Thesis: Literature Review Part II

Table of Contents

The Weight Loss Industry

In the United States and Canada, the weight loss industry is largely unregulated. Any company or person can devise or promote any kind of program without restriction as long as the Food and Drug Act and Regulations are not contravened (Canada Task Force, 1991). Therefore, anyone can call whatever program they develop "treatment" for obesity without any legal obligation to verify results, prove effectiveness, or even guarantee safety. This situation would appear to put most consumers in situations for which there is little if any protection either against the program itself or misleading advertising or information that the program may give.

In 1988, the cost of weight loss products and services in the United States was estimated in the range of $29 billion. This did not include "weight loss" surgeries such as gastroplasty ("stomach stapling"), liposuction or jaw wiring (Garner & Wooley, 1991). A Marketdata report (Berg, 1994) indicates a total of $31.86 billion was spent in 1993 on weight loss products. Almost half of this revenue ($15 billion) was spent on diet soft drinks. Low calorie foods, meal replacements, artificial sweeteners and appetite suppressant pills made up $6 billion, $2 billion was spent on commercial weight loss programs or medically supervised programs, and the rest was spent on fitness spas or exercise clubs. In Canada, it is estimated that the reported revenues in 1990 of weight loss centers was $300 million. The number of diet franchise facilities tripled to 500 between 1987 to 1990 (Canada Task Force, 1991).

In spite of the ample number of commercial programs available for people who want to lose weight, it is striking to note their lack of data in informing consumers of typical outcomes. Anecdotal "success" stories that many weight loss firms use in their advertisements are enticing, but certainly not representative of outcomes for the vast majority of diet program users. The National Institute of Health (1992) recommended that commercial weight loss programs should inform of the public of the percentage of those who begin the program and complete the program, the percentage of those completing the program who achieve various degrees of weight loss, the proportion of weight loss that is maintained at one, three, and even five years, and the percentage of participants who experience adverse medical or psychological effects during their programs. Most commercial weight loss programs have access to this information but do not provide this data to its consumers.

Weight preoccupation has become a normal and intrinsic part of people's lives. I note with concern the increasing amount of weight loss advertising that encourages a culture of weight preoccupation. Thin models are often found in advertisements of how they were able to lose ten pounds of "unsightly fat" using a certain plan or product. The message is clear; even if you are normal weight, you should worry. There is the underlying assumption that once weight is lost, weight preoccupation will end. This is a false assumption. First, weight regain usually occurs with its resultant weight preoccupation and second, those who are maintaining weight loss will often report that they always remain vigilant about and fearful of weight gain.

Physical Treatments

Physical treatments include the full range of weight loss strategies of dieting through food restriction, very low calorie diets, and exercise.

Weight Loss Strategies Through Dieting

Starvation levels of food in third world countries are considered to be less than 1,300 calories per day (Seid, 1994). Most diet programs encourage an average caloric intake from anywhere between 500 to 1,300 calories daily. Therefore, in western society, many women are living on starvation levels of food. It is questionable as to whether a daily intake of about 1,000 calories is sufficient to meet the nutritional needs of women. Furthermore, vitamin supplements are unlikely to compensate for this difference.

Putting oneself on a diet consisting of a significant reduction of calories has several emotional and physical risks. The effects of dieting include depression, irritability, fatigue, weakness, social withdrawal, reduced sex drive, semi-starvation neurosis and cardiac arrhythmias leading to sudden death (Servier Canada, Inc., 1991). After dieting, sense of appetite and satiety are lost, cravings for certain foods develop and there is increasing proeccupation on weight. The long term effects of dieting include nutritional deprivation, depression, anxiety, anger, mood swings, binge eating and chronic eating disorders (Ciliska, 1993b). Garner and Wooley (1991) are clear in their conclusions about the impact of the dietary treatment of obesity: 1) Virtually all programs appear to be able to demonstrate moderate success in promoting at least some short term weight loss; and 2) There is no evidence that clinically significant weight loss can be maintained over the long term by the vast majority of people.

More recently "low-fat" eating has been promoted as an effective weight loss technique. A diet that is low in fat may be advantageous to one's health in preventing some cancers and high blood cholesterol (Bailey, 1991). Blundell, Burley, Cotton, Delargy, Green, Greenough, King, and Lawton (1994) found that eating a diet that was high in fat would result in a rising cycle of increased food consumption without regard to satiety signals. A low-fat diet in which satiety was achieved (that is, feeling full) would result in less overall consumption of food. Therefore, there may be a correlation between low-fat eating and a positive impact on overall health. However, the assumption that low-fat eating will lead to weight loss is not so clear and has yet to be validated through research as opposed to anecdotal evidence.

Very Low Calorie Diets (VLCD's)

Very low calorie diets (VLCD's) are defined as diets that range from 300 to 800 calories per day intake. These calories are usually consumed in the form of food replacement products that are widely available and commercially are called "liquid protein." Long term studies of the use of VLCD's have shown consistent results; patients on VLCD programs regain most or all of the weight lost in the months following the VLCD regime. In fact, one of the most remarkable features of VLCD's is the speed of weight regain following treatment (Garner & Wooley, 1991).

The College of Physicians and Surgeons of Alberta (1994) published a policy paper on VLCD's in which it was strongly stated that VLCD's should only be prescribed and supervised by specially trained physicians. The College was clear in its position that VLCD's should only be used on morbidly obese patients (over 300 pounds) and that the prolonged use of VLCD's is dangerous and potentially lethal. Despite this, VLCD's are widely advertised using prominent actors or models who clearly give the impression that liquid diets are easy, successful and safe for any amount of desired weight loss.

Exercise

Exercise has often been promoted as the "best" way of losing weight. However, exercise alone has not been shown to be significantly effective in achieving weight loss. The amount of weight lost through exercise alone usually ranges from four to seven pounds (NIH, 1992). However, exercise independent of weight loss, has been shown to have a positive impact on cholesterol and increase lean body mass. It improves the function of such body systems as cardiovascular, respiratory, nervous, endocrine, musculoskeletal, and immune and can improve conditions such as arthritis, diabetes, and hypertension. It enhances body appreciation, mood and self esteem. There is increasing evidence that physical fitness independent of body size reduces mortality risk (Garner & Wooley, 1991).

People will often begin an exercise program with the goal of weight loss. Despite the other significant benefits of exercise, if the bathroom scale does not reflect sufficient weight loss during the program, many people will give up the exercise in frustration that it "did not work." It is unfortunate that people have learned to evaluate their health and fitness only through the numbers on the scale rather than through other indications of improved physical and mental health.

Psychological Treatments: Behavior Modification

Behavior modification is teaching awareness and changing the behaviors that may result in increased amounts of food being consumed. It is based on the belief that people who want to lose weight should reduce the amount of food consumed. It assumes that the obese eat significantly more than needed. Slowing down eating, not tasting food while cooking and not shopping while hungry are examples of some behavior modification techniques. Behavior modification techniques are often taught in conjunction with traditional diet programs.

Behavior modification can be potentially helpful in aiding attempts at weight reduction if increased food consumption is an issue. However, while most repeat dieters are well versed in these techniques, they continue to struggle with weight related issues (Garner & Wooley, 1991).

Combination Treatments

There are two types of combination treatments, the traditional weight loss groups and another type of marketed program which I have termed "diets in disguise."

Traditional Weight Loss Groups

Traditional weight loss groups attempt to encorporate a low calorie diet, exercise and behavior modification techniques in a supportive setting where clients are weighed either daily or weekly. Combining changes in diet and exercise can lead to greater short term weight loss than with either alone. Behavior modification also appears to extend the interval before weight is regained. However, as discussed, despite compelling anecdotal evidence, there is a paucity of data coming from commercial weight loss groups to statistically document short or long term weight loss and maintenance or attrition rates.

Wolf (1991) compares weight loss groups with religious cults in their fervor and demand for obedience to their rules. In many ways, diet centers attempt to disempower its users by weekly or daily weighing of members and expecting them to strictly adhere to their food plan with a structured diet plan or through food and supplements that are available from the agency. Bovey (1994) discusses the typical submissive "personality" that members of weight loss groups take on. She feels that these groups encourage women to lose weight by having them respond to an authority figure that weighs and evaluates their "progress" with attitudes of both encouragement and shame.

Diets in Disguise ("DD's")

Many "weight loss experts" will loudly cry about how diets don't work and then encourage consumers to try their own "guaranteed weight loss" method. They continue to deny that they are a diet and often will engage repeat dieters with how diets are doomed to fail and shared experiences of past dieting failures. Usually, their method will be a variation of monitoring fat intake, promoting exercise, or the use of magical types of herbs or devices. They are promoting what I have called, yet another "DD" (diet in disguise). That is, even when they say "don't diet," they usually promote a highly structured plan in conjunction with their method that directs consumers in behavioral, physical and restrictive food intake behaviors. They give consumers a diet.

Often experts in the field will offer the promise of weight loss once emotional eating is under control (Orbach, 1978; Roth, 1992,). The promise made is that if the consumer makes "peace" with food, then the weight will come off. I agree with the importance of looking at one's relationship with food and striving to understand it and disempower food. However, I feel it is deceptive to promise that by doing this, weight will be lost.

There is usually a profit motive. Despite the charisma of the promoter and the presentation of anecdotal evidence in highly charged, emotionally saturated scenes, there is a striking lack of statistics that reveal the true "success" rate of any of these programs.

Non-dieting Treatments

Non-dieting treatments include feminist approaches to weight preoccupation and non-dieting approaches.

Feminist Approaches To Weight Preoccupation

Feminist approaches are critical of many of the traditional methods of dealing with weight preoccupation and dieting in which an unequal status between "helper" and "client" is created. The emphasis in feminist therapy is on empowerment and self determination for the client (Brown, 1993). Feminist theory looks at the personal and political issues as both the causes for and potential solutions to women's preoccupation with food . Feminist counseling integrates three processes based on a feminist understanding of society: a healing process, an educational process, and a political process. The basic philosophy is to replace shame with dignity, self-blame with curiosity and self-criticism with tolerance and self respect (Friedman, 1993).

Feminist therapy recognizes that weight preoccupation is predominantly a women's issue and is consistent with a social work and non-dieting approach. It generally supports striving for acceptance of one's body regardless of size. It promotes the idea of trusting one's body, a process which may be quite frightening for many women. It advocates self care through healthy choices without an emphasis on dieting or weight loss and recognizes the importance of making peace with food through such techniques as irrational eating (Zimberg, 1993). Therefore, it is the treatment modality of choice in developing the theoretical basis to Beyond Dieting.

Non-dieting Programs

There are programs that offer a non-dieting approach to weight preoccupation. It is important for these programs to be clear in their emphasis of encouraging health and NOT alluding to or promising weight loss. Some non-dieting programs are discussed in Brown and Jasper's Consuming Passions: Feminist Approaches to Weight Preoccupation and Eating Disorders (1993). The book includes discussion of Ciliska's (1990) Beyond Dieting program in Toronto and other programs that have taken on a non-dieting approach. Hirschmann and Munter (1995) founded The National Center for Overcoming Overeating in the United States which addresses the issue of body hatred that many women experience and Burgard and Lyons (1994) have established a program providing alternatives for obese women that focuses on health as opposed to dieting. Linda Omichinski (1993) developed the HUGS (TM) program in Canada which also encourages healthy choices as opposed to weight loss. The HUGS(TM) program was developed and is run by registered dietitians. As a result, there is an emphasis on food and eating styles. While this may be helpful to some clients, it is my belief that most repeat dieters are well aware of food choices that they "should" be making. I believe that non-dieting programs have the greatest impact when they address the social and emotional issues that the obese confront. Brown and Zimberg (1993) emphasize the need for a non-dieting program not to promote weight or eating, but to focus on the meaning of the behavior, body image, empowerment, and emotional needs.

Conclusion

Weight loss attempts of any kind: dietary, exercise programs, pharmaceutical interventions, stomach or intestinal surgery and liposuction, have proven to have short term success and intermediate to long term failure often with the additional insult of weight rebound above the original starting point (Ciliska, 1990). The emphasis on "success" and "failure" usually succeeds in intensifying one's preoccupation with food and weight and lowering self esteem.

To study the long term impact of weight loss is most difficult as there are so few individuals who have been able to maintain long term weight loss (NIH, 1992). Given the likelihood that weight will be regained, it remains to be determined whether temporary weight loss leads to any permanent health benefits.

It is important for people to focus on health related choices rather than evaluating one's fitness on the bathroom scale. As discussed, exercise is beneficial for all people independent of size, even without weight loss. A food plan that is similar to that of the Canada's Food Guide (Minister of National Health and Welfare, 1992) promotes healthy eating (fruits and vegetables and low-fat intake) that will lead to health benefits such as less ongoing hunger but is not strongly correlated with weight reduction (Blundell et al., 1994). The next chapter describes the methodology of how the Beyond Dieting program was developed and evaluated.

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