Research on weight loss

SUMMARY Insufficient responses to hypocaloric diets have been attributed to hormonal adaptations that override self- control of food intake. We tested this hypothesis by measuring circulating energy-balance hormones and brain functional magnetic resonance imaging reactivity to food cues in 24 overweight/obese participants before, and 1 and 3 months after starting a calorie restriction diet. Increased activity and functional connectivity in prefrontal regions at month 1 correlated with weight loss at months 1 and 3. Weight loss was also correlated with increased plasma ghrelin and decreased leptin, and these changes were associated with food cue reactivity in reward-related brain regions. However, the reduction in leptin did not counteract weight loss; indeed, it was correlated with further weight loss at month 3. Activation in prefrontal regions associated with self-control could contribute to successful weight loss and maintenance. This work supports the role of higher-level cognitive brain function in body-weight regulation in humans. For more details contact us at info@motivationminceur.ca

We have made what we think is a major breakthrough in research on weight management, in our finding that there are two kinds of weight control motivation. “Positive” motivation comes from the perception of the benefits of weight control and the pain from one’s current weight. “Negative” motivation comes from the perception that weight control involves a loss of pleasure and freedom, takes a great deal of effort, and has a low probability of success. These two kinds of motivation may play different roles in weight management at different time points. For example, overweight people who have no intention and who are making no effort to lose weight will have a relatively low level of Positive motivation. Those with a high level of Positive motivation are more likely to have definite weight loss goals and intentions (e.g. to lose 10 pounds in the next month). Thus, Positive motivation may be an important determinant in the “initiation” of weight loss efforts. Positive motivation is what makes you want to do something. On the other hand, the level of Negative motivation should be related to the strength and persistence of weight loss efforts. Someone with a low level of Negative motivation will be less frustrated and more satisfied with the process of weight control. Therefore, Negative motivation should be a good predictor of weight loss. Negative motivation is what makes you not want to do something. This is what we have learned about Positive and Negative motivation in our recent analysis: We found that the perceived benefits of weight control increase slightly over the first 5 weeks of treatment. At the same time, physical and psychological pain associated with weight decrease significantly. The net result is that Positive motivation stays about the same. Negative motivation decreased significantly over 5 weeks, with consistent decreases in feelings of “resentment,” “regret,” “doubt,” and “perceived effort.” The results for Positive and Negative motivation at Time 1 and Time 2 are presented in Figure 1. The decrease in Negative motivation over 5 weeks was related to improvements in weight, eating habits (decrease in “uncontrolled eating”), depression and stress. However, we did not see any relationship between changes in Positive motivation and these other changes (see Table 1). It seems that a key effect of treatment on motivation is to decrease Negative Motivation. Improvements in negative motivation are not only due to weight loss, but are primarily related to improvements in eating habits and emotional state. Weight loss treatment is not just about following a diet, but about improving psychological risk factors and maintaining a strong motivation. How do we decrease Negative motivation? We learn to see the process of weight control in a more positive light. Instead of thinking about what you can’t have, think about the advantages and pleasures associated with what you can have. If you come to value eating small portions of tasty and healthy food, then it won’t seem like such a burden and there will be less negative thinking. Similarly, if you discover that exercise is fun and feels good your thoughts about exercise will be positive. Motivation is an automatic emotional response (something that we feel) and in order to keep it strong, we have to work on our thoughts and perceptions. Daily, you should continue to think about the benefits of being at your healthy weight and making the right choices, and put a STOP to negative thoughts that are always unrealistic. Switch negative interpretations to positive ones, as follows: Instead of “It is too much of an effort to lose weight,” think “it’s too much effort to carry the extra weight”. Instead of “I resent having to follow a diet and change my eating habits,” think “I resent having to deprive myself of health, energy, youth, and a nice silhouette.” Rather than thinking “I regret not having the food I love,” think “I regret not being the human being I want to be”. Successful long-term weight management (losing the weight and keeping it off) is not just about trying to stick to a diet, but learning to think and feel in less negative and more positive ways. This can easily be accomplished with the therapy tools that you have available to you, which you only need to do for a few minutes per day. Stephen Stotland, Ph.D. & Maurice Larocque, M.D. August 2009 Figure 1 – Table 1 – Correlations between change in motivation, Time, and change in psychological variables and BMI Variable (change T1-T2) Change in Positive Motivation T1-T2 Change in Negative Motivation T1-T2 Female # of days (Time 1-2) -0.05 -0.04 Negative Motivation -0.09 Positive Motivation Uncontrolled eating 0.04 0.53 Depression -0.02 0.40 Perfectionism -0.06 0.25 Stress 0.06 0.36 BMI 0.04 0.21 Male # of days (Time 1-2) Positive Motivation -0.02 -0.03 Negative Motivation 0.03 Uncontrolled eating Depression Perfectionism Stress BMI 0.09 0.05 -0.07 -0.03 0.05 0.48 0.37 0.16 0.37 0.28

RESEARCH UPDATE: Prediction of weight loss We have recently analyzed results from 344 female patients during the first 9 months of their treatment. The following are factors which we found to predict the amount of weight lost during this period: (1) choosing a VLCD rather than a LCD, (2) early weight loss, (3) the number of assessments, and most importantly, (4) early improvement in eating behavior. Together, they make a very substantial difference in the treatment outcome! In the best case scenario there is a reduction of 7.4 BMI points, while the worst case scenario shows a gain of 1.3 BMI points.

https://www.motivationminceur.ca/documents/fichiers/PROLONGED_REFEEDING_IMPROVES_MAINTENANCE.PDF

In Anne. E. Prescott (Ed.), The concept of self in medicine and health care. Nova Science Publishers, Hauppauge NY, 2006. Self­regulation of weight: Basic processes and treatment implications S C Stotland1, 2, M Larocque2, & I Kronick1 1Department of Psychology, McGill University, Montreal, Canada 2MLA Nutrition Clinics, Montreal, Canada Address: Dr. Stephen Stotland 1310 Greene Avenue, Suite 230 Westmount, Quebec H3Z 2B2 (514) 737­3360 sstot@qc.aibn.com SELF­REGULATION OF WEIGHT 1 SELF­REGULATION OF WEIGHT 2 Abstract The regulation of bodyweight is a complex process, with multiple biological, environmental and psychological factors playing a role. The primary treatment for obesity is modification of eating and exercise behavior, the success of which depends on the patient’s adherence to the behavior change plan, and therefore represents a problem of self­regulation. The failure of a large percentage of individuals to achieve their weight loss goals has led a number of authors to question whether or not bodyweight is amenable to effective self­regulation. However, psychological approaches to obesity have not integrated recent theoretical developments concerning self­regulation. The present paper will present a new model of weight control, which considers weight regulation as a broadly applicable, carefully sequenced, self­regulatory process occurring in the context of other goals and challenges, in particular the management of mood states and interpersonal relations. Data relevant to our model is presented, derived from a large sample of individuals in treatment for obesity. Introduction Obesity has received a great deal of scientific and popular attention in recent years. The detrimental physical and emotional effects of obesity have been well documented (Fontaine, Redden, Wang, Westfall, & Allison, 2003; World Health Organization, 1998). However, while weight loss efforts are very common among overweight individuals (Meltzer & Everhart, 1996; Serdula, Mokhad, Williamson, Galuska, Mendlein, & Heath, 1999), only a small percentage reach or maintain a healthy weight (Jeffery, Drewnowski, Epstein, Stunkard, Wilson, Wing, & Hill, 2000; Wadden, Foster, & Brownell, 2002). Nevertheless, where successful, intentional weight loss appears to have positive effects in reducing disease and mortality (Gregg & Williamson, 2002). In view of the urgent need to develop more effective treatment methods, research designed to elucidate factors responsible for successful or unsuccessful weight loss outcomes is extremely important. The present chapter addresses this issue from a “self­ regulation” perspective. Weight Regulation When we talk about the self­regulation of weight, how difficult is the task one is up against? How controllable is weight? As evidenced by the multitudes of perspectives and the huge amount of current research, it is clear that weight regulation is an extremely complex bio­psycho­social process. Genetic factors appear to exert a large effect, estimated to predict anywhere between 25% and 40% of actual weight (Bouchard, 1994; Price, 2002). Physiological processes influence eating by altering hunger and satiety mechanisms (Badman & Flier, 2005; Hellstrom, Geliebter, Näslund, Schmidt, Yahav, Hashim, & Yeomans, 2004). Environmental factors, including the available food and SELF­REGULATION OF WEIGHT 3 features of the social situation, are also powerful influences on eating (de Castro, 2004; Wansink, 2004). It is apparent that genetic and environmental variables interact, such that genetic predisposition combines with an “obesogenic” environment to determine obesity prevalence (Tremblay, Perusse, & Bouchard, 2004). However, such views appear overly “deterministic” when the role of self­regulation is ignored. An understanding of weight self­regulation requires an analysis of eating and exercise self­regulation. This is so because weight can only be controlled, or “self­ regulated,” by controlling eating and exercise. Of course, one could theoretically take a medication that would result in a lower weight without a change in eating and exercise, but that would not be illustrative of “self” regulation, but a direct biological manipulation. Other drugs might cause weight reduction by altering eating or exercise, but this too would not be evidence of self­regulation, but a biological change. Certainly, such a change could have an effect on self­regulation, by making the task easier (i.e. by reducing hunger, increasing satiety, or increasing the drive and ability to move and engage in activity). As physiological and social­psychological research demonstrates, not all self­ regulation is created equal – it may be more or less difficult, depending on biology and circumstances. In any case, self­regulation appears to require a certain amount of energy, or psychological resources, that may be “used up,” which can lead to self­regulatory failure (Baumeister, Bratslavsky, Muraven, & Tice, 1998). In fact, several authors have declared the task of weight self­regulation so difficult that it should be abandoned as a target of obesity treatment; it has been suggested that efforts to reduce the prevalence of obesity should focus exclusively on environmental and pharmacological intervention SELF­REGULATION OF WEIGHT 4 (Herman & Polivy, 2004; Jeffery, 2004; Lowe, 2003; Swinburn, Egger, & Raza, 1999; Wansink, 2004). In rejecting the feasibility of individual­focused intervention, these authors appear to reject the importance of self­regulation of eating, exercise and weight. Lowe (2003) concludes that self­regulation is not up to the task of effective weight control, but rather that some of the answer to the obesity problem lies in helping people make changes in what he calls the “personal food environment.” Such changes might include reducing the “energy density” of the diet (increasing fiber and water content) and reducing the amount of contact with food and the number of eating choices one has to make by relying on prepackaged meals (meal replacements and prepared meals). However, although making changes in the food that one encounters and interacts with seems like an important strategy for weight control, it should be recognized that the implementation of the strategy is dependent on self­regulation. One of the ways that effective weight controllers accomplish weight self­regulation is by making changes in their environments to facilitate self­regulation. This is good problem solving, which is of course an important part of self­regulation as well. The pessimistic tone of recent papers about individual change efforts is not characteristic of the attitudes of clinicians more generally, however, and treatment of the obese individual is still a very important target of medical and psychological intervention. Furthermore, overweight individuals continue to purchase and utilize a huge amount of commercial weight loss products, plans and programs – people evidently believe that weight can be self­regulated (i.e. they display an “internal” weight locus of control – Stotland & Zuroff, 1990). In fact, people generally possess a mixture of internal and external weight locus of control beliefs (Stotland & Zuroff, 1990). Thus, people tend to SELF­REGULATION OF WEIGHT 5 think that they have some degree of control over their weight, but that uncontrollable factors like genetics and luck also play a role. This kind of attitude means that the individual is very open to “treatments” that promise to increase self­control, or to make self­control less necessary. The paradox is that one looks to an external agent to supply internal control (see also, Polivy & Herman, 2002). The popularity of weight control treatments indicates that individuals often do not feel they understand the problem or know how to solve it. They are reaching out for commercial or professional help to supply the answer, as well as needed support. However, recent analyses indicate that results for commercial (Tsai & Wadden, 2005) and professional (Wadden et al., 2002) treatment have been disappointing. The average weight loss over a number of years in studies that include long­term follow­up approaches zero (Wadden et al., 2002). The implications of such failures for psychological theories of obesity treatment have not been fully or adequately examined. Early behavior therapy approaches towards obesity treatment (Stuart, 1967) were based on classical and operant conditioning principles and they attempted to modify behaviour by changing the environmental stimuli associated with maladaptive behaviour. Current behavioural programs utilize a variety of techniques derived from conditioning as well as cognitive theories (Foster, Makris, & Bailer, 2005). There is a growing consensus (Byrne, Cooper, & Fairburn, 2004; Jeffery et al., 2000) that psychological research has so far failed to provide an adequate explanation for why most people fail to maintain weight loss – this being the crucial problem in obesity treatment. The present chapter offers a self­regulation model of weight control as a framework for research and as a guide for the treatment of obesity. SELF­REGULATION OF WEIGHT 6 Self­Regulation Self­regulation theories have become increasingly popular in health psychology research (Maes & Karoly, 2005), but have not been well developed in relation to weight and eating. Self­regulation theories vary in emphasis, but generally include: goal-setting, planning, self-monitoring of outcomes, self-evaluation of progress relative to expectations, emotional response to outcomes, problem-solving when progress does not meet expectations, and emotion-control strategies (see Figure 1). Self­regulation theories begin with the concept of “goal”. The goal is the reference point from which efforts and outcomes can be judged. Of course, there are a great variety of types of goals – goals may be easy or challenging, short­term or long­term, self­chosen or given to one, important or trivial, realistic or unlikely, stressful or relaxing, supported or alone, and perhaps even conscious or unconscious (Little, 1999). Weight self­regulation occurs in the context of other goals that the individual is pursuing simultaneously. Consequently, the goals of maintaining emotional well­being or managing interpersonal relationships may at times conflict with weight goals. This may be for two reasons, (1) focusing on other goals may interfere with weight self­regulation, and (2) eating may serve emotional or interpersonal self­regulation functions that may conflict with weight self­regulation. Thus, when an individual is depressed, eating self­ regulation may be altered, as the individual is engaged in the high priority project of trying to feel better, and may choose to eat (or even overeat) as a means of doing so. To adequately understand eating and weight self­regulation, we need to identify how they fit into the bigger picture of self­regulation. This requires a “molar” level analysis of goals, such as the analysis of “personal action constructs” like personal projects (Little, 1999) SELF­REGULATION OF WEIGHT 7 and current concerns (Klinger, 1975). There has not yet been a comprehensive analysis of goal constructs in relation to eating and weight self­regulation. The weight self­regulation sequence Weight goals may include weight maintenance, weight loss or weight gain. Research indicates that participants in weight loss programs typically have unrealistic goals – while weight loss in such programs rarely exceeds 10% (considered a good outcome from the point of view of improving health), the average weight loss goal tends to be in the range of 20 – 35 % of starting weight (Foster, Wadden, Vogt, & Brewer, 1997). Several authors have suggested that helping patients adopt more realistic weight loss goals may improve maintenance (Byrne et al., 2004), although a recent test of this hypothesis produced equivocal results (Foster, Phelan, Wadden, Gill, Ermold, & Didie, 2004). The process of goal­setting is addressed by a number of cognitive­behaviour theories. The motivation to pursue a goal is considered to be a function of its “value” (compared to alternatives), and the “expectancy” of being able to reach it (Feather, 1982). A variety of motivational variables relevant to goal­setting have been assessed in relation to weight control, including locus of control, outcome expectancy, self­efficacy and self­ determination (for a review, see Baranowski, Cullen, Nicklas, Thompson, & Baranowski, 2003). Once a goal is established, self­regulation proceeds to a planning phase. The act of planning in weight self­regulation consists of deciding when and what to eat and where and when to exercise. Without plans, one is more likely to be influenced by situational factors, such as the kind of food that is available. For example, if one does not bring SELF­REGULATION OF WEIGHT 8 lunch to work and suddenly, at noon, is offered a share in the all­dressed pizza that work colleagues have ordered and that will arrive in moments, the probability of eating pizza is increased. One can learn to respond to such temptations with effective planned strategies. For instance, one could determine never to partake in fast food lunches at work, and when offered to do so, to politely decline, and to go take a walk in search of some more balanced meal. Having a specific plan, or “implementation intention” (Gollwitzer, 1993), appears to increase the probability of healthy eating behaviour (Verplanken & Faes, 1999). The most common weight loss plan is some form of structured diet. An obvious difference between various diet plans is in the rate of weight loss. For example, we found that “very low” calorie (e.g. 600 – 800 calories per day) diets resulted in greater short­ term (up to 9 months) weight loss compared to “low” calorie (e.g. 1000 – 1200) diets (Stotland & Larocque, 2005). Therefore, we were not surprised to find that when given a free choice of diets, a majority of participants chose very low calorie (60%) rather than low calorie diets (40%) (Stotland & Larocque, 2002), reflecting dieters’ desire for rapid weight loss. Goal attainment may be monitored with various methods of self-monitoring, such as calorie counting, following a menu plan, or more subjective judgments (“I feel like I’m following the plan”), as well as weight change. Most weight loss programs teach participants some method of monitoring eating and exercise. A number of studies have shown that better adherence to behavioural self­monitoring predicts better weight loss outcomes (Boutelle & Kirschenbaum, 1998). However, although it is a helpful strategy, most people are not very diligent in monitoring eating (Womble, Wadden, McGuckin, SELF­REGULATION OF WEIGHT 9 Sargent, Rothman, & Krauthamer­Ewing, 2004), and quite inaccurate in reporting what they have eaten (Lichtman, Pisarska, Berman, Pestone, Dowling, Offenbacher, et al., 1992; Weber, Reid, Greaves, De Lany, Stanford, Going, Howell, & Houtkooper, 2001). So how do people self­monitor their eating and exercise behaviour? How do we self­monitor states of hunger and fullness? How much awareness is there of “daily” consumption (i.e. not only what I’ve just eaten and how full I feel right now, but how much I’ve eaten for the day, how balanced my eating has been). Little information is currently available about how much attention people typically give to their eating, or about how such attention influences actual food intake. The self-evaluation of dieting outcomes influences the motivation to continue. Weight change is the most important feedback for a dieter. Weight loss is highly rewarding and therefore rapid weight loss is a strong motivator to adhere to a diet. However, people on diets generally stop losing weight between 3 and 6 months from starting (Jeffery et al., 2000), and consequently very few reach their original weight loss goal (Foster et al., 1997). Given the undeniable logic of the energy­balance equation (Bray, 2002), it would appear that the primary reason that people stop losing weight is that they stop adhering to the diet plan, otherwise they would eventually reach (or come much closer to) their desired weight. If one is still dissatisfied with one’s weight, why do continued weight loss efforts seem to have a diminishing reward value? Why do people slip back to old habits? The more dissatisfied one is with the weight loss result the more one should be motivated to achieve the lower weight goal, yet dissatisfaction with weight loss is associated with poorer weight loss maintenance (Foster et al., 2004). Perhaps it is because, as Bandura SELF­REGULATION OF WEIGHT 10 and Cervone (1982) showed quite some time ago, dissatisfaction is only motivating in combination with high self­efficacy. Only when one believes the goal can be achieved will one be motivated by feedback that the goal has not yet been reached. The tendency appears to be for dieters to blame themselves, attributing the poor result to a lack of effort and willpower (Polivy & Herman, 2002), which contributes to guilt feelings and a loss of self­efficacy. Depending on the results of the earlier steps of the weight self­regulation sequence, the individual then engages in problem solving. Behaviour therapy programs typically include strategies for more adaptive problem solving (Foster et al., 2005). Here, one tries to figure out how to increase the probability of attaining the weight goal, and then whether the required effort is worth it. Little information is available concerning dieters’ problem solving. Anecdotally, the problem solving appears to consist of a vow to “be better tomorrow,” or worse, “start again on Monday.” Thus, there does not seem to be an adequate analysis of the cause of dietary failure. The simple admonition to “try harder,” is unlikely to produce better results. If one feels that progress towards an important goal is too slow but success is judged to be still possible, one may feel frustrated but still motivated. On the other hand, if progress is slow and prospects are doubtful, then frustration will be mixed with anxiety, and if the poor results persist will lead to feelings of disappointment, sadness and eventually hopelessness (Carver, 2004; Vieth, Strauman, Kolden, Woods, Michels, & Klein, 2003). Dieting can have quite dramatic positive or negative effects on emotional state, depending on the weight loss outcome. Generally, problem­solving is enhanced by positive affect and disrupted by negative affect (Frederickson, 2001). Furthermore, SELF­REGULATION OF WEIGHT 11 numerous studies have demonstrated a link between negative affect and overeating tendencies (Canetti, Bachar, & Berry, 2002; Stotland & Larocque, 2004). Thus, the need for dieters to manage emotional states is evident. Dieting vs. lifestyle modification The expected long­term outcome of dieting (although the dieter may not acknowledge it consciously) is “stopping the diet” – no one plans to stay on a diet forever. There is an assumption that after the diet a change will have taken place in eating and exercise habits, so that maintenance of weight loss will be assured. Yet most dieters have less confidence in maintenance than they do in the achievement of the initial weight loss (Stotland & Larocque, 2005). Weak confidence in maintenance unfortunately is an accurate reflection of the typical outcome. Problems in maintaining weight lost may be due to the lack of effort put into meaningful behaviour change during a strict diet program. At a minimum, dieters need to understand that maintenance is a separate goal from weight loss. Weight maintenance requires that one learn how to balance energy intake and output, which requires a modification of one’s former eating and activity patterns – this kind of behaviour change is often referred to as “lifestyle modification.” Diets represent a very different type of self­regulation than lifestyle modification – in lifestyle modification the goal is “healthy eating and exercise behaviour” which is expected to result in the eventual attainment and maintenance of a “healthy weight.” An example of a specific behavioural goal in a lifestyle modification approach is learning to stop eating at a lower threshold of fullness, a goal that requires self­ monitoring and learning a new standard of fullness. If we look closely at the experience SELF­REGULATION OF WEIGHT 12 of eating less we see that the immediate result is simply feeling less full – the link with weight loss is delayed and must be taken on faith. Yet one can learn to appreciate feeling less full as a goal in of itself – this is a glass half full or half empty scenario; one may see eating less as a loss of pleasure, or feel good about eating “just the right amount.” A study of weight control motivation. We measured weight loss goals and related motivational variables in 450 women and 60 men who were participating in a medically­supervised diet program (Stotland & Larocque, 2005). A subset of these subjects (N=276) were assessed again after one month of treatment. We determined the weight loss goal by calculating the difference between current weight and desired weight, as a percentage of current weight. We then asked a series of 22 questions assessing weight control motivation (Table 1). We defined weight control motivation as the sum of attitudes about current weight, desired weight and weight control. These attitudes reflect positive and negative outcome expectancies, self­efficacy, and response expectancy, which are central concepts in cognitive social learning theories of weight control motivation (Baranowski et al., 2003). Our objective was to create a brief scale that would be appropriate for clinical settings and research requiring repeated measures analysis, where the issue of “user friendliness” is paramount, and the length of the scale is a primary consideration. We considered various factor analytic solutions and concluded that a 3­factor model was the most meaningful, accounting for 40.3% of the variance in the items. Factor 1 items appeared to measure self­efficacy and response expectancy, and was labeled confidence & acceptability. Factor 2 included items related to attitudes about current weight and expected benefits of weight loss, and was labeled importance. Factor SELF­REGULATION OF WEIGHT 13 3 included items reflecting the frequency of thoughts about the goal, and was labeled positive goal activation. Examination of Table 2 indicates that several motivation items showed somewhat limited variance. In particular, items related to the value of weight loss had means close to the maximum possible score. This is not surprising considering that the sample included only patients in weight loss treatment. As a consequence of the restricted range, the importance subscale had a somewhat low internal consistency. We would expect that evaluation of this scale in the general population, or in a non­treatment seeking obese sample would reveal more variability and higher reliability. The three motivation scales showed an interesting pattern of correlations with other variables (Table 3). Our current research is exploring a number of unanswered questions, including changes in motivation over longer periods of time during treatment and outside of a treatment context, influences of treatment variables (e.g. therapeutic alliance measures) on motivation, and the causal relationship between motivation, other psychological variables (e.g. depression, stress) and weight changes. Do only dieters engage in eating self­regulation? In research on dietary restraint (Herman & Polivy, 1984; 2004; Ruderman, 1986), people are often grouped into “restrained” and “unrestrained” eaters, a categorization which is sometimes used interchangeably with “dieters” and “non­dieters.” Studies have tended to focus on mapping the cognitive structure of the high restraint group (the “dieters”) while ignoring those who are low on restraint (the “nondieters”). The assumption has been that unrestrained eaters regulate their eating in a much less cognitive SELF­REGULATION OF WEIGHT 14 manner, eating in accord with hunger and taste considerations and are therefore not thought to engage in eating self­regulation. We investigated the cognitive processes underlying the decision to eat or not eat (Stotland & Kronick, 2005) in restrained and unrestrained college females. We used a trait measure of eating restraint, the Restraint Scale (Polivy, Herman, & Warsh, 1978) to measure general attitudes towards dieting, and we developed the Eating Thoughts Inventory to measure thoughts that one might have while deciding whether or not to eat some available food. The scale includes items measuring “restraint” thoughts (“No, I don’t want the cookies; I shouldn’t), “disinhibition” thoughts (“Yes, I want the cookies, what the hell”), and “appetitive” thoughts (“No, I don’t want the cookies, they don’t appeal to me”). We found that eating thoughts were a better predictor than Restraint Scale scores of the decision whether or not to eat. Regardless of level of trait restraint, it was the combination of appetitive thoughts and restraint thoughts that predicted eating/not eating behavior. Even the unrestrained eaters reported a significant number of restraint thoughts and an even greater number of disinhibitive thoughts (which, by definition must firstly involve some level of dietary inhibition). From these results, it may be concluded that what determines whether or not individuals eat is not ultimately their everyday (trait) level of restraint, but rather the actual restrained and appetitive (and disinhibitive) thoughts they are having with regards to the food placed in front of them. We believe that such eating thoughts constitute a form of active self­regulation – one that seems to be taking place in both restrained and unrestrained eaters alike. Indeed, a robust decision making process involving caloric, diet­abiding and taste­related factors SELF­REGULATION OF WEIGHT 15 seems to be at play, mediating food intake in all eaters. Our study thus shows that unrestrained eaters do self­regulate their eating, and are not purely driven by physical needs and desires. Obesity treatment based on self­regulation theory In our view, many obese patients would benefit from a better understanding of self­regulation in weight control. Individuals may need help at various stages of goal pursuit, from the decision making stage in which the pros and cons of beginning a weight loss attempt are evaluated and a specific weight loss goal is determined, the planning stage in which diet and exercise strategies are chosen, the action stage in which the plan is enacted, evaluated and modified, and during which one must persist despite stress and frustration, and the maintenance stage, with the ultimate goal of fully integrating the eating and exercise changes. The self­regulation model describes the processes that guide the weight control process. Failure to achieve the goal may reflect problems in self­regulatory processes, or may be due to other factors interfering with self­regulation (see Figure 1). For example, metabolic adaptations to weight loss may make further weight loss more difficult (Weyer, Proatley, Salbe, Bogardus, Ravussin, & Tataranni, 2000). Negative affective states may reduce weight control self­efficacy and increase emotional eating tendencies (Stotland & Larocque, 2005). Social influences may make self­control more or less likely (Wansink, 2004). Clinicians should appreciate both the complexities of weight self­regulation and the larger context of the individual’s life. The therapeutic attitude described as “autonomy supportive” (Williams, Deci, & Ryan, 1998) encourages the patient to make her own decisions about goals and strategies. SELF­REGULATION OF WEIGHT 16 Motivation is enhanced by emphasizing patients’ awareness of their goals and encouraging discussion of the consequences of their current behavioral choices, along with optimistic collaboration in the development of plans (Rollnick & Miller, 1995). As treatment progresses, self­efficacy is strengthened by helping the patient recognize incremental progress towards the goal or the success of a plan (Bandura, 2004). This is crucial, given the tendencies for dieters to feel dissatisfied and frustrated with their rate of weight loss and to focus on weight rather than behaviour change goals. All of these strategies are important in obesity treatment, because patients often have a significant amount of negative emotional expectancies about the process (Stotland & Larocque, 2005) and treatment drop­out rates are notoriously high (Davis & Addis, 1999). In addition to therapeutic support, there is growing interest in the use of interactive technology as self­regulation tools (Bandura, 2004), which are seen as methods to make treatment available to a much larger number of people, and add a new dimension to treatment in settings where patient­clinician contact is at a premium (e.g. primary care). In our own research we have been evaluating the usefulness of Internet­ based psychological assessment in the treatment of obesity (Stotland & Larocque, 2003). The Larocque Obesity Questionnaire (LOQ; Stotland & Larocque, 2004) is an on­line questionnaire which includes subscales measuring Uncontrolled Eating, Stress Responses, Depression, Perfectionism, and the recently added motivation scales. The questionnaire is brief (requiring 10 – 15 minutes) and is immediately scored, with visual, quantitative and text­based feedback provided. Patients are strongly urged to complete the test on a monthly basis, to evaluate changes and areas of difficulty. SELF­REGULATION OF WEIGHT 17 We believe that an on­line assessment and feedback system such as the LOQ should enhance effective self­regulation, and may therefore have value in improving treatment outcome. We liken this tool to the blood sugar measurements required for effective diabetes self­management – without some sort of objective feedback it is extremely difficult for patient and clinician to guide long­term weight control efforts. Although we have not yet tested it in a controlled experiment we have found that more frequent use of the system was associated with a lower treatment dropout rate during the first 4 1⁄2 months of treatment (Stotland & Larocque, 2003). The potential for on­line assessment and treatment in obesity is still largely untapped (see Womble et al., 2004). Conclusion According to a self­regulation model, individuals who try to reduce their weight require effective goal setting, planning, self­monitoring, self­evaluation, emotional coping and problem­solving. In previous accounts of the behavioural treatment of obesity, many of these elements have been included in treatment plans (Foster et al., 2005), but there has been a lack of theoretical integration or a model that can be used to guide efforts to improve treatment outcome. Our model places the self­regulation of weight, eating and exercise within a broader self­regulatory perspective, considering other goals that the individual is pursuing, and also recognizing the influence that physiological and environmental variables can have on self­regulation. A number of theories have stressed the importance of stages, or phases, or periods, in self­regulation (e.g. Schwarzer, 1999). This is nowhere more necessary than in weight control. The management of obesity is a lifelong concern, and long­term studies are SELF­REGULATION OF WEIGHT 18 required to even begin to appreciate the changes that occur over time in behaviour, motivation and weight. The study of obesity and its treatment require a means of measuring and tracking self­regulation processes. This is an interesting situation in which the means for one group (the patients) to improve self­regulation of weight, by providing them with information relevant to their goals, is the same means for another group (the researchers) to evaluate the causes and effects of weight self­regulation processes. Interactive technology is a means of expanding the scope and access of research and clinical intervention. Yet again, weight self­regulation can never be totally predictable, because it is influenced by other ongoing self­regulation projects. However, as we map out the self­ regulatory strategies of people showing different courses of weight change, response to diets, and adherence to treatment, we may be able to design a blueprint for more successful outcomes. A treatment model based on self­regulation maximizes patient responsibility and facilitates the doctor­patient relationship. By starting with an appreciation of self­regulatory processes, we may gain a better understanding of the difficulties that many people have with weight control, and a framework for developing a more effective treatment of obesity. SELF­REGULATION OF WEIGHT 19 References Badman, M.K., & Flier, J.S. (2005). The gut and energy balance: visceral allies in the obesity wars. Science, 307, 1909­14. Bandura, A. (2004). Health promotion by social cognitive means. Health Education & Behavior, 31, 143­164. Bandura, A., & Cervone, D. (1982). Self­evaluative and self­efficacy mechanisms governing the motivational effects of goal systems. Journal of Personality and Social Psychology, 45, 1017­1028. Baranowski, T., Cullen, K.W., Nicklas, T., Thompson, D., & Baranowski, J. (2003). Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obesity Research, 11, 23S­43S. Baumeister, R.F., Bratslavsky, E., Muraven, M., & Tice, D.M. (1998). 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SELF­REGULATION OF WEIGHT 27 SELF­REGULATION OF WEIGHT 28 Outcome expectancy Self­efficacy, acceptability Goal Accesibility, activation Planning Self-monitoring Socio­ environmental Facilitators & impediments Physiology Emotional state Problem-solving Self-evaluation & emotional response Personality traits Figure 1 – The self­regulation sequence and influences Table 1 – Weight Control Motivation Questionnaire 1. RIGHT NOW, how important is it for you to succeed in weight control? 1234567 It’s not that Important compared To other goals in my Life It’s the most Important. Goal in my Life 2. RIGHT NOW, how much physical pain is caused by your weight? 1234567 None A great deal 3. RIGHT NOW, how much emotional pain is caused by your weight? 1234567 None A great deal 4. RIGHT NOW, do you believe you will be healthier if you lose weight? 1234567 I do not Believe I Will be any healthier I believe I Will be much Healthier 5. RIGHT NOW, do you believe you will be happier if you lose weight? 1234567 I do not Believe I Will be any happier I believe I Will be much Happier 6. RIGHT NOW, how do you feel about having to deal with weight control and trying to maintain healthy (eating and exercise) habits? 1234567 I don’t mind I totally It at all Resent it 7. RIGHT NOW, how much effort do you feel it will take to succeed in weight control? 1234567 A little effort A huge effort 8. RIGHT NOW, how much effort are you willing to make in order to reach your desired weight? 1234567 Hardly any Whatever it takes SELF­REGULATION OF WEIGHT 29 9. RIGHT NOW, how confident are you that you will reach your desired weight? 1234567 I’m afraid I I’m sure I Will fail Will succeed 10. RIGHT NOW, how confident are you that you will maintain the weight you lose? 1234567 I’m afraid I Will regain All of it I’m sure I Will maintain All of it DURING THE PAST WEEK, how often did you do each of the following: 11. 12. 13. 14. 15. 16. Imagined myself at my desired weight. 123456 never once or a few times every day a few times many times twice per day per day per day Told myself that life is short and I deserve to please myself by eating whatever I want. 123456 never once or a few times every day a few times many times twice per day per day per day Felt doubtful about succeeding in weight control. 123456 never once or a few times every day a few times many times twice per day per day per day Talked to someone who made me feel discouraged about losing weight. 123456 never once or a few times every day a few times many times twice per day per day per day Thought about the benefits of losing weight. 123456 never once or a few times every day a few times many times twice per day per day per day Felt regretful about all the things I must give up in order to lose weight (e.g., foods I like, old and comfortable habits, favorite restaurants, parties, etc.). 123456 never once or a few times every day a few times many times twice per day per day per day SELF­REGULATION OF WEIGHT 30 17. Read or listened (TV, radio, tapes, books and Internet) to inspiring material about weight loss. 123456 never once or a few times every day a few times many times twice per day per day per day 18. Reminded myself that I will reach my weight loss goals if I am persistent. 123456 never once or a few times every day a few times many times twice per day per day per day 19. Felt guilty about my weight (or my overeating). 123456 never once or a few times every day a few times many times twice per day per day per day 20. Read or listened to something that made me feel discouraged about losing weight. 123456 never once or a few times every day a few times many times twice per day per day per day 21. Talked about weight loss strategies with a supportive person (friend, advisor, doctor). 123456 never once or a few times every day a few times many times twice per day per day per day 22. Thought that trying to lose weight was too big of an effort. 123456 never once or a few times every day a few times many times twice per day per day per day SELF­REGULATION OF WEIGHT 31 Table 2 – Weight Control Motivation Questionnaire means, standard deviations and reliabilities at time 1 (pretreatment) and time 2 (1 month after start of treatment) SELF­REGULATION OF WEIGHT 32 Scale & Items Time 1 Time 2 t275 Mean SD ! Mean SD ! Confidence & Acceptability 56.5 8.8 .79 64.2 7.8 .82 ­15.3*** 61 5.0 1.7 5.6 1.4 ­6.3*** 9 5.2 1.8 6.0 1.4 ­7.8*** 10 4.2 1.9 5.3 1.5 ­10.3*** 121 5.0 1.1 5.6 0.7 ­7.9*** 131 4.3 1.2 5.0 0.9 ­9.9*** 141 5.6 0.8 5.8 0.5 ­4.9*** 161 4.3 1.2 5.0 0.9 ­11.7*** 191 3.5 1.6 4.7 1.4 ­11.0*** 201 5.5 0.9 5.8 0.5 ­4.9*** 221 5.1 1.0 5.7 0.7 ­8.1*** Importance 38.6 5.4 .69 35.6 5.4 .60 3.7*** 1 5.8 1.1 5.7 1.1 0.6 2 3.0 2.0 2.5 1.6 4.6*** 3 5.0 1.8 3.9 1.9 9.6*** 4 6.6 0.9 6.4 1.2 2.1* 5 6.3 1.1 6.2 1.2 1.4 7 5.6 1.5 4.6 1.7 9.6*** 8 6.3 0.9 6.3 1.0 0.1 Positive Goal Activation 15.4 4.2 .65 17.0 4.4 .76 ­6.4*** 11 3.2 1.4 3.7 1.3 ­6.1*** 15 4.3 1.2 4.3 1.2 0.2 17 2.1 1.2 2.4 1.1 ­3.6** 18 3.2 1.5 3.9 1.3 ­7.6*** 21 2.6 1.0 2.7 1.1 ­1.1 *p< .05 **p< .001 ***p< .0001 Note – 276 of the original sample of 510 patients completed a second psychological assessment 1 ­ item is reverse scored Table 3 – Correlations between weight control motivation scales and age, body mass index and psychological variables SELF­REGULATION OF WEIGHT 33 Variable Confidence & Acceptability Importance Positive Goal Activation Age .19*** ­.03 ­.06 Body Mass Index ­.18*** .36*** .03 Weight Loss Goal1 ­.24*** .36*** .09 Uncontrolled Eating2 ­.58*** .25*** ­.08 Stress Responses2 ­.37*** .35*** ­.01 Depression2 ­.43*** .29*** ­.01 Perfectionism2 ­.35*** .22*** .06 Autonomous Motivation3 .15 .28* .22* Controlled Motivation3 ­.43*** .33*** ­.03 Perceived Health Threat4 ­.30** .34*** .05 Outcome Expectancy4 ­.09 .13 .06 Action Self­ Efficacy4 .44*** .09 .21* Coping Self­ Efficacy4 .34*** .19* .13 Intention4 .25** .19* .32** *p< .05 **p< .001 ***p< .0001 1 – Represents desired weight loss as a percentage of starting weight 2 – Larocque Obesity Questionnaire (Stotland & Larocque, 2004) subscale 3 – Treatment Self­Regulation Questionnaire subscale (Williams, Grow, Freedman, Ryan, & Deci, 1996) 4 – from Schwarzer & Renner (2000)

Article published in "The American Journal of Bariatric Medicine", Fall 2000,Vol.15, N.3. By Maurice Larocque, MD and Stephen Stotland, Ph D . Editor's note: Dr. Larocque, a member of the ASBP, runs an obesity clinic in Montreal. Dr. Stotland is a member of the Cognitive and Behavioural Therapy Service at the Montreal General Hospital. Introduction Treatment of obesity involves changing the underlying behaviours, including excessive food intake and insufficient activity levels. The effectiveness of nutritional and behavioural approaches in the treatment of obesity remains limited. An alarming percentage of patients drop out of treatment within the first few weeks, never reach their healthy weight, or regain all the weight lost.1,2 For the treatment of obesity to be effective, it must necessarily target the psycho-biological mechanisms responsible for lack of self-discipline.3,4 However, to date, research has not been able to shed light on all the psychological variables generally associated with obesity5 even though it is clear that patients always show, during periods of weight loss and maintenance, changes in mood8 and personality that may have clinical significance6,7 . In addition, most physicians believe that emotional factors play a critical role in weight control and are instrumental in the long-term maintenance and return of undesirable behaviours. This article presents a new questionnaire to measure the number of behavioural and psychological variables that may play an important role in weight control. The LOQ has been designed for clinical applications - it is comprehensive, brief and easy to administer on a computer. These aspects are very important in clinical applications, particularly in general medicine, where physicians see many people with obesity but do not have the time or resources to intervene. The LOQ provides an effective and low-cost way to assess problem attitudes and behaviours that may hinder weight control efforts. The questionnaire also provides a customized report identifying problem attitudes and tips for changing them. This questionnaire has been used in a number of clinics over the past decade with approximately 300,000 patients, but to date no reliability and validity analysis has been presented. This paper focuses on a study that examines the statistical properties of the LOQ and its relationship to other psychological measures. Method Topics Seventy-eight women, all aged 18 years and older, who were undergoing a weight-loss program prescribed by physicians specializing in the treatment of obesity, participated in this study. The treatment included a low-calorie diet and physical exercise as well as periodic visits to specialists treating medical or psychological problems related to weight control. The average subject was 37 years of age (+/- 8.7) and weighed 183.4 pounds (+/- 37.8). Only patients with a BMI greater than 25 were accepted into the study. Procedure Subjects completed the LOQ as well as various other self-report questionnaires at different stages of their treatment. Some completed the LOQ prior to their first treatment, while others completed it at a later stage of treatment. The LOQ is a 52-item, computer-administered and computer-corrected, self-report questionnaire that can be completed in 10 minutes. These points measure a variety of behavioural, emotional and personality variables that may be associated with weight control problems. The variables were selected based on the authors' clinical experience in the treatment of obesity. The questionnaire assesses problematic eating habits, food-emotion, food-reward, weight loss goals, feelings of depression, boredom and guilt, responses to stress, and various character traits such as aggression, passivity and paranoia. An earlier factor analysis of 680 obese women (Larocque and Stotland, 1992, unpublished data) showed that the LOQ can be divided into four subscales called Habits, Motivation to Lose Weight, Physical Stress Reactions and Negative Emotions. Examples of items from these four subscales are shown in Table 1. Table 1 Example of LOQ points Subscale Example of points Habits 1. looking back on the last meals you had, try to estimate how long it took you to eat: A. Less than 5 minutes B. Between 5 and 10 minutes C. Between 10 and 20 minutes D. Between 20 and 30 minutes D. More than 30 minutes. 2. When you pass a basket of fruit, food or sweets, how often do you help yourself? A. Always B. Quite often C. Occasionally D. D. Never. Motivation for Weight Loss 1. Deep down, do you believe that you are capable of reaching your desired weight and maintaining it afterwards? A. Not at all B. Maybe C. Probably D. Definitely. 2. If you lose only half the weight you expect to lose in the next month, do you plan to continue your diet? A. Not at all B. Maybe C. Probably D. Definitely. Physical reactions to stress 1. In the past month, when you were at rest, did you experience any of the following symptoms: a rapid heartbeat, a sore throat, or shortness of breath. A. Never B. Occasionally C. Often (once a week on average) D. Very often (several times a week) 2. In the past month, have you experienced any of the following symptoms that are not attributable to any illness: headache, backache, neck pain. A. Never B. Occasionally C. On average once a week D. More than once a week. Negative emotions 1. I feel like my life is going nowhere and has no value. A. That's me B. I often think this way C. I sometimes think this way D. I never think this way. 2. I usually only engage in activities if I am sure I will succeed. A. Yes, absolutely B. I often have this attitude C. I sometimes have this attitude D. No, this is not like me at all. The Eysenck Personality Questionnaire9 is based on a 90-point scale measuring Neurotic Traits, Extraversion and Psychotic Traits. This scale has been widely used and has shown a high level of internal consistency and test-retest reliability. The Neurotic Traits and Extraversion scales were used in this study. Neurotic Traits is defined as a measure of a tendency towards anxiety, mood swings and depression, and psychomotor complaints. Extraversion is supposed to reflect sociability, the need for emotions and change, and relaxation. Beck's Depression Inventory includes 13 study points and measures symptoms and signs of depression. The correlation between the BDI-13 and the full BDI ranges from 0.89 to 0.97, and consistency coefficients generally exceed 0.85. The Body Esteem Scale11 measures three moderately cross-correlated self-reported dimensions of Sexual Attraction, Weight Preoccupation, and Physical Fitness. A total score for Overall Body Esteem was used in this study. The Dutch Eating Behaviour Scale12 has been widely used to assess dietary tendencies (Cognitive Restriction) and overeating in response to emotional states (Food-Emotion). Both scales have high levels of internal consistency and show expected relationships between variables such as caloric intake and binge eating. In order to examine the validity of a discriminant function of the LOQ scales, we compared the 1-interconnections between the LOQ subscales and the 2-interconnections between the LOQ subscales and other variables. Results The reliability of the LOQ subscales was measured using the Cronbach's coefficient, which provides an indication of the internal consistency of the subscale points. The Habits subscale measures a wide range of food and physical activity behaviours at 17 points, so a consistency coefficient of 0.67 was expected. The nine-point Physical Responses to Stress subscale had a consistency coefficient of 0.68, reflecting the wide range of stress-related symptoms observed. The Negative Emotions 19-point subscale had a consistency level of .85, indicating that it measures a relatively consistent construct. The 5-point Motivation for Weight Loss subscale had a consistency coefficient of just 0.46, which may be due to the limited number of points used or the multidimensional nature of this variable. However, the sum of motivation points was considered a useful measure of overall motivation to lose weight and was retained for further analysis. The correlations between the LOQ subscales are presented in Table 2. The Habits subscale was significantly correlated with Motivation to lose weight (r = 0.37, p.01), indicating that patients with healthier habits are more motivated to lose weight, and with Negative Emotions (r = 0.29, p.01), suggesting that better habits are associated with lower levels of negative affect. The most significant correlation was found between Negative Emotions and Physical Stress Reactions (r= .57, p.001), which is consistent with the results of the self-report questionnaires on negative affect and stress reactions. Overall, the LOQ subscales were weakly or moderately correlated, except for the emotion/stress association mentioned above. Thus, it appears that the LOQ subscales represent different psychological constructs. This aspect was further investigated when analyzing the relationships between the LOQ scales and other psychological measures. Table 2 Intercorrelationships between LOQ subscales Habits Motivation to lose weight Physical reactions to stress Negative emotions Habits --- .37*** -.10 -.29** Motivation to lose weight --- -.1 .19 Physical reactions to stress --- .57*** Negative emotions --- * p<.05 ** p<.01 ***p<.001 The Habits subscale was significantly correlated with various psychological variables, including body esteem (r=.31, p.01), cognitive dietary restriction (r=.46, p.001), food-emotion (r=.41, p.001) and BDI scores (r=.32, p.01). These data indicate that subjects with high scores on the Habits subscale tend to have higher body esteem and a higher degree of cognitive dietary restriction and less pronounced tendencies towards food-emotion and depression. Motivation for weight loss was correlated with BDI scores (r=-0.26, p.01) and weight (r=-0.26, p.01), indicating that higher levels of motivation for weight loss were associated with lower levels of depression and lower weight. Physical Stress Reactions were correlated with body esteem (r=-0.39, p.001), BDI scores (r=.63, p.001) and neurotic traits (r=.62, p.001), suggesting that stress reactions were strongly associated with negative affectivity and negative self-perception. Finally, Negative Emotions showed about the same pattern of associations as the Physical Reactions to Stress subscale, with significant correlations with body esteem (r=-0.27, p.01), BDI scores (0.66, p.001) and neurotic traits (r=0.76, p.001). Negative emotions were also associated with higher scores on the Food-Emotion subscale (r=0.42, p.001). Table 3 Relationship between LOQ subscales and other measures Habits Motivation to lose weight Physical reactions to stress Negative emotions Body esteem .31** .08 -.39*** -.27** Cognitive dietary restriction .46*** .20* .14 .01 Food-emotion -.41*** -.19 .19 .42*** BDI -.32** -.26** .63*** .66*** Extraversion .14 .27** .17 .01 Neurotic features -.18 -.13 .62*** .76*** Weight (pounds) -.19 -.26** .17 .01 * p<.05 ** p<.01 ***p<.001 Discussion The LOQ appears to be a reliable instrument for measuring several psychological and behavioural variables associated with obesity. This conclusion is supported by the internal consistency and convergent results of the validity analyses. The results suggest that the LOQ measures a number of variables that are consistent and whose distinctiveness can be established by a discriminant function, and gives predictable associations with other measures. An ongoing study13 will determine whether the variables measured by the LOQ are related to important clinical outcomes (i.e., weight loss or maintenance). One of the LOQ factors, the Motivation for Weight Loss subscale, appears to have a fairly low degree of internal consistency. As mentioned previously, this result could be interpreted as a result of the magnitude of the weight loss motivation construct, since everyone has their own reasons for wanting to lose weight and the various sources of motivation have not been shown to be additive. In any case, more work needs to be done quickly to explore and measure this variable, given its theoretical importance and practical potential. The variables measured by the LOQ are not new. Validated measures of most of these factors already exist.6 However, the real value of the LOQ is that it allows these psychological factors to be measured easily and in a format that is accessible in clinical applications. Given the health consequences of obesity and the ineffectiveness of current treatments, it is imperative to study the processes involved in long-term weight maintenance. Although the barriers to effective weight control are certainly complex and involve a variety of biopsychosocial variables, it is clear that psychological factors are an important part of the equation. The results of this study show that Dr. Larocque's Obesity Questionnaire can be a valuable tool for understanding the psychological processes involved in weight control. References 1. French S, Jeffery R, Murray D. Is dieting good for you? Prevalence, duration and associated weight and behavior changes for specific weight loss strategies over four years in US adults. Int J Obes. 1999;23:320-327. 2. Wing R. Behavioral approaches to the treatment of obesity. In G. Bray, C. Bouchard, & P. James (Eds.), Handbook of Obesity. 1997; New York: Marcel Dekker. 3. Foster, G., Wadden, T., Swain, R., Stunkard, A., Platte, P., & Vogt, R. The eating inventory in obese women: Clinical correlates and relationship to weight loss. Int J of Obes and Rel Metab Dis. 1998;22, 778-785. 4. McGuire M, Wing R, Klem, Lang W, Hill J. What predicts weight regain in a group of successful weight losers? J of Consult and Clin Psych . 1999;67, 177-185. 5. Friedman M, Brownell K. Psychological correlates of obesity: Moving to the next research generation. Psych Bulletin . 1995;17, 3-20. 6. Wadden T, Foster G. Behavioral assessment and treatment of markedly obese patients. In T. Wadden & T. VanItallie (Eds.) Treatment of the seriously obese patient. 1992; New York: Guilford. 7. Williams P, Surwit R, Babyak M, McCaskill C. Personality predictors of mood related to dieting. J of Consult and Clin Psych. 1998;66, 994-1004. 8. Brownell K. Relapse and the treatment of obesity. In T. Wadden & T. VanItallie (Eds.) Treatment of the seriously obese patient. 1992. New York: Guilford. 9. Eysenck H, Eysenck S. Manual of the Eysenck Personality Questionnaire. 1975, San Diego: EdITS. 10. Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch of Gen Psychiat.1961;4, 561-571. 11. Franzoi S, Shields J. The body esteem scale: Multidimensional structure and gender differences in a college population. J of Personality Assessment.1984 12. Van Strein T, Frijters J, Bergers G, & Defares P. (1986). Dutch eating behavior questionnaire for the assessment of restrained, emotional and external eating behavior. Int J of Eat Dis. 1986;5, 295-315. 13. Larocque M, Gougeon R. (1999). Primary care treatment of obesity: Strategy for long-term weight maintenance. American Journal of Bariatric Medicine, 1999;14, 16-20.

https://www.motivationminceur.ca/documents/fichiers/BARIATRIC_SURGERY_VS_LIFESTYLE_CHANGE.PDF

Response to debate in Canadian Family Physician, May 2012 Should obesity be treated? Stephen Stotland, Ph.D. & Maurice Larocque, M.D. In reading the debate in the recent issue of Canadian Family Physician, we were astonished and disappointed, both as clinicians and researchers, to discover strong attitudes suggesting that obesity should not be treated. We found it particularly alarming that doctors should feel so hopeless and no doubt transmitting this frustration to their patients. Thus, we are concerned that numerous obese individuals will be discouraged from taking better care of themselves. This essay examines the basis for hopefulness in obesity treatment research, considering the results of our own research program. In thinking about whether or not obesity should be treated we considered the impact of the well-documented negative bias among health professionals, including physicians, nurses, psychologists, dietitians and others, against obese people and negative attitudes toward the subject of weight management. The obese individual is blamed for the problem and is thought to be perhaps less deserving of care. Such biases, implicit and explicit, have been shown time and again.1 It is our opinion that those offering far-reaching conclusions about whether obesity “should” be treated2, 3 need to recognize the possibility of their own negative bias towards the obese patient and the weight management process. Negative attitudes in practitioners may be linked to their feeling ill-equipped to conduct this type of counseling.4 It is unknown to what extent practitioners are conscious of such feelings of low self-efficacy. Doctors very frequently prescribe healthy behavior like better eating, exercise and stress reduction.5, 6 In fact these are the fundamentals of weight management. Do doctors have greater self-efficacy for influencing health behaviour than they have for influencing weight management? There is a paradox if doctors recognize and support the practice of healthy behavior (eating, exercise, substance use, stress, mood, sleep), but dismiss the likelihood of successful weight management, because if an obese person improves on these health behavior dimensions isn’t it a virtual certainty that they will lose weight? Most of the available obesity treatment research has looked at outcomes primarily in terms of weight change, with insufficient attention to concurrent changes in behavior, attitudes and emotions, and there is almost no consideration of treatment “process.” What is needed is a theory-based account of how processes lead to weight control outcomes, over time. Without a strong theory, if we observe a negative outcome there is no way to use this information to engineer better treatments. Our research is an example of a more theoretically-based approach, an analysis of process and outcome in weight management based on a reliable set of measures of Should obesity be treated? 1 psychological variables and the therapeutic alliance, as well as BMI and other physiological variables. If the outcome of obesity treatment is very poor, as some believe, then we must try harder to understand why results are as they are, and develop a better theory that will predict more successful outcomes. This is not the time for hopelessness. In order to develop and test such a theory, we need studies with multiple observations over time and conditions. This type of research design is a perfect fit for obesity treatment, which involves ongoing treatment visits and assessments over a long period of time. In recent years we have used this type of repeated measures design, employing a multi-level modeling analysis to show: (1) early (approximately one month) improvements in both weight and eating habits (less uncontrolled eating) predict better later weight changes (up to 9 months).7 This indicates we must pay very close attention to the early treatment results; (2) changes in “negative” weight control motivation (feelings of resentment, regret, doubt and effort) are related to changes in weight and improvements in eating behavior and mood, while “positive” weight control motivation (beliefs that weight is causing physical or emotional suffering, and expectations that better weight control will have physical or emotional benefits) is not associated with weight or psychological changes.8 It is clear that the negative motivation dimension must be a focus of treatment research; (3) improvements in psychological variables (eating, depression, stress, perfectionism, negative motivation) are related to improvements in the therapeutic alliance between clinician and patient; the alliance is related to weight loss outcomes, but this effect is fully mediated by changes in psychological variables. Thus, the alliance directly influences the patient’s mood and behaviour, which is then directly related to weight change.9 Our combined body of research leads us to conclude that the outcomes of weight control treatment are more predictable than previously believed (see also10). This research brings needed optimism for practitioners deciding to venture into the field of helping people with their weight. Patients often feel hopeless about weight control and are seeking support from their doctors and therapists. We must practice hope, as we continue to do theory-driven research to try to better understand the processes of weight control failure and success. We were motivated to write this response to counter what we saw as a particularly negative viewpoint that some (but not all11) professionals seem to have about obesity treatment. We believe it is important to promote a stronger commitment to treat this problem. Our research shows that some of the causes of success and failure are controllable, such as helping patients to address their negative attitudes about the weight control process and working to establish a good working alliance. In this regard we would point at that our research shows it is not the initial levels of psychological variables (e.g. depressed mood, emotional eating) or the alliance that predicts outcome, but “changes” in these variables. Patients improve (and backslide) in all of Should obesity be treated? 2 these dimensions simultaneously, which shows that practitioners must be sensitive to such changes. If we accept the premise that lifestyle change is possible, although a difficult, variable and long-term process, we are likely to achieve better outcomes. Surely we must not stop trying to better understand weight control, as we work to develop better ways to help individuals improve all of their health behaviour. Should obesity be treated? 3 References 1. Puhl, R.M., & Heuer, C.A. The stigma of obesity: A review and update. Obesity 2009, doi:10.1038/oby.2008.636. 2. Ladouceur, R. Should we stop telling obese patients to lose weight? Canadian Family Physician 2012, 58, 499. 3. Havrankova, J. Is the treatment of obesity futile? Canadian Family Physician 2012, 58, 508- 510. 4. Greenwood, J.I.J. The complexity of weight loss counseling. J Am Board Fam Med 2009, doi: 10.3122/jabfm.2009.02.080256. 5. Foster, G.D.,Wadden, T.A., Makris, A.P., Davidson, D., Swain Sanderson, R., Allison, D., & Kessler, A. Primary care physicians’ attitudes about obesity and its treatment. Obes Res 2003, 11, 1168-1177. 6. Phelan, S., Nallari, M., Darroch, F.E., & Wing, R.R. What do physicians recommend to their overweight and obese patients? J Am Board Fam Med 2009, 22:115–122. 7. Stotland, S., & Larocque, M. Early treatment response as a predictor of ongoing weight loss in obesity treatment. British J of Health Psych, 2005, 10, 601–614. 8. Stotland, S., Larocque, M., & Sadikaj, G. Positive and negative dimensions of weight control motivation. Eating Behaviors 2012, 13, 20–26. 9. Larocque, C., Stotland, S., Larocque, M., Lecomte, C., Savard, R., & Sadikaj, G. Therapeutic alliance, psychological variables and outcome in obesity treatment. (In preparation). 10. Stubbs, J., Whybrow , S., Teixeira, P., Blundell, J., Lawton, C., Westenhoefer, J., ...& Raats, M. implications for weight control therapies based on behaviour change. Obesity Reviews Should obesity be treated? Problems in identifying predictors and correlates of weight loss and maintenance: 2011, 12, 688-708. 11. Moyer, V.A. Screening for and Management of Obesity in Adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Int Med 2012, 157, 1-6. 4

Abstract This study examined weight control motivation among patients (N = 5460 females and 547 males) who sought weight loss treatment with family physicians. An eight-item measure assessed the frequency of thoughts and feelings related to weight control “outcome” (e.g. expected physical and psychological benefits) and “process” (e.g. resentment and doubt). Factor analysis supported the existence of two factors, labeled Positive and Negative motivation. Positive motivation was high (average frequency of thoughts about benefits was ‘every day’) and stable throughout treatment, while Negative motivation declined rapidly and then stabilized. The determinants of changes in the Positive and Negative dimensions during treatment were examined within 3 time frames: first month, months 2–6, and 6–12. Maintenance of high scores on Positive motivation was associated with higher BMI and more disturbed eating habits. Early reductions in Negative motivation were greater for those starting treatment with higher weight and more disturbed eating habits, but less depression and stress, while later reductions in Negative motivation were predicted by improvements in eating habits, weight, stress and perfectionism. Clinicians treating obesity should be sensitive to fluctuations in both motivational dimensions, as they are likely to play a central role in determining long-term behavior and weight change. Highlights ► We identified two relatively independent dimensions of weight control motivation. ► The value of weight control fluctuates with recent weight change and depression. ► Negative motivation fluctuates with changes in eating habits, weight, and stress. ► Motivation should be assessed repeatedly during weight control treatment.

PRIMARY CARE: PATIENT PREFERENCES FOR VERY LOW CALORIE (VWC) VS. LOW CALORIE (VWC) DIETS Stephen Stotland, Ph.D1. & Maurice Larocque, M.D.2 1Service de Thérapie Comportementale, Hôpital Général de Montréal et 1,2Clinique d'Obésité MLA Présenté au 9ème congrès international sur l'obésité du 24 au 29 août 2002, Sao Paulo (Brésil). Contact: Dr. Stephen Stotland 5450 Cote des Neiges Blvd. Suite 103 Montreal, Quebec H3T 1Y6 514-737-3360 sstot@qc.aibn.com INTRODUCTION Options available to treat obesity include Low Calorie Diets (LCD) and Very Low Calorie Diets (VLCD). Numerous studies have demonstrated the short- and long-term results of this type of approach, suggesting that both types of diets certainly lead to weight loss, with fairly similar long-term results. There is very little research comparing a wide variety of different types of diets (caloric intake brackets) in the same study. Currently there is no clear evidence to recommend one type of diet over another. Therefore, the choice of diet, based on personal preferences and weight loss goals, may be left to the patient.... However, in most previous research, subjects were assigned a specific type of diet. Thus, we have little information on patient preferences for CBD or HBD. Nor do we know whether diet choice is associated with (a) a patient's pre-treatment characteristics, (b) different outcomes, such as continuation of treatment, weight loss, behavioural change (e.g., improved eating habits, reduced level of depression) . Our study explored these issues among 1400 patients treated for obesity in primary care centres. Patients were offered a choice of six different diets, including three CBTDs and three HCDs. METHOD SUBJECTS The study participants, 1400 patients with a Body Mass Index (BMI) of at least 25, included 1220 women and 180 men. The age range of the subjects was between 18 and 70 years. All patients had started their obesity treatment with a general practitioner. Patients were classified into 4 weight groups based on BMI: 25-29.9, 30-34.9, 35-39.9, 40+. PROCEDURE Subjects were seen by physicians as part of a dietary and behavioural intervention. Each patient made his or her own choice of diet and behavioural strategy. The diet choice was made by the patient after consultation with the physician, taking into account the expected weight loss and the advantages and disadvantages of each diet. The six diet choices are presented in Table 1. Options 2 and 4 were not offered to men. Patients were assessed for weight and psychological status at different times, according to an established plan with 4 to 8 weeks between assessments. The mean time between assessments was 38 days. Some patients continued treatment but did not undergo another psychological assessment. Therefore, this subgroup is included in the analysis of weight change but not psychological change. All subjects were weighed and completed a psycho-behavioural questionnaire at the pre-treatment assessment. Subjects were then asked to be weighed regularly and to repeat the psychological assessment once a month. The Larocque Obesity Questionnaire (LOQ) (Larocque and Stotland, 2000; Stotland and Larocque, 2001) was used to measure depression, stress reactions, and uncontrolled eating. Patients were also asked what their weight loss goal was, calculated in kilograms and considered as a percentage of baseline weight. The assessment was administered via the internet through our website www.mla.ca. Depression was measured in 7 points that demonstrated a relatively high level of internal consistency (alpha = .81). The different points assessed feelings such as hopelessness, sadness, inferiority, worthlessness and the desire to cry. Stress reactions were measured in 6 points describing various symptoms commonly associated with stress (e.g., headaches, gastrointestinal discomfort, difficulty concentrating, dizziness, trembling, heavy sweating, and unusual fatigue). Uncontrolled eating was assessed on 11 items measuring a variety of eating behaviours such as eating fast, eating in front of the television, eating impulsively, eating emotionally, eating to relax and eating sweet or fatty foods. The alpha index was .75. STATISTICAL ANALYSIS We studied diet preferences based on gender, BMI, age, desired weight loss and three psychological variables. Frequency analyses were examined to compare diet preferences by age and BMI groups. Groups with different diets were compared in terms of frequency of discontinuation during the initial phase of treatment. Diet groups were compared in pre-treatment using analysis of variance (ANOVA) for age, BMI, depression, stress and eating habits. The groups were also compared based on weight loss at Time 2 and Time 3 (change in BMI, loss in kilograms, percentage change in body weight, kilograms lost per day). The ANOVA measures were repeated to assess the change in psychological variables as a function of diet, Time (T1, T2, T3), and diet x Time interaction. RESULTS Diet Choices, Sex and BMI Table 1 presents patients' preferences for a type of diet according to their gender. For this analysis, two groups of diets were formed - diets 1-3 in the CBD category, and diets 4-6 in the CAD category. It can be seen that, overall, the rate of selection for both CBD and CAD was identical for women and men - 63.4% of women and 57.7% of men selected a CBD. Figures 1 and 2 present the percentages of subjects choosing CBD vs. CAD by sex and age. BMI appears to be an important factor in the choice of diet for men, not for women. Among male subjects, there is a clear difference in the frequency of choice between the thinnest (CBD-50.0%) and the fattest (CBD-87.2%) groups ( Diet choice and patient characteristics in pre-treatment Table 2 shows the averages for groups of men and women in their choice of the six different diets. Variables included age, BMI, stress, depression, uncontrolled eating and weight loss goals. For both men and women, the choice of diet was based on BMI at baseline, although this was more pronounced for men. Women in Group 1 (500 calories) were significantly heavier than those in the other groups, in which there was no difference. For men, there was a clear pattern in weight - the stricter the diet choices, the greater the weight. Again, this reflects the strong influence of weight on men's diet choices. Significant effects on diet were observed for both sexes on weight loss goals, with subjects choosing the lowest calorie diets and having the highest goals. There were no significant differences between the diets on any of the three psychological variables. Diet choice and drop-out rates Table 3 presents the drop-out rate for each diet group, calculated at the time of the second assessment, which took place on average 38 days after the start of treatment. During this 5 1/2 week period, 18% of women and 16% of men dropped out of treatment. In addition, 5-10% of patients (depending on the diet group), considered to have discontinued, resumed treatment later (on average almost 6 months later). The drop-out rate does not appear to differ significantly by diet type. Diet choice and weight change The effect of diets on weight change was studied during the first three assessments. Table 4 shows the average weight loss between the three assessment points. Significant results on weight change were observed in terms of kilogram loss, percent body weight loss, and kilogram per day loss. The results were evident from Time 1 to Time 2, Time 2 to Time 3 and Time 1 to Time 3. It is evident that all three groups in CBD lost more weight than the groups in HBD. Although the results seem even more remarkable in the men, they were somewhat mitigated by the small sample size. All the results for women are extremely significant (all p<.001). Dietary choice and psychological change The ANOVA measures were repeated to assess changes in psychological variables over the three assessment points, with particular emphasis on the Diet Group, Time Group and Diet x Time Interaction Group results. Table 5 presents averages for the psychological variables at each assessment point. For each of the three variables, strong Time scores were observed, indicating that subjects showed significant and significant improvement over time. The contrasts over time indicate that the change occurred from Time 1 to Time 2. The change from Time 2 to Time 3 is not significant. Diet choice is not a determining factor in the degree of psychological change. All groups appeared to show approximately the same rate of change. CONCLUSIONS Les patients obèses à qui on donne le choix de diète, semblent avoir a slight preference for CBTD vs. Fatter men with higher weight loss goals showed a clear preference for CBD choices compared to less obese men. For women, diet choice was somewhat related to starting weight and strongly related to weight loss goals. Psychological variables (depression, stress reactions, uncontrolled eating habits) were not related to diet choice. Diet choice is not related to discontinuation of treatment in the initial phase. The CBD groups lost weight faster than the CAD groups. All groups showed similar and significant improvements in psychological variables. TABLES AND GRAPHS The tables and graphs of this research are available in pdf format by clicking here. ACKNOWLEDGEMENTS This study was made possible thanks to the participation of the Maurice Larocque and Associates clinics. SUMMARY Patients who chose separate diet options did not have significant differences in pre-treatment characteristics. Fatter patients with higher weight loss goals tended to choose lower calorie diets. All diet groups lost significant amounts of weight, with CBD causing faster weight loss than CBD. All types of diets were associated with similar psychological benefits, as evidenced by lower rates of depression, stress reactions and uncontrolled eating. We believe that there is no obvious reason to favour one diet over another. In fact, we believe it is essential to support patients in their autonomy, helping them make an informed choice among different diet options.

National Dialogue on Healthy Weights Conference co-hosted by Obesity Canada, CIHR and Health Canada From 7 to 9 December 2001 Toronto, Ontario The prevalence of obesity is on the rise in Canada. According to the World Health Organization, overweight and obesity is the most neglected health problem today. In order to explore this issue further, a national conference entitled "National Dialogue on Healthy Weights" will be held from Friday, December 7 to Sunday, December 9, 2001, at the Delta Chelsea Hotel in downtown Toronto, Ontario. This two and a half day conference is co-sponsored by Obesity Canada 1, Canadian Institutes of Health Research (CIHR) and Health Canada. This conference will provide an opportunity for scientists, health professionals and stakeholders from different disciplines and regions to engage in a national dialogue on healthy weights and to achieve the following objectives: Develop a common understanding of current knowledge and identify gaps between basic science, clinical, health services and systems research and the social, cultural and environmental determinants of healthy weights. Develop partnerships to achieve long-term national strategies for research and interventions to achieve healthy weights. The following is a brief description of the conference program. Friday, December 7, 2001 19:15-19:30 Welcome and Introductions 19:30-20:30 Plenary Lecture Speaker The paradoxical increase in obesity: an international perspective. W.H. Dietz 20:30-21:30 Reception Program Saturday, December 8, 2001 8:00 - 8:30 a.m. Welcome and Opening Remarks Speakers President, Obesity Canada D. Lau President, CIHR A. Bernstein Scientific Director,Institute of Nutrition, Metabolism and Diabetes D. Finegood 8:30 - 10:00 Plenary Session 1: Impact of Obesity Speakers 8:30 - 9:00 a.m. Health Consequences of Obesity: A National Tragedy J.P. Després 9:00 - 9:30 a.m. Impact of Obesity on Aboriginal People K. Young 9:30 - 10:00 a.m. Economics and Obesity: Evaluating the Cost of the Problem or Evaluating the Solutions? C. Donaldson 10:30-12:00 Plenary Session 2: Characteristics and Trends in Canada 10:30 - 11:00 Secular Trends in Body Weight G. Paradise 11:00 - 11:30 a.m. What are we eating? A. Stephen 11:30-12:00 Are we active enough? Fr. Katzmarzyk 12 noon - 1 p.m. Dinner 1:00 - 3:30 p.m. Workshops2: 1. Impact of Obesity Children and teenagers Aboriginal Economically Vulnerable Populations Health Care Delivery Costs (system and personnel) 2. Characteristics and trends in Canada Children and teenagers Aboriginal Economically Vulnerable Populations Health Care Delivery Costs (system and personnel) 16:00 - 17:00 Workshop Highlights Program Sunday, December 9, 2001 8:00 - 9:40 Plenary Session 3: Determinants of Body Weight Speakers 8:00 - 8:40 Biological Determinants C. Bouchard 8:40 - 9:20 a.m. Environmental Determinants S. Kumanyika 9:20 - 9:40 a.m. Panel discussion 10:10-11:50 Plenary Session 4: Healthy Weight Promotion 10:10 - 10:50 a.m. Have we found effective treatment for obesity? S. Rössner 10:50-11:30 Population-based prevention strategies: Is it feasible? R. Jeffrey 11:30 -11:50 Group discussion 11:50-13:30 Lunch (OC Annual Meeting) 1:30 - 3:30 p.m. Workshops 3. Determinants of body weight Children and teenagers Aboriginal Economically Vulnerable Populations Population 4. Healthy weight promotion Children and teenagers Aboriginal Economically Vulnerable Populations Population 16:00 - 16:30 Summary and Next Steps D. Lau, D. Finegood, M. Bush 4:30 - 4:45 p.m. Acknowledgements and Closing Speakers Alan Bernstein, PhD President, Canadian Institutes of Health Research; Professor, Department of Medical Genetics, Faculty of Medicine, University of Toronto; Director, Mount Sinai Hospital Research Institute, Toronto, Ontario Claude Bouchard, PhD Executive Director, Pennington Center for Biomedical Research; Professor, Louisiana State University, Baton Rouge, LA; Past President, NAASO; President-Elect, International Association for the Study of Obesity Mary Bush, MSc, RD A/Director General, Office of Nutrition Policy and Promotion, Health Canada, Government of Canada Jean-Pierre Després, PhD Professor, Chair of Human Nutrition, Laval University; Scientific Director, Quebec Heart Institute, Quebec City, QC William H. Dietz, MD, PhD Director, Division of Nutrition and Physical Activity, U.S. Centers for Disease Control and Prevention, Atlanta, GA; Past President, NAASO Cam Donaldson, PhD Professor of Health Economics, Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Alberta Diane T. Finegood, PhD Scientific Director, Institute of Nutrition, Metabolism and Diabetes, CIHR, Professor, School of Kinesiology, Simon Fraser University, Burnaby, British Columbia Kue Young, MD, PhD Senior Scientist, CIHR, Professor and Head, Department of Community Health Sciences, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba Peter Katzmarzyk, PhD Assistant Professor, Department of Kinesiology and Health Sciences, York University, Toronto, Ontario Shiriki Kumanyika, PhD Associate Dean, Health Promotion and Disease Prevention, School of Medicine, University of Pennsylvania, Philadelphia, PA David C.W. Lau, MD, PhD President, Obesity Canada; Professor of Medicine, Biochemistry and Molecular Biology; Director, Julia McFarlane Diabetes Research Centre, Faculty of Medicine, University of Calgary, Calgary, Alberta Gilles Paradis, MD, MSc Assistant Professor, Faculty of Medicine, McGill University, Montreal, Quebec Alison Stephen, PhD Assistant Professor, Department of Nutrition and Food Science, University of Saskatchewan, Saskatoon, Saskatchewan Marc Tremblay, PhD Dean, Faculty of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan Stefan Rössner, MD, PhD President of the International Association for the Study of Obesity; Professor of Medicine, Huddinge University, Sweden Robert W. Jeffrey, PhD Professor of Epidemiology, University of Minnesota, Minneapolis, MN http://www.obesitycanada.com/ http://www.cihr.ca/ http://www.irsc.ca/ http://www.hc-sc.gc.ca/francais/index.htm 1. Obesity Canada (OC) is a not-for-profit organization that aims to improve the health of Canadians by reducing the prevalence of obesity and its consequences through research, education, awareness, prevention and treatment. Many OC members are also members of the North American Association for the Study of Obesity (NAASO) and the International Association for the Study of Obesity (IASO). 2. Participants in each workshop will be asked to answer the following four questions: What do we know (knowledge)? What do we need to know? What are the research priorities (filling the gaps)? What to do now (what/whom/when/how)?

Stephen Stotland, Ph.D1. & Maurice Larocque, M.D.2 1Behavioural Therapy Service, Montreal General Hospital and 2MLA Obesity Clinic Presented at the annual convention of NAASO (North American Association for the Study of Obesity), Quebec City, October 2001. Contact: Dr. Stephen Stotland 5450 Cote des Neiges Blvd. Suite 103 Montreal, Quebec H3T 1Y6 514-737-3360 sstot@qc.aibn.com INTRODUCTION Individuals may wish to lose weight for different reasons (such as reducing health risks, improving physical fitness, improving physical appearance, becoming socially assertive and increasing self-esteem). The purpose of our study was to examine the correlations between different incentives to lose weight among obesity patients. We hypothesized that the specific reasons given by each individual are related to factors such as age, degree of obesity and psychological variables. Specifically, we predicted that health-related reasons would be more likely to be cited by older or fatter patients, while psychological reasons would be more associated with high levels of perfectionism and depression. METHOD SUBJECTS 1288 women undergoing obesity treatment with a general practitioner participated in this study. The average age of the subjects was around 42.74 years (+/- 11.24) and the average body mass index was 32.00 (+/- 5.87). PROCEDURE To begin the pre-treatment psychological assessment, subjects were asked four questions about why they wanted to lose weight. The assessment, administered through our interactive website, included measures of depression, stress symptoms, perfectionism and uncontrolled eating behaviour. MEASURES Among the reasons for weight loss, two were related to Health and two were related to Psychological Well-Being (see Table 1). Subjects responded on a three-point scale indicating whether this particular reason applied to them "not really," "somewhat," or "yes, definitely. Depression was rated on an 8-point scale, which showed a high level of internal consistency (alpha= .79). The points measured feelings such as hopelessness, sadness, inferiority, worthlessness, and the desire to cry. Stress Reactions included 6 items describing a variety of symptoms commonly associated with stress (such as headaches, gastrointestinal pain, difficulty concentrating, dizziness, trembling, sweating and unusual fatigue). This scale had an alpha of .72. Perfectionism was rated on eight points, with recurring aspects of perfectionism such as self-disappointment, high expectations, guilt, fear of making mistakes, fear of failure, and the need to be the best at everything. Alpha was .73. Uncontrolled Eating was rated on twelve points measuring a variety of eating behaviours such as eating fast, eating in front of the TV, eating impulsively, eating emotionally, eating to relax, and eating sweet or fatty foods. Alpha was .74. RESULTS The characteristics of pre-treatment patients are presented in Table 2. Table 3 shows the frequencies of evocation of different response options for "reason" questions. It can be seen that both types of reasons, psychological and health-related, were cited by the majority of subjects. We found that psychological reasons are extremely common, with 79.5% of subjects invoking them partially or totally (i.e. 5 or 6 of a possible 6). Health reasons are also common, with 46.8% of subjects invoking them in part or in full. Psychological reasons are not at all related to health reasons (r= .02). In examining the relationship between the two types of reasons (Table 4), health-related reasons were associated with higher BMI, more stress reactions and older age. In other words, those who reported more health-related reasons had more physical problems than they hoped to reduce through weight loss. Psychological reasons, on the other hand, were associated with higher levels of perfectionism, depression, uncontrolled eating, and younger age but were not related to BMI. Thus, it is likely that subjects citing psychological reasons hope that weight loss will help them feel better about themselves. DISCUSSION These results suggest that there are two broad categories of motivations for weight loss: Health-related and Psychological reasons. The independence of these two categories indicates that a person may be motivated by either or both of these reasons. As might be expected, the use of health-related reasons for weight loss is related to the severity of obesity. Highly obese individuals are more likely to suffer from a variety of physical problems and limitations, and this is reflected in their motivation to try to lose weight. These results indicate that seeking weight loss for psychological reasons is not related to BMI. Such motives are more likely to be given priority by less obese individuals, for whom the physical costs of their obesity are less severe. Psychological reasons for weight loss reflect the distress associated with obesity, which appears for the most part as a set of traits such as perfectionism, rather than being overweight. People strive to lose weight to relieve suffering, both physical and psychological. From a medical point of view, improving physical fitness and reducing the risk of disease are the main reasons given for losing weight. There is a risk that a person with a BMI of 24 who feels too fat, ugly and unhappy may not be taken seriously or may even think that his or her problems are not of interest to the doctor. Such an individual has a serious problem, even if there is no medical risk. Individuals who justify their desire to lose weight for self-esteem may or may not need weight loss treatment, but would certainly benefit from advice to treat their psychological problems. Indeed, the fact that 80% of the patients in our sample have strong psychological motivations for weight loss suggests that most patients seeking obesity treatment probably need help to manage psychological concerns related to their weight. ACKNOWLEDGEMENTS This research was made possible through the collaboration of the Insudiet Society, AMIRECA (International Association for Food Behavioral Research) and the physicians of MLA Inc (Louise Comeau, MD; Maurice Larocque, MD; Dominic Larose, MD; Peter Forbes, MD; Harry J. Lefebre, MD; Paul Connolly). Table 1 Reasons to lose weight Why do you want to lose weight? For health reasons 1. To be able to do more over longer periods of time, to be more active. 2. For reasons of poor health or shortness of breath. For psychological reasons 3. For self-esteem and psychological reasons. 4. For reasons of dress, aesthetics. Note. Subjects responded on a three-point scale: 1= not really, 2= a little, 3= yes, mostly. Table 2 Subject characteristics (N= 1288) Average SD Tranche Age 42.74 11.24 18.8 - 69.6 IMC 32.00 5.87 25.0 - 65.1 Reactions Stress1 12.41 3.67 6 - 24 Depression1 14.28 3.85 8 - 31 Perfectionism1 20.12 4.18 8 - 32 Food Uncontrolled1 25.48 5.50 11 - 41 Reasons psychological 5.31 0.96 2 - 6 Reasons health 4.43 1.27 2 - 6 Note. 1Higher scores indicate more symptoms. Table 3 Adherence to the reasons given for weight loss Reason % of subjects adhering to the option Not really. A little. Yeah, mostly. Health-related reasons To be able to do more, over longer periods of time, to be more active. 14.1 26.5 59.5 For reasons of poor health or shortness of breath. 35.5 31.3 33.2 Psychological reasons For self-esteem and psychological reasons 9.5 23.0 67.5 For clothing reasons and aesthetically pleasing. 3.0 20.7 76.3 Table 4 Correlations between weight loss motivations and age, BMI and psychological variables Related Reasons to health Reasons psychological Age .17** - .09* BMI .35** - .04 Reactions to Stress1 .25** .10* Depression1 .11** .22** Perfectionism1 .06 .28** Perfectionism1 . Food Uncontrolled1 .02 .17** Note. *p<.01 ** p<.0001N=1288 1Higher scores indicate more symptoms.

Stephen Stotland, Ph.D1. & Maurice Larocque, M.D.2 1Behavioural Therapy Service, Montreal General Hospital and 1,2MLA Obesity Clinic Presented at the annual convention of NAASO (North American Association for the Study of Obesity), Quebec City, October 2001. Contact: Dr. Stephen Stotland 5450 Cote des Neiges Blvd. Suite 103 Montreal, Quebec H3T 1Y6 514-737-3360 sstot@qc.aibn.com INTRODUCTION Pre-treatment measures of psychological and behavioural variables were found to be insufficient and inconsistent predictors of weight loss. However, it appears that changes in such variables are associated with changes in weight. In other words, an obese patient who shows a significant improvement in eating habits is likely to show a similar improvement in weight and will likely continue to improve. On the contrary, a patient who has been able to lose weight quickly while not improving his or her eating habits or other psychological variables, will likely have difficulty coping with this rapid success. The objective of this study was to measure the relative usefulness of changes in psychological and behavioural variables, compared to pre-treatment levels of these same variables, as predictors of subsequent weight change. METHOD SUBJECTS 377 women with a BMI of at least 25 (mean= 33.0, SD= 6.0) were selected. Subjects ranged in age from 18 to 70 years (mean= 41.3, SD= 11.5). All subjects had started their obesity treatment with a general practitioner. PROCEDURE Patient weight was assessed three (all subjects) or four times (N=249), with a mean interval of 1.5 months between assessments. All subjects completed a psycho-behavioural questionnaire on our website (www.mla.ca) during the first two assessments. The assessment focused on four psychological variables: depression, stress symptoms, perfectionism and uncontrolled eating. Depression was assessed on 8 points, which showed a relatively high level of internal consistency (alpha= .79). These points measured feelings such as hopelessness, sadness, inferiority, worthlessness and the desire to cry. Stress Reactions included 6 items describing a variety of symptoms commonly associated with stress (such as headaches, gastrointestinal pain, difficulty concentrating, dizziness, trembling, heavy sweating and unusual fatigue). This scale had an alpha of .72. Perfectionism was rated on an 8-point scale, with recurring aspects of perfectionism such as self-disappointment, high expectations, guilt, worry about making mistakes, fear of failure, and the need to be the best at everything. Alpha was .73. Uncontrolled Eating was rated on 12 points measuring a variety of eating behaviours such as eating fast, eating in front of the TV, eating impulsively, eating emotionally, eating to relax, and eating sweet or fatty foods. Alpha was .74. STATISTICAL ANALYSIS We examined rapid (Time 1-Time 2) and delayed (Time 2-Time 3, Time 2-Time 4) weight changes and their relationship to measures of uncontrolled eating, depression, stress symptoms, perfectionism and age in pre-treatment, Time 2 and Time 1-Time 2 (residual change results). Gradual regression analysis was used to determine the best set of predictors of BMI change at Time 2, Time 3 and Time 4. RESULTS TREATMENT RESULTS BMI decreased significantly at each assessment point: Q1-Q2, t=22.5, p<.0001; Q2-Q3, t=11.6, p<.0001; Q3-Q4, t= 6.1, p<.0001 (see Figure 1). All psychological variables showed significant improvement from Time 1 to Time 2: Uncontrolled Eating, t= 19.0, p<.0001; Reactions to Stress, t= 13.9, p<.0001; Depression, t= 11.1, p<.0001; Perfectionism, t= 9.5, p<.0001 (see Figure 2). RELATING CHANGES IN IMC Correlations between pre-treatment variables and change in BMI are presented in Table 1. It has been found that higher Uncontrolled Feeding scores are associated with larger changes in BMI from Q1 to Q2 and from Q2 to Q3. This finding indicates that patients with worse eating habits lose relatively more weight than patients with better habits. Au contraire, nous avons constaté que des changements dans les variables psychologiques représentaient des prédicteurs plus constants de changement de l’IMC subséquent (Tableau 2). En fait, l’amélioration des habitudes alimentaires s’avère encore plus reliée au changement subséquent de l’IMC (T2-T3, T2-T4) qu’au changement de l’IMC antérieur (T1-T2). REGRESSION ANALYSES We first used the pre-treatment variables to predict the change in BMI (Table 3). We found that Uncontrolled Feeding was the best predictor, accounting for 6% of the variation in BMI change at Q2 and Q3. A second analysis took into account the psychological variables at Time 2 as well as the results of the change from Q1 to Q2 (BMI and psychological variables), to predict the subsequent change in BMI (Table 4). Improvement in eating habits was the best predictor of BMI change from Q2 to Q3 and Q2 to Q4, accounting for 13.8% and 23.1% of the variation. In both cases, improvement in eating habits was a better predictor than the change in previous BMI (Q1 to Q2). DISCUSSION Pre-treatment variables were found to be weak predictors of weight loss. Only pre-treatment eating habits were significantly related to weight change. Patients with a less controlled pre-treatment diet lost more weight. The "benefit" of poor habits was short-lived. At later assessment points, better habits, as well as lower scores on stress, depression and perfectionism, were associated with greater subsequent weight loss. Regression analysis showed that improvement in eating habits was the best predictor of weight loss. These results underline the importance of behavioural change in the treatment of obesity. It appears that behaviour change predicts subsequent weight loss that is much greater than previous weight loss. ACKNOWLEDGEMENTS This research was made possible through the collaboration of the Insudiet Society, AMIRECA (International Association for Food Behavioral Research) and the physicians of MLA Inc (Louise Comeau, MD; Maurice Larocque, MD; Dominic Larose, MD; Peter Forbes, MD; Harry J. Lefebre, MD; Paul Connolly). Table 1 Correlations between initial BMI change1 , later BMI change and pre-treatment variables Change in BMI T1-T22 Change in BMI T1-T32 Change in BMI T1-T43 Age .03 .03 .09 Uncontrolled Feeding4 .23** .24** .07 Stress Reactions4 .09 .12 .02 Depression4 .02 .01 .01 Perfectionism4 .09 .11 .09 Note. *p<.01 **p<.0001 1 Change = Residual change, representing the change from what previous results on this variable suggested.2 N=3773 N=249 4 Higher scores indicate more symptoms. Table 2 Correlations between change1 in initial BMI, later BMI change and change1 in in psychological variables Change BMI T1-T22 Change BMI T1-T32 Change BMI T1-T43 Change BMI T1 - T2 ----- .24** .35** Changt Uncontrolled Power Supply T1-T2 .26** .38** .43** .43** Changed in Reactions to Stress Time1-Time2 .23** .23** .30** Change in Depression T1-T2 .22** .13* .26** Change in Perfectionism T1-T2 .14* .12* .10 Note. *p<.05 **p<.0001 1 Change= residual change representing the change from what was predicted by previous results on this variable. 2 N=3773 N=249 Table 3 Gradual Multiple Regression Preview for Predictors in Pre-Processing Variable Attached Step Variable input r2mult(adj) F dfs Change in BMI T1-T2 1 Power Supply Uncontrolled .06 24.3*** 1.375 Change in BMI T1-T3 1 Power Supply Uncontrolled .06 23.9*** 1.375 Change in BMI T1-T4 1 no significant predictors Note. ***p<.0001 Table 4 Gradual Multiple Regression Overview for Time 2 Predictors Variable attached Step Variable Partial seizure r2 F dfs Change in BMI T2-T3 1 Change. Power Supply Uncontrolled T1-T2 .138 64.7*** 1.375 2 Change in BMI T1-T2 .023 10.3** 1.374 3 Uncontrolled Power Supply - T2 .012 5.4* 1.373 Change in BMI T2-T4 1 Change. Power Supply Uncontrolled T1-T2 .231 57.1*** 1.247 2 Change in BMI T1-T2 .063 20.6*** 1.246 3 Perfectionism - T2 .014 4.6* 1.245 Note. ***p<.05 **p<.01 *p<.0001

We analyzed the results of 344 women during the last 9 months of their treatment. The following factors were found to be predictive of weight loss during this period: (1) choice of VLCD rather than LCD, (2) weight loss at the beginning of treatment, (3) number of assessments, and most importantly, (4) rapid improvement in eating behaviours. Taken together, these factors represent a substantial difference in treatment outcomes. In the scenario with 4 factors, there is a decrease of 7.4 BMI points, while in the scenario without factors, there is a gain of 1.3 BMI points.

Article published in Le Bariatricien, Autumn 1999,Vol.14, N.3. Dr M. Larocque. Clinique Motivation Minceur, Montreal, Quebec, Canada. Faced with the inconsistent success rate in weight maintenance after treatment, our clinics have invited people who have successfully lost weight to participate in monthly 10-minute follow-up visits focused on motivating them to adopt a new lifestyle and new eating habits. This study tracked the weight profile of 180 patients (148 women, 32 men, initial body mass index (BMI): 31.1±0.5 kg/m2 , weight 83 ±1 kg; age 47±1 year) who had a post-treatment weight of 63.7±0.8 kg or who showed a weight loss of 21.6±0.6% after treatment and whose BMI had decreased by 23.9±0.2 kg/m2. Half of the patients participated in these monthly visits. The following factors - current weight, BMI, number of months post-treatment, sex, age, % weight lost, extent of energy limitations generated during weight loss, % weight lost and maintained, and attendance at visits - were noted. A simple factorial analysis of variance (ANOVA) was used to assess the differences in % weight lost and maintained in relation to these factors. The result: one to four years after treatment, the mean BMI was 26.4±0.3 kg/m2 , significantly lower than initially (p<0.05). The analysis revealed that the only determining factor in weight maintenance was attendance at monthly visits. In fact, those who attended visits had a lower BMI (24.4±0.3 versus 28.4±0.05 kg/m2 p<0.001); their percentage of weight loss maintained was greater (87±3 versus 28±5%, p<0.001). The percentage of weight lost initially in the 4-year treatment group decreased from 27±3 to 23±4, and from 21±2 to 3±4 in the non-treatment group (p<0.001). The type of diet followed had no impact on the final outcome. Among the patients not followed, 71% maintained their weight 5% below the initial weight, which is the success criterion according to the Institute of Medicine. However, the less assiduous follow-up of patients in this group supports our conclusions that primary care physicians should offer motivation and strategies to post-obese patients with short but frequent visits to help them maintain their weight.

Stephen Stotland, Ph.D1. & Maurice Larocque, M.D.2 1Behavioural Therapy Service, Montreal General Hospital and 1,2MLA Obesity Clinic Presented at the annual convention of NAASO (North American Association for the Study of Obesity), Quebec City, October 2001. Contact: Dr. Stephen Stotland 5450 Cote des Neiges Blvd. Suite 103 Montreal, Quebec H3T 1Y6 514-737-3360 sstot@qc.aibn.com INTRODUCTION Recently, a growing number of researchers have suggested that providing the patient with ongoing treatment is among the methods most likely to improve long-term weight loss. This raises the question of how to keep patients on treatment, given that there is often a 50% dropout rate after one month. This study examines the relationship between adherence to a computerized evaluation system with feedback and continued treatment of obesity. We hypothesized that patients who choose to complete the questionnaire voluntarily are more likely to continue treatment than patients who do not. We examined continuation rates at three assessment periods (Time 2, Time 3 and Time 4). METHOD SUBJECTS Our study involved 1827 women with a BMI of at least 25 (range= 25-65, mean= 32.2, SD= 6.0). The age range of our patients was between 18 and 70 years (mean= 41.7 years, SD= 11.5). All of the subjects had contacted a general practitioner to start their obesity treatment. PROCEDURE All subjects were tested at the beginning of treatment using a psycho-behavioural questionnaire. The evaluation questionnaire was administered via the internet via our website (www.mla.ca) (see Figures 1 - 2 - 3 ). Patients were recommended to repeat the test on a monthly basis. Patients who completed the questionnaire received an immediate report with their results on various behavioural and psychological measures and advice on behavioural changes in relation to areas for improvement. Patients were told that the assessment: "will allow you to assess the habits, attitudes and behaviors that are responsible for your weight problem and to identify the causes of your weight problem. And that: "repeating the test on a monthly basis will give you an indispensable tool to get rid of your bad habits once and for all." Subjects were classified into three groups at Time 2: Group 1 consisted of patients who dropped out of treatment, Group 2 of patients who continued treatment but did not complete the psychological evaluation at Time 2, and Group 3 of patients who continued treatment and completed the questionnaire at Time 2. MEASURES The assessment included measures of age, BMI, and four psychological variables; depression, stress symptoms, perfectionism, and uncontrolled eating. Depression was assessed on eight items that showed a relatively high level of consistency (Alpha= .79). The points measured feelings such as hopelessness, sadness, inferiority, worthlessness, and crying. Stress Reactions included six items describing a variety of symptoms commonly associated with stress (such as headaches, gastrointestinal pain, difficulty concentrating, dizziness, trembling, sweating profusely, and unusual fatigue). This scale had an alpha of .72. Perfectionism was rated on eight points, with recurring aspects of perfectionism such as self-disappointment, high expectations, guilt, worry about making mistakes, fear of failure, and the need to be the best at everything. Alpha was .73. Uncontrolled Eating was assessed on twelve points measuring a variety of eating behaviours, such as eating fast, eating in front of the TV, eating impulsively, eating emotionally, eating to relax, and eating sweet or fatty foods. Alpha was .74. STATISTICAL ANALYSIS Time 2 groups were compared according to pre-treatment characteristics using analysis of variation. We used chi-square analysis to compare the groups according to the proportion of patients who were still on treatment at Time 3 and Time 4. RESULTS Table 1 presents the mean groups according to pre-treatment characteristics. The only notable difference is that patients who dropped out at Time 2 had a slightly lower pre-treatment BMI than patients who continued treatment. Rates of treatment continuation are shown in Figure 5. The original assumption was that patients who completed the questionnaire at Time 2 would be better able to continue treatment. This was corroborated by our analysis at Time 3, c2(1, N=1046) = 43.4, p < .001, and at Time 4, c2(1, N=1046) = 28.9, p < .001. These analyses show that patients who completed the questionnaire at Time 2 were significantly still on treatment at Time 3 and Time 4. DISCUSSION This study represents a preliminary step in the search for the usefulness of a new technology in the treatment of obesity. We found that patients who voluntarily participated in our web-based assessment process (at Time 2) were more likely to continue their treatment than patients who chose not to complete the assessment. In fact, patients who completed the questionnaire had a 20% higher continuation rate at Time 3 and a 16% higher continuation rate at Time 4. These results are limited by the correlational nature of the study. Patients who chose to complete the questionnaire at Time 2 may have been different from those who did not in the sense that a tendency to self-select may explain the results. However, we were not able to detect any difference between the pre-treatment groups, nor in the amount of weight loss at Time 2. It is clearly premature to conclude that a web-based evaluation can influence continuation rates. Such a conclusion means that further research, taking into account randomly selected conditions, will be necessary. Nevertheless, these results are very encouraging in that they demonstrate that an internet-based assessment with a feedback system can solve a crucial problem in the treatment of obesity. This effective, inexpensive and "always available" treatment tool could help patients stay connected when they would otherwise be more likely to drop out. ACKNOWLEDGEMENTS This research was made possible through the collaboration of the Insudiet Society, AMIRECA (International Association for Food Behavioral Research) and the physicians of MLA Inc (Louise Comeau, MD; Maurice Larocque, MD; Dominic Larose, MD; Peter Forbes, MD; Harry J. Lefebre, MD; Paul Connolly).

Presented at the 5th International Congress on Obesity, held in Jerusalem, Israel, October 1986 by Dr. Maurice Larocque MD. The Yo-yo Syndrome Over the years, the treatment of obesity has been associated with yo-yo syndrome, multiple weight loss and weight regain. A first attempt to counteract this phenomenon came from "behavior therapy". This therapy is partly based on Pavlov's experiments with the conditioned reflex and could be defined as follows: human behaviour is acquired through repetition; it can therefore be unlearned and replaced by new behaviour. However, the results tested in the clinic and published in various medical publications have been disappointing. The Mental Weight Questionnaire In order to improve the treatment of obesity, we developed the concept of the MENTAL WEIGHT® questionnaire. Using a computerized questionnaire that lasts about 15 minutes, a person can evaluate his or her behaviour with respect to food. The different parameters studied are motivation, eating habits, mental image (personality traits), physical symptoms of stress and emotionality. Once the main behaviours to be improved have been identified, the computer suggests motivational tools (books, audiocassettes, documents) specific to each individual problem. The subject is encouraged to measure his or her behaviour on a monthly basis (reweighing his or her Mental Weight®) just as he or she regularly monitors his or her body weight on the scale. Comparative study After using this program in more than 2,000 patients, we wanted to compare the results of different motivational methods. Selection criteria: retrospectively from a given date all new patients, women between 20 and 60 years old, healthy, at least 18 kg (40 lb) overweight, following the same low-calorie diet supplemented with protein (1.5 g/kg ideal weight), vitamins and minerals, having had at least one check-up and being followed by the same doctor. Selection of groups:- Group O: 21 patients with no motivational method other than weekly visits to the doctor, -WORD GROUP: 19 patients who have followed our motivation method (have evaluated their results at least once in the MENTAL WEIGHT® questionnaire and have read the book "Losing weight through motivation"), -TB group: 10 patients who received behavioural group therapy. Results: Duration of the study: 16 weeks: Average number of pounds lost per patient. group O 14.3 lbs TB group 20.3 lbs MOT group 27.7 lbs Dropout rate in the first month group O 42% TB group 0% MOT Group 4.7%. Average number of weeks on the diet per patient group O 9 weeks TB group 15.3 weeks group MOT 12 weeks Average number of patients who completed 16 weeks group O 23.8% TB group 80% MOT group 52% Average number of pounds lost per patient for those who completed 16 weeks group O 21.2 lbs TB group 22.5 lbs MOT group 40.1 lbs Conclusions 1- Patients who used our motivation program lost twice as much weight as those in the other two groups. 2- "Behavioural" therapy with less abandonment and better attendance ensures a weight loss identical to the group without motivation and half as much as the group with motivation. 3- Patients who used the motivational program lost twice as much weight, had 33% more attendance, 10 times less drop-out in the first month and more than twice as many people who followed the program for 16 weeks as those in the unmotivated group. Discussion We conclude that the motivational program based on the evaluation using software that determines the Mental Weight® questionnaire and the use of motivational tools (pounds) is effective in the short term (16 weeks) for weight loss. What about weight maintenance? We believe that weight maintenance relies on long-term motivation just like other behavioural illnesses such as alcoholism and drug use. When mental fitness is compared to physical fitness, it is the repetition of motivational exercises that should ensure long-term success. Further studies will be completed to validate this assertion.

Presented at the 6th International Congress on Obesity, held in Kobe, Japan, October 1990 by Dr. Maurice Larocque. Purpose of the study Determine the extent to which motivational exercises influence eating behaviour, weight loss and possibly weight maintenance. Selection Criteria We chose 31 female volunteers, aged between 20 and 50 years old, who presented at their first consultation to lose weight with an excess weight between 9 and 18 kg (20 and 40 lbs). All of them followed the same very low calorie diet (between 600 and 800 calories) supplemented with protein supplements, vitamins and minerals. The supervision of these patients was done by the same doctor. They were divided into two groups: group A consisted of 14 people and group B consisted of 17 people. Protocol For the first three weeks, patients in Group A were asked to do motivational exercises that consisted of reading a motivational book (Lose weight through motivation) and/or listening to a mental programming audiotape (Lose weight through suggestion) for at least five minutes per day. During this time, Group B did not do any specific motivational exercises, but simply followed the diet. At the end of the first three-week sequence, a crossover was made: group A stopped all motivational exercises while group B started the same motivational programme. After another three-week period, a new crossover was made, with group A resuming the motivational exercises. Protocol Three-week sequences Motivation Without Motivation Premiere Group A Group B Second Group B Group A Third Group A Group B Study parameters At the beginning and end of each sequence, the patients were weighed. Their Mental Weights® questionnaire results and five behavioural parameters were measured using a computerized questionnaire. It should be noted that the motivational exercises lasted an average of 25 minutes per session, three or four times a week. Results Drop-out rate In the first sequence, the drop-out rate was at least 3 times higher for group B without motivation. It was also almost three times higher for group A when he stopped being motivated during the second sequence. In the third sequence, the rate was identical, suggesting that people who persist beyond six weeks in a weight loss program are self-motivated spontaneously or have a very strong will. Changes in Habits During the first sequence, eating habits improved in both groups with a 20% advantage for group A. In the second sequence, the changes were even more significant as group A stopped being motivated and resumed bad habits and group B, when it started being motivated, continued to improve significantly. In the third sequence, the opposite phenomenon occurred. Changes in motivation In the first sequence, group A improved slightly more than group B. This suggests that weight loss is a motivating factor in itself. In the second sequence, group B improved by 60%. During the third sequence, group A improved very little because it had reached its maximum level of motivation. Changes in mental image The differences in mental image (the human being's assessment of himself) depending on whether or not he uses motivational exercises are very significant in all three sequences. Changes in stress The changes in the physical symptoms of stress were dramatic in both groups during the first sequence. This may be explained by the fact that dieting, weight loss and/or psychological satisfaction with losing weight have the effect of lowering stress hormones. During the second and third sequences, group B was already at its ideal stress level and could no longer improve. On the other hand, there was a greater improvement in group A when they resumed their motivational exercises in the third sequence. Changes in emotions The changes in emotional state were very significant in all three sequences according to the practice of the motivational exercises. In favour of the group that was motivated, 10 times and three times more improvement was noted. Weight loss In the first sequence, a 40% higher weight loss was recorded for the motivated group. In the second sequence, there was an increase in weight loss for group B and a decrease for group A with a differential of more than double. In the third sequence, group A maintained their weight loss while group B slowed their loss considerably by stopping motivation. Changes in the Mental Weight Questionnaire In the first round, the Mental Weight Questionnaire® improved by twice as much for group A; in the second round, group B improved by almost three times as much as the other group. In the third round, group A improved again by nearly double that of the unmotivated group. Conclusions The most important conclusion we can draw is that there are significant and rapid (less than three weeks) changes in the behaviour (habits and attitudes) of people with a weight problem depending on the presence or absence of motivational exercises. Discussion These results suggest that as with fitness, regular repetition of motivational exercises appears to be the key factor in losing and maintaining a healthy weight.