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Randomised controlled trial with follow up at 6 and 18 months.
219 women between 25–50 years of age (mean age 40 y, 85% white) who responded to media advertisements and were 14–41 kg overweight; scored >20 on the Binge Eating Scale (BES); had no history of diabetes, cardiovascular, or gastrointestinal diseases; had no purging behaviour within the previous 6 months; were not pregnant or breast feeding; had physician clearance for a walking regimen; were not enrolled in another weight loss programme; and did not smoke.
Women were allocated to dieting treatment (DT) (n=79), non-dieting treatment (NDT) (n=78), or to a waiting list control (WLC) group (n=62). Participants in the 2 treatment groups attended 24 weekly 1 hour group sessions led by a psychotherapist and a dietitian and 26 biweekly maintenance classes led by a dietitian only. DT focused on self control methods to regulate eating and exercise patterns and included instruction on ways to reduce fat intake to 40 g/day and a home based walking regimen (4–5 h/wk). NDT was based on a philosophy that a history of diet failure and binge eating is associated with a dysfunctional set of cognitions and attitudes that affect the development of healthy lifestyle patterns. An initial psychotherapeutic phase addressed the psychology of being obese in a culture that values thinness, as well as self esteem and body issues. The aim was to ensure that new eating and exercise patterns were perceived as positive lifestyle changes to improve health and energy rather than punitive burdens associated with obesity. Goals included a gradual reduction in dietary fat and a self regulated home based walking programme. The WLC group was assessed at baseline and 6 months, but received no other contact.
Main outcome measures
Weight, eating dyscontrol (BES), and physical activity (7 d recall method) were assessed in all groups after treatment (6 mo) and in the 2 intervention groups at 18 months.
At 6 months, the DT group had lost 0.57 kg, whereas the NDT group had gained 1.35 kg (p<0.04), but neither were significantly different from the WLC group (p=0.26 and p=0.70, respectively). The DT and NDT groups had similar reductions in binge eating scores (p=0.27), and both of these reductions were greater than for the WLC group (p<0.001). At 18 months, the DT and NDT groups had similar weight gains of >1 kg above baseline (p=0.85), similar net decreases in BES scores from baseline (p=0.66), and maintained increases in exercise (2.09 kJ/kg/d [0.50 kcal/kg/d] and 3.01 kJ/kg/d [0.72 kcal/kg/d], respectively). Intention to treat analyses showed similar results.
In women who were obese and were binge eaters, neither a non-dieting nor a dieting intervention resulted in weight loss at 6 months when compared with a waiting list control group; both interventions reduced binge eating. At 18 months, the 2 treatment groups had similar weight gains and decreases in binge eating scores, and both maintained modest increases in exercise.
The problem of weight reduction using psychotherapeutic and dietary interventions is complex and poorly understood. Although many dietary weight loss interventions target healthy eating and behavioural strategies, this study by Goodrick et al is unique because the investigators developed an intervention targeted at the psychological issues of obesity, binge eating, and weight loss attempts. At the core of this intervention was psychotherapeutic counselling that included binge/diet cycling, desensitisation to body thinness, and self and body acceptance strategies.
The participants were predominantly white and well educated (24% had college degrees and 65% had some college). Because obesity affects more minority women, particularly women of low socioeconomic status, the application of these findings to other groups, especially those who are most vulnerable to this health problem, is limited. The 2 intervention groups were not entirely distinct; both were encouraged to exercise, received instruction in low fat eating strategies, and were given the opportunity to explore the psychology of obesity as a stigma in American culture. It would have been interesting to see the effect of a “walking alone” intervention. Recording of actual binge episodes could have strengthened the study.
The results of this study provide interesting, although limited, information for clinicians in primary care settings who care for overweight and obese women. The interventions focused not only on health promotion targeted towards appropriate intake of dietary fats and exercise but also on the stigma that overweight and obese women experience in our society. Although no differences were found in the outcomes of the 2 interventions, nurses in ambulatory clinical settings can learn from this study's methods and results. Too few clinicians recognise the complexity of issues surrounding weight management. This study emphasises the psychotherapeutic aspects of weight management and informs clinicians of the need to more fully explore multiple strategies of weight management techniques beyond basic diet and exercise counselling.
Sources of funding: National Institute of Diabetes and Digestive and Kidney Diseases and American Heart Association and its Puerto Rican Affiliate.
For correspondence: Dr G K Goodrick, Behavioral Medicine Research Center, Baylor College of Medicine, 6535 Fannin, Mailstop F-700, Houston, TX 77030, USA. Fax +1 713 798 4888.
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