Several years ago, I treated hundreds of obese clients as a behavioral consultant to an internationally known hospital-based weight loss program. We applied the latest behavioral strategies, based on the research findings of prominent obesiologists and still ended up with an astronomically high failure rate. Although we could have predicted this on the basis of other program outcomes, we had hoped this program would succeed. The weight loss industry makes its profit off of hope. Without fully comprehending the profundity of genetics, my teammates and I worked arduously and endlessly to change what we didn't realize was the force of nature.

It is no accident that even authorities on weight loss struggle with their own weight daily. It is no accident that the foremost authority on learned optimism advises his readers to accept the realities of biology when it comes to changing your body (Seligman, 1993). The variance in weight accounted for by heredity is estimated to be between .34 -.70 (Brownell & Rodin, 1994; Vogler, Sorensen, Stunkard, Srinivasan, & Rao, 1995). Yet sadly, many of our female clients, then in their 50's and 60's, had spent most of their lives since adolescence trying to lose weight. Many told me they were only a few pounds overweight when they started their search for the "holy grail", fueled by a burning sense of self-dissatisfaction with their bodies. A pervasive body image dissatisfaction is widespread among American women (Cash, 1994; Williamson, Barker, Bertman, & Gleaves, 1995) The media is partly to blame. It promotes an unrealisticaly thin female image as the ideal, just as determine dly as it promotes junk food. It is estimated that children alone are bombarded with 10,000 junk food commercials a year (Azar, 1995), while at the same time viewing "butt-in-your-face" blue jean commercials--in size 3. If we were able to free ourselves from food obsessions, exercise compulsions, and self-loathing, we might really be able to mobilize our resources to help those who are severely and morbidly obese and in real danger of dying. This freedom from negativity based on unrealistic body shape goals must begin with the understanding that THERE IS NO CURE FOR OBESITY. If we accept this, then yo-yo (cycle) dieting might not be a word that everyone is intimate with. Binge-eating and other pathological eating disorders might never reach the proportions they remain at today. Most importantly, the disorder of obesity might finally be prevented. What is neglected, ironically, amidst all the media hype and diet-pushing best sellers is our only effective method in achieving strong fit bo dies in the realistic variations that nature intended. These are the simple, sound principles of proper nutrition and healthy levels of exercise and lifestyle activity. This information must be disseminated, even propagandized, in educational programs that target the prevention of obesity, which is our only hope. Prevention is the key to achieving the United States Year 2,000 weight goal objectives (Russell, Williamson, & Byers, 1995).

Determination to help eradicate obesity has prompted me to design a theoretical environment that necessarily generalizes far beyond the walls of a weight-loss class design. It addresses the issue of body dissatisfaction that often fuels the fires of obesity (not to mention eating disordered behavior),into adulthood. It is a comprehensive community plan designed to educate all families, not just those that could afford to pay thousands of dollars to a program such as the one I worked for. My environment is designed to promote what Kehle (1993) discusses under the acronym of RICH: resources, intimacy, competency and health. These qualities, he explains, have been derived from empirical data based on what mothers all over the world wish for their children, in order to live healthy, fulfilled and independent lives (Kehle). Prior to outlining my strategy, I will present some research issues currently surrounding the topic of obesity. An overview of obesity.

It is estimated that 34 million Americans are at risk of developing diabetes, hypertension, hypercholesterolemia, and certain cancers as a result of obesity (Aronne, 1989; Bray,1985). Obesity not only increases the risk of physical disease, but also affects our emotional well-being (Cash, 1994; Williamson, Barker, Bertman, & Gleaves, 1995) as well as our socio-economic status (Gortmaker, Must, Perrin, Sobol, & Dietz, 1993). A person is classified as obese when they exceed healthy amounts of bodyfat, currently accepted to be approximately 23 and 25% fat levels for men and women respectively (Aronne, 1989; Russell, Williamson, & Byers, 1995). The standard formula used to determine bodyfat is or body mass index (BMI) is weight in kilograms divided by height in meters squared. Bodyfat exceeding these levels pose real health risks---it is not simply a matter of appearance. Researchers claim that 5.5%-8% of all health care costs in the United States (39-52 billion dollars annually) are a result of obesity-related disease (Azar, 1994; Russell et al.,1995).

The etiology of obesity is heterogeneous, with genetics, certain lifestyle behaviors and social contingencies all contributing (Brownell & Wadden, 1991). Many adults gain weight in later years because metabolism typically declines along with their physical activity levels. Children are not immune to serious excess weight gain either. The issue of childrens' obesity is complicated by "growth, physical maturation, self-concept, peer relations and body image" (Brownell & Rodin, 1994). The proportion of overfat children in this country has been steadily increasing since the 1960's (Sarafino, 1990), a dismal proposition considering the failure rate among adults who attempt to lose weight.

Contrary to popular belief, physical abnormalities such as endocrine gland malfunction account only for a very small percentage of weight disorders (Sarafino,1990; Arrone,1989). Biological realities are what ultimately shape the degree to which our weight is behaviorally malleable (Brownell, 1991). Twin studies have demonstrated that whether identical twins are reared together or apart, they resemble their twin in weight in a much stronger correlation than that between fraternal twins (Stunkard, Foch, & Hrubec, 1986). In other adoption studies, children's obesity was most strongly correlated to their biological, not their adoptive parents' weight (Vogler et al., 1995). About seven percent of the offspring of normal-weight parents are obese, while children have a 40% chance of becoming obese if one of their biological parents is, and an 80% chance if both parents are obese (Mayer, 1980).

It is not known with certainty exactly how heredity affects our weight and predisposition toward obesity, but some of the theories include the set point concept, which means the body fights to maintain a certain weight. The hypothalamus may also affect weight by regulating the amount of insulin in the blood. Insulin is a hormone produced by the pancreas which speeds conversion of glucose to fat and promoting the storage of fat. Heredity may also determine the number of fat cells we acquire in life (we never lose fat cells, but there are certain times during physical changes when we can acquire them), making it much more difficult for those who acquire a higher number to maintain a healthy weight (Brownell, 1982). Or perhaps heredity influences metabolic rate which in turn influences our caloric expenditure.

Of course the environment helps to fulfill the genetic prophecy--if the bag of oreos are not in the cabinet, Mrs X, one of my clients, would not have binged on them in five minutes or less. Whether obese people are more sensitive to food cues (Schacter, 1971), or develop restrained eating patterns that encourage bingeing (Ruderman, 1986), we cannot deny the fact that the fast food industry exacerbates our dilemma. Brownell (1994) has even suggested a twinkie tax, which includes a regulation of fast food franchises and a heavy tax on fatty junk food.

Obesity and individual differences

Inactivity seems to be the norm of American life as we watch more television, play more video games and subject our children to staying close to the house, perhaps out of fear of child abduction (Davies, Gregory, & White, 1995). We have also become much more sedentary than our ancestors as vacuum cleaners now self-propel, and cars are utilized to mail a letter at the corner mailbox. The additive effects of a genetic predisposition, with an environment that encourages obesity, and weakens our ability to detect inconsistency between size 3 jeans and daily fast food hamburgers, makes for a self-deprecating, eating disordered, and increasingly obese society.

Few realize the shocking truth that obesity discriminates on the basis of gender. Gender differences in food intake and selection first appear as early as adolescence (Rolls et al., 1991). Women eat less calories and do so in a typically "feminine" way (small bites, etc.). They also experience a great deal more conflict over food and dissatisfaction over body weight than men do (Rolls, et al., 1991). Girls, by nature acquire more fat cells than boys, during adolescence. Hence while boys become more and more the ideal men as nature propels them to acquire lean mass, girls develop into less and less of what media has told us is the ideal woman. It is not surprising that overweight women complete fewer years of school than their normal weight peers, are 20% less likely to marry, and make 6,710 dollars less per year. Overweight men, in comparison are only 11% less likely to marry (Gortmaker, et al., 1993). Because of its visibility there is a real social disability that comes along with obesity (Stunkard

Data also indicates that while men overeat more in response to social situations, women overeat in response to emotion (Rolls, et al, 1991). Also, of those who have acquired eating disorders, only 10% are male, and they seem to have more "feminine" characteristics than their normal-weight cohorts. One plausible reason that these disorders favor women may involve seratonin levels that are affected by dieting in women, but not in men (Rolls et al, 1991). There is a 50% concordance rate for eating disorders among MZT, while only a seven percent concordance rate among DZT. The mortality rate of anorexia is between five and 20%, with another 25% living with chronic illness for the rest of their lives (Rolls).

Ethnic differences need to be researched further in the area of obesity. For example, in the African American population, an estimated 50% of females are obese (Azar, 1995; Russell et al., 1995). Society is the real gender discrimination on the basis of obesity. The lifetime quest of many women for the unrealistic is testimony to this assertion.

While we cannot modify genetics we can design a less discriminatory, more realistic environment with the potential to ultimately eradicate obesity. The focus is on education regarding the nature of obesity, realistic body image, health-promoting lifestyle behaviors for families and holding media and industry responsible for the promotion of anti-health promoting images and products.

The R.I.C.H. Environment

A R.I.C.H. environment (resources, intimacy, competency, health) helps individuals achieve their potential by freeing them of non-medically overweight obsessions, while individualizing obesity treatment for those who are medically at risk. Following are my suggestions toward that goal:

1. Through education we must come to an understanding about the potency of our genetic legacy regarding weight. In addition to accepting, even embracing the fate handed to us by our ancestor, we must hold media and industry responsible for following suit. We've got to encourage media exposure and popular acceptance of "blue jeans" in all sizes, not just size 3 or size big and beautiful; neither are the norm.

2. We must provide education that defines a level of overweight and obesity that is characterized by health risk, and makes a distinction between serious and slight overweight, which carries no known health risks until possibly one begins to yo-yo, or cycle diet (Lissner, Odell, D'Agostino, Stokes, Kreger, Belanger, & Brownell, 1991); a reaction to restrained eating patterns to begin with. If more accepted natural body shape diversity, we could focus our efforts on the real pathology as well as prevention.

3. Education that focuses on appropriate eating habits, good nutrition and an active lifestyle must be available to families of all income levels, for nothing beyond the cost of materials. An effort must be made to get pamphlets into maternity wards, pediatricians offices, school backpacks and supermarkets, to ensure that everyone has the knowledge necessary to promote body acceptance and prevent obesity as soon in life as possible. Note, I did not say information on weight loss or dieting. Health and fitness promoting behaviors for strong, disease-free bodies is the goal, not string bikinis or Mr. Olympia titles.

4. Industry and media must be held accountable and liable. Let's regulate the fast food franchises so that they're not on every corner. Force them to change the types of food they serve. Tax junk foods, which can be just as hazardous to our health as cigarettes and alcohol. Refuse to let advertisers cater to the unrealistically skinny model image that promotes eating-disordered behavior.

5. Require government to acknowledge and allow resources that address the obesity issue in this country.

6. Make medical treatment of obesity no more and no less covered by insurance than any other chronic disease.

7. Require obesity treatment centers to publicize their treatment effects (some diet programs are beginning to be required to do that now), and the credentials of their staff. People that have lost weight themselves are not authorities in the treatment of obesity.

8. Programs that treat obesity should respect the literature on gender and ethnic differences. Just at Brownell has envisioned a stepping program to fit the individual to the type of treatment most appropriate for them (Brownell & Wadden, 1991), the treatment itself should consider and capitalize upon individual differences research. For example women's treatment might be more heavily focused on emotional overeating, and men's on social situations based on such findings in the literature. Specially tailored programs could be designed for the African American female. All treatment should also acknowledge individual rates of weight loss. The focus should be on the active acquisition of behavioral and cognitive behavioral skills, not the passive, elusive numerical figure projected on the scale.

Conclusion

If we all join forces to promote healthful living we could put our hard-earned resources toward personal fulfillment in achieving out potential as individuals and as members of society. We would save millions of dollars spent currently on diet books and program memberships. We'd also have much more time to devote to enriching our lives and our communities if we didn't spend it on obsessing over our next meal, or camouflaging our pot bellies so that we can become Barbie or Ken look-alikes.

Intimacy would grow as the bullying and whispering that starts in childhood ceases to divide the fat and the skinny. When diversity of body type stops being shameful, the rift separates the heavier from the lighter ceases to exist. When we are comfortable with our bodies we are more assured in our movements and can appreciate others who are heavier too. We are more at ease in sexual relations and less a victim of eating disordered pathology. We can enjoy eating in social situations without fear of losing control and feeling guilty. If we know we "can" eat the whole box of oreos, we begin to stop wanting to.

As we gain momentum in our health-promoting behaviors of good nutrition and increased levels of exercise we will take more pride in our bodies generally, and are probably more likely to avoid other health-risks as well (smoking, alcohol comsumption, etc.).

As the focus of our energy shifts from weight obsession, we can focus on attaining competency in areas that fulfill our lives and help a community to sustain itself. I once had a client who spent more of her binge-eating during her work day, than developing competency in her area of work. Had she never developed the dieting mentality from being a harmless few pounds overweight as an adolescent, she might never have become severely obese as an adult, despite her genetics.

I end with a story about a little stout woman who was my mentor. Angelina D'Agostino was overweight by most standards, but not obese. It would have been difficult for this hard-working immigrant who maintained her own grape arbor and wine cellar, stuffed her own sausage, baked her own bread and ran her own meat market, to become severely obese. The overweight part, I don't even think occurred to her. This widow certainly didn't focus on looking like a model. She rarely came in contact with the pressures of the media to change her shape. She had a large family to feed and school. Binge eating a whole bag of oreos was not an issue she struggled with in her lifetime. She and her family ate healthfully, never used butter (only olive oil), drank homemade wine and never even heard of diet cola.

She had plenty of resources to raise and educate all of her children in a foreign land. Her kitchen was always like a quaint but bustling train station, with friends and family dropping in throughout the day to taste her sauce and lose themselves in Italian wisdom. She was an extremely competent business woman and a brilliant cook. She exercised daily, through her work (without joining a franchise gym), and lived a happy, positive life which extended well into her 80's. My grandmother was mentally and physically the fittest human being I have ever known.

There is a lesson we can learn from our ancestors if we pay attention. In doing so we may naturally come to acquire what our mothers from all parts of the world, have wanted for us all along.

References

Aronne, L. J., (1989). Present status of the management of obesity. Paper presented at St. Raphael's Hospital Conference on Obesity.

Azar, B. (1994). Mixed messages fuel dieting dilemmas. The APA Monitor, 25(11), 1.

Bray, G.A., (1985). Complications of Obesity. Annals of Internal Medicine, 103, 1052-1062.

Brownell, K.D., (1991). Personal responsibility and control over our bodies: when expectation exceeds reality. Health Psychology, 10(5), 303-310.

Brownell, K.D., (1993). Whether obesity should be treated. Health Psychology, 12(5), 339-341.

Brownell, K.D., & Rodin, J., (1994). The dieting maelstrom: is it possible and advisable to lose weight? American Psychologist, 49, 781-791.

Brownell, K.D., & Wadden, T.A., (1992). Etiology and treatment of obesity: understanding a serious, prevalent, and refractory disorder. Journal of Consulting and Clinical Psychology, 60, 505-517.

Brownell, K.D., & Wadden, T.A., (1991). The heterogeneity of obesity: fitting treatments to individuals. Behavior Therapy, 22, 153-177.

Cash, T.F., (1994). Body image and weight changes in a multisite comprehensive very-low-calorie diet program. Behavior Therapy, 25, 239-254.

Davies, P.S., Gregory, J., & White, A., (1995). Physical activity and body fatness in pre-school children. International Journal of Obesity, 19, 6-10.

Gortmaker, S.L., Must, A., Perrin, J.M., Sobol, A.M., & Dietz, W.H., (1993). Social and economic consequences of overweight in adolescence and young adulthood. The New England Journal of Medicine, 329, 1008-12.

Kehle, T. J., Clark, E., & Jenson, W. R. (1993). The development of testing as applied to school psychology. Journal of School Psychology, 31, 143-161.

Lissner, L., Odell, P. M., D'Agostino, R. B., Stokes, J., Kreger, B. E., Belanger, A.J., & Brownell, K.D., (1991). Variability of body weight and health outcomes in the framingham population. New England Journal of Medicine, 324, 1839-1844.

Mayer, J. (1980). The best diet is exercise. In P.J. Collipp (ed), Childhood Obesity (2nd ed). Littleton:PSG Publishing.

Rolls, B. J., Fedoroff, I. C., & Guthrie, J. F., (1991). Gender differences in eating behavior and body weight regulation. Health Psychology, 10(2), 133-142.

Ruderman, A.J. (1986). Dietary restraint: a theoretical and empirical review. Psychological Bulletin, 99, 247-262.

Russell, C. M., Williamson, D. F., & Byers, T. (1995). Can the year 2ooo objective for reducing overweight in the united states be reached?: a simulation study of the required changes in body weight. International Journal of Obesity, 19, 149-153.

Sarafino, E.P., (1990). Health Psychology: bosocial interactions. New York: John Wiley & Sons.

Seligman, M. E. P., (1993). What you can change...and what you can't. Ney York: Fawcett Columbine.

Schacter, S. (1971). Some extraordinary facts about obese humans and rats. American Psychologist, 26, 129-144.

Stunkard, A.J., Foch, T. T., & Hrubec, Z,(1986). Atwin study of human obesity. Journal of the American Medical Association, 256, 51-54.

Stundard, A.J., & Sorensen, T.I. (1993). Obesity and socioeconomic status: a complex relation. The New England Journal of Medicine, 329(14), 1036-1037.

Vogler, G. P., Sorensen, T. I., Stunkard, A. J., Srinivasan, M.R., & Rao, D. C., (1995). Influences of genes and shared family environment on adult body mass index assessed in an adoption study by a comprehensive path model. International Journal of Obesity, 19, 40-45.

Wadden, T.A., & Stundard, A.J., (1985). Social and psychological consequences of obesity. Annals of Internal Medicine, 103, 1062-1066.

Williamson, D. A., Barker, S. E., Bertman, L.J., & Gleaves, D. H., (1995). Body image, body dysphoria and dietary restraint: factor structure in nonclinical subjects. Behavioral Research and Therapy, 33, 85-93.