Losing Weight is Not About Diet and Exercise

By Michele Hines, M.D.

Anyone who has a weight problem knows that losing weight is not “just” about diet and exercise. Take the case of Jane.  Middle-aged and moderately inactive, Jane now weighs 15 pounds more than she did after last year's New Year's resolution. Today she told me her “new” New Year's resolution:  “I'm going to lose 40 pounds by Derby day. I just need to get motivated. I just need to eat right and exercise. But, I just can't seem to do, what I know I should do, what I need to do … I guess. Or whatever I have to do ... I guess...”

Sound familiar?

Just what is “motivation”?  Why does motivation seem so hard to get? With all the attention given to “just” eating right and exercising, why is losing weight –and keeping it off – such a struggle for so many of us?

Undoubtedly, excess caloric intake coupled with lack of physical activity leads to weight gain. But the single most important factor in successful long-term weight loss maintenance is motivation to sustain behavioral change – regardless of the type of diet or exercise chosen. 

Why are some people highly successful at behavioral change? What makes a person want to change? How do people change behavior once they have decided to change?  

The answers lie not in what people eat or how they exercise, but in how they think. Thinking (among other brain processes) determines behavior. Thinking can change. Behavior can change when thinking changes. Emotion can also change when thinking changes. Cognitive-Behavioral Therapy (CBT) is a form of psychotherapy focusing on this link between thinking, behavior and emotion. Scientific evidence has long supported the effectiveness of CBT in the treatment of a number of psychological conditions, such as anxiety and depression. CBT is now being applied to the problem of being overweight or obese.

Scientists who study motivation have focused on the link between thinking and behavior.  Several “Stages of Change,” through which each individual passes while in the process of change, have been identified.

These are:

• Pre-contemplation
• Contemplation
• Planning
• Action
• Maintenance

Pre-contemplation occurs when an individual has not yet even begun to think of change. Thoughts are, “I probably need to lose weight, but I'm too busy to think about that right now.”

In the contemplation phase , the individual thinks about behavioral change, but is not yet ready to change. Thoughts are, “I really need to exercise if I'm going to keep eating all these donuts...maybe I won't eat any tomorrow...or maybe I'll start exercising next week sometime...or maybe...”

Planning involves thoughts such as, “I will walk on the treadmill for 30 minutes on Mondays, Wednesdays and Fridays, starting tomorrow at 7 a.m. I will set two alarm clocks to make sure I get up in time.”

Action is acting on/carrying out the plan and thinking things like, “Hey, I'm really doing this...I made it every day for 4 weeks straight...I feel great!”

Maintenance is, “I haven't exercised in three weeks, and I'm starting to re-gain. I know relapse is natural, but tomorrow morning, I'm getting back on the treadmill... I may have had a good reason before, but I'm not going to use that as an excuse now!”

Motivational Interviewing (MI) is another scientifically validated psychotherapeutic technique designed to assist the process of behavioral change.  Change is a natural human tendency, but resistance to change is also a natural human tendency. Ambivalence (mixed feelings) about change occurs whenever our natural tendency to change meets our natural resistance to change. MI helps an individual identify natural resistances and work with them instead of against them. MI can be used effectively by personal trainers, life coaches and others who are not necessarily psychotherapists. MI has been combined with the “Stages of Change” model and applied to weight-loss programs. Successful weight loss/maintenance has been sustained with this combined technique in some studies. Research is ongoing, but already many physicians and others specializing in weight loss are learning to use these techniques.

How could Jane get motivated to lose the weight she thinks she wants to lose?  Applying the MI/Stages of Change technique, Jane would ask herself (perhaps with assistance from a trainer, physician or other specialist), “What stage of change am I in now? How does the body I have now differ from the body I think I want? What are the reasons I don't have that body now? What behavioral changes would I have to make?  What would be the downside of these changes? Am I really willing to accept those challenges?  How badly do I want this? Am I really ready to start now...or is something else I'm not thinking about (shame, guilt, fear, pain, failure) getting in my way?

Questions such as these begin the process of moving toward change...or postponing change until we are ready. Once we understand that what we think determines what we do; once we realize that we decide when we're ready to change, we realize we have much more power over what we think and do than we ever knew! Motivation involves harnessing the power we already have to do what we want to do. Motivation is more than “just” making changes in diet and exercise. Motivation is using the power we already have to change who we are.   

Michele L. Hines, M.D. specializes in the treatment of obesity and overeating disorders. She received her medical degree from Columbia University College of Physicians & Surgeons and completed her residency training in New York City .  She is board certified in adult and addiction psychiatry, and is completing a third board certification in bariatric medicine (non-surgical treatment of obesity). An assistant clinical professor at the University of Louisville School of Medicine, she sees patients exclusively through the University Faculty Physicians' practice.