Escolar Documentos
Profissional Documentos
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after weight
Judith
weight
loss in women:
Bruvold,
women who
and
regained
S Stern
after suc-
ABSTRACT
cessful weight reduction (relapsers, n = 44); formerly obese, average-weight women who maintained weight loss (maintainers, n = 30); and women who had always remained at the same average, nonobese weight (control subjects, n = 34) were interviewed. Most maintainers (90%) and control subjects (82%) ex-
ercised regularly, were conscious oftheir behaviors, used available social support (70% and 80%, respectively), confronted problems directly (95% and 60%, respectively), and used personally developed strategies to help themselves. Few relapsers exercised (34%), most ate unconsciously in response to emotions (70%), few used available social support (38%), and few confronted problems directly (10%). These findings suggest the
advisability vidualized ofdevelopment and treatment programs prospective designed evaluation to enhance of mdiexercise, 1990;52:
loss and regain in laboratory animals and in humans are associated with increased metabolic efficiency and rapid regain on refeeding. The decreased energy requirement needed for weight maintenance could predispose people to regain weight and make subsequent dieting more difficult. Numerous investigators (12-16) have concluded that different processes and strategies are needed to maintain weight than to lose weight. Processes and strategies may vary at different stages ofthe behavior-change process, suggesting that intervention to prevent relapse would best address the problem at each
individuals point in the behavior-change process. Brownell et
coping
800-7.
skills,
and social
support.
Am J C/in
Nuir
Obesity,
maintenance,
relapse,
weight
loss,
social
support,
exercise
weight and
succeed these
for drug,
Recidivism
tobacco
dependency.
Relapse
are
rates
reported
for drug,
alcohol,
range
and
of
tobacco
to be in the
relapse rates for obesity and other dependencies could be overestimates of actual rates since most reports are from clinical programs and are based on people who have received formal treatment. In addition, these figures could overstate the problem: frequently, only the most difficult cases are seen in research-oriented treatment programs and often
only one attempt to change is studied. People attempting to
50-90%
al (1 5) suggest that there are at least three stages of behavior change: 1) commitment and motivation to change, 2) initial change, and 3) maintenance ofchange. Others propose that an additional stage, 4) dealing with success, or living with the changes, is essential (12, 13). This refers both to living with a smaller, thinner self, as well as accepting the changes as part of ones life rather than as unusual things to do as part ofa temporary diet. Surprisingly little is known about those who lose weight and regain it outside of formal treatment programs since most data are from clinical interventions (15). It is difficult to isolate the factors that influence relapse because it is so hard to fully evaluate patients after treatment has ended. Few follow-up studies report long-term results and few studies report results for untreated control subjects. In the present research long-term weight-loss maintainers were sought to learn how they differed from women who relapsed after weight loss and from women who had never been obese. We hoped to gather clues for more
I
From
the Department
of Regional
Health
Education,
Kaiser
Per-
manente, Oakland, CA; the Department ofSocial and Administrative Health Sciences, School of Public Health, University of California, Berkeley; and the Departments ofNutrition and Internal Medicine and
the Food
2
Intake
Laboratory,
University
ofCalifornia
at Davis.
own
may
be successful of relapse
problem
and plagues
for obese
may
relapse
less
Supported in part by grants to SK from the Dr EE Dowdle Fund and the University ofCalifornia Chancellors Patent Fund; by Biomedical Support Grant S-S07-RROS441, National Institutes of Health, to
problem
all areas
people
of subbecause
it is a particular
repeated weight loss followed by weight gain may have mental health, metabolic, and psychological consequences.
idemiologic studies (5) reveal positive effects of weight
detriEploss in
Training in Disease
Program Prevention,
lowering blood pressure and cholesterol and improving glucose tolerance (6). However, when an equal amount ofweight is regained, negative effects on blood pressure and cholesterol may be greater than the positive effects when the weight was lost (7). Some investigators (8- 1 1) found that repeated cycles of weight 800
Am J C/in Nuir
gional
CA
Address reprint requests to S Kayman, Kaiser Permanente ReHealth Education, 1950 Franklin Street, 17th floor, Oakland,
May4, 1989.
94612-2998.
Received
Accepted
Printed
for publication
in USA.
December
20, 1989.
Society for Clinical Nutrition
l990;52:800-7.
1990 American
LONG-TERM
WEIGHT
MAINTENANCE
801
weight range, or average overweight weight, was or were 20% by us-
successful groups.
obesity
treatment
from
a comparison
of these
three
within
a desirable
overweight.
Twenty-percent
calculated
and methods design methods (17) and are oftwo basic types, Selltiz et al (18). One
the second employed the ifa Joint large
of the weight range for a medium-frame height in the 1959 Metropolitan Life InsurNIH Consensus Development Conference on
the
health
Health
risks present 20%
Risks alarming.
research
of Obesity Thus,
to focus
(19)
concluded
level whose 20%
that
were
long-term
undesirable
at the 20 percent
overweight on women
and even
the
was used
overweight
in
put
pothesis generation and tion. This study expressly erate this worthy dure hypotheses method called is successful
them
at increased
overweight,
risk
had
for
problems.
lost
Relapsers
oftheir weight
were
one
previously
( 1 7, 18). In general,
ofpotential hypoth-
and
initially
confirmatory the Joint why and weight
assessed
Method
to identify
was used.
those
most
proce-
or more times but regained it (n these women were neither gaining ers were of average weight and
overweight weight for and had as adults, elapsed groups. Interviews
44). At the time ofthe study, nor losing weight. Maintainhad previously been 20%
the average current At least in all reduced weight weight 1 y had three
A standard
Extreme
but had reduced and maintained 2 y (n = 30). Control subjects were remained for the last within pregnancies pregnancy 3.6 kg oftheir except
groups
eses nificant
were
identified
and a large
one did
number
group not
ofpotential
ofwomen regain
hypothlost a siganthe to
always since
tested amount
(n
34).
and
delivery
other
always Joint were
group
Method generated
A third
group
ofwomen
selected.
who had
maintained
was also
contrasting hypotheses
that
Subjects oped
were
by use The
develused
specifically
procedures
In this way, the more useful explanatory from the larger group and these were used
to develop the questionnaire: 1) Exploration: tapes were made offocused, with 12 subjects (6 relapsers and 6 maintainers)
issues to include in the questionnaire. 2) A preliminary by use ofthe issues until
initial
theory
to guide
future
confirmatory
research
open-ended
and topics
questionnaire
identified from
Potential
nance
subjects
were recruited
the Kaiser
from a central
a large area
health ofthe
mainteOffices in
organization,
Permanente
Medical
3) The questionnaire was tested, revised, and tested again the questions elicited the desired information. The final questionnaire was used to interview the 108 relapsers,
maintainers, Questions tionnaire: and control subjects who met the study criteria. in the quesexperiences; in on the overweight following history topics were included and childhood food
Fremont,
CA. As women
entered
medical
volunteers
into
erage ifthey
three
weight. were
weight
groups:
had
relapsers,
maintainers,
or always
potential infants,
av-
dieting and weight-loss history; reasons for gaining, maintaining, or sustaining weight; positive and negative involvement
Volunteers pregnant,
attempted to lose weight, had lost < 9 kg, were losing weight, were gaining weight, or had experienced a weight change due to illness. From the 700 women who categorized themselves as relapsers, These maintainers, or always average weight, 50 were selected
other people; pregnancy history; smoking meal and snacking patterns; health proband surgeries; exercise patterns; demomarital status, employment, and educa-
tion;
cent
emotion-related
situation
eating;
or
perceived
event version
social
and of the
support;
coping Ways
and
responses, of Coping
re-
evaluated
an open-ended
from
each
weight
were
category
telephoned
for further
to determine
screening.
weight-
1 50 individuals
of maintenance of reduced weight, and meeting all criteria (see next section) and agreeing to be interviewed (n = 108) received letters explaining the study and confirming interview appointments. Potential
subjects view mately author was and were telephoned before their interview to reconfirm. If ultifirst
length Those
questionnaire (20). The study protocol was approved by the Kaiser Permanente Medical Care Program, Northern California Region, Institutional Review Board, and the Human Subjects Committee of
the University ofCalifornia, Berkeley.
Coding
ana/yses responses from and differences the questionnaires between groups were were as-
the prospective
interviewed. each
subject
All interview
cancelled
so that subjects lasted
the appointment,
all potential were from subjects interviewed 1 to 1 .5 h.
rescheduled
sessed with analyses of variance for continuous with chi-square analysis for categorical variables. cance groups ofdifferences of primary subjects was Throughout between interest, further the relapsers and assessed analysis, then and with for maintainers additional qualitative,
Criteriafor Weight
ance Tables
maintainers,
the
1959
Metropolitan
whether
trol
to determine
analyses.
802
I Sociodemographic control subjects*
KAYMAN
ET
AL
TABLE
TABLE
characteristics of relapsers, maintainers, and Comparison ofreduced Control subjects (n = 34)
3
ofweight-loss weight5 methods used by relapsers and maintainers
Relapsers
Characteristic Age(y)
21-44
45-73 Marital Married Divorced,widowed,single
(n
44)
Maintainers (n = 30)
Weight-loss
method
plan
Relapsers (n = 44) 17 (39) 16(36) 19 (43) 13(29) 1 5 (34) 2 1 (47) 5(11) 4 (9)
21 (48)
23(52)
21 (70) 9(30)
Attended
Weight Watcherst
programs or
status 36 (84)
7(16) 22 (50) I 3 (30) 9(20)
23
(77)
Followed
doctors
orders
Followed
Total
S
book, magazine
used ofsubjects;
diet
1 1 (25)
I2 1
-
3(10)
28
-
Caucasian
Hispanic,black
40 (9 I )
4(8)
methods Number
percent
in parentheses.
23(54)
20 (46)t percent from in parentheses. maintainers,
7(21) 27 (79)
t Concord, t Methods
used).
of methods
were
Number
Significantly
ofsubjects; different
0.05.
Methods
Weight-loss
methods
Results
Sample characteristics
Maintainers and relapsers were primarily Caucasian (97% and 91%, respectively), married (74% and 84%, respectively), and middle-aged (mean ages 41 and 47 y, respectively). More maintainers than relapsers completed college (30% vs 20%) and had salaried positions in addition to theirjobs as homemakers (77% vs 46%, P > 0.05). Maintainers did not differ from control subjects in their race, marital status, age, education, or employment (Table 1). Maintainers, relapsers, and control subjects did not differ significantly in the percent who had children (77%, 83%, and 74%,
respectively) 5 in all three or in their groups). mean However, number ofpregnancies gained (range significantly 1relapsers
TABLE
comparison
ofrelapsers,
maintainers,
Control
Relapsers Weight gain (kg) by I y afterlastpregnancy
S
Maintainers
subjects
11.7
lO.4t
S.97.2f
1.8 2.3
SD.
different different from maintainers subjects, and control 0.001. subjects,
t Significantly
PO.OOl. Significantly
from control
A key finding ofthis study was that although the maintainers used many similar strategies to lose weight, each maintainer used these strategies in ways that were specific to her own lifestyle. Few women successfully maintained reduced weight after learning a package of strategies from a class or with the help of a physician or nutritionist (although these resources were available). Maintainers made decisions to lose weight and then devised personal weight-loss plans to fit their lives. These plans usually included regular exercise or activity and a new eating style of reduced fat, reduced sugar, more fruits and vegetables, and much less food than previously eaten. Maintainers reported being patient, setting small goals that they could meet, and sticking to their personally devised weight-loss plans. Some used ideas from earlier weight-loss experiences, some used diets from books, but all persisted until new eating patterns were established. Maintainers reported that ultimately they did not want to eat as much and that such foods as candy and donuts were no longer appealing because they were too sweet or fatty. They changed their cooking methods to avoid frying foods with extra fat and found themselves able to deemphasize food in their lives. However, they did not completely restrict favorite foods and made efforts to avoid feelings of deprivation while changing food patterns. In contrast, few relapsers (36%) had exercised to help lose weight. They had lost weight by taking appetite suppressants, fasting, or going on restrictive diets that they could not sustain. They took diet formulas and went to weight-control groups and programs many times(Table 3). While dieting they did not permit themselves any of the foods they enjoyed and perceived their diet foods as special foods, different from the foods their family could have and different from foods they really wanted. They felt deprived on the restrictive diets and easily went back to old patterns. Many relapsers (77%) reported regaining in response to a negative life event that made it impossible for them to prepare special foods anymore or continue exercising. 0thers reported that they just went back to old ways without even
LONG-TERM
TABLE 4 How maintainers women (control)
WEIGHT
she wanted
also able to to cut back
but in small
notice on food small intake
quantiweight and to
ofreduced weight and always-average-weight subjects stay at their d esired weights5 Control subjects (n = 34)
ties. gains,
Control which
exercise
Se/f-image
more.
Strategy
Maintainers (n = 30)
Whereas
Watches weight on scale (monitors weight) Is active (more active) Eatsless Watchesintake Reduces intake ofhigh-fat foods Reduces intake ofhigh-sugar foods Changed to good eating habits Changed attitude toward food and
eating
most
maintainers
and
control
subjects
(86%
and
lapsers
70%
were
ofrelapsers
mostly
dissatisfied
with
their their
bodies.
25%
More and
than 43%
saw themselves
as heavy
or ugly,
of relaps-
bodies,
Eats what she wants and does not feel guilty about what was eaten, deny, or deprive herself: ifgoes offdiet, does not hate herself or feelbad Knows size by feel ofclothes Does not eat three meals/d Fantasizes, uses imagery techniques Avoids snacking by engaging in activity incompatible with eating Goes to Weight Watchers or other maintenanceprogram Recalls old feelings ofhow bad she felt Knows and avoids situations when she would overeat
S
A major
their activity subjects(82%)
difference
patterns. reported 30 mm) less frequently
between
Most exercising whereas and than
maintainers
maintainers regularly few regainers
and
(90%)
relapsers
and three reported maintainers.
was
control times reg-
relapsers engaging
reported and
less vigorously
Maintainers
daily work
Eating
ofsnacks
Women
beverage
in all three
eaten between
reported
every day
eating
snacks
(food
or
or almost
daily.
How-
(3)
Number
percent
t Significantly :1:Significantly
0.05. 0.001.
ever, relapsers ate significantly more snacks each day than did women in the other groups (mean number ofsnacks eaten daily 4.6, 1 .5, and 2 for relapsers, maintainers, and control subjects, respectively; P < 0.000 1 ). Relapsers ate more candy and chocolate than did women in the other two groups (41% vs 17% and 1 5%, respectively; P < 0.05). Both relapsers and maintainers drank more diet soda than did control subjects (4 1% and 31% vs 8%, respectively; P < 0.05), an interesting finding that may
merit differences additional between investigation. the groups There choices were ofother no snack significant foods or
realizing Relapsers
prised
it or that lifestyle changes made it impossible to diet. seemed to see their lost weight as gone and were surto find themselves heavy strategies again.
beverages,
vegetables,
which
sweet
included
baked
chips,
goods,
crackers,
ice cream,
cheese,
and coffee.
pizza,
fruits,
Weight-maintenance
needed of food
to stay
100
of their subjects
desired
80
a variety
weights, response
able
as listed in Table 4. These strategies were generated in to the question, How do you think that youve been
at the weight you want to be?
60
C
a)
C.)
to stay
Control subjects did not see themselves as women without a weight problem. They consciously stayed trim and worked to keep in shape. They were uncomfortable in their clothes when they gained after a vacation or a period of eating more and reduced their food intake until they returned to their desired weight. They always purposely aware wore of their close-fitting bodies. They clothing knew to keep how they themselves
8.
40
20
U)
C 0
C.)
wanted their bodies to feel to exercise, avoid fats and to eat. One woman said be interested in talking to
(and look) and this prompted them sugar, skip meals entirely, or forget the interviewer probably would not her because she only ate when she
FIG I . Percent of relapsers, maintainers, and control subjects who exercise regularly (at least three times per week, 30 mm per session). 5Significantly different from maintainers and from control subjects, 0.00 1.
804
TABLES Weight-control
KAYMAN
ET
AL
help requested
by relapsers
Checkups with referral suggestions, information, concernedMD Support group, diet partner Emotional help, understanding about needs related to weight, from family, health professional
S
problem-solving or confrontive ways ofcoping with their problerns, compared with maintainers or control subjects, and were more likely to use emotion-focused or escape-avoidance ways of coping, such as eating, sleeping more, or wishing the problem would go away, than were maintainers or control subjects. In contrast, more control subjects reported using relaxation techniques, exercising, or working more when troubled than
did maintainers or relapsers.
15(34) 10 (22)
2(6) 3 (10)
Social
support
9 (20) in parentheses.
1 (3)
Number
ofsubjects:
percent
Most ofthe women in all three groups ate lunch and dinner every day and rarely skipped these meals. However, more relapsers than maintainers and control subjects skipped breakfast
(43%, 37%, and 23%, respectively, skipped
<
breakfast
either
ev-
ofthe
time;
help or other
women
assistance
that
control
or other health
In addition to using more problem-focused than emotionfocused coping in response to problem situations, more maintainers and control subjects sought support or help in dealing with their problems from family, friends, and professionals than did relapsers (Fig 2). More relapsers reported that they had few people available for support or help with their problems than did maintainers (Fig 3). More than half the women in all three groups reported that their husbands were not supportive, either for problems or troubling aspects of their lives or for their weight-control efforts. There were no significant differences in the number of relapsers, maintainers, or control subjects who reported that they had supportive spouses.
Self-reported akohol consumption and smoking
reported
respectively)
reported
that
they
help,
that
help from
others
Most maintainers and control subjects reported themselves to be light drinkers whereas relapsers were divided about equally between the non- and light-drinker categories (Table 7). There was a slight tendency for control subjects to report
contrast, only 36% of relapsers did not want help (P < 0.0001 comparing relapsers with maintainers). Most relapsers (64%) wished they had more help for their weight-control efforts. Table 5 details the kinds of help these women, as well as the few
maintainers might like who were to receive. interested in receiving some assistance,
TABLE
Coping control
6
with problems: subjects comparison ofrelapsers, maintainers, and
Relapsers
Maintainers
Control subjects
Copingresponse
Escape-avoidance Eats, smokes, tranquilizer
(n=35)
27 (7O)t
(n=24)
8 (33)
(n=26)
9 (35)
Coping
with problems
Most relapsers, maintainers, and control subjects (87%, 80%, and 76%, respectively; differences between groups NS) were able to report a stressful or troubling issue, event, or situation in response to the question, What would you say is the most stressful or troubling aspect of your life right now? More relapsers reported experiencing problems related to their overweight and/or their health than did maintainers or control subjects (56%, 10%, and 2%, respectively; P < 0.05). There were no significant differences in the other types of problems reported by women in the three groups, which included problems
with interpersonal relationships (parents, children, husband,
drinks,
takes
Sleeps more
Wishes problems away Seeks social support would go I S (38)t 17 (70) 2 1 (80)
Problem
solving and/or
4(lO) 1 (2) 23(95) 4 ( I 7)j 15(60) 1 1 (42)
and friends), self-fulfillment problems and issues, and job or career problems. Though most women reported a stressful issue or problem, there were significant differences in the ways relapsers, maintainers, and control subjects reported coping with these problerns. Coping-response categories were developed from answers to the question, How are you dealing with this? after the problem or stressful issue was described. These coping-response categories were based on coping-response scales developed from the revised Ways ofCoping checklist (20, 22). Categories are not mutually exclusive and include all reported coping responses. As shown in Table 6, few relapsers used
confronting Tension reduction Exercises, does extra work Shops Uses relaxation techniques Totals
52
56
66
S Ofthe study subjects, 87% ofthe relapsers, 80% ofthe maintainers, and 76% ofthe control subjects stated they had problems now; data in this table are based on the subjects who reported problems. Percents in
parentheses.
t Significantly :t Significantly
different from maintainers: tP < 0.01; P different from control subjects, P < 0.05.
<
0.001.
LONG-TERM
100
WEIGHT
MAINTENANCE TABLE
Alcohol
7
805
intake
and smoking:
comparison
of relapsers,
maintainers,
and control 80
C
Control
a)
C.)
Relapsers
(n
=
Maintainers
(n
=
subjects
(n
=
8. 60
Alcohol intake 40
Nondnnker Light (<5 intake drinks/wk) heavy
44)
30)
34)
2 1 (47.7)t I 8 (40.9)
7 (23.3) 19 (63.3) 4
( 1 1.8)
23 (67.6) 7(20.6)
20
Moderate, (>5
to 10 dnnks/wk)
( I 3.3)
Smoking
emotion-focused
probImfocused
ways of coping
14(46.7)
8 (26.7) 8 (26.7)
24(70.6)
6(17.6) 4
( 1 1.8)
Number
Significantly
ofsubjects;
different
maintainers(D),
and control
subjects
t or
<
0.01.
or problem-focused
ways of coping
who sought social support to aid in coping with problems. Ways-ofcoping categories from Folkman and Lazaruss Ways ofCoping checklist (20, 22). * 55Significantly different from maintainers: 5P < 0.01; **P< 0.001.
ables associated with weight-loss maintenance. These factors were also important for the maintainers in this study. Most maintainers and control subjects in this study exercised
regularly whereas other studies that few relapsers did so. exercise differentiates Exercise has been intake. ofweight on food It was also observed maintainers and shown to increase, efforts Continued in redeare
more moderate-to-heavy drinking than did relapsers. Relapsers reported preferring to eat food rather than drink alcoholic beverages. Problem smoking drinking was not assessed in the current study.
lapsers
crease,
( 1 3, 24-28).
or have
no effect and
needed
tite,
to elucidate
the relationships
maintenance
food
loss.
intake,
appeintake
There
reported
was no significant
difference
groups.
in current
or former
self-
exercise,
Ifcalorie
in the three
Discussion The results ofthe present study support several hypotheses of possible correlates of successful maintenance after weight loss suggested by other investigators (1 5, 16, 23-27). These investigators reported that exercise, positive self-statements related to
. weight-reduction
exercise
to facilitate maintenance.
may elevate
exercise seems to help to achieve long-term weight (32, 33) suggest that exercise
which may facili-
ofwell-being,
efforts, and self-regulatory activities, such as goal setting, self-monitoring of eating or weight, recognition of weight regain, were important vari-
1 00
tate other positive behaviors conducive to successful maintenance ofweight loss. In the present study, weight regain (relapse) was frequently attributed to negative emotional states and unexpected or unpredictable stressful life events. This was also observed by other investigators (34). In addition to supporting this observation, the present study identified an important difference in the way in which maintainers and relapsers coped with their problems.
Whereas maintainers and relapsers (and control subjects) all
80
C a)
C.)
60
S
reported unexpected and unpredictable stressful life events, maintainers believed themselves capable of handling their problems and used problem-solving skills to cope with their
difficulties.
S
a)
0.
In contrast,
relapsers
did
not
deal
with
their
prob-
40
lems directly (perhaps because they lacked effective problemsolving skills) and reported that they used food to make themselves feel better when upset. These findings offer additional
20
0
1 or2 # people FIG 3. Percent ofrelapsers (#{149}) and maintainers (D) reporting that 0, 1 or 2, or 3 people were available for support or help with problems. 5Significantly different from maintainers, P < 0.0 1. 3ormore
support for Marlatt and Gordons theory of relapse (3), which suggests that an individual who has successfully made a behavior change will return to a former negative behavior pattern when a high-risk (problem) situation occurs for which coping skills are lacking. Social support or the perception that family or friends are
available seemed to discuss troubles greater for and the offer help when than needed for the significantly maintainers
relapsers
in the present
study.
There
is some
indication
that
806
social behaviors support (35). plays Social a role support in the maintenance acts of new to buffer
ET
AL
References
1. Council on Scientific Affairs, American Medical Association. Treatment ofobesity in adults. JAMA 1988;260:2547-S 1. 2. Marlatt GA, Gordon JR. Determinants ofrelapse: implications for the maintenance ofbehavior change. In: Davidson P0, Davidson
probably
stress
and may be used to assist people in making stressful decisions (36), but exact mechanisms and details for the role social support plays in maintenance of long-term weight loss are yet to be defined and should be investigated (37). The many genetic and physiologic factors that may be related to maintenance of long-term weight loss such as resting
metabolic bution, mass interact rate, number or type offat cells, adipose-tissue distrilipoprotein lipase activity, or ratio of fat to lean body not the assessed behavioral in this study. How explored these in this factors study may and with factors
health
lifestyles.
New
were
the role each factor may play in contributing to the difficulty relapsers have in becoming long-term weight-loss maintainers is not known. A prospective study to assess genetic and physiologic social, differences cognitive, and and the interplay of these factors with psychological, lose It would and also behavioral as individuals
3. Marlatt GA, Gordon JR, eds. Relapse prevention: maintenance strategies in addictive behaviorchange. New York: Guilford, 1985. 4. Schachter S. Recidivism and self-cure ofsmoking and obesity. Am Psychol 1982;37:436-44. S. Simopoulos AP, Van Itallie TB. Body weight, health, and longevity. Ann Intern Med 1984; 100:285-95. 6. Bray GA, Gray DS. Obesity. Part I-Pathogenesis. West J Med
1988;
7.
149:429-41.
then
maintain
reduced
treatments
weights
could
help
individuals.
to define
the most
103-14.
8. Keys A, Brozek J, Henschel A, Mickelson 0, Taylor H. The biology of human starvation. Minneapolis: University of Minnesota Press, 1950. 9. Leibel RL, Hirsch J. Diminished energy requirements in reducedobese patients. Metabolism 1984; 33:164-9. 10. Brownell KD, Greenwood MRC, Stellar E, Schrager EE. The effects of repeated cycles of weight loss and regain in rats. Physiol Behav 1986;38:459-64. 1 1. Blackburn G, Kanders B, Brownell K, et al. The effect of weight cycling on the rate of weight loss in man. Int J Obes 1987; 1 1: 448A(abstr). 12. Stuart RB. Weight loss and beyond: are they taking it offand keeping it off? In: Davidson P0, Davidson SM, eds. Behavioral medicine: changing health lifestyles. New York: Brunner/Mazel, 1980:
15 1-94.
appropriate
for different
be of interest to investigate whether findings reported here for three relatively small groups of mostly white women are true for men, other ethnic groups, and lower-income women. Also, a prospective study to determine ifrelapsers who lack problemsolving skills could be taught these skills and be helped to lose
and then maintain stressful life events, numbers ofsubjects search with greater
trolled, prospective
weight losses, even when experiencing is needed. Preliminary findings with small are encouraging (38-40) but additional renumbers of individuals is needed in constudies to confirm the hypotheses gener-
atedhere(l7, Though
diet-composition maintainers their desired choices
18). routine,
and the
regular
changes control each
exercise,
sustained subjects woman
lower
over thought
caloric
time about study
intake,
permitted to stay herself The
and
the at and
in this
about
food unique greatly achieved
that
and
made
and
it possible
thought
the
own
to continue
to exercise.
that any
who and
rather implies
comes guided
than
for in
13. Colvin RH, Olson SB. A descriptive analysis of men and women who have lost significant weight and are highly successful at maintaming the loss. Addict Behav 1983; 8:287-95. 14. Brownell KD. The psychology and physiology ofobesity: implications for screening and treatment. J Am Diet Assoc 1984; 84:40614. 15. Brownell KD, Marlatt GA, Lichtenstein E, Wilson GT. Understanding and preventing relapse. Am Psychol 1986;41:76S-82. 16. Wilson GT. Psychological prognostic factors in the treatment of obesity. In: Hirsch J, Van Itallie TB, eds. Recent advances in obesityresearch: IV. London: John Libbey and Co Ltd. 1985:301-1 1.
17.
offer-
Cohen
method.
ofa variety oftreatment options, which may available in all areas, a problem that should be addressed.
In addition, the outcomes of a weight-management screening and referral program should be evaluated to determine if this approach will increase the number of successful long-term
weight maintainers.
El
New York: Harcourt Brace, 1934. 18. Selltiz C, Wrightsman LS, Cook SW. Research methods in social relations. 3rd ed. New York: Holt, Rinehart & Winston, 1976. 19. Burton BT, Foster WR, Hirsch J, Van Itallie TB. Health implications ofobesity: an NIH consensus development conference. Int J Obes l985;9:lSS-69. 20. Lazarus RS, Folkman S. Coping and adaptation. In: Gentry WD,
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Grateful thanks to S Leonard Syme, Richard Lazarus, and Sheldon Margen for guidance and helpful discussions of this work; to John Sommer, Sharon Levine, Tom Shimizu and his staff, Harvey Kayman, Susan Bacigalupa, and the Patient Education Committee of Fremont Kaiser Permanente Medical Offices for their exceptional cooperation and assistance during recruitment and interviewing; to Steve Selvin and
I984:282-325. Nie NH, Hull CH, Jenkins JG, Steinbrenner K, Bent DH. SPSSX Statistical Package for the Social Sciences. 2nd. ed. New York: Mc-
22.
Graw-Hill, 1986. Folkman 5, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Dynamics ofa stressful encounter: cognitive appraisal, coping, and encounter outcomes. J Pers Soc Psychol l986;50:992-l003.
Brownell KD. Behavioral, psychological and environmental dictors of obesity and success at weight reduction. Int preJ Obes
advice: to Judith
Wilhite
for telephoning
par-
23.
ticipants; and to Irene Hepps for coding assistance. Special thanks to the study participants, who so candidly and graciously shared their lives and their stories. Thank you to Kelly Brownell for helpful comments on an earlier draft and to Abby C King for her encouragement and helpful advice during development ofthe manuscript.
1984; 8:543-50.
24. 25. Marston AR, Criss J. Maintenance of successful weight dence and prediction. Int J Obes l984;8:43S-9. Gormally J, Rardin D, Black S. Correlates of successful loss: mciresponse
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support
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29. 30.
Epstein LA, Wing RR. Aerobic l980;S:37 1-88. Woo R, Garrow iS, Pi-Sunyer
l983;38:l43-60. compliance:
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