Drugs Physical Activity Surgery and Other Treatment for Overweight and Obesity - Counseling And Behavioral Therapy

Weight-loss counseling and behavioral therapy aim to assist people to develop the skills needed to identify and modify eating and activity behaviors, and change thinking patterns that undermine weight-control efforts. Behavioral strategies include self-monitoring of weight, food intake, and physical activity; identifying and controlling stimuli that provoke overeating; problem identification and problem solving; and using family and social support systems to reinforce weight-control efforts. Counseling and behavioral therapy are often perceived as necessary components of comprehensive weight-loss treatment, but are also viewed as labor intensive because educating and supporting people seeking to lose weight is time consuming. The effort also requires the active participation of everyone who may be involved in treatment—the affected individuals, their families, physicians, nurses, nutritionists, dieticians, exercise instructors, and mental health professionals. In view of the considerable resources that must be allocated to deliver counseling and behavioral therapy, it is important to know if these approaches effectively promote weight loss.

Michael J. Devlin and his colleagues conducted an evaluation of obesity treatments and reported their findings in "Obesity: What Mental Health Professionals Need to Know" (American Journal of Psychiatry, vol. 157, no. 6, June 2000). The authors observed that comprehensive behavioral weight-control programs to improve eating habits and increase physical activity are considered the "treatments of choice" for overweight and moderately obese individuals because their use not only can reduce body weight by fifteen to twenty pounds and decrease depression and body image dissatisfaction but also can enhance self-esteem and interpersonal functioning. Unfortunately, the favorable results are not enduring. At one-year follow-up evaluations, people who had received behavioral treatment with dietary restriction regained 35% to 50% of their weight loss, both in research clinics and in the general population. Five-year follow-ups revealed that the vast majority of patients had regained all of the weight they had lost.

Like most other obesity researchers, Devlin and his colleagues do not consider psychotherapy as a primary treatment for obesity; however, they acknowledge the effectiveness of cognitive behavioral therapy and interpersonal therapy in normalizing eating and reducing distress in obese patients with binge-eating disorder, although neither approach is associated with significant weight loss. Further, since psychotherapy may enhance self-acceptance, and greater self-acceptance and overall self-esteem are prerequisites for developing and maintaining the motivation to adhere to weight-loss treatment, psychotherapy may be an important component of treatment for some overweight and obese people. The authors stated that "Enhancing self-acceptance may not only provide a more compassionate approach to what has proved a refractory problem, but might also lead to more lasting reductions in weight by virtue of helping patients to accept only modest weight loss and improve compliance with health-relevant eating and exercise behaviors."

Kathleen M. McTigue and her colleagues considered the evidence supporting the efficacy of counseling and behavioral therapy as well as other treatment methods and reported their findings in "Screening and Interventions for Obesity in Adults: Summary of the Evidence for the U.S. Preventive Services Task Force" (Annals of Internal Medicine, vol. 139, no. 11, December 2, 2003). The investigators reported that counseling to promote change in diet, exercise, or both, and behavioral therapy to help patients acquire the skills, motivations, and support to change diet and exercise patterns enabled obese patients to achieve modest but clinically significant, sustained (one to two years) weight loss. Further, they observed that because control groups also frequently received some form of counseling, education, or support, they might have underestimated the effectiveness of counseling. Not unexpectedly, more intensive programs, with more frequent contact, were generally more successful, as were those incorporating behavioral therapy.

Interestingly, the investigators found that treating patients on an individual rather than a group basis did not appear to affect outcomes. This finding offers credence to the theory that the benefits of mutual aid and peer support provided by group programs may be as powerful as the personalized, one-to-one attention afforded patients in individual counseling sessions. If this is true, then group programs might be a laborsaving, cost-effective alternative to individual weight-loss counseling.

The investigators concluded that "All obesity therapies carry promise and burden, which must be balanced in clinical decision-making. Counseling approaches appear the least harmful and produce modest, clinically important weight loss but entail cost in time and resources. Pharmacotherapy promotes modest additional weight loss, but long-term drug use may be needed to sustain this benefit, and long-term adverse events and appreciable cost are unknown. Only surgical options consistently result in substantial long-term weight reduction; however, they carry a low risk for severe complications and are expensive. Body size, health status, and weight-loss history all may influence obesity treatment."

Comparing Weight-Loss Using a Self-Help Program and a Commercial Program

Stanley Heshka and his colleagues reported the results of their research to determine the efficacy of commercial weight-loss programs in "Weight Loss with Self-Help Compared with a Structured Commercial Program: A Randomized Trial" (Journal of the American Medical Association, vol. 289, no. 14, April 9, 2003). Their study randomly assigned one group of obese men and women to a self-help program consisting of two twenty-minute counseling sessions with a nutritionist and provision of self-help resources such as public library materials, Web sites, and telephone numbers of health organizations that offered free weight-control information. The other group was assigned to attend Weight Watchers, a commercial weight-loss program consisting of a food plan, an exercise plan consistent with NIH-recommended physical activity guidelines, regular weight monitoring, printed educational materials, and a behavior modification plan, delivered at weekly meetings.

Subjects were evaluated regularly during the course of the two-year study—at twelve, twenty-six, fifty-two, seventy-eight, and 104 weeks. The primary outcome measure used to evaluate the effectiveness of the programs was change in body weight; however, BMI, waist circumference, and body-fat as quantified by bioimpedance analysis (electrical resistance) were also recorded. Other secondary measures were blood pressure, total cholesterol, HDL cholesterol, triglycerides, insulin, and quality of life measured using the Medical Outcomes Study Short-Form 36 Health Survey and Impact of Weight on Quality of Life Questionnaire.

After one year of participation in the study, subjects in the commercial program had greater weight loss than those in the self-help group. Similarly, waist circumference and BMI decreased more in the commercial group than in the self-help group. Blood pressure and serum insulin showed greater improvement in the commercial group compared with self-help at year one, but only insulin was significantly different at year two. Total cholesterol and the HDL/total cholesterol ratio improved in both groups. The commercial group maintained a weight loss of 4.3 to 5.0 kg (9.48 to 11.02 pounds) at the end of the first year and was 2.7 to 3.0 kg (5.95 to 6.61 pounds) lower than initial weight at the end of the second year. Subjects who attended 78% or more of the commercial group sessions maintained a mean weight loss of almost 5 kg (11.02 pounds) at the end of the two-year study. The investigators concluded that while the structured commercial weight-loss program provided only modest weight loss, it was more effective than brief counseling and self-help for overweight and obese adults over a two-year period.

Weight-Loss Counseling to Change Behavior

The NIH designed a practical protocol, known as an algorithm, for obtaining and organizing information necessary for effective weight-loss counseling. The algorithm is based on the "five As":

• Assessing obesity risk
• Asking about readiness to lose weight
• Advising about a weight-control program
• Assisting to establish appropriate intervention
• Arranging for follow-up

The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults recommends that health-care professionals consider a variety of psychosocial, environmental, and health-related issues when performing a "behavioral assessment" of an individual for whom weight loss is indicated. These issues include:

• Whether the individual is seeking to lose weight on their own or in response to pressure from family members, an employer, or a physician. This is an important consideration because people who feel coerced into seeking weight-loss treatment are not as likely to achieve success as those who seek it on their own initiative.
• Identifying the source of the individual's desire to lose weight to better understand his or her motivation and goals. Since many people have suffered from overweight or obesity for years before seeking treatment, pinpointing the stimulus to lose weight can assist the health-care professional to motivate and support the individual's weight-loss efforts.
• Assessing the individual's stress level to determine if such external stressors as family, financial, or work-related problems might prevent the individual from concentrating on weight loss. It is also important to determine if the individual is suffering from depression or other mental health problems because it is usually advisable to treat mood disorders or other mental health problems before embarking on a weight-loss program.
• Evaluating the individual for the presence of an eating disorder such as binge eating that may coexist with overweight or obesity. People suffering from eating disorders are more likely to require psychological treatment and nutritional counseling to ensure the success of weight-loss programs than those who do not have eating disorders.
• Determining the individual's understanding of the lifestyle and other changes required for weight loss. The success of treatment hinges on the individual's ability to successfully make the required changes, so it is vital to develop a treatment plan that includes realistic activities such as gradually increasing physical activity that the individual agrees are attainable.
• Setting and agreeing upon realistic weight-loss goals and objectives. If an obese individual has unrealistic expectations about the amount of weight that will be lost, then he or she may become discouraged and abandon efforts to lose weight. Health professionals should temper unrealistic expectations by informing individuals about the considerable health and lifestyle benefits of even modest weight loss.

Successful weight loss is more likely to occur when health-care professionals—physicians, nurses, nutritionists, dieticians, and mental health professionals—actively involve people seeking to lose weight in a collaborative effort to establish short-term goals and attain them. "Shaping" is a behavioral technique in which a series of short-term objectives are identified that ultimately lead to a treatment goal, such as incrementally increasing physical activity from ten minutes per day to forty-five minutes per day over time. "Self-monitoring" is the practice of observing and recording behaviors such as caloric intake, food choices, amounts consumed, and emotional or other triggers to eat as well as physical activity performed and daily or weekly monitoring of body weight. Figure 6.5 is an example of the weekly food and activity diary used to self-monitor progress.

Finally, The Practical Guide to the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults reminds health professionals to acknowledge the challenges of accomplishing weight loss and encourages everyone involved in treatment to "focus on positive changes and adapt a problem-solving approach toward shortfalls. Emphasize that weight control is a journey, not a destination, and that some missteps are inevitable opportunities to learn how to be more successful."

Weight-Loss Counseling Online

An expanding array of diet, counseling, and support group programs are available on the Internet; however, little research has compared them or determined their efficacy. Although behavioral counseling has been demonstrated effective for weight loss to reduce the risk of developing diabetes, many public health professionals contend that the large number of people at risk requires a less labor-intensive approach than individual face-to-face-counseling. Deborah Tate and her colleagues at the Brown University School of Medicine, Miriam Hospital, Weight Control and Diabetes Research Center, sought to determine whether varying types of Internet services would prove to be viable alternatives to in-person counseling. They compared the effects of an Internet weight-loss program alone with an Internet program that also provided behavioral counseling via e-mail for one year to people at risk for Type 2 diabetes. Their study was described in "Effects of Internet Behavioral Counseling on Weight Loss in Adults at Risk for Type 2 Diabetes: A Randomized Trial" (Journal of the American Medical Association, vol. 289, no. 14, April 9, 2003).

FIGURE 6.5 Weekly food and activity diary "Appendix K. Weekly Food and Activity Diary," in The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, National Institutes of Health, National Heart, Lung, and Blood Institute, North American Association for the Study of Obesity, October 2000, http://www.nhlbi.nih.gov/guidelines/obesity/practgde.htm (accessed January 12, 2006)

Subjects were randomly assigned to a basic Internet weight-loss program or an Internet plus behavioral e-counseling program. Both groups received a one-hour introductory group weight-loss counseling session that consisted of standard behavioral weight-control instruction on diet, exercise, and behavior change. Recommendations included calorie-restricted diets of between 1,200 and 1,500 calories per day, fat intake of 20% or fewer calories, and a minimum of physical activity sufficient to expend 1,000 calories per week. All participants were encouraged to self-monitor their diets and exercise using diaries and calorie books provided. Both groups accessed the same Web site, which provided a tutorial on weight loss, a new tip and link each week, and a directory of selected Internet weight-loss resources. Each week, all participants received an e-mail reminder to submit their body weight and received weight-loss information.

Subjects in e-counseling submitted calorie and exercise information and received weekly e-mail behavioral counseling and feedback from counselors who had earned master's or doctoral degrees in health education, nutrition, or psychology. During the first month of the yearlong study, counselors e-mailed subjects five times each week, and sent weekly e-mails for the remaining eleven months. Counselor e-mail messages offered feedback on the self-monitoring record, reinforcement, recommendations for change, and answers to questions, as well as general support and encouragement. Subjects who failed to submit reports were sent personal follow-up e-mail messages.

The primary outcome measure used to compare the groups was change in body weight from baseline to twelve months. Weight was measured at baseline and at three, six, and twelve months, and the behavioral e-counseling group had greater reductions in weight than the basic Internet group at each weigh-in. Although both groups reported significant reductions in caloric intake, the behavioral e-counseling group reduced the percentage of calories consumed from fat by 4% compared with a 1% reduction in the basic Internet group. The investigators concluded that the addition of e-mail behavioral counseling doubled the percentage of initial body weight lost compared with an Internet intervention without individualized therapist guidance.

Another evaluation of weight-loss programs included the results of a randomized trial of eDiets.com, an Internet-based intervention, which charges participants $65 for three months of online counseling and diet education. The eDiets.com service offers thirteen diets and provides recipes based on clients' dietary preferences. The company also offers a mutual support program in the form of online chats with other clients as well as e-mail advice from psychologists and dieticians.

After participating in eDiets.com for one year, participants lost 1.1% of their initial weight compared with a 4% loss among a control group simply given a self-help manual about weight management (Adam Gilden Tsai and Thomas A Wadden, "An Evaluation of the Major Weight Loss Programs in the United States" Annals of Internal Medicine, vol. 142, no. 1, January 4, 2005). The researchers also observed that these results likely represented a best-case scenario for eDiets.com since the participants were provided with eleven on-site visits to assess their weight and five consultations with a psychologist. These extra services, which are not offered to average subscribers, may have enhanced participants' motivation and adherence to their diets.

Complementary and Alternative Therapies

Many complementary and alternative medicine practices such as yoga, Dahn—a holistic mind-body training method—and "mindful eating," which teaches greater awareness of bodily sensations such as hunger and satiety and helps people identify "emotional eating," have been used to promote weight loss. Acupuncture and hypnosis are, however, the only alternative medical practices that have been studied as potential treatments for obesity. Several studies reported that acupuncture—the Chinese practice of inserting extremely thin, sterile needles to any of 360 specific points on the body—did not appear to have any benefit greater than placebo.

Hypnosis is an altered state of consciousness. It is a state of heightened awareness and suggestibility and enables focused concentration that may be used to alter perceptions of hunger and satiety, and to modify behavior. Some dieters swear by hypnosis, which today is considered mainstream treatment for addictions and overeating. There are conflicting data about its effectiveness—some studies found that it adds little, if any, benefit beyond that of placebo. Others concluded that hypnosis may have some initial benefit for people seeking weight loss, but that it had very little sustained effect.

In "Hypnotic Enhancement of Cognitive-Behavioral Weight Loss Treatments—Another Meta-Reanalysis" (Journal of Consulting and Clinical Psychology, vol. 64, no. 3, June 1996), University of Connecticut psychologist Irving Kirsch recalculated data from five previous studies that examined the value of hypnosis in weight-loss treatment. Kirsch asserted that his analysis found that the mean weight loss reported in the five studies indicated that hypnosis can more than double the effects of a cognitive/behavioral treatment. He also found that the impact of hypnosis increased over time, suggesting that it might be useful for long-term maintenance of weight loss. He qualified his findings by noting that hypnosis appeared effective only in conjunction with cognitive/behavioral treatment, and he conceded that "obese people would still be obese after losing the amount of weight reported in these studies."