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Guidelines on Overweight and Obesity: Electronic Textbook
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Behavior Therapy

Behavioral strategies to reinforce changes in diet and physical activity can produce a weight loss in obese adults in the range of 10 percent of baseline weight over 4 months to 1 year. Unless a patient acquires a new set of eating and physical activity habits, long-term weight reduction is unlikely to succeed. The acquisition of new habits is particularly important for long-term weight maintenance at a lower weight. Most patients return to baseline weights in the absence of continued intervention. Thus, the physician or staff members must become familiar with techniques for modifying life habits of overweight or obese patients.

The goal of behavior therapy is to alter the eating and activity habits of an obese patient. Techniques for behavior therapy have been developed to assist patients in modifying their life habits.

Evidence Statement: Behavior therapy, in combination with an energy deficit, provides additional benefits in assisting patients to lose weight short-term (1 year). Its effectiveness for long-term weight maintenance has not been shown in the absence of continued behavioral intervention. Evidence Category B.

Rationale: The primary assumptions of behavior therapy are that:

  • by changing eating and physical activity habits, it is possible to change body weight;
  • patterns of eating and physical activity are learned behaviors and can be modified; and
  • to change these patterns over the long term, the environment must be changed.

Behavior therapies provide methods for overcoming barriers to compliance with dietary therapy and/or increased physical activity, and are thus important components of weight loss therapy. Most weight loss programs incorporating behavioral strategies do so as a package that includes education about nutrition and physical activity. However, this standard "package" of management should not ignore the need for individualizing behavioral strategies (579).

Behavior therapy strategies used in weight loss and weight maintenance programs

Studies reviewed for this report examined a range of modalities of behavioral therapy. No single method or combination of behavioral methods proved to be clearly superior. Thus, various strategies can be used by the practitioner to modify patient behavior. The aim is to change eating and physical activity behaviors over the long term. Such change can be achieved either on an individual basis or in group settings. Group therapy has the advantage of lower cost. Specific behavioral strategies include the following:

  • Self-monitoring of both eating habits and physical activity—Objectifying one's own behavior through observation and recording is a key step in behavior therapy. Patients should be taught to record the amount and types of food they eat, the caloric values, and nutrient composition. Keeping a record of the frequency, intensity, and type of physical activity likewise will add insight to personal behavior. Extending records to time, place, and feelings related to eating and physical activity will help to bring previously unrecognized behavior to light (580).
  • Stress management—Stress can trigger dysfunctional eating patterns, and stress management can defuse situations leading to overeating. Coping strategies, meditation, and relaxation techniques all have been successfully employed to reduce stress.
  • Stimulus control—Identifying stimuli that may encourage incidental eating enables individuals to limit their exposure to high-risk situations. Examples of stimulus control strategies include learning to shop carefully for healthy foods, keeping high-calorie foods out of the house, limiting the times and places of eating, and consciously avoiding situations in which overeating occurs (580).
  • Problem solving—This term refers to the self-corrections of problem areas related to eating and physical activity. Approaches to problem solving include identifying weight-related problems, generating or brainstorming possible solutions and choosing one, planning and implementing the healthier alternative, and evaluating the outcome of possible changes in behavior (580).  Patients should be encouraged to reevaluate setbacks in behavior and to ask "What did I learn from this attempt?" rather than punishing themselves.
  • Contingency management—Behavior can be changed by use of rewards for specific actions, such as increasing time spent walking or reducing consumption of specific foods (44). Verbal as well as tangible rewards can be useful, particularly for adults. Rewards can come from either the professional team or from the patients themselves. For example, self-rewards can be monetary or social and should be encouraged.
  • Cognitive restructuring—Unrealistic goals and inaccurate beliefs about weight loss and body image need to be modified to help change self-defeating thoughts and feelings that undermine weight loss efforts. Rational responses designed to replace negative thoughts are encouraged (580).  For example, the thought, "I blew my diet this morning by eating that doughnut; I may as well eat what I like for the rest of the day," could be replaced by a more adaptive thought, such as, "Well, I ate the doughnut this morning, but I can still eat in a healthy manner at lunch and dinner."
  • Social support—A strong system of social support can facilitate weight reduction. Family members, friends, or colleagues can assist an individual in maintaining motivation and providing positive reinforcement. Some patients may benefit by entering a weight reduction support group. Overweight patients should be asked about (possibly) overweight children and family weight control strategies. Parents and children should work together to engage in and maintain healthy dietary and physical activity habits.

Treatment of obese individuals with binge eating disorder

If a patient suffers from binge eating disorder (BED), consideration can be given to referring the patient to a health professional who specializes in BED treatment. Behavioral approaches to BED associated with obesity have been derived from cognitive behavior therapy (CBT) used to treat bulimia nervosa (227).  Among the techniques are self-monitoring of eating patterns, encouraging regular patterns of eating (three meals a day plus planned snacks), cognitive restructuring, and relapse prevention strategies (581).

Recommendation: Behavioral therapy strategies to promote diet and physical activity should be used routinely, as they are helpful in achieving weight loss and weight maintenance. Evidence Category B.
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