Counseling and Behavior Modification Strategies 

 

OBJECTIVE

Facilitate weight loss and maintenance through behavior modification interventions.

 

BACKGROUND

There is good evidence that counseling and behavior modification interventions add additional benefit to diet or exercise therapy alone in helping patients lose weight and prevent weight regain.  Counseling in a weight loss context generally includes providing advice, education, and encouragement about weight loss and weight maintenance, including behavior modification strategies to accomplish the goal.  Common behavior modification strategies include self-monitoring, stimulus control, positive reinforcement, stress management, problem solving or other skill training, social support, and cognitive restructuring.  An explanation of specific behavioral modification strategies is found in the Appendix (Behavior Modification Strategies).   Behavior modification strategies are employed to facilitate the adoption and maintenance of improved dietary and exercise behaviors.   Evidence suggests that no one type of behavioral strategy is superior to the others, but multimodal strategies appear to work better than a single strategy.

 

RECOMMENDATIONS

1.      Behavior modification interventions to improve diet and physical activity should be given to overweight or obese individuals who are willing to attempt weight loss in order to achieve weight loss and weight maintenance. (B)

2.      Behavior modification interventions should be provided at a higher intensity when possible for greater effectiveness. (B)  High intensity is defined as more than one personal contact per month for the first three months (individual or group setting). (B)

3.      Multiple behavior modification strategies should be used in combination for greater effectiveness. (A)

4.      Behavior modification intervention should be delivered in a group format when possible rather than individually. (B)

5.      For individuals unable or unwilling to participate in weight loss treatment in person, telephone or internet-based behavior modification intervention should be considered. (B)

6.      Behavior modification intervention should be continued on a long term basis to promote maintenance of weight loss. (B)

 

 

 

DISCUSSION

Evidence for the efficacy of behavior modification in promoting weight loss and maintenance has been described in the NHLBI (1998) Guidelines, the United States Preventive Services Task Force (USPSTF) review, in Wadden & Butryn, 2003, and in reviews by the Health Technology Assessment group (2004) and the Institute for Clinical Systems Improvement (ICSI) (2005).  Numerous randomized controlled trials have demonstrated additional benefit when behavior modification was used with diet and exercise therapy. Behavior modification is also often labeled “behavior therapy”, “behavioral treatment” or “behavioral counseling.”  These terms refer to a variety of strategies, which, unfortunately,  are not generally described in any detail in studies reported in the literature.  Accordingly, clarity regarding which specific behavior strategies are being utilized in any given study is compromised.

 

A meta-analysis of 4 randomized controlled trials described in the 2004 Health Technology Assessment review reported that adding behavior modification to diet alone resulted in additional weight loss of 7.67 kg at 12 months and 4.1kg at 18 months.  At 36 and 60 months the advantage of adding behavior modification  to diet was in the predicted direction but not significantly different.  However, the number of participants contributing to the comparison decreased over time, limiting the accuracy of the comparisons over the longer time frame.

 

One cluster RCT assessed the added effects of 2 forms of behavior modification  to diet and exercise and measured change in weight at 12 months, where participants were randomized by appointment time. The added effect of “overt” behavior therapy” (defined as self monitoring, stimulus control and cue reduction, slower eating, coping skills, and problem solving) to diet was associated with a mean weight change at 12 months of  -3.26 kg compared with   –4.82 kg in the diet only group, and was not significantly different. The added effect of “cognitive therapy” (defined as modifying eating behavior, cognitive restructuring, and relapse prevention) to diet was associated with a significantly different mean weight change at 12 months of  -6.68 kg compared with –4.82 kg in the diet only group.   Another study assessed the added effect of behavior modification to diet, exercise, and sibutramine.  Although results must be interpreted with caution due to a very low number of participants in the study, behavior modification was reported to be associated with a mean weight change at 12 months of 10.69 Kg.  In comparing all treatments added to diet (“behavior therapy”, exercise, sibutramine, orlistat), the Health Technology Assessment review concluded that behavior therapy was associated with the greatest weight change (-7.67 kg).

 

Intensity of Behavioral Intervention

The USPSTF defined intensity of counseling and behavior modification interventions as high-intensity if more than one, person to person, session occurred per month for the first three months, moderate-intensity if once a month for 3 months, or low- intensity if anything less frequent.   The USPSTF review documented evidence that high intensity interventions had greater effectiveness than moderate and low intensity interventions.  That review concluded that evidence was insufficient to recommend either moderate or low intensity interventions.   

 

Combinations of Behavioral Modification Strategies

Evidence related to behavioral strategies is summarized in the NHLBI Guideline (1998).  Although no single behavior modification strategy is more effective than another, combinations of several strategies have been shown to be more effective than relying on a single strategy.  The vast majority of treatment programs and studies in the literature utilize multiple behavior modification strategies. 

 

Group versus Individual Behavior Modification

Intensive behavior modification treatment is delivered in group settings in most cases, although treatment utilizing either group or individual formats is effective.  Literature comparing the efficacy of group to individual interventions is sparse.  One well controlled study by Renjilian, Perri, Nezu et al. (2001) compared group versus individual behavior modification treatment, as well as participant preference for group or individual format.  For participants who completed the program, weight loss was greater for those in the group format compared to those who received treatment individually (11 kg. Vs. 9.1 kg, respectively).  There was no difference in whether or not the group format was preferred by the participants. 

 

Telephone or Internet-Based Treatment

Treatment by telephone may be an alternative for those who cannot participate in face-to-face treatment.  Although one study (Hellerstedt and Jeffery, 1997) found no difference among groups followed by telephone compared to groups without any follow up, other studies have reported better results.   Taken together, the studies suggest that telephone behavior modification treatment may be an effective method for promoting weight loss.  Boucher, Schaumann, Pronk, et. al. (1999) evaluated a telephone based program for groups either taking weight loss medications or not taking medications.  There was no control group, and only about half of the participants completed the 6 month program.  However, both groups of completers lost weight; 6.1 kg for the group not taking medications, and 11.3 kg for those taking medications.   Jeffery, Sherwood, Brelje, et al. (2003) compared mail and telephone interventions with usual care in a managed care organization.  At the 6 month follow up, all groups had lost weight, but the telephone group had lost significantly more than the usual care group (2.38 kg vs. 1.47 kg, respectively).  However, the differences between groups disappeared by 12 months.  The phone group completed significantly more of the lessons than the mail group. 

 

Another alternative is that of treatment via the internet.  Studies indicate that although intensive in-person treatment may be superior in effectiveness in many cases, internet adaptations are also effective.  Tate, Jackvony, and Wing (2003) studied a group given a basic internet behavioral weight loss program versus a group given the basic internet program supplemented by individualized behavior modification counseling by email from an assigned weight loss counselor.  Although both groups lost weight, an intention to treat analysis demonstrated significantly greater weight loss at 12 months (4.4 kg vs. 2.0 kg.) as well as reduction in BMI and waist circumference  for the group given additional email behavior modification counseling.  The group given additional email counseling logged in more often than the basic internet program group.  Among both groups, those who logged in more often lost more weight.  Tate, Wing, and Winett (2001) compared basic internet education on weight loss with internet education plus weekly behavioral lessons via email.  An analysis of program completers showed a significantly higher weight loss in the education plus behavioral email group compared to the education only group (4.1 kg vs. 1.6 kg). An intention to treat analysis of these groups had similar results.   Harvey-Barino, Pintauro, Buzzell, and Gold (2004) compared groups who participated in a 6 month interactive television weight loss program.  A 12 month maintenance program following the interactive television component offered one of two levels of ongoing in-person support versus internet support.  Results indicated no differences in weight lost among these groups at the end of 18 months of treatment, suggesting that internet follow up was as effective as in-person follow up contact.   

 

Maintenance

Evidence consistently demonstrates that the majority of people who lose weight regain most of that weight (over a period of one to five years) in the absence of continued intervention.  This emphasizes the importance of continuing a maintenance behavioral program on a long-term basis.  Reviews by Wadden and Butryn (2003), by Jeffery et. al. (2000), by McTigue, Harris, Hemphill et. al. (2003) and the ICSI review  describe studies indicating that continued contact related to behavior modification counseling facilitates weight maintenance.   

 

Jeffery, Drewnowski, Epstein, et. al. (2000) reviewed studies that attempted to improve long-term maintenance of weight loss through of variety of means.  The review concluded that extending the length of treatment and increasing the emphasis on exercise were beneficial in delaying the regain of weight formerly lost.  

 

Perri, McAllister, Gange, et.al (1988) compared groups that underwent a 20 week behavioral treatment with no follow up to four forms of follow up contact, each with a different emphasis.  The participants in the four continued contact groups maintained 82.7% of the mean post treatment weight loss compared with 33.3% in the no contact group. 

 

Perri, McKelvey, Renjilian, et al. (2001) compared two extended follow up groups to a no contact group following a 20 week treatment program.  Both the completer only and the intention to treat analysis found that those groups who were given extended contact maintained a significantly greater percentage of their initial weight loss at the 12 month post treatment point.

 

Latner, Wilson, Stunkard, and Jackson (2002) followed participants in satellite clinic behavior modification groups over 5 years.  Participants remaining in the program at 1, 2, and 5 years achieved mean weight losses of 18 %, 19%, and 18.4%, respectively.  Of those who continued in the program, 90% or more achieved weight losses of more than 5% or more than 10% of initial body weight at all points during the 5 year follow up.  The average length of treatment was 2.3 years.

 

EVIDENCE: 

 

Evidence Statement

Sources of evidence

Quality of evidence

Overall Quality

Recommend-ation Level

1

 

Behavior modification interventions add effectiveness to diet and exercise interventions in promoting weight loss

NHLBI, 1998; McTigue, Harris, Hemphill,  et.al., 2003; Wadden & Butryn, 2003; Avenell, Broom, Poobalan, et. al., 2004, Institute for Clinical systems Improvement (2005)

I

 

Good

 

B

 

2

Behavior modification interventions with greater intensity are more effective than those with less intensity in promoting weight loss

NHLBI, 1998;

McTigue, Harris, Hemphill,  et.al., 2003

I

Good

B*

4

Combined behavior modification strategies are more effective than a single behavior modification strategy in promoting weight loss

NHLBI, 1998;

I

Good

A

5

Group-based behavior modification counseling is more effective than individual counseling in promoting weight loss

Renjilian et al., 2001

I

Fair

B

5

Telephone and internet behavioral treatment is effective in promoting weight loss

Boucher, Schaumann, Pronk, et. al. (1999); Jeffery, Sherwood, Brelje, et al. (2003); Tate, Jackvony, and Wing (2003); Harvey-Barino, Pintauro, Buzzell, and Gold (2004)

I

Fair

B

6

Continued behavior modification interventions are effective in sustaining weight loss

NHLBI, 1998; Wadden & Butryn, 2003;

McTigue, Harris, Hemphill,  et.al., 2003, Jeffery,Drewnowski, Epstein, et. al, 2000; Perri, McAllister, Gange, et.al (1988); Perri, McKelvey, Renjilian, et al. (2001); Latner, Wilson, Stunkard, and Jackson (2002)

I

Fair

B

Note: * The McTigue, et.al. evidence review for the USPSTF rated this as “B” level evidence.   The NHLBI Guideline rated this as “A” level evidence using slightly different rating criteria. VA/DOD endorses the rating system used by the USPSTF.     

 

REFERENCES

1.      Avenell A, Broom J, Poobalan A, Aucott L, Stearns SC, Smith WCS, Jung RT, Campbell MK, Grant AM.  Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement.  Health Technology Assessment 2004;8(21).

1.      Bucher JL, Schaumann JD, Pronk NP, Priest B, Ett T, Gray CM.  The effectiveness of telephone-based counseling for weight management.  Diabetes Spectrum 1999;12:121-123.

2.      Harvey-Berino, J, Pintauro S, Buzzell P, Gold EC.   Effect of internet support on long term maintenance of weight loss. Obesity Research 2004;12:320-329.

3.      Hellerstedt WL, Jeffery RW.  The effects of a telephone-based intervention on weight loss.  American journal of Health Promotion 1997;11:177-182.

4.      Institute for Clinical Systems Improvement.  Behavioral therapy programs for weight loss in adults.  Technology Assessment # 87, 2005.

5.      Jeffery RW, Drewnowski A, Epstein LH, et. al.  Long term maintenance of weight loss: current status.   Health Psychology 2000;19(1 Supplement):5-16.

6.      Jeffery RW, Sherwood NE, Brelje K, et. al.  Mail and phone interventions for weight loss in a managed care setting:  Weigh-To-Be one year outcomes.  International Journal of Obesity 2003;27:1584-1592.

7.      Latner JD, Wilson GT, Stunkard AJ,  Jackson ML.  Self-help and long-term behavior therapy for obesity.  Behavior Therapy Research 2002;40;805-812.

8.      McTigue KM, Harris R, Hemphill B, et.al.  Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force.  Annals of Internal Medicine 2003; 139:11, 933-966.

9.      NIH, National Heart Lung and Blood Institute.  Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity and obesity in adults: The evidence report.  NIH Publication # 98-4083, 1998.

10. Perri MG, McAllister DA, Gange JJ, Jordan RC, McAdoo WG, Nezu AM.  Effects of four maintenance programs on the long-term management of obesity.  Journal of Consulting and Clinical Psychology 1988; 56: 529-534.

11. Perri MG, McKelvey WF, Renjilian DA, Nezu AM, Shermer RL, Viegener BJ.   Relapse prevention training and problem-solving therapy in the long-term management of obesity.  Journal of consulting and Clinical Psychology  2001;69:722-726.

12. Renjilian DA, Perri MG, Nezu AM, McKelvey WF, Shermer RL, Anton SD.  Individual versus group therapy for obesity:  effects of matching participants to their treatment preferences.  Journal of Consulting and Clinical Psychology 2001;69:717-721.

13. Tate DF, Jackvony EH, Wing RR.  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 2003;289:1833-1836.

14. Tate DF, Wing RR, Winett RA.  Using internet technology to deliver a behavioral weight loss program.  Journal of the American Medical Association 2001;285:1172-1177.

15. Wadden TA, Butryn ML.  Behavioral treatment of obesity.  Endocrinology and Metabolism Clinics 2003; 32(4):981-1003.