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C HAPTER 38 / Obesity: An Overview of Assessment and Treatment 869
of activities and their caloric expenditure are provided to patients study, the Look AHEAD trial, tests an intensive lifestyle interven-
so that they can monitor progress toward their exercise goals. 73,74 tion that is similar to the DPP; however, this study combines in-
dividual and group meetings to achieve and maintain weight loss
Behavioral Therapy among those with type 2 diabetes. One-year results reveal an av-
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The treatment goal of obesity is to modify eating, physical activ- erage weight loss of 8.6% and improved CVD risk factors among
ity, and cognition or thinking habits that contribute to one’s the lifestyle intervention participants. Although the DPP trial, as
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weight problems. 53 Behavioral therapy helps overweight and well as a similar study that was conducted in Finland, was highly
obese individuals to develop a set of skills that can help regulate successful in using lifestyle modification to achieve 7% weight loss
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their weight. The core of treatment is based on the principle of and prevention of diabetes with individual treatment approaches,
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classical conditioning, which purports that stimuli are presented the group approach is more cost effective for clinical settings. In
before or concurrent to a given behavior and then become associ- one study, the use of groups demonstrated better results among
ated with that behavior. As the events are paired more often, for those who were randomized to the group sessions than among
example, eating high-fat snacks while watching TV, the associa- those who were assigned to receive individual treatment even
tion between the two becomes stronger and eventually one trig- when that was the approach they preferred. 86 The treatment ses-
gers the other. In behavioral treatment, the goal is to identify and sion usually follows a structured curriculum and also provides ad-
extinguish the cues from the antecedent or stimulus. In the analy- equate time for discussion and problem solving among the group
sis of behavior that occurs in treatment, an individual examines members. The structured content is similar to what is provided in
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the consequences or reinforcement value of eating and exercise the LEARN program or the DPP protocol, which is available on
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and how to correct negative thoughts that prohibit one from the DPP Web site. There is a set of behavioral strategies that are
reaching his or her goals. 53,59 implemented in standard behavioral treatment programs to facil-
There are three distinguishing characteristics of behavioral itate behavior change, which are described in detail below.
treatment for weight loss: goal orientation, process orientation,
and making small rather than large behavior changes. 53 Goals are ■ Self-monitoring—often considered theg g sine qua non of behav-
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specific, for example, the number of calories or fat grams per day ioral treatment. It entails having individuals record their food
that one should eat and the minutes spent in physical activity. In- intake, calories, fat grams, and time spent in physical activity
dividuals record food eaten and exercise or physical activity per- in minutes and sometimes identifying the specific activity and
formed in a daily diary and track behavior as to how it compares its intensity. This requires patients to look up these values in
to the goals, which provides feedback on goal achievement. The books provided, which makes them aware of the caloric and fat
process-oriented approach builds on the skill-building philosophy content of food eaten. Self-monitoring may also include
of weight management—that a set of skills can be learned that will recording feelings or mood and circumstances of behavior. The
enable individuals to identify what they wish to accomplish and self-monitoring exercise contributes to the functional analysis
what strategies can be learned to permit them to do this. Finally, of behavior and helps individuals identify the barriers to
this treatment approach advocates making small changes, which is changing behaviors and the high-risk situations they may en-
based on the learning principle of successive approximation or counter. Technology and the Internet have provided alternate
shaping behavior. 53 Similar to the concept of enhancing self-effi- methods to the paper-and-pencil diary. Dietary and physical
cacy, achieving small, incremental successes leads to gradually activity software for personal digital assistants is available to-
shaping new behaviors that are reinforced by success and im- day, which eliminates the need to search for nutrient composi-
proved self-confidence. 80 tion of food in a book since the software contains an extensive
The National Institutes of Health (NIH) treatment guidelines database of nutrients and physical activities. 89 Moreover, some
recommend a multidisciplinary approach; the team may include a software programs date-and-time stamp each entry so the in-
psychologist, nutritionist, exercise physiologist, nurse, or physi- terventionist or provider can determine if the person is record-
cian. 15 Although no studies have evaluated the different health ing in a timely manner. 89,90 In addition, programs are available
care professionals delivering the intervention, the guidelines sug- on the Internet that provide the structure for self-monitoring,
gest that providers avail themselves of the expertise offered by pro- for example, www.FitDay.com, www.sparkpeople.com, and
fessionals who have counseled patients in this area. 15 Since 1974, www.caloriecount.about.com. There is a growing body of evi-
standard behavioral treatment for weight loss has increased in du- dence that supports the pivotal role self-monitoring plays in
ration from 8 weeks to an average of 31 weeks, with current re- successful weight loss outcomes. 91,92
search studies lasting 18 to 24 months. 63,81 The typical treatment ■ Goal setting—patients are given goals for total calories, fatg g
program begins with weekly group sessions for 4 to 6 months, fol- grams and percent of total calories, and energy expenditure
lowed by a gradual decrease in frequency of group sessions, for ex- through exercise. The goals need to be proximal, specific, and
ample, biweekly for an additional 3 to 6 months followed by attainable. Goal setting theory predicts that under most cir-
monthly sessions. 81,82 Behavioral therapy is usually delivered in a cumstances setting specific goals leads to higher performance
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closed-group context, that is, the group is formed at the initiation compared with none or vague goals. Goals need to be specific
of treatment and no new members are added thereafter. This ap- in outcome, proximal in terms of attainment, and realistic in
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proach facilitates the development of group cohesiveness, provides terms of the person’s capability. Success with short-term goals
empathy and social support and also an acceptable level of com- enhances self-efficacy. 94 Goals need to focus on behavior
petition among the group members. 55 change, for example, substituting a piece of fruit for a high fat
The Diabetes Prevention Program (DPP) was a 4-year, multi- snack, rather than on physiological outcomes, for example,
center trial that targeted 7% weight reduction among individuals serum cholesterol, since behaviors are more directly under a pa-
with impaired glucose tolerance and used personal coaches to de- tient’s direct control and several factors can influence physio-
liver individual sessions. 83 An ongoing randomized, multicenter logical changes. Goals that are difficult will not be attempted