 |
|
Obese Patients' Perceptions of Treatment Outcomes and the Factors That Influence Them
Gary D. Foster, PhD;
Thomas A. Wadden, PhD;
Suzanne Phelan, PhD;
David B. Sarwer, PhD;
Rebecca Swain Sanderson, BA
Arch Intern Med. 2001;161:2133-2139.
ABSTRACT
| |
Background Despite considerable professional consensus that modest weight losses
of 5% to 10% are successful for reducing the comorbid conditions associated
with obesity, obese patients often desire weight losses 2 to 3 times greater
than this. Examining ways to reduce the disparities between treatment expectations
and subsequent outcomes, this study evaluated the role of physical characteristics,
treatment setting, and mood in patients' evaluations of treatment outcomes.
Methods This study was conducted in a university outpatient weight loss clinic
with a sample of 397 obese individuals seeking weight loss by a variety of
modalities. Before treatment, participants' heights and weights were measured,
and the Beck Depression Inventory and the Goals and Relative Weight Questionnaire
were administered.
Results Outcome evaluations ranged from 64.4 ± 11.1 kg (mean ±
SD) for dream weight to 90.1 ± 19.1 kg for disappointed weight. Initial
body weight was the strongest predictor of disappointed, acceptable, and happy
weights ( = .90, .76, and .57, respectively). Sex ( = -.37)
and height ( = .37) were the strongest determinants of dream weight.
Heavier participants chose higher absolute weights, but the weight loss required
to reach each of the outcomes was greater for heavier than for lighter patients.
Conclusions These data signal a therapeutic dilemma in which the amount of weight
loss produced by the best behavioral and/or pharmacologic treatments is viewed
as even less than disappointing. Patients with the highest pretreatment weights
are likely to have the most unrealistic expectations for success.
INTRODUCTION
OBESE PATIENTS and their physicians are often at odds about what constitutes
a successful treatment outcome. While there is considerable professional consensus
that modest weight losses of 5% to 10% are successful,1-3
obese patients seeking treatment view things quite differently. Studies suggest
that the desired weight losses of obese patients are 2 to 3 times greater
(a 22%-34% reduction in body weight) than those recommended by professionals
as feasible and health promoting.4-6
Moreover, these expectations greatly exceed the average 10% reductions in
body weight achieved by the best behavioral and/or pharmacologic treatments.7-8 Population studies have reported similar
discrepancies between health provider and lay definitions of desirable weights.9 The discrepancy between desired and actual weight
losses can result in unrealistic and negative evaluations of treatment outcomes.
For example, obese women seeking treatment characterized a 25% weight loss
as "one I would not be happy with" and a 17% weight loss as "one that I could
not view as successful in any way."5 Thus,
the average 10% weight losses produced by the best available nonsurgical treatments
are perceived as even less than unsuccessful.
Based on findings from the broader literature on goal setting, when
goals remain out of reach and progress toward them is unsatisfying, people
experience negative affect,10-11
aversive self-focus,12-13 and
impaired performance,14 which often lead to
abandonment of their goals.15 Decreased disparity
between actual and expected outcomes appears to lessen the negative affect
associated with unmet expectations.16-17
This cycle parallels our clinical experience, in which patients dissatisfied
with their end-of-treatment (usually after 6 months) weight loss engage in
self-critical statements, set unrealistic behavioral goals that are unattainable,
experience "failure," and abandon all weight-control efforts. Among obese
patients, the less the discrepancy between posttreatment weights and the weights
described (before treatment) as "acceptable," the greater the satisfaction
with posttreatment weight.5
One approach to decreasing the discrepancy between expected and actual
outcomes is to produce larger weight losses. Unfortunately, efforts to increase
the magnitude of weight loss, including very-low-calorie diets,18
structured exercise and food-provision programs,19-20
and longer treatment programs,21-22
produce long-term results that are no different than those of standard behavioral
methods. An alternative approach to decreasing the disparity between expected
and actual outcomes is to alter patients' pretreatment expectations about
what constitutes a successful outcome. Efforts to modify patients' outcome
evaluations have been hampered by a paucity of data about patients' views
and the factors that influence them. In our initial study of this topic, we
reported that outcome evaluations were related to body mass index (BMI), body
image, and, to a lesser degree, self-esteem.5
These findings, however, came from a selected sample of 60 women enrolled
in a research study. Less is known about outcome evaluations in more heterogeneous
samples of obese treatment seekers.
To increase our understanding about outcome expectations and the factors
that influence them, we have collected data about outcome evaluations from
nearly 400 participants in research and clinical programs. Specifically, we
evaluated the role of physical characteristics (weight, height, sex, and race),
treatment approach (ie, research participants, patients seeking outpatient
treatment, and patients seeking surgical treatment for obesity), and mood
in outcome evaluations.
METHODS
PARTICIPANTS
Participants were 397 obese individuals who sought weight loss by a
variety of modalities offered at the University of Pennsylvania, Philadelphia.
Participants were recruited from 3 different samples. The first consisted
of 154 women who were evaluated prior to participating in a clinical trial
of behavioral weight loss treatments. The second sample consisted of 193 participants
(157 women and 36 men) who sought outpatient weight loss treatment in our
fee-for-service clinic. Participants in this sample were evaluated on a consecutive
basis from January 1996 to November 1998 and given a $25 reduction in their
initial assessment fee for completing the measures described below.
The third sample consisted of 50 participants (43 women and 7 men) who
presented for a psychosocial assessment prior to undergoing surgical treatment
for obesity. Participants in this surgical sample were evaluated on a consecutive
basis from August 1997 to April 1999 after an initial consultation with a
surgeon. All prospective surgical patients at our institution receive this
psychosocial assessment. All participants completed questionnaires as part
of their assessment packet. Participants gave written and informed consent
as approved by the University of Pennsylvania's institutional review board.
The 397 participants had a mean ± SD age of 43.1 ± 10.9
years, weight of 109.0 ± 28.9 kg, and BMI (calculated as weight in
kilograms divided by the square of height in meters) of 39.3 ± 9.5.
Most (88.9%) were women, 77.9% were white, 21.3% were African American, and
0.8% were Hispanic. The majority (56.3%) of participants were married, 29.7%
were single, 9.5% were divorced, 2.6% were separated, and 1.6% were widowed.
PRIMARY MEASURES
Participants completed these measures before treatment.
Weight and Height
Weight was measured on an electronic digital scale (model 5600; Detecto,
Webb City, Mo) and height by a stadiometer. Participants were dressed in indoor
clothing without shoes.
Outcome Evaluations
Various weight loss outcomes were evaluated using the Goals and Relative
Weight Questionnaire (GRWQ).5 The GRWQ asks
participants to numerically define 4 different weight loss outcomes, as described
in Table 1. Participants assign
a numerical equivalent (in pounds) to each of these weights. One-week test-retest
reliability is extremely high for definitions of happy, acceptable, and disappointed
weights (r>0.96 for all) but less so (r = 0.64; P<.001) for dream weight.5
|
|
|
|
Table 1. Outcome Evaluations of 397 Obese Treatment Seekers*
|
|
|
Mood
Mood was assessed by the Beck Depression Inventory (BDI),23
a 21-item scale with a range of possible scores from 0 to 63. Higher scores
indicate greater dysphoria.
STATISTICAL ANALYSES
Data are presented as mean ± SD. Paired t
tests, adjusted for multiple comparisons, assessed differences among the 4
outcome evaluations using the SPSS software (version 9.0; SPSS Inc, Chicago,
Ill). Simultaneous regression analyses (using the SPSS software) were used
to identify the principal determinants of each of the 4 outcome evaluations
(ie, dream, happy, acceptable, and disappointed weights). For each outcome,
the following variables were entered simultaneously: weight, height, age,
race, sex, treatment setting (ie, research, clinic, surgery), and mood (ie,
BDI score).
RESULTS
OUTCOME EVALUATIONS
Outcome evaluations of the 397 participants ranged from 64.4 ±
11.1 kg (38.4% ± 12.5%) for dream weight to 90.1 ± 19.1 kg (15.7%
± 9.9%) for disappointed weight (Table 1). Each weight was significantly different from the remaining
3 (P<.001 for all). A weight that, on average,
would require a 19-kg (15.7% ± 9.9%) weight loss was considered "disappointing,"
while a 29-kg (24.9% ± 11.0%) weight loss was considered "acceptable."
DETERMINANTS
Subject Characteristics
Simultaneous regression analyses revealed that initial body weight was
the strongest predictor of disappointed, acceptable, and happy weights (
= .90, .76, and .57, respectively [Table
2]). Thus, heavier participants chose higher absolute weights. Nevertheless,
the weight loss required to reach each of the outcomes was greater for heavier
than for lighter patients. For example, participants in the lowest tertile
of mean ± SD body weight (82.6 ± 9.1 kg) required a weight loss
of 14.2 ± 5.7 kg (16.8% ± 6.0%) to achieve an acceptable weight
(68.5 ± 7.0 kg), while those in the highest tertile of body weight
(140.0 ± 26.8 kg) required a weight loss of 48.6 ± 22.3 kg (33.6%
± 11.1%) to achieve an acceptable weight (91.5 ± 16.1 kg; P<.001). Similar results were obtained for disappointed,
happy, and dream weights (P<.001 for all).
|
|
|
|
Table 2. Determinants of Outcome Evaluations in 397 Obese Treatment
Seekers*
|
|
|
Table 3 underscores the
effect of initial weight on outcome evaluations in more clinical terms. Participants
were categorized as grade I, II, or III based on the clinical guidelines of
the National Heart, Lung, and Blood Institute1
(see Table 3 for BMI levels for
each grade). Across all 4 outcomes, grade III participants chose higher absolute
weights. However, the percentage weight loss required to achieve these outcomes
was 11% to 18% greater for grade III participants than for grade I participants.
Thus, grade III patients are likely to have the most unrealistic expectations
for weight loss when presenting for treatment.
|
|
|
|
Table 3. Outcome Evaluations by Clinical Classification of Obesity*
|
|
|
Sex ( = -.37) and height ( = .37) were the strongest
determinants of dream weight, with initial body weight making a modest (
= .26) but significant contribution (Table
2). Thus, taller participants and men chose higher absolute dream
weights. Sex ( = -.27) and height ( = .24) also made modest
but significant contributions to the explanation of variance in happy weight.
In general, the mean ± SD outcome evaluations for men were higher than
those for women (111.7 ± 22.9 vs 87.4 ± 16.8 kg for disappointed,
99.5 ± 17.9 vs 77.1 ± 12.1 kg for acceptable, 94.3 ±
14.1 vs 70.2 ± 9.6 kg for happy, and 85.5 ± 11.7 vs 61.8 ±
7.9 kg for dream). Among the remaining predictors, mood was the only variable
that contributed significantly to all 4 outcomes, although its effect was
weak ( .15). Other predictors (eg, race, age) contributed minimally
(.12 for all), if at all, to the explanation of the outcomes (Table 2).
Treatment Setting
Surgery participants (ie, patients who were screened for surgery, including
those who did not undergo surgical procedures) chose significantly higher
values than research and clinic participants for disappointed, acceptable,
and happy weights (unadjusted values in Table 4). However, as suggested by the regression analysis (Table 2), these differences were largely
a result of the demographic differences among the samples (Table 4). In general, surgery patients had higher BMIs and were
slightly younger than research and clinic patients. Although there were no
differences among the groups in the number of African Americans, the research
sample had a lower percentage of white participants. By design, the research
sample was exclusively female. Thus, after controlling for weight, height,
age, race, and sex, the effects of treatment setting disappeared except for
a very modest ( = .12) effect on disappointed weight, with surgery participants
choosing significantly lower values than research and clinic participants.
|
|
|
|
Table 4. Demographic Variables and Outcome Evaluations for the Research,
Clinic, and Surgery Samples
|
|
|
COMMENT
There are several principal findings from this study. The first is that,
on average, the outcome evaluations in this large, heterogeneous sample of
obese treatment seekers were quite similar to those previously reported among
a small sample of female research participants.5
The weight loss percentages for each of the 4 outcome evaluations were within
1.3% of the values reported previously. This suggests that unrealistic expectations
are not exclusive to female research participants and are likely to be representative
of obese patients seeking a variety of obesity treatments.
These data reflect a therapeutic dilemma in which the weight loss produced
by the best behavioral and/or pharmacologic treatments is viewed by patients,
prior to treatment, as even less than disappointing. The 10% weight loss associated
with both behavioral7 and pharmacologic8 treatments is nearly 6% less than the weight loss
(15.6%) that participants described before treatment as "could not be viewed
as successful in any way" and less than half of the weight loss (24.5%) that
was characterized as one "that I would not be particularly happy with . .
. but could accept."
It is interesting to note that, among the subgroup of female research
participants in this sample (n = 154), a weight that represented a 12% weight
loss was considered disappointing, compared with a 17% weight loss considered
disappointing in our previous but very similar sample.5
Similarly, the weight losses associated with acceptable, happy, and dream
weights were approximately 4% lower among female research participants in
the present sample than in the previous sample. Specifically, values for acceptable,
happy, and dream weights were 21.2%, 27.0%, and 34.8%, respectively, in the
present study compared with 25.1%, 31.4%, and 38.0%, respectively, in the
previous study. The reason for this change is unknown, but it may be because
the benefits of modest weight loss are receiving more attention in the lay
press or because of our larger (154 vs 60) sample. Despite this shift, it
is troubling that patients "could not view as successful in any way" an outcome
(12% weight loss) that approximates what can be expected. This significant
disparity between expected and actual outcomes is consistent with our clinical
experience—patients are reluctant to concentrate on maintaining a weight
they perceive as far from even acceptable.
The second principal finding was that initial weight was a strong predictor
of happy, acceptable, and disappointed outcomes. Despite choosing higher absolute
weights, heavier participants' selections resulted in weight losses (expressed
as a percentage of initial weight) that were greater than those of lighter
patients. For example, participants classified as having grade III obesity
perceived a 33% weight loss as acceptable, while grade I participants viewed
an 18% weight loss as acceptable. Grade III participants desired nearly twice
the weight loss for each of the 4 outcomes. While it is encouraging that heavier
patients are apparently realistic in choosing higher absolute outcomes than
lighter patients, it is troubling that heavier patients desire larger weight
losses, even after controlling for differences in initial weight. Heavier
patients may have a stronger biological predisposition to obesity and are
almost certain to be characterized by adipocyte hyperplasia, each of which
may place limits on weight loss.24-25
Such patients (ie, grades II and III) should be targeted for efforts to modify
outcome evaluations, including education about the biological limits of weight
loss, the medical benefits of modest weight loss, and strategies to improve
body image26 and enhance weight-independent
self-esteem.27-28
The explanatory power of initial weight was lower for dream weight than
for the other outcome weights and was mostly influenced by sex and height.
The impact of sex on definitions of ideal weight has also been reported in
population studies.9 The fact that men and
taller participants chose higher outcome evaluations suggests that "ideal"
versions of body weight may still be based on the Metropolitan Life height
and weight tables, which assigned an ideal weight based on sex and height.29 By contrast, the current clinical assessment of relative
weight is the BMI, which is independent of sex. Despite its effect on dream
and happy weights, it was surprising that sex had no effect on the selection
of disappointed weight and had only a slight effect ( = .09) for acceptable
weight. A similar but more modest effect was observed for race in the selection
of happy and dream weights, while race had no effect on disappointed and acceptable
weights. This suggests that when participants select weights that more closely
approximate achievable outcomes (ie, acceptable and disappointed), sex and
race are not predictive. However, outcomes that are further removed from reality
(ie, dream, happy) appear to be influenced by race and sex. It is possible
that any race and sex effects were attenuated in a treatment-seeking sample.
As might be expected, treatment setting influenced outcome evaluations,
with surgery patients selecting weights that represented larger percentage
reductions in weight for all 4 outcomes, despite choosing higher absolute
weights (Table 4). This appears
to be realistic since surgical treatment provides 2 to 3 times the weight
loss associated with more conservative treatments.30
However, surgical participants "could not view as successful in any way" a
typical surgical outcome (27% weight loss). A 38% or 57-kg reduction in body
weight, clearly beyond the typical surgical outcome, was considered only acceptable.
These data are similar to those reported by Rabner and Greenstein,31 who found that, preoperatively, 70% of gastric surgery
patients expected to lose 46 to 48 kg (neither initial weight nor mean expected
weight loss was reported). It is important to note that the effects of treatment
approach were largely a result of demographic differences among the samples,
particularly in weight. Controlling for these differences, disappointment
in weight was the only outcome affected by treatment approach and the effect
was very modest ( = -.12). Clinically, surgical patients are likely
to desire larger percentage reductions in weight than nonsurgical patients,
but the difference is principally a result of their increased weight.
Mood as assessed by the BDI was the only variable except initial weight
to be significantly related to all 4 outcome evaluations, although the effect
was modest ( = -.08 to -.15). Thus, the higher the level
of dysphoria, the lower the outcome evaluation. This suggests that efforts
to enhance mood before treatment may alter outcome evaluations.
Clinically, the replication of unrealistic and negative outcome evaluations
in varied treatment approaches suggests that there continues to be a significant
disparity between expected and actual outcomes. Previous data suggested that
the discrepancy between actual weight loss and various outcomes (assessed
pretreatment) was strongly related (r = -0.52
to -0.75) to posttreatment satisfaction. Thus, patients will likely
end treatment dissatisfied with their weight. The relationship between satisfaction
with weight loss and maintenance of weight loss has not directly been tested.
One study4 found no relationship between reaching
goal weight and maintenance of weight loss, but no ratings of satisfaction
were obtained, and very few patients (17%) reached their goal weight. The
belief that satisfaction (the discrepancy between expected and actual outcomes)
affects subsequent success is based on the broader literature on goal setting14-15,32 and our own clinical
experience. Thus, this belief needs to be empirically validated in a prospective,
longitudinal fashion.
Despite a large, heterogeneous sample, this study has several limitations.
First, the findings are limited to obese treatment seekers and provide no
information on obese persons who do not seek treatment or who do so in settings
that are not university based. It is possible that those who seek treatment
at tertiary care centers expect more from treatment than others (ie, they
are more unrealistic). Alternatively, those seeking treatment at specialized
centers typically have made multiple previous attempts to lose weight,33 perhaps making them more realistic. Second, although
our sample included men, the number was less than 50, making any conclusions
about sex effects tentative. The disproportionate number of women in this
sample was a result of the greater prevalence of women among obese treatment
seekers and the exclusion of men from the research sample.
Finally, this study was limited to the examination of determinants that,
except for mood, are largely unmodifiable (height, race, sex, etc). Additional
research is needed to identify other unmodifiable (eg, family history of obesity,
weight history) as well as modifiable (eg, attitudes toward exercise, frequency
of self-weighing) variables that are related to patients' outcome evaluations.
Qualitative research methods (eg, ethnographic studies) may be particularly
useful in this regard. While the data in the present study can help identify
patients who are most likely to have unrealistic expectations, more research
is needed to determine how these expectations may be modified to ones that
are achievable (ie, 10% of initial body weight). This will likely include
a 2-step process in which modifiable determinants of outcomes are identified
(eg, body image, self-esteem, attributions about previous weight loss history)
and treatments are developed to alter them. Future research should also focus
on how expectations may vary across different treatment approaches (eg, commercial
weight-loss programs, pharmacologic approaches, very-low-calorie diets), particularly
those that are not university based. Finally, as noted above, it is important
to examine the proposed relationships between outcome evaluations and subsequent
weight change, given the frequency with which weight is regained after obesity
treatment.24-25
AUTHOR INFORMATION
Accepted for publication February 22, 2001.
This work was supported in part by grant DK56114 from the National Institutes
of Health, Bethesda, Md.
Corresponding author and reprints: Gary D. Foster, PhD, University
of Pennsylvania Department of Psychiatry, 3535 Market St, Suite 3027, Philadelphia,
PA 19104 (e-mail: fosterg{at}mail.med.upenn.edu).
From the Department of Psychiatry, University of Pennsylvania School
of Medicine, Philadelphia.
REFERENCES
| |
1. National Heart, Lung, and Blood Institute. Clinical guidelines on the identification, evaluation, and treatment
of overweight and obesity in adults: the evidence report [review]. Obes Res. 1998;6(suppl 2):51S-209S. Available at: http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm. Accessed July 18, 2001.
2. Institute of Medicine. Weighing the Options: Criteria for Evaluating Weight
Management Programs. Washington, DC: Government Printing Office; 1995.
3. US Dept of Agriculture. Nutrition and Your Health: Dietary Guidelines for
Americans. 4th ed. Washington, DC: US Dept of Agriculture; 1995. Home and Garden
Bulletin No. 232. Available at:
http://www.nalusda.gov/fnic/dga/dga95/cover.html. Accessed July 18, 2001.
4. Jeffery RW, Wing RR, Mayer RR. Are smaller weight losses or more achievable weight loss goals better
in the long term for obese patients? J Consult Clin Psychol. 1998;66:641-645.
FULL TEXT
|
ISI
| PUBMED
5. Foster GD, Wadden TA, Vogt RA, Brewer G. What is a reasonable weight loss? patients' expectations and evaluations
of obesity treatment outcomes. J Consult Clin Psychol. 1997;65:79-85.
FULL TEXT
|
ISI
| PUBMED
6. O'Neil PM, Smith CF, Foster GD, Anderson DA. The perceived relative worth of reaching and maintaining goal weight. Int J Obes Relat Metab Disord. 2000;24:1069-1076.
PUBMED
7. Wadden TA, Foster GD. Behavioral treatment of obesity. Med Clin North Am. 2000;84:441-461.
FULL TEXT
|
ISI
| PUBMED
8. Bray GA. Pharmacological treatment of obesity. In: Bray GA, Bouchard C, James WPT, eds. Handbook
of Obesity. New York, NY: Marcel Dekker; 1998:953-976.
9. Crawford D, Campbell K. Lay definitions of ideal weight and overweight. Int J Obes Relat Metab Disord. 1999;23:738-745.
PUBMED
10. Carver CS, Scheier MF. Origins and functions of positive and negative affect: a control-process
view. Psychol Rev. 1990;97:19-35.
FULL TEXT
|
ISI
11. Wicklund RA, Gollwitzer PM. Symbolic Self-completion. Hillsdale, NJ: Lawrence Erlbaum Associates; 1982.
12. Nolen-Hoeksema S. Responses to depression and their effects on the duration of depressive
episodes [review]. J Abnorm Psychol. 1991;100:569-582.
FULL TEXT
|
ISI
| PUBMED
13. Pyszczynski T, Greenberg J. Self-regulatory preservation and the depressive self-focusing style:
a self-awareness theory of reactive depression. Psychol Bull. 1987;102:122-138.
FULL TEXT
|
ISI
| PUBMED
14. Cervone D, Jiwani N, Wood R. Goal setting and the differential influence of self-regulatory processes
on complex decision-making performance. J Pers Soc Psychol. 1991;61:257-266.
FULL TEXT
|
ISI
| PUBMED
15. Klinger E. Consequences to commitment to and disengagement from incentives. Psychol Rev. 1975;82:223-231.
16. McIntosh WD. When does goal nonattainment lead to negative emotional reactions,
and when doesn't it? the role of linking and rumination. In: Martin L, Tesser A, eds. Striving and Feeling:
Interactions Among Goals, Affect, and Self-regulation. Hillsdale, NJ:
Lawrence Erlbaum Associates; 1996:53-77.
17. Hsee CK, Abelson RP. Velocity relation: satisfaction as a function of the first derivative
outcome over time. J Pers Soc Psychol. 1991;60:341-347.
FULL TEXT
|
ISI
18. Wadden TA. Very-low-calorie diets: appraisal and recommendations. In: Brownell KD, Fairburn CG, eds. Eating Disorders
and Obesity: A Comprehensive Textbook. New York, NY: Guilford Press;
1995:484-490.
19. Wadden TA, Vogt RA, Anderson RE, et al. Exercise in the treatment of obesity: effects of four interventions
on body composition, resting energy expenditure, appetite and mood. J Consult Clin Psychol. 1997;65:269-277.
FULL TEXT
|
ISI
| PUBMED
20. Wing RR, Jeffery RW, Burton LR, Thorson C, Nissinoff K, Baxter JE. Food provision vs structured meal plans in the behavioral treatment
of obesity. Int J Obes Relat Metab Disord. 1996;20:56-62.
ISI
| PUBMED
21. Wadden TA, Foster GD, Letizia KA. One-year behavioral treatment of obesity: comparison of moderate and
severe caloric restriction and the effects of weight maintenance therapy. J Consult Clin Psychol. 1994;62:165-171.
FULL TEXT
|
ISI
| PUBMED
22. Perri MG, McAllister DA, Gange JJ, Jordan RC, McAdoo WG, Nezu AM. Effects of four maintenance programs on the long-term management of
obesity. J Consult Clin Psychol. 1988;56:529-534.
FULL TEXT
|
ISI
| PUBMED
23. Beck AT, Steer RA. Beck Depression Inventory Manual. San Antonio, Tex: Harcourt Brace & Co; 1993.
24. Foster GD, Kendall PC. The realistic treatment of obesity: changing the scales of success. Clin Psychol Rev. 1994;14:701-737.
FULL TEXT
|
ISI
25. Anderson DA, Wadden TA. Treating the obese patient: suggestions for primary care practice [review]. Arch Fam Med. 1999;8:156-167.
FREE FULL TEXT
26. Cash TF. The Body Image Workbook. Oakland, Calif: New Harbinger; 1997.
27. Johnson CA. Self-esteem Comes in All Sizes: How to Be Happy and
Healthy at Your Natural Weight. New York, NY: Doubleday; 1995.
28. Foster GD, Johnson C. Facilitating health and self-esteem among obese patients. Prim Psychiatry. 1998;5:89-95.
29. Metropolitan Life Insurance Co. Metropolitan height and weight tables. Stat Bull Metrop Life Insur Com. 1983;64:2-9.
30. Kral JG. Surgical treatment of obesity. In: Bray GA, Bouchard C, James WPT, eds. Handbook
of Obesity. New York, NY: Marcel Dekkar Inc; 1998:977-993.
31. Rabner JG, Greenstein RJ. Obesity surgery: expectation and reality. Int J Obes. 1991;15:841-845.
PUBMED
32. Carver CS, Scheier MF. Control theory: a useful conceptual framework for personality-social,
clinical, and health psychology. Psychol Bull. 1982;92:111-135.
FULL TEXT
|
ISI
| PUBMED
33. Wadden TA, Bartlett SJ, Letizia KA, Foster GD, Stunkard AJ, Conill AM. Relationship of dieting history to resting metabolic rate, body composition,
eating behavior, and subsequent weight loss. Am J Clin Nutr. 1992;56:203S-208S.
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED ARTICLE
Archives of Internal Medicine Reader's Choice: Continuing Medical Education
Arch Intern Med. 2001;161(17):2155-2156.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
What Do Physicians Recommend To Their Overweight and Obese Patients?
Phelan et al.
J Am Board Fam Med 2009;22:115-122.
ABSTRACT
| FULL TEXT
Current Trends in Weight Management: What Advice Do We Give to Patients?
Boucher et al.
Clin. Diabetes 2008;26:115-120.
ABSTRACT
| FULL TEXT
Current Trends in Weight Management: What Advice Do We Give to Patients?
Boucher et al.
Diabetes Spectr. 2007;20:153-158.
ABSTRACT
| FULL TEXT
Review: several pharmacological therapies promote modest weight loss
Kennel
Evid. Based Med. 2005;10:140-140.
FULL TEXT
Review: sparse high quality evidence supports surgery for obesity
Kennel
Evid. Based Med. 2005;10:141-141.
FULL TEXT
Psychosocial Evaluation of Bariatric Surgery Candidates: A Survey of Present Practices
Bauchowitz et al.
Psychosom. Med. 2005;67:825-832.
ABSTRACT
| FULL TEXT
The Escalating Pandemics of Obesity and Sedentary Lifestyle: A Call to Action for Clinicians
Manson et al.
Arch Intern Med 2004;164:249-258.
ABSTRACT
| FULL TEXT
Principles and Practices in the Management of Obesity
Foster
Am. J. Respir. Crit. Care Med. 2003;168:274-280.
FULL TEXT
Weight Loss: Goals, Realities, and Strategies
Reinharth
Arch Intern Med 2002;162:1069-1070.
FULL TEXT
Are There Benefits From Long-term Pharmacotherapy of Obesity?
Kearns
Arch Intern Med 2002;162:1070-1070.
FULL TEXT
|
