Dieting and the Development of Eating Disorders in Overweight and Obese Adults

REVIEW ARTICLE Dieting and the Development of Eating Disorders in Overweight and Obese Adults

National Task Force on the Prevention and Treatment of Obesity

e reviewed articles evaluating the relations among dieting, weight loss treatment, weight cycling, eating disorders, and psychological functioning in overweight and obese adults. Moderate caloric (energy) restriction, in combination with behavioral weight loss treatment, does not seem to cause clinically signifi- Wcant binge eating in overweight adults without preexisting binge eating problems and might ameliorate binge eating, at least in the short term, in those reporting recurrent binge eating before treatment. Most studies of behavioral weight loss interventions report improvements in psychological status during weight loss. However, these improvements might return to baseline with weight regain. Weight cycling does not seem to be associated with clinically significant psychopathologic conditions, although results of cross-sectional studies show an association between weight cycling and binge eating, as well as poorer perceived health status. “Nondieting” approaches seem to lead to improvements in mood and self-esteem; however, weight loss is generally minimal. Con- cerns that dieting induces eating disorders or other psychological dysfunction in overweight and obese adults are generally not supported by empirical studies. Such concerns should not preclude attempts to reduce caloric intake and increase physical activity to achieve modest weight loss or prevent additional weight gain. Arch Intern Med. 2000;160:2581-2589

Overweight and obesity affect millions of weight loss in obese adults and in those Americans, and their prevalence contin- who are overweight and have comorbid ues to increase. Overweight (defined as a conditions. Weight maintenance is rec- body mass index [BMI; calculated as ommended for individuals currently overweight in kilograms divided by the square weight without associated health risks. of height in meters] Ն25) affects more than The health benefits of initial weight half of adult Americans, and 23% meet cri- loss have been well documented. Weight teria for obesity (BMI Ն30).1 Overweight loss lowers blood pressure and choles- and obesity are associated with numer- terol levels and improves glycemic con- ous adverse health conditions, including trol.4 Concerns regarding the association type 2 diabetes and cardiovascular dis- of weight loss5,6 and cycles of weight loss ease. Direct and indirect medical costs at- and regain (weight cycling)7,8 with mor- tributable to obesity are estimated to ap- bidity and mortality also have been dis- proach $100 billion yearly.2 Current public cussed in previous reviews. However, there health policy recommends weight loss or has been less attention to the behavioral maintenance for those above a healthy consequences of dieting and weight loss. body weight. For example, the 1995 Di- Achieving weight loss requires energy re- etary Guidelines for Americans3 contains striction, increased physical activity, or fre- a recommendation to “maintain or im- quently both. Concerns have been raised prove your weight,” whereas the Na- that recommending weight loss, with con- tional Institutes of Health4 recommends comitant dietary restriction, might precipitate the development of eating disor- A complete list of the members of the National Task Force on the Prevention and ders or might exacerbate eating disorders Treatment of Obesity appears in the acknowledgments at the end of this article. among those already affected.9

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2581

Downloaded From: https://jamanetwork.com/ on 09/24/2021 The purpose of this study is to published in languages other than tirely unexpected, given that the review the literature on the impact English were not included. Repre- men’s body weight was reduced 25% of weight loss treatment in general, sentative cross-sectional or prospec- below normal levels and easily met and dietary restriction in particu- tive studies were identified that the weight criterion for anorexia lar, on the development or course of evaluated (1) the relations between nervosa. eating disorders in overweight and dieting, weight loss treatment, or Findings from this study of ad- obese adults. We also consider the weight cycling and the develop- verse effects of caloric restriction in effects of dieting and weight loss on ment or exacerbation of eating dis- normal-weight individuals are of- other psychological variables, most orders in overweight and obese ten extrapolated to those who are notably depression. Because many adults; (2) the relations between di- overweight. However, obese indi- people who lose weight ultimately eting, weight loss treatment, or viduals might be protected from regain it, the effects of weight cy- weight cycling and psychological some of these ill effects by virtue of cling on eating disorders and de- functioning in overweight and obese their larger energy stores. In addi- pressive symptoms are also re- adults; (3) the impact of “nondiet- tion, current recommendations for viewed. Because dietary restriction ing” treatments on weight, eating weight loss in obese adults call for in children and adolescents poses disorders, or psychological func- caloric deficits of 500 to 700 kcal/d special concerns, the conclusions de- tioning; and (4) the effects of weight (2092 to 2929 kJ/d), leading to mod- rived from this review of the litera- gain prevention interventions on est weight loss (eg, 10% of initial ture should be considered appli- psychological functioning and eat- body weight),4 in contrast to the cable to adults only. ing behavior. Although numerous more extreme caloric restriction in studies reached similar conclu- the experiment by Keys et al. The rel- DEFINING DIETING sions (eg, improvement in depres- evance of the findings of Keys et al sion scores with behavioral weight to obese individuals who seek weight The term “dieting” is widely used as loss treatment), not all studies were loss is unclear. if it described a well-defined, accu- cited; however, attempts were made rately measured pattern of behav- to cite any studies with findings dif- RELATION OF DIETING TO ior. The reality is different. In a re- fering from the majority. Because EATING DISORDERS view of the effects of dieting on surgical treatment of obesity is an weight loss and health, French and option for only a small minority of Most eating disorders in over- Jeffery10 concluded that the “re- individuals with severe obesity, ar- weight and obese adults involve sults of studies of dieting are diffi- ticles addressing only the relation binge eating, with binge eating dis- cult to interpret because dieting has between surgical obesity treatment order (BED) being the most com- not been consistently and clearly op- and the variables of interest were not mon eating disorder seen in obe- erationalized.” In addition, some in- reviewed. sity treatment settings.15 Binge eating vestigators11-13 have noted that re- disorder is included in the Diagnos- sults of studies designed to measure HISTORY OF CONCERN tic and Statistical Manual of Mental the impact of “restrained eating” dif- Disorders, Fourth Edition,16 as a di- fer depending not only on the indi- The initial suggestion that dieting agnosis requiring further study. Re- vidual’s body weight but also on and weight loss cause negative psy- sults of studies from the United whether one is currently dieting to chological consequences, includ- States indicate that the prevalence of lose weight or has a history of fre- ing eating disorders and depressive BED in adult community samples is quent dieting. Dieting, as used in this symptoms, came from the study by less than 3%.15 The prevalence in article, refers to the intentional and Keys et al.14 This study involved nor- overweight persons is higher, with sustained restriction of caloric in- mal-weight young men who partici- increasing prevalence as degree of take for the purpose of reducing pated in a semistarvation experi- obesity and intensity of treatment in- body weight or changing body ment in which they received about crease. People with BED report fre- shape. The restriction of caloric in- 1600 cal/d (6694 J/d) (ie, approxi- quent episodes of eating substan- take results in significant negative mately half of their previous food in- tially larger amounts of food than do energy balance. take) for 6 months. The diet re- others in similar circumstances, sulted in loss of roughly 25% of their along with an accompanying feel- STUDY SELECTION body weight. Profound effects were ing of loss of control. These indi- observed across a wide range of func- viduals do not compensate for their Electronic databases (MEDLINE and tioning. Extreme negative emo- overeating by purging (ie, vomit- PsycINFO) were searched for ar- tional reactions, including depres- ing or laxative abuse), fasting, or ex- ticles using varying combinations of sion, irritability, and anger, were cessive exercise, a characteristic that the keywords “dieting,” “weight common. A subgroup of men en- distinguishes them from persons loss,” “weight cycling,” “binge eat- gaged in binge eating that per- with bulimia nervosa.16 ing,” “eating disorders,” “psycho- sisted, in some cases, after free ac- The development of anorexia pathology,” “affective distur- cess to food was restored. The nervosa and bulimia nervosa are al- bances,” “depression,” and “obesity.” majority of men reported a return to most invariably preceded by di- This was supplemented by a manual normal eating 5 months after refeed- etary restriction. It has been sug- search of bibliographies. Studies ing. These findings were not en- gested that weight loss dieting might

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2582

Downloaded From: https://jamanetwork.com/ on 09/24/2021 be a “necessary but not sufficient” classified as non–binge eaters. More- VLCD than were those without BED; condition for the development of eat- over, each of 3 investigations23,26,27 however, in those who lapsed, ing disorders,17 at least in individu- of patients with BED found that greater caloric intake was reported. als with anorexia or bulimia ner- binge episodes declined signifi- Patients diagnosed before treat- vosa. At any given time, 44% of adult cantly during behavioral weight re- ment as binge eaters tended to re- women and 29% of adult men in the duction therapy. An abstract by Mar- port fewer binge episodes at fol- United States describe themselves as cus and colleagues27 reported that low-up (PϽ.06), and their scores on trying to lose weight,18 as do 44% of patients treated with behavioral the Binge Eating Scale declined sig- adolescent girls and 15% of adoles- treatment lost 9.9 kg during a nificantly. Improvements in eating cent boys.19 Although many diet, 6-month program, and the number behavior, as measured by this scale, however, comparatively few go on of binge days decreased from ap- were observed in another study24 that to develop eating disorders: the proximately 20 per month at base- included a 16-week liquid VLCD. In prevalence of eating disorders (in- line to 2.7 per month at the end of that study, the number of patients cluding anorexia and bulimia ner- treatment.23,26,27 with severe binge eating declined vosa) is estimated to be 1% to 4% of The results of these studies sug- from 9 to 5. Wing and colleagues34 adolescent and young adult women, gest that obese adults who partici- found no greater rate of reported di- the populations at highest risk.20 pate in traditional behavioral weight etary lapses in patients treated by Some other factor(s) must interact loss programs are unlikely to de- moderate vs severe energy restric- with dieting to cause eating disor- velop binge eating difficulties. In fact, tion. Patients who report binge eat- ders; possibilities range from ge- the data suggest that such treat- ing difficulties, on average, lose as netic predisposition and biological ment ameliorates binge eating in much weight on a VLCD as those who vulnerability to individual psycho- obese patients who report recur- do not report binge eating.30,31,35,36 pathology, to familial and cultural rent binge eating at the time of study One study,30 however, re- influences. entry.23,26,27 ported a clear increase in binge eating after 12 weeks’ consumption of PROSPECTIVE STUDIES OF Severe Energy Restriction a liquid VLCD. As many as 60% of DIETING AND BINGE EATING patients who, at baseline, had been Very low-calorie diets (VLCDs), pro- classified as non–binge eaters re- An important issue is whether viding 400 to 800 kcal/d (1674 to ported occasional binge episodes in weight loss treatment increases binge 3347 kJ/d), were popular in the the 9 months after consumption of eating in those with or without BED 1980s and continue to be used to- the VLCD. At the final assessment, before starting treatment. We will day on a more limited basis.28 These 12 months after severe caloric re- consider several different ap- diets induce an energy deficit greater striction, 15% of this sample was proaches to weight loss and their re- than 1000 kcal/d (Ͼ4184 kJ/d) in judged to meet the criteria for BED. ported effects on binge eating. The most patients, which yields aver- (By contrast, 39% of patients who be- following studies evaluated treat- age losses of approximately 20% of fore treatment met BED criteria no ments designed to produce weight initial weight in 12 to 16 weeks.21,28 longer did so at the final assess- loss in obese adults rather than tar- Although VLCDs do not seem to ment.) These findings are cause for geting binge eating behaviors. have adverse long-term effects on concern but must be interpreted cau- resting energy expenditure or body tiously. Except for the baseline and Moderate Energy Restriction composition,8,28 they have been an- final assessments, all measure- ecdotally reported to precipitate ments of binge eating were based on Obese adults who seek weight loss binge eating, particularly during the patients’ subjective assessments. in university- or commercial-based refeeding period that follows the ter- Moreover, in the brief period be- programs are usually prescribed mination of severe energy restric- tween the baseline assessments and a diet of conventional foods de- tion.29 The excess eating is thought their beginning the VLCD, 30% of signed to induce an energy deficit of to be a compensatory response to the these patients reported having binge 500 to 700 kcal/d and a weight loss physiologic or psychological ef- eating episodes, although they had of 0.50 to 0.75 kg/wk.21,22 Diet is of- fects of food deprivation.29 Three recently been diagnosed as non– ten combined with recommenda- studies24,30,31 have examined this is- binge eaters by the study’s expert rat- tions to increase physical activity and sue. A study of 38 women on a ers. This finding underscores the modify inappropriate eating hab- weight loss program that included need to use uniform criteria in as- its. Most programs provide some a 12-week VLCD31,32 observed no sessing binge eating. form of individual or group coun- significant increase in the fre- seling to meet these goals. Struc- quency of reported binge days in pa- Weight Loss Medications tured interventions of 16 to 20 weeks tients who, before treatment, were produce average weight losses of 7% classified as non–binge eaters. In ad- A small but significant minority to 10% of initial weight.21,22 dition, there were no significant of obese adults take prescription Three studies23-25 found that changes on the Binge Eating Scale,33 or over-the-counter “diet” pills to this approach was not associated as assessed 6 months after the VLCD. lose weight. Two medications— with reports of binge eating in obese Individuals with BED were no more sibutramine hydrochloride and or- adults who, before treatment, were likely to report deviations from the listat—are approved for weight loss

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2583

Downloaded From: https://jamanetwork.com/ on 09/24/2021 and maintenance of weight loss in tioned, involved normal-weight treatment, in which weight loss the United States.37,38 Sibutramine is rather than obese volunteers. The methods might not reflect those used a combined serotonin-norepineph- second study45 found that 54% of by the general population. Surveys rine reuptake inhibitor that re- obese patients, who were treated in of US adults report exercise and de- duces food intake, apparently by en- a nutrition clinic, reported (retro- creased fat intake57 and counting hancing satiety.37 Orlistat is a spectively) that they had experi- calories58 as the most common gastrointestinal lipase inhibitor that enced symptoms of weakness, ner- weight loss practices. The Weight reduces the absorption of dietary vousness, irritability, fatigue, or Loss Practices Survey,59 using a na- fat.38 Both medications are associ- nausea at some time when previ- tional probability sample of US ated with a gradual 7% to 10% re- ously trying to lose weight. These in- adults, found that the most com- duction of initial weight during 6 dividuals did not report symptoms mon weight loss practices among months of treatment. Maximal of depression, although the report women included weighing oneself weight loss usually occurs by month of the findings was titled the “Diet- regularly (70%) and walking (58%). 6, and there seems to be some sub- ing Depression.” The title derived However, a few report the use of at sequent regain with continued from observations of a second group least one “unhealthy” weight con- therapy. of 25 individuals who were treated trol practice, such as fasting (5%), There have been no system- at an inpatient unit for both their meal skipping (21%), or use of diet atic investigations or published re- psychiatric complications and obe- pills (14%). In that survey, only 13% ports of eating disorders in patients sity. Other early studies, reviewed by of women and 5% of men reported treated with these 2 medications. Al- Stunkard and Rush,46 also reported participation in a formal weight loss though it has been recommended negative emotional responses to program. The degree to which data that weight loss medications, if used, dieting. from weight loss treatment studies be continued on a long-term ba- In contrast to these early find- reflects the experience of individu- sis,39 it is likely that they will be used ings, numerous studies conducted als losing weight using a variety of as short-term or intermittent therapy during the past 25 years have re- weight loss strategies without su- in many cases. It is well established ported reductions in symptoms of pervision remains unclear. that rapid weight gain follows dis- depression and anxiety or, at mini- Although most studies evalu- continuation of weight loss medi- mum, no worsening in affect in ating psychological changes with cation use.39-41 The mechanisms that obese patients treated by behavior weight loss are from those who par- drive body weight levels to return to modification combined with mod- ticipated in clinical studies, recent pretreatment levels remain to be erate caloric restriction,47-50 severe ca- information is available from 629 identified. However, it should be loric restriction,24,47,50,51 or use of women and 155 men in the Na- noted that dexfenfluramine,42 as well weight loss medications.40,52,53 Sev- tional Weight Control Registry, a as the fenfluramine and phenter- eral factors seem to explain the dis- registry of individuals who have lost mine combination,43 before the discrepancy between the early and later at least 13.6 kg (mean, 30.0 kg) and covery of their association with val- findings. Studies in the 1950s and who maintained a required mini- vular heart disease,44 had been 1960s were based primarily on pa- mum weight loss of greater than 13.6 reported to reduce binge eating in tients who were undergoing psycho- kg for more than 1 year (mean, 6 obese patients. At present, there are dynamic psychotherapy and, thus, years).60 Almost half of the individu- not adequate data to suggest that use were likely to have had significant als in this sample report having lost of available weight loss medica- emotional disturbance before weight weight on their own, without a for- tions either precipitates or amelio- loss.54,55 By contrast, more recent be- mal weight loss program, and the re- rates binge eating and related com- havioral studies included obese in- mainder lost their weight in a vari- plications. dividuals who volunteered specifi- ety of weight loss programs. Both cally for weight reduction; most were groups reported using diet and ex- DIETING AND known to be free of significant de- ercise to lose weight. Registry par- PSYCHOLOGICAL pression.56 In addition, most pa- ticipants completed a variety of mea- FUNCTIONING IN tients in recent studies received sures of mood, distress, restraint, OVERWEIGHT AND group support and cognitive behav- disinhibition, binge eating, and purg- OBESE ADULTS ioral therapy, each of which might ing.61 Distress and depression lev- favorably affect mood.54,55 Differ- els were similar to those of commu- We next consider the issue of ences in methods used to assess nity-based samples, as were rates of whether dieting and weight loss in mood, and the frequency of assess- binge eating and purging. Levels of overweight and obese adults cause ment, might further explain the dis- restraint and disinhibition were simi- psychological problems. There have crepancies between the early and lar to those in patients recently been several reviews of this litera- later studies.54 treated for obesity and differed from ture10; therefore, findings are only A potential limitation in deter- those of eating disordered samples. briefly summarized here. mining the relation between diet- Although this is not a random Concerns about a “dieting de- ing and psychological functioning or sample of all long-term weight main- pression” can be traced to 2 early eating disorders is that most stud- tainers, and hence is subject to se- studies, the first by Keys and col- ies were carried out in individuals lection bias, the results provide re- leagues,14 which, as previously men- undergoing supervised weight loss assurance that many individuals who

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2584

Downloaded From: https://jamanetwork.com/ on 09/24/2021 have lost and maintained weight ity) of binge eating. However, be- The psychological changes accompa- through a variety of methods do not cause these studies are cross- nying weight regain include in- experience significant psychologi- sectional or retrospective, it is creased depressive symptoms and de- cal distress or eating disordered be- unclear whether the weight cycling creased self-esteem, self-confidence, haviors. caused the binge eating. Equally and satisfaction with appearance.77 Most findings indicate that obese likely is the possibility that binge eat- However, a recent prospective study74 adults who lose weight are likely to ers are more likely to weight cycle. of the psychological effects of weight experience modest improvements in Weight cycling also has been re- cycling demonstrated that the posi- mood or, at minimum, no worsen- lated to decreased eating self- tive changes in mood corresponding ing in affect. Before weight loss, eg, efficacy,68 increased dietary help- with a 21.1±8.4-kg weight loss were obese individuals typically score in the lessness,69 and poorer body image.70 maintained at follow-up despite to- nondepressed range on the Beck De- In addition, weight cycling has been tal weight regain. Thus, there is a pression Inventory.62 With weight shown to be related to dietary dis- mixed pattern of change in psycho- loss, they report even fewer symp- inhibition.69,71,72 However, Wadden logical status during obesity treat- toms of dysphoria. Binge eaters, who and colleagues73 did not find a rela- ment and follow-up. usually report mild-to-moderate de- tion between weight cycling and dis- Anecdotal accounts72 of re- pression before treatment, might be inhibition when assessed cross sec- peat dieters describe considerable more likely to experience clinically tionally, and decreases in dietary frustration and distress over weight significant improvements in mood disinhibition seen during obesity regain, whereas controlled re- during behavioral weight reduction treatment have been maintained de- search suggests that some of the im- therapy.63 However, some individu- spite weight regain during follow- provements in psychological func- als might have psychological prob- up.74 Some of the distress noted tioning that correspond with weight lems that can be exacerbated by among weight cyclers might be me- loss can be maintained despite re- weight loss.64,65 The clinician should diated by the presence of BED. One turning to baseline levels of obe- remain vigilant for such vulnerable cross-sectional study75 evaluating sity. This discrepancy might be due patients and refer them for assessment weight cycling women with or with- in part to the observation that self- and counseling as appropriate.65 out BED found that those with BED perception of weight cycling may be reported greater psychological dis- more predictive of psychological DOES WEIGHT CYCLING tress and depression and lower self- functioning than actual history of CAUSE EATING DISORDERS esteem than weight cyclers with- weight cycling.78 Research is needed OR PSYCHOLOGICAL HARM? out BED. to understand differences in individuals or treatment protocols that Despite the best efforts of clini- Weight Cycling and result in the maintenance vs dete- cians and researchers, most obese Psychopathologic Disorders rioration of improvements in psy- patients who lose weight are likely chological functioning. to regain it. Many do this repeat- Cross-sectional studies generally edly, initiating a pattern of loss and have found no relation between NONDIETING APPROACHES regain that has been labeled weight weight cycling and increased psy- FOR OBESE ADULTS cycling. A previous review by the chopathologic disorders. Neither National Task Force on the Preven- number of diets nor total lifetime Concern with the generally poor tion and Treatment of Obesity8 noted weight loss correlate with depres- long-term results of weight loss pro- that there was little information sion,73 and history of weight cy- grams,79 as well as with the pos- about the effects of weight cycling cling has not been related to clini- sible adverse behavioral effects of di- on eating behaviors or mood. Since cal levels of psychological distress67,72 eting,9 has led several practitioners publication of that review, more in- or to a maladaptive cognitive style.71 to propose alternative “undieting” or formation on psychological effects Weight cycling, however, might be “nondieting” approaches to weight of weight cycling has become avail- related to lower general physical and control.80-86 These programs differ in able. Research on this topic has used mental well-being.67,68 Thus, weight their specific methods, but all gen- cross-sectional data comparing cy- cycling, although perhaps related to erally seek to (1) increase aware- clers to noncyclers and prospective somewhat lower quality of life, does ness about dieting behaviors and studies that assessed more directly not seem to be associated with clini- their purported ill effects, (2) iden- the effects of weight cycling on binge cally significant psychosocial dys- tify and combat cultural notions that eating and depression. function. “thinner is better” and that body As discussed earlier, behavioral weight can be controlled by will- Weight Cycling and Binge Eating approaches to obesity treatment, in power, (3) help participants “stop di- conjunction with low-calorie diets, are eting” by abandoning efforts to re- Cross-sectional studies32,66,67 have associated with improvements in psy- strict energy intake and avoid certain found a consistent, positive rela- chological functioning after weight foods, (4) help participants iden- tion between weight cycling and loss.55,76 However, weight regain dur- tify and eat in response to the body’s binge eating; thus, the greater the ing follow-up can attenuate these im- “natural” hunger and satiety sig- number of weight loss efforts, the provements,53 with mood some- nals, and (5) increase self-esteem and greater the occurrence (or sever- times returning to baseline levels.77 positive body image through self-

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2585

Downloaded From: https://jamanetwork.com/ on 09/24/2021 acceptance rather than weight re- tively), whereas a control group tervention. Although this result is duction. These programs are di- gained 0.75 kg (PϽ.05 for treat- encouraging, caution should be ex- rected primarily at women, who ment vs control). There were no sig- ercised in interpreting the findings disproportionately bear the burden nificant differences between the CT of this preliminary investigation be- of our nation’s preoccupation with and BT conditions in changes in psy- cause of its small sample size. thinness.87 chological status or eating atti- tudes, although the CT group PREVENTION OF STUDIES OF NONDIETING showed a trend toward greater im- WEIGHT GAIN APPROACHES provements. Although a 6-month follow-up showed continued weight Adults aged 20 to 50 years in the Polivy and Herman83 tested a 10- loss in the CT and BT groups, con- United States typically gain 0.5 to 1.0 week pilot program with the previ- tact was by telephone only, and in- kg per year.94 Prevention of such ous goals. After treatment, obese formation on almost half of the par- weight gain and maintenance of cur- women showed significant improve- ticipants was unavailable, making rent weight are recommended for ments in mood and self-esteem and the findings difficult to interpret. normal-weight adults and over- on several scales of the Eating Dis- The limited data indicate that weight adults with no obesity- orders Inventory,88 including drive nondieting approaches are associ- related comorbidities. Concern has for thinness, bulimia, interoceptive ated with significant improve- been raised that such efforts to pre- awareness, and ineffectiveness. Pa- ments in self-esteem, mood, and eat- vent weight gain in normal-weight tients, however, gained nearly 6 kg ing behavior. Changes are generally and overweight adults might cause during the 10-week program, which comparable to those observed at the eating disorders or psychological dif- decreased at 6 months to a net gain end of treatment with traditional be- ficulties. However, results of recent of only 3.5 kg. No other physical havioral weight reduction therapy. studies do not support this con- characteristics (ie, blood pressure, Nondieting approaches, however, do cern. Jeffery and French95 reported lipid levels, etc) were assessed. not seem to induce clinically signifi- results of a 3-year weight gain pre- Similarly, favorable changes in cant short- or long-term weight loss. vention program. This interven- psychological functioning were re- Thus, compared with weight reduction emphasized weighing oneself ported in 2 additional 10- to 12- tion therapies, nondieting interven- regularly, eating more fruits and veg- week studies85,86; in the second tions are less likely to provide short- etables, reducing consumption of study,86 changes in nondieting women term improvements in weight- high-fat foods, and increasing exer- were significantly greater than those related complications such as cise. Although restriction of energy observed in a control group. Weight hypertension or type 2 diabetes. intake was not specifically recom- and blood pressure, however, did not These complications might be ame- mended, the intervention group re- change significantly in the nondiet- liorated, in the absence of weight ported somewhat greater decreases ing patients. In the longest study to loss, by patients significantly reduc- in fat and calorie intake than the con- date,81 obese female binge eaters ating their fat intake and/or increas- trol group. The intervention group tended 24 weekly sessions, followed ing their physical activity. Such ben- also reported significantly greater in- by 26 every-other-week meetings. efits have yet to be demonstrated creases in their use of healthy weight Half of the women received a nondi- with a nondieting approach, but fur- control practices (such as increas- eting approach and the other half ther study is warranted. In addi- ing fruit and vegetable consump- received a traditional weight loss pro- tion, some populations might tion and cutting down on sweets and gram. The 2 groups reported compa- respond better to less structured in- “junk food”) relative to the control rable reductions in binge eating at the terventions, as was seen in a pilot group. Although there was no sig- end of 6 and 18 months. Nondieting study of Pima Indians, who re- nificant difference in weight change women gained 1.4 kg during the first sponded more favorably to a pro- between the control and interven- 6 months compared with a loss of 0.6 gram emphasizing Pima history and tion groups, participants who re- kg for patients in the dieting condi- culture than to a more traditional nu- ported the greatest increases in these tion. The authors attributed the un- trition and activity intervention.90 healthy weight control practices ex- usually small weight loss for the di- It is also possible that combin- perienced the least weight gain dur- eting women to “deviations from a ing elements of the nondieting phi- ing the 3 years. Individuals in the strict behavioral model” (which in- losophy with modest restriction of weight gain prevention condition cluded not weighing patients energy intake could induce sig- and in the control group reported regularly). nificant long-term weight loss.91-93 comparable decreases in unhealthy One short-term study re- Sbrocco and colleagues,91 eg, found weight control practices such as us- ported small weight losses with a that women treated by a nondieting laxatives, diet pills, or diuretics. “nondieting” approach. An 8-week ing approach, combined with an Another intervention study (the study89 compared the effects of a 1800-kcal/d (7531-kJ/d) diet and in- Women’s Healthy Lifestyle Project) nondieting, cognitive therapy (CT) struction in making more favor- attempted to prevent weight gain in approach with a behavior therapy able dieting and activity choices, lost middle-aged women by encourag- (BT) weight loss program. The CT significantly more weight 1 year af- ing a low-calorie, low-fat diet and in- and BT groups lost small amounts ter treatment than those who re- creased exercise. To prevent antici- of weight (1.8 vs 2.6 kg, respec- ceived a traditional behavioral in- pated weight gain, women with a

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2586

Downloaded From: https://jamanetwork.com/ on 09/24/2021 BMI less than 24 were encouraged • Weight cycling does not seem to be Roosevelt Hospital Center, Columbia to lose 2.25 kg, and those with a BMI associated with clinically signifi- University, New York; Barbara J. Rolls, of 24 or more were encouraged to cant psychopathologic condi- PhD, Pennsylvania State University, lose 4.50 to 6.75 kg depending on tions. Cross-sectional studies show State College, University Park; Judith their initial BMI. Because of con- an association between weight cy- S. Stern, ScD, University of California cern about such intervention in nor- cling and binge eating, as well as at Davis; Thomas A. Wadden, PhD, mal-weight women, the investiga- poorer perceived health status, but University of Pennsylvania, Philadel- tors carefully examined changes in causality cannot be determined. phia; Roland L. Weinsier, MD, DrPH, psychological variables and binge • “Nondieting” approaches seem to University of Alabama at Birming- eating.96 Women in the interven- lead to improvements in mood and ham; G. Terence Wilson, PhD, State tion group experienced greater im- self-esteem; however, weight loss University of New Jersey, Rutgers; and provement than control subjects on is generally minimal. Interven- Rena R. Wing, PhD, Brown Univer- all of the measures included in the tions that combine the strengths of sity, Providence, RI. Staff members of study. For example, depressive “nondieting” approaches in pro- the Division of Digestive Diseases and symptoms, assessed with the Beck moting self-esteem and improve- Nutrition, National Institute of Diabe- Depression Inventory,62 decreased ments in body image with behav- tes and Digestive and Kidney Dis- more in intervention subjects then ioral weight loss techniques for eases, National Institutes of Health, in controls. Binge eating scores also reducing caloric intake and im- Bethesda, Md, are Susan Z. Yanovski, decreased more in women who un- proving physical activity might in- MD; Van S. Hubbard, MD, PhD; Jay H. derwent the intervention than in duce modest weight loss or pre- Hoofnagle, MD; James Everhart, MD; controls, with the greatest de- vent weight gain, but research into and Barbara Harrison, MS. creases seen in overweight women the efficacy of such approaches is Drs Wadden and Wilson serve as in the intervention condition. Thus, needed. consultants or on the Speakers Bu- the results of this study suggest that • Although little information is reaus of Knoll Pharmaceutical Co and prevention of weight gain in normal- available, interventions aimed at Roche Laboratories, manufacturers of weight or slightly overweight adults preventing overweight in at-risk weight loss medications, and Dr Wad- is associated with positive, not nega- populations do not seem to be as- den has received research project sup- tive, psychological consequences. sociated with adverse psychologi- port from Knoll Pharmaceutical Co, cal consequences. However, these Roche Laboratories, and Novartis Nu- CONCLUSIONS studies have been carried out in trition. Drs Weinsier and Stern are adult populations. Research is members of the Weight Watchers Sci- Based on currently available data, we needed to evaluate the impact of entific Advisory Board. Dr Wing has re- conclude the following: weight gain prevention interven- ceived research project support from • Moderate caloric restriction, tions in children and adolescents Roche Laboratories and Schering- combined with behavioral weight to determine the effects on weight Plough. Dr Rolls has served as consult- loss treatment, does not seem to regulation,eatingattitudes,andeat- ant to or received research project sup- cause clinically significant binge ing behaviors. port from Amgen, Knoll Pharmaceutical eating in most overweight adults • Concerns that dieting induces eat- Co, Rhoˆne-Poulenc Rorer, Pzizer, Proc- without preexisting binge eating ing disorders or other psychologi- ter & Gamble, and Ross Products/ problems. Moreover, behavioral cal dysfunction in overweight and Abbott Laboratories. Dr Stern is a mem- weight loss treatment might ame- obese adults are generally not sup- ber of the Xenical Speakers Bureau. Dr liorate binge eating, at least in the ported by empirical studies. Such Pi-Sunyer has consulted for or re- short term, in those reporting re- concerns should not preclude at- ceived research project support from current binge eating before treat- tempts to reduce caloric intake and Knoll Pharmaceutical Co, Roche Labo- ment. Additional studies are needed increase physical activity to achieve ratories, Eli Lilly, Amgen, Genetech, and to determine the optimal se- modest weight loss or prevent ad- Parke-Davis. Dr Hill has served as a quence and content of therapies to ditional weight gain. consultant to or received research ameliorate binge eating and facili- project support from Knoll Pharmaceu- tate sustained modest weight los. Accepted for publication April 28, tical Co, Roche Laboratories, Glaxo- • The impact of weight loss med- 2000. Wellcome, Coca Cola, and Procter & ication use on binge eating The following are the members of Gamble. is currently unknown, and future the National Task Force on the Preven- We thank Lynn McAfee, Coun- studies should attempt to deter- tion and Treatment of Obesity: Charles cil on Size and Weight Discrimina- mine the effects of using these J. Billington, MD, VA Medical Center, tion, Philadelphia, Pa, for her thought- medications on binge eating and as- Minneapolis, Minn; Leonard H. Ep- ful comments. sociated behaviors. stein, PhD, State University of New Corresponding author: Susan Z. • Most studies of behavioral weight York at Buffalo; Norma J. Goodwin, Yanovski, MD, National Institutes of loss interventions report improve- MD, Health Watch Information and Health, 6707 Democracy Blvd, Room ments in psychological status dur- Promotion Service, New York, NY; 665, Bethesda, MD 20892-5450. ing weight loss. However, these im- James O. Hill, PhD, University of Colo- Reprints: Weight-Control Infor- provements might return to rado Health Sciences Center, Denver; mation Network, 1 Win Way, Bethesda, baseline with weight regain. F. Xavier Pi-Sunyer, MD, St Luke’s– MD 20892-3665.

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2587

Downloaded From: https://jamanetwork.com/ on 09/24/2021 22. Wing RR. Behavioral approaches to the treat- trol study, V (weeks 190 to 210): follow-up of par- REFERENCES ment of obesity. In: Bray GA, Bouchard C, James ticipants after cessation of medication. Clin WPT, eds. Handbook of Obesity. New York, NY: Pharmacol Ther. 1992;51:615-618. 1. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson Marcel Dekker Inc; 1998:855-873. 42. Stunkard A, Berkowitz R, Tanrikut C, Reiss E, CL. Overweight and obesity in the United States: 23. Porzelius LK, Houston C, Smith M, Arfkin C, Fisher Young L. D-fenfluramine treatment of binge eat- prevalence and trends, 1960-1994. Int J Obes Relat E. Comparison of a standard behavioral weight loss ing disorder. Am J Psychiatry. 1996;153:1455- Metab Disord. 1998;22:39-47. treatment and a binge eating weight loss treat- 1459. 2. Wolf AM, Colditz GA. Current estimates of the eco- ment. Behav Ther. 1995;26:119-134. 43. Alger SA, Malone M, Cerulli J, Fein S, Howard L. nomic cost of obesity in the United States. Obes 24. Wadden TA, Foster GD, Letizia KA. One-year be- Beneficial effects of pharmacotherapy on weight Res. 1998;6:97-106. havioral treatment of obesity: comparison of mod- loss, depressive symptoms, and eating patterns 3. Dietary Guidelines for Americans. Washington, DC: erate and severe caloric restriction and the ef- in obese binge eaters and non–binge eaters. Obes US Dept of Agriculture, US Dept of Health and Hu- fects of weight maintenance therapy. J Consult Clin Res. 1999;7:469-476. man Services; 1995. Home and Garden Bulletin Psychol. 1994;62:165-171. 44. Cardiac valvulopathy associated with exposure to No. 232. 25. Sherwood NE, Jeffery RW, Wing RR. Binge sta- fenfluramine or dexfenfluramine: U.S. Depart- 4. National Institutes of Health. Clinical Guidelines tus as a predictor of weight loss treatment out- ment of Health and Human Services interim pub- on the Identification, Evaluation, and Treatment come. Int J Obes Relat Metab Disord. 1999;23: lic health recommendations, November 1997. of Overweight and Obesity in Adults: The Evi- 485-493. MMWR Morb Mortal Wkly Rep. 1997;46:1061- dence Report. Obes Res. 1998;6(suppl 2):51S- 26. Agras WS, Telch CF, Arnow BA, et al. Weight loss, 1066. 209S. cognitive-behavioral, and desipramine treat- 45. Stunkard AJ. The “dieting depression”: inci- 5. Williamson DF. Lingering questions about inten- ments in binge eating disorder: an additive de- dence and clinical characteristics of untoward re- tional weight loss [editorial]. Nutrition. 1996;12: sign. Behav Ther. 1994;25:225-238. sponses to weight reduction regimens. Am J Med. 819-820. 1957;23:77-86. 6. Williamson DF. Intentional weight loss: patterns 27. Marcus MD, Wing RR, Fairburn CG. Cognitive in the general population and its association with treatment of binge eating v. behavioral weight con- 46. Stunkard AJ, Rush J. Dieting and depression re- morbidity and mortality. Int J Obes Relat Metab trol in the treatment of binge eating disorder [ab- examined: a critical review of reports of unto- Disord. 1997;21(suppl 1):S14-S19. stract]. Ann Behav Med. 1995;17:S090. ward responses during weight reduction for obe- 7. Williamson DF. “Weight cycling” and mortality: how 28. National Task Force on the Prevention and Treat- sity. Ann Intern Med. 1974;81:526-533. do the epidemiologists explain the role of inten- ment of Obesity. Very low-calorie diets. JAMA. 47. Wing RR, Blair EH, Marcus MD, Epstein LH, Har- tional weight loss? J Am Coll Nutr. 1996;15:6-13. 1993;270:967-974. vey J. Year-long weight loss treatment for obese 8. National Task Force on the Prevention and Treat- 29. Wadden TA, Bartlett SJ. Very low calorie diets: an patients with type 2 diabetes: does including an ment of Obesity. Weight cycling. JAMA. 1994; overview and appraisal. In: Wadden TA, Van Ital- intermittent very-low-calorie diet improve out- 272:1196-1202. lie TB, eds. Treatment of the Seriously Obese Pa- come? Am J Med. 1994;97:354-362. 9. Polivy J, Herman CP. Dieting and binging: a causal tient. New York, NY: Guilford Press; 1992:290- 48. Wing RR, Marcus MD, Epstein LH, Kupfer DJ. analysis. Am Psychol. 1985;40:193-201. 330. Mood and weight loss in a behavioral treatment 10. French SA, Jeffery RW. Consequences of dieting 30. Telch CF, Agras WS. The effects of a very-low- program. J Consult Clin Psychol. 1983;51:153- to lose weight: effects on physical and mental calorie diet on binge eating. Behav Ther. 1993; 155. health. Health Psychol. 1994;13:195-212. 24:177-193. 49. Taylor CB, Ferguson JM, Reading JC. Gradual 11. Howard CE, Porzelius LK. The role of dieting in 31. Yanovski SZ, Gormally JF, Lesser MS, Gwirts- weight loss and depression. Behav Ther. 1978;9: binge eating disorder: etiology and treatment im- man HE, Yanovski JA. Binge eating disorder af- 622-625. plications. Clin Psychol Rev. 1999;19:25-44. fects outcome of comprehensive very-low- 50. Wadden TA, Stunkard AJ. Controlled trial of very 12. Lowe M, DiSimone-Weiss RT, Furgueson C, et al. calorie diet treatment. Obes Res. 1994;2:205- low calorie diet, behavior therapy, and their com- Restraint, dieting, and the continuum model of bu- 212. bination in the treatment of obesity. J Consult Clin limia nervosa. J Abnorm Psychol. 1996;105:508- 32. Yanovski SZ, Sebring NG. Recorded food intake Psychol. 1986;54:482-488. 517. of obese women with binge eating disorder be- 51. Wing RR, Marcus MD, Blair EH, Burton LR. Psy- 13. Lowe M, Gleaves DH, Murphy-Eberenz KP. On the fore and after weight loss. Int J Eat Disord. 1994; chological responses of obese type II diabetic sub- relation of dieting and bingeing in bulimia ner- 15:135-150. jects to very-low-calorie diet. Diabetes Care. 1991; vosa. J Abnorm Psychol. 1998;107:263-271. 33. Gormally JF, Black S, Daston S, Rardin D. The as- 14:596-599. 14. Keys A, Brozek J, Henschel A, et al. The Biology sessment of binge eating severity among obese 52. Wadden TA, Berkowitz RI, Vogt RA, Steen SN, of Human Starvation. Minneapolis: University of persons. Addict Behav. 1982;7:47-55. Stunkard AJ, Foster GD. Lifestyle modification in Minnesota Press; 1950. 34. Wing RR, Shiffman S, Drapkin RG, Grilo CM, the pharmacologic treatment of obesity: a pilot in- 15. Yanovski SZ. Diagnosis and prevalence of eating McDermott M. Moderate versus restrictive diets: vestigation of a potential primary care approach. disorders in obesity. In Ailhaud G, Guy-Grand B, implications for relapse. Behav Ther. 1995;26:5- Obes Res. 1997;5:218-226. et al, eds. Progress in Obesity Research: 8. Lon- 24. 53. Brownell KD, Stunkard AJ. Couples training, phar- don, England: John Libby & Co; 1999:229-236. 35. LaPorte DJ. Treatment response in obese binge macotherapy, and behavior therapy in the treat- 16. American Psychiatric Association. Diagnostic and eaters: preliminary results using a very low calo- ment of obesity. Arch Gen Psychiatry. 1981;38: Statistical Manual of Mental Disorders, Fourth Edi- rie diet (VLCD) and behavior therapy. Addict Be- 1224-1229. tion. Washington, DC: American Psychiatric As- hav. 1992;17:247-257. 54. Smoller JW, Wadden TA, Stunkard AJ. Dieting and sociation; 1994. 36. Wadden TA, Foster GD, Letizia KA. Response of depression: a critical review. J Psychosom Res. 17. Wilson GT. Relation of dieting and voluntary weight obese binge eaters to treatment by behavior 1987;31:429-440. loss to psychological functioning and binge eat- therapy combined with very low calorie diet. J Con- 55. Wing RR, Epstein LH, Marcus MD, Kupfer DJ. ing. Ann Intern Med. 1993;119:727-730. sult Clin Psychol. 1992;60:808-811. Mood changes in behavioral weight loss pro- 18. Serdula MK, Mokdad AH, Williamson DF, Ga- 37. Lean MEJ. Sibutramine: a review of clinical effi- grams. J Psychosom Res. 1984;28:345-346. luska DA, Mendlein JM, Heath GW. Prevalence of cacy. Int J Obes. 1997;21:30S-36S. 56. Telch CF, Agras WS. Obesity, binge eating and psy- attempting weight loss and strategies for control- 38. Sjostrom L, Rissanen A, Andersen T, et al. Ran- chopathology: are they related? Int J Eat Disord. ling weight. JAMA. 1999;282:1353-1358. domised placebo-controlled trial of orlistat for 1994;15:53-61. 19. Serdula MK, Collins ME, Williamson DF, Anda RF, weight loss and prevention of weight regain in 57. Neumark-Sztainer D, Sherwood NE, French SA, Pamuk E, Byers TE. Weight control practices of obese patients. Lancet. 1998;352:167-172. Jeffery RW. Weight control behaviors among adult U.S. adolescents and adults. Ann Intern Med. 1993; 39. National Task Force on the Prevention and Treat- men and women: cause for concern? Obes Res. 119:667-671. ment of Obesity. Long-term pharmacotherapy in 1999;7:179-188. 20. American Psychiatric Association. Practice guide- the management of obesity. JAMA. 1996;276: 58. Serdula MK, Williamson DF, Anda RF, Levy A, Hea- line for eating disorders. Am J Psychiatry. 1993; 1907-1915. ton A, Byers T. Weight control practices in adults: 150:212-228. 40. Craighead LW, Stunkard AJ, O’Brien RM. Behav- results of a multistate telephone survey. Am J Pub- 21. Wadden TA. Treatment of obesity by moderate and ior therapy and pharmacotherapy for obesity. Arch lic Health. 1994;84:1821-1824. severe caloric restriction: results of clinical re- Gen Psychiatry. 1981;38:763-768. 59. Levy AS, Heaton AW. Weight control practices of search trials. Ann Intern Med. 1993;119:688- 41. Weintraub M, Sundaresan PR, Schuster B, Aver- U.S. adults trying to lose weight. Ann Intern Med. 693. buch M, Stein EC, Byrne L. Long-term weight con- 1993;119:661-666.

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2588

Downloaded From: https://jamanetwork.com/ on 09/24/2021 60. Klem ML, Wing RR, McGuire MT, Seagle HM, Hill Stunkard AJ, Conill A. Relationship of dieting his- 85. Roughan P, Seddon E, Vernon-Roberts J. Long- JO. A descriptive study of individuals successful tory to resting metabolic rate, body composi- term effects of a psychologically based group pro- at long-term maintenance of substantial weight tion, eating behavior, and subsequent weight loss. gramme for women preoccupied with body weight loss. Am J Clin Nutr. 1997;66:239-246. Am J Clin Nutr. 1992;56(suppl):203S-208S. and eating behaviour. Int J Obes. 1990;14:135- 61. Klem ML, Wing RR, McGuire MT, Seagle HM, Hill 74. Foster GD, Wadden TA, Kendall PC, Stunkard AJ, 147. JO. Psychological symptoms in individuals suc- Vogt RA. Psychological effects of weight loss and 86. Ciliska D. Evaluation of two nondieting interven- cessful at long-term maintenance of weight loss. regain: a prospective evaluation. J Consult Clin tions for obese women. West J Nurs Res. 1998; Health Psychol. 1998;17:336-345. Psychol. 1996;64:752-757. 20:119-135. 62. Beck AT, Steer RA. Manual for the Beck Depres- 75. Kensinger GJ, Murtaugh MA, Reichmann SK, 87. Striegel-Moore R. Etiology of binge eating: a de- sion Inventory. New York, NY: Psychological Cor- Tangney CC. Psychological symptoms are greater velopmental perspective. In: Fairburn CG, Wil- poration; 1987. among weight cycling women with severe binge son GT, eds. Binge Eating: Nature, Assessment, 63. Gladis MM, Wadden TA, Vogt R, Foster G, Kue- eating behavior. J Am Diet Assoc. 1998;98:863- and Treatment. New York, NY: Guilford Press; hnel RH, Bartlett SJ. Behavioral treatment of obese 868. 1992:144-172. binge eaters: do they need different care? J Psy- 76. Wadden TA, Vogt RA, Andersen RE, et al. Exer- 88. Garner DM, Olmstead MP, Polivy J. Develop- chosom Res. 1998;44:375-384. cise in the treatment of obesity: effects of four in- ment and validation of a multidimensional eating 64. Felitti VJ. Childhood sexual abuse, depression, and terventions on body composition, resting energy disorders inventory for anorexia nervosa and bu- family dysfunction in adult obese patients: a case expenditure, appetite, and mood. J Consult Clin limia. Int J Eat Disord. 1983;2:15-34. control study. South Med J. 1993;86:732-736. Psychol. 1997;65:269-277. 89. Tanco S, Linden W, Earle T. Well-being and mor- 65. O’Neil PM, Jarrell MP. Psychological aspects of 77. Wadden TA, Stunkard AJ, Liebschutz J. Three- bid obesity in women: a controlled therapy evalu- obesity and dieting. In: Wadden TA, Van Itallie TB, year follow-up of the treatment of obesity by very ation. Int J Eat Disord. 1998;23:325-339. eds. Treatment of the Seriously Obese Patient. New low calorie diet, behavior therapy, and their com- 90. Narayan KM, Hoskin M, Kozak D, et al. Random- York, NY: Guilford Press; 1992:252-270. bination. J Consult Clin Psychol. 1988;56:925- ized clinical trial of lifestyle interventions in Pima 66. Spitzer RL, Devlin M, Walsh BT, et al. Binge eat- 928. Indians: a pilot study. Diabet Med. 1998;15:66- ing disorder: a multisite field trial of the diagnos- 78. Friedman MA, Schwartz MB, Brownell KD. Differ- 72. tic criteria. Int J Eat Disord. 1992;11:191-203. ential relation of psychological functioning with 91. Sbrocco T, Nedegaard RC, Stone JM, Lewis EL. 67. Venditti EM, Wing RR, Jakicic JM, Butler BA, Mar- the history and experience of weight cycling. J Con- Behavioral choice treatment promotes continu- cus MD. Weight cycling, psychological health, and sult Clin Psychol. 1998;66:646-650. ing weight loss: preliminary results of a cognitive- binge eating in obese women. J Consult Clin Psy- 79. Garner DM, Wooley S. Confronting the failure of behavioral decision-based treatment for obesity. chol. 1996;64:400-405. behavioral and dietary treatments for obesity. Clin J Consult Clin Psychol. 1999;67:260-266. 68. Foreyt JP, Brunner RL, Goodrick GK, Cutter G, Psychol Rev. 1991;11:729-780. 92. Miller WC, Eggert KE, Wallace JP, Lindeman AK, Brownell KD, St. Jeor ST. Psychological corre- 80. Foreyt JP, Goodrick GK. Living Without Dieting. Jastremski C. Successful weight loss in a self- lates of weight fluctuation. Int J Eat Disord. 1995; Houston, Tex: Harrison Publishing; 1995. taught, self-administered program. Int J Sports 17:263-275. 81. Goodrick GK, Poston WS, Kimball KT, Reeves RS, Med. 1993;14:401-405. 69. Carmody TP, Brunner RL, St. Jeor ST. Dietary help- Foreyt JP. Nondieting versus dieting treatment for 93. Miller WC, Wallace J, Lindeman AK, Dyer DL. The lessness and disinhibition in weight cyclers and overweight binge-eating women. J Consult Clin Non-Diet Diet: a 100-point scoring system for maintainers. Int J Eat Disord. 1995;18:247-256. Psychol. 1998;66:363-368. monitoring weight loss behavior. J Am Diet As- 70. Foster GD, Wadden TA, Vogt RA. Body image in 82. Hirschmann JR, Munter CH. Overcoming Over- soc. 1991;91:973-975. obese women before, during, and after weight loss eating. New York, NY: Ballantine Books; 1988. 94. Williamson DF. Epidemiologic analysis of weight treatment. Health Psychol. 1997;16:226-229. 83. Polivy J, Herman CP. Undieting: a program to help gain in U.S. adults. Nutrition. 1991;7:285-286. 71. Kuehnel RH, Wadden TA. Binge eating disorder, people stop dieting. Int J Eat Disord. 1992;11: 95. Jeffery RW, French SA. Preventing weight gain in weight cycling, and psychopathology. Int J Eat Dis- 261-268. adults: the pound of prevention study. Am J Pub- ord. 1994;15:321-329. 84. Rothblum ED. “I’ll die for the revolution but don’t lic Health. 1999;89:747-751. 72. Bartlett SJ, Wadden TA, Vogt RA. Psychosocial ask me not to diet.” In: Fallon P, Katzman MA, 96. Klem ML, Wing RR, Simkin-Silverman L, Kuller consequences of weight cycling. J Consult Clin Wooley SC, eds. Feminist Perspectives on Eat- LH. The psychological consequences of weight Psychol. 1996;64:587-592. ing Disorders. New York, NY: Guilford Press; 1994: gain prevention in healthy, premenopausal women. 73. Wadden TA, Bartlett S, Letizia KA, Foster GD, 53-76. Int J Eat Disord. 1997;21:167-174.

(REPRINTED) ARCH INTERN MED/ VOL 160, SEP 25, 2000 WWW.ARCHINTERNMED.COM 2589

Downloaded From: https://jamanetwork.com/ on 09/24/2021