Am J Clin Nutr-1990-Kayman-800-7.pdf

8/14/2019 Am J Clin Nutr-1990-Kayman-800-7.pdf

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80 0 Am J C /in N u ir l9 90 ;52 :800 -7 . P rin ted in USA . 1990 Am erican Soc ie ty fo r C lin ical N u trition

M ain tenance and re lapse a fte r w e igh t lo ss in w om en :behav io ra l a spec tsS u sa n K a ym a n W illiam B ru vo ld a n d Ju d ith S S tern

ABSTRACT Obese w om en w ho rega in ed w eig h t a fter suc-cessfu l w eigh t redu ctio n re lap se rs , n 44); fo rm erly ob ese, av -e rag e-w eig h t w om en who m ain ta ined w e igh t lo ss m ain ta ine rs ,n 30); and w om en w ho had a lw ays rem a ined a t the sam eav erage , no nob ese w e igh t con tro l sub jects , n 34 ) w ere in te r-v iew ed . M o st m ain ta in ers 90 ) and con tro l sub jec ts 82 ) ex-erc ised regu lar ly , w e re con scio us o fth eir behav io rs , u sed ava il-ab le soc ia l sup port 70 and 80 , re sp ec tive ly ) , con fro n tedp ro b lem s d irec tly 95 and 60 , re spec tive ly ) , and used p er-sona lly d ev elo ped strateg ie s to he lp them selv es . F ew re lapse rsex erc ised 34 ), m o st ate u nconscio usly in re spo nse to em o-tions 70 ) , few u sed av a ilab le soc ia l sup port 38 ), an d fewconfron ted p ro b lem s d irec tly 10 ). These find in gs sug gest thead v isab ility o fd ev e lo pm ent an d prospec tive eva lu ation o f md i -v idua lized treatm en t p rog ram s designed to en hance exerc ise,cop ing sk ills , and soc ia l su ppo rt. A m J C /in N u ir 1990 ;52 :800-7 .

K EY W O RD S Obes ity , m ain tenance , re lapse , w e igh t lo ss ,stre ss and co p ing , soc ial sup port, exe rciseIntroduction

A m ajo r p rob lem faced by peop le w ho su cceed in losin gw eig h t is tha t the m a jo rity can no t m ain tain th ese losse s 1).Recid iv ism is a lso comm on in peop le trea ted fo r d ru g , a lcoh o l,and tob acco d ependency . R e lapse ra te s fo r d rug , a lcoh o l, andtobacco trea tm en t p ro gram s are rep orted to b e in th e rang e of5 0-9 0 2 , 3 ). R eported re lap se ra te s fo r o besity an d o the r de -pend en c ie s cou ld b e ove restim ate s o f ac tu al ra te s s ince m ostrep orts a re from c lin ica l p ro g ram s and are b ased on p eo p le w hohave receiv ed fo rm a l treatm en t. In add itio n , the se fig u res cou ldo ve rsta te th e p ro b lem : frequ en tly , o n ly th e m o st d ifficu lt casesa re seen in re search -o rien ted trea tm en t p ro g ram s an d oftenon ly on e a ttem p t to change is s tu d ied . P eop le a ttem p ting tochang e on the ir ow n m ay b e succes sfu l and m ay relapse le ssfrequ en tly 4 ).

A ltho ugh th e p rob lem of re lapse p lag ues a ll a rea s o f sub -stance abuse, it is a p ar ticu la r p ro b lem for o bese p eo p le becauserep ea ted w e igh t lo ss fo llow ed by w eig h t ga in m ay h av e d etr i-m en ta l hea lth , m e tab o lic , an d psy ch o log ica l con sequences. Ep -idem io log ic s tud ies 5) revea l pos itive e ffec ts o f w eigh t loss inlow erin g b lo od pres su re and ch o le stero l and im p rov ing g lucoseto le ran ce 6). H ow eve r, w hen an equ a l am oun t o fw eig h t is re -g ain ed , neg ativ e e ffec ts on b lo od pre ssu re and cho les te ro l m aybe grea te r than the p ositiv e e ffec ts w h en th e w eig h t w as lost 7 ).S om e in vestiga to rs 8 - 1 1 ) fo und tha t repeated cyc le s o f w e igh t

lo ss and reg ain in labora to ry an im a ls and in hum an s a re assoc i-a ted w ith in creased m e tabo lic e ffic iency and rap id reg ain onrefeed ing . T he decreased ene rg y requ irem en t needed fo r w e igh tm a in tenance co u ld p red ispo se p eo p le to reg ain w e ig h t andm ake sub seq uen t d ie ting m ore d ifficu lt.

N um erou s in vestiga to rs 12 -16 ) h av e conc lud ed tha t d iffe r-en t p ro cesse s an d stra teg ie s a re need ed to m a in tain w e igh t th anto lo se w eig h t. P ro cesses and stra teg ie s m ay va ry a t d iffe ren tstages o fthe b eh av io r-chang e process, sugg esting tha t in te rven -tio n to p reven t re lapse w ou ld b est add re ss the p ro b lem a t eachind iv idu a ls po in t in the b eh av io r-change process. B rownell e ta l 1 5) sugg es t th at the re a re a t least th ree stages o f behav io rch an g e : 1 comm itm en t and m otiv atio n to ch an ge , 2 in i t ialchan ge , and 3 m ain ten an ce ofch ange . O th ers p ropo se th at anadd itiona l stag e, 4 dea ling w ith success, o r liv in g w ith thechan ges, is es sen tia l 12 , 13 ). T h is re fers bo th to liv ing w ith asm a ller , th inn er se lf , a s w ell as accep tin g the chang es as pa rt o fo ne s life ra th er th an as unu sua l th ing s to do as pa rt o fa tem po -rary d iet .

S u rp ris in g ly little is k now n abou t th ose w ho lose w eig h t andreg a in it ou tside o f fo rm a l trea tm en t p rog ram s sin ce m ost d ataa re from c lin ical in terven tio ns 15). It is d iff icu lt to iso la te thefac to rs tha t in fluen ce relapse becau se it is so ha rd to fu lly eva lu -a te pa tien ts a f ter trea tm en t has end ed . F ew fo llow -up stud ie srep ort lon g-te rm resu lts and few stu d ie s rep ort re su lts fo r un -treated con tro l sub jec ts . In th e p re sen t re search lon g-termw eigh t- lo s s m a in ta ine rs w ere so ugh t to lea rn h ow they d iffe redfrom w om en who re lapsed afte r w e igh t lo ss an d from w om enw ho h ad neve r been o bese . W e hoped to g ath er clu es fo r m ore

F rom th e D epa rtm en t o f R eg ion a l H ea lth E duca tion , K a ise r P e r-m an en te , O ak land , CA ; the D ep artm en t o fS oc ial and A dm in istrativ eH ealth S c iences, S cho o l of P ub lic H ea lth , U n iv ersity o f C a lifo rn ia ,B erke ley ; an d th e D epa rtm en ts o fN u tritio n an d In te rna l M ed ic ine an dthe F ood In tak e L abora to ry , U nivers ity o fC alifo rn ia a t D av is.

2 Suppo rted in p art by g ran ts to SK from th e D r EE D ow dle Fundan d the U niv ersity o fC a lifo rn ia C hance llo rs P a ten t F und ; by B iom ed -ica l S upport G ran t S -S07-RROS441 , N ationa l Institu tes o f H ealth , tothe S ch oo l o f P u b lic H ealth , U n ive rsity o f C a lifo rn ia, B e rk e ley ; an dby a p ostdo cto ra l fe llow sh ip to 5K from th e C ard iov ascu lar D iseaseP reven tion T ra in ing P rogram gran t HL -0 7034) , S tan fo rd C en te r fo rR esearch in D isease Prev en tion , S tan fo rd U nivers ity S choo l o f M cdi-c ine .

Address rep rin t requ ests to S K aym an , K a ise r P erm anen te R e-g iona l Hea lth Edu catio n , 19 50 F ran k lin S tree t, 17 th f loo r, Oakland ,C A 9 46 12 2 99 8

Received M ay4 , 198 9 .A ccep ted fo r p ub lica tion D ecem ber 20 , 198 9 .


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L O N G -T ER M W E I G H T M A I N T E N A N C E 80 1success ful obes ity treatm ent from a co m parison of these threegroups.

Sub j ect s and m ethodsE xperim en ia / desig n

R esearch m ethods are oftw o basic ty pes, according to Co henand N ag e l (1 7 ) and S e lltiz et al (1 8 ). One ty pe is used fo r hy-po thesis generation and the second for hypotheses confirm a-tion. This study expressly em ployed a m ethod designed to gen-erate hy potheses called the Jo int M etho d ( 1 7, 1 8). In general,this m etho d is successful ifa large num ber ofpotential hypoth-eses are g enerated and initially asse ssed to identify tho se m ostw orthy ofsubsequent co nfirm atory research. A standard proce-dure for conducting the Jo int M ethod w as used. Ex trem eg roups w ere identified and a larg e num ber ofpotential hy poth-eses w ere tes ted to explain w hy one group ofw om en lost a s ig -nificant am ount of w eight and did not regain it, w hereas an-o ther group los t but reg ained. A third g ro up ofw o m en w ho hadalw ay s m aintained av erag e w eight w as also se lec ted. B rie fly , theJo int M ethod invo lv ed tw o steps: first, potential hy pothesesw ere g enerated by rev iew ing the literature and by talking tow om en in the three contrasting groups selec ted for study . S ec-o nd, these potential hypotheses w ere screened by use of stan-dard statistical pro cedures that assessed w hether the gro ups ac-tually dif fered. In this w ay , the m o re useful explanatory ideasw ere se lec ted from the larger group and these w ere used to de-v elo p initial theory to guide future co nfirm ato ry researchefforts.Subjec ts

Po tential subjec ts w ere recruited from a large health m ainte -nance organizatio n, the Kaiser Perm anente M edical Off ices inFrem o nt, CA . A s w om en entered a central area ofthe m edicaloffices, they rece ived a questionnaire, w hich they com pleted (n= 14 75) and s igned if they w ished to vo lunteer (n = 9 0 2 ) to beinterv iew ed. S even hundred vo lunteers categorized them se lvesinto three w eig ht groups: re lapsers, m aintainers, or alw ays av -erage w eig ht. V olunteers w ere not cons idered potential subjectsifthey w ere pregnant, had recently de livered infants , had nev erattem pted to lose w e ight, had lost < 9 kg , w ere lo sing w eig ht,w ere gaining w e ight, or had experienced a w e ig ht chang e dueto i ll ne s s.

From the 7 00 w om en w ho categorized them selv es as re laps-ers , m aintainers , or alw ays av erag e w eight, 50 w ere selec tedrandom ly from each w e ight catego ry fo r further screening .These 1 50 indiv iduals w ere te lepho ned to determ ine w eight-lo ss history , length of m aintenance of reduced w eig ht, andhealth status. Tho se m eeting all criteria (see nex t sectio n) andagree ing to be interv iew ed (n = 1 0 8 ) rece ived le tters explainingthe study and confirm ing interv iew appo intm ents. Potentialsubjects w ere te lepho ned before the ir interv iew to reconfirm . Ifthe prospectiv e subjec t cance lled the appo intm ent, the inter-v iew w as rescheduled so that all potential subjects w ere ulti-m ately interv iew ed. A ll subjects w ere interv iew ed by the firs tautho r and each interv iew lasted fro m 1 to 1 .5 h.C rite ria fo r sub jec ts

W eig ht standards from the 195 9 M etro po litan Life Insur-ance Tables ( 1 9 ) w ere used to determ ine w hether w om en w ere

w ithin a desirable w eight rang e , or average w eight, o r w ere 20 %o verw eight. Tw enty-percent overw eig ht w as calculated by us-ing the m idpo int o f the w e ight range fo r a m edium -fram ew o m an for a g iven he ig ht in the 195 9 M etropo litan Life Insur-ance Tables . The N IH C onsensus D ev elo pm ent Conference onthe H ealth Risks o f O besity (19 ) concluded that lo ng-termhealth risks at the 20 percent o verw eight leve l w ere undes irableand ev en alarm ing . Thus, this lev el o fo verw e ight w as used inthe present research to fo cus o n w om en w ho se overw eight putthem at increased risk for health problem s. Re lapsers w ere 2 0% overw eig ht, had prev ious ly lost 2 0% ofthe ir w eight oneor m ore tim es but regained it (n = 44). A t the tim e ofthe study ,these w o m en w ere ne ither g aining no r lo sing w e ig ht. M aintain-ers w ere of average w eig ht and had prev iously been 20 %overw eight but had reduced and m aintained the reducedw eight for 2 y (n = 30). C ontro l subjects w ere average w eightand had alw ays rem ained w ithin 3 .6 kg ofthe ir current w eightas adults , except fo r pregnanc ies (n = 34 ). A t least 1 y hadelapsed s ince the last preg nancy and delivery in all threegroups.

In te rv iewsS ubjects w ere interv iew ed by use of a questio nnaire deve l-

oped spec ifically for this s tudy . The fo llo w ing m ethod w as usedto de ve lop the que stio nnaire:

1) Explo ration: tapes w ere m ade offocused, open interv iew sw ith 1 2 subjec ts (6 re lapsers and 6 m aintainers) to identify keyis sues to inc lude in the questionnaire .

2 A pre lim inary open-ended questionnaire w as dev elo ped,by use o fthe issues and topics identified from the tapes.

3) The questio nnaire w as tes ted, rev ised, and tes ted ag ainuntil the questions e licited the desired inform ation.The final ques tionnaire w as used to interv iew the 108 re lapsers,m aintainers, and contro l subjects w ho m et the study criteria.

Questions o n the fo llow ing to pics w ere inc luded in the ques-tionnaire: overw eight history and childho od food experiences;dieting and w eight-lo ss history; reaso ns for gaining , m aintain-ing , o r sustaining w eig ht; po sitive and negative invo lv em ent inw eight contro l from other peo ple ; pregnancy histo ry ; sm okingand alcoho l intake; m eal and snacking patterns; health prob-lem s, m edications , and surgeries; exercis e patterns; dem o -graphic data on age , m arital status, em plo ym ent, and educa-tio n; em otio n-re lated eating; perceiv ed soc ial suppo rt; and re -cent troubling s ituation o r event and coping responses ,ev aluated w ith an open-ended version of the W ays o f Co pingquestionnaire (20 ) .

The study protoco l w as appro ved by the K aiser Perm anenteM edical Care Prog ram , N orthern C alifornia Reg io n, Institu-tional Rev iew B oard, and the H um an S ubjec ts C om m ittee o fthe U niversity ofC alifornia, B erke ley .Coding and sta tistica / a na /yses

Co m m ents and respo nses fro m the questio nnaires w eregrouped and coded and differences be tw een groups w ere as-sessed w ith analyses o f v ariance for continuous v ariables andw ith chi-square analysis for categorical variables. The s ig nifi-cance ofdifferences betw een re lapsers and m aintainers, the tw ogroups of prim ary interest, and then for m aintainers and co n-tro l subjects w as further assessed w ith additional chi-squareanaly ses . Thro ughout the analys is , qualitative , open inform a-


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80 2 KA Y M A N ET A LT A B L E IS oc iodem ographic characteris tics o f re lapsers , m aintainers, andc ontro l s ubje cts *

ControlRelapsers Maintainers subjects

Characteristic (n = 44 ) (n = 30 ) (n = 34 )A ge(y )

21-44 21 (4 8) 21 (70 ) 25(7 3)45 -7 3 23 (52) 9 (3 0) 9(26)

Marital statusMarried 36 (84) 23 (77 ) 25 (74)Divorced,widowed,single 7 16 7 23 9 26

E du cati onal l ev el< HS o r H S g raduate 22 (5 0) 8 (27 ) 6(18)S om e c ol le ge I 3 (30) 1 3 (43 ) 1 6(47)Colle geg raduate 9(20) 9(30) 1 2(35)

E thnic g ro upC aucas ian 40 (9 I ) 29 (97 ) 32(9 4)Hispanic,blac k 4(8) 1(3) 2(6)

O cc up ati on al s ta tu sHomemakeronly 23(54) 7(23) 7(21)Em ployed for salary 20 (46)t 23 (77 ) 27 (79)

S N umber o fsubjec ts; perc ent in pare ntheses .t S ignificantly diffe rent from maintainers , P 0 .05 .

tion w as catego rized, coded, and grouped to hig hlight keydifferences am ong the g ro ups. SPSSX (2 1) w as used for dataanalyses.

ResultsS am p le c ha ra ct er is ti cs

M aintainers and re lapsers w ere prim arily Caucasian (9 7%and 91%, respec tive ly ), m arried (7 4% and 8 4%, respec tive ly ) ,and m iddle-aged (m ean ages 41 and 47 y , re spec tive ly ) . M orem aintainers than re lapsers co m ple ted co lleg e (30 % v s 2 0%) andhad salaried positio ns in additio n to the irjobs as ho m em akers(77% vs 46%, P > 0 .0 5 ) . M aintainers did not differ from contro lsubjec ts in their race, m arital status, age , education, o r em ploy -m ent (Table 1 .

M aintainers, re lapsers, and contro l subjects did no t differ sig -nif icantly in the percent w ho had children (7 7%, 83 %, and 74 %,respective ly ) or in the ir m ean num ber ofpregnanc ies (range 1-5 in all three g roups). How ever, re lapsers gained signif icantlym ore w e ight from preg nancy to 1 y after their last preg nancycom pared w ith m aintainers and contro l subjec ts (Table 2 ).

T A BL E 2W eight gain after pregnanc ies : com parison o fre lapsers , m aintainers,and co ntro l subje cts *

ControlRelapsers M aintainers subjects

W eight gain (kg) by I yafterlas tpregnancy 11 .7 lO .4t S .9 7 .2 f 1 .8 2 .3S SD .t S ignificantly dif ferent from m aintainers and co ntro l subjects ,

PO.OOl. S ignificantly different fro m contro l subjects, P 0 .001 .

TA B LE 3Co m parison ofw eight-loss m ethods used by re lapsers and m aintainersofreduced w eight5

W eig htlo ss m etho dRelapsers(n = 44 )

Maintainers(n = 30 )

D ev ised perso nal-eating plan 1 7 (39) 22 ( 7 3)Exerc ised 16(3 6) 23(7 6)A tte nde d W eig ht W atc he rst 19 (43 ) 3 (10 )A ttended other program s or

groups 13(2 9) 3 (10 )Fo llo we d do cto r s o rde rs 1 5 (34 ) 6 (20)Too k pills , shots 2 1 (47 ) 1 ( 3)Fasted 5 11 1 3U nderw ent hypnos is 4 (9 ) - -Fo llow ed boo k, m ag az ine die t 1 1 (25 ) 3 (10 )Total m ethods used I 2 1 - 28 -

S N um ber o fsubjects; percent in parentheses.t Co ncord, CA .t M ethods preceding w eight regain (com binations o f m ethods w ere

used). M etho ds pre ce ding s uc ce ss ful m ainte nanc e.

W eight-loss m ethodsA key finding ofthis study w as that although the m aintainers

used m any s im ilar s trateg ie s to lo se w e ight, each m aintainerused these strateg ie s in w ays that w ere spec if ic to her ow n life -sty le. Few w o m en successfully m aintained reduced w e ight afterlearning a packag e of strateg ie s fro m a c lass or w ith the helpo f a physic ian or nutritionist (althoug h these resources w ereavailable ). M aintainers m ade dec isions to lose w e ight and thendev ised personal w e ight-lo s s plans to fit the ir live s. These plansusually inc luded reg ular exerc ise or ac tiv ity and a new eatingsty le o f reduced fat, reduced sug ar, m o re fruits an d v eg etabl es ,and m uch les s foo d than prev iously eaten. M aintainers re-ported be ing patient, se tting sm all g oals that they could m eet,and sticking to the ir personally dev ised w eig ht-lo ss plans. S o m eused ideas fro m earlier w e ight-lo s s ex periences, som e used die tsfro m boo ks, but all persisted until new eating patterns w ereestablished. M aintainers reported that ultim ate ly they did no tw ant to eat as m uch and that such foods as candy and donutsw ere no long er appealing because they w ere too sw ee t or fatty .They chang ed their coo king m ethods to avo id fry ing fo ods w ithex tra fat and fo und them se lves able to deem phasize food inthe ir liv es. H ow ever, they did not co m ple te ly restrict favo ritefoo ds and m ade e fforts to av o id fee lings o f depriv atio n w hilechang ing fo od patterns.

In co ntrast, few re lapsers (36 %) had exercis ed to he lp losew e ight. They had lo st w e ight by taking appetite suppressants ,fasting , or go ing on restric tive die ts that they could not sustain.They took diet form ulas and w ent to w eig ht-co ntro l groups andpro gram s m any tim es(Table 3 ) . W hile die ting they did not per-m it them se lves any o f the fo ods they enjo yed and perce ivedthe ir die t foods as special fo ods , different from the foo ds the irfam ily could have and different fro m foods they really w anted.They fe lt depriv ed o n the restrictiv e die ts and eas ily w ent backto o ld patterns . M any re lapsers (77%) reported regaining in re-sponse to a negative life event that m ade it im poss ible for themto prepare spec ial foo ds anym ore or continue exercis ing . 0 th-ers repo rted that they just w ent back to o ld w ays w itho ut even


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80 4 KA Y M A N ET A LT A B L E SW eight-contro l he lp requested by re lapsers and m aintainers5

Relapsers(n=44)

Maintainers(n=30)

C heckups w ith referrals ug g es ti on s, i nf orm ati on ,concernedM D 15 (34) 2 (6 )

S upport gro up, die t partner 10 (22) 3 (10)Em otio nal he lp, understanding

about needs re lated tow eight, from fam ily , healthprofessional 9 (20) 1 (3 )

S N um ber ofsubjects : percent in parentheses.

M ost o fthe w o m en in all three groups ate lunch and dinnerevery day and rarely skipped these m eals . H ow ev er, m o re re-lapsers than m aintainers and contro l subjec ts skipped breakfast(43%, 37%, and 2 3%, respective ly , skipped breakfast e ither ev-ery day or m ost o fthe tim e; P < 0 .01 ) .Professiona l he lp or o ther assis tance w ith w e igh t con tro l

N one ofthe w o m en reported that a phy sic ian or other healthprofes sional w as he lpful to them althoug h three re lapsers andone m aintainer reported that a physic ian w as not he lpful. M ostm aintainers and contro l subjects (83% and 7 6%, respectiv ely )reported that they did no t w ant he lp, that he lp from others forthe ir w eight-contro l e fforts w as no t an issue for them , and thatw eig ht contro l and food intake w ere the ir ow n co ncerns. Incontrast, o nly 36% o f relapsers did no t w ant he lp (P < 0 .0001co m paring re lapsers w ith m aintainers). M o st re lapsers (64%)w ished they had m ore he lp fo r the ir w e ight-contro l e fforts . Ta-ble 5 details the kinds o f help these w o m en, as w e ll as the fewm aintainers w ho w ere interes ted in rece iv ing som e ass istance ,m ight like to receive .Coping w ith prob lem s

M ost re lapsers, m aintainers , and co ntro l subjec ts (87 %, 8 0%,and 7 6%, respec tive ly ; differences be tw een g roups N S ) w ereable to report a stre ssful or tro ubling issue , event, or situatio nin response to the ques tion, W hat w ould you say is the m os ts tre ssful or troubling aspect o f y our life right now ? M ore re -lapsers repo rted experienc ing problem s re lated to their over-w e ight and/or the ir health than did m aintainers or contro l sub-jec ts (56 %, 10%, and 2 %, respec tive ly ; P < 0 .05 ). There w ereno sig nificant differences in the o ther ty pes o f problem s re -ported by w o m en in the three groups, w hich inc luded pro blem sw ith interpersonal re lationships (parents , children, husband,and friends), se lf-fulf illm ent problem s and issues, and jo b o rc are er pro bl em s.

Though m ost w o m en repo rted a stressful issue o r problem ,there w ere s ignif icant differences in the w ays re lapsers, m ain-tainers, and contro l subjec ts reported co ping w ith these prob-lerns. C oping-respo nse catego rie s w ere deve loped from answ ersto the question, H ow are y ou dealing w ith this? after theproblem o r stressful issue w as described. These co ping -re-spo nse categ ories w ere based on co ping -respo nse scale s dev el-oped from the rev is ed W ay s ofCoping checklist (2 0 , 22 ). Cate-go rie s are not m utually ex clusive and inc lude all reported cop-ing responses. A s show n in Table 6 , few re lapsers used

problem -so lv ing or confro ntive w ay s ofcoping w ith the ir pro b-lerns, com pared w ith m aintainers or contro l subjec ts , and w erem o re like ly to use em o tion-fo cused or escape -av o idance w aysof co ping , such as eating , sleeping m ore , or w ishing the prob-lem w ould g o aw ay , than w ere m aintainers or contro l subjects .In co ntras t, m ore contro l subjec ts reported using relax atio ntechniques, exerc ising , o r w orking m o re w hen troubled thandid m aintainers or re lapsers .S oc ia l supp ort

In addition to us ing m o re pro blem -focused than em otio n-focused coping in respo nse to problem s ituations, m ore m ain-tainers and contro l subjec ts soug ht support or help in dealingw ith the ir pro blem s from fam ily , friends, and pro fe ssio nalsthan did re lapsers (Fig 2 ) . M ore re lapsers reported that theyhad few people av ailable for suppo rt or he lp w ith the ir prob-lem s than did m aintainers (Fig 3 ). M ore than half the w om enin all three groups reported that their husbands w ere not sup-portive, e ither fo r pro blem s o r troubling aspects o f the ir live so r for the ir w e ight-contro l effo rts . There w ere no significantdifferences in the num ber of relapsers, m aintainers, or co ntro lsubjec ts w ho repo rted that they had supportiv e spouses .Se lf- repor ted akoho l consum p tio n and sm o kin g

M o st m aintainers and co ntro l subjec ts repo rted them selv esto be light drinkers w hereas relapsers w ere div ided abo utequally be tw een the non- and light-drinker categ orie s (Table7 . There w as a slig ht tendency for co ntro l subjec ts to report

TA B LE 6Coping w ith problem s: com parison o fre lapsers , m aintainers, andc ontro l s ubje cts

ControlRelapsers M aintainers subjects

Co ping response (n= 35 ) (n= 2 4) (n= 26)Escape-avoidance 27 (7O )t 8 (33) 9 (35)

Eats, sm okes , drinks, takestranquilizer

S le eps m oreW ishes problem s w o uld g o

awayS ee ks s oc ial suppo rt I S ( 38 )t 1 7 ( 70 ) 2 1 (80)

Talks o ut fe eling sSeeks profess ional he lp

S elf-co ntro lling 5 (13) 4 (164 10(43 )K eeps fee lings to se lfGoes over things to se lf

Pro ble m so lv ing and/o rconfro nting 4(lO ) 23 (95) 15(60 )

Tens ion reduction 1 (2 ) 4 ( I 7 )j 1 1 (42)Exerc ises , does extra w o rkShopsU ses re la xa ti on te c hn iq ue sTotals 52 56 66S O fthe study subjec ts , 87% o fthe re lapsers, 8 0% ofthe m aintainers,

and 76% ofthe contro l subjects stated they had problem s no w ; data inthis table are based on the subjec ts w ho reported pro blem s. Percents inparentheses.

t S ig nific antly diff erent fro m m aintaine rs: tP < 0 .01 ; P < 0 .001 .:t Significantly different from contro l subjects, P < 0 .05 .


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e m otio n -fo c u s e d p ro b Im o c u s e d s ee k s o c s u p p o r

S

S

1 o r2 3orm ore

LON G -TERM W EIG H T M A IN TEN A N CE 80 5

Ca)C.8 .

100

80

60

40

20

0

w a y s o f c o p in gFIG 2 . Percent ofre lapsers(U ), m aintainers(D ) , and co ntro l subjects

(0 ) w ho used em o tion-fo cused or problem -fo cused w ays o f co ping orw ho sought soc ial suppo rt to aid in coping w ith problem s. W ays-o f-coping categ ories from Folkm an and Lazaruss W ays ofCoping check-list (20 , 22). * 55S ignificantly different fro m m aintainers: 5P < 0 .01;* *P< 0.001.

m ore m oderate -to -heavy drinking than did re lapsers. Re lapsersrepo rted pre ferring to eat foo d rather than drink alcoho lic bev -erages. Pro blem drinking w as not assessed in the current s tudy .There w as no sig nificant difference in current or form er se lf-reported sm oking in the three groups.

DiscussionThe results o fthe present study support sev eral hypo theses o f

pos sible co rre late s o f successful m aintenance after w e ight losssug gested by o ther investigators (1 5, 16 , 2 3 -2 7) . These investi-gators reported that exerc ise , positive se lf-s tatem ents re lated to

. w eight-reduc tion e fforts , and se lf-regulatory ac tiv itie s , such asappropriate go al setting , s elf-m onito ring o f eating or w e ight,and early recognition of w e ight regain, w ere im portant vari-

CaC.a0.

1 00

80

60

40

20

0

# pe op leFIG 3. Percent o fre lapsers ( {149})n d m a in ta in e rs (D ) repo rting that 0 ,

1 o r 2 , or 3 peo ple w ere av ailable for support o r help w ith problem s.5 Sig nific antly diffe re nt fro m m aintaine rs , P < 0 .0 1 .

T A B L E 7A lco ho l intake and sm o king: co m parison of re lapsers , m aintainers,and c ontro l

ControlRelapsers(n = 44

Maintainers(n = 30

subjects(n = 34 )

A l co ho l i nta keN ondnnke r 2 1 (47 .7)t 7 (23 .3) 4 ( 1 1 .8 )L ig ht i ntake

( 5 to 10 dnnks /w k) 5 ( 1 1 .4 ) 4 ( I 3 .3 ) 7 (2 0 .6)Smoking

N eversm o ked 23(5 2 .3 ) 14(4 6 .7 ) 24(7 0 .6 )Form er sm oker 1 2 (27 .3) 8 (26 .7) 6 (1 7 .6)Smoker no w 9 (2 0.5) 8 (26 .7) 4 ( 1 1 .8 )

S N um be r o fs ubje cts ; pe rc ent i n pare nthe se s.t S ignific antly diffe re nt from m aintaine rs and f ro m c on tro l s ubje cts , P < 0 .01 .

able s asso ciated w ith w e ight-lo s s m aintenance. These fac torsw ere also im portant for the m aintainers in this study .

M ost m aintainers and contro l subjec ts in this study exercis edregularly w hereas few re lapsers did so . It w as also observed inother studies that ex ercise differentiates m aintainers and re-lapsers ( 1 3 , 2 4-28) . Exerc ise has been show n to increase , de-crease , or hav e no effec t on foo d intake . Continued effo rts areneeded to e luc idate the relatio nships am ong foo d intake , appe -tite , exerc ise, and m aintenance ofw eig ht loss . Ifcalorie intakedoes not increase w hen obese subjec ts beg in ex erc ising (29 , 3 0 ) ,or ev en decreases (29 ) , the additio nal energy o utput o fa regularexerc ise routine m ay co ntribute to the w eight-loss m ainte -nance . A no ther possibility is that regular exerc ise m ay increaseresting m etabo lic rate (3 1 . In any case , ex erc is e seem s to helpto facilitate behav io rs necessary to achieve long -term w eightm aintenance . S o m e inv estig ato rs (32 , 3 3 ) suggest that exerc isem ay elevate m oo d and fee lings ofw ell-be ing , w hich m ay fac ili-tate o ther pos itive behav io rs conduc ive to successful m ainte-nance ofw eig ht los s .

In the present s tudy , w e ight reg ain (relapse) w as frequentlyattributed to negative em otional state s and unex pected or un-predic table stre ssful life events . This w as also observed by otherinv es tigators (34 ). In addition to supporting this observation,the present study identif ied an im portant difference in the w ayin w hich m aintainers and relapsers coped w ith their pro blem s.W hereas m aintainers and re lapsers (and contro l subjects ) allreported unex pected and unpredictable stress ful life events ,m aintainers be lieved them se lves capable o f handling the irpro blem s and used pro blem -so lv ing skills to co pe w ith theirdifficultie s. In co ntrast, re lapsers did not deal w ith their prob-lem s direc tly (perhaps because they lacked e ffec tive pro blem -so lv ing skills) and repo rted that they used foo d to m ake them -se lv es fee l better w hen upset. These findings offer additionalsupport for M arlatt and G ordo ns theory of relapse (3 ), w hichsugg ests that an indiv idual w ho has successfully m ade a behav-io r change w ill re turn to a form er negative behav ior patternw hen a high-risk (problem ) situation occurs fo r w hich co pings kills are lac king .

So c ial suppo rt o r the perception that fam ily or friends areav ailable to discuss troubles and offer help w hen neededseem ed s ignificantly g reater fo r the m aintainers than for there lapsers in the present study . There is som e indication that


7/8

80 6 K A Y M A N ET A Lsoc ial support plays a ro le in the m aintenance of new healthbehav iors (3 5). S oc ial support probably acts to buffer s tress (20)and m ay be used to assist peo ple in m aking stressful dec isions(3 6 ) , but exac t m echanism s and details for the ro le so cial sup-po rt play s in m aintenance of lo ng -term w eight lo ss are ye t tobe defined and should be investig ated (37 ).

The m any g enetic and phys io log ic fac tors that m ay be re -lated to m aintenance of long -term w eig ht lo ss such as restingm etabo lic rate, num ber or type offat ce lls, adipose- tis sue distri-bution, lipoprote in lipase activ ity , or ratio of fat to lean bodym ass w ere not assessed in this s tudy . H ow these factors m ayinteract w ith the behav ioral fac tors explored in this study andthe ro le each fac tor m ay play in co ntributing to the diff icultyre lapsers have in beco m ing long-term w eig htlo ss m aintainersis not know n. A prospec tive study to asse ss gene tic and phys io -log ic differences and the interplay of these w ith psycho log ical,so cial, cog nitiv e, and behav ioral fac tors as indiv iduals lose andthen m aintain reduced w e ights could he lp to de fine the m ostappro priate treatm ents for different indiv iduals. It w ould alsobe of interest to investigate w hether findings reported here fo rthree relative ly sm all groups of m ostly w hite w om en are truefo r m en, o ther e thnic groups, and low er-incom e w o m en. A lso ,a prospectiv e s tudy to determ ine ifre lapsers w ho lack pro blem -so lv ing skills could be taught these skills and be he lped to loseand then m aintain w e ight losse s, even w hen ex perienc ingstres sful life events , is needed. Pre lim inary findings w ith sm allnum bers o fsubjects are encourag ing (38-40 ) but additio nal re-search w ith greater num bers o f indiv iduals is needed in co n-tro lled, prospective studies to confirm the hypotheses gener-atedhere (l7 , 1 8 ).

Though routine , regular exerc ise , low er calo ric intake , anddie t-com pos itio n chang es sustained over tim e perm itted them aintainers and the contro l subjects in this study to stay atthe ir desired w eig hts, each w om an thought about herse lf andabout her life in w ays that m ade it po ssible for her to m ake thefood cho ices she did and to continue to exerc ise . The w om enachieved these behav iors and tho ught patterns in the ir ow nunique w ays. B ased on this observ ation, that indiv iduals v arygreatly in the w ays they achieve successful lo ng-term w eightlo ss m aintenance, w e suggest that each person w ho com es fo rtreatm ent be asse ssed be fo re any interv ention and guided inselec tion of the m ost appropriate treatm ent, rather than offer-ing the sam e program to all. This suggestio n im plies the av ail-ability o fa varie ty oftreatm ent options, w hich m ay not be c ur-rently available in all areas, a pro blem that sho uld be addressed.In additio n, the outco m es o f a w eig ht-m anagem ent screeningand re ferral pro gram should be evaluated to de term ine if thisapproach w ill increase the num ber of successful long -termw eig ht m ai ntai ne rs . El

Grateful thanks to S Leo nard Sym e, Richard Lazarus , and S heldonM argen for guidance and helpful discussions of this w ork; to JohnS om m er, Sharo n Lev ine , Tom S him izu and his s taff, H arvey K ay m an,S usan B acig alupa, and the Patient Education C om m ittee o f Frem ontKaiser Perm anente M edical Offices for the ir exceptional cooperationand ass istance during recruitm ent and interv iew ing ; to Steve S e lv in andB ob S ho ltz fo r statistical adv ice: to Judith W ilhite fo r telephoning par-tic ipants ; and to Irene Hepps fo r coding assis tance. S pec ial thanks tothe study partic ipants, w ho so candidly and grac ious ly shared the ir liv esand the ir sto ries . Thank you to K elly B row nell for helpful com m entson an earlier draft and to A bby C K ing for her encouragem ent andhelpful adv ice during deve lopm ent o fthe m anuscript.

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