Obesity, depression and recovery

Obese people can be seen as belonging to two separate groups.  "Group 1" is characterized by having a generally satisfactory life, with interests and hobbies (other than food) and reasonably good relationships.  "Group 2" people are usually depressed and/or unhappy, with few or no sources of pleasure other than food. 

Group I people are frequently successful with rigorous diet and exercise programs.  While they may relapse into overeating, they do lose weight at least while they continue the program.  They are able to make a rapid change in their eating and exercise habits, frequently picking a particular date to start and then following through.  Their lives have plenty of good things in them that don't depend on eating.  They frequently have trouble seeing why other obese people have such difficulty losing weight. 

Group 2 people are almost never successful with rapid weight-change programs.  Because they are already depressed or unhappy, they are easily overwhelmed by the amount of change they see as necessary.  They think "I just can't do all that", while envisioning major changes in exercise and food intake.  They have little other sources of pleasure, so that giving up the one and sometimes only pleasure they have, eating, leaves them contemplating a life with nothing rewarding or good in it.  They can't seem to get started.  They don't understand how others can succeed at such a difficult task, which further convinces them of their own inadequacy.

For Group 2 people to succeed, they have to make small behavioral changes, not the large ones they feel overwhelmed by.  They can't deal with losing "a hundred pounds".   They can't accept "no more desserts" or "walking three miles".  They may pick a starting date, but they either don't do it or they give up almost immediately, feeling helpless and intimidated by the task.  Their failures increase their low self-esteem and their depression.

In helping depressed patients overcome their depression, we use what I call the "2-Plate Rule".  This rule applies to all overwhelming tasks, which for depressed people includes almost everything.  The rule states that if washing 2 dishes in the sink is too much to do, change the size of the task by a half. Wash 1 plate.  If that's overwhelming, plan to wash a saucer.  It is crucial that the size of the task be reduced until it can be accomplished, and it doesn't really matter how small the task is as long as it can be done.  My patients are instructed to stop when they have completed the task, and not to treat their success as some kind of trick so they can be urged to do more.  Depressed people need more successes, not more failures.

Group 2 patients need to be assisted in reducing the initial tasks involved in beginning to lose weight until the initial task is something doable.  For instance, the patient may be instructed to pick a task involving exercise or involving diet (not both) and break it down into smaller "chunks".  An exercise "chunk" might involve walking to the end of the driveway and back on the first day, and staying with that chunk for a week (or some specific short length of time).  If they are successful with that task, they might decide that walking to the end of the block is possible.  At the first failure, they are to recognize that they gave themselves too much to accomplish, and that they need to choose a smaller task. 

A diet "chunk" might be to decide to have a smaller dessert, such as a half-piece of cake or pie. Or it might be to decide to not have anything to eat after midnight.  The patient is instructed to stay with their success for at least a week.   Later in their program they can shorten the length of time between changes, as long as they find the task something they can accomplish.  If they have a problem carrying out their task in their time frame, apply the 2-Plate Rule.