Cognitive Change in Obese Adolescents Losing Weight

Oct 20, 05

Objectives: To investigate how obese adolescents think about themselves in terms of exercise, eating, and appearance and whether these cognitions change over the course of a residential weight loss camp.

Research Methods and Procedures: Obese adolescents [N = 61; age, 14.1 (±0.2) years; BMI, 33.9 (±0.7) kg/m2] completed assessments of body weight and height and self-esteem and a sentence-completion test eliciting thoughts and beliefs about exercise, eating, and appearance at the start and end of the camp (mean stay, 26 days). They were compared with a single assessment of 20 normal-weight adolescents [age, 15.4 (±0.2) years; BMI, 21.8 (±0.5) kg/m2].

Results: The obese adolescents lost 5.7 kg and reduced their BMI SD score by 0.25. Camp residence was associated with a significant reduction in the number of negative automatic thoughts and an increase in positive thoughts, especially related to exercise and appearance. There was no change in conditional beliefs, either functional or dysfunctional. Including BMI SD score change as a covariate took away all the main and interaction effects of time, showing that cognitive change was largely accounted for by the reduction in weight. Despite this improvement, campers remained cognitively more negative and dysfunctional than the normal-weight comparison adolescents.

Discussion: Obese adolescents not only lost weight, but they improved their self-representation, specifically in terms of automatic thoughts about exercise and appearance. Although these are short-term cognitive changes, they reflect positively on the camp experience and show the value of psychological improvement in assessing obesity-treatment outcomes.

Children’s summer camps are very popular in the U.S. for children with a range of health problems and disabilities that include diabetes, burn injuries, learning disabilities, eating disorders, asthma, and cancer. They have also become popular settings for encouraging weight loss in overweight and obese children. However, this increase in availability and in interest in the media, which have labeled them “fat camps,” has not been accompanied by a surge of publications providing an evidence base for their acceptability or effectiveness. The report by Gately et al is one of the few detailed accounts of the impact of summer camp participation on weight loss and its post-camp maintenance. This 8-week camp in Massachusetts resulted in a reduction of 4.4 BMI units, with those participants who were available at follow-up still being at a lower-than-pre-camp BMI 1 year later.

Weight loss camps, like many other treatments for child obesity, focus on behavior change. Providing a safe and sociable environment in which to be physically active and acquire new skills should enable these changes to be implemented, practiced, and reinforced by improved fitness and weight loss. The hope is that these changes will be maintained when the adolescent returns to his or her home environment. Cognitive strategies are increasingly being incorporated into adult behavioral weight loss treatments with the aim of maintaining behavior change or dealing with specific issues such as body image problems. These approaches often derive from the treatment of eating disorders and reflect a growing interest and confidence in the relevance of cognitive factors for eating and weight control.

Assessments of eating disorder cognitions in anorexia or bulimia nervosa show elevated levels of negative thinking about shape, weight, food, and eating, compared with women without eating disorders. The few published studies of cognitions in obesity have followed the same direction. They have shown, for example, a stronger belief in dysfunctional food and weight-related cognitions in obese compared with normal-weight people and more frequent negative self-schemas related to shape, weight, or eating in obese binge eaters compared with obese non-binge eaters . These studies have all been conducted with adults. The existence of similarly focused and negatively toned thinking has yet to be examined in obese youngsters.

Also lacking is any indication that weight loss may be accompanied by cognitive change. Athletic competence and physical appearance are domains of perceived competence that are particularly affected by obesity in young adolescent girls. We have recently reported on some of the short-term psychological benefits associated with camp attendance. Central to this was an improvement, but not rehabilitation, of obese adolescents’ self-esteem and body satisfaction, without any exacerbation of existing worries about appearance or weight. How obese adolescents think about themselves in terms of exercise and appearance, whether self-representation changes during treatment, and whether girls respond differently to boys are potentially important indicators of program acceptability and longevity of benefit. This was the main focus of the present study.

Self-report questionnaires have previously been used to investigate cognitive content in eating disorders, but have been criticized for their restrictive and retrospective format. Of the alternative methodologies, sentence-completion tests have shown their value in characterizing depression-related changes in thinking and the cognitive processes of female exercisers with eating disorder psychopathology.1 Sentence completions offer the opportunity to examine automatic thoughts (e.g., situational specific, moment-to-moment, unplanned thoughts) alongside schema driven conditional beliefs (If… . then… . . ). Being literally open-ended, sentence completions invite individual and personal accounts, rather than the level of agreement indications characteristic of most questionnaire items. Moreover, in this type of assessment sentence, stems can be selected to prompt cognitions about distinct and pertinent issues such as appearance, eating, and exercise.

Accordingly, the aim of this study was to measure the thoughts and beliefs about exercise, eating, and appearance in obese adolescents at the start and end of a residential weight loss camp. It was hypothesized that cognitive content would change from the start to the end of the camp and, given that this was an activity-based camp, that there would be specificity in this change in relation to thoughts about exercise. Second, cognitive content would be different in valence (i.e., more negative and dysfunctional) to that of comparison normal-weight adolescents, remaining so at the end of the camp [as has been found previously for self-esteem]. Third, the change in cognitive content would be related to change in BMI and self-esteem.

Discussion

The study outcome was broadly in line with what was hypothesized. First, residence at the weight loss camp was associated with a change in cognitive content, most clearly seen as a reduction in negative thoughts and a concomitant increase in positive automatic thoughts. Moreover, there was specificity in this change. Thoughts about exercise and appearance became less negative and more positive, whereas those about eating did not change. In contrast, there was no change in conditional beliefs, either functional or dysfunctional.

Second, compared with normal-weight adolescents, obese adolescents had more negative thoughts and dysfunctional beliefs and fewer positive thoughts. By the end of the camp, only the number of positive automatic thoughts could be considered normalized, no longer differing from those expressed by the lean comparison adolescents. This camp-related improvement in psychological state, but without full remission, has also been observed on measures of perceived self-competence and body shape satisfaction. It serves as a reminder of the depth of psychological distress experienced by some obese adolescents.

Third, the improvement in automatic thoughts over the camp was largely accounted for by the reduction in weight. Adolescents who reduced their BMI sds the most were those who showed the greatest valence change in automatic thoughts. However, whereas cognitive content and self-esteem were both correlated with weight change, there was a particularly strong association between the two psychological measures. Improvements in automatic thoughts about exercise and appearance were strongly related to improvements in global self-worth. Again, this cognitive change mirrors the improvement in athletic competence and physical appearance observed in a smaller part of this cohort.

To our knowledge, this is the first investigation of cognitive change in obese adolescents losing weight. Four characteristics of this change (i.e., level, specificity, timing, and longevity) are worthy of brief comment. Automatic thoughts were found to change, but conditional beliefs did not; therefore, campers ended their stay with the same majority of dysfunctional, maladaptive beliefs that they had come with. Automatic thoughts are unplanned self-statements that describe a person’s self-representation and are broadly positive or negative. Conditional beliefs, on the other hand, reflect the operation of deeper cognitive structures called self-schemata. Self-schemata are cognitive generalizations that guide and organize the processing of incoming self-related information. Derived from past experience, much of it early in life, self-schemata are extremely resistant to change. Four weeks of residential camp experience is, therefore, unlikely to have much of an impact at this cognitive level.

The observed change in self-representation was specific to exercise and appearance and manifested as a change in tone (negative to positive), rather than in the type of completions made. Tone changed modestly, rather than overwhelmingly, starting with a very negative portrayal of appearance and a much more positive presentation of exercise. The initial low frequency of negative completions for exercise stems would not have been surprising if the camp attracted adolescents favorably disposed to exercise and sports activities. However, it was a basic dislike of sports activities that was voiced to staff on their introduction. This ambivalence diminished, so that, by the end of the camp, automatic thoughts about exercise were overwhelmingly positive. Positive exercise self-schemata are important because they predict future exercise engagement in lean young adults, and high levels of physical activity are associated with increased self-efficacy in adolescents. The present sample of obese adolescents, in which girls were no less positive about exercise than boys, should, therefore, be expected to derive generalized psychological benefit from this experience in terms of self-efficacy.

Even though self-representation changed, we are unclear about the timing of this change. For example, did the positive exercise self-representation develop early in the camp? Did body appearance become more positive later, being dependent on weight loss, or were the changes simultaneous? The longevity of these changes is also uncertain. Although we were able to conduct follow-up with 40% to 50% of campers after 12 months by telephone or postal contact, the SCEE was not deemed suitable for postal administration. The modest degree of change in automatic thoughts brings into question its maintenance post-camp. How generalizable will the self-representational change be outside the camp? If one of the benefits of exercise participation is mood regulation, how easy will it be for these adolescents to recreate the conditions to enable exercise away from the camp?

In summary, this study has used an open-ended technique for exploring the cognitions and self-representation of obese adolescents losing weight. It was found that the greater the weight loss, the greater the exchange of negative for positive thoughts, especially in relation to exercise and appearance. Although concerns remain about the longevity of these effects, this research shows the potential value of residential weight loss camps for obese adolescents. It also emphasizes the importance of psychological and social outcomes, alongside weight loss, in evaluating obesity treatment success.

Source: Stephen B. Barton, Lucy L.M. Walker, Gillian Lambert, Paul J. Gately and Andrew J. Hill

Academic Unit of Psychiatry & Behavioural Sciences, University of Leeds, Leeds, United Kingdom and
School of Leisure & Sport, Leeds Metropolitan University, Leeds, United Kingdom.

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