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Abstract

Introduction

Behavioral interventions targeting sustained weight loss have largely failed for decades, with little chance of improvement using prevailing methods.

Objective

To address treatment limitations, a focused 25-year research program was reviewed through the lens of social cognitive theory, probative investigations, and original predictive models. Innovative, but evidence-based, treatment suggestions were sought.

Results

Task 1 of the research program addressed adherence to exercise, a well-established requirement for maintained weight loss. A culminating model addressing this treatment aspect suggested that interrelations among changes in self-regulatory skills usage, self-efficacy, and mood should guide exercise-support programming. Task 2 attached an eating-behavior change component and probed for malleable psychosocial variables predictive of success over the weight-loss phase (initial 6 months after treatment initiation). After thorough evaluation of selected theory- and research-driven psychosocial variables, changes in self-regulation, self-efficacy, and mood were again deemed to be the most salient predictors driving eating change. In Task 3, treatment foci related to changes in the 3 psychosocial variables were supported into the weight-loss maintenance phase (beyond 6 months), and the carry-over of changes in self-regulation and self-efficacy from exercise- to eating-related contexts was identified and leveraged. Task 4 suggested value in additionally addressing emotional eating as a distinct factor.

Conclusion

Suggestions informing principles and extensions of a treatment approach previously demonstrating atypically high degrees of success with maintaining weight loss in field- and community-based settings are provided. Those methods emanate from the reviewed research program, which shaped novel procedures to leverage exercise-induced psychosocial changes for their carry-over benefits for controlling eating.

Introduction

Persistent problems with behavioral obesity treatments

Obesity continues to escalate in industrialized countries and, more recently, globally. 1 It is a chronic medical disorder with many severe comorbidities and high levels of relapse. 2 Although reducing caloric intake and increasing exercise will reliably reduce weight, these behavioral changes have been extremely difficult to maintain beyond the initial 3 to 6 months. 3,4 By and large, eating behaviors remain unhealthy, 5 and the minimum amount of physical activity/exercise recommended for health benefits (at least 150 min per week 6 ) was shown to occur in less than 4% of the adult US population (ages 20–59 years). 7
For many decades, behavioral (nonsurgical, nonpharmacologic) obesity interventions have had minimal effects beyond the short term. 4,8,9 Most of the programs are atheoretical and require individuals to consume and persistently act on information related to explicit eating practices (ie, “diets”) and specialized exercise regimens through dependence on their existing internal resources. Such knowledge-based programs have had some of the worst outcomes of all tested treatment approaches. 4,10 Providing “assurances” of rapid weight losses, when ignoring evidence-based support of sustaining requisite behaviors, most commercially available programs focus on short-term effects rather than sustained reductions in health risks. It is rare for the present array of weight-loss programs to provide more than cursory efforts at addressing the persistent barriers to attaining and maintaining the required behavioral changes. 11 When or if evaluations of effects are undertaken, they often fail to incorporate intention-to-treat analytic formats in favor of including only “compliers,” who typically demonstrate the most favorable outcomes. 12,13 This approach provides skewed estimates of the effects of weight-loss programs on the typical participant. Also, related research is mainly of brief durations (eg, 8–15 weeks), which does not adequately account for expected plateaus and regains in weight.
Although most energy deficits required for meaningful weight loss will come from changes in eating behaviors, regular exercise has been a robust, and possibly the strongest, predictor of maintained reductions in weight. 14,15 Some researchers have suggested that, in the context of treating obesity, the benefits of exercise for weight loss stem more from its ability to foster psychological changes that affect improved eating than direct caloric expenditures, which are nominal in adults of high weight. 16–18 This assertion is supported by research indicating that adherence, rather than exercise frequency and intensity, best predicts sustained weight loss in adults with obesity. 19–21
Whereas attempts to advance obesity treatments beyond simply educating individuals on specific eating practices and mandating severely reduced caloric intakes are scarce, state-of-the-science behavioral approaches seeking to deal with challenges to the required behavior changes have also had limited long-term success. For example, after senior researchers recently developed 22 and applied a 44-week protocol incorporating one-on-one sessions with professional counselors and advanced cognitive-behavioral methods focused specifically on maintaining lost weight (at an estimated cost of US$4000 per participant), near total regain of the initially substantial weight loss was observed at 2- to 3-year follow-up. 23 As in most programs, exercise was suggested as merely a useful adjunct to a nearly singular focus on dietary and caloric changes. Because of the apparent rigor and scientific strength of that program and because of the similarity between its associated weight-regain pattern and that of other behavioral weight-loss approaches (ie, weight loss for 6 to 9 months, followed by a plateau and then a trajectory toward full regain), its developers suggested that behavioral obesity treatments have, overall, failed to ever demonstrate enough promise to warrant their continued research and development. 23 Although some researchers disagreed with such advisement to end all related behavioral research because of this circumstance, 24 there was near universal consensus that innovative treatment methodologies would be required to have any chance of success, especially techniques that could have broad enough applications to meaningfully impact the health of the general public. 24,25

Emergent possibilities from previous shortcomings

In efforts to leverage behavioral theory and previous studies in an innovative manner, our systematic program of field research was undertaken. Four key deductions emerged in attempts to definitively improve behavioral obesity treatments. The first was that social cognitive theory 26 offers a coherent framework for the necessary applied research to follow. Social cognitive theory emphasizes the dynamic relationship among behaviors, cognitive factors, and situational factors. Thus, it was considered especially salient for program development because it implied that the participant must play an active role and that competencies and other predictors of needed behavioral changes could be fostered through directed treatment methods. 27 The second was that exercise should have a central, rather than adjunctive, role in treatment. However, because adherence to exercise was typically poor, 28,29 formidable processes for supporting regular exercise were required. Although exercise was already a component of many weight-loss interventions, its use had been directed at energy expenditures rather than the facilitation of psychological changes beneficial to eating behaviors. The third was that, because the linkage between exercise and eating-behavior changes was understudied, as were the dynamics of psychological correlates of improvements in those behaviors, theory-driven inquiry should be targeted in this area for the guidance of treatment curricula. Finally, because periods for expected weight loss (baseline to 6–9 months) and regain (beyond 6–9 months) could differ in their dynamics and contingencies, 30 both of these periods should be distinctly investigated for intervention development purposes. Such differences between weight-loss and weight-loss-maintenance “phases” were also being advanced elsewhere in the research literature. 3,17,31
Through the lens of social cognitive theory, 26,27 the investigation of psychosocial predictors of exercise, eating, and weight loss and their interrelations could lend itself to explanatory models capable of effectively shaping treatments. Further investigation of correlates and embedded paths toward behavioral improvements could refine those models and corresponding interventions. Inspection of the relative variances explained within predictive relationships might also help prioritize program time dedicated to distinct aspects, which could both reduce redundancies and increase efficiency. As suggested by Baranowski and colleagues, 32,33 treatments emerging from such developmental processes could be tested for effects and then decomposed through their mediators and moderators in ongoing efforts to maximize productivity.

Consolidation of the present research program

Thus, based on the described approach, this report elucidates a 25-year program of research (from 1997 to the present) on exercise, eating, and weight-loss behaviors (approximately 150 peer-reviewed studies incorporating approximately 24,000 participants across 4 countries) from established behavioral theory → theory adaptations based on context → refinement of interrelations among variables → treatment curriculum development → tests of program effects via mediators/moderators → refinement of treatment priorities and assessment of outcomes → revised curriculum propositions for sustained change. The ultimate goal was to inform the most-current iteration of a cognitive-behavioral weight-loss program applicable in field settings and capable of large-scale applications. 34

A Research-to-Practice Focus

The remainder of this article explains the described process and its implications for obesity-related treatment. Although the investigative course was not linear, it is ordered here for ease of comprehension. General foci of the research program are denoted as Task 1 through Task 4.

Task 1: Adherence to exercise

A review of the relevant research literature yielded an initial predictive model intended to inform an exercise-adherence treatment component. 35–37 The model proposed that scores on the measured constructs of social support, ability to tolerate discomfort, self-regulatory skills usage, and commitment would predict maintained exercise. High cross-loadings between commitment and self-regulation responses instead advanced a 3-factor model of social support, ability to tolerate discomfort, and self-regulatory skills usage. 38 Each of the constructs independently contributed to the considerable explained variance in exercise program maintenance (R 2 = 0.43). A treatment regimen of 6 one-on-one sessions (of 20–30 minutes each) over 6.5 months was created based on those findings because there was evidence that dropout was far less pronounced after that period. 39 Based on a participant’s score on the described 3-factor survey, 38 instructor attention was directed to the factor or factors for which the score was lower than the normative mean minus 1 standard error. Additional consideration could thus be directed to these areas. Even given such personalized adjustments, methodologies were appropriate for large-scale applications because they emphasized brief protocol-driven cognitive-behavioral methods that did not require advanced degrees or high-level credentialing in instructors.
Consistent with social cognitive theory 26 and goal setting theory, which emphasizes the value of targeting and documenting incremental progress, 40 initial treatment processes required that considerable attention be focused on 1) proximal (over distal) goals, 2) ongoing progress tracking, 41,42 and 3) behavioral support using self-regulatory methods. Borrowing from principles of operant conditioning that emphasize reinforcement potentials for behavioral change, 43 exercise regimens were cross-checked and accordingly adjusted to ensure that they were associated with reinforcing (eg, increased revitalization) rather than punishing (eg, increased exhaustion) changes in feeling states. 43–54 Extensive field tests of that treatment protocol involving 8318 participants within 52 trials across 3 countries were associated with improved exercise-adherence outcomes averaging 52% relative to usual-care controls with matched amounts of support time. 29,55–58 There was a strong correlation between program attendance and exercise sessions completed during a 6-month period. 59
As our efforts prepared for extensions of this initial exercise-adherence task to also address eating behaviors and excess weight, the associated model development continued. It was posited that, although social support, ability to tolerate discomfort, and self-regulatory skills usage were clearly important and warranted treatment attention, through the lens of social cognitive theory 26 augmented by consideration of tenets of self-regulation theory, which suggests that goal-directed behaviors can be bolstered through internal processes, 60 these factors could also each be viewed under the self-regulation domain. After reflections emanating from subsequent propositions by Baker and Brownell, 61 including consideration of physical self-concept, personal incentives (eg, health, appearance improvement), body satisfaction, and self-motivation as predictors of behavioral change, 50,62–79 a modified model was established comprising what was then identified to be the most salient predictors of exercise behaviors that were logically malleable through intervention.
That model consisted of treatment-associated changes in self-regulation, self-efficacy, and mood as predictors of increased exercise. The overall variance in exercise explained by these factors was, coincidently, again 43%, with the change scores in each variable independently contributing significantly. 80 By that point, multiple studies already supported self-regulatory change (eg, increases in the use of methods such as goal setting/incremental progress tracking, cognitive restructuring, relapse prevention, dissociation from discomfort, and stimulus control) as the strongest single predictor, warranting the most program attention and time. 41,42,49,80,81 The revised model’s emphasis on longitudinal changes, as well as the incorporation of only theory-based constructs that could improve intervention foci, enabled the cultivation of treatment extensions/revisions that improved the strength in fostering maintained exercise from 52% to 58% improvement over a control condition. 79 The evolution of the posited predictors of increased exercise, exercise maintenance, and reduced dropout (ie, exercise attendance) is shown in Figure 1.
Figure 1: Research program-related evolution of predictive models for exercise adherence. Δ = change in the designated construct.
Later research served to reinforce these model and treatment revisions by finding relationships among the 3 proposed theory-driven predictors. For example, treatment-associated changes in participants’ use of self-regulation to successfully overcome lifestyle barriers were, understandably, associated with their increased feelings of ability (ie, increased self-efficacy) 82–91 ; and mood improvements that were associated with moderate exercise 47,92–101 promoted improved use of self-regulatory skills. 102–109 In consideration of challenged adherence to exercise, 28,39 several of our studies evaluated the minimum amount required for mood improvements. This exercise amount was shown to be a manageable 2.5 to 3 moderate-intensity sessions per week. 94,99,110–112 In later research, the same amount was found to be associated with major weight loss, 20,21 although an average of only 18% of the detected lost weight was directly attributable to exercise-associated energy expenditures. 78,80,113–116 This finding supported the premise of an expanded role for exercise in weight loss. Exercise-induced mood change was also associated with greatly improved blood pressure 117–119 and blood glucose 120 values.
Some of our other research examined the most appropriate length of exercise-support programming. Adding an additional session to the existing 6-session, 6.5-month protocol (lengthening it to 8.5 months) did not improve effects. 29 Thus, this extra session was removed from consideration. Although social support appeared to be productive, especially support centered around the task of sustaining exercise or “task cohesion,” 62,121 it could be cultivated by simply grouping participants (eg, walking groups, beginner group exercise) rather than by adding additional instructor attention, which would be less efficient. Based on other research on exercise-related “team building,” 122 we had originally posited, incorrectly, that more extensive instructor effort would be required to substantially enhance social cohesion across participants. Although the training and credentialing of the instructors administering the program was minimal, given the intent to apply the final program at a low cost in community-based settings, testing of beneficial personal characteristics was completed to guide the selection process. No outcome benefit was detected for a match between instructor and participant genders, 123 the proportion of men and women among a facility’s instructors, 57 or an instructor’s full-time or part-time work status. 57 However, an instructor’s personal characteristic of control or autonomous accountability emerged as a substantial correlate of better adherence to exercise in the participants they were charged with supporting. 124 Thus, this characteristic was added as a tool for hiring instructors through the development of structured interview questions. An objective 10-item “audit” of instructors’ treatment protocol compliance (based on rater observation and scoring) was also validated as a predictor of participant outcomes. 125 Through the combined evidence, the overarching treatment philosophy (see Figure 2) was supported.
Figure 2: Overarching philosophy shaping treatment curricula.

Task 2: Combining exercise and eating behavior support

After Task 1 had been suitably addressed, instruction on nutrition aspects was added. The initial related research incorporated a basic plan for healthy eating administered by registered dieticians in group settings. Again guided by Baker and Brownell’s 61 adaptation of principles of social cognitive theory, 26 possible psychosocial predictors of eating and weight change, as well as their interrelations, were assessed during program implementation. These included measures of physical self-concept, body image, mood/well-being, self-regulation (termed “coping” in Baker and Brownell’s model 61 ), and self-efficacy. Preliminary findings indicated that eating-related self-regulation explained more of the variance than the other included factors, which was similar to the case for exercise-related self-regulation in Task 1. 20,102,107,116,126–130 This finding was supported by a systematic review of 35 studies on the value of self-regulation processes applied to exercise- and eating-behavior change in overweight- and obesity-reduction programming, which also identified the high predictive strength of self-efficacy. 131
Also, although improvements in each of the tested variables appeared to be favorable for weight loss in bivariate analyses, the considerable interrelations among the variables suggested possibilities for reducing their number to consolidate treatment foci and maximize efficiency. 71,73-78,82,83,100,113,132–140 In addition, our research was substantiating the finding that exercise frequency and intensity (beyond the point of 3 moderate-intensity sessions per week) were relatively unrelated to weight loss in participants with obesity and severe obesity. Rather, the effect of exercise was thought to be due to its impact on the associated changes in psychological correlates of improved eating. 113,141 This conclusion would later be more fully confirmed, along with our earlier findings 94,114,142 indicating that even 2.5 to 3 sessions per week of moderate exercise was associated with improved mood, with no significantly better impacts being observed from greater amounts that might challenge adherence. 143 The manageable exercise amount of approximately 3 moderate sessions per week was also associated with the reduction of elevated depression and anxiety to normal levels, 99,142,144 which ran contrary to suggestions that 5 to 7 sessions per week were required for mental health benefits. 145 To provide a more comprehensive assessment of the interrelation of changes in variables, a path model toward changes in weight or body mass index (Figure 3) was fit and tested. 83
Figure 3: Path model toward change in body mass index incorporating factors derived from social cognitive theory 26 and Baker and Brownell’s predictive model. 61
As for the prediction model shaping the programming for exercise support, the importance of changes in eating-related self-regulation, self-efficacy, and mood emerged as salient correlates of eating and weight changes. These 3 factors predicted success with weight loss as effectively as when physical self-concept and body image were also included, 146 as had been suggested by Baker and Brownell. 61 The 3-factor model was also stronger than considering change in self-efficacy as the sole predictor, as implied by self-efficacy theory. 146,147 Also of high interest were findings indicating that exercise-related self-regulation predicted eating-related self-regulation and that exercise-related self-efficacy predicted eating-related self-efficacy. 21,80,90,105,109,148–153 Although self-regulation theory 60 alludes to the possibility of such an association from one context (eg, exercise) to another (eg, eating), it also indicates the plausibility of “depletion” of individuals’ limited self-regulatory resources under such conditions of 2 challenging behavioral changes occurring concurrently. 154 Carry-over from exercise to eating changes through (assumed) self-regulatory processes was found elsewhere. 155
Our later work suggested that, when self-regulatory skills were purposefully taught and rehearsed (as in our treatments), they tended to strengthen rather than diminish. 156 This implied that considerable treatment attention was warranted for supporting the transfer of self-regulatory skills (eg, instruction on how skills such as cognitive restructuring and relapse prevention could be adapted from an exercise to eating context). Although reciprocality between changes in exercise- and eating-related self-regulation and self-efficacy were apparent, the previously cited research also supported the hypothesized directionality from exercise to eating contexts by incorporating lagged-variable analyses. 157 Reciprocal relations between weight loss and changes in body satisfaction and physical self-concept in individuals with severe obesity 158,159 suggested that they were an artifact of behavioral progress rather than a malleable predictor requiring targeted treatment attention.
Also, consistent with other research, 160 improved mood (ie, exercise-associated improvement in mood) was found to be associated with an increase in self-regulatory skills usage. 89,103,106,109,149,161–163 The utility of such mood changes for other psychological changes had been posited in both social cognitive theory 26 and Baker and Brownell’s paradigm. 61 Based on those findings, an additional model was proposed that accounted for the transfer (or carry-over) of exercise-related changes in self-regulation and self-efficacy to eating-related self-regulation and self-efficacy. Change in mood was also accordingly included in that revision (Figure 4).
Figure 4: Proposed pathways toward weight loss through treatment-associated changes in self-regulation, self-efficacy, and mood carried over from exercise to eating contexts.
Adapted with permission from: Annesi JJ. Supported exercise improves controlled eating and weight through its effects on psychosocial factors: extending a systematic research program toward treatment development. Perm J 2012;16(1):7–18. doi:10.7812/11-136. 80
The applicability of the model of the weight-loss phase from baseline to month 6, represented in Figure 4, was carefully tested under various participant conditions including age, gender, initial body mass index, body image, mood, race/ethnicity, health risk status, nutritional behaviors, and self-regulatory skills usage. 54,80,84,87,89,90,103,106,111,112,114,118,126,129,139,146,148,149,151,153,161–182 Also, the expected effect of acute exercise-induced changes in feeling states on chronic mood change was supported. 101 This suggested the viability of the treatment component of evaluating an exercise plan in terms of the associated pre- to post-exercise changes in feeling states. That program element was enhanced through our development and validation of an abbreviated scale that could be used for easy assessment of pre- to post-exercise feeling-state changes. 52
Mechanisms of the relationships among changes in self-regulation, self-efficacy, and mood pointed to the need to address each factor separately in treatment. However, although each was, generally, an important independent predictor of exercise and eating changes, complex interactions were uncovered that further supported previously described suppositions that improvement in self-regulation has roles in increased self-efficacy and that better mood improves the development and use of self-regulatory skills. 84
Although some outcome differences were identified by participant type, they did not rise to the level of necessitating treatment adjustment by subgroup. 150 Rather, processes could be individually adapted within the auspices of a standardized protocol that could be used across participant characteristics. Also, the substantial mood improvements associated with manageable amounts of exercise did not appear to demonstrate additional benefits when basic mood-improvement methodologies (eg, deep breathing, abbreviated progressive relaxation) were added. 183 Thus, such approaches were minimized in the interest of program efficiency. Early investigation of additional effects of emotional eating were started, 183–185 but they did not hold treatment implications.

Task 3: Evaluation of longitudinal effects

Because some success during the weight-loss phase was derived using curricula associated with Figure 4, the present research program then began to position greater attention on the weight-loss maintenance phase. Emphases on fostering improvements in mood and carryovers from exercise-related self-regulation to eating-related self-regulation and from exercise-related self-efficacy to eating-related self-efficacy were incorporated by attending only to exercise adherence for 2 months and then ”stepping in” methods to help generalize already-learned self-regulatory skills to eating behaviors. 18 Overall, the revised program lasted a full year (group nutrition meetings approximately every 2 weeks starting at month 2), with brief phone follow-ups into a second year.
Our more recent studies incorporating the perspective of “coaction” between the behavioral changes in exercise and eating 91,186 confirmed our interpretations and program-based processes. Exercise-related self-efficacy was thought to carry over to eating-related self-efficacy through a generalized sense of ability to advance requisite (goal-driven) behaviors for weight loss. 80 Although considerable attention was being placed on the weight-loss maintenance phase by the National Institutes of Health because of sustained problems in that area, 3 the present method of instituting exercise prior to any eating-behavior changes was novel. However, support for our approach could be gleaned from other research indicating the benefits of developing self-regulatory skills for 8 weeks in advance of attempting weight loss. 187
The results of trials utilizing our methodologies were uncharacteristically favorable for cognitive-behavioral obesity interventions. 20,150 Using strict intention-to-treat processes, we observed a mean weight loss of approximately 6.5% from baseline that was almost fully maintained over 24 months. Our other data sets using similar methods confirmed that the viability of addressing the aforementioned predictors of changes in self-regulation, self-efficacy, and mood carried over to predict changes in exercise and eating behaviors over multiple years. 188,189 Moreover, a series of our probative and confirmatory studies 21,86,91,102,104,105,107,115,116,127–129,152,188–192 suggested the that weight-loss and weight-loss maintenance phases have distinct properties that require separate analyses and that emotional eating might be a construct independent from the already-addressed mood–eating relationship. 106,183–185 Thus, a modified and extended model was produced that incorporated the 2 phases as separate. It also accounted for a period between phases in which a plateau in lost weight is reliably predicted. 3,4,25 At that point, it additionally reflected the uncertainty of addressing emotional eating as a distinct construct. 193,194
That model, 18 presented in Figure 5, suggests the following conclusions: During the weight loss phase, 1) changes in exercise-related self-regulation predict exercise through (mediated by) changes in self-efficacy, 2) mood affects the self-regulation–exercise relationship, 3) changes in exercise-associated mood and self-regulation impact eating (and weight change) through changes in self-efficacy, 4) changes in both self-regulation and self-efficacy carry over from an exercise behavior context to an eating-behavior context, and 5) the mood–eating relationship might be affected by emotional eating. During the weight-loss maintenance phase, 1) the generalization of self-regulation from the weight-loss phase to the weight-loss-maintenance phase is mediated by carried over self-efficacy and 2) maintained weight loss is primarily predicted by eating-related self-regulation, with mood as a major moderator. In a test of this model’s phase-specific predictions for women with obesity (N = 103 and N = 101, respectively, for the weight-loss and weight-loss maintenance phases), there was strong agreement with the posited relationships. 195 According to analyses of the composition of the diet, our findings 196,197 agreed with other research 198–201 suggesting that fruit and vegetable intake serves as a proxy for the health of the overall diet and is a strong independent predictor of weight loss. Thus, because increasing fruit and vegetable consumption might be the most efficient and productive treatment focus in terms of the diet, it was selected as the primary nutritional target. As for the exercise-support program component, an audit form guiding the observation of program sessions was incorporated to assess instructors’ protocol compliance.
Figure 5: Causal chain predicting weight loss and weight-loss maintenance through psychosocial mediators and moderators.
Adapted with permission from: Annesi JJ. Sequential changes advancing from exercise-induced psychological improvements to controlled eating and sustained weight loss: a treatment-focused causal chain model. Perm J 2020;24:19.235. doi:10.7812/TPP/19.235.
Δ= change in the designated construct; a = path a (predictor → mediator); b = path b (mediator → outcome); c′ = path c′ (predictor → outcome, controlling for the mediator); Eat = for eating; Ex = for exercise; SE = self-efficacy; SR = self-regulation. The proposed sequence of interrelations among variables is represented with labels from 1 to 7.

Task 4: Consideration of emotional eating

To resolve the role of emotional eating in our causal chain model (Figure 5, dashed lines), 182 an additional series of studies was completed. This inquiry was also precipitated by research indicating the importance of emotional eating in general 202 and, as identified more recently, particularly during the weight-loss-maintenance phase. 203 Because we identified relationships among changes in emotional eating, intake of healthy and unhealthy foods, and weight that extended the mood–eating relationship, 88,108,109,186,193,196,204–207 emotional eating was deemed a construct worthy of program attention. 193 Because the treatment protocol guided by the causal chain model was already associated with greatly reduced emotional eating (generally moderate effect sizes), the benefit of additional methods for increasing this effect and/or the amount of treatment time focused on this issue remains unclear. Future research is planned to resolve this question. Findings suggest a path from improvements in exercise → mood → emotional eating → eating behavior → weight. 208 Also, exercise-induced improvements in depression were shown to affect depression-related emotional eating, and changes in anxiety were shown to impact anxiety-related emotional eating. 88,108,186,207 Thus, the primary treatment concern related to reducing emotional eating might simply be maintaining approximately 3 moderate sessions of exercise per week (ie, an exercise-adherence concern). However, the development of self-regulatory skills specifically targeting emotion-related prompts to uncontrolled eating might also be warranted. The effect of self-regulation on emotional eating does not now appear in the causal chain model (Figure 5), 18 but it is being investigated as a possible addition/revision. 88,205,207

Summary

This article reviewed a 25-year research program seeking to direct behavioral weight-loss programming capable of large-scale applications and reliably sustained outcomes. Because consideration of applied research guided by accepted behavioral theory was deemed key, that approach was prioritized. Driven by the evidence of physical activity/exercise as a reliable predictor of maintained weight loss, 14,15 research-related tasks proceeding from supporting exercise, to the effects of exercise on psychological correlates of weight loss, to psychological predictors of weight loss and maintenance across distinct temporal phases, to additional implications for emotional eating were offered through the demonstration of a (somewhat) systematic evolution of research represented by a progression of predictive and explanatory models.
Based on most measures, the research program was largely successful. It informed a behavioral treatment yielding considerable weight loss that was sustained over multiple years 209 that was successfully replicated. 20 Such findings are extremely rare, especially considering that the treatment was designed for large-scale application within the YMCA and other community-based venues. The identified losses in weight were consistent with reductions in health risks in two-thirds of participants, 210 which was also a primary goal and was atypical of behavioral intervention outcomes. The associated peer-reviewed studies incorporated strict intention-to-treat analytic principles rather than inflating reported weight losses by removing data from program dropouts, which is a widespread practice in weight-loss intervention research leading to the misinterpretation of the viabilities of many (often popular) regimens. 211 Thus, confidence in the present findings was increased. However, analyses conducted after the previously mentioned trials also suggested areas for improvements, including increased attention to the construct of emotional eating.
Although explanatory relationships and paths toward weight-loss behavior changes should never be considered finalized, 212–214 an aim of this article was to present immediate suggestions, guided by the extant research, for a “next-iteration” treatment capable of advancing the field of behavioral weight loss beyond its current state of mediocrity. These treatment suggestions are provided in Table 1. An urgency for their widespread dissemination is clear. Data on outcomes and the decomposition of effects associated with programs incorporating these suggestions will be forthcoming. A goal of additional weight loss beyond the weight-loss phase remains, and we continue to explore follow-up processes that will facilitate such. So far, reinforcing previously learned self-regulatory skills seems a viable path.
Table 1: Research program-based treatment suggestions
Address adherence to exercise 1 to 2 mo before eating-behavior changes are pursued.
Provide exercise support for approximately 6 mo and support of eating behaviors for a minimum of 12 to 24 mo (with ongoing follow-up).
Initiate behavioral changes through participant-directed setting of their long-term goals.
Actively work with each participant to establish and document a series of proximal goals consistent with each long-term goal.
Help create a personal action plan for the attainment of each proximal goal that is acceptable to the participant.
Support attainment of proximal goals through a behavioral contract that is regularly updated (with signatures to increase commitment).
Establish a participant-recorded measurement process for each proximal goal.
For physical activity/exercise, include regular increases in existing (weekly) amounts as a proximal goal. For eating, include increases in fruit and vegetable intake and adherence to daily caloric limits.
For weight-loss goals, regular self-weighing should occur at least once per week (more frequently is also acceptable). Weekly weights should be recorded.
Caloric tracking should be completed at least 1 weekday and 1 weekend day per week, with more frequency preferable.
Adjust proximal goals regularly based on progress tracking.
Omit nuanced aspects of a diet (eg, macronutrient proportions, nutritional supplements) within the behavioral treatment.
Overeating should not be “made up” the next day (it should simply be denoted as a “malfunction” that should not persist for another day). Increased exercise should not authorize increased caloric consumption beyond the established amount (which is typically 1200–1500 kcal/d, based on present weight).
Participants should self-select types of physical activities/exercises to maximize acceptability. Food availability and preferences should also be considered while emphasizing non-fried vegetables and fruits.
Initially, adjust exercise plans on the basis of pre- to post-exercise changes in feeling states (rather than primarily physiological considerations such as time in a “target heart rate zone” or associated caloric expenditure). Rate of perceived exertion and duration (time) can be used for “standardizing” an adequate volume across physical activity/exercise modalities. Leverage exercise-associated feeling improvements to address acute bouts of emotional eating.
Although exercise amounts may be progressively increased, treatment targets should reflect findings that approximately 3 moderate sessions per week predict favorable psychological changes.
An array of self-regulatory skills should be prioritized, focused first on maintained exercise and then generalized to controlling eating (eg, cognitive restructuring, relapse prevention, dissociation from discomfort, stimulus control, self-reward). Although these should be a primary program focus, only 1 or 2 skills should be taught and rehearsed per session (participants will naturally gravitate to preferred skills).
Each of the exercise-related self-regulatory skills should be explicitly adapted for use in controlling eating behaviors (eg, adapt dissociation from exercise-induced discomfort to distancing one’s attentional focus away from non-hunger-related prompts to eating).
Require each participant to create a list of likely lifestyle barriers (eg, disinterest in physical activity, high food availabilities, social pressures to overeat) where the learned self-regulatory skills may be focused. Provide help with “problem solving” for each of them (often using already-established self-regulatory skills).
Provide means for participants to evaluate behavioral/psychological prompts to eating (eg, emotional eating), including a scale for assessing satiety. Methods such as completing a brief bout of exercise, deep breathing, and cognitive restructuring might reduce anxiety-related prompts. Preloading with water and fiber might also minimize hunger and uncontrolled eating.
Regularly survey participants on their perceived exercise- and eating-related progress, especially those focused on stated lifestyle barriers. Refocus self-regulatory skills for overcoming such problematic areas to increase self-efficacy.
Track (measured) improvements in chronic mood as an added reinforcer for exercise-related persistence. Leverage such mood changes to address emotional eating.
Encourage means for social support across participants (eg, group walks/group exercise, electronic communications).
Treat weight loss and weight-loss maintenance as separate aims. Prepare participants for predicted plateaus in weight loss between those phases by mandating maintenance goals for 4 to 6 wk (rather that continued weight loss).
Select treatment instructors based on characteristics demonstrated to be associated with their participants’ success.
Regularly audit instructors to maximize their treatment protocol compliance.
Present a rationale for the present program, which often differs from participants’ expectations of an assigned “diet” (especially those given the most attention in the popular media).

Conclusion

The scientific quest of adequately addressing the obesity epidemic through behavioral means, and adhering to principles that suggest clear benefits for maximizing efficiency through minimizing treatment complexity, 215,216 continues. As was attempted within this lengthy (and ongoing) research program, investigators and intervention developers within the domain of translational behavioral medicine should be ever-cognizant of striking a balance between internal and external validity 217 and maintaining scientific integrity in the field of behavioral overweight/obesity treatment, which has been marred by anecdotal/intuitive approaches, demands for short-term “fixes,” expensive and inaccessible processes, and transient effects. Because many medical practitioners are unable to dedicate the amount of time suggested here to maximize probabilities for sustained weight loss in their patients with excess weight, it is hoped that community-based venues capable of such ongoing processes can be called upon for referral. It is hoped that such collaboration will become commonplace enough to impact the obesity epidemic and public health.

Future Considerations

There were several notable considerations concerning the described approaches toward fostering resilient improvements in the targeted weight-loss behaviors and excess weight for the future. The first is that behavior-change methods are often required to be directed toward instructors delivering the protocols, as well as toward participants. The reason for this is that simply educating participants on exercise and healthy eating, and expecting changes to emanate from their own volition and “willpower,” is often instructors’ (and possibly medical professionals’) default process. Conceivably, this is influenced by their own previous experiences and education. When participants fail to comply with instructions, they are often blamed for a lack of “commitment” and/or “motivation.” Because such a perspective is contrary to the presently suggested approaches derived from behavioral science, interventions should either set up reinforcement contingencies for instructors based on their compliance with the delivery of the required methodologies or prepare for the cumbersome process of persuading them that providing education to their participants (although possibly being technically quite correct) is generally insufficient for establishing maintained behavioral changes.
The second consideration is that unrealistic expectations derived from participants’ exposure to commercial program advertisements can incite goals that cannot realistically or safely be met. Although aspects written into the suggested protocol attempt to adjust for this, such as accounting for an expected plateau in weight loss to occur for which the goal is mandated to be maintenance for a period rather than continued loss (to minimize disappointment and dropout), it remains a challenge requiring the attention of program developers and administrators.
The third future consideration is somewhat related to the first. It is a reductionist philosophy common to participants, as well as many instructors. It centers on the belief that, if an individual “just wants it enough,” there will be success; otherwise, failure that cannot be countered by treatment will ensue. Such attitudes view obesity as an inherent personal weakness, which is exacerbated by the “thin ideal” for women. 218 Such individuals might feel coddled by the many cognitive-behavioral elements intended to help them overcome common lifestyle barriers, which is the centerpiece of the planned programming. Presenting evidence that overweight/obesity occurs in nearly three-fourths of adults, although worthy of inclusion, is not always helpful in normalizing the problem and justifying to participants the need for support processes over the long term given that they have a chronic condition with high probabilities for relapse. 2
Certainly, medical professionals seeking to refer and support the behavioral principles needed for sustained improvements in their patients’ health behaviors will also benefit from the aforementioned considerations, which were derived from the merger of behavioral science and its community-based application. It is likely that, in addition to innovative methodologies, a multidisciplinary approach will be required for success over a problem that has typically not responded well to mainstream approaches. Thus, our evidence-based work diligently continues with an open mind.

Footnote

Author Contributions
JJA was the sole author, responsible for all aspects of the article.

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cover image The Permanente Journal
The Permanente Journal
Volume 26Number 2June 2022
Pages: 98 - 117
PubMed: 35933678

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Keywords

  1. Obesity
  2. Weight Loss
  3. Cognitive-Behavioral
  4. Treatment
  5. Exercise
  6. Self-Regulation

Authors

Affiliations

James J Annesi, PhD, FAAHB, FTOS, FAPA [email protected]
University of Alabama at Birmingham, Birmingham, AL, USA
Central Coast YMCA, Monterey, CA, USA

Notes

James J Annesi, PhD, FAAHB, FTOS, FAPA [email protected]

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None declared

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None declared.

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  • Short- and Long-Term Weight Loss Among Women Is Unrelated to Completed Exercise Within an Obesity Intervention Focused on Self-Regulation, The Permanente Journal, 10.7812/TPP/23.043, 27, 4, (14-24), (2023).
  • Cognitive Behavior–Based Programming to Increase Physical Activity and Control Overweight/Obesity in Youth: An 18-Year Research Program Informing Novel Curricula, The Permanente Journal, 10.7812/TPP/22.022, 26, 3, (114-127), (2022).

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