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Behavioral Treatment Strategies for Obesity Management
Principles of learning from schools of classical and operant conditioning can be applied to train patients how to adopt new behaviors.
By George A. Bray, MD
Overweight and obese individuals must be managed with a combination of diet, exercise, and behavioral modification. For some patients, these tactics are not adequate, and pharmacologic therapy or even bariatric surgery will need to be considered. The goal of a behavioral approach to weight loss is to assist patients in establishing long-term lifestyle changes. Patients are taught to modify and monitor their diet, become physically active, and to control environmental factors that may trigger eating.
This article summarizes the use of behavioral strategies to treat obesity. The complete text of this review originally appeared online at www.UpToDate.com.
BACKGROUND
According to the literature, behavior modification for weight loss has been used since at least 1967. Today, these types of programs are longer and more intense. Jeffery et al reported that average weight loss in behavioral programs for people who are overweight has increased about 75% between 1974 and 1994.1 Patients in current programs typically lose 7% to 10% of their initial body weight. These results peak within the first 6 months of treatment,1-3 and continued weight loss maintenance is difficult.4
Researchers have learned that the longer the program, the more effective it can be. For example, one study revealed that a 40-week program yielded significantly greater weight loss compared with one that lasted for 20 weeks.5
Weight loss clinicians have put forth two assumptions that underlie behavior modification therapy for overweight patients. The first is that obese people have learned poor eating and exercise habits that contribute to their weight gain and/or maintenance of their overweight state. The second assumption is that patients can modify these learned behaviors and that they will then be able to lose weight. Based on these notions, principles of learning from schools of classical and operant conditioning are applied to train patients how to adopt new behaviors. The goals of behavioral treatment for overweight patients are to change the environment, its reinforcement contingencies, and to create improved behaviors regarding eating and exercise.
Why do people fail at changing their behavior? There are several possible reasons:
- Expectations exceed what is feasible;
- People predict that they can change more quickly and easily than is possible;
- People overestimate their abilities; and
- People believe that making a change will improve their lives more than can reasonably be expected.
ELEMENTS OF BEHAVIORAL STRATEGIES
There are several components of a behavioral strategy to weight loss. These include:
- Self-monitoring (keeping food diaries and activity records)
- Control of the stimuli that activate eating
- Slowing down the eating process, goal setting
- Behavioral contracting and reinforcement
- Nutrition education and meal planning
- Modification of physical activity
- Social support
- Cognitive restructuring
- Problem solving
The DPP (Diabetes Prevention Program)3 is an example of a successful lifestyle intervention. The lifestyle intervention portion of DPP had two major goals: a minimum of 7% weight loss and a minimum of 150 minutes of exercise (such as brisk walking) per week. To achieve these goals, investigators in DPP used behavioral self-management training, individual case managers, group and/or individual sessions, individualized adherence strategies, and a network of training, feedback, and clinical support.6 In fact, in the DPP, the lifestyle approach was more effective for preventing diabetes than a pharmacological intervention (eg, metformin).3
Successful behavioral programs may be implemented individually3,7 or in a group setting.8 Although group programs may be more cost-effective, a meta-analysis of four trials comparing individual with group therapy found insufficient evidence to conclude one therapy to be superior. The LEARN Program for Weight Management 2000 provides information and tips on individual behavioral strategies.9
Using food diaries and activity records as a form of self-monitoring is intrinsic to the success of a behavioral weight loss program. Patients record all that they eat, the food's calories, and the situation in which they are eating. According to Guare et al, self-monitoring in this manner is predictive of a successful weight loss program.10 Additionally, the National Weight Control Registry reported that self-monitoring is one of the techniques most frequently used among patients who successfully lose weight and maintain weight loss.11,12
Another important factor in a behavioral weight loss program is stimulus control.13,14 This refers to the patient controlling the environmental factors that encourage eating and changing the environmental factors that cause overeating. An example would be teaching overweight individuals to shop for fresh fruits and vegetables, to prepare lower calorie foods, and to have healthy items easily accessible in the refrigerator or on the counter. How much people eat may be influenced by the accessibility of food and the shape and size of the serving container. Participants are also taught to focus on the act of eating unto itself—stimulus control—such as not eating in front of the television or reading during meals. Eating more slowly can give the body a physiological signal for satiety.
GOALS, EDUCATION, AND EXERCISE
Because lifestyle changes take time, it is important that the patient and practitoner set realistic weight loss goals (ie, 0.5 to 1 kg/week).15 A 1,000 kcal/day reduction in energy intake can achieve this. Positive reinforcement of success by offering nonfood "prizes" may help many patients. The therapist must also educate participants on nutrition and teach meal planning skills. When individuals are given a structured meal plan they are more successful than without.1,12 The use of portion-controlled plates19 or diets is one tactic that offers patients a plan for eating. Dietary counseling has been shown to assist in weight loss, particularly in the early stages of the intervention.
For a behavioral program to be successful it must have a physical activity component.12 Among members of the National Weight Control Registry, increasing physical activity was an important element in success. Members of this group of more than 4,000 individuals have lost ≥13.6 kg (30 lbs) and kept it off for at least 1 year, with an average weight loss of 33 kg maintained for an average of 5.7 years. Registry participants report an equivalent of about 1 hour per day of moderate-intensity activity.16
Success in the long-term also depends on an individual's level of social support.17 When spouses or family members are included in the program, participants have better results. The meta-analysis by Avenell et al of four 12-month behavioral programs that included family members revealed a 3-kg greater mean weight loss in the family-based intervention group versus the control behavioral programs.8
Anecdotally, other behavioral tools may help with weight loss such as cognitive restructuring (adopting positive rather than negative self-talk), problem solving (developing a plan to manage food intake in difficult situations), assertiveness training, and stress reduction.
WEIGHT LOSS PROGRAMS
A meta-analysis of randomized trials of weight loss diets found that the addition of behavioral therapy increased weight loss after 12 months by 7.7 kg.8 Self-help or commercial weight loss incorporates varying degrees of behavioral modification strategies. A systematic review of the major available programs in the United States reported the following:18
The two largest self-help programs are the not-for-profit groups Take Off Pounds Sensibly (TOPS) and Overeaters Anonymous. Although there is little evidence to suggest that these programs are effective, the costs and risks are minimal. Some patients report finding the emotional support that these programs offer to be helpful.
The largest commercial programs are Weight Watchers, Jenny Craig, and LA Weight Loss. Weight Watchers is the only one of the three that has funded clinical trials to determine its efficacy. A 26-week, multicenter trial included 423 patients randomized to attendance at weekly meetings versus a self-help control group (two 20-minute sessions with a nutritionist and provision of printed materials). Those assigned to Weight Watchers lost 5.3% of their initial weight after 1 year and maintained a loss of 3.2% after 2 years, versus 1.5% and 0%, respectively, in the control group.19
Many Internet-based weight loss programs are available,20-28 however, efficacy data are somewhat limited. Trials indicate that programs including a behavior modification component are more effective than those that do not.21,29,23
WEIGHT LOSS MAINTENANCE
Most patients who successfully lose weight with diet and/or behavioral therapy gain the weight back, although behavioral interventions may be helpful for maintaining weight loss.
A trial of 314 patients who had lost a mean of 19 kg in the previous 2 years were then randomized to either a group that received quarterly newsletters (control), a group that received Internet-based behavioral intervention, and a group that received the behavioral intervention face-to-face.30 The intervention was the same for both treatment groups, emphasizing self-weighing and self-regulation. After 18 months, individuals assigned to the face-to-face group gained less weight (2.5 kg) versus the internet and control groups (4.7 and 4.9 kg, respectively). The proportion of patients regaining ≥2.3 kg was similar in the face-to-face and Internet groups (45.7% and 54.8%, respectively), but higher in control patients (72.4%).
A second trial in which patients randomized to monthly personal contact for 30 months after an initial weight loss yielded similar results;31 however, a third randomized trial of 254 patients reported successful weight loss maintenance with both Internet-based support and in-person support.26
It has also been shown that behavioral therapies can be beneficial in children, particularly with parental support and reduction of television time.32,33
CONCLUSIONS, RECOMMENDATIONS
To effectively manage overweight and obesity, any strategy must include a combination of diet, exercise, and behavioral modification. Some patients will ultimately need pharmacologic therapy or bariatric surgery. Behavioral treatment seeks to help patients make long-term changes in their eating behavior, become physically activity and self-monitoring are particularly important components for success.
George A Bray, MD, is Boyd Professor and Chief, Division of Clinical Obesity and Metabolism, Pennington Biomedical Research Center, Louisiana State University. He may be reached at BrayGA@pbrc.edu; phone 225-763-3140; or fax: 225-763-3045
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