History Of Behavioral Approaches To Obesity

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A Development of Treatments from 1970 to 1990

The earliest report of a behavioral treatment program for obesity was by Stuart, who successfully treated eight overweight women (4). These women experienced an average weight loss of 17 kg over a 12-month period, ranging from a weight loss of 12-21 kg. It should be noted that Stuart (an eminent behavior therapist) conducted the treatment program himself, selecting each patient individually and tailoring the program to fit the needs of the individual patient. At the start of therapy, the treatment sessions were scheduled frequently (several times per week), and then gradually less frequently. Eating and exercise behaviors were targeted, and patients weighed themselves four times each day. The program included cognitive interventions, as patients were taught to deal with their weight-related fears, and the patients were helped to develop new hobbies as alternative sources of reinforcement.

Stuart's successful report led to a flood of behavioral research studies. These studies in the early 1970s typically involved 10 weeks of group treatment with mildly overweight subjects, and were often conducted as part of a student's doctoral dissertation (5,11). Thus, in many ways these studies represented an abrupt departure from Stuart's landmark treatment. The emphasis in these programs was on changing eating patterns (where and when foods were eaten), but the nutritional aspects of the diet (number of calories, macronutrient distribution) were ignored, in part to distinguish behavioral treatment from traditional dieting interventions. These early studies showed that behavior modification was more effective than nutrition education (12) or psychotherapy (13). On average, © participants lost 3.8 kg over an 8.4-week treatment interval (5). When followed up an average of 15.5 weeks I

m later, participants had maintained a weight loss of 4.0 kg.

The evolution of behavioral treatments from 1974 to 1990 is shown clearly in Table 1. As seen in this table, behavioral treatments gradually evolved over this period (1974-1990) to include heavier participants (from 73 to 92 kg at entry), longer treatment intervals (from 8.4 to 21.3 weeks in length), and longer follow-up durations (increasing to a yearlong follow-up). The program itself changed as well, placing far greater emphasis on nutrition (14). Patients in behavioral programs were now given calorie goals (usually 1200-1500 kcal/d) and self-monitored not only the events surrounding eating but also exactly what they ate (8,15). Calorie goals for exercise were also prescribed. Cognitive behavioral strategies were given greater emphasis (2), and financial incentives were often utilized. Thus, behavioral programs evolved from teaching strictly behavioral strategies to focusing equally on diet, exercise, and behavior modification. With this longer, more inclusive, intervention, average weight losses increased from 3.8 kg in 1974 to 8.5 kg in 1990. At 1-year follow-up, subjects maintained an average weight loss of 5.6 kg (66% of their initial weight loss).

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