Psychology Of Obesity And Weight Management Lecture PDF

The psychology of obesity and weight management Stephen Stotland, Ph.D. Montreal Comprehensive Weight Management Program October 4, 2024 NUTR 511 Nutrition and Behaviour Introduction Obesity is a physical condition, physical condition impacts mental...

The psychology of obesity and weight management Stephen Stotland, Ph.D. Montreal Comprehensive Weight Management Program October 4, 2024 NUTR 511 Nutrition and Behaviour Introduction Obesity is a physical condition, physical condition impacts mental health and vice versa what does psychology have to do with it? need to give them tools, need to have Weight management is about motivation eating less and exercising more, isn't it? Can't we just tell people what to do? Do dietitians need to be no, but need to know the basics bc counselling psychologists to deal with obesity? A brief history Obesity=physical condition —> psychosomatic Psychoanalytic CBT psychosomatic - turning psychological pain into a perception of the problem physical condition, in this case hunger, craving and insatiability self-regulation oral fixation - due to a problem in the early mother- child relationship addiction, in general, was looked at as an "oral level fixation" Bruch; Kaplan & Kaplan Behavioural Biobehavioural Learned habits externality - appetite system based on neurological systems driving hyperreactivity operant and respondent conditioning to food cues stimulus control behavioural susceptibility theory self-control through rearranging contingencies regulation of cues Stuart Schachter; Wardle My history B.A., M.A., Ph.D. in Psychology and Clinical Psychology Rresearch in eating behaviour and weight control Multidisciplinary behavioural treatment programs Restrained eating 30+ years Self-efficacy In 2017 started a hybrid program, including On-line and repeated assessment of process and clinic visits, remote sessions, and remote outcome patient monitoring (RPM; activity, sleep, Weight control motivation weight, blood pressure) Self-regulation – restraint, moderation and Since 2020, a 100% virtual multidisciplinary internalization program: THE MONTREAL COMPREHENSIVE WEIGHT Prediction of weight change MANAGEMENT PROGRAM Also research on: eating disorders, diabetes www.montrealcomprehensive.ca [email protected]  Social Cognitive Personality Many domains of psychology Psychology are relevant to obesity & Developmental Neuro weight management Clinical Examples of research questions from different areas of psychology Why do people eat more when they eat with others? not paying attention to portion (distraction) modeling people make more food when come over people encourage you to eat more time spend at the table Examples of research questions from different areas of psychology Do overweight people process information about food, exercise, and weight differently than normal weight people? Are there differences in knowledge? Examples of research questions from different areas of psychology Do some personality traits create a risk for weight gain and obesity? tendency towards - emotions: could be a reason Do some traits make it difficult to succeed in weight management? self-esteem Examples of research questions from different areas of psychology Are some people more likely to overeat due to heightened response to food in brain “reward centers”? yes Are there other brain processes controlling eating, activity, and weight? Examples of research questions from different areas of psychology What are the risk factors for child or adolescent obesity? Should we focus prevention and treatment on chidren/adolescents or families? prevention is hard still need treatment Examples of research questions from different areas of psychology Are obese people more likely to suffer from emotional disorders? might be correlation especially with morbid OB Are those disorders cause or effect of the weight problem? A few basic concepts Behaviour is motivated Behaviour is learned Behaviour occurs in a particular context, which includes the internal and external environment Basic concept 1: Behaviour is motivated What motivates behaviour? dopamine reward pleasure feeling What motivates eating, physical activity, weight management? Basic concept 2: Behaviour is learned What behaviour is related to obesity and weight management? overeating How is this behaviour learned? can be through childhood, accessibility How can it be unlearned or replaced? can be unlearned with restructuring Basic concept 3: Behaviour occurs in a paticular context, which includes the internal and external environment Define internal and external environment internal: hunger external: accessibility What are the physiological (e.g. hormones), physical (e.g. types and amounts of food present) and social (e.g. others' attitudes and modeling) influences? What are people and health professionals thinking when they seek (or offer) help with obesity? As they enter the clinical context, therapist and patient may be thinking about "each other": Patient Therapist “Help me, I feel hopeless” “It’s hopeless” “Make me lose weight” “I have the answers” “If I don’t follow the plan perfectly, I’ll fail” “You must follow the plan perfectly, or else you are a “resistant” patient and you will fail” “Health professionals never listen to me” “Obese patients never listen to me” “Health professionals reject me” “I really don’t like obese patients” As they enter the clinical context, therapist and patient may be thinking about "treatment strategies": Patient Therapist “I need to lose fast” “If you lose fast you will regain fast” “It’s dangerous to lose fast; it’s better to lose slowly” “Slow weight loss leads to better maintenance” “I need better habits” “So why don’t you change your habits already?” “Diets don’t work….I’ve tried them all” “Diets don’t work, you should love yourself as you are” “I exercise and still don’t lose weight” “You must exercise an hour per day” “Yo-yo dieting will ruin my metabolism and make me “Yo-yo dieting is dangerous” fatter” “I need medication or surgery” As they enter the clinical context, therapist and patient may be thinking about "biology": Patient Therapist “I’m always hungry” “You should eat 6 times per day to avoid hunger” “I can’t handle being hungry” “Eat when you’re hungry and stop when you’re “It’s genetic, my whole family is overweight” full” “I have a slow metabolism” “It’s genetic, there’s no solution except surgery” As they enter the clinical context, therapist and patient may be thinking about "emotions": Patient Therapist “I’m too stressed/depressed/anxious to lose “I don’t treat that. Go and get treated for your weight” emotional problems before you try to lose weight” “When I’m emotional I lose control of my eating” As they enter the clinical context, therapist and patient may be thinking about weight loss and maintenance "outcomes": Patient Therapist “I can lose weight but not maintain” “Maintenance is almost impossible – more than 95% will regain their weight or more” “It’s hard to lose weight but I’m sure if I can lose it I will be able to maintain the loss” Psychological theories Psychological and emotional factors related to weight: Mechanisms linking changes in psychological variables and outcome are not well delineated Behaviour Weight Psychology (eating & Change exercise) Satisfaction Motivation  Restraint Theory not the actual restriction —> mental attitude to wanting to restraint Restraint is not the same thing as restriction “Restraint” is defined as the desire and intention to follow a set of eating rules in order to limit food intake, with the goal of weight loss or prevention of weight gain. Restraint Scale – Herman & Polivy analog to binge disinhibiting dieters become dishinibit when they overeat bc now they say I’ve blowed it so wtv when you force dieters to break diet: will eat more Restrained vs. Unrestrained eaters response to preloads The boundary model of weight regulation boundaries gets further out bc they are used to not eat won’t experience hunger until they are really hungry and vice versa for satiety in middle: small range where they are not hungry and not full —> neutral  Restraint Theory Restraint X Low High What is the relationship Disinhibition Disinhibition Disinhibition Combinations between Restraint and Disinhibition? Early research saw them Low Restraint Low, low Low, high as two sides of the same coin Later research suggests High Restraint High, low High, high they may be independent dimensions  Restraint theory and CBT  CBT explicitly or implicitly promotes a high Restraint and low Disinhibition combination higher the restraint, the lower the disinhibition is, the more ppl will lose weight but longer term? can it be maintained?  Numerous studies have shown that restraint increases and disinhibition decreases during treatment ◼ the amount of these changes appears to be correlated with the outcome (e.g. the amount of weight lost)  Can high restraint and low disinhibition be maintained?  Restraint theory and CBT Is there a better kind of restraint? Flexible: have principles rigid: rule s  Flexible vs. Rigid Restraint  Better maintenance with flexible restraint?  “Non-dieting” approaches to obesity treatment  The non-dieting approach has as its central premise that dieting does not work and may even be hazardous  first proposed by Herman & Polivy in the early 80’s  The dieting and non-dieting approaches seem irreconcilable... Weight Control Motivation Scale (Stotland, Larocque, & Sadikaj, 2012) Self-Regulation Process and Goal Physiology Influences Problem Solving Planning Personality Self- Evaluation & Self- Emotional Monitoring Response Social Environment WEIGHT SELF-REGULATION Definition Weight outcomes are partly determined by the effects of intentional (voluntary) goal-directed activity. Not only physiological control Simple example: A patient is too depressed to organize his eating or to exercise. In the depressed state the outcome doesn’t seem to matter as much and the prospects of success seem less likely. The state of inaction and apathy leads to poor choices and less positive outcome… My study of the "Stages of change in weight self-regulation"  The stages are defined by combinations of the following constructs: WEIGHT CONCERN SELF-EFFICACY RESTRAINT MODERATION INTERNALIZATION OF LIFESTYLE CHANGE  Operationalizing the stage model  The Weight Self- Group N Age BMI Regulation Inventory College dieters 45 21.9 22.3 College 47 21.8 20.2 nondieters ED-active 114 21.4 20.9 ED-partially recovered 81 24.0 19.0 ED-recovered 55 23.6 21.0 Pre-bariatric 244 43.6 47.1 surgery Post-bariatric 145 43.3 30.5 surgery (~ 2 yrs) Weight 126 45.0 38.7 management  Weight Concern Cognitive Concern –  7 items Group Total engagement item  Example items: College dieters 1.34 2.57  My weight is causing me a lot College of physical problems nondieters 0.51 0.43  My weight is causing me a lot ED-active 2.14 2.87 of emotional problems ED-partially  I am happy with my weight as recovered 2.14 2.79 it is ED-recovered 1.55 2.44  My weight is not something I Pre-bariatric often think about, and I do surgery 2.49 2.57 not make any efforts to Post-bariatric control it. surgery 1.18 2.48 Weight 2.24 2.45 management  Self-efficacy  4 items  Example items: I am very confident about controlling my weight.  I am frequently doubtful about my ability to reach my weight goals  Restraint  14 items  Example items: I try to eat less than I really want, in order to control my weight  I often count my calories  I always think about my weight when deciding what to eat  I try to eat very little  I always try to follow my eating rules  Moderation  11 items  Example items: I listen carefully to signs of hunger and fullness  I eat what I like, in good balance  I really enjoy eating slowly and consciously  I choose small portions, but I’m free to have more if I’m still hungry Internalization of Lifestyle Change  9 items  Example items:  Eating healthy comes naturally to me now.  I don’t feel like I could ever go back to bad habits.  I’m at peace with my relationship with food.  My way of eating and exercising does not require what I would call “effort,” it’s more like doing what I want to do.  Group Differences on Individual Constructs Self-efficacy Restraint Moderation Internalization Group College dieters 1.96 1.38 1.57 1.60 College nondieters 2.70 0.90 1.82 1.68 ED-active 1.34 2.47 1.22 1.00 ED-partially recovered 1.22 2.16 1.25 1.13 ED-recovered 1.94 1.65 1.89 1.61 Pre-bariatric surgery 0.94 1.34 1.27 1.04 Post-bariatric surgery 2.15 1.51 2.24 1.73 Weight management 1.10 1.29 1.22 1.06  DISENGAGED No Weight Concern Stages of weight Yes self-regulation Self-efficacy HELPLESS No Yes Restraint No Yes Moderation Moderation PREPARATION No Yes RIGID No Yes RESTRAINT FLEXIBLE MODERATION RESTRAINT Internalization Internalization No Yes No Yes  Weight Concern No Stages of weight DISENGAGED Yes self-regulation 12.7% No Self-efficacy - Pretreatment HELPLESS (surgical and Yes 65.7% nonsurgical; N=370) Restraint No Yes Moderation Moderation No Yes No Yes RIGIDLY PREPARATION RESTRAINED Internalization Internalization 7.8% 4.3% No Yes No Yes 2.2% 1.4% 2.7% 3.2% “Disengaged” vs. “Helpless” vs. “Preparation” vs. “Rigidly Restrained” – pretreatment group Variable Disengaged Helpless Preparation Rigidly Restrained Concern 2.23 2.45 2.26 2.20 Self-efficacy 0.94 0.54 2.30 2.22 Restraint 1.01 1.35 0.95 1.83 Moderation 1.04 1.21 1.12 1.13 Internalization 0.93 1.02 0.99 1.07 Emotional 1.8 1.6 1.5 1.9 Eating Life Satisfaction 2.9 3.0 3.2 3.5  Weight Concern No Stages of weight DISENGAGED Yes self-regulation 11.0% No Self-efficacy - Surgical Follow-up (N=145) Yes HELPLESS 18.6% people often have unrealistic expectations for weight loss Restraint No Yes Moderation Moderation No Yes No Yes FLEXIBLY MODERATE RESTRAINED Internalization Internalization 2.8% 0% No Yes No Yes 7.6% 22.8% 6.2% 31.0% “Disengaged” vs. “Helpless” vs. “Flexibly Restrained” vs. “Moderate” – post-surgery group Variable Disengaged Helpless Flexibly Moderate Restrained Concern 0.99 1.64 0.91 0.39 Self-efficacy 1.93 0.78 2.47 2.59 Restraint 1.53 1.44 1.89 1.15 Moderation 1.94 1.78 2.44 2.40 Internalization 1.56 1.26 2.15 2.02 Emotional 1.25 1.49 0.83 0.72 Eating Life Satisfaction 3.94 2.57 4.25 4.83 Weight loss % 31.4 32.1 39.9 39.5 Stage model of weight self-regulation (Stotland, 2011) more likely to regain weight if no restraint Case studies Brigitte B. Celine B. Nancy B. Arash A. The treatment process Is the treatment of obesity a technical or an interpersonal process?  Even if the "formula" for weight management is pretty simple, the success of implementation is very much influenced by the nature of the interaction between client and therapist(s) Richard Stuart (1967): Behavioral control of overeating  Landmark study based on the principles of operant (Skinnerian) and respondent (Pavlovian) conditioning But still… “More occurred in the interaction between therapist and patients than the presentation of the curriculum and a review of progress. Reassurance was given as an antecedent to each new step and praise was given for success. More tightly controlled research is needed in order to isolate the contribution of the non-specific interaction effect to total therapeutic outcome.” Most research on obesity treatment focuses on outcomes rather than process Examples:  Weight loss and impacts on medical morbidity and mortality  Comparison of weight loss for different types of treatment Even research on lifestyle approaches focus mostly on weight loss outcomes  Even though behavioural treatments are based on behavioural analysis and behaviour change Hopefully I have demonstrated by now that research on process is critical Process research looks at how the change takes place over time  For example, how do changes in weight relate to changes in eating habits, self-efficacy, emotional states and coping strategies? The therapeutic relationship Key to the treatment process is the formation, maintenance and (sometimes) repair of the therapeutic relationship How does the quality of the therapeutic relationship influence the treatment process and outcome? When talking about the therapeutic relationship we often refer to the "therapeutic alliance".  Refers to the general quality of the interaction between client and therapist Typically defined by 3 interdependent dimensions The creation of an emotional bond An agreement on goals An agreement on plans and tasks The alliance is important in all forms of treatment  The impact of the alliance is seen across all forms of psychotherapy, as well as in primary medical care, in cancer treatment, etc. What do we know about the effects of the quality of the alliance in obesity treatment?  Not much  Related research:  Stereotypes and discrimination  Obesity and personality  Obesity and attachment styles  Obesity stigma in health care settings Leske, Strodl & Hou (2012) How does the alliance affect outcomes  A good alliance is associated with improvements in behavioural and emotional variables, which predict weight change, so the effect of the allliance is indirect, but essential Larocque, C., Lecomte, C., Savard, R., Stotland, S., & Sadikaj, G. (2015). Ruptures in the alliance  There are often moments in the treatment process where the alliance suffers a deterioration  this can be due to disagreement in the goals or tasks of the treatment, or a problem with the emotional bond  People are often hesitant to express disagreements and dissatisfaction  Hill, Thompson, Cogar & Denman (1993) suggest that 65% keep their negative thoughts about the process to themselves Markers of alliance ruptures  2 types of markers (Safran, Muran, Samstag & Steven, 2001) 1. Withdrawal 2. Confrontation  If they are not dealt with, these ruptures can lead to dropout or poor results How can we improve the alliance?  Think of the process as bi-directional, with therapist and client equally invested, responsible, and collaborative  Pay attention to the client's perceptions, expectations, and subjective responses to the process, and make sure the client feels you have a good understanding of their point of view, before suggesting any changes  Therapists need to develop the capacity to detect small ruptures in the alliance and learn ways to heal them, which means to communicate with the client to understand and hopefully correct the problem Conclusions  Psychology is central to the treatment process, and helps us understand what is going on inside the client, in the environment, and in the consulting room  All members of the multidisciplinary team are engaged in a kind of behaviour therapy, and must understand the processes of change, within the client and in the therapeutic interaction  Lastly, it is important to remember that "it takes only one psychologist to change a lightbulb, but the lightbulb has to really want to change" Thank you