in large part on the nature of the sample studied and the methods used to assess the psychological effects (Smoller et al., 1987). Early reports were based largely on observations by psychiatrists of obese patients undergoing psychodynamic psychotherapy; this sample of health-care providers was undoubtedly biased toward psychopathology. Furthermore, the psychiatrists' reports were based on observations made over the entire course of treatment. The later reports of positive changes in mood with weight loss were based largely on patients undergoing behavioral weight control. Also, these patients were assessed by paper-and-pencil tests usually administered only before and after treatment, so any shorter-term emotional disturbances would not be measured. Wadden et al. (1986) confirmed the hypothesis that the differences in reports were based on the method of assessment. In their study of 28 women who lost 19.2 kg, a significant decrease in pre- to post-measures of depression coexisted with a significant increase (often to clinically significant levels) in the level of depression during the course of treatment among half of the patients.
Dieting has been linked with the onset of binge eating, and anecdotal reports have linked rigid and restrictive VLCDs to an increased risk for binge eating (Spitzer et al., 1992; Wilson et al., 1993). The problem in validating this proposition is the very high prevalence of dieting, making it difficult to find people who binge who have not already dieted.
All weight-loss and weight-management programs should provide (or mandate or encourage) an assessment of the potential client's physical health and psychological status, attend to improvements in diet and increases in physical activity, and ensure that the program is at least reasonably safe. It is reasonable to expect that individuals have some basic knowledge about their overall state of physical health and psychological status that will help them determine if they are ready to try to lose weight and, if so, identify which programs might be best for them. Health-care providers as well should learn more about obesity and the treatment of this disease.
Because improvements in the quality of the diet and especially the amounts of food consumed are important to weight loss, as is modifying one's lifestyle to incorporate reasonable physical activity, any weight-loss program must attend to these two components, providing the participant with necessary information and, ideally, skills. Since dieting is not entirely risk free, programs must also make efforts to ensure that they are as safe as possible; this is of special importance to do-it-yourself and nonclinical programs where some participants may not be receiving any medical care or monitoring throughout the weight-loss attempt.