Behavioral Treatment
Ariana M. Chao
Kerry M. Quigley
Thomas A. Wadden
CASE STUDY 1
A 60-year-old female patient with a history of osteoarthritis presents to your office complaining of bilateral knee pain. She states that 6 months ago she lost 20 lb by following a ketogenic diet, which helped relieve her knee pain. However, she has since gained back almost all the weight, and her knee pain is returning. She is taking naproxen prn over the counter. The patient comments that she does not understand why she is gaining weight. You ask her to tell you about her eating habits. She states they vary a lot day to day. She says that yesterday she had a yogurt and fruit for breakfast, turkey sandwich for lunch, a few cookies for a snack, and chicken for dinner but she cannot remember all the details. Two days ago, she was very busy with work and did not eat anything until dinner, which was a burger, milkshake, and fries from a fast-food restaurant. She wants to lose weight but feels like no matter what she does, she cannot keep the weight off. On examination, weight is 185 lb, height 5′4″, blood pressure (BP) 132/84, heart rate (HR) 88, and body mass index (BMI) 31.8 kg/m2. The remainder of examination and laboratory tests are unremarkable.
CLINICAL SIGNIFICANCE
Behavioral modification is a core component of obesity treatment. Behavioral weight control consists of a package of principles and techniques that aims to help patients make long-term changes in their eating behaviors and physical activity.1 It is goal directed and process oriented and emphasizes that new habits can be learned.
Numerous expert panels have recommended that adults with a BMI ≥30 kg/m2 be offered intensive, multicomponent, behavioral interventions for weight loss. These include the US Preventive Services Task Force2; the American Association of Clinical Endocrinologists the American College of Endocrinology3; the American Heart Association, the American College of Cardiology and The Obesity Society.4 The Centers for Medicare and Medicaid Services (CMS) has approved reimbursement for intensive behavioral weight loss counseling provided to Medicare beneficiaries in primary care settings by physicians, nurse practitioners, clinical nurse specialists, and physician assistants, as well as other auxiliary personnel (e.g., registered dietitian nutritionists) who bill “incident to” one of the aforementioned health professionals. Coverage is provided for brief (15 minute) weekly counseling visits for the first month, followed by biweekly visits for the following 5 months. Patients who lose >3 kg (6.6 lb) in the first 6 months are eligible for six additional monthly visits.
The purpose of this chapter is to discuss strategies to deliver efficient and effective behavioral treatment for obesity within the context of primary care. First, this chapter will provide an overview of the basic theoretical principles and core components of behavioral treatment for obesity, followed by a description of the efficacy of this approach. It then will describe the 5 A’s framework for obesity counseling, as well as a treatment protocol that can be used by providers to deliver treatment in primary care settings.
BEHAVIORAL TREATMENT OF OBESITY
Theoretical Basis
Behavioral treatment of obesity incorporates a number of different theories of behavior change. These include the transtheoretical model, behavioral and cognitive-behavioral theories, and social cognitive theory.5 The transtheoretical model describes behavior change as a series of six stages: precontemplation, contemplation, preparation, action, maintenance, and termination. This model
supports matching behavioral counseling strategies to different stages of change.6 For example, patients who are not interested in actively working on their weight would be identified in the precontemplation stage of change. For these patients, simply mentioning that weight loss may help them achieve improved health and that you are there to assist when they are ready is sufficient. In contrast, some patients present in the preparation stage, having already downloaded a smart phone app to track their diet and joined a health club. These patients are ready and interested in receiving further guidance on how to take action to lose weight.
supports matching behavioral counseling strategies to different stages of change.6 For example, patients who are not interested in actively working on their weight would be identified in the precontemplation stage of change. For these patients, simply mentioning that weight loss may help them achieve improved health and that you are there to assist when they are ready is sufficient. In contrast, some patients present in the preparation stage, having already downloaded a smart phone app to track their diet and joined a health club. These patients are ready and interested in receiving further guidance on how to take action to lose weight.
Behavioral and cognitive-behavioral theories posit that individuals have learned maladaptive patterns of eating and exercise which contribute to weight gain and/or maintenance of their weight status.7,8,9 These patterns may be influenced by external or internal factors. Behaviors can be unlearned and modified to induce weight loss. Social cognitive theory is based on the premise that behavior is the result of interactions between personal, behavioral, and environment factors.10 People learn from watching and modeling the behaviors, attitudes, and emotional reactions of others. Learning can also occur through the observation of rewards and punishments. Social cognitive theory also emphasizes the importance of self-efficacy, an individual’s confidence in their ability to take a specific action or to overcome barriers to engage in a specific behavior, as a major motivator for behavior change. For example, patients who previously lost weight by attending a commercial weight loss program may have gained self-efficacy that they can lose weight if they are provided a structured program with accountability.
Behavior Change Components
The following components of behavioral weight loss provide the foundation for what to discuss and emphasize during a focused obesity encounter. Not all components need to be included in every encounter. By using active listening, the provider can pick and choose which elements are most pertinent to assist the patient at that time. With experience, the flow of using the components becomes easier and more time efficient.
Self-monitoring
Self-monitoring of dietary intake, physical activity, and weight is a cornerstone of behavioral weight management and is the first behavioral change that should be recommended. It involves the use of food logs, activity records, and self-weighing and is a crucial element to successful weight loss and maintenance.11,12,13,14,15 Self-monitoring helps patients become more aware of their behaviors, increase accountability, monitor progress, and enhance motivation. In addition, self-monitoring can help patients and providers identify patterns and modifiable stimuli that might contribute to overeating and sedentary behaviors.
Dietary Intake and Calories
Self-monitoring of food intake is perhaps the most important behavioral strategy for weight control. Patients can be given paper copies of food journals or encouraged to use an internet program or smart phone app (e.g., MyFitnessPal). Patients are instructed to record everything they eat and drink, portion size, method of preparation, and the time of consumption. Ultimately, they should also record the calorie value for each food and drink item. They should be told that successful self-monitoring requires accuracy, consistency, and timeliness in relation to the performance of the behavior.16 Patients should be advised that the process of self-monitoring diet is a learning process that takes time to develop. It is important to keep in mind that patients may get frustrated by the challenge of not finding the exact food item they are consuming in the electronic tracking database or the difficulty of tracking when eating out or consuming recipes with multiple ingredients. It is important to remind them that they do not need to be perfect and the very act of tracking will increase mindfulness about their dietary intake—a key therapeutic objective of self-monitoring.
It is crucial to discuss a plan for record keeping including when and where patients will record their food intake and how they will remember to record. At subsequent visits the healthcare professional (HCP) reviews the number of meals eaten per day, type of foods eaten, and calories consumed and provides brief comments about the patient’s eating plan. Calorie counting is introduced early in treatment. Following methods used in the Diabetes Prevention Program15 and the Look AHEAD study,17,18,19 patients who weigh <250 lb are prescribed a diet of 1,200 to 1,499 kcal/day, with approximately 15% to 20% kcal from protein, 20% to 35% from fat, and the remainder from carbohydrate. Patients who weigh >250 lb are prescribed 1,500 to 1,800 kcal/day. These calorie goals may be reached by recommending conventional foods or meal replacements (i.e., a protein shake or protein bar that provides 15 to 20 g of protein, vitamins and minerals, and at least 5 g of fiber). Patients are shown how to determine calories using a book such as CalorieKing or by looking up calories online. Patients are encouraged to keep a running calorie total throughout the day. Later in treatment, patients can be encouraged to record the situations and contextual factors in which they are eating to help identify and target cues. Education on how to read food labels and measure food to increase accuracy is an important skill. It is also useful if patients are provided with meal plans which offer breakfast, lunch, and
dinner options for the week. A link to examples of meal plans is available in the Practical Resources section of this chapter. In summary, the HCP should recommend that the patient monitor diet as a first step to weight loss (“Ms. Jones, I recommend that you start recording all food and liquid intake and aim for 1,200 cal/day.”) For the clinician, it is important to keep in mind that patients often underestimate their calorie intake. Thus, the patient who is struggling with calorie intake despite a low-calorie count can be encouraged to lower their target by 200 to 300 kcal/day.
dinner options for the week. A link to examples of meal plans is available in the Practical Resources section of this chapter. In summary, the HCP should recommend that the patient monitor diet as a first step to weight loss (“Ms. Jones, I recommend that you start recording all food and liquid intake and aim for 1,200 cal/day.”) For the clinician, it is important to keep in mind that patients often underestimate their calorie intake. Thus, the patient who is struggling with calorie intake despite a low-calorie count can be encouraged to lower their target by 200 to 300 kcal/day.
Physical Activity
Although individual prescriptions will vary, most patients can be instructed to engage in low- to moderate-intensity physical activity (principally walking or similar aerobic activity) 5 days/week, gradually building to ≥180 minutes/week at approximately month 6 of treatment.19,20 The goal is increased to >225 minutes/week starting after the first 6 months of treatment, which is around the time that weight loss typically hits a plateau and is consistent with targets required for the maintenance of lost weight.21 Patients are instructed to record the duration and type of physical activity including any bouts of physical activity of 10 minutes or more. This recommendation is based on findings that four 10-minute bouts, spread across the day, result in similar improvements in fitness as one continuous 40-minute bout.20 Just as patients self-monitor their calorie intake through recording, they can self-monitor energy expenditure through the use of devices (e.g., Fitbit, Apple watch).
Weight
Patients should be weighed in the office regularly and also be encouraged to weigh themselves weekly or daily at home. The weight should be recorded in their food journal or on a weight tracking sheet or graph. This helps to track progress, establish relationships with their weight control behaviors, and catch small weight gains and make behavioral changes as necessary.14,22 For patients who are sensitive about their weight and hesitant to self-weigh at home, this recommendation can be put aside until the patient gains more comfort and confidence in the process.
Goal Setting
Setting goals related to weight control behaviors and weight loss can help to focus treatment and provide structure for visits.23 Patients are encouraged to set goals regarding weight, as well as specific weight control behaviors. We also encourage patients to set “SMART” goals that are Specific, Measurable, Achievable, Realistic, and Timely for weight loss and weight control behaviors. There is often a mismatch between HCPs and patients in terms of weight loss goals. Many obesity treatments recommend weight loss goals of 5% to 10% of initial body weight, as these goals are achievable and also are clinically valuable.17,24 On the other hand, patients often select goals that are two to three times larger than the average weight change outcomes and may be unrealistic.25,26 High weight loss goals, also called stretch goals, generally do not undermine weight loss efforts in the short or long term.27,28 Thus, they do not focus on the discrepancy between the patient’s ideal goals and what is realistic and instead focus on factors that predict successful outcomes such as consistent self-monitoring. Inform patients that you seek to help them reach their goals by making gradual, healthy, and reasonable changes in their eating and activity. However, it is useful to break larger weight loss goals into smaller goals such as 0.5 to 1 kg (1.1 to 2.2 lb) loss per week or 5% to 10% of baseline weight within 6 months.4 You can also say to patients, “Let’s work toward this goal first. When you reach this goal, we’ll discuss going further. You can definitely aim for higher goals if you’d like. I am here to help support you.” Occasionally you may have patients who want to lose less weight than the 5% and would benefit from greater weight loss. You can respond by saying, “You can decide what goals are best for you. Tell me why you would want to aim for a lower weight loss goal.”
Antecedents-Behaviors-Consequences Model
HCPs should individually tailor their treatment approach. This can be done using an analysis of the antecedents, behaviors, and consequences (“ABCs”) related to the patient’s weight-related behaviors. Antecedents are cues—either external or internal—that prompt a behavior, such as the sight of a high-calorie food or favorite restaurant, food cravings, hunger, or stress from work. Consequences are negative or positive actions or responses that come after the behavior, such as feeling guilty for overeating, receiving positive social reinforcement related to weight change, or having more energy. ABCs, which can be identified from self-monitoring records, form a behavior chain which can then be intervened upon to promote healthy eating and physical activity and to develop specific behavioral plans.
An example of a behavioral chain—and ways to break the chain—is provided in Figure 7.1. As shown, the patient stayed up late working on a presentation and was subsequently late for work, leaving her with no time to make breakfast or pack lunch (Links 1-3). This led to the patient eating two doughnuts in a meeting (4). This chain could be broken by making a plan to pack lunch the night before, or by calorie counting the doughnuts and planning the next meal accordingly. The patient
heads home after a long day and decides not to stop for groceries, even though she does not know what she will make for dinner (6). She opens the refrigerator and sees a few slices of leftover cake (7). Very hungry, she eats the cake while surfing the web, telling herself that she needs something delicious to make herself feel better (8, 9). The patient could have broken the chain by eating a go-to frozen meal option that she knows fits within her calorie goal, calling a friend instead of turning to the cake for comfort, or saving a slice of cake for after dinner and putting the rest in the freezer so it requires defrosting. The patient eating the cake might lead to negative self-talk or drastic recovery measures like skipping meals the next day to make up for calories, ultimately leading to feeling very hungry at dinner and overeating (10-13). Breaking chain links here could occur through meal planning for the following day, as skipping meals would only make one feel hungrier later. Ideally, an intervention should occur as early as possible in the chain. However, providing multiple strategies to break the link in several places is beneficial as patients can get an idea of what would be the “weakest link” for them to break.
heads home after a long day and decides not to stop for groceries, even though she does not know what she will make for dinner (6). She opens the refrigerator and sees a few slices of leftover cake (7). Very hungry, she eats the cake while surfing the web, telling herself that she needs something delicious to make herself feel better (8, 9). The patient could have broken the chain by eating a go-to frozen meal option that she knows fits within her calorie goal, calling a friend instead of turning to the cake for comfort, or saving a slice of cake for after dinner and putting the rest in the freezer so it requires defrosting. The patient eating the cake might lead to negative self-talk or drastic recovery measures like skipping meals the next day to make up for calories, ultimately leading to feeling very hungry at dinner and overeating (10-13). Breaking chain links here could occur through meal planning for the following day, as skipping meals would only make one feel hungrier later. Ideally, an intervention should occur as early as possible in the chain. However, providing multiple strategies to break the link in several places is beneficial as patients can get an idea of what would be the “weakest link” for them to break.
 FIGURE 7.1 Example of a behavioral chain. Each chain represents a process that can lead to unhealthy eating behaviors. Examples of interventions are in yellow bubbles. |
While the above example is fairly extensive and detailed, it can also be effective to discuss ABCs in a more general way or to focus on a particular part of the chain with patients as a way to target intervention strategies. For example, Ms. Jones may remark that she frequently overeats cookies after dinner. The provider could ask Ms. Jones, “what events, situations, thoughts, feelings, or behaviors may contribute to overeating episodes?” One trigger that Ms. Jones may identify is that she has a hard time resisting the cookies because she sees them on the counter. Ms. Jones and the provider could then discuss ways to decrease this behavior, such as keeping the cookies in the cabinet or by not keeping cookies in the house.
Stimulus Control
Stimulus control focuses on modifying external, environmental factors to make them more conducive to weight control goals. These strategies can be used to increase or decrease cues that foster healthy eating and exercise habits. Examples of stimulus control strategies include removing high-calorie foods from the home (or keeping them out of sight), asking work colleagues to keep high-calorie foods out of sight at work, keeping lower calorie foods (fruits and vegetables) on the counter or easily accessible, and putting gym shoes by the door (as a reminder to go for a walk). While these principles of behavior modification may seem intuitive, it is often the case that patients have not considered them. Thus, it is often helpful to check with patients that they are aware of the behavior patterns linked with excess food intake or minimal physical activity.
Problem-solving
Problem-solving is aimed at assisting individuals to develop adaptive solutions to cope effectively when faced with challenges encountered in everyday life. As outlined in Table 7.1, this approach uses a five-step problem-solving technique: (1) identify a problem; (2)
brainstorm potential solutions; (3) consider the pros and cons of each option; (4) choose a solution and develop plans for implementing it; and (5) test the efficacy of the strategy for a specific period of time. The process can be repeated if the problem was not successfully solved.
brainstorm potential solutions; (3) consider the pros and cons of each option; (4) choose a solution and develop plans for implementing it; and (5) test the efficacy of the strategy for a specific period of time. The process can be repeated if the problem was not successfully solved.
TABLE 7.1 Problem-Solving Steps | ||||||||||||
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Cognitive Restructuring
Maladaptive thought patterns can be antecedents to consumption of high-calorie food, underexercising, and reductions in weight control efforts (Figure 7.2). Thoughts such as, “I’ve had a tough day, so I deserve a treat,” or “I gained weight again; I knew I would never be able to lose weight” may be triggers to overeating or inactivity. Cognitive restructuring involves challenging problematic thoughts, emotions, and ideas that undermine efforts and hinder treatment adherence. These strategies help patients adopt positive rather than negative self-talk (e.g., if you eat a bowl of ice cream, choose to eat fewer calories the following day, rather than feeling guilt or shame). Patients may be asked to monitor and record their thoughts and feelings before or after eating. Any negative thinking patterns are identified and then reframed or countered with thoughts more conducive to weight loss, such as “I deserve a treat, so I think I’ll listen to some music,” or “Although I overate this time, I can learn from this and get back on track.”
Reinforcement
There are many rewards related to weight loss that can be reinforcing, especially in the early stages of treatment such as wearing smaller size clothes, observing decreased health risks, and receiving compliments from others. However, additional positive reinforcement is needed, especially during weight loss maintenance when the scale is no longer moving. Self-reinforcement incorporates assisting the patient to develop forms of self-reward. The type of reinforcement most effective for motivating behavior change differs for each person. Extrinsic motivators or incentives such as money or a new outfit are common; however, intrinsic motivation (self-enjoyment or satisfaction from achieving a goal) can also be powerful. For example, a patient who is struggling with logging her food may reward herself at the end of each day she meets the goal with 15 minutes of reading a new book or watching a new series. Patients should be encouraged to develop and keep their own reward system.
Social Support
Enhancing social support also may improve weight loss. Including family members or friends is one way to accomplish this. Patients should be asked about people who may be supportive of their weight control behaviors and what these individuals might do to further encourage the patients’ success. Patients may also need to develop strategies for dealing with weight loss “saboteurs” or “enablers” such as family members, coworkers, or friends who encourage overeating (whether consciously or unconsciously).
Relapse Prevention
Setbacks in patients’ weight control efforts are inevitable, and “slips” or less than perfect eating episodes are normal parts of the weight loss and maintenance process. Relapse prevention strategies have been adapted from substance abuse treatment for weight management to handle these setbacks.18,29 Patients should also be taught the difference between a lapse versus a relapse. Lapses are expected, temporary slips. For example, overeating snack foods for a day or two,
or skipping exercise for a week. A relapse is a return to frequent problematic weight control behaviors and is associated with weight regain. It is essential that patients learn to reverse small weight gains or lapses as they occur. These instances can be viewed as opportunities to learn and get back on track. Using relapse prevention techniques, HCPs teach patients to identify and describe potentially risky situations in which overeating or underexercising may occur. Patients and providers discuss strategies and step-by-step plans to flexibly manage these situations. For example, a patient may identify a high-risk situation as going out for lunch with coworkers. The HCP and patient may discuss several strategies such as bringing lunch, suggesting a healthier restaurant, or making sure to look at the menu beforehand to pick a lower calorie lunch option and then sticking with that choice. Discussions should also include scenarios in which the patient does have a lapse, say by going to lunch but consuming more calories than anticipated. Patients should be encouraged to spot the problem early and to restart self-monitoring (if they have stopped) and other weight control behaviors, to ask for social support, and to identify and address the trigger of the setback.
or skipping exercise for a week. A relapse is a return to frequent problematic weight control behaviors and is associated with weight regain. It is essential that patients learn to reverse small weight gains or lapses as they occur. These instances can be viewed as opportunities to learn and get back on track. Using relapse prevention techniques, HCPs teach patients to identify and describe potentially risky situations in which overeating or underexercising may occur. Patients and providers discuss strategies and step-by-step plans to flexibly manage these situations. For example, a patient may identify a high-risk situation as going out for lunch with coworkers. The HCP and patient may discuss several strategies such as bringing lunch, suggesting a healthier restaurant, or making sure to look at the menu beforehand to pick a lower calorie lunch option and then sticking with that choice. Discussions should also include scenarios in which the patient does have a lapse, say by going to lunch but consuming more calories than anticipated. Patients should be encouraged to spot the problem early and to restart self-monitoring (if they have stopped) and other weight control behaviors, to ask for social support, and to identify and address the trigger of the setback.
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