INTRODUCTIONBehavior modification is an essential component of a weight loss strategy, whether used alone or in combination with pharmacotherapy or bariatric surgery .Diet change alone can produce a weight loss of 5 to 10 percent below baseline weight, with comprehensive lifestyle modifications (combination of diet change, exercise, and behavioral interventions) resulting in even greater weight loss.The use of behavioral strategies to treat obesity in adults is reviewed here. Other therapies for obesity, including drug therapy, specific diets, exercise, and bariatric surgery, are reviewed separately. Issues of obesity in children, adolescents, and pregnant women are also reviewed separately.
Importance of behavioral therapy
More than two-thirds of adults in the United States are either trying to lose weight or maintain their weight at any given time. However, only 20 percent are both eating fewer calories and exercising on a regular basis. Thus, all clinicians can play an important role in educating people regarding the optimal strategies for losing weight and/or maintaining lost weight. Behavioral-based treatment programs improve weight loss results and are associated with improvements in obesity-associated morbidity The US Preventive Services Task Force (USPSTF) recommends that all adults with a body mass index (BMI) ≥30 be offered intensive, multicomponent, behavioral interventions to achieve and maintain weight loss.
Patients who report receiving weight loss advice from a health care provider more frequently report behavior change attempts (77 versus 33 percent) and weight loss Clinicians, including nurse practitioners, nurse specialists, and physician assistants, can be reimbursed for providing intensive behavioral therapy for patients with obesity in the primary care setting .Alternately, patients can be referred to Registered Dietitian Nutritionists (RDs or RDNs), who are the clinical experts in providing comprehensive medical nutrition therapy for obesity treatment. In the United States, insurance coverage for nutritionist evaluation varies, with some insurers only covering such care for patients with diabetes.
What is behavioral therapy?
Behavior modification or behavior therapy is considered to be an essential component of managing the patient with overweight or obesity. The goals are to help patients make long-term changes in their eating behavior by:
- Modifying and monitoring their food intake
- Modifying their physical activity
- Controlling cues and stimuli in the environment that trigger eating and overeating
A principal determinant of weight loss appears to be the degree of adherence to the chosen program.Thus, patient preference is an important consideration when recommending any behavioral weight loss program. The concepts described are included in most behavioral therapy programs conducted by trained providers, such as registered dietitian nutritionists (RDs or RDNs) and psychologists, as well as many self-help groups.
The assumption underlying behavioral therapy is that improving health behaviors, primarily those related to eating and activity, reduces the risk of chronic disease and provides health benefits; these benefits are often conferred via weight loss [8].
Behavioral treatment for the patient who has overweight or obesity seeks to:
- Alter the environment
- Alter environmental reinforcement contingencies
- Shape eating behavior and physical activity
- Provide health benefits by reducing the risk for developing diseases associated with obesity.
It is important to recognize that behavior change is complex and often challenging, especially given the availability and appeal of highly caloric foods and sedentary behaviors in modern society .Important, too, are the contributions of the social determinants of health; food access and insecurity are linked to obesity, as are other stressors related to poverty and racism.
Elements of behavior change — Comprehensive lifestyle interventions usually provide a structured behavioral program that includes a number of components .These can be broadly categorized as nutrition education and self-regulation.
Nutrition education focuses on providing motivation (why to) and facilitation (how to) towards a specific behavioral goal (eg, drinking water instead of sugary beverages) and often also encompasses physical activity behaviors in addition to nutrition behaviors. Motivating factors include social support, understanding the benefits of behavior change and risks of not changing behavior, and self-efficacy. Facilitating factors include knowledge and skills.
Self-regulation includes a set of supportive behaviors that have been demonstrated to improve initiation and maintenance of a behavior change goal, such as:
- Goal setting
- Self-monitoring (keeping food diaries and activity records)
- Controlling or modifying the stimuli that activate eating
- Eating style (slowing down the eating process)
- Behavioral contracting and reinforcement
- Meal planning
- Cognitive restructuring
- Problem solving
These same elements of behavior change are recommended to maintain weight loss, especially physical activity and periodic weight monitoring.
Furthermore, it is important to consider the influence on energy balance related behaviors proposed in the socioecological model: internal, social, community, and policy.
Setting weight loss goals — Changes in eating behavior require time and commitment, and it is important for the patient and health care provider to set weight loss goals, such as 0.5 to 1 kg/week, or 5 to 10 percent of baseline weight within six months.To achieve this goal, patients are encouraged to reduce energy intake by 500 kcal/day, which can be done with diet instruction, provision of food, or the use of portion-controlled foods.
Setting behavioral goals — It is likewise important to set behavioral goals. These goals are Specific, Measurable, Achievable, Reasonable, and Time-bound (SMART), and should be within a patient’s control. Some examples include: make half of your plate fruits and vegetables, and eat fast food less than once a week.
Self-monitoring — Self-monitoring, often involving the use of food diaries, activity records, and self-weighing, is one of the elements of a successful behavioral weight loss program.
Stimulus control — Stimulus control is another element in a behavioral program .It focuses on gaining control over the environmental factors that trigger eating and eliminating or modifying the environmental factors that facilitate overeating. Since food is a key issue in weight gain, participants are taught to buy more fresh fruits and vegetables, to prepare easy-to-eat lower calorie foods, and to place them prominently in the refrigerator or on the counter.
Stimulus control also includes making the act of eating a focus of its own. Thus, turning off the television set and putting down reading materials may allow the individual to concentrate on eating. Stimulus control in children who substituted active behaviors for sedentary behaviors was associated with a significantly smaller rise in age and gender-adjusted body mass index (BMI) scores at 6 and 12 months .
Eating style — Slowing down the eating process may give time for “physiologic” signals for fullness to come into play. “Mindful eating” includes concentrating on the tastes and textures of food and savoring what is being eaten by chewing more slowly; this technique can slow down eating. Other techniques might involve leaving the table briefly during a meal and drinking water between bites or just prior to the meal.
Regular weighing — Regular self-weighing as a strategy for self-monitoring has been recommended in some studies .There were concerns that regular weighing might lead to anxiety and weight regain, but this was not observed in a systematic literature review of 17 studies.
Behavioral contracting and reinforcement — Reinforcing successful outcomes by providing rewards for weight loss may be beneficial.
Portion control and meal planning — Portion control and meal planning are also helpful behavioral strategies. Providing a defined meal structure results in greater weight loss than the absence of such a structure . Use of portion-controlled plates or meal replacements are examples of such strategies.
Increasing physical activity — Increasing physical activity is another part of a successful behavioral program.
Social support — Enhancing social support may also be a means for improving long-term weight loss.
Other tools — Although there is no high-quality evidence to demonstrate the efficacy of these techniques, a number of additional behavioral tools may help with weight loss:
- Cognitive restructuring – Adopting positive rather than negative self-talk (for example, if one eats a piece of cake, choosing to exercise rather than blaming oneself)
- Problem-solving – Developing strategies to manage food intake in difficult situations such as restaurants and parties
- Assertiveness training – Learning to say “no”
- Stress reduction – Identifying and reducing stressors that are triggers for eating efficacy
Behavioral-based programs — Behavioral-based treatment programs improve weight loss results. Multicomponent interventions that include dietary modification, exercise, pharmacotherapy, and counseling on behavioral strategies are more effective than interventions that focus on a single component. Self-help or commercial weight loss programs — Self-help or commercial weight loss programs incorporate varying degrees of behavioral modification strategies.
