Weight Reduction and Weight Control Strategies for Obese Individuals: A Case for Behavior Modification Russell T. Werner, MEd Russell T. Werner, MEd, is Allied Health Adminis trutor, Allied Health Division, Nort hampton Count y Area Community College, Bethlehem, Pennsylvania
The number of obese individuals in the United States has increased to the point that obesity can accurately be considered a national problem, and perhaps, a national obsession. Obesity is defined as being over-fat; this is not synonomous with being overweight. An individual is considered overweight if his weight exceeds that which is listed on one of the height-weight tables developed by insurance companies. Most height-weight tables list the average weight for a specific height according to the sex and age of an individual. The problem is being “overweight” does not indicate what those “extra” pounds consist of, whether it is fat tissue, lean tissue, or both. Obesity is a condition in which there is an excessive accumulation of body fat. A general rule-ofthumb which may be utilized in the determination of obesity is women are considered obese if more than 20% of body weight is composed of fat. For men, obesity exists if fat exceeds 14%of body weight. An obese person may be underweight, and it is possible for an overweight person not to be obese. There are two factors which determine body fat (weight): ( 1 ) the number of calories in the form of food ingested daily, and ( 2 ) the number of calories expended daily in the form of energy. However, the reduction of weight is a difficult problem. Obesity is recognized not only as a physical and social problem, but as a psychological one as weil. Considerable study has been made of the “obese personality.” Such information may be helpful in the treatment and understanding of an obese person; however, there is a need for identification and validation of effective techniques of weight reduction. Of equal importance, there is a need for better discrimination between those who are successful in programs of weight reduction and those who are not. 602
The obese individual cannot achieve optimal health and is more likely than the non-obese person to experience diabetes, high blood pressure, heart and kidney diseases, low self-esteem and poor body image, a feeling of self-consciousness, and skeletal or joint problems. In addition, life expectancy is reduced, surgery is usually more difficult, and the incidence of accidents is greater among the obese. Interestingly, persons who are over-fat are less likely than the slender to die from suicide, tuberculosis, stomach or duodenal ulcer, and for women, breast cancer. With such an obvious imbalance of health risks and with the potential for infringement on personal happiness and fulfillment, it should be no surprise that there is a national preoccupation with the treatment or remediation of obesity. An editorial in the British Journal (The Lancet, May 1970, p. 1094) reveals the irony of the probIem, however, “Obesity is chemically fairly simple and clinically appallingly difficult.” The purpose of this paper is to review recent literature relative to the strategies now commonly employed to remediate obesity. These strategies may be grouped into four categories: ( 1 ) diet restriction, ( 2 ) use of drugs or medications, ( 3 ) surgical treatment, and ( 4 ) behavior modification.
Behavior Modification Scientific evidence supports the notion behavior modification is the best remediation plan for weight reduction and permanent weight control. Levitz and Stunkard (1974) investigated the effectiveness of behavior modification conducted by a professional therapist, behavior modification conducted by a TOPS leader, nutrition education conducted by a TOPS leader, and the continuation of the usual TOPS program. TOPS, with a membership of 320,000 persons, is a self-help group whose name derives from the concept “Take Off Pounds Sensibly.” Each of the 234 subjects was assigned ta one of the treatment conditions. After 12 months, DECEMBER 1976 VOLUME XLVl NO. 10
there was significant attrition in the nutrition education and control groups, 55% and 67% respectively, as compared to 3890 and 41% in the behavior modification groups. According to Levitz and Stunkard, TOPS is a relatively ineffective method of weight control. The behavior modification treatment conducted by a TOPS leader achieved a mild degree of success in terms of weight loss and weight control. However, the professional-led behavior modification groups maintained their weight loss after the end of the treatment, and increased by onehalf their weight loss that they had attained in three previous years of TOPS membership. The nutrition education program also proved ineffective as a treatment. In a study involving 32 obese persons comparing behavior modification with traditional group psychotherapy, Penick et al (1971)found that those treated with behavior modification lost more weight than the matched control group. Furthermore, 13% of the patients in the behavior modification group lost more than 40 pounds and 53% lost more than 20 pounds. These results rank with the best in medical literature. Foreyt and Kennedy ( 1970)paired noxious smells with the favorite foods of obese patients to help them achieve an initial weight loss. Initially, and after 48 weeks, five of the six subjects showed weight loss. Foreyt and Kennedy concluded aversive conditioning may prove to be useful as part of an inclusive weight reduction program in combination with techniques to assist the patient to modify behaviors contributing to an obese condition. Pliner ( 1973) hypothesized that differences in eating behavior between obese and normal persons can be explained in terms of differences in thinking behavior. An investigation was conducted whereby 36 normal weight and 36 obese male college students were required to immerse their hands in an ice water solution under the pretext of having their physiological responsiveness to cold assessed. Three experimental conditions were effected: ( 1) Cues-present condition, (2)Cues-absent condition, and ( 3 )No-cues condition. The dependent variables included selfreports of how long the subjects thought about the assigned topics and measurement of latencies of report of cold-produced pain. Pliner concluded that the study indicated the thinking behavior of the obese is externally controlled to a greater degree than that of normal persons. Furthermore, the effect of external cues on the thinking behavior of obese and normal subjects demonstrated in the study does much to clarify the observed effect of external cues on the eating beTHE JOURNAL OF SCHOOL HEALTH
havior of the obese. I t was observed that the obese may not eat when food is not visible because they are not thinking of food. For the obese, it appears that out of sight is truly out of mind. Pliner states, “More generally, the data presented here suggest that in selecting their therapeutic regimes, the designers of any weight-loss programs might do well to take into account the evidence that cognitive behavior among the obese appears to be strongly under external control.”
Use of Drugs or Medications Dykes ( 1974) suggested effective and sustained weight reduction is based upon an understanding of good nutrition and an alteration of underlying psychologic or pathologic factors producing excessive caloric intake. Further, he states anorexiants should be prescribed temporarily, if at all, to suppress the appetite of patients who overeat to gratify inappropriate hunger or who have difficulty adhering to a prescribed diet because of the discomforts produced by caloric restriction. Dykes found clortermine, fenfluramine, and mazindol are more effective than a placebo in suppressing appetite. Dextroamphetamine (Dexedrine), Phenmetrazine ( Preludin), or Chlorphentermine ( Pre-Sate) are equally effective. However, no one anorexiant has consistently demonstrated effectiveness in terms of suppression of appetite and weight loss on a permanent or sustained basis. Elmaleh and Miller (1974)report the effective use of the anorexiant, mazindol, as an appetite suppressant, and subsequently, an agent of weight reduction. However, it would appear the limited length of the study (12weeks) would invalidate the study in terms of long-term weight reduction and control. A study involving death rates for 7,286 patients over a ten-year period during and after the treatment for obesity with “diet pills” was conducted by Asher (1972).Of 20 nonheart-associated deaths, two occurred during treatment (auto accidents), three within two weeks after the last medication was taken, and 15 during the nontreatment period. Of 19 heart deaths, seven occurred during treatment, one within two weeks after the last medication was taken, and 11 in the nontreatment period. During treatment, female heart death rates were 77.690of the 1966 General Mortality Table rates for a comparable age group and 145% during nontreatment; combined male and female heart death rates were 87% and 15170,respectively. At the start of treatment, hypertension existed in 68% (13of 19)who later died of heart disease. According to Gwinup ( 1970),the administration 603
of drugs or medications has proven to be ineffective when tested in controlled studies in treating obesity. When drugs are discontinued in treatment, there is a phase of hunger rebound so that the patient invariably regains the weight lost. Drugs are capable of causing habituation and drug dependence as well as other undesirable and sometimes dangerous effects on the central nervous system. Patients taking them tend to fluctuate between a keyed-up feeling and a state of fatigue. For these reasons, their prolonged use is inadvisable.
Surgical Treatment Surgical treatment is recommended by Braasch certain circumstances, ie, the patient should be strongly motivated to lose weight, there should be no mental problems, and there should be extenuating circumstances. Complications that would justify surgical intervention include cardiovascular disease, pulmonary insufficiency, diabetes mellitus, stasis disease of the legs, and abdominal hernia combined with “massive obesity.” Braasch states dietary restriction and the use of medications producing appetite control may be effective temporarily but fail on a long-term basis. Therefore, within the parameters suggested above, he recommends jejunioleostomy (removal of a portion of the jejunum and the ileum). This treatment usually effects a weight loss of 10 to 11 pounds per month declining to approximately two pounds per month by the third year. A weight plateau will normally occur after a year at an optimal level. Although this treatment is effective in terms of weight education and control, even with careful postoperative care, metabolic abnormalities such as diarrhea and electrolyte deficiency, hepatic failure and personality disruption can occur. According to an article (Nutrition Review, November, 1974), the jejuno-ileal bypass is associated with a disturbingly high rate of hepatic dysfunction with unpredictable progression to hepatic failure and death. Intestinal bypass operations for obesity are recommended by Baber et al (1973)for obese persons who are seriously threatened by the complications of morbid obesity. Baber et al state in addition to the previously described prerequisites for an intestinal bypass operation, all other methods of weight reduction must have been attempted and failed, and the patient must be under 50 years of age. They suggest the 15 and 5 inch jejunioleal bypass is preferred as it seems to give adequate weight reduction and is relatively free of complications. ( 1971) under
Diet Restriction Garrow (1973)reports that the results of dieting 604
are generally disappointing and Bray ( 1970) has shown in most published series only 20%-30% of obese subjects lose as much as 10 kg, and only 5% lose as much as 20 kg. In the treatment of obese patients, Garetz ( 1973) points out it is important to recognize that all too much emphasis is placed on the food content and quantities of food and far too little emphasis is placed on thQ process of eating and the circumstances of eating which will best aid the patient in the quest to lose weight. Overeating and obesity are related to certain extant social, cultural, economic and familial variables. Therefore, to treat an obese patient with temporary “dietary alterations” without helping the patient to modify his behavior is doomed to failure. According to Laveille and Romos (19741,the ingestion of relatively few large meals is undesirable for human beings. The data on the incidence of obesity, hypercholeoterolemia, and abnormal glucose tolerance show these three conditions decrease if meal frequency increases. Studies from obesity clinics show although many patients can achieve a weight loss by restricting the diet, a very small number are able to maintain it for a year or more. Gwinup suggests during the period when weight loss is occumng, there is the obvious satisfaction of seeing the day-to-day results, but when the goal has been reached, progress is replaced by the dreary task of maintenance, which is likely to discourage the most resolute dieter. This accounts for the fluctuating up-and-downpattern of the weight records of so many dieters. Tremolieres (1973)advances the hypothesis, “It is apparently impossible, clinically, to change human dietary behavior by external influence without taking account of the psychosensorial (ie, affective) and the symbolic motivations of the food drive.” He also expresses the dilemma of diet restriction by reporting obese patients eat quickly in an aggressive and regressive way and stop eating with a sensation of a full stomach and not by an oral sensation. They may be determined to reduce their diet for a period of time, but are very unstable in their determination. I t is interesting to note that published surveys (Widdowson 1962,Johnson, Burke and Mayer 1956) fail to show fat people eat more than lean persons. Garrow (1973)states, “Other things being equal, obesity would still occur even if no one over-eat.”
Conclusions The effective treatment of obesity on a long-term basis is best achieved by behavior modification. Dieting enables an obese person to lose weight, but DECEMBER 1976 VOLUME XLVl NO. 10
this usually is a temporary solution in that invariably the dieter returns to previous eating habits and the lost fat is quickly restored. Diets often create nutritional problems unless they are well-balanced and under medical supervision. There is at present no evidence available which would support the idea that any of the more extreme diets recently popularized has any advantage over a calorically restricted, balanced “normal” diet for the person concerned with weight reduction. A balanced diet containing no less than 14% protein, no more than 30% fat, with the remainder composed of carbohydrates, is recommended. However, it is not realistic to expect that such a diet with the appropriate quantity of calories can be prescribed for obese persons and be successful in weight reduction and control without additional intervention or attention on the part of the therapist. The use of drugs for purposes of suppressing hunger is often effective during the first few weeks of administration. Usually, however, over a sustained period of time, a tolerance to their effect develops. The most unsatisfactory feature of their use by the obese is when they are discontinued, an individual usually returns to previous eating habits with a subsequent restoration of the fat lost. Medically, of equal importance, is the undesirable effects amphetamine-type drugs may have on the central nervous system. These drugs are capable of causing habituation and drug dependence. Since maintenance of fat loss is far more difficult than losing weight, it might be assumed if an individual is not able to lose fat without a medication or some other support mechanism, the obese will certainly be unable to maintain the loss once the crutch is taken away. At the present time, jejuno-ileal bypass is associated with a disturbingly high rate of complications including unpredictable progression to death. Until careful experimentation can develop means of prevention of serious complications, bypass procedures should only be considered for those obese patients who are suffering from morbid obesity and who exhibit the other prerequisites for this type treatment. The treatment of obesity via behavior modification appears to be the most effective strategy for permanent weight reduction and control for most individuals. Obesity, unless physiological disorders are present, is a result of behaviors that lead to the ingestion of an excess of calories beyond caloric needs on the part of the over-fat person. Obese individuals must not only adjust how much they eat to effectively control fatness, they also THE JOURNAL OF SCHOOL HEALTH
must modify the speed at which they ingest food in addition to the environmental and psychologic situations associated with eating. There is evidence that suggests all eating should be confined to one place such as the dining room, and it should be a pure experience, unaccompanied by any other activity. “Doctoring” favorite snack foods to give them an aversive taste can provide a negative means of controlling food behavior. Obese persons must learn to identify and substitute acceptable behaviors for activities or cues that cause eating to occur, ie, express angry feelings on paper rather than eating, take a shower upon returning home from work rather than having a martini, and disassociate snacking with watching television. Increasing energy output is an important aspect of behavior modification. Recent studies indicate in all age levels, over-fat persons did not consume more calories than their normal weight counterparts, but they led much more sedentary lives. It is surprisingly easy to lose 8 to 10 pounds in a month by moderately increasing one’s physical activity provided food consumption remains the same. Appetite does not increase as physical activity increases. In fact, in some cases, appetite may decrease as energy output increases. Because the obese individual has large stores of fat, exercise does not stimulate the appetite of the over-fat person. The purpose of an effective and permanent program of weight loss and weight control is the development of self-control of eating and related daily activities. Weight loss should occur as a consequence of the adaptive behaviors resulting from self-control. The obese individuals must understand how the overfat condition developed and how life patterns must be altered. With a new pattern of living, it is possible for obese-proneindividuals to have absolute control of their weight.
BIBLIOGRAPHY Asher WL: Mortality rate in patients receiving diet pills. Therapeutic Res Press 14:525-530, 1972. Baber JC. Hayden WF, Thompson BW: Intestinal bypass operations for obesity. A m J Surg 126:769-772, 1973. Braasch JW: The surgical treatment of obesity. Surg Clin North A m 51567-673, 1971. Bray GA. A m J Clin Nutr 23:1141-1148, 1970. Current status of jejuno-ileal bypass for obesity. Nutr Reu 32: 333-336, 1974. Dykes HM: Evaluation of three anorexiants. J A M A 230:270-272, 1974. Elmaleh MK, Miller J: Controlled clinical evaluation of a new anorectic agent in obese adults. Pa Med 46-50, 1974. Foreyt JP, Kennedy WA: Treatment of overweight by aversion therapy. Behau Res Therapy 9:29-31. 1971. Garetz FK: Sociopsychological factors in overeating and dieting with comments on popular reducing methods. J A bnorm Psychd 210:671-676. 1973. 605
Garrow JS: Diet and obesity. Proc R Soc Med 66:642-644, 1973. Gwinup G: Energetics, Your Key to Permanent Weight Control. Los Angeles, Sherborne Press, 1970. Johnson ML, Burke BS, Mayer J: A m J Clin Nutr 4:37-44, 1956. Leveille CA. Romsos DR: Meal eating and obesity. Nutr Today
obese and normal subjects. JAbnorm Psycho1 82:233-238, 1973.
The Lancet
1094, 1970.
Tremolieris J: Symposium on obesity in man. Proc Nutr Soc 32: 169-174, 1973.
Widdowson EM. PIVCNutr Soc 21:121-128, 1962.
4-9, 1974.
Levitz LS. Stunkard AJ: A therapeutic coalition for obesity: Behavior modification and patient self-help. A m J Psychiatry 131~423-427,1974.
Penick SB, Filion R. Fox, Stunkard AJ: Behavior modification in the treatment of obesity. Psychosom Med 33:49-55, 1971. Pilmer PL: Effect of external cues on the thinking behavior of
The author of this article is Russell T. Werner, MEd, Allied Health Administrator, Allied Health Division, Northampton County Area Community College, 3835 Green Pond Road, Bethlehem, P A 1801 7.
Public Law 94-317: Title I On June 23, the President signed into being Public Law 94-317. Title I of the Act is called “National Consumer Health Information and Health Promotion Act of 1976.” Following is an article adapted from the September 1976 issue of Focal Points which presents a detailed review of Title I, and a description of major processes necessary to implement the new law. GENERAL AUTHORITY (Section 1701) This section requires the Secretary of HEW to: (1)Develop national goals and strategies concerning health information and promotion, preventive health services, and education in the appropriate use of health care. , .(2)Analyze necessary and available resources for implementing the goals and recommend educational and quality assurance policies for needed manpower resources identified by this analysis. . . (3) Undertake and support necessary activities and programs to: Incorporate appropriate health education components into our society, especially into all aspects of education and health care. . .increase use of health knowledge, skills, and practices b y the general population.. establish systematic exploration, development, demonstration and evaluation of innovative health promotion concepts. . , (4)Conduct and support research and demonstrations concerning health information and promotion, preventive health services, and education in the appropriate use of health care. . .(5) Undertake and support training in operation of effective and efficient programs of health information and promotion, etc. . .(6) Undertake and support, through improved planning and implementation of tested models and evaluation, effective and efficient programs concerning. . .(7) Foster information exchange and cooperation in conducting research, demonstration and training programs respecting health information and promotion, etc. . .(8) Provide technical assistance for such programs. . .(9)Use other available authorities for programs concerned with health information and promotion, preventive health services, and education in the appropriate use of health care. Section 1 7 0 1 also directs the Secretary to administer Title I in a manner consistent with the national health priorities set forth in section 1502 of the National Health Planning and Resources Development Act (P.L. 93-641) and with health planning and resources development activities undertaken under P.L. 93-641. 606
RESEARCH PROGRAMS (Section 1702) This section authorizes t h e Secretary to conduct and support research in health information and promotion, etc. In addition, t h e Secretary shall: Provide consultation and technical assistance to persons who need help in preparing research proposals o r in conducting research. . .Determine the best methods of disseminating information o n preventive health services, appropriate use of health care, personal health behavior, and affecting behavior, 80 that this information is applied to maintain and improve health and prevent disease, reduce its risk, o r modify its course o r severity. . .Study, various factors that affect health, and determine areas in which educational and preventive measures could be used to improve health as it is affected by these factors. . .Develop methods to determine the cost and effectiveness of activities in health information and promotion, etc., reimbursement o r payment methods for these activities, models and standards for conducting such activities, including models and standards for education (by providers of institutional health services) of individuals receiving such services. . .Develop a method for assessing the cost and effectivenees of specific medical services and procedures under various conditions of use. , .Enumerate and assess preventive health measures and services with respect to their cost and effectiveness under various conditions of use. This section also directs t h e Secretary t o make a periodic survey of t h e needs, interests, attitudes, knowledge, and behavior of the American public regarding health and health care. The findings of such surveys are to be taken into consideration in developing policy concerning health information and promotion, preventive health services, and education in the appropriate use of health care.
COMMUNITY PROGRAMS (Section 1703) The Secretary is authorized to conduct and support new and innovative programs in health information and promotion, preventive health services, and education in t h e DECEMBER 1976 VOLUME XLVl NO. 10
The number of obese individuals in the United States has increased to the point that obesity can accurately be considered a national problem, and perhaps, a national obsession. Obesity is defined as being over-fat; this is not synonomous with being overweight. An individual is considered overweight if his weight exceeds that which is listed on one of the height-weight tables developed by insurance companies. Most height-weight tables list the average weight for a specific height according to the sex and age of an individual. The problem is being “overweight” does not indicate what those “extra” pounds consist of, whether it is fat tissue, lean tissue, or both. Obesity is a condition in which there is an excessive accumulation of body fat. A general rule-ofthumb which may be utilized in the determination of obesity is women are considered obese if more than 20% of body weight is composed of fat. For men, obesity exists if fat exceeds 14%of body weight. An obese person may be underweight, and it is possible for an overweight person not to be obese. There are two factors which determine body fat (weight): ( 1 ) the number of calories in the form of food ingested daily, and ( 2 ) the number of calories expended daily in the form of energy. However, the reduction of weight is a difficult problem. Obesity is recognized not only as a physical and social problem, but as a psychological one as weil. Considerable study has been made of the “obese personality.” Such information may be helpful in the treatment and understanding of an obese person; however, there is a need for identification and validation of effective techniques of weight reduction. Of equal importance, there is a need for better discrimination between those who are successful in programs of weight reduction and those who are not. 602
The obese individual cannot achieve optimal health and is more likely than the non-obese person to experience diabetes, high blood pressure, heart and kidney diseases, low self-esteem and poor body image, a feeling of self-consciousness, and skeletal or joint problems. In addition, life expectancy is reduced, surgery is usually more difficult, and the incidence of accidents is greater among the obese. Interestingly, persons who are over-fat are less likely than the slender to die from suicide, tuberculosis, stomach or duodenal ulcer, and for women, breast cancer. With such an obvious imbalance of health risks and with the potential for infringement on personal happiness and fulfillment, it should be no surprise that there is a national preoccupation with the treatment or remediation of obesity. An editorial in the British Journal (The Lancet, May 1970, p. 1094) reveals the irony of the probIem, however, “Obesity is chemically fairly simple and clinically appallingly difficult.” The purpose of this paper is to review recent literature relative to the strategies now commonly employed to remediate obesity. These strategies may be grouped into four categories: ( 1 ) diet restriction, ( 2 ) use of drugs or medications, ( 3 ) surgical treatment, and ( 4 ) behavior modification.
Behavior Modification Scientific evidence supports the notion behavior modification is the best remediation plan for weight reduction and permanent weight control. Levitz and Stunkard (1974) investigated the effectiveness of behavior modification conducted by a professional therapist, behavior modification conducted by a TOPS leader, nutrition education conducted by a TOPS leader, and the continuation of the usual TOPS program. TOPS, with a membership of 320,000 persons, is a self-help group whose name derives from the concept “Take Off Pounds Sensibly.” Each of the 234 subjects was assigned ta one of the treatment conditions. After 12 months, DECEMBER 1976 VOLUME XLVl NO. 10
there was significant attrition in the nutrition education and control groups, 55% and 67% respectively, as compared to 3890 and 41% in the behavior modification groups. According to Levitz and Stunkard, TOPS is a relatively ineffective method of weight control. The behavior modification treatment conducted by a TOPS leader achieved a mild degree of success in terms of weight loss and weight control. However, the professional-led behavior modification groups maintained their weight loss after the end of the treatment, and increased by onehalf their weight loss that they had attained in three previous years of TOPS membership. The nutrition education program also proved ineffective as a treatment. In a study involving 32 obese persons comparing behavior modification with traditional group psychotherapy, Penick et al (1971)found that those treated with behavior modification lost more weight than the matched control group. Furthermore, 13% of the patients in the behavior modification group lost more than 40 pounds and 53% lost more than 20 pounds. These results rank with the best in medical literature. Foreyt and Kennedy ( 1970)paired noxious smells with the favorite foods of obese patients to help them achieve an initial weight loss. Initially, and after 48 weeks, five of the six subjects showed weight loss. Foreyt and Kennedy concluded aversive conditioning may prove to be useful as part of an inclusive weight reduction program in combination with techniques to assist the patient to modify behaviors contributing to an obese condition. Pliner ( 1973) hypothesized that differences in eating behavior between obese and normal persons can be explained in terms of differences in thinking behavior. An investigation was conducted whereby 36 normal weight and 36 obese male college students were required to immerse their hands in an ice water solution under the pretext of having their physiological responsiveness to cold assessed. Three experimental conditions were effected: ( 1) Cues-present condition, (2)Cues-absent condition, and ( 3 )No-cues condition. The dependent variables included selfreports of how long the subjects thought about the assigned topics and measurement of latencies of report of cold-produced pain. Pliner concluded that the study indicated the thinking behavior of the obese is externally controlled to a greater degree than that of normal persons. Furthermore, the effect of external cues on the thinking behavior of obese and normal subjects demonstrated in the study does much to clarify the observed effect of external cues on the eating beTHE JOURNAL OF SCHOOL HEALTH
havior of the obese. I t was observed that the obese may not eat when food is not visible because they are not thinking of food. For the obese, it appears that out of sight is truly out of mind. Pliner states, “More generally, the data presented here suggest that in selecting their therapeutic regimes, the designers of any weight-loss programs might do well to take into account the evidence that cognitive behavior among the obese appears to be strongly under external control.”
Use of Drugs or Medications Dykes ( 1974) suggested effective and sustained weight reduction is based upon an understanding of good nutrition and an alteration of underlying psychologic or pathologic factors producing excessive caloric intake. Further, he states anorexiants should be prescribed temporarily, if at all, to suppress the appetite of patients who overeat to gratify inappropriate hunger or who have difficulty adhering to a prescribed diet because of the discomforts produced by caloric restriction. Dykes found clortermine, fenfluramine, and mazindol are more effective than a placebo in suppressing appetite. Dextroamphetamine (Dexedrine), Phenmetrazine ( Preludin), or Chlorphentermine ( Pre-Sate) are equally effective. However, no one anorexiant has consistently demonstrated effectiveness in terms of suppression of appetite and weight loss on a permanent or sustained basis. Elmaleh and Miller (1974)report the effective use of the anorexiant, mazindol, as an appetite suppressant, and subsequently, an agent of weight reduction. However, it would appear the limited length of the study (12weeks) would invalidate the study in terms of long-term weight reduction and control. A study involving death rates for 7,286 patients over a ten-year period during and after the treatment for obesity with “diet pills” was conducted by Asher (1972).Of 20 nonheart-associated deaths, two occurred during treatment (auto accidents), three within two weeks after the last medication was taken, and 15 during the nontreatment period. Of 19 heart deaths, seven occurred during treatment, one within two weeks after the last medication was taken, and 11 in the nontreatment period. During treatment, female heart death rates were 77.690of the 1966 General Mortality Table rates for a comparable age group and 145% during nontreatment; combined male and female heart death rates were 87% and 15170,respectively. At the start of treatment, hypertension existed in 68% (13of 19)who later died of heart disease. According to Gwinup ( 1970),the administration 603
of drugs or medications has proven to be ineffective when tested in controlled studies in treating obesity. When drugs are discontinued in treatment, there is a phase of hunger rebound so that the patient invariably regains the weight lost. Drugs are capable of causing habituation and drug dependence as well as other undesirable and sometimes dangerous effects on the central nervous system. Patients taking them tend to fluctuate between a keyed-up feeling and a state of fatigue. For these reasons, their prolonged use is inadvisable.
Surgical Treatment Surgical treatment is recommended by Braasch certain circumstances, ie, the patient should be strongly motivated to lose weight, there should be no mental problems, and there should be extenuating circumstances. Complications that would justify surgical intervention include cardiovascular disease, pulmonary insufficiency, diabetes mellitus, stasis disease of the legs, and abdominal hernia combined with “massive obesity.” Braasch states dietary restriction and the use of medications producing appetite control may be effective temporarily but fail on a long-term basis. Therefore, within the parameters suggested above, he recommends jejunioleostomy (removal of a portion of the jejunum and the ileum). This treatment usually effects a weight loss of 10 to 11 pounds per month declining to approximately two pounds per month by the third year. A weight plateau will normally occur after a year at an optimal level. Although this treatment is effective in terms of weight education and control, even with careful postoperative care, metabolic abnormalities such as diarrhea and electrolyte deficiency, hepatic failure and personality disruption can occur. According to an article (Nutrition Review, November, 1974), the jejuno-ileal bypass is associated with a disturbingly high rate of hepatic dysfunction with unpredictable progression to hepatic failure and death. Intestinal bypass operations for obesity are recommended by Baber et al (1973)for obese persons who are seriously threatened by the complications of morbid obesity. Baber et al state in addition to the previously described prerequisites for an intestinal bypass operation, all other methods of weight reduction must have been attempted and failed, and the patient must be under 50 years of age. They suggest the 15 and 5 inch jejunioleal bypass is preferred as it seems to give adequate weight reduction and is relatively free of complications. ( 1971) under
Diet Restriction Garrow (1973)reports that the results of dieting 604
are generally disappointing and Bray ( 1970) has shown in most published series only 20%-30% of obese subjects lose as much as 10 kg, and only 5% lose as much as 20 kg. In the treatment of obese patients, Garetz ( 1973) points out it is important to recognize that all too much emphasis is placed on the food content and quantities of food and far too little emphasis is placed on thQ process of eating and the circumstances of eating which will best aid the patient in the quest to lose weight. Overeating and obesity are related to certain extant social, cultural, economic and familial variables. Therefore, to treat an obese patient with temporary “dietary alterations” without helping the patient to modify his behavior is doomed to failure. According to Laveille and Romos (19741,the ingestion of relatively few large meals is undesirable for human beings. The data on the incidence of obesity, hypercholeoterolemia, and abnormal glucose tolerance show these three conditions decrease if meal frequency increases. Studies from obesity clinics show although many patients can achieve a weight loss by restricting the diet, a very small number are able to maintain it for a year or more. Gwinup suggests during the period when weight loss is occumng, there is the obvious satisfaction of seeing the day-to-day results, but when the goal has been reached, progress is replaced by the dreary task of maintenance, which is likely to discourage the most resolute dieter. This accounts for the fluctuating up-and-downpattern of the weight records of so many dieters. Tremolieres (1973)advances the hypothesis, “It is apparently impossible, clinically, to change human dietary behavior by external influence without taking account of the psychosensorial (ie, affective) and the symbolic motivations of the food drive.” He also expresses the dilemma of diet restriction by reporting obese patients eat quickly in an aggressive and regressive way and stop eating with a sensation of a full stomach and not by an oral sensation. They may be determined to reduce their diet for a period of time, but are very unstable in their determination. I t is interesting to note that published surveys (Widdowson 1962,Johnson, Burke and Mayer 1956) fail to show fat people eat more than lean persons. Garrow (1973)states, “Other things being equal, obesity would still occur even if no one over-eat.”
Conclusions The effective treatment of obesity on a long-term basis is best achieved by behavior modification. Dieting enables an obese person to lose weight, but DECEMBER 1976 VOLUME XLVl NO. 10
this usually is a temporary solution in that invariably the dieter returns to previous eating habits and the lost fat is quickly restored. Diets often create nutritional problems unless they are well-balanced and under medical supervision. There is at present no evidence available which would support the idea that any of the more extreme diets recently popularized has any advantage over a calorically restricted, balanced “normal” diet for the person concerned with weight reduction. A balanced diet containing no less than 14% protein, no more than 30% fat, with the remainder composed of carbohydrates, is recommended. However, it is not realistic to expect that such a diet with the appropriate quantity of calories can be prescribed for obese persons and be successful in weight reduction and control without additional intervention or attention on the part of the therapist. The use of drugs for purposes of suppressing hunger is often effective during the first few weeks of administration. Usually, however, over a sustained period of time, a tolerance to their effect develops. The most unsatisfactory feature of their use by the obese is when they are discontinued, an individual usually returns to previous eating habits with a subsequent restoration of the fat lost. Medically, of equal importance, is the undesirable effects amphetamine-type drugs may have on the central nervous system. These drugs are capable of causing habituation and drug dependence. Since maintenance of fat loss is far more difficult than losing weight, it might be assumed if an individual is not able to lose fat without a medication or some other support mechanism, the obese will certainly be unable to maintain the loss once the crutch is taken away. At the present time, jejuno-ileal bypass is associated with a disturbingly high rate of complications including unpredictable progression to death. Until careful experimentation can develop means of prevention of serious complications, bypass procedures should only be considered for those obese patients who are suffering from morbid obesity and who exhibit the other prerequisites for this type treatment. The treatment of obesity via behavior modification appears to be the most effective strategy for permanent weight reduction and control for most individuals. Obesity, unless physiological disorders are present, is a result of behaviors that lead to the ingestion of an excess of calories beyond caloric needs on the part of the over-fat person. Obese individuals must not only adjust how much they eat to effectively control fatness, they also THE JOURNAL OF SCHOOL HEALTH
must modify the speed at which they ingest food in addition to the environmental and psychologic situations associated with eating. There is evidence that suggests all eating should be confined to one place such as the dining room, and it should be a pure experience, unaccompanied by any other activity. “Doctoring” favorite snack foods to give them an aversive taste can provide a negative means of controlling food behavior. Obese persons must learn to identify and substitute acceptable behaviors for activities or cues that cause eating to occur, ie, express angry feelings on paper rather than eating, take a shower upon returning home from work rather than having a martini, and disassociate snacking with watching television. Increasing energy output is an important aspect of behavior modification. Recent studies indicate in all age levels, over-fat persons did not consume more calories than their normal weight counterparts, but they led much more sedentary lives. It is surprisingly easy to lose 8 to 10 pounds in a month by moderately increasing one’s physical activity provided food consumption remains the same. Appetite does not increase as physical activity increases. In fact, in some cases, appetite may decrease as energy output increases. Because the obese individual has large stores of fat, exercise does not stimulate the appetite of the over-fat person. The purpose of an effective and permanent program of weight loss and weight control is the development of self-control of eating and related daily activities. Weight loss should occur as a consequence of the adaptive behaviors resulting from self-control. The obese individuals must understand how the overfat condition developed and how life patterns must be altered. With a new pattern of living, it is possible for obese-proneindividuals to have absolute control of their weight.
BIBLIOGRAPHY Asher WL: Mortality rate in patients receiving diet pills. Therapeutic Res Press 14:525-530, 1972. Baber JC. Hayden WF, Thompson BW: Intestinal bypass operations for obesity. A m J Surg 126:769-772, 1973. Braasch JW: The surgical treatment of obesity. Surg Clin North A m 51567-673, 1971. Bray GA. A m J Clin Nutr 23:1141-1148, 1970. Current status of jejuno-ileal bypass for obesity. Nutr Reu 32: 333-336, 1974. Dykes HM: Evaluation of three anorexiants. J A M A 230:270-272, 1974. Elmaleh MK, Miller J: Controlled clinical evaluation of a new anorectic agent in obese adults. Pa Med 46-50, 1974. Foreyt JP, Kennedy WA: Treatment of overweight by aversion therapy. Behau Res Therapy 9:29-31. 1971. Garetz FK: Sociopsychological factors in overeating and dieting with comments on popular reducing methods. J A bnorm Psychd 210:671-676. 1973. 605
Garrow JS: Diet and obesity. Proc R Soc Med 66:642-644, 1973. Gwinup G: Energetics, Your Key to Permanent Weight Control. Los Angeles, Sherborne Press, 1970. Johnson ML, Burke BS, Mayer J: A m J Clin Nutr 4:37-44, 1956. Leveille CA. Romsos DR: Meal eating and obesity. Nutr Today
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The author of this article is Russell T. Werner, MEd, Allied Health Administrator, Allied Health Division, Northampton County Area Community College, 3835 Green Pond Road, Bethlehem, P A 1801 7.
Public Law 94-317: Title I On June 23, the President signed into being Public Law 94-317. Title I of the Act is called “National Consumer Health Information and Health Promotion Act of 1976.” Following is an article adapted from the September 1976 issue of Focal Points which presents a detailed review of Title I, and a description of major processes necessary to implement the new law. GENERAL AUTHORITY (Section 1701) This section requires the Secretary of HEW to: (1)Develop national goals and strategies concerning health information and promotion, preventive health services, and education in the appropriate use of health care. , .(2)Analyze necessary and available resources for implementing the goals and recommend educational and quality assurance policies for needed manpower resources identified by this analysis. . . (3) Undertake and support necessary activities and programs to: Incorporate appropriate health education components into our society, especially into all aspects of education and health care. . .increase use of health knowledge, skills, and practices b y the general population.. establish systematic exploration, development, demonstration and evaluation of innovative health promotion concepts. . , (4)Conduct and support research and demonstrations concerning health information and promotion, preventive health services, and education in the appropriate use of health care. . .(5) Undertake and support training in operation of effective and efficient programs of health information and promotion, etc. . .(6) Undertake and support, through improved planning and implementation of tested models and evaluation, effective and efficient programs concerning. . .(7) Foster information exchange and cooperation in conducting research, demonstration and training programs respecting health information and promotion, etc. . .(8) Provide technical assistance for such programs. . .(9)Use other available authorities for programs concerned with health information and promotion, preventive health services, and education in the appropriate use of health care. Section 1 7 0 1 also directs the Secretary to administer Title I in a manner consistent with the national health priorities set forth in section 1502 of the National Health Planning and Resources Development Act (P.L. 93-641) and with health planning and resources development activities undertaken under P.L. 93-641. 606
RESEARCH PROGRAMS (Section 1702) This section authorizes t h e Secretary to conduct and support research in health information and promotion, etc. In addition, t h e Secretary shall: Provide consultation and technical assistance to persons who need help in preparing research proposals o r in conducting research. . .Determine the best methods of disseminating information o n preventive health services, appropriate use of health care, personal health behavior, and affecting behavior, 80 that this information is applied to maintain and improve health and prevent disease, reduce its risk, o r modify its course o r severity. . .Study, various factors that affect health, and determine areas in which educational and preventive measures could be used to improve health as it is affected by these factors. . .Develop methods to determine the cost and effectiveness of activities in health information and promotion, etc., reimbursement o r payment methods for these activities, models and standards for conducting such activities, including models and standards for education (by providers of institutional health services) of individuals receiving such services. . .Develop a method for assessing the cost and effectivenees of specific medical services and procedures under various conditions of use. , .Enumerate and assess preventive health measures and services with respect to their cost and effectiveness under various conditions of use. This section also directs t h e Secretary t o make a periodic survey of t h e needs, interests, attitudes, knowledge, and behavior of the American public regarding health and health care. The findings of such surveys are to be taken into consideration in developing policy concerning health information and promotion, preventive health services, and education in the appropriate use of health care.
COMMUNITY PROGRAMS (Section 1703) The Secretary is authorized to conduct and support new and innovative programs in health information and promotion, preventive health services, and education in t h e DECEMBER 1976 VOLUME XLVl NO. 10
