological factors that might mean that each of those disorders are contributing to obesity and back the other way, that perhaps obesity is contributing to stress and depression as well.
Corinne Podger: that begs the $64,000 question obviously which is if you’re looking at the studies where people are most likely to drop out what did that have to say about approaches to weight loss where people were most likely to stay the course, the lowest number of drop-outs?
Leah Brennan: in terms of trends in the literature, if you’re doing a more comprehensive intervention with more support from health professionals and also from others in a similar situation or from family and friends you’re more likely to be able to sustain your weight loss efforts.
Corinne Podger: Does that suggest that signing up to a support group is a good thing in terms of a predictor of staying the course?
Leah Brennan: the research is more around I guess recruiting other people in your life to provide social support. so whether that be a health professional who’s helping you in a structured kind of way to lose weight, or whether it be involving your partner or a friend to be supportive of your weight loss effort, people that engage other people to help them out are more likely to sustain their efforts.
Corinne Podger: Support or the lack of it rings plenty of bells for Nick, Jenny and Lyn.
Lyn: My main issue is family, cooking for teenagers. They don’t like all the food on the program and then you’ve got to cook two separate meals and when you’ve got time constraints with work that’s not always an option.
Jenny: Yeah, my portions are much bigger than what they should be and I know I don’t take particularly well to a set diet because I’m still the main cook in the family, and I’ve got three big adult males to contend with.
Nick: I’m sabotaged, other people walking up to me like an aunty of mine who said Nick you know I prefer you to 250 kilos you look better to me, I just don’t like it when you lose the weight, you just don’t look as good.
Corinne Podger: now to a crucial conundrum in this story. You might think that losing excess kilos then keeping them off are part of the same challenge but in fact research suggests that they are both distinct both physically and psychologically. Maintaining your new lower weight is a whole lot harder for surprising reasons. Professor Sue Byrne.
Sue Byrne: Maintaining a new lower weight is highly effortful. You really, really have to work at it. There’s a big difference physiologically between someone who has always been 80 kilos and someone who was 150 kilos and has lost down to 80 kilos because your body remember is programmed to defend a higher weight, so it will be doing everything it can to make it easy for you to regain weight. your metabolism will be much slower, you’ll have higher levels of leptin, lower levels of ghrelin which tend to mean that the drive to eat is very strong and that you tend to not feel full, even though you’ve eaten a lot. And if the person I guess perceives that the effort isn’t worth it, they are not even happy with that weight anyway, they are highly likely to give up and abandon efforts at weight control and weight maintenance.
Corinne Podger: And what’s more maintaining your weight takes unusual staying power – Leah Brennan.
Leah Brennan: with other behavioural changes we do find that people get to a point where they no longer have to put in the same amount of conscious effort in order to maintain their behaviour. Such as with smoking – eventually your environment changes enough, you consider yourself a non-smoker and it’s no longer a conscious effort not to smoke. whereas with weight because of the environmental pressures that are there it’s sort of a lifelong battle that you always are required to put in a conscious effort to maintain health behaviours in an environment that pressures you to be unhealthy.
Sue Byrne: They are very different processes, most diets and slimming clubs and so on really only focus on weight loss and the implication is that people just have to keep on going losing weight until they get to some sort of ideal weight, whatever that might be, and there’s no focus on what to do when you get there, or even on trying to maintain a higher weight than you might have initially wanted.
Corinne Podger: one of the interesting findings from one of your research studies runs completely counter to the way that many of us conceptualise weight loss, which is that people who are actively trying to lose weight at the same time as maintain what they’ve lost are at the most risk of putting it all back on again. Why was that?
Sue Byrne: I think the main issue here is that most people come into some sort of treatment program for overweight with an unrealistic idea about the amount of weight they can achieve during treatment. so for example most females would come in for treatment and her weight would be 105 kilos and when you would ask her what weight would you like to achieve by the end of this treatment they would say 65 kilos. Obesity research has been around since the 1960s and there’s been hundreds of treatment trials of behavioural treatments, drug treatments to try to get people to lose weight and we know that at best people are going to lose hopefully between five per cent and 10 per cent of their body weight. so for someone weighing 105 kilos that’s about 10 and a half kilos, they’ll end up being 90 kilos and not 65. What happens then is people get very despondent about it, they think well I’m nowhere near where I want to be and this is hard and even losing that much weight was so difficult and they sort of give up, they say what’s the point, I’m not happy where I am so I may as well go back to what I was doing before.
Corinne Podger: You need a psychological bang for your buck if you’re going to stay on track and you don’t get that when you’re just trying to keep your weight steady. Psychologist Leah Brennan.
Leah Brennan: when you’re talking about weight loss you’re talking about making large changes to your habits and routines and you’re seeing the benefits of those changes, so you’re seeing weight loss and you’re experiencing the benefits of that. so changes in clothing sizes, comments from friends, capacity to do things that you couldn’t otherwise do, so there’s constant positive reinforcement coming from your environment in terms of the benefits of your efforts.
Corinne Podger: Sandra, who’s doing the weight loss program we heard about earlier, knows exactly how that feels.
Sandra: I just think that the perception of what other people say and make comment and go wow, you’ve lost some weight and you actually feel quite good. that positive feedback does make you feel pretty good inside.
Corinne Podger: whereas with weight loss maintenance that’s not quite the same picture is it?
Sandra: No it’s quite different, so once your weight stabilises you’re no longer getting those positive reinforces from your environment, so you’re not buying newer, smaller clothes, your friends are no longer commenting on the changes and you’ve kind of got used to the things you’re able to do at your lower weight.
Corinne Podger: Corinne Podger with you on All in the Mind this week on ABC Radio National, Radio Australia and as podcast. with all the money spent on weight loss why are we getting fatter? Today looking at how our minds sabotage us in concert with our bodies.
At that moment when you give up on a well planned weight loss program, what’s going on in your head? well food it seems is a way many of us resolve life’s hard problems, as Anna, Nick and Jenny can testify.
Nick: Studying at university, not being able to do a physics equation and throwing the physics book from one end of the room to the other, that would be the first thing and then dumping the diet would be the second thing.
Anna: Basically with the operations and so on that I’ve been through there was like a lot of stress going through all of that. not having any support from work colleagues, there was a lot of stress going on there. No support from family, stress from there as well, a lot of things going on.
Jenny: the antisocial aspects including just within my own family of being the one to have the little tray of stuff and meanwhile cooking proper nice meals for everybody else, and there’s a limit to how long you can do that I think.
Lyn: And I’m a sweet tooth, so if I get stressed — and I’m not talking major stress like there for family I’m just talking a small stress will make me eat, I’m a comfort eater as well, so if the kids were annoying me, if I’ve had a bad day, I basically gave up and was just eating what I wanted to eat.
Corinne Podger: so let’s look at thinking styles as part of this story. Sue Byrne with British colleagues have found that people who are better at problem solving and so coping with stress, including the stress of not losing as many kilos as they initially hoped, do better in the weight stakes.
Sue Byrne: we recruited a whole bunch of people who had managed to lose a significant amount of weight, most of them were about 20 per cent of their body weight, they’d lost a lot of weight and were now almost healthy weight, or in the healthy weight range and had kept it off for at least two years. we also recruited a bunch of people who had lost a lot of weight but had regained all the weight they’d lost within the last two years. we also interviewed a group of people who’d never had a weight problem, who’d always been in the healthy weight range and whose weight didn’t seem to deviate. we talked to all these people at length, drove round the country interviewing them and trying to get an idea, because we really didn’t have any good hypotheses about what people might need to do psychologically to maintain a new lower weight.
People who were able to lose a lot of weight and keep it off just kept doing all the right things, they were very careful with their diets, they were very active, prioritised their weight and their shape and their fitness and they invested a lot of time and effort in maintaining a new lower weight. the people who regained weight had tended to adopt very strict dietary practices to lose weight, had sort of developed quite rigid rules about their diet. They either went on liquid diets or very restrictive diets that they weren’t able to maintain in the long term. it was almost impossible to keep living like that. And the other interesting factor was to do with expectations about weight loss. the people that were able to maintain weight were happy with losing a moderate amount of weight. so rather than having some sort of rigid unrealistic goal weight that you felt like you had to achieve, people were able to modify their original hopes or expectation about the weight they wanted to achieve and modify it up. so they were more flexible about the weight they were happy to be and therefore more accepting of themselves as people and their bodies at whatever weight they were.
Another factor was a type of thinking style and one that we called dichotomous thinking, or black and white thinking and that is the tendency for people to think in very all-or-nothing terms. And we found that people who did have that thinking style, who were very black and white, or all-or-nothing thinkers, were much more likely to regain weight. And we figured it partly had to do with the overlap between this thinking style and having rigid unrealistic weight goals. so the people who were black and white thinkers and didn’t achieve their weight goal were more likely to throw in the towel and say well I can’t get there I may as well not bother at all. whereas people who were more flexible and were able to say well, I didn’t get to the weight I really wanted to get to but this is OK and I’m better off here than where I was before so it’s worthwhile maintaining, working hard to maintain this weight, were more like to be able to do that.
Corinne Podger: And you might have more luck if you have a clear understanding of why you’re doing what you’re doing. another of Leah Brennan’s studies has found that many of us look to weight loss to solve other problems that have nothing to do with the extra kilos.
Leah Brennan: we started with working through what was already in the literature and also taking to a range of clinicians who’d worked with people trying to lose weight to identify a very long list of reasons people give for wanting to lose weight. so we started with something like 170 different reasons that people gave for trying to lose weight. then we set up a questionnaire which we then administered to 127 people who were overweight and actively trying to lose weight and from that we were able to identify the key themes that came out in terms of people’s underlying primary goals for weight loss.
Corinne Podger: some of the goals were physical in nature. For example wanting to reduce joint pain, wanting to avoid swollen legs, get rid of back pain, some of it was very much about the psychological, I want to be attractive, I want to have more confidence to get ahead in my work. What sorts of goals were helpful for people that kept them focussed?
Leah Brennan: What the theory predicts is that people actually need to be working towards achieving those goals directly, that often those goals are not weight dependent so you don’t have to lose weight in order to feel more self confident. And sometimes they’re not even weight related so losing weight doesn’t necessarily mean that you’ll find a new partner. so perhaps weight loss intervention should also incorporate helping people to achieve those other goals and perhaps we’re doing it around the wrong way. If we are helping people to achieve those other goals they then might be more motivated to maintain their weight loss efforts. whereas if they are continuing to rely on weight loss in order to achieve those goals and never quite getting there then it’s hard to sustain the motivation.
Corinne Podger: Cognitive behavioural therapy (CBT) targets unhelpful thoughts and can help us reconfigure them. so does it have a role then in stopping our minds sabotaging our diets?
Leah Brennan: one of the biggest challenges that people come along with is that they say they know what to do but they don’t know how to do it. And so really cognitive behavioural therapy is all about teaching people how to do it. so the behavioural part is teaching people how to change their behaviours, not just telling them what behaviours to change but how to set goals, how to keep track of what they’re doing, how to change their environment so that it supports behaviour change so they don’t have to put so much effort into being healthy.
The cognitive part then looks at how our thinking can be helpful and how it might be getting in the way, so looking at goals and setting goals that are actually helpful rather than detrimental to our efforts. Also looking at thinking styles, so one of the key thinking styles that comes out as being unhelpful is called dichotomous or black and white thinking.
Corinne Podger: This is an approach you’ve tested with adolescents, what were your findings?
Leah Brennan: the initial study was with 63 adolescents who were overweight or obese. we found that they were able to lose weight but also more importantly to improve their body composition which showed us that they were losing fat rather than muscle. so they were able to improve their health behaviours and also to improve their mental health compared to the group we didn’t offer treatment to. that study has since been replicated in South Australia and also here in Melbourne with positive results.
Corinne Podger: Leah Brennan. But overall results with cognitive behavioural therapy have been decidedly patchy. Sue Byrne.
Sue Byrne: I was involved in a study, a big randomised controlled trial of cognitive behavioural therapy for the treatment of obesity that was conducted at the University of Oxford in the late 1990s/2000. This was a trial where we randomised people to three different treatment groups, these were all overweight people, so one group got cognitive behavioural therapy where the focus was very much on the psychological factors associated with being overweight, and there was also a strong focus on maintaining a new lower weight once you’d lost weight.
Another group were randomised to just traditional behavioural therapy, which is the strongest focus really is just on weight loss. And the third group were randomised to just a self-help program which is more of a control group, which is people who were given a self-help manual. And then we followed these people up throughout the whole treatment, there was individual therapy which lasted for 11 months and then followed up for five years. so that’s why it has taken such a long time to get the results because you need a longer-term follow-up so you can see whether they were actually successful in the longer term.
Corinne Podger: And your findings?
Sue Byrne: What we found was as we expected people who were in the behaviour therapy, the traditional behaviour therapy group and the people that were in the cognitive behavioural therapy group lost a modest amount of weight on average, round about 5 per cent/10 per cent of their initial body weight, which we actually know is clinically significant. You get really good medical benefits even from losing that small amount of weight. however, what we also found over the next five years was that everyone regained weight at the same rate, so basically we failed to find a better treatment for overweights for maintaining a new lower weight even though we gave it our best shot.
Corinne Podger: That’s depressing.
Sue Byrne: Yeah. so basically what we found is that people tend to regain weight. the vast majority of people will regain all the weight they lost within three to five years.
Corinne Podger: People don’t enjoy doing the same thing over and over again and failing at it. is there a psychological cost to repeatedly failing to lose weight?
Sue Byrne: That’s a really good question and that’s one I don’t think we really know the answer to yet because there is a psychological cost to losing weight and regaining, losing weight and regaining; that yo-yo dieting of weight cycling that it’s sometimes called is associated with poor self-esteem and depression, the rate of depression in people who are overweight or obese is a lot higher than in the general population, especially among females.
So the question is would it be better both medically and psychologically for people to never try to lose weight, to maintain an overweight status as opposed to going through these cycles of losing weight but regaining it, losing and regaining. I don’t think we know the answer to that question yet.
Nick: Every time I basically lose hope sure I mourn for about five minutes but the pants that I’m currently wearing I couldn’t wear two months ago and you know when I first put them on it triggered memories of getting dressed up and going out on a Saturday night or a Friday night, things that I couldn’t do at 250 kilos. I feel like the Nick that I consider to be the true Nick.
Natasha Mitchell: the true Nick speaking to Corinne Podger as was Professor Sue Byrne before him and others. something of an antidote don’t you think to shows like the biggest Loser? Lots of references on our website along with the transcript and audio.
And has what you’ve heard today resonated with your own efforts to drop the kilos, what’s worked, what hasn’t – get talking over at abc.net.au/rn/allinthemind look for add your comment on this week’s story. I’m Natasha Mitchell, thanks to Maria Tickle, catch you next week.
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