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To lose, to maintain, to ignore: Weight management among women Janet Davidson Allan RN, PhD, CNP
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a
School of Nursing , University of Texas , Austin Published online: 14 Aug 2009.
To cite this article: Janet Davidson Allan RN, PhD, CNP (1991) To lose, to maintain, to ignore: Weight management among women, Health Care for Women International, 12:2, 223-235, DOI: 10.1080/07399339109515943 To link to this article: http://dx.doi.org/10.1080/07399339109515943
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
TO LOSE, TO MAINTAIN, TO IGNORE: WEIGHT MANAGEMENT AMONG WOMEN Janet Davidson Allan, RN, PhD, CNP
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School of Nursing, University of Texas at Austin
The purpose of this study was to describe the process of weight management and the factors that influence this process in a sample of 37 middle-class and working-class white women of varied body size. A naturalistic study design, with a cultural-ecological theoretical orientation and ethnographic interviewing techniques, was used. The findings indicated that there were five stages through which women moved, repeatedly, as they managed weight: appraising, deemphasizing, mobilizing, enacting, and maintaining. Each stage consisted of multiple processes characterized by the use of personally developed tactics and strategies. Concern about appearance rather than health was a more salient factor in the initiation of weight-loss efforts. Progression through the five-stage pathway for weight management was influenced by time and informants' weight. Implications for practice include helping clients reduce the difficulty of altering cultural routines of eating and exercise and eliciting clients' own norms for body size.
Of central concern to research and practice in women's health is the high prevalence of overweight and obesity (McBride, 1988). Currently, more than 24 percent of women are overweight (Dawson, 1988). Moreover, more women than men are overweight even though women are more likely to engage in weight-loss activities (Dawson, 1988) and to experience greater cultural pressure to maintain ideal weight (Lakoff & Scherr, 1984).
While conducting this research for a doctoral degree in medical anthropology at the University of California, Berkeley, the author was the recipient of a 3-year National Research Service Award Fellowship, awarded by the U.S. Public Health Service, Department of Health and Human Services, Division of Nursing (F31 NU 0S687-03). Health Care for Women International, 12:223-235, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Despite extensive research, obesity among women continues to elude effective understanding and treatment. Most treatment programs for weight reduction are dismal failures, with high recidivism rates (Wooley & Wooley, 1984). However, because most women desiring to lose weight do not attend such programs (Colvin & Olson, 1983; Schachter, 1982), little is known about their self-care activities for weight management or about the environmental milieus in which such activities occur. In this article, I use data from intensive interviews with 37 normal and overweight white women to describe the process of weight management and the factors influencing this process. The results reported are part of a larger cultural-ecological study of weight management among white women (Allan, 1986). WEIGHT MANAGEMENT AND FACTORS INFLUENCING IT Although researchers have addressed problems surrounding overweight, there is very little documentation concerning the process of weight management or the factors involved in starting or maintaining weight loss. The literature on cultural values and body size provides some sense of the context within which women manage weight. Weight Management and Motivation to Lose White (1984), in a study using grounded theory, interviewed 89 obese women enrolled in weight-control programs about the process of embarking on such a course. White identified four stages through which women progressed as they entered treatment for obesity. Adapting to sex-role norms was found to be the basic process linking the stages. White found that body concerns (ie., physical attractiveness) were a stronger motivator in weight control than health concerns. Mallick (1981), in her study of 144 high school girls, reported that the desire for a good figure was a major motivator for weight-control activities. Laffrey (1986) reported similar findings, suggesting that health concerns were not a strong motivator for weight loss because overweight individuals did not define themselves as unhealthy. Colvin and Olson (1983), in a community study of 13 men and 41 women who had successfully maintained weight loss for 2 years, found that 54% of the men but only 20% of the women identified a critical incident as triggering weight-loss efforts.
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Cultural Values and the Pressure to Be Thin The influence of dominant cultural values about body size and beauty on women and their weight-management activities has been discussed by many authors (Lakoff & Scherr, 1984; MacKenzie, 1976; Ritenbaugh, 1982). According to MacKenzie (1976), overweight individuals, particjjarly women, contradict many American values related to self-control ind beauty and thus become culturally diagnosed as bad, out of control, and incompetent. Ritenbaugh (1982) suggested that the current biomedi:al weight norms reflect the value of youth and sexiness. Others (Lakoff & Scherr, 1984; McBride, 1988) have pointed out the pressure on women deriving from conformist standards of appearance. Numerous iuthors view the current national obsession with dieting among women is a response to these powerful cultural influences (Hayes & Ross, 1987; Wooley & Wooley, 1984). WEIGHT: A CULTURAL-ECOLOGICAL DRIENTATION The cultural-ecological orientation for this study was based on sensi:izing concepts drawn from ecology (Stini, 1981), anthropology (Benlett, 1976; Kleinman, 1980), and psychology (Lazarus & Folkman, 1984). These concepts have provided a framework from which to exDlore women's experiences in dealing with weight within the milieus of Jieir lives and have enabled the examination of processes like weight •nanagement. Stini defined weight as a function of adjustment to the învironment through cultural and physiological means. In a society such is that in the United States, major influences on weight management nclude sedentary life-style (Ritenbaugh, 1982), high-fat diet (Jerome, 1981), and the cultural value of thinness (Lakoff & Scherr, 1984). Such in environment taxes women's ability to maintain weight stability within :ulturally (biomedically) prescribed norms solely through physiologic nechanisms. In response, women need to learn ways to cope with these itressors. Coping (Bennett, 1976; Lazarus & Folkman, 1984) is a process hrough which the individual manages over time the demands of an mvironment that is appraised as stressful. Weight management, for this ;tudy, is defined as all efforts directed at coping with actual or potential weight gain as a hazard to well-being. Kleinman's (1980) concept of an explanatory model was modified to ;xamine individual perceptions of weight management, such as ideas ibout what one should weigh and how one loses or maintains weight. These models are epic categories that represent the individual's subjec-
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tive perspective: how individuals classify and interpret their own health experience.
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METHOD A descriptive naturalistic study design (Lincoln & Guba, 1985) using ethnographic interviewing techniques (Spradley, 1979) and anthropométrie measures was used. A combination of "snowball" and theoretical sampling techniques (Lincoln & Guba, 1985) was used to make contact with 37 white middle- and working-class women. I was able to obtain a community-based sample by using various resources, such as occupational health nurses, personnel directors, and businesswomen, to advertise the study. In naturalistic studies, the sample size is achieved when no new dimensions (data saturation) are identified (Lincoln & Guba, 1985). In this study, saturation began occurring after 30 interviews. Using the snowball technique, I asked informants to refer me to other women. To reduce bias, I selected individuals who were less known to the informant. Theoretical sampling guided the selection of single or married, working- or middle-class, or thin or heavy women as choices arose. Informants met the following criteria: (a) normal weight to moderate obesity (40%-1009& over ideal weight, representing 95% of all obesity in women), (b) born in the United States and living in.the study area, (c) between the ages of 18 and 55 years, and (d) white. Ethnic diversity was not a sample criterion because I plan to study white, black, and Hispanic women separately and then to examine cross-ethnic differences and similarities. Members of the study group were young, married, well educated, of normal weight, and white-collar workers (see Table 1). The mean age was 33.7 years, with a range of 19-56. All but 3 women worked; most were employed in clerical and sales positions. An unstructured interview and anthropométrie measures of height and weight were used to collect data over a 7-month period. The interview began with the same question: "Tell me the history of your weight and your experiences over time with dealing with your weight." Subsequent probes elicited more data concerning knowledge of how much to weigh, reasons for wanting to lose weight, factors that hindered or helped weight management, and the selection of particular methods. Multiple interviews with each informant were conducted. To reduce the analytic bias of the researcher, all interviews were tape-recorded and transcribed verbatim. Triangulation of data collection methods, solicitation of informants' reactions to emerging themes, and independent corroboration from several informants were used to strengthen the study's credibility (Lincoln & Guba, 1985).
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lable 1. Characteristics of the Study Group (N = 37)
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Characteristics Marital status Married Single Widowed Divorced Education High school graduate Some college College graduate Ilass Middle Working Veight" Normal Overweight Obese
Frequency (n)
Percentage
18 13 3 3
48.6 35.1 8.1 8.1
11 12 14
29.7 32.4 37.8
21 16
57 43
21 7 9
56.7 18.9 24.3
'Normal weight was defined as body mass index (BMI) of 18.8 to 24; overweight, BM1 of 24 to Í8; and obesity. BMI greater than 28 (Bray, 1979).
Content-analysis, constant-comparison, and phase-analysis techniques veré used to analyze the transcribed interviews for categories, themes, ind processes (Lincoln & Guba, 1985; Spradley, 1979). Manifest and atent content-analysis techniques were used to identify categories and iomains. Emerging categories were presented for the informant's reac:ion in subsequent interviews. Phase analysis was used to trace the development of weight management over time. Both trace-back and traceforward starting points from a period of weight gain or loss were used to îxplicate the steps that women go through as they manage weight. The reliability of coding was enhanced by having two nursing colleagues review the categories and code several interviews. FINDINGS I identified five stages through which women moved as they managed weight gain: appraising, de-emphasizing, mobilizing, enacting, and maintaining. Each stage consisted of multiple processes characterized by the use of personally created tactics and/or strategies. Women used this general five-stage pathway repeatedly as they attempted to manage weight. In addition, the complexity of the tactics and strategies of each
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stage increased as informants repeated the process. Although aspects of each stage are discussed as separate processes, they were interactive. During initial efforts at weight loss, most informants moved through all five stages. However, women who learned to maintain their weight successfully eventually moved to a three-stage process: appraising, enacting, and maintaining. The fives stages of weight management are depicted in Figure 1.
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Appraising Appraising was defined as the ongoing and evolving assessment of one's weight. This complex stage had three aspects: becoming aware of one's weight, creating personal weight norms, and developing criteria for weight appraisal (see Figure 2). Appraising comprised a series of self-care tactics for coping with weight and the pressure to be thin. Becoming aware of one's weight involved the realization of one's body size, essentially noticing one's weight. This awareness included defining one's self as overweight or having gained weight. This was a very vague and general awareness, not necessarily congruent with medical definitions of overweight. Women became aware of their weight through social encounters and role and physiological transitions. Some informants, usually those with childhood obesity, developed an awareness of their weight early in life, mostly at school. This awareness of weight was often triggered by a social encounter, such as teasing by Appraising
Maintaining
Enacting
De-emphasizing
Mobilizing
Fig. 1. The five stages of the weight-management process.
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APPRAISING 1. Becoming aware of one's weight receiving comments about weight making role transitions experiencing physiologic transitions 2. Creating personal weight norms
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ideal weight acceptable weight overweight weight
3. Developing criteria for weight assessment appearance physical feelings weight charts
DE-EMPHASIZING 1 . Avoiding not weighing wearing larger clothing avoiding health care system 2. Isolating not participating
MAINTAINING 1. Modifying dieting tactics reducing exercise adding foods/meals 2. Solidifying lifestyle changes making more changes continuing enacting efforts 3. Reverting to former patterns stopping exercise resuming former food habits ENACTING
MOBILIZING 1. Seeking information reading popular media asking family/friends reading "scientific material" 2. Preparing the environment buying new foods throwing out foods telling friends about plans 3. Rehearsing eliminating foods or meals experimenting with exercise
1. Dieting skipping meals reducing high calorie foods exercising 2. Changing lifestyle new eating patterns new lifestyle
Fig. 2. Processes, tactics, and strategies involved in the five stages of weight management. fellow students, remarks by family or friends, or comparisons of oneself with others. For example, a 50-year-old overweight social worker discussed how she became aware that she was heavy. She stated, "I've always had this self-image of being overweight. I remember learning about it in the first grade. We all weighed in front of each other, and I weighed more than anyone else, even the boys. I felt fat and different."
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For some informants, gaining weight in the role transition periods of college or marriage, or physiological transitions such as retaining weight after pregnancy, triggered the awareness of weight. Becoming aware of one's weight was a very vague and general realization. Informants needed to develop a specific idea of how much to weigh before moving to the next stages of weight management. Thus, creating personalized weight norms was another aspect of appraising. Every informant had three different weight norms: an ideal weight, an acceptable weight, and an overweight weight. Each of these weight norms was defined in terms of a specific range of pounds, for instance 140-150 lbs (63-68 kg). Informants perceived these weight" norms as based on their own ideas or personal interpretations of the biomédical weight standards, not the standards themselves. These weight norms, representing new standards of behavior and levels of aspiration, were a form of problem-focused coping that enabled each woman to create a norm of weight that was more flexible and reflective of her age and lifestyle. These concepts are more fully discussed elsewhere (Allan, 1988). Linked to the process of creating personal weight norms was the process of developing criteria for weight appraisal. Women developed and used various criteria to determine whether they were within their weight norms. The use of these criteria, in conjunction with personalized weight norms, led informants to a specific subjective determination of whether they were overweight. There were three major criteria: appearance, physical feelings, and weight charts (Allan, 1988). Once women had become aware of their weight, created their own weight norms, and defined themselves as being at an acceptable or overweight weight, they had completed the appraisal process. At this point, informants who defined themselves as overweight moved to the stage of de-emphasizing. Women who defined themselves being of normal weight remained in the stage of appraising until this definition changed. De-emphasizing De-emphasizing weight was defined as the process of reducing the awareness and stress of being overweight. All women entered this stage prior to starting weight-loss efforts for the first time. In subsequent weight-loss efforts, most informants skipped this stage and moved directly to other stages. Similar to White's (1984) stage of isolating, deemphasizing involved efforts by women to avoid situations in which they would have to compare their weight or body size to others or to their own norms for acceptable weight. As informants encountered situations that forced them to appraise their weight, they developed tactics to de-emphasize those situations. De-emphasizing was viewed as a pro-
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cess instituted by women to regulate the emotional response to their weight. The tactics used enabled informants to ignore their weight by not invoking the process of appraisal. As 1 obese woman stated, "I'm into pretending nothing is wrong and ignoring my weight" [laughs]. De-emphasizing consisted of two processes: avoiding and isolating (see Figure 2). Avoidance tactics involved multiple behavioral efforts to ignore weight; these included wearing larger clothing sizes or tentlike clothing, not weighing, and avoiding health appointments. Normalweight women with small weight gains tended to use only the tactic of not weighing. Isolating tactics involved not participating in certain activities, particularly social events or sports activities. These tactics were used primarily by obese informants. For example, an obese 23-year-old receptionist talked about why she didn't go with her husband to the fitness club. She stated, "The real reason that I didn't go was that I didn't feel good about myself, and I didn't want to get into a pair of shorts and have people laugh at me, especially all those thin types." Normal-weight informants with small weight gains usually stayed in the stage of de-emphasizing for short periods of time. By contrast, most overweight and obese informants remained in this stage for years after defining themselves as overweight. At some point in their weight histories, these women moved from de-emphasizing to the next stage of mobilizing. Although the factors involved in this move were difficult to identify, findings suggested that for obese women, in particular, personal crises such as divorce or death of a spouse triggered weight-loss activities. Mobilizing Mobilizing was defined as the process of preparing for action, the action of losing weight. Mobilizing involved three aspects: seeking information, preparing the environment, and rehearsing (see Figure 2). Seeking information consisted of purposely gathering information about how to lose weight. Despite the mass-media blitz of weight-loss methods, most informants, before entering this stage, possessed minimal information about how to lose weight. For the study group, their peers and the media were the major sources of dieting information. The health-care system was not perceived as a major source of information about how to lose weight. In addition to gathering information, informants began preparing the environment. This aspect of mobilizing involved a range of simple to complex activities readying the physical and social environment of the informant for weight-loss actions. Social tactics included telling friends or spouse about starting weight-loss efforts, setting a start-up date, and
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altering typical social activities. Behavioral tactics included eating up or throwing out fattening foods, buying a lot of diet food, and planning special menus. A 52-year-old obese secretary detailed her preparation tactics. She stated, "I get busy in the kitchen and go through all the cabinets, the refrigerator, and do a massive clean out. I buy diet foods because it's impossible for me to start a diet with the foods usually in the house." Although all informants initiated some environmental changes, overweight women reported a more complex set of activities than normalweight women. The process of preparing the environment functioned to strengthen informants' resolve and create a supportive milieu to start weight-loss activities. Rehearsing consisted of a process of short-term experimentation with various simple weight-loss methods. As they became involved in this process of weight management for the first time, informants moved through the process of rehearsing as a prelude to selecting one method to enact weight loss. They would typically fast for a day, stop drinking nondiet cola for a week, skip lunch, or walk after work each day for a few days. Rehearsing enabled women to practice what they termed dieting before moving to enacting. All informants went through the stage of mobilizing in their first efforts at weight management. When they became more skilled at weight management, many moved directly from appraising to enacting. The exceptions were obese women, who always went through the stage of mobilizing before entering the stage of enacting. Enacting Enacting was defined as the process of using various tactics and strategies to lose weight. The methods of weight loss may be categorized into two major processes: dieting and changing one's life-style (see Figure 2). All informants, regardless of weight, initially started this stage with dieting. Dieting represented short-term tactics ranging from fasting to diet pills to going to Weight Watchers, and involved making temporary changes in eating or exercise patterns. Most women had tried several methods. However, only three of these were used repeatedly and successfully: skipping meals, reducing intake of high-calorie foods, and exercising regularly. Changing one's life-style represented a complex series of long-term strategies that involved making permanent changes in one or more lifestyle behaviors. Two major strategies were used: new eating patterns and new life-style. Methods of successful weight loss and maintenance are discussed in greater detail elsewhere (Allan, 1989).
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Maintaining Maintaining was defined as the process of attempting to sustain weight loss. The stage of maintaining consisted of three processes: modification of dieting tactics, solidification of life-style changes, and reversion to previous patterns (see Figure 2). Modification of dieting tactics usually involved the less rigorous continuation of methods used in the enacting stage. Most informants would often reduce the frequency of planned weekly exercise and/or begin to add nondiet foods or meals to their daily regimen. The solidification of life-style changes entailed the continued use of enacting tactics and strategies and often the incorporation of additional changes. The reversion to previous patterns involved the abandonment of all enacting activities and the resumption of former exercise and eating routines. Informants who reverted to previous patterns stated that they thought they would be able to maintain weight loss in this manner. CONCLUSIONS This study identified a complex, interactive five-stage pathway through which women moved as they attempted to manage their weight. The process represented a complex series of personally constructed self-care activities for dealing with weight gain and the cultural value of thinness. Although initially all women went through every stage, subsequent progression differed according to informants' weight. I view the repetitive use of this process, over time, as a creative way of coping with environment Stressors that impinge on women in industrialized societies. Similar to the conclusions of Colvin and Olson (1983), this study's findings suggest that in order to be of biomedically normal weight, informants were compelled to deal with factors such as lack of exercise and high-fat/highsugar diets that mitigated against weight maintenance in adulthood. The stages of de-emphasizing and mobilizing clearly illustrated the tremendous difficulty of changing routine behaviors such as eating. The realization of the time and energy that would be required to alter eating routines might be one explanation for the fact that all informants entered the stage of de-emphasizing in their first attempt at weight loss. Similar reasoning could apply to the findings that heavier women often stayed for years in the stage of de-emphasizing. They also dropped out of enacting more frequently than thinner women. Sennott-Miller and Miller (1987), in a series of studies on weight-reduction activities, found that the greater the perceived difficulty of adopting a particular activity, the lower the likelihood of adoption. The findings from this investigator's study suggest that the gap between heavier women's routines of eating and exercise and
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those required for weight loss is so great that the effort to initiate and sustain such activities is perceived as too difficult. Contrary to the emphasis in the health-care system, the major consequences of weight gain for informants related to appearance and not to health. As one very obese informant stated, "So you are a little heavy, but you can get around." The definition of health may be at issue here. As suggested by several researchers (Allan, 1986; Laffrey, 1986), health concerns are a weak motivator for initiating weight-loss actions because women do not define overweight as unhealthy. The saliency of appearance as a motivator for weight loss may explain why some studies (Hayes & Ross, 1987; Colvin & Olson, 1983) have found women to be more responsive to comments from friends and colleagues, rather than from men, as a trigger to weight loss. Health-care professionals have emphasized health in attempts to prevent and treat overweight. These findings suggest that concerns about appearance may be even more important and should be assessed and incorporated into care planning. The findings of this study may have implications for clinical practice in women's health. If women are constructing their own weight norms, it would be useful for clinicians to assess clients' ideas about how much they should weigh and how they decide whether they are normal or overweight. Such emic categories of weight should form the basis of further care planning. These findings and those presented elsewhere (Allan, 1989) suggest that certain methods are more effective than others for long-term weight loss. This information could be used to assist clients in developing successful tactics and strategies for losing weight. It might also be used to assist clients in reducing the difficulty of altering their exercise and eating routines. Because of ethnic differences in the prevalence of obesity and perception of body size (Dawson, 1988), exploration of weight management in Afro-American and Hispanic women is relevant. More research is needed on the behavioral and cognitive antecedents to initiating weight-loss efforts. Further exploration is needed concerning the factors involved in the difficulties obese women have in enacting and sustaining weight-loss efforts. Because most knowledge about women and weight management comes from research on individuals attending professional weight-loss programs and from single-variable positivistic studies, a greater balance might be achieved by emphasizing naturalistic studies that attempt to understand the environmental milieus in which women conduct their lives. REFERENCES Allan, J. (1986). Patterns and processes of weight management among urban dwelling women. Unpublished doctoral dissertation, University of California, Berkeley.
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Allan, J. (1988). Knowing what to weigh: Women's self-care activities related to weight. Advances in Nursing Science, 11(1), 47-60. Allan, J. (1989). Women who successfully manage their weight: A naturalistic study. Western Journal of Nursing Research, 11(6), 657-675. Bennett, J. (1976). Ecological transition: Cultural anthropology and human adaptation. New York: Pergamon Press. Bray (1979). Obesity in America. International journal of Obesity, 3, 363-375. Colvin, R., & Olson, S. (1983). A descriptive analysis of men and women who have lost significant weight and are highly successful at maintaining the loss. Addictive Behaviors, 8, 287-295. Dawson, D. (1988). Ethnic differences in female overweight: Data from the 1985 National Health Survey Interview. American Journal of Public Health, 78 (10), 1326-1329. Hayes, D., & Ross, C. (1987). Concern with appearance, health beliefs, and eating habits. Journal of Health and Social Behavior, 28, 120-130. Jerome, N. (1981). The U.S. dietary pattern from an anthropological perspective. Food Technology, 35(2), 37-42. Kleinman, A. (1980). Patients and healers in the context of culture. Berkeley: University of California Press. Laffrey, S. (1986). Normal and overweight adults: Perceived weight and health behavior characteristics. Nursing Research, 55(3), 173-177. Lakoff, R., & Schert, R. (1984). Face value: The politics of beauty. Boston: Routledge & Kegan Paul. Lazarus, R., & Folkman, S. (1984). Stress, appraisal and coping. New York: Springer. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage. MacKenzie, M. (1976). Obesity as a failure of American culture. Obesity/Bariatric Medicine, 5, 132-133. Mallick, M. J. (1981). The adverse effects of weight control in teenage girls. Advances in Nursing Science, 3(2), 121-123. McBride, A. B. (1988). Fat: A women's issue in search of a holistic approach to treatment. Holistic Nursing Practice, 5(1), 9-15. Ritenbaugh, C. (1982). Obesity as a culture-bound syndrome. Culture, Medicine and Psychiatry, 6, 374-381. Schachter, S. (1982). Recidivism and self-cure of smoking and obesity. American Psychologist, 37, 436-444. Sennott-Miller, L., & Miller, J. (1987). Difficulty: A neglected factor in health promotion. Nursing Research, 36(5), 268-272. Spradley, J. (1979). The ethnographic interview. New York: Holt, Rinehart & Winston. Stini, W. (1981). Body composition and nutrient reserves in evolutionary perspective. In D. Walcher & N. Kretchmer (Eds.), Food, nutrition and evolution (pp. 107-120). New York: Mason. White, J. H. (1984). The process of embarking on a weight control program. Health Care for Women International, 5, 77-91. Wooley, S., & Wooley, O. (1984). Should obesity be treated at all? In A. Stunkard & E. Stellar (Eds.), Eating and its disorders (pp. 185-192). New York: Raven Press.
Health Care for Women International Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uhcw20
To lose, to maintain, to ignore: Weight management among women Janet Davidson Allan RN, PhD, CNP
a
a
School of Nursing , University of Texas , Austin Published online: 14 Aug 2009.
To cite this article: Janet Davidson Allan RN, PhD, CNP (1991) To lose, to maintain, to ignore: Weight management among women, Health Care for Women International, 12:2, 223-235, DOI: 10.1080/07399339109515943 To link to this article: http://dx.doi.org/10.1080/07399339109515943
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
TO LOSE, TO MAINTAIN, TO IGNORE: WEIGHT MANAGEMENT AMONG WOMEN Janet Davidson Allan, RN, PhD, CNP
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School of Nursing, University of Texas at Austin
The purpose of this study was to describe the process of weight management and the factors that influence this process in a sample of 37 middle-class and working-class white women of varied body size. A naturalistic study design, with a cultural-ecological theoretical orientation and ethnographic interviewing techniques, was used. The findings indicated that there were five stages through which women moved, repeatedly, as they managed weight: appraising, deemphasizing, mobilizing, enacting, and maintaining. Each stage consisted of multiple processes characterized by the use of personally developed tactics and strategies. Concern about appearance rather than health was a more salient factor in the initiation of weight-loss efforts. Progression through the five-stage pathway for weight management was influenced by time and informants' weight. Implications for practice include helping clients reduce the difficulty of altering cultural routines of eating and exercise and eliciting clients' own norms for body size.
Of central concern to research and practice in women's health is the high prevalence of overweight and obesity (McBride, 1988). Currently, more than 24 percent of women are overweight (Dawson, 1988). Moreover, more women than men are overweight even though women are more likely to engage in weight-loss activities (Dawson, 1988) and to experience greater cultural pressure to maintain ideal weight (Lakoff & Scherr, 1984).
While conducting this research for a doctoral degree in medical anthropology at the University of California, Berkeley, the author was the recipient of a 3-year National Research Service Award Fellowship, awarded by the U.S. Public Health Service, Department of Health and Human Services, Division of Nursing (F31 NU 0S687-03). Health Care for Women International, 12:223-235, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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Despite extensive research, obesity among women continues to elude effective understanding and treatment. Most treatment programs for weight reduction are dismal failures, with high recidivism rates (Wooley & Wooley, 1984). However, because most women desiring to lose weight do not attend such programs (Colvin & Olson, 1983; Schachter, 1982), little is known about their self-care activities for weight management or about the environmental milieus in which such activities occur. In this article, I use data from intensive interviews with 37 normal and overweight white women to describe the process of weight management and the factors influencing this process. The results reported are part of a larger cultural-ecological study of weight management among white women (Allan, 1986). WEIGHT MANAGEMENT AND FACTORS INFLUENCING IT Although researchers have addressed problems surrounding overweight, there is very little documentation concerning the process of weight management or the factors involved in starting or maintaining weight loss. The literature on cultural values and body size provides some sense of the context within which women manage weight. Weight Management and Motivation to Lose White (1984), in a study using grounded theory, interviewed 89 obese women enrolled in weight-control programs about the process of embarking on such a course. White identified four stages through which women progressed as they entered treatment for obesity. Adapting to sex-role norms was found to be the basic process linking the stages. White found that body concerns (ie., physical attractiveness) were a stronger motivator in weight control than health concerns. Mallick (1981), in her study of 144 high school girls, reported that the desire for a good figure was a major motivator for weight-control activities. Laffrey (1986) reported similar findings, suggesting that health concerns were not a strong motivator for weight loss because overweight individuals did not define themselves as unhealthy. Colvin and Olson (1983), in a community study of 13 men and 41 women who had successfully maintained weight loss for 2 years, found that 54% of the men but only 20% of the women identified a critical incident as triggering weight-loss efforts.
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Cultural Values and the Pressure to Be Thin The influence of dominant cultural values about body size and beauty on women and their weight-management activities has been discussed by many authors (Lakoff & Scherr, 1984; MacKenzie, 1976; Ritenbaugh, 1982). According to MacKenzie (1976), overweight individuals, particjjarly women, contradict many American values related to self-control ind beauty and thus become culturally diagnosed as bad, out of control, and incompetent. Ritenbaugh (1982) suggested that the current biomedi:al weight norms reflect the value of youth and sexiness. Others (Lakoff & Scherr, 1984; McBride, 1988) have pointed out the pressure on women deriving from conformist standards of appearance. Numerous iuthors view the current national obsession with dieting among women is a response to these powerful cultural influences (Hayes & Ross, 1987; Wooley & Wooley, 1984). WEIGHT: A CULTURAL-ECOLOGICAL DRIENTATION The cultural-ecological orientation for this study was based on sensi:izing concepts drawn from ecology (Stini, 1981), anthropology (Benlett, 1976; Kleinman, 1980), and psychology (Lazarus & Folkman, 1984). These concepts have provided a framework from which to exDlore women's experiences in dealing with weight within the milieus of Jieir lives and have enabled the examination of processes like weight •nanagement. Stini defined weight as a function of adjustment to the învironment through cultural and physiological means. In a society such is that in the United States, major influences on weight management nclude sedentary life-style (Ritenbaugh, 1982), high-fat diet (Jerome, 1981), and the cultural value of thinness (Lakoff & Scherr, 1984). Such in environment taxes women's ability to maintain weight stability within :ulturally (biomedically) prescribed norms solely through physiologic nechanisms. In response, women need to learn ways to cope with these itressors. Coping (Bennett, 1976; Lazarus & Folkman, 1984) is a process hrough which the individual manages over time the demands of an mvironment that is appraised as stressful. Weight management, for this ;tudy, is defined as all efforts directed at coping with actual or potential weight gain as a hazard to well-being. Kleinman's (1980) concept of an explanatory model was modified to ;xamine individual perceptions of weight management, such as ideas ibout what one should weigh and how one loses or maintains weight. These models are epic categories that represent the individual's subjec-
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tive perspective: how individuals classify and interpret their own health experience.
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METHOD A descriptive naturalistic study design (Lincoln & Guba, 1985) using ethnographic interviewing techniques (Spradley, 1979) and anthropométrie measures was used. A combination of "snowball" and theoretical sampling techniques (Lincoln & Guba, 1985) was used to make contact with 37 white middle- and working-class women. I was able to obtain a community-based sample by using various resources, such as occupational health nurses, personnel directors, and businesswomen, to advertise the study. In naturalistic studies, the sample size is achieved when no new dimensions (data saturation) are identified (Lincoln & Guba, 1985). In this study, saturation began occurring after 30 interviews. Using the snowball technique, I asked informants to refer me to other women. To reduce bias, I selected individuals who were less known to the informant. Theoretical sampling guided the selection of single or married, working- or middle-class, or thin or heavy women as choices arose. Informants met the following criteria: (a) normal weight to moderate obesity (40%-1009& over ideal weight, representing 95% of all obesity in women), (b) born in the United States and living in.the study area, (c) between the ages of 18 and 55 years, and (d) white. Ethnic diversity was not a sample criterion because I plan to study white, black, and Hispanic women separately and then to examine cross-ethnic differences and similarities. Members of the study group were young, married, well educated, of normal weight, and white-collar workers (see Table 1). The mean age was 33.7 years, with a range of 19-56. All but 3 women worked; most were employed in clerical and sales positions. An unstructured interview and anthropométrie measures of height and weight were used to collect data over a 7-month period. The interview began with the same question: "Tell me the history of your weight and your experiences over time with dealing with your weight." Subsequent probes elicited more data concerning knowledge of how much to weigh, reasons for wanting to lose weight, factors that hindered or helped weight management, and the selection of particular methods. Multiple interviews with each informant were conducted. To reduce the analytic bias of the researcher, all interviews were tape-recorded and transcribed verbatim. Triangulation of data collection methods, solicitation of informants' reactions to emerging themes, and independent corroboration from several informants were used to strengthen the study's credibility (Lincoln & Guba, 1985).
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lable 1. Characteristics of the Study Group (N = 37)
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Characteristics Marital status Married Single Widowed Divorced Education High school graduate Some college College graduate Ilass Middle Working Veight" Normal Overweight Obese
Frequency (n)
Percentage
18 13 3 3
48.6 35.1 8.1 8.1
11 12 14
29.7 32.4 37.8
21 16
57 43
21 7 9
56.7 18.9 24.3
'Normal weight was defined as body mass index (BMI) of 18.8 to 24; overweight, BM1 of 24 to Í8; and obesity. BMI greater than 28 (Bray, 1979).
Content-analysis, constant-comparison, and phase-analysis techniques veré used to analyze the transcribed interviews for categories, themes, ind processes (Lincoln & Guba, 1985; Spradley, 1979). Manifest and atent content-analysis techniques were used to identify categories and iomains. Emerging categories were presented for the informant's reac:ion in subsequent interviews. Phase analysis was used to trace the development of weight management over time. Both trace-back and traceforward starting points from a period of weight gain or loss were used to îxplicate the steps that women go through as they manage weight. The reliability of coding was enhanced by having two nursing colleagues review the categories and code several interviews. FINDINGS I identified five stages through which women moved as they managed weight gain: appraising, de-emphasizing, mobilizing, enacting, and maintaining. Each stage consisted of multiple processes characterized by the use of personally created tactics and/or strategies. Women used this general five-stage pathway repeatedly as they attempted to manage weight. In addition, the complexity of the tactics and strategies of each
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stage increased as informants repeated the process. Although aspects of each stage are discussed as separate processes, they were interactive. During initial efforts at weight loss, most informants moved through all five stages. However, women who learned to maintain their weight successfully eventually moved to a three-stage process: appraising, enacting, and maintaining. The fives stages of weight management are depicted in Figure 1.
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Appraising Appraising was defined as the ongoing and evolving assessment of one's weight. This complex stage had three aspects: becoming aware of one's weight, creating personal weight norms, and developing criteria for weight appraisal (see Figure 2). Appraising comprised a series of self-care tactics for coping with weight and the pressure to be thin. Becoming aware of one's weight involved the realization of one's body size, essentially noticing one's weight. This awareness included defining one's self as overweight or having gained weight. This was a very vague and general awareness, not necessarily congruent with medical definitions of overweight. Women became aware of their weight through social encounters and role and physiological transitions. Some informants, usually those with childhood obesity, developed an awareness of their weight early in life, mostly at school. This awareness of weight was often triggered by a social encounter, such as teasing by Appraising
Maintaining
Enacting
De-emphasizing
Mobilizing
Fig. 1. The five stages of the weight-management process.
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APPRAISING 1. Becoming aware of one's weight receiving comments about weight making role transitions experiencing physiologic transitions 2. Creating personal weight norms
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ideal weight acceptable weight overweight weight
3. Developing criteria for weight assessment appearance physical feelings weight charts
DE-EMPHASIZING 1 . Avoiding not weighing wearing larger clothing avoiding health care system 2. Isolating not participating
MAINTAINING 1. Modifying dieting tactics reducing exercise adding foods/meals 2. Solidifying lifestyle changes making more changes continuing enacting efforts 3. Reverting to former patterns stopping exercise resuming former food habits ENACTING
MOBILIZING 1. Seeking information reading popular media asking family/friends reading "scientific material" 2. Preparing the environment buying new foods throwing out foods telling friends about plans 3. Rehearsing eliminating foods or meals experimenting with exercise
1. Dieting skipping meals reducing high calorie foods exercising 2. Changing lifestyle new eating patterns new lifestyle
Fig. 2. Processes, tactics, and strategies involved in the five stages of weight management. fellow students, remarks by family or friends, or comparisons of oneself with others. For example, a 50-year-old overweight social worker discussed how she became aware that she was heavy. She stated, "I've always had this self-image of being overweight. I remember learning about it in the first grade. We all weighed in front of each other, and I weighed more than anyone else, even the boys. I felt fat and different."
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For some informants, gaining weight in the role transition periods of college or marriage, or physiological transitions such as retaining weight after pregnancy, triggered the awareness of weight. Becoming aware of one's weight was a very vague and general realization. Informants needed to develop a specific idea of how much to weigh before moving to the next stages of weight management. Thus, creating personalized weight norms was another aspect of appraising. Every informant had three different weight norms: an ideal weight, an acceptable weight, and an overweight weight. Each of these weight norms was defined in terms of a specific range of pounds, for instance 140-150 lbs (63-68 kg). Informants perceived these weight" norms as based on their own ideas or personal interpretations of the biomédical weight standards, not the standards themselves. These weight norms, representing new standards of behavior and levels of aspiration, were a form of problem-focused coping that enabled each woman to create a norm of weight that was more flexible and reflective of her age and lifestyle. These concepts are more fully discussed elsewhere (Allan, 1988). Linked to the process of creating personal weight norms was the process of developing criteria for weight appraisal. Women developed and used various criteria to determine whether they were within their weight norms. The use of these criteria, in conjunction with personalized weight norms, led informants to a specific subjective determination of whether they were overweight. There were three major criteria: appearance, physical feelings, and weight charts (Allan, 1988). Once women had become aware of their weight, created their own weight norms, and defined themselves as being at an acceptable or overweight weight, they had completed the appraisal process. At this point, informants who defined themselves as overweight moved to the stage of de-emphasizing. Women who defined themselves being of normal weight remained in the stage of appraising until this definition changed. De-emphasizing De-emphasizing weight was defined as the process of reducing the awareness and stress of being overweight. All women entered this stage prior to starting weight-loss efforts for the first time. In subsequent weight-loss efforts, most informants skipped this stage and moved directly to other stages. Similar to White's (1984) stage of isolating, deemphasizing involved efforts by women to avoid situations in which they would have to compare their weight or body size to others or to their own norms for acceptable weight. As informants encountered situations that forced them to appraise their weight, they developed tactics to de-emphasize those situations. De-emphasizing was viewed as a pro-
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cess instituted by women to regulate the emotional response to their weight. The tactics used enabled informants to ignore their weight by not invoking the process of appraisal. As 1 obese woman stated, "I'm into pretending nothing is wrong and ignoring my weight" [laughs]. De-emphasizing consisted of two processes: avoiding and isolating (see Figure 2). Avoidance tactics involved multiple behavioral efforts to ignore weight; these included wearing larger clothing sizes or tentlike clothing, not weighing, and avoiding health appointments. Normalweight women with small weight gains tended to use only the tactic of not weighing. Isolating tactics involved not participating in certain activities, particularly social events or sports activities. These tactics were used primarily by obese informants. For example, an obese 23-year-old receptionist talked about why she didn't go with her husband to the fitness club. She stated, "The real reason that I didn't go was that I didn't feel good about myself, and I didn't want to get into a pair of shorts and have people laugh at me, especially all those thin types." Normal-weight informants with small weight gains usually stayed in the stage of de-emphasizing for short periods of time. By contrast, most overweight and obese informants remained in this stage for years after defining themselves as overweight. At some point in their weight histories, these women moved from de-emphasizing to the next stage of mobilizing. Although the factors involved in this move were difficult to identify, findings suggested that for obese women, in particular, personal crises such as divorce or death of a spouse triggered weight-loss activities. Mobilizing Mobilizing was defined as the process of preparing for action, the action of losing weight. Mobilizing involved three aspects: seeking information, preparing the environment, and rehearsing (see Figure 2). Seeking information consisted of purposely gathering information about how to lose weight. Despite the mass-media blitz of weight-loss methods, most informants, before entering this stage, possessed minimal information about how to lose weight. For the study group, their peers and the media were the major sources of dieting information. The health-care system was not perceived as a major source of information about how to lose weight. In addition to gathering information, informants began preparing the environment. This aspect of mobilizing involved a range of simple to complex activities readying the physical and social environment of the informant for weight-loss actions. Social tactics included telling friends or spouse about starting weight-loss efforts, setting a start-up date, and
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altering typical social activities. Behavioral tactics included eating up or throwing out fattening foods, buying a lot of diet food, and planning special menus. A 52-year-old obese secretary detailed her preparation tactics. She stated, "I get busy in the kitchen and go through all the cabinets, the refrigerator, and do a massive clean out. I buy diet foods because it's impossible for me to start a diet with the foods usually in the house." Although all informants initiated some environmental changes, overweight women reported a more complex set of activities than normalweight women. The process of preparing the environment functioned to strengthen informants' resolve and create a supportive milieu to start weight-loss activities. Rehearsing consisted of a process of short-term experimentation with various simple weight-loss methods. As they became involved in this process of weight management for the first time, informants moved through the process of rehearsing as a prelude to selecting one method to enact weight loss. They would typically fast for a day, stop drinking nondiet cola for a week, skip lunch, or walk after work each day for a few days. Rehearsing enabled women to practice what they termed dieting before moving to enacting. All informants went through the stage of mobilizing in their first efforts at weight management. When they became more skilled at weight management, many moved directly from appraising to enacting. The exceptions were obese women, who always went through the stage of mobilizing before entering the stage of enacting. Enacting Enacting was defined as the process of using various tactics and strategies to lose weight. The methods of weight loss may be categorized into two major processes: dieting and changing one's life-style (see Figure 2). All informants, regardless of weight, initially started this stage with dieting. Dieting represented short-term tactics ranging from fasting to diet pills to going to Weight Watchers, and involved making temporary changes in eating or exercise patterns. Most women had tried several methods. However, only three of these were used repeatedly and successfully: skipping meals, reducing intake of high-calorie foods, and exercising regularly. Changing one's life-style represented a complex series of long-term strategies that involved making permanent changes in one or more lifestyle behaviors. Two major strategies were used: new eating patterns and new life-style. Methods of successful weight loss and maintenance are discussed in greater detail elsewhere (Allan, 1989).
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Maintaining Maintaining was defined as the process of attempting to sustain weight loss. The stage of maintaining consisted of three processes: modification of dieting tactics, solidification of life-style changes, and reversion to previous patterns (see Figure 2). Modification of dieting tactics usually involved the less rigorous continuation of methods used in the enacting stage. Most informants would often reduce the frequency of planned weekly exercise and/or begin to add nondiet foods or meals to their daily regimen. The solidification of life-style changes entailed the continued use of enacting tactics and strategies and often the incorporation of additional changes. The reversion to previous patterns involved the abandonment of all enacting activities and the resumption of former exercise and eating routines. Informants who reverted to previous patterns stated that they thought they would be able to maintain weight loss in this manner. CONCLUSIONS This study identified a complex, interactive five-stage pathway through which women moved as they attempted to manage their weight. The process represented a complex series of personally constructed self-care activities for dealing with weight gain and the cultural value of thinness. Although initially all women went through every stage, subsequent progression differed according to informants' weight. I view the repetitive use of this process, over time, as a creative way of coping with environment Stressors that impinge on women in industrialized societies. Similar to the conclusions of Colvin and Olson (1983), this study's findings suggest that in order to be of biomedically normal weight, informants were compelled to deal with factors such as lack of exercise and high-fat/highsugar diets that mitigated against weight maintenance in adulthood. The stages of de-emphasizing and mobilizing clearly illustrated the tremendous difficulty of changing routine behaviors such as eating. The realization of the time and energy that would be required to alter eating routines might be one explanation for the fact that all informants entered the stage of de-emphasizing in their first attempt at weight loss. Similar reasoning could apply to the findings that heavier women often stayed for years in the stage of de-emphasizing. They also dropped out of enacting more frequently than thinner women. Sennott-Miller and Miller (1987), in a series of studies on weight-reduction activities, found that the greater the perceived difficulty of adopting a particular activity, the lower the likelihood of adoption. The findings from this investigator's study suggest that the gap between heavier women's routines of eating and exercise and
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those required for weight loss is so great that the effort to initiate and sustain such activities is perceived as too difficult. Contrary to the emphasis in the health-care system, the major consequences of weight gain for informants related to appearance and not to health. As one very obese informant stated, "So you are a little heavy, but you can get around." The definition of health may be at issue here. As suggested by several researchers (Allan, 1986; Laffrey, 1986), health concerns are a weak motivator for initiating weight-loss actions because women do not define overweight as unhealthy. The saliency of appearance as a motivator for weight loss may explain why some studies (Hayes & Ross, 1987; Colvin & Olson, 1983) have found women to be more responsive to comments from friends and colleagues, rather than from men, as a trigger to weight loss. Health-care professionals have emphasized health in attempts to prevent and treat overweight. These findings suggest that concerns about appearance may be even more important and should be assessed and incorporated into care planning. The findings of this study may have implications for clinical practice in women's health. If women are constructing their own weight norms, it would be useful for clinicians to assess clients' ideas about how much they should weigh and how they decide whether they are normal or overweight. Such emic categories of weight should form the basis of further care planning. These findings and those presented elsewhere (Allan, 1989) suggest that certain methods are more effective than others for long-term weight loss. This information could be used to assist clients in developing successful tactics and strategies for losing weight. It might also be used to assist clients in reducing the difficulty of altering their exercise and eating routines. Because of ethnic differences in the prevalence of obesity and perception of body size (Dawson, 1988), exploration of weight management in Afro-American and Hispanic women is relevant. More research is needed on the behavioral and cognitive antecedents to initiating weight-loss efforts. Further exploration is needed concerning the factors involved in the difficulties obese women have in enacting and sustaining weight-loss efforts. Because most knowledge about women and weight management comes from research on individuals attending professional weight-loss programs and from single-variable positivistic studies, a greater balance might be achieved by emphasizing naturalistic studies that attempt to understand the environmental milieus in which women conduct their lives. REFERENCES Allan, J. (1986). Patterns and processes of weight management among urban dwelling women. Unpublished doctoral dissertation, University of California, Berkeley.
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Allan, J. (1988). Knowing what to weigh: Women's self-care activities related to weight. Advances in Nursing Science, 11(1), 47-60. Allan, J. (1989). Women who successfully manage their weight: A naturalistic study. Western Journal of Nursing Research, 11(6), 657-675. Bennett, J. (1976). Ecological transition: Cultural anthropology and human adaptation. New York: Pergamon Press. Bray (1979). Obesity in America. International journal of Obesity, 3, 363-375. Colvin, R., & Olson, S. (1983). A descriptive analysis of men and women who have lost significant weight and are highly successful at maintaining the loss. Addictive Behaviors, 8, 287-295. Dawson, D. (1988). Ethnic differences in female overweight: Data from the 1985 National Health Survey Interview. American Journal of Public Health, 78 (10), 1326-1329. Hayes, D., & Ross, C. (1987). Concern with appearance, health beliefs, and eating habits. Journal of Health and Social Behavior, 28, 120-130. Jerome, N. (1981). The U.S. dietary pattern from an anthropological perspective. Food Technology, 35(2), 37-42. Kleinman, A. (1980). Patients and healers in the context of culture. Berkeley: University of California Press. Laffrey, S. (1986). Normal and overweight adults: Perceived weight and health behavior characteristics. Nursing Research, 55(3), 173-177. Lakoff, R., & Schert, R. (1984). Face value: The politics of beauty. Boston: Routledge & Kegan Paul. Lazarus, R., & Folkman, S. (1984). Stress, appraisal and coping. New York: Springer. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry. Beverly Hills, CA: Sage. MacKenzie, M. (1976). Obesity as a failure of American culture. Obesity/Bariatric Medicine, 5, 132-133. Mallick, M. J. (1981). The adverse effects of weight control in teenage girls. Advances in Nursing Science, 3(2), 121-123. McBride, A. B. (1988). Fat: A women's issue in search of a holistic approach to treatment. Holistic Nursing Practice, 5(1), 9-15. Ritenbaugh, C. (1982). Obesity as a culture-bound syndrome. Culture, Medicine and Psychiatry, 6, 374-381. Schachter, S. (1982). Recidivism and self-cure of smoking and obesity. American Psychologist, 37, 436-444. Sennott-Miller, L., & Miller, J. (1987). Difficulty: A neglected factor in health promotion. Nursing Research, 36(5), 268-272. Spradley, J. (1979). The ethnographic interview. New York: Holt, Rinehart & Winston. Stini, W. (1981). Body composition and nutrient reserves in evolutionary perspective. In D. Walcher & N. Kretchmer (Eds.), Food, nutrition and evolution (pp. 107-120). New York: Mason. White, J. H. (1984). The process of embarking on a weight control program. Health Care for Women International, 5, 77-91. Wooley, S., & Wooley, O. (1984). Should obesity be treated at all? In A. Stunkard & E. Stellar (Eds.), Eating and its disorders (pp. 185-192). New York: Raven Press.
