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CHAPTER 3: THE ITAND PROGRAMME
Overview
Taking cognisance of the escalating global overweight and obesity epidemic with the associated severe health risks, there is a need for the development of innovative treatment interventions and for an understanding of the processes mediating successful weight loss maintenance enabled by new treatment models. The superfluous short-term-based quantitative research focusing on overweight and obesity treatment, and the absence of long-term qualitative research provides further motivation for the necessity of developing an integrative model for treatment and for conducting a qualitative long-term follow-up regarding the maintenance of weight loss and the constructs perceived as mediating the successful treatment of overweight and obesity.
The current research constitutes a qualitative study regarding the maintenance of weight loss and the constructs mediating success of an integrative, transactional analysis non-diet (ITAND) model. The research may add considerable value to the identification and understanding of the psychological as well as the physiological processes which mediate lifelong weight loss maintenance.
The aim of this study is to identify, explore and examine the weight narratives of women who had successfully lost a significant percentage of their weight (≥20%) and maintained the weight loss for over 20 years through participating in the ITAND Programme.
The ITAND Programme was previously known as the Weight-Winners Programme. I developed and introduced the Weight-Winners (ITAND Programme) in South Africa in 1989.
My personal narrative
In order to contextualise this study it is important to provide a description of the ITAND Programme. Since the development of the ITAND Programme is pivotally connected to my personal journey with food, my body, overweight and my attainment of permanent weight loss, it is appropriate to begin by sharing my personal narrative.
For as far back as I can recall I considered myself to be on the “overweight” side of the fat-thin continuum. I reached puberty at age 13 feeling uncomfortable and distressed about my body. I was consumed with negative “self-talk” regarding my appearance, which affected my self-perception, self-projection and along with it every relationship I was engaged in. Thoughts of being overweight dominated my thinking and I knew I had to do something to lose weight. At the age of 14 carrying 72 kilograms on my 1,60 m frame, I went on my first diet.
At the time, dieting seemed the only way accessible to me which would help me lose weight. My first diet was randomly chosen from an array of commercial diets and the absurdity of both the name, ‘The Drinking Man’s Diet’ and the special allowance of alcohol included did not occur to me at the time!
I lost weight while I followed the diet and felt delighted as I began to shed some unwanted kilograms. I felt “lighter”, my outlook on life improved and I began to feel my confidence improving. However, after three months on the diet I developed difficulty following the diet. The problem I had was that I became preoccupied with and developed cravings for the food I was not permitted to eat on the diet. I felt like I was fighting an internal tug-of-war. One part of me was screaming “I want ice cream” (and all the other forbidden foods), while another part of me was attempting to stop the screaming “part” by shouting it down, “You can’t have an ice cream because you are fat!”. Eventually the screaming childlike voice won over the autocratic, controlling voice, and I began eating all the foods which were disallowed on the diet. I ate even more than I did before the diet because I felt so deprived by the food on the diet and I was terrified I would be deprived of these foods again. Painfully, I regained all the weight I had lost and went on to gain even a few extra kilograms. I felt like a failure and knew my failing was evident for everyone to see. I felt totally exposed. I was now the heaviest I had ever been and at 75 kilograms I felt absolutely desperate about my eating , my body and my weight .
Following several attempts at an array of other diets obtained through diet books, which all resulted in failure after failure and continual weight cycling, a family friend suggested that I seek professional help and consult with a dietician. Her suggestion was based mainly on feeling that I needed a personalised eating plan and regular individually based professional assistance which would serve the dual purpose of constant guidance as well as focused monitoring to make sure I did not deviate from the agreed prescription. I left the dietician consultation with a restrictive eating plan in which almost all the foods I enjoyed were removed or offered in very restricted quantities. I really did my best to follow this diet but from the start began to feel preoccupied with food. I ruminated over the food I wanted but wasn’t allowed, felt hungrier than ever before and always deprived in social eating situations. However, I realised I was privileged to have professional help and used all the “willpower” I could harness to remain committed to both the diet and my weekly consultations with the dietician. When I had lapses in my willpower and ate incorrectly the weekly session would help to put me back on track. I remained on diet for four months and lost 9 kgs, by which time the dietician felt she could start reintroducing some previously forbidden foods as substitutes to deal with my “forbidden food” cravings.
This approach just heralded back in my increasing need to compensate myself for having been deprived of these foods – I overate continuously. I began to slowly regain the weight I had lost. With each kilogram I regained my despondency increased and in response I ate even more. I felt stuck in a vicious cycle – a cycle I later named the “Diet Destructive Cycle”. As I steadily regained weight to reach 78 kgs I felt more desperate than ever before. At this stage I persuaded my mother, who was most resistant to the idea, to take me to a medical physician who specialised in pharmacological treatment. He prescribed an “appetite suppressing” medication which he promised would help me lose weight by altering my appetite. I believed I now I had my “miracle cure”. However the medication caused side-effects and after noticing that it was seriously affecting my mood, resulting in me becoming disorientated, my mother insisted on me terminating the treatment.
A school friend suggested that I should try another diet, a moderate sensible diet, which both she and her mother were doing and which really “worked”. With renewed enthusiasm I enrolled on this programme which provided a “balanced” rather than extreme approach to weight loss. I recall standing in “weighing-in” queues week after week, waiting my turn to be weighed and being applauded for losing weight and felt totally ashamed in the weeks I did not lose weight. The endless hours of preoccupation with purchasing and preparing my food as well as having to weigh and measure the food drove my family mad and was not a suitable eating lifestyle for a teenager. Eventually I abandoned that attempt too.
By the time I was 18, I had been on more diets than I care to recall and continued the repetitive cycle of losing weight while I harnessed sufficient “willpower” to “stick to” the diet, and the regaining of all the weight I had initially lost, and often a few kilograms more (due to my overeating of every food I felt deprived of while following the diet). During my matric year I began to question what it was that kept me locked in a cycle of defeat in the area of managing my weight. I asked myself how I could be successful in the other areas of my life and yet fail with managing my weight. Was there something that I was doing differently in those areas of my life in which I succeeded which I was not applying to my food, weight and my body?
In the process of my self-reflection I reached the insight that in every area of life in which I was successful I put “myself” in charge. I took personal responsibility for my decisions, functioning and conduct. My locus of control was internal. I listened to the views of other people, reflected on them, understood them, digested them, but in the final analysis I reached my own decisions. The only area of my life in which I had totally given away responsibility for my decisions and behaviour was in regard to food and eating. When it came to my personal nutrition, I had come to rely on the dictates of an external authority and had believed that a diet plan or diet physician knew better than I did, when it was appropriate for me to eat, what I should eat at a prescribed time as well as the quantities which I should eat.
As I sat with this insight, my realisation regarding the ineffectiveness of diets as a weight loss method, and the irrationality of what I was doing, became increasingly evident. How had I regarded someone else, whom I often randomly selected, as knowing better than myself when, what and how much to eat? The answer I arrived at was that the reliance on an external authority would never work for me in winning my battle with food and my weight. I knew with clarity I had to learn to work out the answers for myself. I needed to take back control of my decision making in relation to food and nourishing myself. This would mean I would have to stop dieting. I understood that taking the decision not to diet would not be easy and that it would be a journey during which there would be much to discover for myself.
This insight was coincidentally timed with my co-occurring experience of becoming physically ill and having to be hospitalised for several surgical procedures within the time span of five months. While in hospital, I became aware that I often did not feel like eating, and that I had the ability to follow the needs of my body and could reject food when I did not feel like eating. This was the first time I became aware of my body in relation to food and eating, and I began to identify my unique hunger and satiation signals. Armed with insight regarding my locus of control, as well as my insight into the experiential workings of my body, I made the decision on my recovery to take personal responsibility for my weight and to stop dieting. The only directive I gave myself was to “focus inward” and to eat in response to hunger and to be aware of my own physiological cues. I would also select what I ate by problem-solving around food in the same way as I made other decisions in my life. Within six months I lost 20 kilograms. Most importantly, during this time I was responsible for directing my eating and I had developed a normal relationship with all food.
My clinical experience
Following graduation from secondary school, I studied for a Bachelors of Arts Degree and following that an Honours and a Master’s degree in Psychology. In 1984 I registered with the Professional Board as a counselling psychologist and started a private primary care practice, specialising in working with people who had weight problems. During this time I discovered that weight was a primary issue in governing the way a person felt about him- or herself. Overweight and obesity had a negative effect on my patients’ self-esteem. In affecting the way they felt about themselves, it affected the way they projected themselves, and in affecting self-projection, it affected every relationship that they were engaged in. So overweight was not simply accompanying dysthymia and depression, but overweight in fact was a major causative factor in my patients’ development of depression. I also discovered with many patients the causes for being overweight were actually not always psychodynamic but instead cognitive and behavioural. In many instances the causes for overeating were easy to identify, unravel and understand. This was a significant insight for me and influenced my thinking in writing the ITAND Programme. My approach to therapy was integrative. In addition to my psychodynamic orientation, I employed a transactional analysis and cognitive-behavioural therapeutic orientation which led me to reach an insight which I believed could contribute to a “paradigm shift” for the treatment of overweight and obesity.
Through a counselling process with many overweight and obese patients, I discovered that their destructive relationship with food, their weight and their bodies was attributable to four major factors – all of which were underpinned by the “diet mentality”, that is, a mind-set generated by prescriptive, restrictive eating plans and schedules.
The first factor was that diets, and the associated behaviours, alienated my patients from their own physiological functioning. More specifically, it alienated them from their physiological cues regarding hunger and satiety. The loss of ability to identify hunger was critical in causing, maintaining and escalating my patients’ struggle with food, weight and their bodies. While I uncovered that many patients had lost touch with their physiological cues of hunger and satiation through family eating scripts and/or more complex emotions associated with life events, diets served to overlook this alienation, thereby exacerbating the very issue which required focus in order to regain personal comfort with food, weight and their bodies. My patients required physiological awareness coaching which focused on learning hunger satiation awareness in order to lose weight and develop a comfortable relationship with food and their bodies.
The second contributing factor to the destructive relationship patients had with food, their weight and their bodies, was that diets and the associated behaviours had resulted in my patients externalising their locus of control in the belief that an external authority, such as a dietician or weight physician, would provide the answer to their struggle with food, weight and their bodies. My patients needed to be coached in internalising their locus of control regarding food and eating in order to restore the physiological and emotional integration essential to permanent weight loss. My patients needed to learn that they were able to determine for themselves when to eat as well as to decide what to eat and how much to eat through remaining in touch with their relearned awareness.
CHAPTER 1: OVERVIEW
1.1 Statement of the problem
1.2 Literature review
1.3 Conclusion
CHAPTER 2: LITERATURE REVIEW
2.1 Introduction
2.2 Defining overweight and obesity
2.3 Demographics of the overweight and obesity epidemic
2.4 Health risks and consequences associated with overweight and obesity
2.5 Causes of obesity
2.6 Treatment of obesity
2.7 Weight loss maintenance
2.8 Conclusion
CHAPTER 3: THE ITAND PROGRAMME
3.1 Overview
3.2 My personal narrative
3.3 My clinical experience
3.4 My synthesis of research studies
3.5 ITAND Programme overview
CHAPTER 4: METHODOLOGY
4.1 Introduction
4.2 Qualitative versus quantitative methodology1
4.3 Qualitative methodolog
4.4 Sample selection
4.5 Data collection
4.6 Analysis of the qualitative data
4.7 Quality
4.8 Reflexivity
4.9 Ethical considerations
4.10 Conclusion
CHAPTER 5: TRANSFORMATIVE LEARNING
5.1 Overview
5.2 Transformative Learning Theory (TLT)
5.3 Transformative Learning Theory and long-term weight loss maintenance
5.4 Transformative Learning and personal transformation
5.5 Conclusion
CHAPTER 6: THEMATIC ANALYSIS
6.1 Introduction
6.2 Themes6.3 Conclusion
CHAPTER 7: CONCLUSION, LIMITATIONS, RECOMMENDATIONS AND REFLECTION
7.1 Introduction
7.2 Strengths and limitations of this study
7.3 Contributions and recommendations for further research
7.4 Concluding self-reflection
REFERENCE
GET THE COMPLETE PROJECT
THE LONG-TERM WEIGHT MAINTENANCE NARRATIVES OF WOMEN FOLLOWING THEIR PARTICIPATION IN AN INTEGRATIVE, TRANSACTIONAL ANALYSIS, NON-DIET PROGRAMME
