Simply telling a patient not to eat when under stress is useless, of course. Instead, use the following three-step approach. First, recommend a period of observation and recording to enable the patient to recognize the cue. For instance, one can ask the patient to wear his or her watch upside down as a reminder to ask "Why am I reaching for the food at this time?" If the patient is not physically hungry, one of the possibly inappropriate eating cues is most likely in play, and its nature should be guessed at and recorded. Second, suggest the substitution of other responses for inappropriate eating. For stress, this might be writing down what the stress is, formulating a plan for doing something about it, doing something (besides eating) to relieve the stress on the spot, or, at the very least, substituting a walk around the block or a call to a friend for the bag of potato chips. The third step is repetition, that is, to keep making appropriate responses to the problematic cue and to reap the rewards of the new behavior, which include the positive responses of others to the change in approach, not just to eating, but to life, that the patient makes.
Although some degree of change is necessary and beneficial, not every maladaptive behavior must be completely eliminated nor must every rich food be replaced by celery sticks without dip. Although losing a large amount of weight in a reasonable amount of time does require a fairly aggressive diet program, maintaining a new lower weight does not. If the patient can learn to control even partially a few of the more important inappropriate eating behaviors and to shift to a diet somewhat lower in calories than baseline, that is often sufficient to maintain weight in the new, lower range. This is easy to see and difficult to do, but impossible if behaviors are not addressed as part of a comprehensive approach to the treatment of obesity.
Another behavior of interest in obesity is restraint. One can simplistically categorize patients as restrained or unrestrained eaters. Restrained eaters believe that they must exercise a good deal of control over their eating—they are always conscious of what they can and cannot eat. Unrestrained eaters do not control their eating to any great extent. Restrained eating may lead to some paradoxical results; once restraint is relaxed, an exaggerated response may ensue (all-or-nothing behavior). Such patients may be superb dieters, but are equally superb at overeating once the diet has been "broken." The issue of restraint is one of too much of a good thing. Although a certain amount of control and monitoring is necessary for maintaining weight loss, high levels of restraint may be more problematic than low ones in the long run. One solution is to couple the teaching ofways to control inappropriate eating cues with dietary changes that emphasize foods lower in fatand calories, and higher in fiber and water content, so that lower restraint is required to maintain a given intake. Skipping meals when the patient is physically hungry should be discouraged, and a low calorie, nutritious breakfast encouraged rather than skipping it in the false belief that this will aid weight control.
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