As obesity continues to increase in this country, so does the frustration of overweight people trying to lose and/or maintain their weight loss. In an attempt to understand obesity, many theories and treatment programs have emerged over the years. These include commercial programs providing a smorgasbord of behavioral techniques, fad diets, drugs, and specific medical programs. Despite all of this, however, the understanding and management of this disorder remains perplexing.

To shed some light on obesity and better understand the problems of motivation and living up to the commitment to loose (compliance) which are critical to dietary success, let's examine the process of change. After all, weight loss involves a commitment to change - to change lifestyles and eating habits.

In general, people resist change for several reasons. First, people are creatures of habit and routine. We feel secure when we're able to predict when things will happen. For example, where do you sit at the dinner table each night? And how do you feel when a guest sits in your seat? Obviously, change throws people out of their comfort zones.

Second, when change occurs, whether it is positive or negative, it creates a loss - of routine, loved ones, comfort zones, etc. From this loss comes unhappiness, and, at times, depression. Consequently, one way to avoid the loss associated with change is to simply avoid making the change.

Third, people resist change because it creates stress. Stress levels increase with feelings of unhappiness, anxiety, and loss. As a coping mechanism, some turn to food.

Let's examine this theory through the eyes of one committed to overcoming obesity. Mrs. Smith decides to make a change in her life and lose weight. When she begins her diet, numerous lifestyle changes occur (modified diet plan, exercise, etc.), resulting in loss (the loss of old habits), manifesting itself as frustration, unhappiness and stress. To cope, Mrs. Smith returns to her old/predictable lifestyle and eating habits (relapse).

In an attempt to help Mrs. Smith, the health educator increases lectures about the importance of remaining on her diet or recommends several techniques to enhance dieting success. All of this is admirable, but it is as effective as putting out a fire with gasoline.

If Freud was correct in that the two main motivators are pain and pleasure, then it is necessary to re-analyze motivation techniques for weight loss. Traditional wisdom is to avoid pain and gravitate towards pleasure. Applying this wisdom in the weight loss field creates an obvious paradoxical bind.

Change, as stated earlier, creates loss and increases stress. When dieting, therefore, feelings of deprivation and loss occur (pain). In effect, the immediate pain of dieting is more powerful than the eventual advantages of being thin and healthier! This creates a difficult and confusing dilemma. Even the term weight loss has a negative connotation. In order to lose weight, dieters experience discomfort, loss, stress and other negative feelings - the very feelings that often trigger overeating. Given this scenario, it is entirely understandable that dieting fails and that dieters return to their old habits. Due to the inherent need to resist change, the "program" or individual is often blamed for the imperfect outcome.

Many prepackaged treatments for obesity are destined to fail. Why? Because obesity is not just one single problem or a unidimensional disease but is instead determined by a complicated interaction between genetic, metabolic, psychological, and environmental factors. It is critical, therefore, for people to choose a program that can be "tailored" to their needs. Just taking a "pill," a supplement, or vitamin often leads to frustration and empty wallets. Many issues need to be considered when attempting to change a behavior.

Preparing for a lapse or relapse is crucial in successful weight loss and maintenance. "Relapse" is defined as a return to baseline levels of eating and activity behaviors, with a concomitant regain of weight. "Lapse" is defined as any violation of the rules, etc., which relate to the selected target behavior. It's important to realize that lapses will occur but that not every lapse will turn into a relapse.

A good metaphor I often use when teaching relapse prevention skills is that of a forest ranger. The responsibility of a forest ranger is to prevent fires, but, if a fire occurs, to put it out as quickly as possible. With regards to weight loss, it's important to identify triggers that cause a lapse/relapse (like the forest ranger recognizes smoke as a sign of fire).

When a lapse occurs, maintain a rational and logical perspective. Once you allow negative thoughts to prevail, a relapse is more likely.

The following conversation with a patient may serve as a good example of confronting negative thinking:

DR. LEVICK:
How was your week?

PATIENT:
Terrible! I had a big fight with my husband and ate a pound bag of potato chips. I can't believe I broke my diet.

DR. LEVICK:
I can.

PATIENT:
What are you talking about?

DR. LEVICK:
Why did you eat the chips?

PATIENT:
Because I felt terrible after I fought with my husband.

DR. LEVICK:
Haven't we identified a pattern of overeating when you become upset?

PATIENT:
Yes.

DR. LEVICK: Then, doesn't it make sense that you overate after your fight?

PATIENT:
I know that, but I shouldn't still be doing that.

DR. LEVICK:
Why not? It's a habit you're attempting to change.

PATIENT:
Are you telling me I should keep overeating when I'm upset?

DR. LEVICK:
No. What I'm saying is that you are still working on changing some old, well-conditioned habits. It takes time and numerous attempts before people make changes. And just because you had a slip doesn't mean you failed. It just means you ate a specific amount of calories (2,440).

PATIENT:
I know it takes time. But my husband and I fight a lot. What am I suppose to do? Nothing seems to work when I start feeling bad.

DR. LEVICK:
Nothing?

PATIENT:
Well, you know what I mean.

DR. LEVICK:
I think I do. I recognize your frustration and I know you're trying hard to handle things differently. Keep in mind that if you continue to do the same old things and expect different results, you will continue to be frustrated and upset - which will lead to more overeating. Can you see the vicious cycle you put yourself in?

PATIENT:
Yeah, so what can I do?

DR. LEVICK:
Let's talk about some alternative strategies that will help you when you become upset . . . .

Changing any behavior is extremely difficult. Confronting negative thinking and preparing for normal lapses is critical for one's success. There are no formulas for weight loss motivation and maintenance. Motivation is an individual mental state that needs to be created and nurtured. It's up to each of us to take responsibility for our health and well-being. No program, pills, etc. can do it for us.

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