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Why and when do patients most often lapse from their diet?

Mandy Cassidy
BSc MSc
Psychotherapist, Independent Consultant

Mandy Cassidy explores why so many patients turn to food and alcohol during times of transition and how this may help us understand how to offer more effective treatment and support

Obesity is one of the major challenges to the physical, mental and economic health of our nation; and yet, so little energy appears to be given to understanding the psychology of obesity.

When you explore the history of a person who has suffered with obesity over many years it is not uncommon to see a substantial or repeated increase in weight following certain patterns. This type of weight increase often follows transitional periods, such as moving school or house, leaving home, first adult job, childbirth, divorce or death.

When looking at the patient's history there may be a single initial trigger related to one of life's major transitions that, when reactivated subsequently, may trigger a similar response - turning to food to manage the associated emotions. A common example would be of the patient who started putting on weight between the ages of five and six as a response to dealing with the demands of letting go of mother and starting school. Later in life this person might experience a similar reaction when leaving home to start their first adult job or attend university, turning to both food and alcohol in an attempt to manage these same emotions.

Developmental psychology helps us understand the process of maturation and how this involves growing demands on the individual; which, when met and supported appropriately lead to growth and a strengthening of the self. When the individual, for some reason, does not have sufficient resources, or when the resources available are overwhelmed (as in the case of trauma), then defences are used to cope with these transitions to suppress or manage the associated anxiety.

In the case of the obese patient these defences may well involve the use of food. As the feeling starts to bubble up into awareness, food is quickly consumed to anesthetise or suppress the emotion. The purpose of eating the food is to ensure the patient does not become aware of the underlying experience and related memories and this is why so many obese patients have difficulty identifying and reporting the underlying reasons for over-consuming.

Puberty is a major transitional phase that includes considerable physiological as well as substantial psychological changes. Often, patients will report that their weight gain began at this age, attributing it to puberty alone. Children usually move from their primary school to their secondary school around this time, a demanding transition requiring a considerable ability to adjust and grow up. On occasion, this move is also associated with difficulties in the social arena, such as bullying.

These factors bring considerable stress, which may be responded to by the use of food. Food may be used to anaesthetise difficult and uncomfortable feelings and this may become the pattern for the future, eventually resulting in serious obesity.

Pregnancy is often a surface reason for a considerable weight increase; but it does not explain why the weight increase is sustained. I would propose that having children is a major transition from being independent, earning, and gaining status and meaning in the outside world, to one of learning the skills of mothering, no longer bringing in an income, change in a relationship with a partner, change in support networks, and a change in how one measures self-esteem. Therefore, it is not surprising that the mother turns to food to manage these anxieties. It is not the pregnancy or childbirth that is at the root of this, but the attempt to deal with the anxiety of these transitions.

Such patients need psychological support to enable them to recognise and manage these feelings, without the use of food, if they are to maintain a healthy weight in the long term. Diets and education alone are insufficient.

Anthropology shows us clearly that all cultures ritualise major transitions and use food, alcohol or drugs as an intrinsic part of this process. Transitions are a movement from one state to another that implies a phase of unstructured identity that inevitably arouses some degree of anxiety. This may be a transition from childhood to adulthood, as in the initiation ceremony or 21st birthday celebration; from being single to married marked by the wedding; the funeral signifying the transition from life to death, accompanied by the feast or wake. Many religious ceremonies have food as an essential part of their rituals; think of fasting over Ramadan, or the Christmas feast.

Food and drink in many of these circumstances serve a far more important function than merely satisfying hunger and dealing with anxiety alone. They denote acceptance in the group and belonging, and may even reflect social status. Acceptance in the social group affords identity, protection and belonging. To refuse food or be denied food, at some primitive level, could be experienced as life-threatening. Neurobiology is providing us with the scientific evidence to suggest humans not surprisingly still operate at this primitive level.

Most societies acknowledge various life-stage transitions, such as birth, christenings or naming ceremonies, bar mitzvahs, weddings and even death. Each of these rites of passage is associated with traditional food and drink. It could even be said that our current youth culture is attempting to ritualise their transition into adulthood by the use of drugs and alcohol.

Maybe this is why patients find it so challenging to stay with
their diet at these important times. It is not lack of motivation or willpower, but the greater need to manage anxiety and to belong within the protection of the group or family.

Each of us experiences many transitions throughout our normal day. Leaving home and going to work is a transition; and how many of us arrive at work carrying a cup of coffee or head immediately to put the kettle on? The time between the morning and the afternoon (called lunch) is a transition. Tea breaks are a transition, usually associated with food and drink.

Coming home from work is a transition; how many of us head straight for the fridge or bottle? Friday night is a transition from work to the weekend so often associated with a ”special meal”, even if it's only a takeaway. Entering the home from the public space is a transition. When we welcome guests through the threshold into our home, often the first phrase out of our mouth is, “Would you like a cup of tea?” These are the rituals of transitions on a daily basis.

Patients on a diet so often report that these transitions are the times they are most vulnerable to lapsing, and the times they habitually reach for food and alcohol without being aware of their real needs. I doubt if physical hunger is the most important factor involved here; managing anxiety and group belonging could be far more important than motivation, willpower or hunger.

Treatment and advice for the obese patient that does not take these factors into account is likely to be less effective than a holistic approach that includes substantial psychological understanding.