lifestyle modification and relapse-prevention training during treatment for weight loss

BEHAVIOR THERAPY 28, 307-321, 1997

Lifestyle Modification and Relapse-Prevention Training During Treatment for Weight Loss

SUSAN HEAD

Duke University Diet and Fitness Center

ALAN BROOKHART

University of California, Berkeley

A program evaluation involving the assessment of return patients at the Duke Uni- versity Diet and Fitness Center (DDFC) was undertaken with the intention of improving relapse-prevention training for patients during weight-loss treatment. Two- hundred and fifty-two patients (143 women, 109 men) who had previously lost weight at the DDFC were assessed on the first day of their return visit regarding their lifestyles at home, most frequently encountered high-risk situations, and strategies used to prevent relapse. The study was designed to determine which of these factors were associated with continued weight-loss and maintenance after discharge. Regression analysis (F = 19.89, p < .0001) indicated that time elapsed since treatment was associated with weight gain. Multiple regression analysis controlling for the effect of time on weight change indicated strategies associated with decreased weight during follow-up included "planning and monitoring" (t = -2.19, p < .03), and "positive self-talk, putting self first" (t = -2.51, p < .01). Lifestyle factors associated with success after discharge included "support" (F = 10.83, p < .001), "amount of daily activity" (F = 10.98, p < .001), and "quality of daily activity" (F = 7.69, p < .006). When we examined the "most successful" versus the "least successful" patients after discharge, "planning and monitoring" (F = 8.15, p < .005) and "positive self-talk, putting self first" (F = 8.85, p < .004) were associated with the "most successful;' while "using no strategies" (F = 7.47, p < .007) was associated with the "least successful?' In light of the findings, suggestions are made for including lifestyle modification as a major part of relapse-prevention training.

Short-term weight loss is relatively easy to achieve. Conservative approaches (e.g., comprehensive behavioral treatment) produce losses of about 10% to 15% of initial weight for, moderately obese individuals (see review by Wadden & Sarwer, in press). Very low calorie diets (VLCDs) produce even greater initial losses, ranging from 15% to 22% of initial weight (Wadden

Address correspondence to Susan Head, Ph.D., Duke University Diet & Fitness Center, 804 W. Trinity Ave., Durham, NC 27701. Email address: [email protected]. Phone: (919) 684-6331, ext. 240.

307 0005-7894/97/0307-0321 $1.00/0 Copyright 1997 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

308 HEAD & BROOKHART

& Sarwer). And surgery (i.e., gastric bypass) produces weight losses of about 60% to 70% of excess body weight (i.e., amount over ideal weight) in the morbidly obese (Kral, Sjostrom, & Sullivan, 1992; Sugarman et al., 1992). The problem with losing weight is not initial losses but long-term weight loss and maintenance. Most people who lose weight by conventional methods regain their weight after treatment (see review by Foster & Kendall, 1994). Even those who lose weight through surgery remain about 50% above ideal weight, and the surgery failure rate is about 15% (Sugarman et al.).

Why is weight loss so difficult to maintain after treatment? What seems like a simple problem of energy regulation-less food + more exercise = weight-loss-is far more complicated than originally thought. Factors such as physiology, emotional well-being, and behavioral conditioning confound the picture, rendering a simple energy regulation model inadequate. Often treatment does not prepare patients to cope with the physiological processes that compensate for weight loss (e.g., lowered metabolism) and the negative psychological consequences that result from the inability to sustain weight loss (e.g., self-blame and guilt). Additionally, since treatment often occurs in a highly structured environment, patients may find themselves unprepared to cope with the environment at home. Relapse-prevention programs have been implemented to address these problems (see Brownell, Marlatt, Lich- tenstein, & Wilson, 1986; Perri & Nezu, 1993). Still, the majority of patients relapse after weight loss (Foster & Kendall, 1994; Perri & Nezu; Wadden & Sarwer, in press).

Posttreatment follow-up programs, including therapist contact, aerobic exercise, social support, and/or combinations of these components, improve maintenance at home (see Perri, Nezu, & Viegener, 1992). However, even with extended follow-up, patients usually start to regain soon after follow-up ends. Additionally, extended follow-up programs can be time-consuming and costly. In spite of these problems, some sort of follow-up is probably necessary if patients are to maintain their focus. Clearly, research needs to focus on creating feasible follow-up programs.

Even with follow-up, patients need relapse-prevention training during treatment to prepare them for the challenges they will face at home. Perri, McAdoo, Spevak, & Newlin (1984) examined the effects of relapse-prevention training as defined by Marlatt and Gordon (1980). Relapse-prevention training consisted of (a) identifying high-risk situations, (b) training in problem- solving, (c) in vivo practice in coping with high-risk situations, and (d) cognitive restructuring to cope with the guilt feelings and sense of failure associated with slips. Perri et al. (1984) found that relapse-prevention training improved the efficacy of therapist contact during follow-up. However, relapse- prevention training without therapist contact did not significantly improve maintenance. They suggest that the failure of relapse-prevention training without follow-up may be due to patients being trained in too many strategies in too brief a period to master them well enough to use at home. Additionally, training may be too generic, failing to take into account individual differences among patients and their problems at home.

LIFESTYLE AND RELAPSE-PREVENTION 309

The conclusion is that standard relapse-prevention training is necessary yet insufficient when relied on as the sole means to prevent relapse. Ideally, relapse-prevention should be combined with some sort of follow-up program. Whether as an adjunct to follow-up or as the only means to improve success after weight-loss, relapse-prevention training needs to be improved for the reasons cited above. Perhaps improved training to prevent relapse would create less reliance on outpatient follow-up.

Marlatt and Gordon's (1985) relapse-prevention model, as described above, focuses on situational obstacles (i.e., high-risk situations) to successful weight management practices (e.g., meal-plan adherence arid regular exercise). Awareness of high-risk situations and problem-solving are obviously necessary for success. But what may be missing from traditional relapse-prevention is a focus on more global aspects of the maintenance problem, particularly one's overall lifestyle.

Obviously there is overlap between the concept of lifestyle and high-risk situations. After all, a person's lifestyle is composed of an accumulation of daily situations, some of which may be high-risk. But lifestyle is more than just an accumulation of situations. It is driven by basic attitudes and ideas about how life should be lived, including conditions considered necessary for happiness and satisfaction, and methods of seeking those conditions. The maintenance situation for many people is similar to that of a recovering alco- holic living in a nightclub. Regardless of how well one may have learned to cope with high-risk situations, the basic lifestyle contains so much risk that failure is inevitable. One patient recently admitted that eating rich foods and drinking fine wines in restaurants is a large part of what he considers "the good life" proof of his success as a businessman. In this case, food is an important part of the lifestyle because it symbolizes success. Another example illustrates the problem of conveying to patients that their weight status is not isolated from the way they live their lives. During a group session on lifestyle change, a patient was asked how he would need to alter his lifestyle to maintain his weight loss. His response was, "I'll have to eat less" While that response is certainly accurate, it reveals a lack of understanding how his lifestyle may make it more difficult to simply "eat less." Patients need to evaluate their overall lifestyles, values, and the role food plays in their lives in order to understand why coping with high-risk situations and eating less is often so difficult.

Perri (1992) and others (e.g., Colvin & Olson, 1983) have acknowledged the importance of establishing a lifestyle, unique to the individual, that supports a healthier, leaner physique. However, global lifestyle assessment and recommendations for modification have not typically been a part of relapse- prevention training. Adding a global assessment of the patient's lifestyle and planning specific interventions to create a lifestyle conducive to success may improve the traditional relapse-prevention model.

The model we propose addresses general issues including lifestyle, high- risk situations, and effective coping strategies common to most patients as


well as issues specific to each individual. The proposed model consists of four components:

1. Lifestyle assessment and recommendations to reduce activities and interests correlated with overeating and lack of exercise, replacing them with activities and interests that support a healthier, leaner physique. Such an assessment would have patients consider basic premises about what comprises a satisfying life, and how they obtain positive reinforcement in their lives.

2. Recognition of common (e.g., buffet dining) as well as individual (e.g., after argument with spouse) high-risk-situations.

3. Generation of appropriate strategies (cognitive, behavioral, stress management) to address specific high-risk situations.

4. In vivo and/or imaginal practice using strategies in high-risk situations.

To facilitate general relapse-prevention training by improving lifestyle, recognizing high-risk situations, and using strategies, it should be helpful to determine which elements of these items are common to a majority of patients, and which differentiate successful maintainers from those who gain weight at home. A general approach would educate and improve awareness of important variables for success in these three domains. Then a more idiographic assessment, as suggested by Perri and Nezu (1993), could be utilized to tailor the relapse-prevention plan to the individual. Knowing which factors are important to address, both in general and for specific individuals, should help alleviate the problem noted by Perri et al. (1984) of training in too many strategies in too brief a period of time. Such an approach would also insure that training is not generic.

This study was designed to determine which lifestyle factors, high-risk situations, and relapse-prevention strategies differentiated those who were successful from those who gained weight at home. The study was part of our ongoing program evaluation to improve the programs we offer. The intent was to use the findings to enhance general education and training in lifestyle modification and relapse-prevention common to most patients. We assessed patients who had previously been in treatment for weight loss at our center and were currently enrolled in our Return Patient program for further treatment. Since return patients have had the opportunity to practice what they have learned previously, they should have greater clarity about what contrib- utes to success and failure than those who come into treatment for the first time. We assessed patients on the first day of their return visit while memories of their situations at home were still fresh.

This study addressed the following questions:

1. How long are individuals typically successful at home before relapse occurs? It is our observation that weight fluctuations of 3 or 4 pounds are common and do not necessarily indicate relapse. Therefore, relapse was defined as "weighing 5 pounds or more above discharge weight"


This definition is commonly used by our staff and is based on anecdotal patient reports (e.g., "I know I am in trouble if I put on 5 pounds") and our clinical observations. Relapse was determined by comparing current weights to previous discharge weights.

2. Since individuals typically lose weight in treatment and relapse at home, how do their lifestyles at home differ from their lifestyles during treatment in terms of the elements that contributed to success during treatment (e.g., support, structure, stress-management, availability of exercise, availability of appropriate food, amount and quality of daily activities); and which of these variables distinguishes those who are successful (i.e., gain less than 5 pounds or continue to lose) from those who gain weight after treatment?

3. Which situations pose the greatest risk at home, and are specific situations associated with weight status upon return?

4. Which strategies are most often used to deal with high-risk situations, and are specific strategies associated with success status?

5. Are there gender differences in terms of success status, high-risk situations, and strategies for preventing relapse?

Method Subjects

There were 252 subjects in this study. This sample was derived from 342 consecutive participants in the Return Patient program at the Duke University Diet and Fitness Center (DDFC) over the course of 15 months. Since the sta- tistical analyses used weight change since last discharge from the DDFC as the dependent variable, only those patients whose weights could be verified by our records were included in the study. Ninety of the original 342 subjects were omitted from the study because of (a) inability to verify weight change since discharge (n = 72), or (b) incomplete assessment information (n = 18). We were unable to verify weights on 72 patients for one of two reasons: the previous discharge weight was not recorded in the patient's record; or, the patient's first weight during his/her return visit was not recorded. Since this study, more careful weight recording practices have been adopted in the clinic.

Of the 252 subjects remaining in the study, 143 (57%) were women. The average age was 53.8, ranging from 24 to 81 (SD = 12). The average pretreatment weight at the time of first visit was 243.86 pounds, ranging from 114.8 to 494 (SD = 69.8). These subjects lost an average of 15.16 pounds, and stayed in treatment an average of 4 weeks. These subjects were similar to other treatment samples at the DDFC (see for example, Head, Hamilton, Babyak, Brownlow, & Kolotkin, 1997), in which the averages on 785 subjects were reported as follows: age = 53.39, pretreatment weight = 246.04, weight-loss during the initial visit = 19.2 pounds, 58% female, and length of stay = 4 weeks.


Of the 90 subjects omitted from the study, we were able to obtain the following information: 50% were female (n = 84), the average age was 50.4 (n = 63), ranging from 22 to 73 (SD = 14), and the average pretreatment weight was 265.14 (n = 60), ranging from 148 to 618 (SD = 81.57). The subjects omitted from the study did not differ significantly on these variables from the subjects who remained in the study.

The DDFC is a multidisciplinary day treatment program for obesity in Durham, North Carolina. The treatment approach at the DDFC includes assessment, education, and training in four areas: medical, nutrition, physical fitness, and psychological/behavioral. We emphasize the importance of establishing a healthy lifestyle that supports long-term weight management. Our endeavor is to offer a model of such a lifestyle at the center that includes a variety of stimulating educational, physical, and social activities. Participants come from all areas of the country and stay for about 4 weeks. They are mostly Caucasian and of middle- to upper-middle-class socioeconomic status.

Design and Procedure On the first day of the return visit, patients met as a group with a psychol-

ogist or social worker from the behavioral staff. The group typically consisted of about eight persons. Each person filled out a brief questionnaire inquiring: (1) how long it had been since the last visit; (2) how successful they perceived themselves to be at home; (3) why they decided to return to the DDFC; (4) weight change status, i.e., whether they lost, maintained, or gained weight at home; (5) elements of the home environment compared to the DDFC environment; (6) specific high-risk situations; and (7) specific strategies that helped prevent relapse. Weight status was verified by comparing subjects' self-report of weight change (i.e., whether they reported having lost, maintained, or gained weight since discharge) with actual recorded changes from previous discharge to current admission, yielding an estimate of reporting accuracy. Reporting accuracy was 75% overall. Percent agreement for the three groups was as follows: weight-losers, 80%; maintainers, 50%; weight-gainers, 81%. The criterion for maintenance (current weight within 5 pounds of previous discharge weight) required more accurate knowledge of weight change, which may account for less agreement between reported and actual weight change in that group. After answering the questionnaire, a discussion ensued to help subjects clarify their answers and focus on goals for their return visit.

Questionnaire development. We developed a questionnaire to evaluate lifestyle, high-risk situations, and relapse-prevention strategies at home. The lifestyle factors examined in this study were chosen by mutual agreement among the four behavioral staff members (two clinical psychologists and two clinical social workers). Based on our clinical experience, we decided upon the lifestyle elements that seemed to help patients succeed while on our program. Those factors were: "Interpersonal support,' "Structure" "Stress man-


agement," 'Accessibility of exercise" 'Accessibility of appropriate food" 'Amount of daily activities" and "Quality of daily activities:' The questionnaire asked subjects to rate these factors according to the following instruc- tions: "Please rate the [above-listed] aspects of your home environment compared with the environment of the DDFC, using the following scale: 1 =

m u c h worse , 2 = s l ight ly worse , 3 = abou t the same , 4 = a little bet ter , 5 = m u c h be t t e r " Therefore, a rating of 2 on "interpersonal support" would indicate that interpersonal support at home was slightly worse than it was at the DDFC. Such a response would indicate an area in which improvement at home may be required.

The questionnaire also evaluated high-risk situations and relapse-prevention strategies at home. The questions concerning these factors were open-ended. Subjects were asked to list the situations that posed the most difficulty in terms of sticking with their weight-loss program at home. They were also asked to list any strategies that helped them stick with their program. The first author reviewed and coded the answers. Then both authors categorized the high-risk situations and strategies by mutual agreement. Five high-risk and six strategy categories were obtained. Situations, strategies, and fre- quency of endorsements are listed in Table 1. The high-risk situations were labeled and include the following: "Eating in restaurants" includes restaurant eating during the work day, while socializing, and when traveling for business or pleasure; "Lack of structure or planning" includes failure to plan meals or exercise, changes in normal routine that interfere with planned meals and/or exercise, and severe weather or other unexpected external conditions that interfere with plans; "Socializing and entertaining" includes situations in which food is a major component of having a good time, such as social events or when entertaining in the home; "Food temptations and cravings" include strong spontaneous urges to eat and urges to overeat during meal preparation, "cocktail hour," or other times when food is readily available; "Emotional and physical problems" includes items indicating that internal triggers such as emotional stress, illness, or injuries triggered eating episodes.

The strategies for preventing relapse were labeled and include the following: "Planning, monitoring, and structure" includes preplanning meals

TABLE 1 HIGH-RISK SITUATIONS AND RELAPSE-PREVENTION STRATEGIES REPORTED BY RETURN PATIENTS

High-Risk Situations Freq. Relapse-Prey. Strategies Freq.

1. Eating in restaurants 2. Lack of structure, planning 3. Socializing, entertaining 4. Food temptations/cravings 5. Emotional and/or physical problems

65 1. Planning, monitoring 108 101 2. Nonspecific strategies 26 32 3. No strategies 45 66 4. Exercising regularly 54 76 5. Positive self-talk, putting self first 39

6. Social support 18


and snacks, sticking to a daily schedule or routine, and monitoring meals and snacks; "Nonspecific strategies" was coded when a subject responded that they used general skills or strategies that they had learned during a previous visit to the DDFC; "No strategies" was coded when the strategies question was left blank or answered as "none"; "Exercising regularly" is self- explanatory; "Using positive self-talk, putting self first" includes items indicating the use of cognitive restructuring to reduce feelings of failure, positive coping statements, and making one's weight loss and health goals a top priority; "Social support" includes utilizing support from family and friends as well as professional support from a dietitian, psychotherapist, or personal trainer. Five subjects reported coming back to the DDFC as a strategy. Since there were so few endorsements for that item, it was not included in the analyses. It was not coded as "social support" because returning to the DDFC for an intense 1- to 4-week visit seems to differ fundamentally from social support at home (e.g., a weekly visit with a professional or regular support from a friend or family member).

Results Weight Change and Time

Patients were categorized as "successful" if they had gained less than 5 pounds above their previous discharge weight or had continued to lose weight at home. Of the 252 subjects in the study, 40% (n = 102) were successful at home, while the remainder gained weight. Of those who gained weight at home (n = 150), weight gain averaged + 16.66 pounds, and ranged from +5.0 to +77.8 pounds (SD = 12.06). Of those who were successful at home, weight change averaged -10.05 pounds, ranging from +4.8 to - 6 4 . 2 (SD = 14.29). Since it is known that subjects are likely to regain weight over time, a regression was used to look at the relationship between weight change and time elapsed since treatment. Time since treatment (here- after referred to as "time") ranged from 2 to 42 months, accounted for 7% of the variance in weight change, and was significant (F = 19.89, p < .0001). This finding indicates that the longer the time between discharge and a return visit, the more likely it is that weight will be regained.

We also compared the successful (i.e., "success") to the unsuccessful (i.e., "gain") group in terms of "time" A t-test indicated that these groups were significantly different, (t = 3.87, p < .0001), and averaged as follows: "gain" = 12.67 months (range = 2 to 42, SD = 8.38); "success" = 9.32 months (range = 2 to 24, SD = 5.34).

Weight Change, Lifestyle Factors, High-risk Situations, and Relapse-prevention Strategies

A multiple regression was performed to assess the effect of several subject characteristics on weight change since discharge. The variables of interest were: age, sex, pretreatment weight, amount of weight lost during initial


visit, and length of first treatment. The regression model was nonsignificant (F = .56, p < .73), indicating that these variables had no significant effect on weight change since previous discharge. Therefore, these variables were not included in the subsequent regression analysis.

Next, a multiple regression was used to analyze the association between weight change and lifestyle factors, high-risk situations, and relapse- prevention strategies. Since "time" was shown to be significantly associated with weight change, it was also included in the model. Therefore, this multiple regression model included the following variables: time, lifestyle variables (support, structure, stress, food, exercise, amount of daily activities, quality of daily activities), five high-risk situations, and six relapse- prevention strategies (see Table 1). Weight change was the dependent variable. The model was significant (F = 2.59, p < .0005) and accounted for 20% of the variance. Factors that contributed significantly to the model were time (t = 3.55, p < .0005), and two of the relapse-prevention strategies: "planning and monitoring" (t = -2.18, p < .03), and "positive self-talk, putting self first" (t = -2.50, p < .01). These findings indicate that weight gain over time is strongly associated with time elapsed since treatment. Weight loss, on the other hand, is associated with planning, monitoring, making personal improvement goals a top priority, and using positive self-talk, regardless of time elapsed since treatment. None of the lifestyle factors nor the high-risk situations were associated with weight change.

Group Differences on Lifestyle, High-Risk, and Relapse-prevention

Group differences were examined for the success versus the gain group, using analysis of covariance (ANCOVA), with time as the covariate. Bonfer- roni corrections were used to obtain an overall alpha of .05. Prior to con- ducting the ANCOVAs, the groups were compared with regard to age, sex, pretreatment weight, amount of first weight loss, and length of stay during initial visit. There were no significant group differences on any of these variables. Therefore, they were not included in the following analysis.

The ANCOVAs comparing differences in lifestyle variables indicated that the success group evaluated the following variables significantly higher compared with the gain group: "support" (F = 10.83, p < .001), "amount of daily activity" (F = 10.98, p < .001), and "quality of daily activity" (F = 7.69, p < .006). There were no significant group differences on the "high-risk situation" or "relapse-prevention" variables. These findings indicate that lifestyle factors including support, amount, and quality of daily activities are important for maintaining success at home. Apparently, neither high-risk situations nor relapse-prevention strategies differentiated these two groups. Table 2 shows the means, standard deviations, percent variance, F and p values for the two- group ANCOVAs comparing "lifestyle" variables, with time as a covariate.

Next, ANCOVAs were used to compare the "most successful" to the "least successful" subjects. We anticipated that comparisons of these two extreme groups would be more likely to reveal significant differences in lifestyle, high-


TABLE 2 ANCOVAs COraPAR1NG SUCCESS (n = 102) TO GAIN (n = 150) GROtJP

ON LIFESTYLE FACTORS WITH "TIME" AS A COVARIATE

Success Group Gain Group Variance Lifestyle Factors X / S D X / S D Accounted For F / p - v a l u e

Support 3.10/1.25 2.60/1.05 .04 10.83/.001 * Structure 2.36/1.18 2,03/ 1. I l .02 5.73/.02 Stress 2.24/1.29 2,05/1.13 .006 1.68/. 19 Access to exercise 2 .93/ .99 2.91/1.19 .002 .0/.97 Access to food 2.83/1.02 2.61/1.15 .01 2.95/ .09 Amount of activity 2.76/1.25 2.24/1.12 .05 10.98/. 001 * Quality of activity 2.85/1.23 2.35/1.14 .05 7.69/ .006"

Scoring: 1 = m u c h worse , 2 = s l ight ly worse , 3 = abou t the s a m e , 4 = a l i t t le bet ter , 5 =

m u c h better.

* Significant at Bonferroni corrected alpha < .007.

risk situations, and relapse-prevention strategies. The "most" and "least" successful subjects were selected by examining the top and bottom quartiles of the weight change distribution, then assigning weight cutoff scores. The "most successful" subjects (n = 55) were those who lost more than 5 pounds and fell in the lowest 25 percentile on the weight change distribution. The "least successful" subjects (n -- 61) were those who gained more than 15 pounds and fell in the highest 25 percentile on the weight change distribution.

Average weight change for the "most successful" group was - 19.41 pounds (range = -5 .6 to -64 .2 , SD = 13.45). Average weight change for the "least successful" group was +26.83 pounds (range = + 15 to +77.8, SD - 13.14). The most successful differed significantly from the least successful on time since previous discharge. The most successful averaged 9.27 months since treatment (range = 3 to 24, SD = 4.77), while the least successful averaged 13.67 months (range = 3 to 42, SD = 9.29). Time was used as a covariate in the ANCOVAs. The groups did not differ significantly on age, sex, pretreatment weight, amount of first weight loss, or length of stay during initial visit.

The ANCOVAs indicated that the most successful differed from the least successful on only one of the lifestyle factors: "quality of daily activities" accounted for 9% of the variance (F = 7.29, p = .008). The average score on this factor was 2.84 (SD = 1.19) for the most successful group, and 2.13 (SD = 1.12) for the least successfulgroup. These two groups did not differ on high-risk situations. However, there were significant group differences on the following relapse-prevention strategies: "planning and monitoring" (F = 8.15, p < .005), "using no strategies" (F = 7.47, p < .007), and "positive self- talk, putting self first" (F = 8.85, p < .004). These findings indicate that the quality of daily activities is important for success. In addition, the most successful used relapse-prevention strategies including planning, monitoring, and positive self-talk more frequently than did the least successful subjects.


TABLE 3 ANCOVAs COMPARING "MOST SUCCESSFUL" (n = 55) TO "LEAST SUCCESSFUL" (n = 61)

SUBJECTS ON RELASPE-PREVENTION STRATEGIES WITH TIME AS A COVARIATE

Most Least Variance Relapse-Prevention Successful, Successful, Accounted Strategies # Endorsements # Endorsements for F/p-value

Planning/monitoring 31 (56 %) 17 (28 %) .09 8.15/.005" Nonspecific strategies 5 (9%) 4 (7%) .002 .27/.60 No strategies 5 (9%) 20 (33%) .10 7.47/.007* Regular exercise 14 (26%) 15 (25%) .05 .35/.56 Positive self-talk 14 (26%) 4 (7%) .07 8.85/.004* Social support 6 (11%) 3 (5 %) .01 1.27/.26

* Significant at Bonferroni corrected alpha < .008.

The least successful were more likely not to use any strategies at all to prevent relapse. Table 3 shows the number of endorsements for each group, variance accounted for, F and p values for relapse-prevention strategies.

Gender Differences T-tests were used to compare men (n = 109) and women (n = 143) on

the following variables: "time" "weight change" and "lifestyle factors." Men and women did not differ on any of these variables. Chi-square analyses were used for gender comparisons on "high-risk situations" and "relapse-prevention strategies" There were no significant gender differences on any of the variables listed above except for "planning and monitoring" for relapse-prevention. Women were significantly more likely to use planning and monitoring to prevent relapse than were men (~2 = 7.58, p < .006). Fifty percent of women reported using planning and monitoring, compared with only 33% of men.

Discussion This study was part of a program evaluation designed to improve main-

tenance after weight-loss treatment. We expanded the model of relapse- prevention to include lifestyle modification. We assessed the home envi- ronments of our return participants in terms of lifestyle factors, high-risk situations, and relapse-prevention strategies, in order to compare successful patients with those who gained weight at home. The purpose of the study was to gain information about what helps individuals succeed at home, and to use this information to improve relapse-prevention training. The subjects were all returnees to the DDFC. We looked at weight change as a continuous variable and also divided subjects into two groups-successful versus those who gained weight-based on weight change since previous discharge. We also compared the "most" with the "least" successful. Finally, we examined gender differences relative to the factors of interest. Since time elapsed since


previous discharge was associated with weight change after discharge, we controlled for the effects of time in our analyses.

As expected, we found a significant association between weight change and amount of time elapsed since last visit. In general, the longer one waits to return to treatment, the more likely one is to relapse. More specifically, our findings indicate that those who continued to lose or maintain their weight loss returned to the center after about 9 months. Those who gained weight waited over a year to return to the center.

That those who continue to lose or maintain their weight loss at home tend to return to the DDFC sooner than do those who regain weight may indicate a fundamental difference in attitude about long-term weight loss and maintenance. This difference indicates that those who are successful use return visits as a strategy to prevent relapse, while gainers use return visits as crisis intervention. Once relapse occurs it is often accompanied by a sense of loss of control, personal failure, and guilt. These feelings make it difficult to regain control over eating. Successful individuals who return to treatment before gaining weight may have developed an "early warning system" as described by Perri and colleagues (1993), that allows them to avert crises by responding to lapses before they become relapses. A prevention rather than a crisis intervention attitude to weight maintenance needs to be encouraged during treatment.

In regard to lifestyle factors, the group comparisons indicated that a sup- portive environment and satisfaction with amount and quality of daily activities were important factors associated with success after treatment. Assess- ing the quality of the support system and satisfaction with amount and quality of daily activities should be an important first step in lifestyle modification training. Because of their obesity, patients often report a sense of alienation from family, friends, and others in their social environment. Perri and colleagues (1992) make several suggestions for improving support for weight loss at home. Additionally, some patients may require skills training (e.g., communication, assertiveness) to improve their ability to get their interpersonal needs met. While patients are in treatment, it may also be helpful to provide references of weight-loss professionals in particular locales.

The "daily activities" items probably reflect satisfaction with one's general lifestyle. It is not surprising that satisfaction with amount and quality of daily activities is associated with successful weight loss and maintenance after treatment, since it is generally accepted that positive emotions such as satisfaction, joy, and contentment enhance goal achievement, whereas negative emotions delay progress in reaching goals (see, for example, Kanfer & Schefft, 1988). As stated earlier, many patients may assign food a prominent role as entertainment and reinforcement, or there may be too much reliance on food as a coping strategy. Patients may require assistance in examining the role food plays in their lives as an activity, a source of entertainment, and as a source of reinforcement. Then assistance can be directed at helping patients develop other sources for entertainment and positive reinforcement.


In the analyses of high-risk situations, there were no significant differences between successful and unsuccessful subjects. It is not surprising that overall high-risk situations were not significantly associated with weight change. High-risk situations often occur without warning and are, therefore, as likely to occur for those who are losing weight as for those who are gaining. Differ- ences among groups are more likely to correspond with the basic lifestyle and with how well a person copes with risky situations.

In the regression analysis as well as the group comparisons of "most" and "least" successful subjects, "planning and monitoring" and "positive self-talk, putting self first" were significantly associated with success at home. In terms of training for relapse-prevention, emphasis should be placed on meal- planning, monitoring daily meals and exercise, and structuring daily meals, exercise, and other activities. The importance of "putting self first"- making one's healthy lifestyle changes a priority-also needs to be stressed. Addition- ally, patients need training in using positive self-talk to diminish guilt, lowered self-esteem, and decreased motivation following lapses.

Not surprisingly, using no skills at all to prevent relapse was significantly associated with weight gain when we compared the "most" to the "least" successful subjects. Apparently, many patients still do not understand the importance of using strategies for long-term weight-loss.

It is interesting to note that in the first set of group comparisons that included the entire sample (i.e., "Success" versus "Gain"), there were significant differences in lifestyle variables, yet no differences in relapse- prevention strategies. However, in the second set of group comparisons between the "most" and "least" successful, there was only one significant difference on lifestyle variables, yet there were several significant differences in relapse-prevention strategies. One explanation may be that the larger sample size in the first comparison contributed to increased power, therefore making significant differences more likely on the lifestyle variables. At the same time, the patients omitted in the second set of comparisons were those who had lost less than 5 pounds or gained up to 15 pounds. As such, these individuals may not have been using strategies that enable one to be truly successful at home. Their responses seemed to have clouded the issue in terms of defining strategies that contribute to success.

The only area in which men differed significantly from women on any of the variables was in their lack of planning and monitoring to prevent relapse. Men may be more likely to rely on sheer will power to lose weight, rather than planning and monitoring their progress. The reasons for this are open to speculation.

The findings of this study point to several way~ in which relapse-prevention training can be improved during treatment. This study emphasized deter- mining general areas of importance for lifestyle intervention, recognizing high-risk situations, and strategies training. The idea is to address the important areas that apply to the most people, then proceed with a more idiographic intervention as described by Perri et al. (1992). This approach should reduce


the tendency to train in too many strategies, and eliminate generic training. We particularly endorse including lifestyle assessment and recommendations for change as an integral part of relapse-prevention training. Lifestyle change should aim to create an environment at home that includes the essential elements to support a healthier leaner physique (see Table 2).

In terms of strategies used to prevent relapse, it seems that some sort of strategy is usually attempted (i.e., only 45 patients endorsed "no strategies used"), but no specific strategy received unanimous endorsement (i.e., the highest number of endorsements were 108 for "planning, structure, and monitoring"). These results suggest that, in general, we need to place greater emphasis on the importance of using strategies. Also, since men were much less likely to use planning and monitoring, perhaps we need to emphasize to men the advantage of planning and monitoring their daily food intake and exercise.

There are several limitations to this study that should be acknowledged. First, our study sample was a rather select group of upper middle-class, mostly Caucasian subjects who willingly returned to the DDFC for follow-up treatment. Therefore, the generalizability of our findings may be somewhat limited. For example, important lifestyle variables may differ considerably for persons of lower socioeconomic status. Also, the data itself were drawn from retrospective self-report, and as with all self-report data, subject to recall bias. We did, however, attempt to limit recall bias by assessing patients on the first day of their return visits while memories were relatively fresh. There are also limitations of our questionnaire for which there is no data on reliability or validity. We attempted to minimize these limitations by dis- cussing the questionnaires at the time of administration to ensure that all questions were thoroughly understood. Additionally, both authors categorized the open-ended questions to ensure agreement on high-risk situations and relapse- prevention strategies. The study also could have been improved by assessing inter-rater reliability for coding of high-risk and relapse-prevention strategies.

Another issue concerns assessing lifestyle variables versus high-risk situations versus relapse-prevention strategies. As noted earlier, clearly there is overlap between situations and general lifestyle. In our study, for example, some reference to "structure" or lack thereof appeared in all three categories. Perhaps structure is indeed both a feature of one's lifestyle and a strategy that can be implemented to address high-risk situations. Research is needed to define the elements that set lifestyle apart from mere situations or strategies.

This study addresses the need for continued program evaluation to improve our models of treatment. The concept of lifestyle change as an integral part of maintenance of new behaviors is well-established. However, integrating lifestyle change into a relapse-prevention training model, with or without follow-up, enhances the traditional model of relapse-prevention training. It will be interesting to see if attention to lifestyle modification duririg relapse- prevention training decreases the need for intensive follow-up after treatment.


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RECEIVED: August 10, 1996 ACCEPTED: May 13, 1997

lifestyle modification and relapse-prevention training during treatment for weight loss

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