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

Behavioral Approaches to Behavioral Approaches to Weight LossWeight Loss

Valerie H. Myers, PhDValerie H. Myers, PhD

Pennington Biomedical Research Pennington Biomedical Research CenterCenter

Prevalence of Overweight and Prevalence of Overweight and Obesity Among US Adults, Age 20-Obesity Among US Adults, Age 20-

74 Years*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.

47

60

40

20

0

80

NHANES II1976-80

(n=11207)

NHANES 1999

(n=3601)

Overweight or obese(BMI 25.0)

Overweight (BMI 25.0-29.9)

Obese (BMI 30.0)

5661

32 33 34

15

2327

NHANES III1988-94

(n=14468)

PercentPercent

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.

Impact of Effective TreatmentImpact of Effective Treatment

Impact on Other Medical Impact on Other Medical ConditionsConditions

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.

Impact on Other Medical Impact on Other Medical ConditionsConditions

Miscellaneous Each kg of weight loss = 1.7-2.5 mm Hg BP blood glucose levels in overweight and

obese persons without diabetes

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 Therapy and 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

Behavioral Treatment: Behavioral Treatment: OverviewOverview

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


Weekly treatment sessions (16-26 wks)

Groups* of 10-20 pts Weigh-in, review food/fitness diaries,

new dietetics or PA topic

Individual vs. Group Weight Individual vs. Group Weight Loss Loss

Renjilian et al (2001). JCCP

http://www.obesityresearch.org/content/vol12/suppl_3/images/large/z781120412750003.jpeg


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


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

Behavioral Treatment: Behavioral Treatment: ContentsContents

Goal-setting Self-monitoring* Stimulus Control Modification of Eating and Activity

Patterns Contingency Management Cognitive Behavioral Techniques Stress Management

Goal SettingGoal 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


Be Specific Set criteria: time, frequency, duration

Make it measurable

Make it realistic


Be SpecificVague Goals Specific GoalsI will exercise more I 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


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)


Tips cont’dTips 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

Self-monitoringSelf-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

Self-monitoringSelf-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

Self-monitoringSelf-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

Stimulus ControlStimulus 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


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”)


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

Stimulus Control-ExampleStimulus Control-Example

Eating Out, Party, and Holiday TipsEating 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

Modification of Maladaptive Modification of Maladaptive Health PatternsHealth 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

Contingency ManagementContingency 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


Effective rewards are Immediate Desirable Based on meeting a specific goal Eliminate all rewards centered around the

maladaptive behavior Rewards

Tangible (External) Intangible (Internal)


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


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


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

Cognitive Behavioral Cognitive Behavioral TechniquesTechniques

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

Cognitive Behavioral Cognitive Behavioral TechniquesTechniques

Thoughts

Feelings Behaviors

Stress ManagementStress Management

Stress Management Techniques(Physiological)

Diaphragmatic Breathing Progressive Muscle Relaxation Imagery Exercise Sleep Hygiene Reduce caffeine


Stress Management Techniques(Behavioral)

Limit Setting Time Management Training Scheduling Pleasurable Events


Stress Management Techniques(Cognitive)

Identify negative/faulty thinking Cognitive Restructuring Setting Realistic Expectations

Documents

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