Behavioral Approaches to Weight Loss

1. Behavioral Approaches to Weight Loss Valerie H. Myers, PhD Pennington Biomedical Research Center

2. 80 Obese (BMI 30.0) Overweight or obese (BMI 25.0) Overweight (BMI 25.0- 29.9) 61 60 56 47 40 Percent 34 33 32 27 23 20 15 0 NHANES 1999 (n=3601) NHANES III 1988-94 (n=14468) NHANES II 1976-80 (n=11207) Prevalence of Overweight and Obesity Among US Adults, Age 20-74 Years* *Age-adjusted by the direct method to the year 2000 U.S. Bureau of the Census estimates using the age groups 20-34, 35-44, 45-54, 55-64, and 65-74 years.

3. Impact of Effective Treatment • Sustained weight loss of 10% • Fewer years of living with chronic diseases: • Hypertension, hypercholesterolemia, type II diabetes • Reduces incidences of • stroke and heart disease • increase in life expectancy • reduces medical costs by $2,200 to $5,300 • Oster G, Thompson D, Lifetime Health and Economic Benefits of Weight Loss Among Obese Persons, Am J Public Health, 1999;89:1536-1542.

4. Impact on Other Medical Conditions • 5-10% weight loss • 5-10% total and LDL cholesterol • HDL • glycosylated hemoglobin (1-2.5%) • blood pressure 3-8 mm HG. • 2-4% weight loss • 30%-50%in diabetes incidence • 20% -30%in high blood pressure Clinical guidelines. National Heart, Lung, and Blood Institute Web site. Available at:http://www.nhlbi.nih.gov/nhlbi/cardio/obes/prof/guidelns/ob_gdlns.htm.

5. Impact on Other Medical Conditions • Miscellaneous • Each kg of weight loss = 1.7-2.5 mm Hg BP • blood glucose levels in overweight and obese persons without diabetes

6. The recommended treatments for various BMIs BMI Description Health Risk Weight Goal Strategy 19-25 Acceptable Weight Very Low Maintain Weight Healthy Diet and Regular Physical Activity 25-29 Over weight Low Maintain Weight or Lose 5% of Weight Health Diet (Low-Fat, Low Energy Density), Portion Control, Exercise, Behavior Therapy 30-34 Obese Moderate Lose 10% of weight or BMI <30 Healthy Diet (Low-Fat, Low Energy Density Diet, Portion Control, Exercise, Behavior Therapyand Medication >35 Morbidly Obese High Lose >15% weight or BMI reduction of >3 units Exercise and Health Diet, Medication, Surgery NHLBI Guidelines for Management of Obesity 1998 and Bray 2003 Atlas of Obesity

7. Behavioral Treatment: Overview • Lifestyle modification • Diet • Reduction in intake of 500-100 kcal/day • Exercise • 30 min/day 5-6 days/wk • Behavior therapy • Set of techniques for modifying diet & exercise

8. Behavioral Treatment: Overview • Weekly treatment sessions (16-26 wks) • Groups* of 10-20 pts • Weigh-in, review food/fitness diaries, new dietetics or PA topic

9. Individual vs. Group Weight Loss Renjilian et al (2001). JCCP

10. Behavioral Treatment: Overview • Efficacious treatment (>100 controlled studies) • Helpful with maintenance efforts • Successfully used with other forms of treatment • Short-term weight loss: 8-10% over 6 months • Helpful for mild to moderate overweight and obesity • Essential to long-term lifestyle change

11. Behavioral Treatment: Overview • Overall, 10% initial wt loss • 80% completed tx • Increase in wt loss in last 3 decades • Weight regain is problematic • 30-35% regain at 1 yr • 50% of pts have regained all of their wt by 5th yr

12. Behavioral Treatment: Contents • Goal-setting • Self-monitoring* • Stimulus Control • Modification of Eating and Activity Patterns • Contingency Management • Cognitive Behavioral Techniques • Stress Management

13. Goal Setting • The initial starting point of behavioral programs • Involves setting goals for calories, fat, physical activity, and other modifiable behaviors • People are often unrealistic in their expectations • Realistic expectations for short-term and long-term goals should be discussed

14. Goal Setting • Be Specific • Set criteria: time, frequency, duration • Make it measurable • Make it realistic

15. Goal Setting • Be Specific Vague GoalsSpecific Goals I will exercise moreI will walk 20 minutes a day five days of the week I will lose weight I will lose 1-2 lbs each week for the next 10 weeks

16. Goal Setting • Tips • Write it down • Setting goals helps keep up motivation • Need to plan ahead • If having trouble, may need to change goal • Don’t set yourself up for failure • Set yourself up for success (set positive, valued goals)

17. Goal Setting • Tips cont’d • Set short and long-term goals – use a step-by-step approach • Take advantage of the skills you already have • Approach this as a challenge

18. Self-monitoring • The “cornerstone” of behavioral treatment • Involves daily observation and record keeping of behaviors • Monitoring is used to increase awareness of behavior patterns • identifying antecedents and reinforcing consequences that lead to faulty health patterns • Time, place, feelings, social situation… • Record keeping can also be expanded to include a variety of information including emotions

19. Self-monitoring • Keep track of progress to know if goals are being met • Allows you to look back at situations in which it was easier or more difficult to keep going • Gives immediate feedback • Reward yourself when you see change • Prevents false discouragement or assurance

20. Self-monitoring • Tips • Define specific behaviors to be monitored (steps, miles, calories, carbs, etc) • Determine how they will be recorded (pedometer, form, pda) • Start with a clear baseline for later comparison

21. Stimulus Control • Discriminative Stimulus: an external or internal cue that signals that a given response will be reinforced if performed • People are often unaware of how their environment influences their behavior • Used to identify and then modify environmental antecedents that influence behavior patterns • Goal is to restrict environmental circumstances that serve as discriminative stimuli for maladaptive behaviors

22. Stimulus Control • Procedures are used to decrease the number of conditioned stimuli or situations that may trigger a maladaptive behavior • Identify and minimize stimuli that trigger target behaviors that you want to decrease • Eliminate cues that compete with what you want to accomplish • Avoid driving by the Krispy Kreme, smell of fries, commercials, “out of sight out of mind”)

23. Stimulus Control • Other techniques include • Specified number of meals and snacks to eat • Specified eating times or places • Changing serving and food storage techniques • Develop new stimuli to trigger new targeted adaptive behavior • Set new routines with strong associated cues • Wear a pedometer

24. Stimulus Control-Example • Eating Out, Party, and Holiday Tips • Plan ahead • Eat before you go • Eat slowly • Avoid buffets • Don’t pile plate • Don’t take a little of every item (special items) • Take low fat/calorie items

25. Modification of Maladaptive Health Patterns • Goal is to modify faulty health behaviors that may interfere with accomplishing new adaptive behavior by encouraging new behavior • slowing pace of eating, reducing portion sizes, measuring food intake, leaving food on plate, improving food choices, eliminating second servings, taking the stairs, parking farther from the building, walking or biking rather than driving, etc… • Breaking the cycle

26. Contingency Management • Once a target behavior is performed, it needs to be strengthened by reinforcement • Positive reinforcement (e.g., reward) is used to stabilize and increase the maintenance of new adaptive health patterns • Punishment or loss of reinforcement may also be used to change behaviors • Contingency contracting • Self reinforcement • External reinforcement

27. Contingency Management • Effective rewards are • Immediate • Desirable • Based on meeting a specific goal • Eliminate all rewards centered around the maladaptive behavior • Rewards • Tangible (External) • Intangible (Internal)

28. Contingency Management • Intangible Reward Tips • Feeling good about yourself and what you are doing • Focus on the benefits of what you are doing • Watch out for pessimism or criticism (from yourself or others) • Don’t wait to pat yourself on the back until you are 100% successful

29. Contingency Management • Tangible • Give yourself to keep your motivation high (like social activities, money, extra time for hobbies, etc.) • Helps to tide you over until internal rewards are enough

30. Contingency Management • Other tips • Premack Principle • Make your intentions known to others • Join others with common goals • Have others support you when you meet goals, and “ignore” you when you don’t

31. Cognitive Behavioral Techniques • These strategies combine the traditional behavioral treatment components with emphasis on thinking patterns that may affect eating behaviors • Focus on perfectionistic standards, negative self-statements and unrealistic goals • Goal is to alter mood, unhelpful beliefs, unrealistic standards, and negative evaluations that affect healthful behaviors

32. Cognitive Behavioral Techniques Thoughts Feelings Behaviors

33. Stress Management • Stress Management Techniques (Physiological) • Diaphragmatic Breathing • Progressive Muscle Relaxation • Imagery • Exercise • Sleep Hygiene • Reduce caffeine

34. Stress Management • Stress Management Techniques (Behavioral) • Limit Setting • Time Management Training • Scheduling Pleasurable Events

35. Stress Management • Stress Management Techniques (Cognitive) • Identify negative/faulty thinking • Cognitive Restructuring • Setting Realistic Expectations