7.1,- 3.‘ ,. a' u u 1 9n" awé-Iv-y..- ( L » ...", v ' nr "xv" éfl'v' ., x..;4:..5-.-.—‘.._. "Farr-5 - ...- .v 1,.1 "' -’ (r ' x‘ rely ll! 23:15! rm. 5 9-1 Jr. - , I .~ I; ,, 1, M ,{.;,J,., .... . ”.03.: I r "' 'H‘Iw 1m. u, .J.L~..u,'__ I J..." J ~121- .-.'- .. .n 4r r :' 1‘. x ., ....w...” v “‘rItr { V " 2 1 r‘ 7' ‘ ,1. .V'. v .r x w- - ..n: ; 1 v -. . 51 v ...1 ~- ' '. ' . " mar-~- w . I ,.. 'I - .. .. ' , . ., . ., r n rn ‘0. ...u ,. ‘ ; g _:.’, f‘ . - - ‘ r N ; 41:". , rruv. 14 n. v #11:... . rm . .1211! . :l' k. . amt]: f; "2-; . . -:.r 'n m . 1-21.. 1 , " J u . x u, s _. . ”in?” .,. _ u e. "'1 .3 :f;.:_. 1 a ...“... ~ .. - iq-—-:~,.,,,J.. n; ... r . mun-":5 ”r h""‘3r; A. .-..» www- . . r-vx mm. 71.513 till/W//IIll/llI///Illl/l/liil/lllli/lll/l/ll/ll This is to certify that the thesis entitled Comparison of a Behavioral and a Non-Restrictive Weight Loss Treatment Program presented by Laurie L. Friedman has been accepted towards fulfillment of the requirements for M.A. degree in PSYChOlOQY )szM /.77 (p=.01). Similarly, when MANOVAs were performed on these separate scales, there was a redundancy of results. Therefore, the above-mentioned four factors were combined into the non-physiologically-cued eating scale. The entire Rosenberg (1965) Self-Esteem Scale produced reliabilities of .86 to .89. Eighteen items from the Body 24 Cathexis Scale (Secord & Jourard, 1953) produced reliabilities of .85 to .90. Nineteen evaluation items, derived from Mavis' (1987) Program Evaluation and additional original items had a reliability of .95. From intercorrelations of the Manipulation Check items, two distinct (non-correlated) scales emerged (one for each treatment), with reliabilities of .97 (for 12 items) and .91 (for 10 items). Descriptive statistics of these scales at all three times are presented in Table 2. Scale intercorrelations are presented in Table 3. Comparability of Groups The initial questionnaires administered at the first treatment sessions were used to determine the similarity between subjects in the two treatment conditions. These questionnaires gathered background and demographic information, data related.to prior attempts at weight control, perceived social support, reasons for wanting to lose weight, as well as initial scores on eating behavior, self-esteem, and body image. At the first session, initial weight was determined (via a medical scale) , from which percentage overweight was calculated. Group comparisons based on Multivariate Analysis of Variance (MANOVA) are presented in Table 4; similar comparisons based on Chi-Square analyses are shown in Table 5. Although full random assignment to groups was constrained due to participant considerations and pre- existing relationships between subjects, only one significant difference was discovered at Time 1 for 29 variables: There was a significant difference between the groups in the 25 reported weight of their best friend (p=.04). Irt is very likely that this minor difference is due to chance, although it will be considered when examining the results. The initial assignment of subjects to treatment conditions appears to have resulted in equivalent groups based on pre- treatment characteristics and scores. The groups were within acceptable homogeneity of variance in terms of demographic backgound and initial scores at Time 1. Testing the Hypotheses A probability level of .05 was used as the criterion for significance for each of the hypotheses tested. Univariate and multivariate Analyses of Variance and Covariance were calculated using the SPSSX program. Initial weight was controlled by using it as a covariate when testing effects on body weight and percentage overweight. The hypotheses refer to effects of treatment outcome; therefore, these results are based on the data for those participants for whom data was obtained for all three times. The homogeneity of variance across groups was tested for each of the outcome measures. The homogeneity test is based on Cochran (1941); it is the ratio of the largest variance to the sum of all variances across conditions. Thus, it is the test of the proportion of variance attributable to any single study condition. The results indicate that the necessary assumption of homogeneous variances was met for all of the treatment measures. Group and time effects. There were no significant 26 differences between the two treatments at post-treatment or follow-up on the outcome measures of total weight, percentage overweight, overeating behavior, self-esteem, or body image. Similarly, there were no significant differences between the groups on satisfaction with treatment. As expected, both groups showed significant changes over time in total weight, percentage overweight, restrained and overeating behavior, self-esteem, and body image. Of the 49 subjects who were initially enrolled, 35 (71%) completed the treatment, and of those, 26 (74% of 35; 53% of the initial total; 13 from each group) lost weight. There were no significant differences between the groups in the number of subjects who lost weight at Time 2 and Time 3. From analyses done on the sample for which data were available for all three times (31 to 32 subjects, depending on the variable), the only significant group effect was a time- by-group interaction for restrained eating behavior (F=4.16, p=.02) . Although both groups reported significantly increased restraint from Time 1 to Time 2 (F=16.72, p<.001 for LEARN; F=6.60, p=.02 for E A T), the LEARN group then significantly decreased in restraint from Time 2 to Time 3 (F=7.34, p=.02). Overall, the LEARN group reported greater and more significantly increased restraint over time than did the E A‘T group, to produce a significant time-by-group effect. Cell means of weight and scale scores at Time 1, 2, and 3 are presented in Table 6. Repeated-Measures ANOVAs for restrained eating and the other self-reported outcome variables are 27 presented in Table 7. Repeated-Measures ANACOVAs for weight and percentage overweight are presented in Table 8. Means and F statistics of program satisfaction and relative weight loss are presented in Table 9. Therewwas also’a significant time-by-group interaction for weight loss (F=4.50, p=.04, n=35), with. the ILEARN’ group showing greater weight loss from Time 1 to Time 2 than the E A T group, as presented in Table 10. This interaction effect was not found for weight loss when analyzing all three times. In addition, there were no significant group differences in relative weight loss at Time 2 or Time 3 (see Table 9). Treatment Integrity A manipulation check scale was administered at the last treatment session along with the program.evaluation to measure the degree to which the leader focused on various program components (leader and program integrity). There were significant differences between the groups on the two manipulation check scales (F=141.56, p<.001 for MC1; F=34.13, p<.001 for MC2). Means and F statistics are presented in Table 11. Similarly, there was a significant negative correlation between scores on MC1 and.MC2 (r=-.63, p<.01) (see Table 2). Correlational Analyses Although not part of the hypotheses, a correlational analysis was performed on non-ordinal demographic and background data, initial scores, and the outcome measures of relative weight loss, attendance, and satisfaction with 28 treatment. The only significant results were positive correlations between relative weight loss and age (r=.39, p=.05) and relative weight loss and program attendance (r=.40, p=.05) for the entire sample. Because of the group differences in program attendance, the relationship between attendance and relative weight loss was looked at for each treatment separately. There was a significant positive correlation between relative weight loss and attendance in the E A T group (r=.48, p=.05), but this relationship was not significant for the LEARN group. In testing the scale properties, correlational analyses were also performed on scale scores at all three times (see Table 3). Interview Data Interviews were conducted with 33 subjects-—14 from the LEARN group and 19 from the E A T group. Most of the interviews were done face-to-face, but four were conducted via telephone with subjects who were unable to meet in person. The interviews produced rich and interesting data. Overall, subjects were unable to identify the purpose of the research or what happened in the other treatment condition. Most subjects were unaware that the other group received a different type of treatment. In addition, most subjects could not identify expectations that the experimenter might have had. The interview data that were quantified and analyzed statistically fell into three catagories: Why the subject lost weight, which program tools worked or were helpful, and 29 why the subject didn't lose weight (or more weight than he/she did). Reasons given for why subjects lost weight included using the tools and techniques taught in the program, commitment/motivation, attending the meetings, lack of pressure/guilt/dieting, increased activity or exercise, social support, and participation in another weight loss program. The tools mentioned which facilitated weight loss included awareness of eating, awareness of emotions, awareness of hunger and the body's needs, no set eating schedule, ability to eat anything, being free to not eat, keeping a food diary, cutting down on specific foods or amount eaten, and counting calories. Reasons reported for why subjects did not lose weight included not using the tools, difficulty using the tools, dissatisfaction with the program, conflicts with work, low motivation, interference from work or social engagements, stress or personal crises, and lack of social support. Pearson Chi-Square analyses of these data produced six significant group differences, presented in Table 12. Five subjects in the LEARN group (36%) and none in the E A T group (0%) reported commitment or motivation as a reason why they lost weight (p<.005). Similarly, seven subjects Zhl LEARN (50%) and only one in E A T (5%) reported that the program meetings facilitated their weight loss (p<.005). When asked to identify helpful or effective tools, 11 subjects in the E A.T group (58%) and zero in the LEARN group (0%) mentioned awareness of hunger and the body's needs (p<.001) . Conversely, three subjects in LEARN (21%) and zero in E A T 3O (0%) reported that keeping a food diary was a helpful tool (p=.03), and four in LEARN (29%) and none in E A T (0%) reported that counting calories was an effective tool (p=.01) . Finally, three subjects in the LEARN group (21%) and zero in the E A T group (0%) reported low motivation as a reason why they didn't lose weight (or more weight) (p=.03). DISCUSSION The E A T method was generally as effective as the LEARN method, but not more effective, according to this study. There were comparable and significant changes over time in the outcome variables measured, and, with two exceptions, there were no significant differences between the two groups on these variables. The two exceptions were a significant time- by-group effect for restrained eating behavior scores, and a significant time-by-group effect for weight loss, from Time 1 to Time 2. There were also significant differences between the groups on the manipulation check measure and on attendance. Several interpretations of these results can be made. First, the highly significant group effect on the manipulation check suggests that, although both treatments were led by the principal investigator, subjects in the two conditions did actually receive distinct treatments. Despite the self-reported nature of these data, demand characteristics are likely minimal: Even if a subject tried to give the "right" response to be a "good subject," this must reflect what actually occurred in the sessions, or the subject would not know which would be the desired response. These results indicate that subjects did receive two different treatments, as the study intended, and that no leader bias was detected. 31 32 The significant group effect for program attendance indicates that subjects in the E A T group had better attendance than those in the LEARN group. .Before the programs began, I had expected the E A T group to have worse attendance than the LEARN group, because the E A T class was longer, met later in the evening, and did not meet every week after the first six sessions. I had feared that E A T subjects would forget when to meet, since it wasn't every week. However, this was not the case. Several possible explanations for this group difference in attendance can be made. It may be that unidentified subject differences (e.g., readiness for treatment, motivation) were responsible for differences in attendance. Significantly more subjects in the LEARN group did identify low motivation as a reason why they didn't lose weight. It may be that non- treatment group differences (e.g., time or length of the class, frequency of sessions, mode of presentation of material, group dynamics, etc.) were related to attendance. Perhaps subjects were more willing to attend fewer sessions than one every week” Or, the actual content of the treatments may account for the variance in attendance. Perhaps subjects in the LEARN group became discouraged by the restriction involved in the program, or perhaps they had already learned the material from other programs or books and were therefore bored. However, subjects' liking of the programs cannot be assumed to account for the difference in attendance, because there was no significant difference between the groups on the 33 Program Evaluation measure. Perhaps subjects in the LEARN group felt they did not need to attend the sessions because the material was in their workbooks, which they could read without attending the sessions. The attendance effect is interesting, but unfortunately one can only speculate about its cause. The comparable and significant changes over time on the outcome variables suggest that a) both groups showed improvement over time, and b) one treatment was not more "effective" than the other. What cannot be ascertained from these results is whether the changes over time were due to actual treatment.effects.or2rather'to.non-specific "treatment" effects. Given the lack of a no-treatment control group (due to difficulty recruiting subjects) or pre-treatment data from several months prior to treatment, there is no way to know whether these time effects would have occurred even without the treatment. In future research, a control group and pre- pre-treatment data would provide more conclusive results. However, the significant positive correlation between the outcome measure of relative weight loss and attendance in the E A T group suggests that the treatment sessions may have contributed to weight loss. An alternative interpretation of this correlation is that those subjects with good attendance were highly motivated to lose weight or succeed, and this motivation may have been the cause of their weight loss and other improved scores. If the signficant changes over time in the outcome 34 variables can be attributed to actual treatment effects, these results offer important implications for theory of weight regulation and weight loss treatment. The fact that subjects in the E A T group lost a significant amount of weight and showed significant improvement on the other outcome measures suggests that a non-restrictive weight loss program like Eating Awareness Training lg effective in promoting weight loss, and may be as effective, or more so, in the long run, as a traditional behavioral method, although the latter may produce greater and faster weight loss initially (as suggested by the larger weight loss in the LEARN group from Time 1 to Time 2). This study suggests that traditional behavior modification techniques of external control and reinforcment of behavior (although perhaps faster) are not necessary to facilitate weight loss. Instead, with training and practice, it seems that the human body can relearn to respond appropriately to natural signals of hunger and satiety, and that an individual can choose to eat according to these signals, without external control or cognitive restraint. These time results support the E A T philosophy and suggest that a non-restrictive approach is a viable and effective alternative to behavioral weight loss methods. The significant group and time effects for restrained eating behavior have their own interesting implications. The time effects indicate that both groups increased significantly in restrained eating from Time 1 to Time 2, although the LEARN group showed a greater and more significant increase. From 35 Time 2 to Time 3, the LEARN group decreased significantly in restraint, whereas theiEZXT‘group increased slightly (but not significantly). This time-by-group effect.may indicate real differences in eating behavior between the groups, or it may be the result of demand pressures and self-presentation needs. Given that the LEARN'program.did encourage restrained eating as a weight loss technique, subjects in this group :might have positively endorsed restraint items to please the experimenter or to present a certain (and "improved") image. However, subjects in the E A T group would not necessarily be expected to endorse restraint items, as (cognitive) restraint was discouraged in their program. Furthermore, the fact that LEARN subjects significantly decreased in restraint after the treatment was over suggests that demand pressures were pp: responsible for the changes over time in reported restraint. If they were, one would expect restraint to continue to increase in the LEARN group at Time 3, or at least to stay the same. Another indicator that the group difference in restrained eating may reflect a real difference is the fact that low scores on the LEARN manipulation check (indicating endorsement of LEARN components) were significantly correlated with high restraint scores at Time 2, reinforcing a group difference in restrained eating at Time 2. In addition, there was a significant difference between the mention of "counting calories" as a helpful tool in the post-interviews. Counting 36 calories is a common technique of restraint which was taught only in the LEARN treatment. Hence, data from several sources seem to converge to validate the group difference in restrained eating behavior. However, given the limitations of self-report measures and subjects' self-presentation needs (Hogan & Nicholson, 1988; Kagan, 1988), one is unable to know the exact meaning of this group difference in reported restrained eating. If this reported restraint difference is a "real effect" (not from demand or self-presentation pressures), it suggests that weight loss may be achieved without the degree of cognitive restraint, restriction, and external control of food intake previously thought necessary to lose weight. This implication supports the premise behind the Eating Awareness Training method--that an individual can lose weight, not by restricting intake, but by responding appropriately to the body's needs and messages. The unexpected increase in "restraint" in the E A T group from Time 1 to Time 2 may reflect a change in eating from overeating behavior to a more conscious or controlled eating. Eating only when hungry, instead of anytime, may show up as increased restraint on the restraint scale. This group effect for restrained eating is exciting in that it appears to support the E A T philosophy and method. One would expect the potential for long-term maintenance of weight loss and behavior changes to be greater for an approach which does not require cognitive restraint, restriction, or 37 control, especially in light of current research on the negative effects of restrained eating (e.g., Heatherton, Polivy, & Herman, 1991). Additionally, the decrease in elevated restraint scores in the LEARN group supports the belief that restrained eating cannot be successfully maintained for long periods of time. However, further research on the long-term effects of the E A T method are needed. Results from the post-interviews also have interesting implications. These data serve to cross-validate the manipulation check , by a1 lowing subjects to state spontaneously which program tools they said worked for them (and hence, were presented in their program) . These interview data may reflect subjects trying to be "good subjects" by reporting that the tools presented in their treatment were the reason that they lost weight (see Weber & Cook, 1972). However, two techniques mentioned by E A T subjects but not by any LEARN subjects, "hunger awareness" and "not eating by a set schedule," are the exact opposite of traditional behavioral weight loss techniques. With these tools, subjects become aware of their physiological hunger and eat according to this hunger, and not according to time of day, "the clock," or social convention. It is possible (and promising) that these tools did actually allow E A T subjects to lose weight, as the subjects reported. Methodological Limitations There are several methodological limitations which may 38 have inhibited the discovery of additional significant results. In this study, although the self-report measures used had been previously tested and validated, it was necessary to eliminate items which were not internally reliable for this sample. Therefore, with the exception of the Rosenberg (1965) Self-Esteem scale, items used in the final analyses did not constitute the entire scales from which they were taken. Furthermore, due to the small sample size (less than 50 subjects), a full factor analysis could not be performed to factor the reliable items into reliable sub— scales. Instead, a "poor person's factor analysis" was done by correlating sub-scales and combining those scales which were highly'correlatedn 'This process is acceptable but only second in preference to the full factor analysis. ‘With.more reliable or valid measures, or with a sample size large enough to more fully test the measures, it is possible that more significant results might have been discovered. Despite these considerations, scale tests for reliability and other properties were generally satisfactory. Internal reliabilities were high for all scales at all three times, the lowest being .79 for restrained eating at Time 1” .Average inter-item correlations within a scale were greater than interscale correlations. Skewness and kurtosis were within reasonable limits, with the exceptions of non-physiological eating at Time 3, self-esteem at Time 2, and the LEARN manipulation check. As desired, scale means were not extreme, but standard deviations were less than half the size of the 39 means, indicating low variability, which is less desirable than high variability in scores. It is unclear exactly how these scale characteristics affect the results, but it is true that the scales were not as robust as desired. In addition, the validity of the self-report measures used in this study is unknown, as stated previously. It is generally unknown whether self-reported scores reflect the subjects' actual behavior. Given the social desirability (or undesirability) of the constructs and behaviors measured, it is possible that subjects' memory of their own past behavior or thoughts may have been distorted by the need to see themselves in a positive light. It is also possible that initial pre-treatment scores were exaggerated, while post- treatment responses may have been endorsed to display "improvement" on the outcome variables“ IHowever, if this were the case, one would expect scores to remain "improved" at follow-up (Time 3), which.was ppp the case for most variables. Most outcome measures showed the pattern over time of improving at Time 2, with a slight "relapse" (sometimes significant and sometimes not) at Time 3. This relapse of scores supports the validity of the self-report measures. Data from the interviews also lessen the estimated influence of demand pressures in that most subjects reported no knowledge of the purpose of the study nor what the experimenter expected» IHowever, even.if the measures used did reflect true responses related to actual behavior, it is unknown whether the self-report measures were sensitive enough 40 to detect changes after relatively short-term treatment. Related to the sensitivity of the measures is the concept of statistical power and subject attrition. A test of power was pp; performed in order to determine the necessary sample size to detect group differences in changes in the variables. Instead, sample size was constrained by the number of available and interested participants. Much to the experimenter's dismay, recruitment of subjects was difficult and slow, such that 49 subjects were judged as "enough" when it didn't seem possible to recruit any more. Unfortunately, sample size was also reduced due to attrition of subjects, which is a major concern in weight loss research (Eufemia & Wesolowski, 1985). Due to the length of both programs (16 weeks) or numerous other factors, subjects gig drop out, or participate minimally in the program. This attrition. reduced. the. original sample size of 49 to 31 subjects for which data were obtained for all three times. Such attrition can bias results, in that poor weight-losers may drop out at a higher rate than do those who lose greater amounts, so that those who remain in treatment may be selected for greater weight loss (Levitz & Stunkard, 1974). Or, the direction of the possible bias may be unknown. External validity is then jeopardized, since attrition reduces generalizability, and internal validity is compromised if there is differential attrition across treatment groups. It was advised, however, that the resulting unequal groups would not statistically affect the results, because the repeated 41 ANOVA keeps the data proportional (R. Frankmann, personal communication, August 12, 1991). The main problem with subject attrition is that it reduces the sample size and the power of the study, such that real group differences may not be detected.due to low power. Large sample sizes are needed. to detect group differences in outcomes, especially in weight loss research (Mavis, 1987). Unfortunately, this study could not fulfill the large sample size ideal. It may, however, have been possible to obtain more data on subjects who did not attend the last or follow-up session, had the experimenter been more persistent in her efforts (e.g., follow-up phone calls if questionnaires were not returned by mail). The other difficulties with attrition is how "drop outs" are classified and interpreted. In this study, subjects were included in the analyses if data were available for all three times. However, some subjects seemed to drop out of the program, but did attend the last session and even the follow- up (perhaps to receive their monetary deposit back). Such subjects received incomplete treatment, which may have biased the results. Chi-Square analyses of attendance above and below the median split showed a highly significant group differenceu A greater number and percentage of E A.T subjects received more of their actual treatment than did the LEARN subjects. Although "receiving" the treatment does not guarantee its application or subsequent behavior change, it nevertheless must be considered in a treatment study. 42 The interpretation of the significance of drop outs also poses a challenge. Should the 14 subjects who did not complete the treatment.be considered program failures?’ Or did they drop out for individual reasons, not due to the treatment? Since data on these subjects are unavailable, it is impossible to determine whether these subjects were program failures or successes. During the course of the treatments, the experimenter saw one subject who had not been to class for several sessions at a store in the community, and this woman said she had stopped coming to the meetings because she had lost all the weight she'd wanted to (which she said was about 15 pounds). It is unfortunate that data on these subjects who dropped out were not obtained. Another possible limitation of this study is group leader bias. Since the leader was also the principal investigator, she was also the one who collected and analyzed the data, in addition to administering both treatments. Due to the scale of this study, it was not possible to hire other group leaders or data collectors. However, both the results of the program evaluation, the manipulation check, and the post-interviews suggest that leader bias was pg present, at least in the delivery of the two treatments. Another possible limitation was the influence of nonspecific treatment effects. Subjects may have lost weight, not due to any planned component of either treatment, but simply because they were in a weight loss program or to please the program leader. However, the debriefing interviews did 43 identify specific treatment components which subjects reported were responsible for their weight loss, but even these interviews may have been biased by demand characteristics of the subjects. Another possible limitation of this study is what might be called "nonspecific subject effects." For example, age was found to be positively correlated with.relative weight loss in this study. Subjects' readiness for treatment and behavior change has been considered in other research, especially in the treatment of alcoholism and drug abuse. Subjects' readiness for treatment and change was pp; assessed in this study, so it is possible that subject differences and characteristics may have contributed to the within-group variance and the effectiveness of both treatments. Because readiness was not assessed with other pre-treatment data, its effect on the outcome variables and program attendance and participation cannot be determined. Future research would benefit from including' an assessment of readiness, like Berish's (1990) preliminary’ Client. Readiness for Therapy scale. I believe that until an individual is truly ready to change (his/her behavior, body, self-image, identity), treatment will be resisted or rejected altogether and thus, be rendered "ineffective." Finally, this research is lacking a long-term follow-up of subjects. At this writing, it is two years since the end of the treatment programs. Athough 4-month follow-up data were collected, longer follow-up data, like two or three years 44 post-treatment, would be helpful in assessing long-term treatment effects and maintenance of weight loss and other changes. Such a longer follow-up is not being planned at this time, although it is possible. Conclusions Despite these limitations, this study was the first of its kind to examine the effectiveness of a truly non-restrictive program like Eating Awareness Training, in comparison with an established behavioral program- 'Bhe fact that subjects in the Eating Awareness Training group lost a significant amount of weight and showed significant.improvement on the other outcome variables suggests that a previously unresearched, non- restrictive method lg effective in promoting weight loss, and may be as effective, or more so, in the long run, as a traditional behavioral method. These results suggest that traditional behavior modification techniques of external control and reinforcement of behavior are not necessary to facilitate weight loss. Instead, with training and practice, it seems that the human body (and.mind) can relearn to respond appropriately to natural signals of hunger and satiety, and that an individual can choose to eat according to these signals, without external control or cognitive restraint. This type of change in eating behavior may be a more realistic and long-term solution to the problem of obesity and overweight than behavioral changes which require restriction, control, and possible physical discomfort (e.g., unsatisfied hunger). Hopefully, this study' will motivate continued 45 research on the non-restrictive approach to weight loss, which seems a promising alternative to traditional behavioral methods. APPENDIX A Recruitment Advertisements 46 ra/Vl W I98? NEED TO LOSE WEIGHT? Persons who want to lose weight are invited to participate in a weight management proiect sponsored by the Michigan State University Weight Loss Research Program. If you are interested in learning more about the proiect, call 353-4880 weekdays during regular business hours. You will receive an information package and be invited to an introductory meet- ing. Those attending the introductory meeting are under no obligation to participate in the proiect. MSll WEIGHTLOSS ' RESEARCH. m "NEW “axacfaw..z“...t; Seeks overweight 3:er m :32; men and women :30 ”rough summer. 9n. for weightloss ——' program. $30 through summer. 332-0256 47 NISU. WEIGHT LOSS RESEARCH PROJECT HAHTEDZ AH'I’OHE OVER THE AGE OF 18 WHO IS AT LEAST 20% ABDUE HIS/HER IDEAL HEIGHT. THE PURPOSE OF THIS RESEARCH IS TO COMPARE THE EFFECTIUEHESS OF DIFFERENT WEIGHT LOSS TREATMENT METHODS. INTERESTED? CALL LAURIE AT 332-0256 FOR MORE INFORMATION AND DETAILS APPENDIX B Recruitment Letter 48 MSU Weight Loss Research Project, Round 2 Dear Potential Participant: Thank you for your interest in weight loss and in this research project. The following information should answer most of your questions about the project. PLEASE TAKE THE TIME TO READ THIS INFORMATION CAREFULLY. If you have any further questions or concerns, call Laurie Friedman at 332- 0256. Objectives of the Project The purpose of this research is to compare the effectiveness of different weight loss treatment methods. Program Description The current project lasts 16 weeks, and sessions will meet once a week, or less frequently, depending on the class you are assigned to. The sessions will be held on Tuesday nights, at 5:30 PM or 7:00 PM on the university campus; class size will be limited to 25 participants. The program is open to anyone over the age of 18 who is at least 20% over his/her ideal weight and who is not pregnant. A physician's consent form may be required. The program will start as soon as all of the class slots are filled. If you are interested in participating, you must attend one of the scheduled orientations meetings or call Laurie Friedman at 332-0256. Research This program is offered as a research project by a graduate student. This means that in addition to receiving a quality weight control program, you will be asked to complete several questionnaires during the program, participate le a post- program interview, and attend a 3—month follow-up session. The questionnaires cover your weight history as well as your eating behavior and other variables. Orientation Meetings The first orientation meetings will be held in 219 Berkey Hall on the MSU campus (on East Circle Dr. off of Collingwood) on Tuesday, April 25, from 5:30—6:30 and 7:00-8:00 PM. You can attend the time most convenient for you, but this may not be the time your program session will meet. 49 If you cannot attend the orientation meeting but are still interested in participating, please call Laurie Friedman at 332-0256. Additional orientation meetings will be scheduled as needed. The purpose of the orientation is for you to meet with the representative of the program to answer any questions you may have regarding the program. You can attend the orientation without any obligation to participate in the research» If you would like to join the program, you can reserve your place by making a $30 deposit at the orientation meeting. Cost of the Program There is no fee for the program itself, but you may be charged a small amount for program materials (i.e., $5). There is, however, a mandatory $30 deposit which will be refunded contingent upon completion of the program and attendance at the follow-up meeting. This deposit will also reserve your place in the program. Exact cash or check payable to the MSU Psychological Clinic is appreciated. Credit cards are NOT accepted. Thank you for your interest! I look forward to meeting you soon. Sincerely, A ‘7 I'll I I . I. Laurie L. Friedman Psychology Graduate Student APPENDIX C Behavioral Program Outline Week Week Week Week Week Week Week Week Week Week Week Week 10 11 50 LEARN Schedule Is the time right?; expected weight loss; description of LEARN program; questionnaires The LEARN approach; record keeping; reasons for overweight; exercise, relationships, nutrition; a word of caution; self-assessment Reviewing the diary; the role of exercise; why dieting is so difficult; the mysterious calorie; not all dieters are created equal; determining your target calorie level Analyzing the expanded diary; keeping the backfield in motion; a walking partnership; cravings vs. hunger; the mighty calorie The ABC's of behavior; perfecting the walking program; shaping the right attitudes; following a balanced diet; solo and social dieting; your target calorie level; introducing a new monitoring form Wresting control of eating; making exercise count; calorie values of exercise; food and weight fantasies; a quiz for choosing a partner; servings from the four food groups Slowing the eating rate; continuing walking and lifestyle activity; steps for taking your pulse; communticating with your partner; protein; yogurt and your diet; planning healthy meals Shopping for food; introducing programmed exercise; an exercise threshold attitude; striving for perfection; a shopping partnership; carbohydrates and your diet; breakfast cereals Storing foods; selecting and starting a programmed activity; internal attitude traps; the role of fat in the diet; fish oil and risk of heart disease Serving and dispensing food; more on exercise; impossible dream thinking; something for the partner; facts about vitamins For the family; dealing with pressures to eat; another attitude trap; jogging and cycling; water soluble vitamins Eating away from home; aerobics; pleasurable partner activities; poultry vs. red meat; fat soluble vitamins Week Week Week Week Week 12 13 14 15 16 51 The behavior chain; a chain and its links; interrupting the chain; using stairs; fast food Preventing lapse, relapse, and collapse; using alternative activities; facts, fantasies, and fiber Coping with lapse and preventing relapse; becoming a forest ranger; life on chutes and ladders; cholesterol The master monitoring form; holidays, parties, and special events; the national walking movement; minerals Interpreting progress; examining the master monitoring form; making habits permanent; doing a master self-assessment; saying farewell, monetary payback; questionnaires APPENDIX D Non-Restrictive Program Outline Week Week Week Week Week Week Week Week Week Week Week Week Week Week 10 11 12 13 52 E A T Schedule Introduction; questionnaires Relaxation techniques; goals; trust; body awareness; illusion and reality; the mind; now body--natural shape; appropriate responses; attention, without interference; potential and performance; E A T techniques; staying in the present; amnesia; responsibility; scales; practice for Week 1 Fear of reality; hunger; fear of hunger; handling hunger for special occasions; comfort; the clean plate syndrome; the human body is not a garbage can; abusing the body to please others; practice for Week 2 Fear of non-gluttony; danger signals; fear of mistakes; approval.and.disapproval; the mind; past decisions; automatic responses; concepts and judgments; past failures; how to deal with the mind; the when syndrome; practice for Week 3 Mind attacks; freedom; fear of success; fear of loss; cravings; choosing foods; to satisfy or not to satisfy; nutrition; practice for Week 4 Time and energy; what do I really want?; fear of unhappiness; image; what will they think?; identification; self image; more fear of reality; practice for Week 5 Stop fighting the body; the when, what, how much, and why; awareness; reminders; applying E A T skills to other aspects of life; breaking habits; observing the mind; stress and other signals; have patience‘with.others; experience; enjoy being free Review; questions and answers; feedback; eliminating obstacles Review; questions and answers; feedback; eliminating obstacles Review; questions and answers; feedback; Week 14 Week 15 Week 16 53 elimination of obstacles Review; questions and answers; feedback; elimination of obstacles; setting up a support group; final weigh in; monetary payback; questionnaires APPENDIX E Treatment Contract 54 Treatment Contract I, , agree to participate fully in this 16-week weight loss program. I agree to attend all sessions, complete any and all homework assignments, and comply with program requirements (which may include keeping a food diary and other behavioral changes). I understand that my $30 deposit will be refunded upon my completion of the program, half at the last session, and half at a three month follow-up session. Signature: Date: APPENDIX F Registration and Consent Forms 55 Registration Form Name: Address: Zip Telephone: Daytime Evening Sessions for this program will be held on TUESDAY EVENINGS at 5:30 PM and 7:00 PM. If there is a time which you CANNOT attend, please indicate below. I cannot attend session on Tuesdays at: 5:30 PM 7:00 PM I cannot auarantep the time of your program, however, please indicate below if one time is more convenient for you to attend. I would rather attend the 5:30 PM session (I would rather attend the 7:00 PM session Is there someone you would like to be in the same program with; that is, are you driving with someone or attending with a family member? No Yes. If so, who? 56 Informed Consent 1. I have freely consented to participate in this study being conducted by Laurie Friedman, under the supervision of Dr. Joseph Reyher. I understand that the study involves a comparison of weight loss approaches. 2. The study has been explained to me, although full disclosure of the complete design will not take place until the last session. 3. I understand that the $35 I contribute to the program represents a $5 fee for program materials and a $30 refundable deposit, half of which will be returned at the last session, and half of which will be returned at a 3-month follow-up session. 4. I understand that I will be expected to complete all questionnaires, attend all program sessions during the 16-week program, participate in a post- program interview, and attend a 4-month follow-up session. 5. I understand that I am free to discontinue my participation in the program at any time. However, if I decide not to continue, I understand that all money I contributed, including the $30 deposit, will be forfeited. 6. I understand that the results of the program will be strictly confidential and anonymous. Only group results will be reported; no individuals will be identified. 7. I understand that my participation in the program does not guarantee any beneficial results to me. 8. If under a doctor's care, I understand that I will be asked to consult with my physician before beginning this program. At this time, I AM NOT pregnant. Should this change during the course of the program, I will immediately notify the program leader. 9. I understand that, at my request, I can receive additional explanation of the study from Laurie Friedman after my participation is completed. Print Name: Date: Signature: 57 Informed Consent I have freely consented to participate in this study being conducted by Laurie Friedman, under the supervision of Dr. Joseph Reyher. I understand that the study involves a comparison of weight loss approaches. The study has been explained to me, although full disclosure of the complete design will not take place until the last session. I understand that the $30 I contribute to the program represents a $30 refundable deposit, half of which will be returned at the last session, and half of which will be returned at a 4-month follow- up session. I understand that I will be expected to complete all questionnaires, attend all program sessions during the 16-week program, participate in a post- interview, and attend a 3-month follow-up session. I understand that I am free to discontinue my participation in the program at any time. However, if I decide not to continue, I understand that all money I contributed, including the $30 deposit, will be forfeited. I understand that the results of the program will be strictly confidential and anonymous. Only group results will be reported; no individuals will be identified. I understand that my participation in the program does not guarantee any beneficial results to me. If under a doctor's care, I understand that I will be asked to consult with my physician before beginning this program. At this time, I AM NOT pregnant. Should this change during the course of the program, I will immediately notify the program leader. I understand that, at my request, I can receive additional explanation of the study from Laurie Friedman after my participation is completed. Print Name: Date: Signature: 58 Medical Release Form , a patient of yours, is interested in participating in a weight loss research program through the MSU Department of Psychology. The program is based.on current.medical and scientific research in the fields of psychology, nutrition, and. exercise physiology; The program is conducted by a psychology graduate student who is trained. to deal. with. weight-related. problems, under the supervision of Dr. Joseph Reyher. As part of the program, participants can expect to lose.weight at a rate of 1 to 2 pounds per week. Central to this weight loss program is a goal to help people develop healthful eating and lifestyle habits. There is no specific diet, The program encourages eating in moderation from a balanced diet. Participants will be expected to participate in a walking program to increase their activity level. A program syllabus is included for your information. If you have any questions about this program, contact Laurie Friedman at (517) 332-0256. If you believe your patient can safely participate in this program, please sign the release below. ******* is medically able to (patient's name) participate in this weight loss program. Special precautions the patient should take: Signed Date 59 Medical Release Form , a patient of yours, is interested in participating in a weight loss research program through the MSU’Department.of Psychologyu ‘The program teaches participants how to listen to and respond to their body's physiological signals of when, how much, and what to eat. The program teaches eating awareness techniques and hunger and body awareness. The program will be conducted by a psychology graduate student who is trained to deal with weight-related problems, under the supervision of Dr. Joseph Reyher. If you have any questions about this program, contact Laurie Friedman at (517) 332-0256. If you believe your patient can safely participate in this program, please sign the release below. ******* is medically able to (patient's name) participate in this weight loss program. Special precautions the patient should take: Signed Date 6O EATING AWARENESS TRAINING (R) NAME PHONE (BUS) (HOME) ADDRESS BIRTH DATE OCCUPATION HOW LONG HAVE YOU HAD A WEIGHT PROBLEM? GOALS FOR SEMINAR REFERRED BY THE EATING AWARENESS TRAINING AGREEMENT In exchange for the course fee of $ , the Consultant, Laurie Friedman, having been trained by Molly Groger, dba Eating Awareness Training, shall provide the Client with ( ) lessons and applicable accompanying written materials, including but not limited to advice about developing awareness of eating habits, instruction in techniques to increase consciousness when eating, and consultation about utilizing the awareness developed to achieve eating natural to the Client's body. Consultant is not a licensed health care professional or psychological expert. The content of the course consists solely of techniques for developing awareness and performance concerning consciousness while eating. No medical or psychological counseling or advice is intended or will be given. Consultant represents and warrants that, upon completion of the course, the Client will be more aware of his or her eating patterns and habits. 'Under no circumstances shall the Consultant be liable to the Client or any other person for incidental or consequential damages of any nature, including, without limitations, damages for personal injury, however occasioned, whether alleged. as resulting from breach of warranty by Consultant, the negligence of Consultant, or otherwise. It is understood and agreed by the parties that Molly Groger has spent many hours in research and development of this awareness program; that Molly Groger has spent many hours training Consultant, and, after assuring herself that Consultant can effectively instruct, has licensed Consultant to train others in the Eating Awareness Training techniques; 61 and that Molly Groger's combination of business plans and methods could only be independently reproduced at considerable cost and effort. Thus the information and advice given by Consultant constitutes confidential information. The Client shall not divulge to others or use for his or her own benefit or profit any confidential information obtained.as a result of this Agreement or Course including but not limited to information or data, the method or processes used to develop this program, the educational materials or techiques, the names of clients, and inventions or discoveries patentable or otherwise, with which the Client may become familiar during the term of this Agreement. This Agreement is the entire.Agreement.between.parties and any amendments or modifications hereof shall not be effective unless in writing signed by both parties. DATE CLIENT APPENDIX 6 Timing of Program Measures 62 Timing of Measures Used in the Programs Questionnaire Items Week 0 Week 16 Week 17 Week 28 Demographic Information Weight Loss History Social Support Weight Eating Behavior Self-Esteem >< X X >4 N X X N N X N Body Image >< ><>< >4 N Program Evaluation * Self-reported weight. APPENDIX 11 Interview Schedule 63 POST-INTERVIEW INSTRUCTIONS (Introduce yourself. Thank person for coming; their coming tonight is important for the research and we appreciate it. .Ask their name and make sure it's clear on the tape. Mention that you are taping.) Did you lose weight during this program? (if yes,) How much? (IF YES) Can you tell me why it was that you lost the weight you did? (Let them answer and prompt them to continue.) (if not already answered, prompt) What was it about the program that seemed to work for you? Anything else? Was there anything else going on that seemed to help you lose weight. during’ this ‘time? (ie, other factors besides ‘the program) Can you tell me what your goals or expectations were for this program? Do you feel satisfied with the results of your participation in this program? (if yes, go to end. If no, continue with "if no" questions) (IF NO) Can you tell me why you think you didn't lose weight / as much weight at you had hoped? (prompt if necessary) Can you think of anything about the program that didn't seem to help or work for you? Anything else? Was there anything else going on that seemed to get in the way of you losing weight during this time? (Ask about goals and expectations and if they were satisfied with the program, if you haven't asked already.) * * ~k * * Did you.have any thoughts as to the purpose of the experiment? (if subject doesn't mention other treatment group, say) You knew about the other group, right? 64 Did it cross your mind about what the other group was doing? What do you think? Do you.have an idea of what results the experimenter expected? (if yes,) How do you know/ What makes you think this? Do you think the experimenter had any expectations of how you and others in your group were supposed to respond to the program? THANK YOU VERY MUCH FOR TAKING THE TIME TO SPEAK TO ME! 65 Name Group Weight 1” Lost weight? yes no 2. Why they lost weight (program reasons): 3. Other reasons: ‘4. Goals/expectations: 5. Satisfied w/ program? yes no 6. Why they didn't lose weight (program reasons): 7. Other reasons: 8. Purpose of research: 9. Ideas about other group: 10. What Laurie expected: 11. What Laurie expected of them/their group: 12. Other comments: APPENDIX I Measurement Instruments 66 Initial Questionnaire Name Date Please answer the following items by filling in the blank or circling the number next to your response. DEMOGRAPHICS 1. Age: 2. Sex: 1. Male 2. Female 3. Current marital status: 1. Never married 2. Married 3. Divorced or separated 4. Widowed 5. Other Education: Highest grade or degree completed Ethnic background: White Black Native American Asian Hispanic . Other ONUI-bLJNl-l Occupation: (Fill in and circle the number below next to your answer) 1. Part-time (less than 30 hours a week) 2. Full-time (30 hours or more a week) 3. I don't work outside of the home for pay. Are you currently under a physician's care for a) high blood pressure 1. Yes 2. NO b) diabetes 1. Yes 2. No 8. Are you currently under treatment for a known eating disorder, such as anorexia nervosa or bulimia? 1. Yes 2. No 9. Do you currently smoke cigarettes? 1. Yes 2. NO 10. Are you currently taking any medications? 1. Yes 2. No If YES, please specify which medication(s): If YES, do any of these medications affect your weight? 1. Yes 2. NO 3. Don't know Which one(s)? WEIGHT 11. Age of onset: Please indicate the age at which you first became concerned about your weight 1. Before or at age 15 2. Age 16 or older 12. Did your weight gain appear to result from a specific I 67 event? 1. Yes 2. No If YES, please indicate the specific event below by circling the number next to your choice. Please choose only one . 1. Death of a loved one 2. Serious illness 3. Divorce or relationship break-up 4. Birth of a child 5. Change in job 13. Weight trend: What is your present weight? 14. 15. 16. 17. 18. 19. 68 6. Quit smoking 7. Marriage 8. Other (specify) What was your weight 1 month ago? What was your weight 3 months ago? What was your weight 6 months ago? What was your weight 12 months ago? What is the maximum weight you have been (excluding pregnancy)? pounds What has been your maximum weight gain within a single week, excluding menstrual weight gain? pounds In a typical week, how much does your weight fluctuate, excluding mentrual weight gain? pounds What is your height without shoes? What is your current weight? pounds What is your goal or ideal weight? pounds PRIOR DIETS: 20. 21. 22. How many serious attempts have you made at losing weight? 1. A few (1-5) 2. Several (6-10) 3. Numerous (11-20) 4. Too many to count (over 20) What is the maximum amount of weight you have ever lost within one month, from a deliberate attempt to lose weight (excluding illness or the first three months after the birth of a baby?) pounds The following is a list of factors which most people indicate as reasons for wanting to lose weight. Please circle the MOST IMPORTANT reason in your case. Circle only ppg. 1. Concern for your health 2. Personal appearance 3. Family pressure 4. Social pressure 23. 5. 6. 69 Recommendations from your physician Self-esteem Please indicate if you have tried any of the following methods of losing or maintaining weight. (Circle all that apply.) 1. 2. 10. 11. 12. 13. 14. 15. 16. l7. 18. 19. 20. 21. 22. Surgical (bypass or stapling) Jaw wiring Psychoanalysis or psychotherapy Behavior modification Acupuncture Self-help groups Exercising more Cutting down on snacks Cutting down on junk foods Skipping meals Eating smaller meals without counting calories Using low-calorie or diet foods or drinks Using special diets which involve eating mostly one kind of food, such as grapefruit or high-protein diets Counting calories Drinking less water or other liquids Using sauna or steam baths Fasting Using diet pills Using diuretic pills Using laxatives Vomiting Other (Specify) 70 SOCIAL SUPPORT: 25. Please indicate the attitudes of the following people about your attempts to lose weight. Are they: NEGATIVE -- They disapprove or are resentful INDIFFERENT -— They don't care or don't help POSITIVE -- They encourage you Circle the number representing your response. Leave blank if non-applicable. NEGATIVE INDIFFERENT POSITIVE Significant other 1 2 3 Children 1 2 3 Mother 1 2 3 Father 1 2 3 Employer/Supervisor 1 2 3 Best friend 1 2 3 26. How would you describe the WEIGHT of the following people in your life? (Leave blank if non-applicable.) Very Slightly' .About Slightly Overweight Overweight Average Underweight Significant other 1 2 3 4 Child 1 2 3 4 Child 1 2 3 4 Child 1 2 3 4 Mother 1 2 3 4 Father 1 2 3 4 Employer/Supervisor 1 2 3 4 Best friend 1 2 3 4 71 Current Status Questionnaire Name Date Please answer the following questions based on how you currently feel or behave by rating yourself on a scale of 1 to 5. Circle the appropriate number for each item. 1. Do you feel that your weight or eating interfere with your work-life or daily activities? 1 2 3 4 5 Very much Not at all 2. How often are you distracted by thoughts about dieting or eating? 1 2 3 4 5 Very often Not at all 3. How often do you experience unhappiness over the looks or feel of your body? 1 2 3 4 5 Very often Not at all 4. How would you rate your present energy level? 1 2 3 4 5 Low High 5. Your present health? 1 2 3 4 5 Poor Excellent 6. On a typical day, do you generally feel tense or relaxed? 1 2 3 4 5 Very tense Very relaxed 7. How much time and energy do you devote to thinking about eating and/or dieting? l 2 3 4 5 Considerable None 8. How physically active are you? 1 2 3 4 5 Sedentary Very active How happy are you? 1 2 3 Not at all 72 Very 73 Eating Behavior Please read each statement and decide whether or not it describes you. If you agree with the statement, circle T for true. If you disagree with the statement, circle F for false. Please answer each item either true or false, even if you are not completely sure of your answer. 1. When I smell a sizzling steak or see a juicy piece of meat (or something else I like), I find it very difficult to keep from eating, even if I have just finished a meal. T F 2. I usually eat too much at social occasions, like parties and picnics. T F 3. When I have eaten my quota of calories, I am usually good about not eating any more. T F 4. I deliberately take small helpings as a means of controlling my weight. T F 5. Sometimes things just taste so good that I keep on eating even when I am no longer hungry. T F 6. When I feel anxious, I find myself eating. T F 7. Life is too short to worry about dieting. T F 8. Since my weight goes up and down, I have gone on reducing diets more than once. T F 9. When I am with someone who is overeating, I usually overeat too. T F 10. I have a pretty good idea of the number of calories in common food. T F 11. Sometimes when I start eating, I just can't seem to stop. T F 12. It is not difficult for me to leave something on my plate. T F 13. If I eat a food that that I wish I hadn't, I consciously eat less for a period of time to make up for it. T F 14. When I feel blue, I often overeat. T F 15. I enjoy eating too much to spoil it by counting calories or watching my weight. T F 74 16. I often stop eating when I am not really full as a conscious means of limiting the amount of food I eat. T F 17. My weight has hardly changed at all in the last 10 years. T F 18. When I feel lonely, I console myself by eating. T F 19. I consciously hold back at meals in order not to gain weight. T F 20. I eat anything I want, any time I want. T F 21. Without even thinking about it, I take a long time to eat. T F 22. I count calories as a conscious means of controlling my weight. T F 23. I do not eat some foods because they make me fat. T F 24. I pay a great deal of attention to changes in my figure. T F 25. If I eat a food that I wish I hadn't, I often then splurge and eat other high calorie foods. T F Please answer the following questions by circling the number above the response that is appropriate to you: 26. How often are you dieting in.a conscious effort to control your weight? 1 2 3 4 Rarely Sometimes Usually Always 27. Would a weight fluctuation.of 5 pounds affect the way you live your life? 1 2 3 4 Not at all Slightly Moderately Very much 28. Do your feelings of guilt about overeating help you to control your food intake? 1 2 3 4 Never Rarely Often Always 75 29. How conscious are you of what you are eating? 1 2 3 4 Not at all Slightly Moderately Extremely 30. How likely are you to shop for low calorie foods for yourself? 1 2 3 4 Unlikely Slightly Moderately Very likely unlikely likely 31. Do you eat sensible in front of others and splurge alone? 1 2 3 4 Never Rarely Often Always 32. How likely are you to consciously eat slowly in order to cut down on how much you eat? 1 2 3 4 Unlikely Slightly Moderately Very likely likely likely 33. How likely are you to consciously eat less than you want? 1 2 3 4 Unlikely Slightly Moderately Very likely likely likely 34. Do you go on eating binges though you are not hungry? 1 2 3 4 Never Rarely Sometimes At least once a week 35. How frequently do you avoid "stocking up" on tempting foods? 1 2 3 4 Almost Seldom Usually Almost never always 36. On a scale of 0 to 5, where 0 means no restraint in eating (eating whatever you want, whenever you want it) and 5 means total restraint (constantly limiting food intake and never "giving in"), please circle the number would you give yourself. 0 Eat whatever you want, whenever you want it 1 Usually eat whatever you want, whenever you want it 76 2 Often eat whatever you want, whenever you want it 3 Often limit food intake, but often "give in" 4 Usually limit food intake, rarely "give in" 5 Constantly limiting food intake, never "giving in" 37. To what extent does this statement describe your eating behavior? "I start dieting in the morning, but because of any number of things that happen during the day, by evening I have given up and eat what I want, promising myself to start dieting again tomorrow." 1 2 3 4 Not like me Little like Pretty good Describes me me me description perfectly Please answer the following questions according to the scale below. NEVER SELDOM SOMETIMES OFTEN VERY OFTEN UIALONJH II II II II II NEVER OFTEN 38. Do you eat when you are irritated? 1 2 3 4 5 39. Do you eat when you have nothing to do? 1 2 3 4 5 40. Do you eat when you are depressed or discouraged? 1 2 3 4 5 41. Do you eat when you are feeling lonely? 1 2 3 4 5 42. Do you eat when somebody lets you down? 1 2 3 4 5 43. Do you eat when you are cross or angry? 1 2 3 4 5 44. Do you eat when you are approaching something unpleasant to happen? 1 2 3 4 5 77 45. Do you eat when you are anxious, worried, or tense? 1 46. Do you eat when things are going against you or when things have gone wrong? 1 47. Do you eat when you are frightened? 1 48. Do you eat when you are disappointed? 1 49. Do you eat when you are emotionally upset? I 50. Do you eat when you are bored or restless? 1 51. If food tastes good to you, do you eat more than usual? 1 52. If food smells and looks good, do you eat more than usual? 1 53. If you see or smell something delicious, do you eat it? 1 54. If you walk past the baker, do you buy something delicious? 1 55. If you walk past a snack-bar or a cafe, do you buy something delicious? I 56. If you see others eating, do you also eat? 1 57. Can you resist delicious foods? 1 58. Do you eat more than usual, when you see others eating? 1 59. When preparing a meal, are you inclined to eat something? 1 78 Please answer the following questions based on hOW' you currently feel or behave. 1. How often do you weigh yourself? (Circle the number next to your response.) 1. More than 5 times daily 2. 2-5 times daily 3. Once a day 4. 2-5 times weekly 5. Once a week 6. Seldom or never Please answer the following questions by rating yourself on a scale of 1 to 5. Circle the appropriate number for each item. 2. How often do you eat to satisfy physical hunger? 1 2 3 4 5 Very often Not at all 3. How often do you eat when you are not hungry? 1 2 3 4 5 Very often Not at all 4. How often do you continue eating when you are no longer hungry (or have "had enough")? 1 2 3 4 5 Very often Not at all 5. How well can you distinguish true hunger from the urge to eat? 1 2 3 4 5 Very often Not at all 6. How often do you eat what your body is craving? 1 2 3 4 5 Very often Not at all 7. How often do you experience discomfort due to overeating? 1 2 3 4 5 Very often Not at all 10. 11. 12. 79 How often do you have low energy due to dieting? 1 2 3 4 5 Very often Not at all Do you ever feel guilty about your eating habits? 1 2 3 4 5 Always Never Do you ever feel guilty about eating certain foods? 1 2 3 4 5 Always Never How compulsive or obsess ive do you consider your eating behavior? 1 2 3 4 5 Extremely Not at all How light and comfortable do you feel when you finish eating? 1 2 3 4 5 Very heavy Very light & uncomfortable & comfortable 80 Perceptions of Body The following items are a number of characteristics about yourself. Circle the number for each one that best represents your feelings about that item according to the following scale: 1 = Have strong positive feelings 2 = Have moderate positive feelings 3 = Have no feeling one way or the other 4 = Have moderate negative feelings 5 = Have strong negative feelings POSITIVE NEGATIVE 1. Hair 1 2 3 4 5 2. Facial complexion 1 2 3 4 5 3. Appetite 1 2 3 4 5 4. Hands 1 2 3 4 5 5. Distribution of hair (over body) 1 2 3 4 5 6. Nose 1 2 3 4 5 7. Physical stamina 1 2 3 4 5 8. ZElimination 1 2 23 4 5 9. Muscular strength 1 2 3 4 5 10. Waist 1 2 3 4 5 11. Energy level 1 2 3 4 5 12. Back 1 2 3 4 5 13. Ears 1 2 3 4 5 14 . Age 1 2 3 4 5 15. Chin 1 2 3 4 5 16. Body build 1 2 3 4 5 17. Profile 1 2 3 4 5 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 3o. 31. 32. 33. 34. 35. 36. 37. 38. 34. 40. Height Keeness of senses Tolerance for pain Width of shoulders Arms Chest/breasts Appearance of eyes Digestion Hips Resistance to illness Legs Appearance of teeth Sex drive Feet Sleep Voice Health Sex activities Knees Posture Face Weight Sex organs 81 POSITIVE 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 l 2 3 l 2 3 1 2 3 1 2 3 1 2 3 l 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 1 2 3 l 2 3 1 2 3 1 2 3 1 2 3 NEGATIVE 5 82 Perceptions of Self The following are a series of statements. Please read each statement carefully and indicate hOW' much you agree or disagree with each one, using the categories given below. 1 = STRONGLY AGREE 2 = AGREE 3 = DISAGREE 4 = STRONGLY DISAGREE STRONGLY STRONGLY AGREE DISAGREE 1. I feel that I'm a person of worth, at least on an equal basis with others. 1 2 3 4 2. I feel that I have a number of good qualities. 1 2 3 4 3. All in all, I am inclined to feel that I am a failure. 1 2 3 4 4. I am able to do things as well as most people. 1 2 3 4 5. I feel I do not have much to be proud of. l 2 3 4 6. I take a positive attitude toward myself. 1 2 3 4 7. On the whole, I am satisfied with myself. 1 2 3 4 8. I wish I could have more respect for myself. 1 2 3 4 9. I certainly feel useless at times. 1 2 3 4 10. At times I think I am no good at all. 1 2 3 4 83 Evaluation Please complete the following scales, indicating how you perceive the program leader and materials by circling the appropriate number for each item. The program leader is: 1. Pleasant 1 2 3 4 5 Unpleasant 2. Valuable 1 2 3 4 5 Worthless 3. Unhelpful 1 2 3 4 5 Very helpful 4. Supportive Unsupportive/ and caring 1 2 3 4 5 disinterested 5. Not very Very motivating 1 2 3 4 5 motivating 6. Very actively Passively involved 1 2 3 4 5 involved 7. Not very Very knowledgeable knowledgeable l 2 3 4 5 8. Very Unenthusiastic enthusiastic 1 2 3 4 5 9. Inexperienced Very experienced I 2 3 4 5 10. Very competent 1 2 3 4 5 Incompetent The program materials are: 11. Unhelpful 1 2 3 4 5 Very helpful 12. Boring 1 2 3 4 5 Interesting 13. Difficult to Easy to understand 1 2 3 4 5 understand 14. Not very Very motivating 1 2 3 4 5 motivating 84 How much does the program leader seem to endorse or believe in the program? 15. Very much 1 2 3 4 5 Not at all Please rate the degree to which the program leader focused on the following principles or techniques for weight loss, given the scale below: 1 = VERY MUCH 2 = SOMEWHAT 3 = NOT MUCH 4 = NOT AT ALL 1. Weighing yourself regularly 1 2 3 4 2. Relaxation 1 2 3 4 3. Keeping a weight graph 1 2 3 4 4. Trusting your body 1 2 3 4 5. Following an eating schedule 1 2 3 4 6. Reality vs. illusion 1 2 3 4 7. Eating in one place only 1 2 3 4 8. Observing the mind 1 2 3 4 9. Shopping on a full stomach I 2 3 4 10. Appropriate responses 1 2 3 4 11. Keeping problem foods out of sight 1 2 3 4 12. Attention without interference 1 2 3 4 13. Nutrition education 1 2 3 4 14. Staying in the present 1 2 3 4 15. Leaving the table after eating 1 2 3 4 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. Amnesia I 1 Eating one portion at a time 1 Visualizing your natural shape 1 Keeping an exercise diary 1 Recording hunger and comfort _ 1 Walking regularly 1 Hunger 1 Outlasting urges to eat 1 Not eating by the clock 1 Eating approximately 1200 to 1500 l calories a day Satisfying cravings 1 Behavior modification 1 Danger signals 1 Eating a balanced diet 1 Listening to your body 1 85 86 Please indicate how this program has affected you in the following areas, based on the scale below: 1 = NEGATIVE IMPACT 2 = NO CHANGE 3 = POSITIVE IMPACT 4 = VERY POSITIVE IMPACT 1. Eating problem 1 2 3 4 2. Weight problem 1 2 3 4 3. General health 1 2 3 4 4. Stress level (less tense, more ~ relaxed) 1 2 3 4 5. Energy level 1 2 3 4 6. Ability to function at work (energy, concentration, efficiency) 1 2 3 4 7. Ability to function in life situations (relationships, parenting, etc.) 1 2 3 4 8. Do you feel this program was worthwhile? l 2 3 4 5 Not at all Very 9. Do you feel this program would be valuable to others? 1. Yes 2. No General comments about your experience in this program: APPENDIX J Statistical Tables 87 Table 1 Chi-Sgpare Analysis of Program Attendance Group 1 Group 2 Variable LEARN E A T Attendance 2 At or Above 55% (X =5.98, df=1, p=.01) Yes 10 (42%) 19 (76%) No 14 (58%) 6 (24%) Subjects per Group 24 25 Table 2 Descriptive Statistics and Reliabilities of Scales 88 _ # of Inter-item Scale* X SD Items Range Skew Kurt Alpha Correlation RESl 2.18 .49 17 l.13-3.34 .19 .36 .79 .21 RESZ 2.60 .68 17 1.13-3 73 -.12 -.96 .89 .35 RES3 2053 056 17 1078-3091 047 -053 081 023 NPCl 3.62 .93 20 1.37-4.73 -.88 -.02 .95 .52 NPC2 2.78 .97 20 1.10-4.85 .19 -.49 .95 .54 NPC3 2.87 .91 20 1.15-4.17 -.26 -1.19 .94 .50 SE1 1.99 .58 10 1.00-3.50 .41 .20 .86 .40 SE2 1.58 .51 10 1.00-3.20 1.23 2.04 .86 .40 SE3 1.62 .55 10 l.00-2.80 .83 -.45 .89 .46 BI1 2.54 .52 18 1.17-3.44 -.68 .18 .85 .24 BIZ 2.21 .62 18 1.11-3.22 -.23 -.80 .90 .35 BI3 2.39 .59 18 1.11-3.33 -.55 -.64 .89 .32 MCl 2.52 1.08 12 1.00-4.00 .01 -1.74 .97 .74 MC2 1.60 .60 10 1.00-3.10 .88 -.30 .91 .52 EVAL 3.50 .75 19 2.35-5.00 .31 -.79 .95 .48 *Scale Names: RESl, RESZ, RES3= Restrained Eating at Times 1, 2, and 3 NPCl, NPC2, NPC3= Non-Physiologically-Cued Eating at Times 1, 2, and 3 SE1, SE2, SE3= Self-Esteem at Times 1, 2, and 3 811, BI2, BI3= Body Image at Times 1, 2, and 3 MCl= Manipulation Check for LEARN MC2= Manipulation Check for E A T EVAL= Satisfaction with Treatment High scores on Self-Esteem and Body Image scales represent low self-esteem and poor body image. Descriptive statistics were based on the full sample; reliabilities and inter—item correlations were based on only those subjects who reported data for all three times. Table 3 Scale Intgrcorrelations 89 ** p<.01 (2-tailed) Time 1 RESl NPCl BIl SE1 EVAL MCl MC2 RES]. 1000 -020 -008 -005 021 008 002 NPCl -.20 1.00 -.01 .28* ‘.05 -.29 .00 BIl -.08 -.01 1.00 .23 -.01 -.01 .22 $31 -.05 .28* .23 1.00 .06 -.08 .20 EVAL .21 -.05 -.01 .06 1.00 -.00 -.23 MC]. 008 -029 -001 -008 ’000 1000 -063** MC2 .02 .00 .22 .20 -.23 -.63** 1.00 Time 2 _§2 NPC2 BIZ 532 EVAL MCI MC2 RESZ 1.00 -.08 -.09 -.00 .03 -.34* .27 NPC2 -.08 1.00 .53** .31 -.19 -.19 .18 BIZ -.09 .53** 1.00 .52** .04 .03 .04 SE2 .00 .31 .52** 1.00 .02 .07 .02 EVAL .03 —019 .04 002 1000 -000 -023 MCI -.34* -.19 .03 .07 -.00 1.00 -.63** MC2 .27 .18 .04 .02 -.23 -.63** 1.00 Time 3 _53 NPC3 BI3 SE3 EVAL MCl MC2 RE83 1.00 -.02 -.10 -.00 .09 -.17 -.06 NPC3 -.02 1.00 .32 .41* -.22 -.17 .02 BI3 -.10 .32 1.00 .29 -.07 -.06 .04 SE3 -.00 .41* .29 1.00 -.04 .31 -.18 EVAL .09 -.23 -.07 -.04 1.00 -.00 -.23 MCI -.17 -.17 -.06 .31 -.00 1.00 -.63** MC2 -.06 .02 .04 -.18 -.23 -.63** 1.00 * p<.05 Table 4 9O Pre-Treatment Means and F-Rgtiog Group 1 Group 2 Variable LEARN E A T F Rgpio Age 42.00 (13.47) 36.60 (13.15) 2.02 Weight (in pounds) 198.81 (39.04) 196.58 (34.67) .04 Percent Overweight 26.2% (11.4) 23.9% (13.2) .42 Height 65.19" (2.70) 66.09" (3.24) 1.12 Education (in years) 14.92 (1.69) 15.13 (1.75) .18 RESl 2.19 (.45) 2.17 (.53) .02 NPCl 3.72 (.78) 3.54 (1.07) .45 SE1 2.07 (.65) 1.88 (.51) .27 BIl 2.57 (.49) 2.52 (.57) .74 *p<.05, n=49 Standard Deviations in parentheses ( ). No covariates were used in these analyses. 91 Table 5 Chi-Sgpare Tests Comparing Subjects by Treatment Condition Group 1 Group 2 Variable LEARN E A T Gender (X2=.12, df=1, p=.73) Male 3 (13%) 4 (16%) Female 21 (87%) 21 (84%) Marital Status (x2=5.33, df=4, p=.25) Never Married 4 (17%) 10 (40%) Married 14 (58%) 10 (40%) Divorced/Separated 5 (21%) 4 (16%) Widowed 1 (4%) O (0%) Other 0 (0%) 1 (4%) Ethnicity (X2=.98, df=1, p=.32) Caucasion 24 (100%) 24 (96%) Asian 0 (0%) l (0%) Employment (x2=1.39, df=2, p=.50) Part-Time 4 (17%) 7 (28%) Full-Time 19 (79%) 16 (64%) Not Working 1 (4%) 2 (8%) Onset of Problgm (Xa=1.0l, df=1, p=.32) Before Age 15 10 (42%) 14 (56%) After Age 15 14 (58%) ll (44%) Previous Attempts (Xa=1.7l, df=3, p=.63) A Few (1-5) 9 (38%) 12 (48%) Several (6-10) 4 (17%) 6 (24%) Numerous (ll-20) 6 (25%) 4 (16%) Over 20 5 (21%) 3 (12%) Reasons for Participation (X?=7.50, df=3, p=.06) Concern for Health 6 (25%) 7 (28%) Appearance 5 (21%) 12 (48%) Social Pressure 0 (0%) 1 (4%) Self-Esteem 13 (54%) 5 (20%) Subjects per Group 24 25 92 Table 6 Cell Means of Outcome Measures at All Three Times Group 1 - LEARN Group 2 - E A T Variable T1 T2 T3 T1 T2 T3 Weight 214.46 203.84 207.50 189.57 184.91 185.84 % Overweight 31.00 27.50 28.40 21.00 19.10 19.70 Rel. Wt. Loss --- .16 .08 --- .13 .06 RES 2.15 2.87 2.64 2.21 2.44 2.49 NPC 3.61 2.90 2.92 3.43 2.69 2.82 BI 2.50 2.17 2.38 2.49 2.25 2.39 SE 2.02 1.53 1.43 1.95 1.73 1.79 Table 7 Repeated-Measures ANOVA§_for Outcome Variables at All 3 Timgg Restrained Eating Source df MS F Within Cells 30 .83 Group 1 .70 .84 Within Cells 60 .11 Time 2 2.00 18.00*** Group by Time 2 .46 4.16* * p<.05, ***p<.001 n=32 93 Table 7 (continued) Repeated-Measures ANOVAs for Outcome Variables at All 3 Times Non-Physiologically-Cued Eating Source df MS F Within Cells 30 2.18 Group 1 .64 .29 Within Cells 60 .28 Time 2 5.01 18.16*** Group by Time 2 .03 .10 ***p<.OOl n=32 Body Image Sourcg df MS F Within Cells 32 .93 Group 1 .02 .02 Within Cells 64 .10 Time 2 .70 6.70** Group by Time 2 .01 .14 n=34 Self-Esteem Sourcg df MS F Within Cells 32 .64 Group 1 .67 1.05 Within Cells 64 .14 Time 2 1.46 10.71*** Group by Time 2 .38 2.81 ***p<.001 n=34 Table 8 94 Repeated-Measures ANACOVAs for Weight at All 3 Times Body Weight Source df MS F Within Cells 28 75.77 Regression 1 108696.57 l434.48*** Group 1 70.10 .93 Within Cells 58 34.05 Time 2 472.43 13.88*** Group by Time 2 68.41 2.01 ***p<.001 n=31 Percent Overweight Sourcg df MS F Within Cells 28 .01 Regression l .97 93.65*** Group 1 .01 .76 Within Cells 58 .00 Time 2 .01 11.63*** Group by Time 2 .00 1.03 * p<.05, ***p<.001 n=31 95 Table 9 Means and F-Rgtiogiof Proqram Satisfaction End Relative Weight Loss Group 1 Group 2 Variable LEARN EiA T F Ratio Satisfaction 3.50 3.44 .06 RWL (Time 2) .16 .08 1.30 RWL (Time 3) .13 .06 .62 *p<.05, **p<.01 n=34 (Satisfaction and RWL at Time 3) n=35 (RWL at Time 2) Table 10 Repeated-Measures ANACOVA for ngqht by Group (Timg 1 to Timg 2) Source df MS F Within Cells 32 30.61 Regression 1 83195.94 2718.09*** Group 1 74.19 2.42 Within Cells 33 34.00 Time 1 885.64 26.05*** Group by Time 2 153.15 4.50* *p>.05, ***p<.001 n=35 Table 11 Means and F-Rgtiog of Manipulation Chgck Scales Group 1 Group 2 Variable LEARN E A T F Rgtio MCl 1.47 3.39 141.55*** MC2 2.07 1.21 34.13*** ***p<.001 n=34 96 Table 12 Significant Chi-Square Tests for Interview Data Group 1 Group 2 Variable LEARN E A T Why Subjects Lost Weight: Commitment (X2=7.98, df=1, p<.005) .Mentioned 5 (36%) O (0%) Not Mentioned 9 (64%) 19 (100%) Meetings (X2=8.78, df=1, p<.005) .Mentioned 7 (50%) l (5%) Not Mentioned 7 (50%) 18 (95%) Tools thgt Worked: Hunger Awareness (Xa=12.l6, df=1, p<.001) Mentioned 0 (0%) 11 (58%) Not Mentioned 14 (100%) 8 (42%) Food Diary (X2=4.48, df=1, p=.03) Mentioned 3 (21%) O (0%) Not Mentioned 11 (79%) 19 (100%) Count Calories (Xa=6.61, df=1, p=.01) Mentioned 4 (29%) 0 (0%) Not Mentioned 9 (71%) 19 (100%) Why They Didn't Lose Weight: Low Motivation (X2=4.48, df=1, p=.03) Mentioned 3 (21%) 0 (0%) Not Mentioned 11 (79%) 19 (100%) Subjects per Group 14 19 Appendix R Literature Review 97 Theories and Treatment of Obesity Theories of Obesity In order to develop an effective weight loss treatment, one must take into account the etiology of obesity; A.natural biological mechanism for the regulation of body weight and the control of food intake has been.corroborated by animal studies (Hoebel & Teitetbaum, 1966) and by studies of humans (Keys, Brozek, Henschel, Mickelson, & Taylor, 1950; Stunkard, 1983). These studies indicate that initially nonobese individuals naturally regulate their body weight after having been starved or overfed. To account for obesity, Nisbett (1972) has suggested.that overweight individuals also regulate their body weight, but, for some reason (genetic predisposition or early experience), the "set-point" about which their weight is regulated is higher than what is accepted by society's standards (statistical. normality). Nisbett. notes ‘that "overweight individuals behave as if they were always--and inflexibly-- hungry" (1972, p. 440). As Schachter (1971) has also found, obese people eat more per meal, they eat more rapidly, and they are more responsive to taste and less responsive to postingestional feeding cues. Nisbett argues that obese individuals may be perpetually physiologically hungry because they exist. at. a ‘weight level b810W’ their "biologically dictated set-points" (p. 441). 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