What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (50 page)

31
. I adopt the usage of
acedia
from Robertson Davies’s essay “The Deadliest Sin of All,” in
One Half of Robertson Davies
(New York: Viking, 1977), 62–68. Much of what follows derives from this brilliant essay.

CHAPTER
12
Dieting

1
. This is a truly voluminous subject, full of articles that contradict one another, and peopled by scientists and clinicians caught in a conflict between an emerging truth about the ineffectiveness of dieting on the one hand, and making a living on the other.

I want to single out two major pieces of work about dieting, both unpopular: The first is J. Polivy and P. Herman,
Breaking the Diet Habit
(New York: Basic Books, 1983). Although a decade old now and out of print, its basic contentions on the ineffectiveness and dangers of dieting continue to be borne out in this fast-moving field. The second is the most up-to-date, scholarly review of dieting: D. Garner and S. Wooley, “Confronting the Failure of Behavioral and Dietary Treatments for Obesity,”
Clinical Psychology Review 11
(1991): 729–80. Both are whistle-blowing (though possibly overstated) and ahead of their time. I lean on them strongly in this chapter. They are must reads for all students in this field, and if taken to heart they will go a long way toward making psychology a more responsible profession.

Finally, the consumer should consult the splendid “Diets: What Works—What Doesn’t,”
Consumer Reports
, June 1993, 347–57.

2
. The Metropolitan Life table is adapted from E. Weigley, “Average? Ideal? Desirable? A Brief Overview of Height-Weight Tables in the United States,”
Journal of the American Dietetic Association
84 (1984): 417–23.

3
. The argument that being over your “ideal” weight means that you would live longer if you dieted down to your “ideal” weight is a non sequitur of the first magnitude. It astonishes me that serious physicians have been dispensing such advice for decades. Technically speaking, it is a fallacious argument on two grounds: First, it confuses correlation and cause. Some third variable may cause people at their “ideal” weight both to have that weight
and
to live longer. Second, it ignores the health cost of dieting to get to a lower weight, which in itself could offset the health benefit of being at that lower weight.

There is something else to be said against the Met Life “ideal” weights. Met Life charged about 20 to 30 percent extra in life-insurance premiums to the overweight. A good number of the overweight policyholders were willing to pay an extra premium because they knew something was wrong with their health that the company didn’t. This means that the overweight people that Met Life insured were probably unhealthier than people of the same weight who didn’t try to get insurance. Policyholders systematically select against the company, and the result of this is that the “ideal” weight figure is probably markedly too low.

4
. J. Garrow,
Energy Balance and Obesity in Man
(New York: Elsevier, 1974), and S. Wooley, O. Wooley, and S. Dyrenforth, “Theoretical, Practical, and Social Issues in Behavioral Treatment of Obesity,”
Journal of Applied Behavior Analysis
12 (1979): 3–25, review these studies. K. Brownell and T. Wadden, “The Heterogeneity of Obesity: Fitting Treatments to Individuals,”
Behavior Therapy
22 (1991): 153–77, is a useful general source debunking the myths of overweight.

New studies of doubly labeled water challenge the view that the obese don’t overeat, however. According to such studies, obese people underreport how much they eat by 30 percent. See D. Schoeller, “Measurement of Energy Expenditure in Free-Living Humans by Using Doubly Labeled Water,”
Journal of Nutrition
118 (1988): 1278–89.

5
. R. Striegel-Moore and J. Rodin, “The Influence of Psychological Variables in Obesity,” in K. Brownell and J. Foreyt, eds.,
Handbook of Eating Disorders
(New York: Basic Books, 1986), 99–121.

6
. “What’s Ahead? The Weight Loss Market,”
Obesity and Health
(July 1989), 51–54. J. LaRosa,
Dieter Beware: The Complete Consumer Guide to Weight Loss Programs
(Valley Stream, N.Y.: Marketdata Enterprises, 1991), is a useful if unselective compendium of the facts and financial doings of the diet industry.

7
. D. Garner, P. Garfinkel, D. Schwartz, and M. Thompson, “Cultural Expectations of Thinness in Women,”
Psychological Reports
47 (1980): 483–91; R. Jeffrey, S. Adlis, and J. Forster, “Prevalence of Dieting Among Working Men and Women: The Healthy Worker Project,”
Health Psychology
10 (1991): 274–81.

8
. M. Hovell, A. Koch, C. Hofstetter, et al., “Long-term Weight Loss Maintenance: Assessment of a Behavioral and Supplemented Fasting Regimen,”
American Journal of Public Health
78 (1988): 663–66; T. Andersen, K. Stokholm, O. Backer, and F. Quaade, “Long-term (5-Year) Results After Either Horizontal Gastroplasty or Very-Low-Calorie Diet for Morbid Obesity,”
International Journal of Obesity
12 (1988): 277–84; D. Johnson and E. Drenick, “Therapeutic Fasting in Morbid Obesity: Long-term Follow-up,”
Archives of Internal Medicine
137 (1977): 1381–82; P. Stalonas, M. Perri, and A. Kerzner, “Do Behavioral Treatments of Obesity Last? A Five-Year Follow-up Investigation,”
Addictive Behavior
9 (1984): 175–83. T. Wadden, A. Stunkard, and J. Liebschutz, “Three-Year Follow-up of the Treatment of Obesity by a Very Low Calorie Diet, Behavior Therapy, and Their Combination,”
Journal of Consulting and Clinical Psychology
56 (1988): 925–28, found that six out of forty-five patients maintained weight loss completely after three years.

The most complete source is “Methods for Voluntary Weight Loss and Control,” proceedings of a National Institutes of Health conference, 30 March-i April 1992, along with its staggering 1,119-item bibliography (“Methods for Voluntary Weight Loss and Control,” in
Current Bibliographies in Medicine
[CBM 92–1] [Washington, D.C.: U.S. Government Printing Office, 1992].

9
. See Garner and Wooley, “Confronting the Failure of Behavioral and Dietary Treatments,” for a review and bibliography of all the long-term follow-up studies. See also M. Holmes, B. Zysow, and T. Delbanco, “An Analytic Review of Current Therapies for Obesity,”
Journal of Family Practice
28 (1989): 610–16.

10
. K. Brownell and T. Wadden, “Etiology and Treatment of Obesity: Understanding a Serious, Prevalent, and Refractory Disorder,”
Journal of Consulting and Clinical Psychology
60 (1992): 505–17, are representative of the group that remains undaunted by the poor long-term results of dieting. They call for more realistic goals—reasonable weight rather than “ideal” weight—better screening for really motivated clients, and more research on maintenance. They write articles on a “balanced” view of dieting in response to the data in this chapter. I admire their dogged persistence, but I do not share their optimism about the future of the dieting industry. There is little reason to hope that ten-pound losses will be maintained any better than twenty-five-pound losses are. There is little reason to believe that people who suffer through diet after diet are unmotivated, and there is even less reason to expect any breakthrough about maintenance.

Brownell and Wadden assert that the public good will not be served if people come to believe “(a) diets do not work; (b) dieting is more dangerous than staying heavy; and (c) excess weight is a trivial risk factor.” This statement astonishes me. Brownell and Wadden are two of the investigators whose very research makes these propositions so plausible. Rather than hoping to chill debate about whether dieting is useless or even harmful, I believe it is very much in the public interest to
provoke
such debate.

11
. See R. Jeffrey, J. Forster, and T. Schmid, “Worksite Health Promotion: Feasibility Testing of Repeated Weight Control and Smoking Cessation Classes,”
American Journal of Health
3 (1989): 11–16; and R. Jeffrey, W. Hellerstedt, and T. Schmid, “Correspondence Programs for Smoking Cessation and Weight Control: A Comparison of Two Strategies in the Minnesota Heart Health Program,”
Health Psychology
9 (1990): 585–98.

12
. The serious scholar should read “Methods for Voluntary Weight Loss and Control” (see note 9, above). The upshot is that no known diet keeps weight off in the long run, except for a very small minority of dieters.

13
. The rat model of yo-yo dieting was developed by K. Brownell, M. Greenwood, E. Stellar, and E. Shrager, “The Effects of Repeated Cycles of Weight Loss and Regain in Rats,”
Physiology and Behavior
38 (1986): 459–64. The increased metabolic efficiency is well replicated, but whether yo-yo rats rebound to a higher weight is still controversial. See R. Contreras and V. Williams, “Dietary Obesity and Weight Cycling: Effects on Blood Pressure and Heart Rate in Rats,”
American Journal of Physiology
256 (1989): 1209–19. See R. Keesey, “The Body-Weight Set Point,”
Postgraduate Medicine
83 (1988): 115–27, and Garner and Wooley, “Confront the Failure of Behavioral and Dietary Treatments,” for reviews.

In spite of all the press on yo-yo dieting, I believe that more animal research is still needed to determine which effects of yo-yoing are reliable.

14
. G. Blackburn, G. Wilson, B. Kanders, et al., “Weight-cycling: The Experience of Human Dieters,”
American Journal of Clinical Nutrition
49 (1989): 1105–9; E. Drenick and D. Johnson, “Weight-Reduction by Fasting and Semi-Starvation in Morbid Obesity: Long-term Follow-up,” in G. Bray, ed.,
Obesity: Comparative Methods of Weight Control
(London: John Libbey, 1980), 25–34; C. Geissler, D. Miller, and M. Shah, “The Daily Metabolic Rate of the Post-Obese and the Lean,”
American Journal of Clinical Nutrition
45 (1987): 914–20.

I do not believe that the human literature on this issue is yet conclusive. The rat literature and the human literature have replicated increased metabolic efficiency during starvation and dieting. But what happens after weight is regained is less certain: I would like to see replications of whether weight overshoots to higher levels in rats and humans. I would also like to see a longitudinal study with long-term follow-up looking at metabolic efficiency after weight regain along the lines of the cross-sectional study of Geissler et al., “The Daily Metabolic Rate.” See also Garner and Wooley, “Confront the Failure of Behavioral and Dietary Treatments.”

15
. Geissler et al., “The Daily Metabolic Rate;” Blackburn et al., “Weight-cycling.”

16
. P. Brown and M. Konner, “An Anthropological Perspective on Obesity,”
Annals of the New York Academy of Sciences
499 (1987): 29–46.

17
. E. Sims, “Experimental Obesity, Diet-Induced Thermogenesis, and Their Clinical Implications,”
Clinics in Endocrinology and Metabolism
5 (1976): 377–95.

18
. Sims, “Experimental Obesity;” A. Stunkard, J. Harris, N. Pedersen, and G. McClearn, “The Body-Mass Index of Twins Who Have Been Reared Apart,”
New England Journal of Medicine
322 (1990): 1483–87; A. Stunkard, T. Sorenson, C. Hanis, et al., “An Adoption Study of Human Obesity,”
New England Journal of Medicine
314 (1986): 193–98. The correlation is stronger for the lean than for the obese, indicating that environmental factors may play more of a role in obesity. See R. Price and A. Stunkard, “Commingling Analysis of Obesity in Twins,”
Human Heredity
39 (1989): 121–35; C. Bouchard, A. Tremblay, J. Despres, et al., “The Response to Long-term Overfeeding in Identical Twins,”
New England Journal of Medicine
322 (1990): 1477–82. For the relation between “ideal” weight and actual weight, see A. Keys, “Overweight, Obesity, Coronary Heart Disease and Mortality,”
Nutrition Reviews
38 (1980): 297–307.

19
. The best prevalence statistics come from C. Fairburn and S. Beglin, “Studies of the Epidemiology of Bulimia Nervosa,”
American Journal of Psychiatry
147 (1990): 401–8.

20
. Antidepressant drugs have some positive effects. They do better than a placebo at reducing binging and purging, with about a 60 percent reduction in frequency. But most patients still have the symptoms at the end of treatment, with only 22 percent, on average, symptom free. Once antidepressants are stopped, rate of relapse is very high. For a review of the antidepressants in bulimia, see C. Fairburn, W. S. Agras, and G. T. Wilson, “The Research on the Treatment of Bulimia Nervosa: Practical and Theoretical Implications,” in G. Anderson and S. Kennedy, eds.,
The Biology of Feast and Famine: Relevance to Eating Disorders
(New York: Academic Press, 1992), 318–40.