Intensifying the Behavioral Component

Whereas the research described previously focused on ways to enhance negative energy balance through modifications in diet and physical activity, other investigations have examined ways to intensify behavioral components in weight loss or weight loss maintenance interventions. These strategies include extending professional contact, increasing social support, enhancing motivation using incentives, providing skills training, and combining some of these strategies into multicomponent maintenance programs.

Extending professional contact As noted previously, the maximum weight loss in a behavioral weight loss intervention is typically attained at 6 months, which also represents the end of the weekly phase of therapy and the start of the less intense maintenance phase. Weight regain is commonly assumed to be due to a failure to continue practicing effective behavioral techniques when treatment transitions. One way to sustain behavioral strategies is to lengthen treatment or to continue to provide some form of professional contact during the maintenance phase.

Lengthening the initial phase of treatment has been shown to increase initial weight loss. For example, when behavioral treatments of identical content, differing only in length of treatment (20 vs. 40 weeks), are compared, the two programs produce similar weight losses at 20 weeks (—9.5 kg), but the extended treatment produces greater weight loss at 40 weeks (-13.6 vs. -6.4kg). Based on this, several investigators tried to develop year-long programs with weekly meetings throughout. Weight losses at the end of the year were 10-14 kg, but attendance became quite poor toward the end of the program and the cost-effectiveness of such long-term weekly programs was questioned. Thus, investigators have considered how best to provide contact after the end of the 6-month weekly program.

One of the first methods employed to extend professional contact during the maintenance phase was the use of booster sessions. Booster sessions take place on a fairly infrequent basis after treatment, with an increasing interval of time between sessions to fade professional contact (e.g., meeting at months 1, 3, 6, and 12). Booster contacts have yielded inconsistent results. This finding and the fact that better maintenance of weight loss occurs when participants continue to be seen biweekly suggest that patients need a fairly high level of contact during maintenance. Studies using biweekly maintenance programs have found better weight loss maintenance at 6-month (120% (continued weight loss) vs. 83% (weight regain)) and 18-month (87 vs. 33%) follow-ups compared to a control intervention receiving no maintenance component. The specific content of the maintenance sessions appears less critical than the frequency of ongoing contact, the regular weighing of patients, and the emphasis on continued self-monitoring. Although face-to-face contact appears most effective, it may also be possible to provide extended contact by phone, mail, or e-mail.

Social support Another approach to provide long-term support is to involve friends and family of participants in the treatment program. Spouses have been included in treatment, but the effects have been mixed. A meta-analysis of the spouse support literature showed a small positive effect through 2 or 3 months of follow-up. One study examined the effectiveness of natural social support (participants were recruited with three other friends and family members who were all losing weight in the same program) and experimentally created social support (through the use of intragroup activities and intergroup competitions) during a standard behavioral weight loss intervention. Sixty-six percent of participants recruited with a friend and given the social support intervention retained their weight loss in full from month 4 to month 10 compared to 24% of individuals recruited alone and given the standard behavioral intervention without any social support intervention.

Peer support can also be developed among group members in the same weight loss intervention. Support from other members of the group may explain the finding that group treatment tends to be more successful than individual therapy. One investigation conducted a 7-month weight loss maintenance program involving peer support following a behavioral obesity treatment. Participants formed peer self-help groups, which met biweekly and used group problem-solving skills to handle difficulties with weight loss. The peer support group maintained a greater weight loss at 1-year follow-up than the control group that received no maintenance program (-6.5 vs. -3.1kg). These studies suggest that social support is helpful in long-term weight loss and weight loss maintenance.

Incentives for weight loss and weight loss maintenance Behavioral interventions used in obesity treatments focus on changing antecedents and consequences of behaviors that influence energy balance. Behaviors that produce negative energy balance, and consequential weight loss, can be reinforced, thereby increasing the likelihood that these behaviors will continue. The effects of contracting for healthy behaviors and weight loss have been inconsistent. Contracting with participants to attend supervised exercise sessions doubled the number of walks attended but had no effect on overall activity level or weight loss. Likewise, providing financial incentives (a substantial cash payment was given each week to participants when the weekly weight loss goal was met) during a standard behavioral weight loss program had no effect on long-term weight loss. Procedures in which patients deposit money at the start of the program and then earn portions back each week for meeting specific weight loss goals or self-reported caloric intake goals appear more effective. In one study showing positive results, the financial deposits were returned based on the average weight loss of the whole group.

Skills training Another approach to improve maintenance of weight loss is to provide participants with training in specific skills. These specific skills can provide participants with the ability to cope with high-risk situations that increase the likelihood of a relapse of problematic eating and activity behaviors.

Two types of skill-based maintenance programs, provided after the completion of a standard behavioral weight loss intervention, have been investigated. One approach focuses on relapse prevention, in which participants are taught a variety of methods to anticipate and cope with the problem of relapse in weight loss maintenance. In the second approach, participants are taught to use the steps of problem-solving to manage difficulties during weight loss maintenance. After 1 year of a maintenance program, participants in the problemsolving intervention had better weight loss than those who had received no maintenance program following treatment ( — 10.8 vs. —4.1kg). There was no difference in weight loss between participants in the relapse prevention program and those participants who received no maintenance program (—5.9 vs. —4.1kg). These results suggest that strengthening problem-solving skills during weight maintenance improves weight loss maintenance.

Multicomponent programs Since long-term weight loss maintenance is believed to be difficult for many reasons, an approach that combines several different strategies used after initial weight loss treatment may produce better weight loss maintenance. These multicomponent maintenance programs have used different combinations of extending professional contact, increasing peer support, providing incentives, and increasing physical activity. All programs using a multicompo-nent maintenance program show better weight loss maintenance at 18-month follow-up compared to no maintenance program, but the multicomponent programs do not produce greater weight loss maintenance than simple programs that just extend professional contact.

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