As part of my Nutrition Research Rotation, I wrote a Literature Review on The Behavioral Management of Obesity.

1. Behavioral Management of Obesity Introduction and the Obesity Epidemic: In recent years, healthcare professionals have taken a great interest in helping people that struggle with obesity, however the epidemic has become increasingly alarming (1). According to the National Heart, Lung, and Blood Institute, overweight is defined as a BMI of 25 to 29, obesity is a BMI of 30 and extreme obesity is a BMI of 40 (2). If left untreated, “the obesity epidemic” could potentially pose a threat to the future of our nation’s health. According to the latest National Health and Nutrition Examination Survey (NHANES for 2003-2004), an estimated 66.3% of US adults 20 years of age or older are either overweight or obese. This shows a relative increase of 18% from the previous estimate of 56% from NHANES III (1988 –1994). In the 2003-2004 NHANES the estimated prevalence of obesity alone was 32.3%, a relative increase of 40.6% from the estimated 22.9% prevalence reported in NHANES III (1988-1994). It is evident from this data that the prevalence of obesity has increased throughout the past two decades (2). In addition, research suggests that with the increased prevalence of obesity comes the increase in other health problems, such as CVD, Type 2 Diabetes and High Blood Pressure, to name a few (2). If left untreated these health problems can lead to complications and worsen one’s condition, making it harder for them to lose weight. This public health issue has remained an enigma regarding treatment, as even those obese people who were able to lose weight at one point or another were often unable to maintain their weight loss. In addition, there has not been any clear guidance on everlasting strategies that will help people to achieve long term weight loss maintenance (2). A multitude of factors may make attempts to control weight tricky, however current research indicates that behavioral therapy is a promising tool that can help for the long term management of obesity. Behavior Therapy Approach: Behavioral therapy is a type of therapy that provides people with a set of techniques and values that will enable them to change their eating and activity patterns (3). Contrary to psychotherapy, behavior therapy does not seek to treat a psychiatric disorder but instead seeks to change behaviors and habits. Ultimately, behavior therapy is an intervention equipped to educate people on skills and tools to facilitate the change of their problems (3). This paper will discuss the behavioral management of obesity and will provide: (1) a brief overview of strategies used in behavioral management of obesity (2) a summary of clinical and case controlled studies of behavioral management in the treatment of obesity; and (3) a plan for future research. Trends and Strategies Used in Behavior Therapy: In the past, behavioral weight-loss programs consisted of weekly 60 to 90 minute sessions with each person for about 6 months. According to research, these programs typically resulted in average weight losses of about 10% of initial weight (3). However, without continued treatment, the participants usually regained approximately one third of their lost weight within the first 6 months after stopping treatment and within 5 years the participants returned to their original weights (3). It has been found through various studies that weight regain can be minimized through maintenance programs offered every other week for an additional 12 months. Decades of research on the behavioral treatment of obesity have lead to a comprehensive approach to obesity management, consisting of various components including, self monitoring, stimulus control, problem solving, cognitive restructuring, and relapse prevention. Together, these components make up the “Standard Behavioral Treatment of Obesity” which is part of a Lifestyle Modification Program (3). The Self-Monitoring Component: Self Monitoring is possibly the most important skill taught in “standard behavior therapy” and also the most challenging to correctly implement (3). This approach is used to educate patients on the use of measurement tools such as cups and spoons, nutrition facts labels and calorie counting guides in order to evaluate their own behaviors. Patients are instructed to record all foods eaten in a food log and include specifics such as time, amount, preparation and calorie content of all foods and beverages. In addition, it is important that the patient records how he or she is feeling (i.e. hunger rating, emotions, activities done while eating, etc.). This helps the patient to identify eating-related trends and can help them to target areas where they want to change (3,4). The Goal-Setting Component: This approach is used to help patients set specific and more importantly, attainable behavioral goals. These goals should be within a 1 week time frame depending on when sessions meet and they should be realistic and somewhat challenging at the same time. Instead of using “I’ll try harder” as a goal, patients are taught how to express observable behaviors that they will actually employ such as, “I will prepare my dinners for the week on Sunday so I can avoid eating out this week.” Setting a goal like this will increase the chance of the person succeeded and will bring about a feeling of accomplishment, which in turn can be reinforced (3). The Stimulus Control Component: Stimulus Control is taken from the operant conditioning theory that states that reinforcing stimuli leads to the probability that a given behavior will be repeated. In the case of behavior management, the therapist is not in control of the stimuli itself, but teaches lifestyle modification techniques that aid the patients in determining schedules and principles for rewarding themselves for advantageous behaviors. Principles of classical conditioning are also used for behavioral weight control and are used to “break” the chain of association between nonfood cues with eating, for example, eating breakfast in the car during the morning commute. If a habitually does this they end up associating their car with eating. Thus, patients are taught cues such as only eating in the kitchen or dining room table. Lastly, stimulus control involves decreasing the number of cues for unwanted behavior (i.e. overeating) and increasing the cues for desirable behavior (i.e. eating a salad before lunch and dinner). Patients will learn how to modify their environment as to take away the temptation for a certain food, sometimes this means ridding the pantry of a specific food altogether (3,4). The Problem Solving Component: Problem solving is a multi-step process where the patients are taught to first identify the problem or events leading up to the problem behavior. Throughout this process, one or more links are targeted leading to the second step where possible solutions come about. The next step involves listing pros and cons and using a cost-benefit plan of analysis for each solution. The fourth step is to select the best and most feasible solution and implement it for a period of time. Once the period of time is over, the last step takes place. The last step is evaluation. When all is said and done, successful solutions are sustained and the process continues again for those with failed solutions (3). The Cognitive Restructuring Component: These patients are taught to screen for any thoughts that pose a barrier to their ability to meet behavioral goals, identify any distortions within those thoughts, and replace the distorted thoughts with more sensible and rational ones. Cognitive restructuring can be utilized to correct these warped thoughts within a lifestyle medication program (3,4). Results of Behavioral Treatment of Obesity: According to reports of a 2 year randomized controlled trial entitled “Study to Prevent Regain” or “STOP”, it’s illustrated that increased contact with a health care provider is in fact beneficial to preservation of weight loss. Results from the study show that behavioral techniques such as, frequency of self-weighing and increased physical activity are predictors of weight maintenance. The study suggests that self-weighing combined with face-to face contact and continual dialogue are important for long-term maintenance of weight loss (5). Lifestyle modification programs are typically provided weekly for an initial period of 16-20 weeks. In hospitals and clinics, therapy is offered to groups of 10 to 20 individuals by Registered Dietitians, Behavioral Psychologists, and/or related health professionals. One controlled study found that group treatment produced a larger initial weight loss than individual treatment. In fact, those currently treated with a comprehensive group behavioral approach lost about 10.7kg (~24 pounds) or 10% of their initial weight in 30 weeks of treatment. Analysis of both earlier and more recent behavioral weight loss studies revealed that weight losses have increased three times over the past 40 years as treatment duration has increased (6). Short Term Modification: Researchers have looked at various dietary interventions combined with behavior treatment to increase initial weight loss. Earlier studies measured the use of low-calorie diets providing 1400-1800 calories per day. The results indicated that this diet produced almost twice the amount of weight loss as those produced by 1200-1500 calorie diets consisting of conventional foods. However, the losses could not be maintained beyond 1 year even with intensive follow-up care. This study suggests that large, rapid weight losses, even when combined with behavioral therapy leads to counteracting changes in the body causing the person to return to their baseline weights (6). Long Term Modification: Many studies also examine the effect of long-term weight management combined with behavioral therapy. Long-term weight management continues to remain a challenge. In one study, individuals treated by lifestyle modification for ~20-30 weeks (only 5-7 months) typically regained approximately 30% of their weight loss in 1 year following treatment. After the first year, it was shown that weight regain slowed, and by 5 years greater than or equal to 50% of patients most likely returned to their baseline weights. Given these results, we see that the need for long-term treatment to prevent weight regain is imperative (6,7). Behavioral Therapy: A Possible Long-Term Treatment of Obesity According to two recent studies published in Clinical Pharmacology and Therapeutics, results demonstrate that long-term weight loss can be achieved. The first study looked at a register of over 1000 people from all over the United States who maintained large weight losses for a period of years. One strategy used by the patients to maintain long-term weight losses included use of continued care after the first phase of treatment. As stated earlier, this care can be provided from RD’s, Therapists, and other health care providers through on-site visits, phone calls, and email. It was found that those patients who attended sessions every other week throughout the year following weight loss were able to maintain 13kg (~29 pounds) of their 13.2kg (~30 pound) totally weight-loss (6). Those who did not receive therapy were only able to maintain about half of their original weight loss. The subjects reported that their success was attributed to continuing care and continuing implementation of strategies learned through behavioral treatment programs such as, self monitoring of food intake and physical activity, weekly weighing, better nutrition, and exercise (6,7). Thus, we see the positive effects that long term behavioral management can have on maintenance. Future Research: Over the past couple of decades there have been notable improvements in the initial and long-term weight losses that can be attained via behavioral weight-loss interventions (8). When looking back to studies from 1978-1980, the average participant lost 10 lbs during the initial phase of treatment compared to the year 2000 where patients lost ~ 20 lbs by the end of treatment and maintained about 2/3 of that weight after 1 year (8). Future research is focusing on new and cost-effective ways to continue care with patients through internet and email. Further research is needed on this concept as well as developing more effective solutions for long term habit change and boredom, which is often a major processor to weight regain (8). It is hopeful that future research will help map out prevention and intervention strategies to help fight the obesity epidemic and make American healthy again. References: 1.Kumanyika, S.K., et al., Population-based prevention of obesity: the need for comprehensive promotion of healthful eating, physical activity, and energy balance: a scientific statement from American Heart Association Council on Epidemiology and Prevention, Interdisciplinary Committee for Prevention (formerly the expert panel on population and prevention science). Circulation, 2008. 118(4): p. 428-64. 2.Lacey, J.M., A.M. Tershakovec, and G.D. Foster, Acupuncture for the treatment of obesity: a review of the evidence. Int J Obes Relat Metab Disord, 2003. 27(4): p. 419-27. 3.Fabricatore, A.N., Behavior therapy and cognitive-behavioral therapy of obesity: is there a difference? J Am Diet Assoc, 2007. 107(1): p. 92-9. 4.Berkel, L.A., et al., Behavioral interventions for obesity. J Am Diet Assoc, 2005. 105(5 Suppl 1): p. S35-43. 5.Foster, G.D., A.P. Makris, and B.A. Bailer, Behavioral treatment of obesity. Am J Clin Nutr, 2005. 82(1 Suppl): p. 230S-235S. 6.Jones, L.R., C.I. Wilson, and T.A. Wadden, Lifestyle modification in the treatment of obesity: an educational challenge and opportunity. Clin Pharmacol Ther, 2007. 81(5): p. 776-9. 7.Latner, J.D., et al., Effective long-term treatment of obesity: a continuing care model. Int J Obes Relat Metab Disord, 2000. 24(7): p. 893-8. 8.Wing, R.R., Behavioral interventions for obesity: recognizing our progress and future challenges. Obes Res, 2003. 11 Suppl: p. 3S-6S. 9.Wadden, T.A., et al., Benefits of lifestyle modification in the pharmacologic treatment of obesity: a randomized trial. Arch Intern Med, 2001. 161(2): p. 218-27. 10.Lyznicki, J.M., et al., Obesity: assessment and management in primary care. Am Fam Physician, 2001. 63(11): p. 2185-96.