deficits in eating control and dieting behaviors affect success in weight management (Wilson, 1993). Although dietary restraint and binge eating have been reported as factors that reduce success in weight-loss programs, results are conflicting (Wadden and Letizia, 1992).

Process Factors

Process factors include attendance and early weight loss. Attending intervention classes has consistently been shown to be related to weight loss. Early weight loss in programs is related to final weight loss as well as to attendance (Wadden and Bell, 1990). However, some speculate that a higher level of early weight loss, especially if the final attained weight is too low, may increase the likelihood of relapse. Alternatively, smaller changes in weight reflecting gradual changes in eating and exercise habits may ensure better maintenance (Goodrick and Foreyt, 1991). Small initial weight losses have been related to early dropout for females in very-low-calorie programs (Wadden et al., 1991). A client may leave a program out of frustration, or leaving may reflect insufficient motivation. Counseling clients to accept a slower rate of weight loss may result in better treatment retention. Some believe that large changes in lifestyle lead to better success at long-term weight management (see, for example, Ornish, 1993), but there are no studies to support this view.

The correlation between attendance and weight loss seems obvious, but both factors may be influenced by a third one, such as increased motivation or fear. Table 7-2 lists those factors that have been reported to be correlated with attendance in weight-management programs. Age, weight, percentage of body fat, mood, and age of onset of obesity have not been linked with attendance. Excessive stress from life difficulties predicts early dropout and weight regain (Wadden and Letizia, 1992).

A feeling of lethargy is associated with obesity (Sims, 1988; Thompson et al., 1982). This lack of energy is expected to be related to poorer attendance at, and adherence to, a weight-loss program, and this has been found in one study (Pekarik et al., 1984). Excessive use of caffeine to feel more energetic while on restrictive diets has been observed. Future research should evaluate the efficacy of monitoring perceived energy level while paying special attention to behaviors that affect energy expenditure (e.g., sleeping patterns, physical activity, and intake of specific foods and beverages). A gradual approach to exercise or increasing physical activity focused on boosting perceived energy could prove to be efficacious.

Most behavioral treatment programs use closed groups (i.e., groups that form at the beginning of a program and stay together throughout treatment without new members joining). Attrition rates in such programs

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