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Behaviour Research and Therapy 42 (2004) 13411356

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Psychological predictors of weight regain in obesity


Susan M. Byrne , Zafra Cooper, Christopher G. Fairburn
Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford OX3 7JX, UK
Received 9 March 2003; received in revised form 8 September 2003; accepted 16 September 2003

Abstract
It is a consistent nding that, among obese patients, the weight lost as a result of the most widely
available treatments for obesity is almost always regained. This relapse appears to be attributable to the
individuals inability to persist with the behavioural strategies needed to maintain the new lower weight.
Little research has investigated the psychological mechanisms that might account for this phenomenon.
This study aimed to identify psychological factors that predict weight regain. Fifty-four women with
obesity who had lost weight by attending community slimming clubs were interviewed immediately after
losing 10% of their initial body weight, and then followed-up every 2 months for a period of 1 year by
means of telephone interviews. The results identied two prospective predictors of weight regain: one
cognitive factor (dichotomous thinking) and one historical variable (maximum lifetime weight). The nding that a specic cognitive style is a signicant predictor of relapse has implications for the treatment of
obesity.
# 2003 Elsevier Ltd. All rights reserved.
Keywords: Obesity; Weight maintenance; Weight regain; Psychological factors; Dichotomous thinking

1. Introduction
Obesity is a major public health problem, and currently there are no satisfactory treatments
for it. Anti-obesity drugs, such as orlistat and sibutramine, produce modest weight loss, but
weight regain is common when treatment is discontinued (Aronne, 2002; Hollander et al., 1998;
Sjostrom et al., 1998). Surgery is reserved for only a small proportion of severely obese people
(Balsiger, Murr, Poggio, & Sarr, 2000; Kral, 1998). The most widely available treatment for


Corresponding author. Psychology Department, University of Western Australia, Nedlands, WA 6009, Australia.
Tel.: +61-8-9380-3579; fax: +61-8-9380-2655.
E-mail address: sbyrne@psy.uwa.edu.au (S.M. Byrne).
0005-7967/$ - see front matter # 2003 Elsevier Ltd. All rights reserved.
doi:10.1016/j.brat.2003.09.004

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obesity is psychological (behavioural) treatment. A large number of treatment outcome studies


have shown behavioural treatment to produce clinically signicant weight loss in the region of
510% of initial body weight (Wing, 1998). However, research is consistent in indicating that
the weight lost as a result of this type of treatment is almost always regained, with about half of
the weight lost being regained in the rst year following treatment and weight regain continuing
thereafter (Wadden, Sternberg, Letizia, Stunkard, & Foster, 1989). By 35 years post-treatment,
the majority of patients (about 85%) have returned to, or even exceeded, their pre-treatment
weight (e.g., Jeery et al., 2000; Kramer, Jeery, Forster, & Snell, 1989; Stalonas, Perri, & Kerzner,
1984; Wadden & Frey, 1997; Wadden et al., 1989; Walsh & Flynn, 1995).
In order to improve the long-term outcome of treatments for obesity, it is important to
understand why most people who lose weight regain it. Clinical experience suggests that relapse
in obesity is often attributable to individuals inability to persist with the weight-control behaviours that they adopted to achieve weight loss (Cooper & Fairburn, 2002; Perri & Corsica, 2002;
Wilson & Brownell, 2002), such as eating a low-fat diet, taking regular exercise and monitoring
any changes in their weight (Wing & Hill, 2001). However, little research has been carried out
on the psychological mechanisms that may account for this phenomenon. While prospective
studies of patients who have participated in clinical treatment trials for obesity and data generated by the American National Weight Control Registry (Wing & Hill, 2001) have been consistent in identifying specic behaviours that are associated with successful weight maintenance,
little information has been obtained regarding the actual psychological factors which determine
whether or not patients continue to practice these behaviours. It is not clear how or why a small
proportion of individuals are able to persist with these behaviours when most people do not.
The present study was designed to investigate psychological predictors of weight maintenance
and relapse in obesity. A number of psychological factors that appeared to be involved in
weight regain had been identied in a prior qualitative study which used in-depth interviews to
assess the characteristics of successful weight maintainers, as compared with weight regainers
and with stable healthy-weight participants (Byrne, Cooper, & Fairburn, 2003). These factors
included the failure to achieve weight goals, dissatisfaction with the weight achieved, the tendency to judge self-worth in terms of weight and shape, a lack of vigilance with regard to weight
control, a dichotomous thinking style, and the tendency to use eating to regulate mood, to
avoid negative aect or to cope with adverse life events. The present study used quantitative
research methods to test these factors, prospectively, in a community sample of women who had
recently lost weight.

2. Method
2.1. Design
The study took the form of a prospective cohort study, following-up formerly obese women
who had recently lost at least 10% of their body weight. These participants underwent a series
of semi-structured interviews over a period of 1 year.

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2.2. Participants

Aim

2.2.1. Recruitment
Permission to recruit members of community slimming classes was obtained from two major
slimming organizations in the UK. Both of these slimming organizations advocate the use of
some standard behavioural weight loss procedures. Members who attend their slimming classes
weigh in on arrival and record their weight. This is followed by a brief group meeting, dealing with topics such as keeping a food diary, or eating out, run by a trained leader (who
has often previously attended classes as a member).
The rst author attended weekly meetings of every slimming class run by these two organizations in Oxfordshire over a period of 5 months (29 classes in total). At each meeting, the
study was described to class members, and the aims of the study (i.e., to nd out about more
about long-term weight control and, particularly, to nd out why people tend to regain weight
that they have lost) were made explicit. Eligible women (those between the ages of 20 and 60
years with a body mass index (BMI) of 30.0 kg/m2 or more, and who had started attending
their slimming class within the last 4 weeks) were invited to participate. One hundred and
twenty-six out of a possible 232 women (54%) volunteered to take part.
Upon recruitment, every participant was provided by the rst author with a specic target
weight representing a 10% weight loss from their initial body weight (dened as their weight
on their rst weigh in at the slimming club) and was asked to contact her once they had
reached this weight. Participants were telephoned every month to check on their progress (if
they had not contacted the researcher in the meantime). If the participant reported having
achieved 10% weight loss, informed consent was obtained, and a time was scheduled for a faceto-face interview.
2.2.2. Sample
The initial sample of 126 volunteers had a mean age of 40.5 years (SD 12:75), and a mean
weight of 95.44 kg (BMI 37:31 kg=m2 ). Fifty-four (43%) succeeded in losing 10% of their
initial weight within the 1 year recruitment time frame. One of these participants was excluded
because it was discovered that her weight loss could have been due to a medical condition
rather than solely due to deliberate weight control. The mean age of the remaining 53 women
was 42.51 (SD 10:12) years. Over three quarters (78%) were married, and 70% had at least
one child. The majority belonged to social class II (38%), followed by social class III-nm (21%)
and social class III-m (13%) (Standard Occupational Classication; Oce of Population Censuses and Surveys, 1995). All of the women were Caucasian.1
1

The 72 participants who failed to lose 10% of their initial weight in time to take part in the study were followedup by post three times over the 12 month follow-up period and asked to complete a short questionnaire. Sixty of
these participants (83%) responded to all three of the questionnaires. These 60 women had a mean weight of 94.91 kg
(mean BMI 37:07 kg=m2 ) when they originally volunteered for the study. At the 12 month follow-up, 22% (n 13)
of these women had since gained more than 3.2 kg (range 3:21 12:05 kg); 33% (n 13) had maintained a relatively
stable weight (ranging from a loss of 3.2 kg to a gain of 3.2 kg); and 45% (n 27) had lost more than 3.2 kg
(range 3:4 20:8 kg).

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2.3. Procedure
Each participant took part in an individual face-to-face interview within 2 weeks of achieving
10% weight loss. These interviews took place in participants homes, and lasted 6090 min. Participants were then followed-up every 2 months for 1 year by telephone interviews. Each telephone interview took about 20 min to complete.
2.4. Measures
2.4.1. Initial face-to-face interview
The initial interview was made up of three sections.
1. Section 1 involved obtaining demographic information, current weight details, and a history
of the participants weight problems, including onset of obesity, family history of obesity,
number and outcome of previous weight loss attempts, and history of an eating disorder. A
10% weight loss was conrmed by checking the participants slimming class record card
(which showed measured weights taken in class), or, in the case of those who had stopped
attending their slimming class by the time of the initial interview, by weighing on the
researchers scales (SECA 761 Dial Personal Scales). History of an eating disorder was
assessed using the diagnostic items from the Eating Disorder Examination (EDE; Fairburn &
Cooper, 1993), assessed over the participants lifetime and in accordance with the Diagnostic
and Statistical Manualfourth edition (DSM-IV) of the American Psychiatric Association
(1994).
2. Section 2 focused on behaviours that have been associated with successful weight maintenance: dietary intake, activity level and weight monitoring. Dietary intake was assessed using
the Leeds Food Frequency Questionnaire (FFQ; Margetts, Cade, & Osmond, 1989), a selfreport questionnaire designed primarily to assess dietary fat intake. Activity level was assessed
by assisting participants to calculate the total number of hours over the past 4 weeks that they
had been engaged in sedentary behaviour (such as lying in bed awake, eating or reading while
sitting down, desk work, watching television); lifestyle activity (such as housework, shopping,
gardening, stair climbing); formal exercise (e.g., jogging, swimming, working out at the gym),
and walking with the intention of exercising. Weight monitoring behaviour was assessed by
recording the number of times participants had weighed themselves over the past 4 weeks; and
by asking how often they had checked their body shape over the past 4 weeks (by looking in
mirrors, assessing the tightness of specic clothes, or measuring themselves).
3. The third section addressed the psychological factors implicated in adherence to the forms of
behaviour assessed in Section 2. This section consisted of a series of questions, which focused
on those factors identied in the prior qualitative study. Participants were asked to respond
in relation to their thoughts, feelings and behaviour over the past 4 weeks, and their
responses to each question were coded by the researcher using a 46 point scale.
4. Participants also completed a Dichotomous Thinking Scale (DTS) which was designed
specically for the purposes of this study. This was a short self-report questionnaire consisting of 16 items in the form of a 4-point Likert-type scale (not at all true of me to very
true of me). It contained two types of itemssix items pertaining specically to food, eat-

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ing, dieting and weight, for example; I view my attempts to diet as either successes or failures; and 10 items pertaining to more general issues such as; Even if I dont do a job very
well, I still think it is worth doing. The DTS was developed after detailed examination of
items that appeared to reect the construct of dichotomous thinking included in the following scales: the Dysfunctional Attitude Scale (DAS; Beck, Brown, Steer, & Weissman, 1991;
Weissman, 1979); several perfectionism scales (Burns, 1980; Frost, Marten, Lahart, & Rosenblate, 1990; Garner, Olmstead, & Polivy, 1983; Hewitt & Flett, 1991); and two Tolerance of
Ambiguity Scales (Budner, 1962; MacDonald, 1970). However, none of the items included in
the DTS replicated items from these existing measures. A total of 24 items were initially
developed (11 relating specically to food, eating and weight, and 13 more general items),
and these were reduced to 16 items after piloting the DTS on obese women participating in a
clinical treatment trial. Four items were reverse coded. The DTS was scored by assigning a
value of 14 to each response, with a score of 4 corresponding to the most extreme dichotomous response for each item. This scoring method resulted in a total score ranging from a
possible minimum of 16 to a possible maximum of 64, with higher scores indicating a greater
degree of dichotomous thinking.
The DTS was found to have satisfactory internal consistency (alpha 0:81). In addition,
when considered as two separate subscales, the six items relating specically to food, eating
and weight, and the 10 more general items were both found to have satisfactory internal consistency (alpha 0:67 and 0.75, respectively).
2.4.2. Follow-up interviews
The follow-up interviews, although conducted over the telephone, were almost identical in
content to the initial interview, with the following exceptions: (1) it was not necessary to retake
participants weight history; (2) the DTS was completed at the initial interview only; (3) participants were asked to respond to the questions based on an 8-week rather than a 4-week time
frame; (4) during the follow-up period, the Leeds FFQ was posted out to participants 1 week
prior to their scheduled follow-up interview and participants were asked to complete the survey
and return it to the researcher before the scheduled telephone interview; (5) participants were
asked to report their current weight at each follow-up interview as well as the number of times
in the last 8 weeks that they had attended their slimming class.
2.5. Statistical analysis
For comparisons involving more than two groups, one-way analyses of variance were used for
continuous dependent variables. For comparisons involving two groups, t-tests for two independent samples were used for continuous dependent variables and MannWhitney U-tests were
used for ordinal dependent variables. Chi-square analyses were used for all comparisons involving
categorical data. Because of the number of analyses, only results with a p value less than or equal
to 0.01 were considered statistically signicant. The distributions of all continuous dependent variables were examined prior to analysis and found to be adequately normally distributed. A logistic
regression analysis was used to identify factors which signicantly predicted which participants
were classied as weight regainers, as opposed to weight maintainers, at 1-year follow-up.

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3. Results
Fifty of the 53 participants (94%) completed all the follow-up interviews (two women became
pregnant during the follow-up period and were withdrawn, and one participant emigrated to
another country). These 50 women had a mean initial weight of 96.08 kg (SD 18:63,
range 68:5 150:1 kg), which corresponded to a mean BMI of 37.55 kg/m2 (SD 6:58). This
had been the rst weight loss attempt for 16% of these participants, but 66% had tried (and
failed) to maintain a new lower weight on 15 previous occasions, 6% had made between 5 and
10 previous weight loss attempts, and 12% had tried to lose weight on more than 10 occasions
in the past. Almost one quarter (22%, n 11) reported a history of an eating disorder, most
commonly binge eating disorder (BED) (16%, n 8), although 4% (n 2) reported a history of
bulimia nervosa and one participant reported a history of both anorexia nervosa and bulimia
nervosa. Nearly three quarters (70%) reported a family history of obesity, with 32% reporting
one obese parent and 38% reporting two obese parents.
During their most recent weight loss attempt, the participants succeeded in losing an average
of 14.07 kg (range 6:8 45:3 kg) or 14.6% of their initial body weight (range 10 38%) over a
period of 8.44 months (SD 6:5 months), reducing their body weight to an average of 82 kg
(BMI 32:07). Nevertheless, this weight loss fell far short of their desired weight loss. Their
mean desired weight was 68.66 kg (SD 8:34 kg; range 52 98 kg), which would have
required a weight loss of 27% of their initial body weight (range 11 48%) or an average
weight loss of 27.41 kg (range 7:50 67:60 kg). So, on average, participants achieved about
half the weight loss that they had originally desired.
3.1. Weight trajectories
There was a large degree of variation with regard to weight change over the 12-month followup period, ranging from a further weight loss of 18.2 kg to a weight gain of 25.4 kg. Participants were classied into three groups according to their weight trajectories over the follow-up
period. Forty-two percent (n 21) succeeded in maintaining their new lower weight (i.e., their
weight on entry to the study) to within 3.2 kg (or half a stone) at the 12-month follow-up, and
were classied as Maintainers.2 At the 12-month follow-up assessment, Maintainers weighed, on
average, 0.25 kg less than their post-weight loss (baseline) weight (range 3:0 to 2:8 kg).
Forty percent of participants (n 20) had regained more than 3.2 kg at 1-year follow-up and
were classied as Regainers. Over the year, Regainers had regained an average of 11.1 kg
(range 3:8 25:4 kg)nearly three quarters of the weight that they had lost (71.5% regain; ran
ge 31 116% regain). A third small group of participants (n 9; or 18% of all cases) continued
to lose weight (more than 3.2 kg) over the follow-up period. These participants lost, on average,
a further 9.59 kg (8.26% further weight loss; range 4:3 to  18:2 kg, or 614% further
weight loss). Fig. 1 shows the average weight trajectories of these three groups from initial (preweight loss) weight to 12 month follow-up. Table 1 presents the weight details of participants in
each of the three groups.
2

This range (3.2 kg) was decided upon both to discriminate between mere weight uctuation and weight regain,
and to ensure a clear demarcation between Maintainers and Regainers.

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Fig. 1. Weight trajectories of the three groups of participants over the follow-up.

It can be seen from Table 1 that the participants who continued to lose weight (the Reducers)
had the highest maximum lifetime weight and the highest initial weight, and (post-weight loss)
they remained the furthest from their goal weight. These participants were also the most likely
to have reported an early onset of obesity (during childhood or adolescence) and the most likely
to have reported a history of an eating disorder.
3.2. Comparisons between Maintainers and Regainers
3.2.1. Baseline characteristics
3.2.1.1. Weight history. Regainers and Maintainers diered signicantly with regard to several
aspects of their weight histories. Regainers had a higher maximum lifetime weight (and BMI)
than Maintainers, t 39 3:125, p 0:004. They also had a higher initial weight than Maintainers, t 39 3:02, p 0:005, although both groups lost the same percentage of initial
body weight (15%) over about the same time period (about 9 months). Both groups also had
similar goal weights (69 vs. 66 kg). This meant, however, that the Regainers originally desired a
greater weight loss than Maintainers (30% vs. 22%), t 39 2:97, p 0:005, and were further
from their goal weight after weight loss (discrepancy score 16:08 vs. 6.48 kg), t 39 2:75,
p 0:009. There was a trend for Regainers to be more likely than Maintainers to report an
early onset of obesity, v2 1 4:79, p 0:03, and a history of an eating disorder, v2 1 2:78,
p 0:09. The majority of participants in both groups reported a family history of obesity,
v2 1 1:64, p 0:20.
3.2.1.2. Behavioural factors. At the initial assessment, there were no signicant dierences
between the two groups with regard to reported dietary fat intake, activity level, or the frequency of weighing or shape checking, and both groups reported similar responses to any

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Table 1
Weight details (means and standard deviations) and weight history of participants in each group

Highest lifetime weight (kg)


Highest lifetime BMI (kg/m2)
Initial weight (kg)
Initial BMI
Goal weight (kg)
Desired weight loss (%)
New lower weight (kg)c
New lower BMIc
Percent weight loss achieved
Discrepancy between goal weight
and weight achieved (kg)
Months taken to lose weight
Weight at one year follow-up (kg)
BMI at 1 year follow-up
Number of previous weight loss
attempts
Onset of obesityd
Childhood or adolescence
Adulthood
History of an eating disorder
None
Anorexia nervosa (AN)
Bulimia nervosa (BN)
AN and BN
Binge eating disorder
Any eating disorder
Family history of obesity
None
One parent
Both parents

Maintainers
(N 21)

Regainers
(N 20)

Reducers
(N 9)

F value

p value

87.22a (14.81)
34.36a (5.45)
85.72a(13.34)
33.84a (4.58)
66.09 (6.01)
22%a
72.56a (10.15)
28.69a (4.00)
15%
6.48a (18.54)

103.04b (16.36)
39.83b (6.52)
100.57b (17.7)
38.86 (6.74)
69.45 (6.58)
30%
85.54b (16.86)
33.07a (6.60)
15%
16.08 (13.94)

114.59b (22.75)
44.96b (6.74)
111.30b (20.34)
43.71b (6.74)
73.22 (14.25)
33%b
97.20b (19.64)
38.15b (6.58)
13%
23.98b (18.54)

8.47
8.81
8.32
8.76
2.37
5.35
8.71
8.59
0.50
6.42

0.001
0.001
0.001
0.001
0.106
0.008
0.001
0.001
0.610
0.004

8.90 (5.23)
72.34a (10.19)
28.62a (4.00)
3.20 (3.56)

9.10 (8.65)
96.62b (18.73)
37.33b (7.31)
4.37 (4.98)

5.69 (1.53)
87.61b (15.64)
34.42b (5.17)
5.38 (6.50)

0.854
12.86
11.41
0.723

0.432
0.000
0.000
0.491

14%
86%

45%
55%

67%
33%

91%
0%
0%
0%
9%
9% (n 2)

70%
0%
10%
5%
15%
30% (n 6)

67%
0%
0%
0%
33%
33% (n 3)

38%
24%
38%

20%
35%
45%

22%
56%
22%

Note: Means with dierent superscripts dier signicantly at p < 0:01. Standard deviations are shown in brackets. 0
c
New lower weight and new lower BMI weight and BMI at the initial interview.
d 2
v 12 7:32, p 0:03 trend toward Regainers and Losers being more likely than Maintainers to report a childhood onset of obesity.

detected weight gain at this point. These ndings were expected, since all participants in both
groups had been losing weight immediately prior to the interview, and (following instructions
from their slimming clubs) many participants were aiming to continue to lose weight.
3.2.1.3. Psychological factors. Apart from the discrepancy between goal weight and achieved
weight (mentioned earlier), the only psychological variable which signicantly discriminated
between the two groups was dichotomous thinking, with Regainers showing signicantly higher
scores than Maintainers on the total DTS score (mean scores 43:63 and 33.80, respectively),

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Table 2
Mean ranks (or scores) of each psychological factor assessed at baseline for Maintainers and Regainers
Psychological variable

Discrepancy between goal weight and weight


achieved (kg)a,
Satisfaction with weight achieved
Extent to which achieved primary goal 1
Extent to which achieved primary goal 2
Extent to which achieved primary goal 3
Importance of shape and weight for selfevaluation
Negative self-evaluation due to shape and weight
Prioritising weight control
Vigilance
Perception of deprivation
Perception of dietary restraint
Perceived eort
Eort vs. benet payo
Self-ecacy
Comfort eating
Avoidance eating
Adverse life events
Dichotomous thinking: total scorea,
Dichotomous thinking: food and weight-related
itemsa,
Dichotomous thinking: general dichotomous
thinking itemsa,
a


Maintainers
(N 21)

Regainers
(N 20)

Mean rank
or score

Mean rank
or score

6.48
(SD 6:94)
22.92
22.40
18.19
10.36
17.40

16.08
(SD 13:94)
16.92
17.47
17.79
8.95
22.74

19.25
17.73
20.25
22.00
19.35
18.35
19.30
18.63
20.23
21.40
20.27
33.80
(SD 7:13)
16.30
(SD 3:55)
19.85
(SD 5:12)

20.79
22.39
19.74
17.89
20.68
21.74
19.72
21.45
19.76
18.53
19.71
43.63
(SD 6:88)
19.53
(SD 2:99)
26.74
(SD 5:19)

MWU
(or t) value

p value

2.747

0.009

131.50
142.00
149.50
32.50
138.00

0.09
0.14
0.90
0.55
0.13

175.00
144.50
185.00
150.00
177.00
157.00
171.00
162.50
185.50
162.00
184.50
4.38

0.67
0.18
0.88
0.23
0.71
0.30
0.89
0.42
0.89
0.41
0.86
0.00

3.06

0.004

4.17

0.000

Indicates comparisons using t-tests for independent samples, showing mean score (SD), and t value.
Indicates groups signicantly dierent at p<0.01.

t 39 4:38, p < 0:001. In addition, Regainers showed signicantly higher scores than Maintainers on the two DTS subscalesthe six items relating specically to food and weight,
t 39 3:06, p 0:004, and the 10 items relating to a general tendency to think dichotomously, t 39 4:17, p < 0:001 (Table 2).
3.2.2. Prospective predictors of weight regain
All variables that signicantly discriminated between the two groups at baseline were entered
into a logistic regression model. Those variables yielding a p value of less than 0.2 were also
entered into the model, in accord with Altmans (1991) guidelines. DTS entered the model on
the rst step, v2 1 12:33, p 0:0004, followed by maximum lifetime weight, v2 1 4:61,
p 0:03. No other variables entered the equation (see Table 3). There was no signicant interaction eect, v2 1 1:59, p 0:207, indicating that the combined eect of these variables was
an additive one.

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Table 3
Variables entering the logistic regression model
Variable

SE

Signicance level (p)

Exp (B)

Dichotomous thinking
Maximum lifetime weight
Constant

0.179
0.067
13.320

0.067
0.033
4.390

0.008
0.043
0.002

1.196
1.069

When this analysis was repeated substituting the two DTS subscales for the total DTS
score, the score on the 10 items relating to a general tendency to think dichotomously entered
on the rst step, v2 1 13:15, p 0:0003, followed once again by maximum lifetime weight,
v2 1 4:12, p 0:04. No other variables entered the equation.
3.2.3. Other factors associated with weight regain
In a secondary analysis, the responses of each Regainer, recorded at the assessment point just
before she began to regain weight, were compared to the responses of a Maintainer at the same
time-point. The aim of this analysis was to try to identify any dierences between the two
groups of participants at this critical point just before the Regainers began to regain weight. In
order to investigate this possibility, the individual weight trajectory of each Regainer was examined separately, to identify the time-point at which her weight had increased by 3.2 kg or more
from baseline. Then her responses to the follow-up assessment immediately prior to that timepoint were isolated, and these scores were matched to the responses of a Maintainer (selected
using random number tables) at the same assessment point. The data were recoded so that overall comparisons could be made between the responses of the Maintainers and Regainers regardless of the actual time-point yielding the data.
Maintainer and Regainers diered signicantly on three variables in this matched-comparison
analysis (see Table 4). Firstly, at the assessment point immediately prior to signicant weight
regain, Regainers reported signicantly more weight change (in the direction of weight gain) over
the previous 8 weeks than Maintainers over a similar time period, t 39 4:85, p < 0:001, who
showed a slight weight change in the opposite direction. Secondly, compared to Maintainers,
Regainers reported that they felt less satised with their weight and shape than Maintainers,
M WU 89:50, p 0:01, and there was a trend toward a greater discrepancy between goal
weight and current weight for Regainers than for Maintainers, t 39 2:32, p 0:03. Thirdly,
over the 8 weeks immediately prior to weight regain, Regainers reported having assigned a lower
priority to weight control than had the Maintainers, M WU 92:00, p 0:01.
4. Discussion
The main aim of this study was to identify psychological predictors of weight regain in obesity. Two factors measured at baseline (i.e., immediately after weight loss) were identied as signicant predictors of weight regain at one-year follow-up: one was a current cognitive factor
(dichotomous thinking), and one was a historical variable (maximum lifetime weight).
The most powerful predictor of weight regain was dichotomous thinkingwith a greater
degree of dichotomous thinking at the time of at least 10% weight loss, signicantly predicting

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1351

Table 4
Matched-comparison analysis: mean ranks (or mean scores) of each variable for Maintainers and Regainers
Variable
Mean score (SD), or mean rank
Behavioural factors
Daily calorie intakea
Percent of calories from fata
Sedentary behaviour (h)a
Lifestyle activity
Formal exercise (h)a
Walkinga (h)
Weighing (occasions)a
Checking (days)a
Weight change (kg)
Attendance at slimming club (occasions)a
Objective binge eating (episodes)a
Psychological factors
Discrepancy between goal weight and
current weight (kg)a
Satisfaction with weight
Achievement of primary goals
Importance of weight and shape
Negative evaluation due to weight and
shape
Prioritizing weight control
Vigilance
Perception of deprivation
Perception of dietary restraint
Eort
Eort vs. benets
Self-ecacy
Signicant adverse life events
Comfort eating (episodes)
Avoidance eating (episodes)
a


Maintainers
(N 21)

Regainers
(N 20)

t value or MW U p value
value

1677.00
(SD 141:6)
28.39 (SD 4:4)
310.10 (115.93)
20.21
19 (23.53)
13.16 (14.61)
16.79 (18.26)
10.53 (31.18)
0.90 (1.59)
6.63 (2.43)
0.37 (1.38)

1549.00
0.255
(SD 313:3)
26.57 (SD 8:9)
1.10
294.35 (139.29)
0.370
16.59
129.00
13.97 (16.21)
0.753
6.5 (13.28)
1.45
11.29 (13.49)
1.02
1.93 (7.22)
1.04
1.51 (1.32)
4.85
4.17 (3.62)
2.42
1.88 (4.53)
1.28

4.48 (6.18)

13.11 (14.19)

2.32

0.030

23.29
22.29
18.32
15.82

14.47
14.26
18.71
22.36

89.50
89.50
158.00
110.50

0.010
0.021
0.925
0.066

23.16
21.45
19.58
19.55
17.92
16.41
8.94
16.90
19.95
19.98

14.61
15.21
17.29
17.21
19.15
14.31
9.06
21.47
20.05
20.03

92.00
105.50
141.00
141.50
150.50
95.00
35.50
128.00
189.00
189.50

0.010
0.076
0.531
0.531
0.731
0.536
0.963
0.209
0.989
0.731

0.680
0.413
0.714
0.315
0.457
0.157
0.317
0.305
0.000
0.022
0.217

Indicates comparisons using t-tests for independent samples, showing mean score (SD), and t value.
Indicates groups signicantly dierent at p < 0:01.

weight regain at 1-year follow-up. Moreover, the results suggested that it was a general dichotomous thinking style, rather than dichotomous cognitions relating specically to food, weight
and eating, which was the key predictor. Dichotomous thinking has not been previously linked
to the problem of weight regain in obesity. Although in a recent study, Teasdale et al. (2001)
identied a dichotomous cognitive style as a signicant predictor of relapse in depression.
The second factor to signicantly predict weight regain was maximum lifetime weight. Participants who had a higher maximum weight were more likely to regain weight than those with a
lower maximum weight. This nding is consistent with the results of several earlier studies

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(Foster, Wadden, Vogt, & Brewer, 1997; McGuire, Wing, Klem, Lang, & Hill, 1999; Pasman,
Saris, & Westerterp-Plantenga, 1999) which have also found a higher maximum lifetime weight to
be associated with weight regain. A history of a high maximum weight may be a consequence of a
variety of physiological or psychological processes. For example, it could reect a biological vulnerability to gain weight that predisposes some individuals to weight regain following weight loss,
or it might reect an established pattern of overeating in response to environmental stimuli.
No interaction was found between dichotomous thinking and maximum lifetime weight, so
their eect on weight regain was independent and additive. Thus, although a dichotomous
thinking style was shown to be the most important single predictor of weight regain, a dichotomous thinking style and a high maximum lifetime weight both increase the risk of relapse.
Dichotomous thinking and maximum weight were the only factors, of those tested, to be
identied as prospective predictors of weight regain. However, three additional factors were
found to be associated with weight regain in a secondary analysis involving a matched comparison between the responses of Regainers, recorded during the critical period immediately prior to
weight regain, and Maintainers (at the same point). Compared to Maintainers, Regainers were
more dissatised with their weight and less likely to perceive that they had achieved their goal
weight; less vigilant with regard to weight control; and more likely to be showing evidence of
weight uctuations (in the direction of weight gain). These same factors have been linked with
weight regain in several previous studies (Colvin & Olson, 1983; Ferguson, Brink, Wood, &
Koop, 1992; Jeery et al., 1984; Marston & Criss, 1984; McGuire et al., 1999; Poston et al.,
1999; Westerterp-Plantenga, Kempen, & Saris, 1999).
It should also be noted that while the matched-comparison analysis found no signicant differences between the physical activity patterns of Maintainers and Regainers, this may be
attributable to the small sample size and relative lack of statistical power. For example, during
the period immediately prior to the start of their weight regain, Regainers reported less than
half the number of hours of walking than Maintainers (6.5 vs. 13.16 h, p 0:16; see Table 4).
With a larger sample size, this dierence may have reached statistical signicance. Other studies
have found signicant exercise dierences for Regainers vs. Maintainers (e.g., Wing & Hill,
2001). This caution may also apply to the other between-group dierences involving behavioural
factors that failed to achieve statistical signicance in this study.
The results of the present study suggest that psychological factors may, at least partly,
account for some individuals lack of persistence with weight maintenance behaviours following
successful weight loss. One cognitive factor, in particular (dichotomous thinking) appears to
play a prominent role in this process. Dichotomous thinking is a form of cognitive rigidity
whereby individuals tend to place all experiences in one of two opposite categories (Beck,
Rush, Shaw, & Emery, 1979, p. 14), instead of on a continuum. The attitude If Im not a total
success, Im a failure is an example. This style of absolutist, categorical, all-or-nothing
thinking is one of a range of cognitive distortions that have been associated with psychological
disorders such as depression (Beck, 1976; Beck et al., 1979), anxiety (Clark, 1986), bulimia nervosa (Fairburn, 1985), anorexia nervosa (Garner & Bemis, 1982) and borderline personality disorder (Linehan, 1993; Sheeld et al., 1999). Dichotomous thinking, specically, has been found
to be characteristic of suicidal persons (Litinsky & Haslam, 1998; Neuringer, 1961, 1967, 1968;
Neuringer & Lettieri, 1971) and has been linked to problem-solving decits (Weishaar, 1996),
interpersonal problems (Linehan, Chiles, Egan, Devine, & Laaw, 1986), the perception of

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1353

stress (Mraz & Runco, 1994; Rotheram-Borus, Trautman, Dopkins, & Shrout, 1990), chronic
pain (Dyck & Agar-Wilson, 1997) and aggressive behaviour (Eckhardt & Kassinove, 1998).
How might dichotomous thinking contribute to weight regain in obesity? One possibility may
relate to whether or not an individuals expectations about weight loss have been met, including
the achievement of weight goals and the degree of satisfaction with the weight achieved. Individuals with a dichotomous thinking style may be more likely than those with a more exible
cognitive style to interpret falling short of their goal weight as evidence of a total failure, and to
consider the weight loss that they have achieved to be inadequate and unsatisfactory. As
Cooper and Fairburn (2001, 2002) have noted, under such circumstances it is unlikely that such
individuals will be motivated to work at maintaining a weight that they do not consider to be
worthwhile. This, in turn, may lead to the abandonment of any eorts toward weight maintenance or further weight loss, particularly in those who tend to judge their actions in dichotomous terms. This explanation is consistent with the nding that, just prior to regaining weight,
the Regainers were less satised with their weight than were Maintainers, and were more likely
than Maintainers to demonstrate a lack of vigilance with regard to weight control. It may be
that they simply did not consider it worthwhile to invest eort in maintaining a weight that they
did not believe to be acceptable.
It should be pointed out that the majority of the participants in the present study both Maintainers and Regainers failed to reach their weight goals during weight loss and were not completely satised with their new lower weight (although, on average, Maintainers came closer to
achieving their goal weight than did Regainers). So it is not the failure to achieve weight goals
per se, but perhaps the interpretation or appraisal of this shortfall that may be critical. Thus, it
may be that the people most vulnerable to weight regain are those who are dissatised because
they have failed to meet their weight goals and have a dichotomous thinking style.
If replicated, the results of this study will have implications for the prevention of relapse in
obesity. The nding that dichotomous thinking is a signicant predictor of weight regain implies
that the modication of this all-or-nothing thinking style might enhance weight maintenance. A
cognitive-behavioural approach to relapse in obesityone that is based on a cognitive conceptualization of the mechanisms that operate to bring about relapse (e.g., Cooper & Fairburn,
2001, 2002)might therefore provide a more eective way of minimizing weight regain than
more behavioural treatments.
Strengths of the study include its prospective design; the community sampling (as opposed to
the more common practice of following-up patients who have participated in university-based
treatment trials); the low attrition rate; and the use of structured interviews to collect data
rather than exclusive reliance on self-report questionnaires. The studys limitations include the
relatively small sample size and the homogenous nature of the sample; the reliance on selfreported weight, as opposed to measured weight, during the follow-up;3 and the fact that the
reliability and validity of some of the measures used (including the DTS) are currently unknown
3

However, there is a substantial amount of evidence to suggest that both self-reported current weight and recall of
previous weight information correlate highly with actual measured weight (Casey et al., 1991; Davis & Gergen, 1994;
McGuire, Wing, & Hill, 1999; Stevens, Keil, Waid, & Gazes, 1990; Stunkard & Albaum, 1981). The National Weight
Control Registry (Wing & Hill, 2001) is also based on self-reported weights.

1354

S.M. Byrne et al. / Behaviour Research and Therapy 42 (2004) 13411356

since they were developed specically for this study. These limitations need to be addressed in
any replication.

Acknowledgements
This research was supported by a programme grant from the Wellcome Trust (046386). In
addition, SB was supported by a Wellcome Prize Studentship (050858) and CGF is supported
by a Wellcome Principal Research Fellowship (046386).
We would also like to acknowledge our colleague Anna Bevan, who assisted with the recruitment and assessment of participants.

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