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Interview with Daniel S. Kirschenbaum, Ph.D.

Daniel S. Kirschenbaum, Ph.D. received his doctoral degree in Clinical Psychology from the University of Cincinnati in 1975. Dr. Kirschenbaum is a Professor of Psychiatry & Behavioral Sciences at Northwestern University Medical School, where he has also served as Director of the Eating Disorders Program. He is currently the Director of the Center for Behavioral Medicine in Chicago, which provides programs in weight control, medical psychology, anxiety and stress management, and sport performance enhancement. Dr. Kirschenbaum is a Fellow of the American Psychological Association and the Association for the Advancement of Applied Sport Psychology.

As one of the nation’s leading experts on weight management, Dr. Kirschenbaum has consulted to major corporations, including the U.S. Olympic Committee and Weight Watchers. His weight management program is strongly endorsed by the American Coucil on Exercise. He has also been awarded numerous grants for research and has presented invited addresses at conferences world-wide. Dr. Kirschenbaum has written over a hunderd articles for professional journals concerning weight loss and related topics and he has also written eight books of his own. His most recent book, The Nine Truths About Weight Loss: The No-Tricks, No-Nonsense Plan for Lifelong Weight Control (Holt, May 2000), offers not only one of the most comprehensive approaches to weight management, but also provides the real scientifically researched facts about weight loss (finally!) amongst a sea of diet books selling nothing but gimmicks and false information.

Dr. Daniel Kirschenbaum can be reached at:

Center for Behavioral Medicine & Sport Psychology
676 N. St. Clair, Suite 1790
Chicago, IL 60611
(312) 751-9610
D-Kirsch@nwu.edu
http://www.chicagocbm.com

Dr. Cynthia Levin (CL): In your new book, “The 9 Truths about Weight Loss – The No Tricks, No Nonsense Plan for Lifelong Weight Control“, you provide a very comprehensive approach to weight loss. Dan, without giving away what the “9 Truths” are (unless you want to!), can you give a condensed version of what you feel the most essential components are for an effective weight loss program?

Dr. Dan Kirschenbaum (DK): Sure. . . The bottom line of an effective weight loss program is an extremely consistent approach. Most diet plans emphasize moderation. That doesn’t work. The research evidence indicates that weight control is a journey that does not begin with just the first step. It begins when all of the steps start coming together in a very consistent way. A strong degree of consistency in doing the behaviors that lead to weight loss is necessary in order to overcome the very resistant biology of excess weight.

Most books that are written about weight loss emphasize, “Well, it’s not that hard really; it’s just that you have to do these things. But, if you deviate a little bit, that’s ok. Don’t worry about it, that’s normal. . . ” That approach is too loose; it creates a lot of problems.

Let’s think about it this way, why does anybody regain weight when they have lost 50 or 100 lbs.? Well, they gain it back because they let up on the consistency; they ease back on the throttle and they say to themselves, “Well, a little birthday cake is okay”, “Oh, I don’t have to exercise everydayI’m feeling a little tired today”, “Oh, I can eat this; I’ve been eating pretty low-fat food”, “I can have a little fried this, a little of that”, and that’s all it takes!

Eighty-five to ninety percent of your meals can be low-fat; but if five to ten percent are pretty high in fat, you can undo all the effort from the previous 6-7 days in just a matter of minutes. So, that’s why the weight regain business is such an insidious process. People can lose weight by dieting for a certain amount of time. But, when they let up and go for the more moderate approach, they fail.

When you look at what really successful weight controllers do, they’re very, very consistent. They’re very stringent about low-fat eating. They’re very consistent about exercising. Highly successful weight controllers exercise more frequently than ninety-five percent of adults in the United States. They’re not in the middle fifty percent; that’s not moderation; they’re in the top five percent. Their consumption of fat is half or less than what average Americans are eating. These successful weight controllers are not taking a moderate approach. They are using a highly consistent approach; it’s not that unpleasant to do either. It’s just that you have to change your attitude from moderation to a more extreme attitude of “No, I’m not going to be moderate. I’m going to be a healthy fanatic about this.”

CL: But how do you help people change their attitudes about being inconsistent so that they can stick to this more extreme approach?

DK: Well, the “9 Truths” book is probably the only weight loss book that has a full chapter on self monitoring (systematically observing oneself and writing it down). That’s the heart of staying consistent. That’s the ticket. What people have to do is get very systematic about observing themselves by writing down the foods they eat and looking up fat grams and/or calories, keeping a tight net around their behaviors.

This is not that difficult once you get used to it. People say, “Well, I don’t have time for that.” This really has nothing to do with time. It doesn’t take that long to do. I’ve actually timed it. I’ve been doing this with people for twenty-eight years and I’ve timed it with hundreds of people. It takes less than 2 minutes to do a whole day of both writing down fat grams, calories of everything eaten, and exercise; less than 1 minute for most people.

Self-monitoring is a matter of focus. And once that focus is increased and consistent, the natural drive that people have to achieve their goals kicks in. You’re going to be driven to try to do well. What people have to learn is how to stay positive about one’s own foibles. People tend to be too hard on themselves, not too easy.

CL: So, do you find that if people are consistent with their self-monitoring and recording that it actually continues to motivate them?

DK: Oh, it’s very motivating; it’s also a coping device because it helps teach people how to solve problems. For example, some people go through a mini-panic because they ate a doughnut and think, “Oh my God, I destroyed this diet”. Well, a plain doughnut has 12 fat grams. It’s not 1,000 fat grams; it’s a finite number. You are going to survive this.

What happens is that when people eat something that’s not quite right, like a doughnut, or they eat more than they’d like, then they start getting upset with themselves. They don’t want to think about what they have eaten anymore because it feels too negative. So, they start decreasing their monitoring; they lose focus.

I teach people that by getting this experience written down/recorded/thought about, it helps them think of it as a problem. That’s all. It’s a problem to be solved. The approach I take is not, “Ok, well, you deserve the doughnut because you’ve been doing so well and it’s okay to give yourself permission to eat that.” No, it’s not okay. It’s a problem; but a problem isn’t an emotional event. It’s not cheating. There’s no moral corruption involved with eating a doughnut. It’s just something that is a problem to be solved.

So, what I do with people is try to defuse an emotional reaction to an eating event and just say “Well, what else could you have done in that situation. Let’s plan it out, see what you could’ve come up with, how else could you have handled it?” I help them think about what are some other ways of handling the situation that could’ve prevented them from eating a food that they did not want to eat?

I also work with people about developing this sort of obsessive/fanatic approach (but in a healthy way) of planning out what they’re doing. “Where are you going this week? What’s going to go on? If you’re traveling, what that’s going to be like?” It’s a mind-set of a tightly woven net around this part of one’s life. Utilizing this approach may sound awful at first, but it’s more fun than being overweight.

As one of my client’s said, and many of my client’s have echoed this sentiment, that the life of an overweight person is incredibly difficult. It’s filled with unhappiness about oneself and awkwardness about such things as, “What am I going to wear” and “I don’t look good in this” and “Nothing fits” and “I don’t like this thingI’m awkward and I can’t move and I’m aching.” It’s just so filled with negativity.

So, what I’m talking about in terms of using a more obssessive approach isn’t actually a horror story. It’s an improvement. Yeah, you have to focus and that’s not a lot of fun and you have to deal with yourself when you don’t do what you want. But, it is a much better life than leading the life of an overweight person.

CL: So you’re really helping people weigh the costs and benefits of using this extreme approach for weight loss, as compared to what life is like as an overweight or obese person?

DK: That’s right!

CL: It sounds like you’re also helping people “think” about their lives in a different way.

DK: Absolutely!

CL: Have you found that overweight people tend to have any underlying psychological differences that may increase the likelihood that they will have problems with food and eating as compared to people who do not struggle with their weight?

DK: No. The research on overweight people vs. non-overweight people shows that they’re psychologically fairly similar. They’re not any smarter, dumber, more neurotic, less neurotic, more depressed, less depressed. As a population, they’re pretty normal people. It’s just that overweight people have to overcome a resistant biology and they have to become super-normal in their way of handling everything that affects their eating and exercising. So, it’s much more like an athlete in training than it is like somebody with a neurotic problem.

CL: I definitely noticed in your book, Dan, that you describe better than I’ve ever seen in any other weight loss book, all of the biological factors that are a challenge for people who are overweight. When you inform your patients about these biological challenges that they are up against, does this tend to motivate them more or can it sometimes be a negative factor for them ?

DK: Well, almost always it’s motivating for people because among the “9 Truths” is #1 – “Your biology will resist permanent weight loss.” But Truth #2, right behind #1 in the same exact chapter, is “Biology is not destiny.” I have to emphasize that. Biology is something that is a starting point.

How overweight people should think of their biologies is similar to the way athletes have to think about their performances. Research on skilled performance – everything from chess to piano to athletic performance shows that the difference between better performance and worse performance, more than anything else, is the amount of time, practice, and quality of instruction.

So, it’s the same deal with weight loss. If you want to put the time into this, if you want it to get better, you can do it! Just because your biology says “Here’s the way I’d like to go,” doesn’t mean you give into it. We have biological urges every single day that we resist from sexual things, to overeating, to grabbing things out of a storefront. We always have to manage urges in which our biology is directing us in one place and we have to go somewhere else. That’s the way it is with weight control – the biology is moving you in a certain direction but you gotta say, “Well, I’m not going there, biology.”

CL: Since there are so many biological as well as psychological components here, what is your philosophy then as a psychologist about medications such as Phen-Fen or others that try to deal with weight management from a biological approach?

DK: Because a problem has its origins in one form or one typology doesn’t mean the treatment has to follow that. For example, headaches are decreased by taking aspirin; but that doesn’t mean that a lack of aspirin causes headaches. Some headaches can also be lessened by non-biological treatments, such as relaxation. It’s the same thing with weight control -you don’t have to necessarily treat this largely biological problem with a biological solution.

However, that being said, in conjunction with a professional weight control program that helps a person to stay systematically focused and make long-term behavioral changes, there is some evidence that these medications can be pretty useful. But the evidence isn’t overwhelmingly favorable at this point. In my clinical practice and in some of the research, there are indications that medications for weight loss can do some good for some people, some of the time.

CL: What about if someone comes to you who is on a psychotropic medication, let’s say maybe for anxiety or depression. How does that fit in with your weight loss program, considering that sometimes some of these medications can cause weight gain?

DK: Well, they rarely cause much in the way of weight gain. People do gain some weight sometimes on these medications. Actually, some of the weight gain that’s attributed to these medications is because you’ve got biologically predisposed people who gain weight. When they’re feeling a little better, when they have a little less depression or less tension, they don’t maintain an edge that they actually need to help them stay focused on weight loss. In some ways, they sort of give into it a little more. So, it isn’t that biologically the medications flip a switch and the people gain weight, but that the medications change a mood that can lead to a change in goals. It’s very important to work with people about weight management who are on those medications because it helps them to focus again and get back the control they wanted in this part of their lives.

CL: Speaking of focus and control, since so many people gain the weight back after they have lost it, have you found there to be any emotional or behavioral indicators that helped you as a therapist know whether or not someone is truly ready to take an extreme approach to weight loss?

DK: Well, that’s an interesting one. I can go over with you a couple of the things that are predictive of failure to succeed. It’s a little harder to predict success actually, but we can tell when someone’s likely to have more trouble. If they have chronic psychological problems, that’s not a good situation for long term weight loss. If they have commitment problems in which the strength and the clarity of their commitment to change is somewhat weak, this is a problem. An example of a person with a lack of committment is when somebody comes to me because a doctor recommends that they get this kind of help or their spouse has been nagging at them to come in and talk to me.

I had a gentleman come in once, not too long ago, who had a friend who was in the program, who was incredibly successful with it. So this gentleman thought, “I wouldn’t mind losing 20 pounds or so, so I’m going to call, too.” He was a very wealthy man – he has airplanes, companies, all kinds of material possessions and plenty of time on his hands. He’s one of those people who has enough support people so that he doesn’t even need to work, even though he’s relatively young. He waltzed into my office late, with his wife. I started going over what he’d have to do and he said, “No, I’m not going to do that – are you kidding?” It’s as if he thought I would wave a magic wand over him. He didn’t read any of the literature I sent him about the program and what it would take to lose weight. He left quickly and never came back; so, his commitment was incredibly weak.

Employment stability and financial stability are other factors. Generally it’s nice to have your ducks lined up in a row when you’re about to undertake something that’s challenging. If your job’s not going so great or if you’re experiencing tremendous financial stress – these are negative factors that may influence your success.

People such as accountants and lawyers who have well-developed internal coping and self-regulatory skills tend to do particularly well in programs like this. These are achievement-oriented people who are used to looking at details. More artistic people, who are more free flowing in the ways that they focus on themselves and their goals, that’s not consistent with what it seems to take to manage the challenge of weight loss.

Personal crises, such as marital problems, can also be negative factors for trying to lose weight. Social support can become an issue, too. If you’re living with 3 teenagers who can eat the walls, this could be a problem. And if your life is full of chaos in other ways or if you don’t have people who are supportive of your efforts, that’s also potentially negative.

These are all research-based influences that can produce challenges and decrease the probability of success. When we do evaluations in my center, (see the website, http://www.chicagocbm.com), the client and myself will go over and rate themselves on these factors so they can start out knowing, “Well, I’ve got a few strikes against me, but generally I can still do this.” Clients can see that this isn’t just about what you eat or whether you exercise; it’s about your life. Is your life capable of supporting this fairly big change? Can you put the energy into it?

Conversely, the more factors people have that are related to stability, the better that they will do with weight loss. I presented a paper at a national convention showing that in our program people over age sixty tend to do better than middle-aged people. The reasons, to me, were about stability. People over age sixty tend to be more stable, they have kids out of the house, they have more control over their lives, and their finances tend to be set. They’re stable.

CL: This is very interesting. Have you found any differences between the genders in terms of weight loss, especially considering that for women so much of their self-esteem is tied up in their physical appearance?

DK: There is some slight evidence that men do a little better in weight control than women. Though women do have more riding on it in terms of the social pressures about physical appearance, men have more leeway in terms of how their bodies look and the extent that they are accepted by the other sex. But, on the other hand, that’s more motivation, you would think, for women.

I think that gender itself isn’t the biggest factor, but some of the roles in women’s lives make it difficult to concentrate on this. Women tend to have more roles, more obligations. I work in a big city (Chicago) and a lot of people who have jobs also have families. So, they are very busy and there’s more of a burden on women to deal with all of those different roles. Men go to work and that’s it. They have some family obligations, but it tends to be less of a double full-time job than a lot of women are dealing with.

The other area that’s a slight advantage for men is that a lot more men grow up with exercise as a way of life, even the ones who are overweight. It’s a little easier for men, then, because it is a little more natural to exercise more often. Women have a little bit more against them in terms of growing up and not exercising. But, that’s not as true today as it was 20 years ago.

If anything, it is more from a biological standpoint that women are at a disadvantage because of having babies and having a higher percentage of body fat. There is a propensity to gain weight during pregnancy and there’s pretty reasonable evidence that having babies is a high-risk time for women. During pregnancy there tends to be some weight gain and the body goes through such tremendous changes, so there’s a definite disadvantage there. I also think menopause is another potential disadvantage in terms of weight gain.

CL: Given that body image is such a central issue for those trying to lose weight (especially women), how do you help them ultimately accept their body image; especially if they had an image in their head of how they’d look once they’d reach their goal and then they don’t quite look like that?

DK: Actually, the vast majority of people who want to lose weight don’t reach their weight loss goals. But they improve their health, well-being and fitness if they really work at it. So, if somebody has to lose seventy pounds, and they work pretty hard at it, they can lose thirty-five to forty pounds and maintain that loss, quite often. They look a lot better than they did and they feel better, but they’re still not where they want to be. I think some of that is probably okay. Some of that “I’m not there yet; I still want to get there”, leaves motivation intact to keep working at weight loss, that’s part of what it takes to persevere.

What also happens is there’s an adjustment to the new body image. Professional cognitive behavioral therapy works well to help people think more about the quality of their lives everyday. So, it’s not a matter of when I get to be X number of pounds, then I’m going to be happy. I’m always working with people about being happy today. If you’re doing what you can do on this issue today, why not try to feel as good as you can feel, today? What possible advantage does it get you to be miserable? So I try to work with people about that and not to have them wait until they lose weight to feel good.

For example, I encourage people to get clothes that make them look good now and not wait until they lose all of their weight. I help people to deal with their bodies as temples, as something to be proud of, no matter what shape they’re in, if they can possibly do it. A lot of people can make this shift and that makes them feel better right away. This doesn’t mean they’re less motivated – in some ways it makes them more motivated because they’re focusing on their physical beings.

CL: That’s a great idea. It’s really getting them to focus more on the present rather than focusing on being happy in the future once they’ve lost their weight. You help them to see that they can be happy today.

DK: That’s right, and when you look at research on weight loss, people’s moods change. My approach is a fairly extreme, fairly demanding kind of approach in terms of what the goals are. But, I’m not like some ogre demanding that people do this. It’s up to them. I’m just a consultant. I’m just saying “This is what your problem demands in order to succeed.” I’m just the conveyor of this information, but I do it in a positive way. I say to people, “Look, I know how tough this is to be this focused, but it’s better than the alternative. Let’s work on it. But when you work on it, why not feel better while you are going through it?” And, the research shows that people very consistently feel better once they engage in this process.

CL Since a weight loss program requires so many different components in order to be effective, including psychological, behavioral, nutritional, and exercise counseling, what is the process clients go through when they come to you for weight management? What are the components of your treatment program? Do you have other health-care professionals that you’re working with as well?

DK: I have physicians that are associated with our program. I’ve been doing this program in the Chicago area for 15 years and there’s a network of about 200 physicians that refer to our clinic. But aside from that, I rarely work with dieticians. The nutritional information that one needs is in my book. Plus, you need a good calorie and fat gram counter. Corinne Netzer’s book called “The Complete Book of Food Counts” is particularly good. At my office we have those books on hand and we sell them to people at cost. We also have blank self-monitoring booklets that we give to people.

One of our key staff members is a clinical social worker and the rest of us are psychologists. After we conduct the initial evaluation, we give them a copy of my book, a monitoring booklet, a folder to puthandouts in, and a calorie counting book.

CL: What about the exercise component?

DK: The way exercise requirements go, and there’s a chapter in my book on it, is the desired goal is every day; a half-hour brisk walk or its equivalent (or more) and that’s it! So a half-hour brisk walk a day is hardly something that needs elaborate instruction. It’s something we’re meant to do. It’s really good if someone can work on strength training exercises, and certainly stretching exercises are very important as well.

If there are very unusual circumstances about whether the person can exercise because of medical reasons, then we have to talk to clients about it and talk to their physicians. But, that’s very unusual, even with someone 100-150 pounds overweight. A person who is 200 pounds overweight can exercise. Their body tells them when they have to sit down.

Even someone with heart disease or congestive heart failure can exercise. They do have trouble breathing. I’ve worked with a number of these clients and their physicians say, “Well, if they feel like they’re running out of breath, they can sit down.” That’s what any athlete does. You push it to a certain point and when you can’t do it, you slow down.

CL: Do you also encourage having family members, friends, or other people close to the overweight client integrated into the program so that they can offer social support?

DK: Yes, that’s an important part of what we do. In my book I provide a list of guidelines for spouses and other family members about how to work with this person in the most helpful way (pages 167-170). We also, quite often, will have the spouse and family come in and we’ll spend some time talking about their understanding about what goes on with weight control and why it’s difficult. That’s important because most people don’t understand the biology of being overweight. They really don’t get that part or they don’t believe it. They think it’s mainly that the person isn’t working hard enough.

So, we like the support people to understand that this is a very challenging, biological situation, which their spouse can overcome. But, it would be nice if their spouse got credit for what they’re doing and how hard it is at that level. It is also important that the family member understand why the moderation approach fails. “Well, you can have a little of this, you can have a little of that. You haven’t eaten this in 3 months, why not? We’re having ribs tonight. Why can’t you have some ribs occasionally?” I like to go over the approach that I take to weight loss and why the consistency of it is what it really takes to be successful. I also go over the same information about exercise because it can have an impact sometimes on the family. If someone’s suddenly making absolutely sure they get their exercise in every single day, there needs to be some accommodation for that in the family.

CL: Dan, given that weight management in this country is such a big issue, what compelled you as a psychologist and as a person to specialize in this area?

DK: Well, I was overweight as a child – that’s partly a factor. When I graduated from high school I was twenty-eight percent overweight myself and so I’ve had some pretty negative experiences of what it was like to be overweight. When I went away to sleep-away camp at eight-and-a-half years old, my nickname was “Chubsy”. I didn’t like that very much. That’s cute now, but it wasn’t much fun living it then. So, I had experienced some of the pain of growing up overweight.

I was always pretty athletic, but I was limited in what I could do athletically, which bothered me, too. The weight limited me and I didn’t like that. So, I learned about difficulties with being overweight from my own experiences.

When I went to graduate school in psychology, I worked with a particular professor, Dr. Fred Kanfer. He really developed the notion of behavioral self-control. I wanted to work with him because I really liked his idea of giving the “power to the person.” It’s a ’60’s thing, but I happen to think it’s a great idea, as opposed to using some big theory, like psychoanalytic theory that basically decides for people what they need to do.

The behavioral self-control approach offers to people a set of techniques and ways of thinking that they can use if they want to, if they elect to, to improve their lives. I like that philosophically. So my research early on was focused on this philosophy, and not just in weight control, but in areas like study skills, sport performance, smoking and a variety of other self-control challenges.

I’ve worked clinically with overweight clients since 1972. I got even more focused and involved in weight control specifically when I came to Northwestern University in the mid-’80’s to work with and become the director of the eating disorders program there. I’d published on weight loss before then quite a bit. This is an area that I’ve focused on a lot, partly because there is such a problem out there and because people are willing to get some help for it.

CL: So, what type of training track would you recommend to other clinicians who are starting out who may want to work with people who are struggling with weight loss?

DK: I would suggest a concentration in health psychology. I would also certainly recommend that they have a lot of training in cognitive behavior therapy, to have a very solid theoretical knowledge about how to help people set goals, think and behave.

CL: Considering that you have been involved in the area of weight management for so long, do you think there are going to be any new approaches for weight loss on the horizons or do you think this extreme approach will be the best method even into the future?

DK: Well, the big picture of weight control in this country is that there is so much ignorance about science. Ten million people in this country bought Dr. Atkins’ book, five million bought Suzanne Sommers’ book “Eat Great, Lose Weight“. Suzanne Sommers! She says she doesn’t eat turkey sandwiches because it puts a strain on the digestive system to eat protein and carbohydrates at the same meal. This is where America is at about weight loss. As behavioral scientists, we forget where people really are about weight loss.

So, the big challenge to me is to get people to look at something like “The 9 Truths about Weight Loss” in the first place; to get them to start understanding that there is a science to this and that science is the only thing that we know that’s relatively unbiased. Science is not out there to sell them a packaged piece of goods. Everything that I say in this book has reference notes to it. It has journal articles where people worked their whole lives to publish this scientifically researched information and get paid less than garbage collectors to do this kind of work. We have to somehow find a way to get this culture changed into understanding what science is and to value it.

To me, that’s the biggest challenge. Let’s think about the Atkins Diet for example. We need to get people to ask themselves, “Does it really make sense?” Basically, he’s selling people on a high fat diet. That flies in the face of what’s been learned about weight control and about heart health; what’s been learned for over thirty years. It’s just completely opposite of what we know to be true and it’s in every bookstore. You go into Barnes & Noble and they have a whole shelf on Dr. Atkins’ diet. A whole shelf on decreasing carbohydrate eating and eating more protein. None of that makes any sense at all and there are whole shelves devoted to it with labels like – “Carb Busting Diets.”

People still don’t understand that the question to ask when you’re looking at a book like Atkins is to say “Where’s the science here? Show me the publications that say that people who lose weight and keep it off, do this diet. Show me the publications that show that eating a high fat diet doesn’t increase my cholesterol level.” In fact, one study that was done in 1980, twenty years ago, showed an eighteen percent increase in low-density lipoproteins (the bad kind of cholesterol) when they went on Atkins for a couple of months.

Why are people even considering diets like that? It’s not a minor trend, it has been going on for decades. “The Zone” was another diet plan right before the Atkins re-revolution. The author of “The Zone” has a Ph.D. in Bio-something, but he has never published a single article on weight control in his life. Atkins never published an article on weight loss. Where’s our education system failing us that people don’t even know what science is, let alone to value it enough to ask some basic questions such as “Why would I ever consider going on something like this diet plan? Just because Joe Schmoe gets on T.V. and says I did it and lost weight?” That’s it. That’s what our criteria are?

So, what I think has to happen here is we have to have a kind of cultural revolution to deal with these diet revolutions. That’s what I’d like to see. If we could do that, then we can really do some good. Before that, it doesn’t matter how sophisticated we get about weight loss until people start to look at the facts.

I do think, though, that the next level up in weight control help is going to be more assistance with helping people to focus on their behaviors that lead to weight loss. You certainly can use things like the internet, pagers, and Palm Pilots, which will help make it easier for people to stay focused. There are so many devices currently that people can carry with them that actually can be preprogrammed to help them stay aware of what they’re trying to do. That, I think, will definitely be useful.

CL: Definitely! And hopefully, Dan, with your book “The Nine Truths About Weight Loss“, people will learn the facts about how to lose weight and keep it off in a healthy and effective manner. Maybe we can start to get people losing weight in the right way.

DK: I hope so! We’ll see! We can try anyway.

CL: It really is critical for both people’s psychological and physical health to learn the real facts about weight loss. Thank you, Dan, for sharing your well researched knowledge and professional clinical experience about weight management with our viewers.

CL: Speaking of focus and control, since so many people gain the weight back after they have lost it, have you found there to be any emotional or behavioral indicators that helped you as a therapist know whether or not someone is truly ready to take an extreme approach to weight loss?

DK: Well, that’s an interesting one. I can go over with you a couple of the things that are predictive of failure to succeed. It’s a little harder to predict success actually, but we can tell when someone’s likely to have more trouble. If they have chronic psychological problems, that’s not a good situation for long term weight loss. If they have commitment problems in which the strength and the clarity of their commitment to change is somewhat weak, this is a problem. An example of a person with a lack of committment is when somebody comes to me because a doctor recommends that they get this kind of help or their spouse has been nagging at them to come in and talk to me.

I had a gentleman come in once, not too long ago, who had a friend who was in the program, who was incredibly successful with it. So this gentleman thought, “I wouldn’t mind losing 20 pounds or so, so I’m going to call, too.” He was a very wealthy man – he has airplanes, companies, all kinds of material possessions and plenty of time on his hands. He’s one of those people who has enough support people so that he doesn’t even need to work, even though he’s relatively young. He waltzed into my office late, with his wife. I started going over what he’d have to do and he said, “No, I’m not going to do that – are you kidding?” It’s as if he thought I would wave a magic wand over him. He didn’t read any of the literature I sent him about the program and what it would take to lose weight. He left quickly and never came back; so, his commitment was incredibly weak.

Employment stability and financial stability are other factors. Generally it’s nice to have your ducks lined up in a row when you’re about to undertake something that’s challenging. If your job’s not going so great or if you’re experiencing tremendous financial stress – these are negative factors that may influence your success.

People such as accountants and lawyers who have well-developed internal coping and self-regulatory skills tend to do particularly well in programs like this. These are achievement-oriented people who are used to looking at details. More artistic people, who are more free flowing in the ways that they focus on themselves and their goals, that’s not consistent with what it seems to take to manage the challenge of weight loss.

Personal crises, such as marital problems, can also be negative factors for trying to lose weight. Social support can become an issue, too. If you’re living with 3 teenagers who can eat the walls, this could be a problem. And if your life is full of chaos in other ways or if you don’t have people who are supportive of your efforts, that’s also potentially negative.

These are all research-based influences that can produce challenges and decrease the probability of success. When we do evaluations in my center, (see the website, http://www.chicagocbm.com), the client and myself will go over and rate themselves on these factors so they can start out knowing, “Well, I’ve got a few strikes against me, but generally I can still do this.” Clients can see that this isn’t just about what you eat or whether you exercise; it’s about your life. Is your life capable of supporting this fairly big change? Can you put the energy into it?

Conversely, the more factors people have that are related to stability, the better that they will do with weight loss. I presented a paper at a national convention showing that in our program people over age sixty tend to do better than middle-aged people. The reasons, to me, were about stability. People over age sixty tend to be more stable, they have kids out of the house, they have more control over their lives, and their finances tend to be set. They’re stable.

CL: This is very interesting. Have you found any differences between the genders in terms of weight loss, especially considering that for women so much of their self-esteem is tied up in their physical appearance?

DK: There is some slight evidence that men do a little better in weight control than women. Though women do have more riding on it in terms of the social pressures about physical appearance, men have more leeway in terms of how their bodies look and the extent that they are accepted by the other sex. But, on the other hand, that’s more motivation, you would think, for women.

I think that gender itself isn’t the biggest factor, but some of the roles in women’s lives make it difficult to concentrate on this. Women tend to have more roles, more obligations. I work in a big city (Chicago) and a lot of people who have jobs also have families. So, they are very busy and there’s more of a burden on women to deal with all of those different roles. Men go to work and that’s it. They have some family obligations, but it tends to be less of a double full-time job than a lot of women are dealing with.

The other area that’s a slight advantage for men is that a lot more men grow up with exercise as a way of life, even the ones who are overweight. It’s a little easier for men, then, because it is a little more natural to exercise more often. Women have a little bit more against them in terms of growing up and not exercising. But, that’s not as true today as it was 20 years ago.

If anything, it is more from a biological standpoint that women are at a disadvantage because of having babies and having a higher percentage of body fat. There is a propensity to gain weight during pregnancy and there’s pretty reasonable evidence that having babies is a high-risk time for women. During pregnancy there tends to be some weight gain and the body goes through such tremendous changes, so there’s a definite disadvantage there. I also think menopause is another potential disadvantage in terms of weight gain.

CL: Given that body image is such a central issue for those trying to lose weight (especially women), how do you help them ultimately accept their body image; especially if they had an image in their head of how they’d look once they’d reach their goal and then they don’t quite look like that?

DK: Actually, the vast majority of people who want to lose weight don’t reach their weight loss goals. But they improve their health, well-being and fitness if they really work at it. So, if somebody has to lose seventy pounds, and they work pretty hard at it, they can lose thirty-five to forty pounds and maintain that loss, quite often. They look a lot better than they did and they feel better, but they’re still not where they want to be. I think some of that is probably okay. Some of that “I’m not there yet; I still want to get there”, leaves motivation intact to keep working at weight loss, that’s part of what it takes to persevere.

What also happens is there’s an adjustment to the new body image. Professional cognitive behavioral therapy works well to help people think more about the quality of their lives everyday. So, it’s not a matter of when I get to be X number of pounds, then I’m going to be happy. I’m always working with people about being happy today. If you’re doing what you can do on this issue today, why not try to feel as good as you can feel, today? What possible advantage does it get you to be miserable? So I try to work with people about that and not to have them wait until they lose weight to feel good.

For example, I encourage people to get clothes that make them look good now and not wait until they lose all of their weight. I help people to deal with their bodies as temples, as something to be proud of, no matter what shape they’re in, if they can possibly do it. A lot of people can make this shift and that makes them feel better right away. This doesn’t mean they’re less motivated – in some ways it makes them more motivated because they’re focusing on their physical beings.

CL: That’s a great idea. It’s really getting them to focus more on the present rather than focusing on being happy in the future once they’ve lost their weight. You help them to see that they can be happy today.

DK: That’s right, and when you look at research on weight loss, people’s moods change. My approach is a fairly extreme, fairly demanding kind of approach in terms of what the goals are. But, I’m not like some ogre demanding that people do this. It’s up to them. I’m just a consultant. I’m just saying “This is what your problem demands in order to succeed.” I’m just the conveyor of this information, but I do it in a positive way. I say to people, “Look, I know how tough this is to be this focused, but it’s better than the alternative. Let’s work on it. But when you work on it, why not feel better while you are going through it?” And, the research shows that people very consistently feel better once they engage in this process.

CL Since a weight loss program requires so many different components in order to be effective, including psychological, behavioral, nutritional, and exercise counseling, what is the process clients go through when they come to you for weight management? What are the components of your treatment program? Do you have other health-care professionals that you’re working with as well?

DK: I have physicians that are associated with our program. I’ve been doing this program in the Chicago area for 15 years and there’s a network of about 200 physicians that refer to our clinic. But aside from that, I rarely work with dieticians. The nutritional information that one needs is in my book. Plus, you need a good calorie and fat gram counter. Corinne Netzer’s book called “The Complete Book of Food Counts” is particularly good. At my office we have those books on hand and we sell them to people at cost. We also have blank self-monitoring booklets that we give to people.

One of our key staff members is a clinical social worker and the rest of us are psychologists. After we conduct the initial evaluation, we give them a copy of my book, a monitoring booklet, a folder to puthandouts in, and a calorie counting book.

CL: What about the exercise component?

DK: The way exercise requirements go, and there’s a chapter in my book on it, is the desired goal is every day; a half-hour brisk walk or its equivalent (or more) and that’s it! So a half-hour brisk walk a day is hardly something that needs elaborate instruction. It’s something we’re meant to do. It’s really good if someone can work on strength training exercises, and certainly stretching exercises are very important as well.

If there are very unusual circumstances about whether the person can exercise because of medical reasons, then we have to talk to clients about it and talk to their physicians. But, that’s very unusual, even with someone 100-150 pounds overweight. A person who is 200 pounds overweight can exercise. Their body tells them when they have to sit down.

Even someone with heart disease or congestive heart failure can exercise. They do have trouble breathing. I’ve worked with a number of these clients and their physicians say, “Well, if they feel like they’re running out of breath, they can sit down.” That’s what any athlete does. You push it to a certain point and when you can’t do it, you slow down.

CL: Do you also encourage having family members, friends, or other people close to the overweight client integrated into the program so that they can offer social support?

DK: Yes, that’s an important part of what we do. In my book I provide a list of guidelines for spouses and other family members about how to work with this person in the most helpful way (pages 167-170). We also, quite often, will have the spouse and family come in and we’ll spend some time talking about their understanding about what goes on with weight control and why it’s difficult. That’s important because most people don’t understand the biology of being overweight. They really don’t get that part or they don’t believe it. They think it’s mainly that the person isn’t working hard enough.

So, we like the support people to understand that this is a very challenging, biological situation, which their spouse can overcome. But, it would be nice if their spouse got credit for what they’re doing and how hard it is at that level. It is also important that the family member understand why the moderation approach fails. “Well, you can have a little of this, you can have a little of that. You haven’t eaten this in 3 months, why not? We’re having ribs tonight. Why can’t you have some ribs occasionally?” I like to go over the approach that I take to weight loss and why the consistency of it is what it really takes to be successful. I also go over the same information about exercise because it can have an impact sometimes on the family. If someone’s suddenly making absolutely sure they get their exercise in every single day, there needs to be some accommodation for that in the family.

CL: Dan, given that weight management in this country is such a big issue, what compelled you as a psychologist and as a person to specialize in this area?

DK: Well, I was overweight as a child – that’s partly a factor. When I graduated from high school I was twenty-eight percent overweight myself and so I’ve had some pretty negative experiences of what it was like to be overweight. When I went away to sleep-away camp at eight-and-a-half years old, my nickname was “Chubsy”. I didn’t like that very much. That’s cute now, but it wasn’t much fun living it then. So, I had experienced some of the pain of growing up overweight.

I was always pretty athletic, but I was limited in what I could do athletically, which bothered me, too. The weight limited me and I didn’t like that. So, I learned about difficulties with being overweight from my own experiences.

When I went to graduate school in psychology, I worked with a particular professor, Dr. Fred Kanfer. He really developed the notion of behavioral self-control. I wanted to work with him because I really liked his idea of giving the “power to the person.” It’s a ’60’s thing, but I happen to think it’s a great idea, as opposed to using some big theory, like psychoanalytic theory that basically decides for people what they need to do.

The behavioral self-control approach offers to people a set of techniques and ways of thinking that they can use if they want to, if they elect to, to improve their lives. I like that philosophically. So my research early on was focused on this philosophy, and not just in weight control, but in areas like study skills, sport performance, smoking and a variety of other self-control challenges.

I’ve worked clinically with overweight clients since 1972. I got even more focused and involved in weight control specifically when I came to Northwestern University in the mid-’80’s to work with and become the director of the eating disorders program there. I’d published on weight loss before then quite a bit. This is an area that I’ve focused on a lot, partly because there is such a problem out there and because people are willing to get some help for it.

CL: So, what type of training track would you recommend to other clinicians who are starting out who may want to work with people who are struggling with weight loss?

DK: I would suggest a concentration in health psychology. I would also certainly recommend that they have a lot of training in cognitive behavior therapy, to have a very solid theoretical knowledge about how to help people set goals, think and behave.

CL: Considering that you have been involved in the area of weight management for so long, do you think there are going to be any new approaches for weight loss on the horizons or do you think this extreme approach will be the best method even into the future?

DK: Well, the big picture of weight control in this country is that there is so much ignorance about science. Ten million people in this country bought Dr. Atkins’ book, five million bought Suzanne Sommers’ book “Eat Great, Lose Weight“. Suzanne Sommers! She says she doesn’t eat turkey sandwiches because it puts a strain on the digestive system to eat protein and carbohydrates at the same meal. This is where America is at about weight loss. As behavioral scientists, we forget where people really are about weight loss.

So, the big challenge to me is to get people to look at something like “The 9 Truths about Weight Loss” in the first place; to get them to start understanding that there is a science to this and that science is the only thing that we know that’s relatively unbiased. Science is not out there to sell them a packaged piece of goods. Everything that I say in this book has reference notes to it. It has journal articles where people worked their whole lives to publish this scientifically researched information and get paid less than garbage collectors to do this kind of work. We have to somehow find a way to get this culture changed into understanding what science is and to value it.

To me, that’s the biggest challenge. Let’s think about the Atkins Diet for example. We need to get people to ask themselves, “Does it really make sense?” Basically, he’s selling people on a high fat diet. That flies in the face of what’s been learned about weight control and about heart health; what’s been learned for over thirty years. It’s just completely opposite of what we know to be true and it’s in every bookstore. You go into Barnes & Noble and they have a whole shelf on Dr. Atkins’ diet. A whole shelf on decreasing carbohydrate eating and eating more protein. None of that makes any sense at all and there are whole shelves devoted to it with labels like – “Carb Busting Diets.”

People still don’t understand that the question to ask when you’re looking at a book like Atkins is to say “Where’s the science here? Show me the publications that say that people who lose weight and keep it off, do this diet. Show me the publications that show that eating a high fat diet doesn’t increase my cholesterol level.” In fact, one study that was done in 1980, twenty years ago, showed an eighteen percent increase in low-density lipoproteins (the bad kind of cholesterol) when they went on Atkins for a couple of months.

Why are people even considering diets like that? It’s not a minor trend, it has been going on for decades. “The Zone” was another diet plan right before the Atkins re-revolution. The author of “The Zone” has a Ph.D. in Bio-something, but he has never published a single article on weight control in his life. Atkins never published an article on weight loss. Where’s our education system failing us that people don’t even know what science is, let alone to value it enough to ask some basic questions such as “Why would I ever consider going on something like this diet plan? Just because Joe Schmoe gets on T.V. and says I did it and lost weight?” That’s it. That’s what our criteria are?

So, what I think has to happen here is we have to have a kind of cultural revolution to deal with these diet revolutions. That’s what I’d like to see. If we could do that, then we can really do some good. Before that, it doesn’t matter how sophisticated we get about weight loss until people start to look at the facts.

I do think, though, that the next level up in weight control help is going to be more assistance with helping people to focus on their behaviors that lead to weight loss. You certainly can use things like the internet, pagers, and Palm Pilots, which will help make it easier for people to stay focused. There are so many devices currently that people can carry with them that actually can be preprogrammed to help them stay aware of what they’re trying to do. That, I think, will definitely be useful.

CL: Definitely! And hopefully, Dan, with your book “The Nine Truths About Weight Loss“, people will learn the facts about how to lose weight and keep it off in a healthy and effective manner. Maybe we can start to get people losing weight in the right way.

DK: I hope so! We’ll see! We can try anyway.

CL: It really is critical for both people’s psychological and physical health to learn the real facts about weight loss. Thank you, Dan, for sharing your well researched knowledge and professional clinical experience about weight management with our viewers.

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