Weight Management Counseling
Sue Popkess-Vawter
Nurse Healer OBJECTIVES
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Theoretical
Discuss the strengths and weaknesses of biological, behavioral, psychological, and cognitive theories of weight management.
Describe and explain the cognitive restructuring Balance from the Inside Out (BIO) strategies for healthy weight management.
Clinical
Describe three differences between unidimensional and multidimensional interventions for long-term weight management.
Discuss and adapt the basic principles of the Holistic Self-Care Model for long-term weight management to clients in your nursing practice.
List one positive self-talk statement to replace the three negative self-talk statements most frequently used by your clients, and identify in which of the eight metamotivational states the negative statements originated.
Personal
Discuss how you base your eating habits on the food pyramid and the American Diabetic Association diet using the EAT (Eat, Ask, Tell) for Hunger strategy.
Describe your personal aerobic and strength exercise program using the Exercise for LIFE (Learn the habit, I am important, Friends, Enjoy) strategy.
Describe how you nourish your self-esteem through spiritual connections each day (Energy, Spirit, Time, Eating, Exercise, Meditation).
DEFINITIONS
Body mass index (BMI): Weight in kilograms divided by height squared (m2), with healthy weight less than or equal to 24.9.
Obesity: Body mass index greater than or equal to 30.
Overeating: Eating when not hungry or eating more than is required to satisfy hunger.
Overfat: Percentage of body fat greater than recommended for a client’s gender and age (e.g., 28% for women and 20% for men).
Overweight: Body mass index of 25-29.9.
Self-talk: Mental verbalizations that elicit emotional responses.
Weight cycling/yo-yo dieting: Repeated weight loss greater than 10 pounds followed by weight gain, in a repetitive pattern three or more times over the past 2 years.
Weight management: Holistic, long-term lifestyle adjustments in clients’ bio-psychosociocultural-spiritual dimensions to promote a high level of individual wellness;
caring for and assisting clients to reach sufficient self-acceptance, self-love, and selfresponsibility to adjust their lifestyles to support eating for hunger, exercising regularly, and esteem.
caring for and assisting clients to reach sufficient self-acceptance, self-love, and selfresponsibility to adjust their lifestyles to support eating for hunger, exercising regularly, and esteem.
▪ THEORY AND RESEARCH
The Weight Gain Epidemic in the United States
Obesity has been a serious healthcare epidemic for more than 3 decades. More than two-thirds of adults in the United States are overweight or obese despite efforts and national initiatives to abate this unchecked problem.1 Progress in the past 10 years toward Healthy People 2010 objectives for overweight and obesity was of little consequence, thus requiring retention and revision of objectives for healthy weight and obesity in the new Healthy People 2020 objectives.2
For adults aged 20 years or older, overweight is defined as a body mass index (BMI) of 25-29.9, Class 1 obesity is defined as a BMI of 30-34.9, Class 2 obesity is a BMI of 35-39.9, and Class 3 obesity is a BMI greater than 40.3 Weight management failures result from lack of practical, long-term interventions to address holistic influences of weight gain (e.g., biological, psychological, sociocultural, and spiritual).4 Experts agree that environmental influences, rather than biological reasons, explain the obesity epidemic of the past 3 decades. There is general agreement that four key factors can explain the environmental stimulus-response nature of the rise in obesity in the United States: (1) fast-paced eating style of fatty, glycemic “fast foods” and super sizing; (2) excessive calorie intake; (3) reduced physical activity and greater use of high-tech devices; and (4) heightened sensitivity to food as a stimulant from the media.
Only recently has the weight gain epidemic in the United States been recognized as multifactorial, and as such calls for multifactorial and multidimensional approaches to abate the problem. Although classic theories of energy balance remain accurate in describing why body weight is gained, cognitive and behavioral theories may better address the multifactorial overweight situation. Weight management approaches need to account for energy in (food), energy out (exercise), psychological aspects such as self-esteem and stress management, “toxic environments” that do not support healthy eating and exercise, comorbidity and obesogenic medications, and family-job influences. The current trend, in light of consistent failures, is to correct and reprogram thinking of American citizens, healthcare providers, community planners, and policymakers to promote small, consistent lifestyle changes that encompass all multifactorial influences. The Surgeon General and national healthcare professional organizations advise consideration of all influencing factors to promote modest weight loss. Improvements in insulin sensitivity, type 2 diabetes, blood lipids, and blood glucose/A1c, sleep apnea, and blood pressure were demonstrated with 5-10% weight loss (for example, a 10- to 20-pound loss in a 200-pound person or a 15- to 30-pound loss in a 300-pound person).5
History may shed light on the context of the recent weight gain epidemic in the United States. During the Great Depression and through World War II, people focused on peace and financial security. Times were literally lean because of financial and nutritional shortages. As the economic struggles began to resolve and people gained greater wealth, they also gained weight. Advances in automation rapidly mechanized a once physically active society, making it faster paced but paradoxically slowing it down physically. People learned to overeat in celebration of their new-found freedom and prosperity, and, at the same time, they learned to use eating as a coping mechanism. From an operant conditioning perspective, food acted as the powerful positive reinforcer that stopped the unpleasant feeling of physical and emotional hunger (i.e., the negative reinforcers). Eating to feel better, in the presence or absence of hunger and a wide variety of pleasant and unpleasant feelings, soon became a habit in U.S. culture as foods (usually those high in fat, sugar, and starch) became more affordable and convenient.
Around 1950, dieting to lose weight came into style to achieve the thinness of fashion models and movie stars, which constantly flashed before Americans’ eyes in the burgeoning media. Soon, feelings of deprivation and preoccupation with food and dieting yielded a rise in eating disorders and weight cycling.
Long-term habits of overeating without hunger and little or no physical exercise in a fastpaced society can explain the U.S. weight crisis. To date, most weight loss interventions in the United States have not contributed to long-term weight loss and probably have exacerbated the overweight problem. Comorbid conditions associated with overweight and obesity include heart disease and hypertension, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and cancers (e.g., endometrial, breast, prostate, colon); the most dramatically rising overweight comorbidity is type 2 diabetes.6
Long-term habits of overeating without hunger and little or no physical exercise in a fastpaced society can explain the U.S. weight crisis. To date, most weight loss interventions in the United States have not contributed to long-term weight loss and probably have exacerbated the overweight problem. Comorbid conditions associated with overweight and obesity include heart disease and hypertension, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and cancers (e.g., endometrial, breast, prostate, colon); the most dramatically rising overweight comorbidity is type 2 diabetes.6
Approaches to Weight Management
Most weight management approaches are based on at least one of four categories of theories—biological, behavioral, psychological, and cognitive.
Biological Theories
Interventions based on biological theories aim to correct excess weight and fat by reducing the number of available calories so that excessive fat is not deposited and fat stores are used. Traditionally, four biological theories explain excess weight gain from genetic and energy balance perspectives.
According to two genetic theories, individuals have a genetic predisposition to an excessive accumulation of fat, either by hypertrophy (enlarged size) or hyperplasia (excessive numbers) of fat cells. The Hypertrophy Theory focuses on the size of the fat cell as a regulatory mechanism for food consumption; that is, when existing adipocytes have expanded to their size limitation, a signal causes the individual to stop eating. According to the Hyperplasia Theory, individuals are destined to continue their degree of fatness according to the number of fat cells present in childhood and adolescence. The adipocyte Hypertrophy Theory supports adult-onset obesity, while the adipocyte Hyperplasia Theory supports child-onset obesity. Neither genetic theory leaves much room for therapeutic interventions.
Set Point Theory, another popular theory, gained attention in the 1980s and 1990s. Nesbitt, who introduced this theory in 1972, claims that individuals have but one body weight at which their energy expenditure is normal.7 Despite changes in the rate of energy expenditure, be it higher or lower, individuals eventually will gain or lose weight to return their weight to its set point.8
Energy Balance Theory has been widely used as the basis of weight loss interventions.9 Simply put, the theory holds that an excessive number of calories ingested, but not required for metabolic needs, results in an excessive body weight. Conversely, fewer calories in the presence of demanding exercise and work create a deficit that allows weight loss to occur. No matter what the source of energy (e.g., carbohydrate, protein, fat), excessive calories are converted to be stored as fat. Excessive body weight, then, usually is from excessive intramuscular and subcutaneous fat stores.
Behavioral Theories
The primary focus of behavioral theories in weight management is that behaviors such as overeating are learned responses. Interventions such as behavior modification techniques (based on Skinner’s Stimulus-Response Theory) aim to control stimuli that result in actions that perpetuate overeating.10 Some believe stimulus control strategies can permanently change external motivations related to eating. Thus, stimulus control strategies are designed to control eating by restricting calories, choices, locations, and timing, while avoiding environmental or external stimuli that may lead to eating outside those limitations.
Many calorie-restricted diets and food supplements are a type of stimulus control strategy that concentrate on controlling antecedent stimuli (i.e., controlling what, when, where, and how much to eat). At one end of the nutritional continuum are extreme and unhealthy diets (e.g., a grapefruit diet or a high-protein diet); at the other end are balanced, healthy diets from the food pyramid. Even healthy diets can be difficult to comply with over the long term when they are aimed at controlling hunger. No matter how healthy they may be, stimulus-controlled diets focus on avoiding or eliminating hunger. When the body’s natural, physiologic, internal signals of hunger are erased or minimized, individuals are forced to focus on external cues to tell them when they need to eat.
A behavioral change theory that healthcare providers have found useful is Prochaska and DiClemente’s Stages of Change, or Transtheoretical, Model (TTM).11 The TTM posits that health behavior change involves progress through five stages of change: precontemplation, contemplation, preparation, action, and maintenance. Authors found consistent patterns among individuals’ reasons for changing and the stages of change. Improvements have been demonstrated in program recruitment, retention, and progress using stage-matched, proactive recruitment procedures and interventions. Healthcare providers and health promotion program designers are beginning to recognize greater long-term behavioral change using the TTM as a guide.
The Holistic Self-Care Model for long-term weight management is based on the premise that stimulus control addresses only part of the reasons for weight gain—the external reasons. The other reasons for weight gain are internal. For individuals to make long-term lifestyle changes that promote fat loss, it is necessary to emphasize healthy eating for hunger rather than the elimination of hunger.
Clients should be assisted in calculating the number of calories that they require to meet their basic metabolic and exercise metabolic needs, based on American Dietetic Association guidelines (daily calories greater or equal to 1,200). Health-promoting behavioral techniques help clients learn how to distribute calories among the food pyramid groups and record daily intake according to time, place, kinds, amounts, pyramid groups, social situation, and hunger level. Most behavioral programs require individuals to monitor and record their compliance with prescribed dietary restrictions. Often they are assisted with setting up a meaningful reward system, such as money, special gifts, and entertainment. Individuals usually are weighed weekly because weight loss becomes the external indicator of progress. Generally, less emphasis is placed on internal indicators of progress, such as changes in thinking and feelings, than on external indicators, such as weight, body shape, and body size. Although the National Heart, Lung, and Blood Institute (NHLBI) recommends keeping records and weighing regularly, tailoring these techniques to individual clients can help them transition from external to internal monitoring. Behavioral therapy is effective on a short-term basis but is less effective for helping obese individuals address disturbed thinking, emotions, and body image related to overeating and poor self-esteem.
Psychological Theories
Weight management interventions based on psychological theories usually are directed toward decreasing stress-induced eating and helping to find ways to control eating in the presence of stressful situations. Similarly, negative body image, poor self-esteem, depression, and issues of social discrimination become the focus of psychotherapy, while dietary and exercise prescriptions usually receive less emphasis during therapy. Binge eating disorder, bulimia, and compulsive overeating are treated as relationship disorders that have similar etiologies but that manifest differently. Usually, in psychotherapy individuals with eating disorders are encouraged to focus on related issues of abandonment and verbal, sexual, and physical abuse rather than the eating problem per se, unless physical well-being is threatened. Depression and obesity as related concerns are on the rise in the United States, especially among younger age groups.12
Cognitive Theories
Beck explains how unrealistic, negative thinking triggers unpleasant emotional responses, which can lead to overeating and not getting regular exercise.13 Interventions based on cognitive theory are aimed at providing rapid symptomatic improvement, understanding of mood changes, coping strategies for self-management when upset, and guidance for personal growth. Individuals are assisted in assessing their basic values and attitudes that lead to negative feelings, as well as in reevaluating and challenging basic assumptions about their self-worth. Problem-solving and coping techniques help clients to deal effectively with major, realistic problems (e.g., low self-esteem, guilt) and minor vague irritations (e.g., frustration, apathy) that seem to have no obvious external cause.
Beck offers cognitive restructuring techniques to help identify and eliminate cognitive distortions that elicit irrational emotional responses.
Beck’s approach to cognitive restructuring uses three steps:
Beck’s approach to cognitive restructuring uses three steps:
Identify automatic thoughts that are selfcritical.
Identify any cognitive distortions and unrealistic beliefs underlying the thoughts.
Provide rational responses that defend the self.
Cognitive restructuring aims to substitute objective rational thoughts for illogical, harsh self-criticisms that predominate in response to negative events. Overall, clients learn how underlying beliefs relate to thinking, thinking relates to feelings, and feelings relate to actions. As seen in the following cognitive theory progression, actions must be addressed through feelings and thinking to identify underlying beliefs that initiate the chain of events: Beliefs → Thoughts → Feelings → Actions. Focusing only on actions is a behavior modification and stimulus-response approach. A more in-depth and lasting approach is exploration of basic beliefs as a means to change thinking, feelings, and actions.
Failure of Traditional Weight Management Interventions
In 1994, failure rates for most weight reduction programs were estimated to be as high as 90-95%.14 These high dieting failure rates may be indirectly reflected in the National Health and Nutrition Examination Survey (NHANES) report of the prevalence of overweight and obesity in adults. Overweight adults comprised 47% of the population in 1976, 56% in 1988, and 65% in 1999. The prevalence of obese adults rose from 15% in 1976, to 23% in 1988, and to 31% in 1999.15 Weight gain trends appeared to reach a relatively steady state from 1999 to 2008; people were not gaining weight at the rapid rates since 1976, but overweight and obesity prevalence remained about the same, especially for women. Men, on the other hand, showed a somewhat upward trend in weight gain. The NHANES report for 2007-2008 showed overall prevalence of overweight and obesity for adults was 68% (approximately 72% among men and 64% among women).1 Obesity prevalence for women was 35.5% and 32.2% for men. Class 3 obesity was reported to have increased at greater rates than any other class of obesity in the United States.16 Over the past 3 decades, childhood obesity has more than doubled among children ages 2-5 years, has tripled among youth ages 6-11 years, and has more than tripled among adolescents ages 12-19 years. About 17% of American children ages 2-19 years were obese—a 1 in 6 incidence rate. Overweight and obesity have a greater effect on minorities; blacks had 51% and Hispanics had 21% higher obesity prevalence compared with whites.
Over these past decades, many interventions that fail to promote long-term weight management have characteristics in common: (1) they are restrictive in calories, choices, and times to eat; (2) they are unidimensional, using only one major means to achieve weight loss, and do not include regular exercise; (3) they do not permit individuals to tailor weight management to their preferences, lifestyles, and humanness; and (4) they do not focus on internal motivations for overeating and not exercising regularly.
Restrictions on Calories, Choices, and Times
Interventions that restrict calories, choices, and times to eat offer a temporary and artificial modification that is unrealistic for the long term. In the 1960s, 7% of men and 14% of women were on reducing diets (21% total). In the 1990s, 24% of men and 40% of women were on diets.17 Despite dieting attempts, the prevalence of overweight Americans increased from 25% to 33% between 1980 and 1991. Although Americans were trying to eat less fat, they were getting fatter. In a 1994 U.S. Department of Agriculture survey of 5,500 U.S. citizens, one in three adults was overweight.18 In an effort to follow recommendations to reduce fat intake, they reported eating more grains, but in doing so increased their intake of snacks by 200% and their intake of ready-to-eat cereals by 60%. It seems that their responses to dietary restrictions and deprivation ultimately resulted in overeating, which may have led to weight gain reflected in the current 68% incidence of overweight and obesity. When calories and choices are restricted, human beings often revert to old patterns that led to being overweight in the first place. In response, the national guidelines on weight management have become less restrictive and provide for human
fallibility, which is the necessary ingredient for long-term weight management.
fallibility, which is the necessary ingredient for long-term weight management.
Unidimensional Treatment
Many medical interventions that yield weight loss in the short term usually fail in the long term. Such interventions include surgical reduction of the gastrointestinal tract, stomach expansion devices and lap band restriction devices to produce a full feeling, and drugs to suppress the appetite and block fat absorption—all aimed at reducing amounts of ingested and metabolized foods. Sibutramine hydrochloride (satietyenhancing agent) and orlistat (inhibits intestinal lipase) were approved pharmacologic support for weight management despite distressing physiologic side effects.19 Often dramatic weight regain occurs when surgical procedures fail and medications are withdrawn because clients lack insight into why they overeat and do not exercise. It is vital that clients learn healthy eating, exercise, and self-esteem before or concurrently with other weight management treatments. Perhaps equally disconcerting about use of surgery and pharmacologic agents are the detrimental side effects. Dietary, pharmacologic, and surgical treatments that reduce intake and restrict calories, choices, and when to eat offer temporary modifications that are unrealistic for the long term and often are accompanied by rebound weight gain and damaging psychological consequences.20
Regular exercise as part of weight management is no longer controversial. Researchers have found supportive evidence that exercise plays a vital role in weight loss. Research findings suggest that exercise can prevent a reduction in the resting metabolic rate, either by elevating it following the exercise or by maintaining or increasing fat-free mass (lean body mass). Research supports both aerobic and strength (i.e., resistance) exercises to promote healthy weight. Short 10-minute bouts of exercise throughout the day, three to five times per day, have been shown to be equally beneficial in healthy weight management.21
Insulin resistance syndrome, or metabolic syndrome, formerly called syndrome X, is a condition of insulin resistance associated with a cluster of abnormalities typical for type 2 diabetes and its comorbidities.22 Most individuals who display metabolic syndrome are hypertensive, overweight, glucose intolerant, and have lipid abnormalities, all of which put them at a higher risk for cardiovascular disease. Noninsulin-dependent diabetes mellitus, or adultonset diabetes, is now called type 2 diabetes and accounts for almost 95% of all diagnosed cases of diabetes.23 As the degree to which a person is overweight increases, so does the risk for developing type 2 diabetes, especially when visceral adiposity increases, as evidenced by greater waist circumference, or an “apple shape.” Waist measurements greater than 35 inches for women and 40 inches for men may indicate a higher disease risk than that of people with smaller waist measurements. Increased central obesity among Americans may be related to greater intake of high glycemic index foods (e.g., high sugar and starch, low fiber, refined and processed foods), in addition to recognized overindulgence of fatty, fast foods. High sugar and starch content in lowfiber, refined foods may be directly related to the growing incidence of insulin resistance. The “good news” about this disheartening evidence is that modest weight loss of 5% to 10% of initial body weight can improve glucose tolerance and reduce blood pressure, lipids, and mortality.24 Healthcare providers are urged to assess those at risk for insulin resistance and related health risks and offer long-term lifestyle interventions to reverse this growing epidemic.
The U.S. media potentiates magical thinking and encourages individuals to seek “quick-fix, magic bullet” programs. Some individuals hold to the magical thinking that they can rapidly achieve slimmer images and will have lasting results without extended and consistent use of nutritional and exercise strategies. In the author’s experience, women who do not think magically about weight loss are usually older (35-45 years old), have tried many weight loss methods, failed frequently, and learned from their experiences that quick-fix weight loss methods only lead to more failures. Realistic thinkers can articulate what they want in life and are more willing to expend effort to achieve “a healthier, more energetic body, mind, and lifestyle.”
Inability to Tailor Weight Management Programs to the Individual
Interventions that do not permit individuals to tailor weight management to their preferences,
lifestyles, and humanness do not last. Weight loss interventions fail when program directives are too stringent for individuals to gain a sense of ownership and to accept the weight management strategies as a way of life. Instead, individuals view weight management as something that will happen magically if they can endure program directives long enough. Usually, they do not view “the program” as a long-term lifestyle change and, therefore, do not address their individual preferences (e.g., dislike for certain foods and types of exercise), way of life (e.g., working nights, family versus single), and “being human” along the way (e.g., not feeling guilty or dropping out when they deviate from the plan).
lifestyles, and humanness do not last. Weight loss interventions fail when program directives are too stringent for individuals to gain a sense of ownership and to accept the weight management strategies as a way of life. Instead, individuals view weight management as something that will happen magically if they can endure program directives long enough. Usually, they do not view “the program” as a long-term lifestyle change and, therefore, do not address their individual preferences (e.g., dislike for certain foods and types of exercise), way of life (e.g., working nights, family versus single), and “being human” along the way (e.g., not feeling guilty or dropping out when they deviate from the plan).
The American Dietetic Association states that to achieve long-term weight management adults must make a lifelong commitment to healthy lifestyle changes.25 Both daily physical activity and eating should be sustainable and enjoyable— terms that imply personal tailoring of healthy, yet livable lifetime habits. Without individualization, a lifelong program is not possible, because life is always changing and adaptation is the norm.
Inability to Focus on Internal Motivation for Overeating and Lack of Exercise
Interventions that are not focused on internal motivations for overeating and for lack of regular exercise generally do not uncover important underlying reasons for being overweight. This idea is reminiscent of the old saying, “Don’t look where you fell, but where you slipped.” Weight management programs often do not help overweight individuals uncover motivations for weight regain or reasons for staying overweight. Perhaps the reason that stimulus control techniques have had limited success is because they seek to control the diet and environment but do not take into account that eating may be a coping mechanism to manage unpleasant feelings.26 Weight management should include biological, psychological, and social interventions to normalize eating and separate physical from emotional hunger.
Toxic stress is the uncontrollable, chronic type of stress that causes sustained high levels of serum cortisol, the powerful stress hormone necessary for fueling stressful events.27 Sustained high cortisol levels can lead to fatigue, impaired immune response, lower mental sharpness, and stimulated appetite, all of which can contribute to metabolic syndrome. Attempts to lower stress usually include relaxation exercises and physical exercise. Techniques to prevent a toxic stress response involve seeking a different, healthier perception of troublesome stressors through healthy self-esteem. Healthy self-esteem can be cultivated through daily spiritual nurturance and spiritual coping, which conceptually can lower levels of the stress response and, thus, can lower cortisol. Healing from the “inside out” may be the only lasting intervention to address America’s overstressed, overweight epidemic. Support books such as The Language of Letting Go and 10 Secrets for Success and Inner Peace can help clients reach the inner healing necessary to make lifelong lifestyle changes.28,29
Multidimensional Weight Management Interventions
Successful weight management programs focus on internal motivations for overeating and not exercising regularly and are multidimensional and flexible. According to the 2009 American Dietetic Association position statement, multidimensional long-term weight management comprehensive programs should comprise dietary and physical activity strategies to lose and maintain weight loss as well as multiple cognitive behavioral strategies.25 Suggested cognitivebehavioral strategies are self-monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support.
Weight management professionals need to be aware of differences between behavioral strategies and cognitive behavioral strategies in weight management. Behavioral strategies, or behavior modification, focus on changing individuals’ behaviors with little or no concern for their underlying reasons for overeating, not exercising, and unhealthy coping behaviors. For example, large multisite clinical trials, such as the Action for Health in Diabetes Look AHEAD studies, incorporate both successful meal replacement and exercise behavioral strategies;30 nevertheless, little or no attention may be paid to help participants transition to “normal eating,” exercise that is realistic for their lifestyles, and related emotional issues. Such programs could be termed “multifaceted unidimensional”
programs because they use several behavioral strategies that emphasize stimulus control of intake and output by dieting and weight-related behavior modification. Unidimensional programs focus on overweight behaviors without regard for individuals’ beliefs, thinking, feelings, and related behaviors (cognitive behavioral theory). Researchers and professionals may believe that eating and exercise behavioral programs should “cover” the major etiologic factors to promote weight reduction and maintenance. Failure to address the cognitive factors of weight management, however, may sabotage long-term maintenance and could be partly responsible for continued escalation of the overweight and obesity epidemic.
programs because they use several behavioral strategies that emphasize stimulus control of intake and output by dieting and weight-related behavior modification. Unidimensional programs focus on overweight behaviors without regard for individuals’ beliefs, thinking, feelings, and related behaviors (cognitive behavioral theory). Researchers and professionals may believe that eating and exercise behavioral programs should “cover” the major etiologic factors to promote weight reduction and maintenance. Failure to address the cognitive factors of weight management, however, may sabotage long-term maintenance and could be partly responsible for continued escalation of the overweight and obesity epidemic.
Many multidimensional programs claim to use cognitive restructuring techniques, but only focus on thinking about food, relationships with others around food, and restructured thinking about hunger and satiation. Cognitive restructuring is defined as reprogramming of negative, derogatory self-talk to positive, constructive self-talk. Self-talk is defined as automatic thoughts in one’s mind, often derived from parents, authority figures, and religious teachings. Few programs directly address how negative beliefs and negative self-talk about one’s shortcomings and interactions with others can repeatedly increase tension, distort attitudes, and lead to negative behaviors, such as overeating and skipping exercise.
The Centers for Disease Control and Prevention (CDC) lists psychological disorders associated with obesity, including depression, eating disorders, distorted body image, and low self-esteem, which can be associated with suboptimal weight loss.12 Nondieting weight programs usually focus on emotional overeating, including programs such as 12-step Overeaters Anonymous,31 religious-oriented Weigh Down Workshops,32 and the Solution Developmental Method.33 These programs are multidimensional (psychological, sociocultural, religious, spiritual) and help people maintain healthy weight loss without undue dieting, exercise, and constant monitoring of both.
Cognitive therapy based on Reversal Theory serves as the basis of the holistic self-care approach to healthy weight management. A brief overview of cognitive therapy and Reversal Theory sets the stage for clear understanding of the Holistic Self-Care Model.
Cognitive Therapy Based on Reversal Theory
Beck describes cognitive therapy as helping clients restructure self-statements to be more realistic and positive, which in turn elicits positive responses.13 Cognitive theories by themselves cannot explain why people can cope with stressors some of the time (and do not overeat to cope) and not at other times (leading to overeating to cope). Reversal Theory, a relatively new theory, offers an added dimension to cognitive restructuring. It provides the necessary organizing structure to locate tension stress in motivational states where negative self-talk originates and can be targeted for positive self-talk replacements to decrease tension stress.
Reversal Theory
Reversal Theory is explained as the basis of the Holistic Self-Care Model. Tension stress, defined as the discrepancy between where individuals are and where they want to be, is reviewed as the foundation for cognitive strategies used in holistic self-care for healthy weight management.
Apter’s theory of psychological reversals, commonly referred to as Reversal Theory, provides a framework to explain factors related to overeating and lack of exercise in overweight individuals.34 According to this phenomenologic theory of arousal, motivation, and action, Apter posits that personality is inherently inconsistent and that individuals reverse between opposing, paired states called metamotivational states because they are not, in themselves, concerned with motivation, but rather with the way in which motivation is experienced. Psychologically healthy individuals experience their motivations and actions in different ways, depending on metamotivational states. Four pairs of opposing states have been identified: telic and paratelic, conformist and negativistic, mastery and sympathy, and, last, alloic and autic (see Exhibit 22-1). At a given point in time, individuals are in combinations of the different states, consisting of one state of each of the four pairs, but never in both states of a pair at the same time.
When in the telic state, individuals are seriousminded and goal oriented; when in the paratelic
state, they are playful and spontaneous. When in the conformist state, people prefer to go along with rules and regulations; when in the negativistic state, they prefer to break rules and want to be rebellious or noncompliant. When in the mastery state, individuals feel that being tough and being in control are important; when in the sympathy state, they feel that being tender and noncompetitive are important. In the alloic state, people derive pleasure from thinking of others before themselves in an altruistic way; in the autic state, they derive pleasure from thinking of themselves before others. Healthy individuals reverse between states easily and often throughout the day. The balance that results when individuals reverse easily between the four pairs of motivational states is termed “Eight Ways of Being Human.”
state, they are playful and spontaneous. When in the conformist state, people prefer to go along with rules and regulations; when in the negativistic state, they prefer to break rules and want to be rebellious or noncompliant. When in the mastery state, individuals feel that being tough and being in control are important; when in the sympathy state, they feel that being tender and noncompetitive are important. In the alloic state, people derive pleasure from thinking of others before themselves in an altruistic way; in the autic state, they derive pleasure from thinking of themselves before others. Healthy individuals reverse between states easily and often throughout the day. The balance that results when individuals reverse easily between the four pairs of motivational states is termed “Eight Ways of Being Human.”
EXHIBIT 22-1 Apter’s Reversal Theory Metamotivational States Pairs and Characteristics
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