behavioral approaches to weight loss valerie h. myers, phd pennington biomedical research center
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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
Behavioral Treatment: Behavioral Treatment: OverviewOverview
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
Behavioral Treatment: Behavioral Treatment: OverviewOverview
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
Behavioral Treatment: Behavioral Treatment: OverviewOverview
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
Goal SettingGoal Setting
Be Specific Set criteria: time, frequency, duration
Make it measurable
Make it realistic
Goal SettingGoal Setting
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
Goal SettingGoal 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)
Goal SettingGoal Setting
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
Stimulus ControlStimulus 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”)
Stimulus ControlStimulus 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
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
Contingency ManagementContingency 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)
Contingency ManagementContingency 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
Contingency ManagementContingency 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
Contingency ManagementContingency 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
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
Stress ManagementStress Management
Stress Management Techniques(Physiological)
Diaphragmatic Breathing Progressive Muscle Relaxation Imagery Exercise Sleep Hygiene Reduce caffeine
Stress ManagementStress Management
Stress Management Techniques(Behavioral)
Limit Setting Time Management Training Scheduling Pleasurable Events