Sequential Changes Advancing from Exercise-Induced Psychological Improvements to Controlled Eating and Sustained Weight Loss: A Treatment-Focused Causal Chain Model

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James J Annesi, PhD, FAAHB, FTOS, FAPA¹

Perm J 2020;24:19.235 [Full Citation]

https://doi.org/10.7812/TPP/19.235

E-pub: 04/10/2020

ABSTRACT

Introduction: Behavioral (nonsurgical/nonpharmacologic) weight loss treatments have been overwhelmingly unsuccessful beyond the short term. Rather than incorporating accepted behavioral change theory, most have inadequately relied on providing exercise and nutrition information. Although adherence is a challenge, exercise has emerged as the most robust predictor of sustained weight reduction. However, exercise might be more associated with long-term weight loss through the relationship of its associated psychological changes with improved nutrition than through direct effects of energy expenditures, which are typically minimal in deconditioned individuals.

Objective: To facilitate improved helping methods through a proposed theory-based causal chain model in which supported exercise predicts sustained weight loss through successive changes in exercise-related, then eating-related, self-regulation, self-efficacy, and mood.

Results: Segments of the model predict that 1) exercise and eating behaviors will be sequentially improved through increased self-regulatory skill use and self-efficacy and 2) exercise-induced mood improvements will foster greater self-regulation and reduced emotional eating. Short-term psychosocial changes can be leveraged to carry over to longer-term changes and maintained weight reductions. Suggested interventions emerging from the model and supporting research include using self-regulation to enable a habit of regular moderate exercise, facilitating a transfer of self-regulatory skills from an exercise to eating context, and leveraging mood improvements associated with manageable volumes of exercise to improve eating behaviors.

Conclusion: The model presents an evidence-based explanation of the exercise-weight loss association through psychosocial mechanisms. It also informs the development of practical methods to facilitate sustainable reductions in weight and health risks in adults with obesity.

INTRODUCTION

The persistent inability to reduce excess weight is associated with health risks, including the cardiovascular disease-related conditions of type 2 diabetes, hypertension, and hypercholesterolemia; various cancers; and musculoskeletal disorders.¹ Compliance with behavioral changes required to manage weight has been extremely problematic.^2,3 However, most nonsurgical and nonpharmacologic treatment methods for obesity have been atheoretical.^2,3 These methods are related to the spurious assumption that informing individuals about the need to be more physically active and to eat in a healthier manner will improve those weight management behaviors.^4-8 However, less than 4% of US adults complete the minimum amount of exercise required for health,⁹ and approximately 72% of Americans are at a higher-than-healthy weight.¹⁰ Examination of the association between the considerable amount of information already provided and the present levels of exercise and overweight/obesity in the US supports the need for the development of a viable but practical explanatory model capable of better shaping helping methods. Preferably these techniques would be able to be applied in an efficient and cost-effective manner.

Adding to that challenge is the realization that even state-of-the-art cognitive-behavioral methods have been deficient at facilitating sustained changes in weight loss behaviors for decades.^2,3,11-13 After treatment is initiated, weight loss consistently plateaus within 6 to 9 months. A near-complete weight regain then begins and persists.^2,3,11-13 Senior behavioral scientists cite even their own carefully prepared^2,14 but failed treatments as evidence of the futility of attempting sustained weight loss.^15,16 Because of an unmistakable inability to alter weight management behaviors over the long term,^2,3,11-13 some researchers professed that further efforts toward development of behavioral interventions are useless and thus should be terminated.¹⁵

Other researchers, along with this article’s author, disagree with the suggestion to end applied research activities in the behavioral weight management treatment arena. Yet, it cannot be refuted that sustained weight reduction has been “a problem that simply does not yield to treatment”,^17p717 and “most obesity prevention interventions have attained only limited or no behavioral changes … and have rarely impacted targeted physiological or anthropomorphic health outcomes.”^18p1 Most researchers concur that considerable innovation would be required for any future chance at success.^2,3,12 Possibilities for the use of behavioral methods as an adjunct to bariatric surgery¹⁹ and pharmacotherapies^2,11 were posited. However, the prospect of exercise holding importance well beyond its relatively minor direct function in weight loss (because energy expenditures are minimal in deconditioned individuals^20,21) was also advanced as a possible cost-effective basis for large-scale intervention.¹³ It was acknowledged, however, that adherence to regular exercise regimens was problematic, requiring an inventive solution,² and uses of exercise as the sole treatment element for weight loss lacked positive results.¹³ 

Recent research has sporadically assessed theoretically driven psychosocial correlates of weight loss,^22-25 and roles for exercise beyond its typically minor function from energy expenditures have occasionally been suggested.^26-28 Despite this, a comprehensive predictive model applicable for treatment development and utilization has been absent. Given the substantial scope of the obesity problem, some researchers with a translational behavioral medicine outlook asserted that emergent methods require large-scale application potentials.^13,29 Presently, however, the fragmented assortment of pretest/posttest, correlational, mediation, and moderation analyses falls far short of providing a map sufficient for effective intervention architectures. Beyond acknowledging that there are many personal barriers to sustained change to overcome and that obesity is a chronic disorder requiring lengthy attention, there is little consensus on how to revise failed processes.^2,3 As a result, many physicians and other health care professionals simply provide basic encouragements to eat healthier and to get more physical activity while realizing there is little chance of success through such advice alone.

Foundations of a Predictive Model for Behavioral Change

Before development of a theory-based causal chain model, a review of the related research was conducted considering the mediation/moderation framework for analyses of behavioral obesity reduction processes suggested by Baranowski and colleagues.¹⁸ This review was influenced by the following factors: 1) research indicating that exercise is the strongest predictor of success with sustained weight loss^20,30,31; 2) a previously proposed model suggesting a path from exercise to weight loss that included improvements in mood, well-being, body image, self-efficacy (ie, feelings of ability/competence), self-esteem, and coping leading to increased commitment, more psychological resources, and improved adherence to diet and exercise²⁸; and 3) a path where interrelations between exercise-related and eating-related self-regulation and self-efficacy were identified.^26,27 Results of subsequent investigation indicated that the changes in self-regulation, self-efficacy, and mood that explained large portions of the variances in exercise and healthy eating behaviors over 6 months will, under the correct conditions, also be associated with maintained changes.^32,33 Such self-regulatory skills included methods such as managing negative self-talk, preparing for inevitable behavioral lapses, and setting interim goals. Research findings also supported propositions that exercise-associated psychosocial improvements carry over, or generalize, to parallel psychosocial predictors of eating changes in the presence of behavioral treatments focused on self-regulation.^34-38 Additionally, eating changes (as opposed to energy expenditures) explain the preponderance of the variance in weight loss.^26,39

It should be noted, however, that when a treatment does not purposefully develop its participants’ self-regulatory skills (ie, instead use only their existing skills), their usage might diminish for use in controlling eating because they have been “depleted” by their focus on maintaining regular exercise.^34,40 Moreover, other research findings indicated that also accounting for emotional eating would be productive,⁴¹ and various theory- and research-based relationships (eg, between exercise-induced mood change and emotional eating; effects of mood change on self-regulatory skills use) required better accounting for longer-term changes in behaviors. Various other tested psychosocial predictors of behavioral changes (eg, body satisfaction, self-motivation, self-concept) were excluded from consideration for a next-generation predictive model because of either covariance issues demonstrated with other predictors or trivial additional impacts on the essential behavioral changes and weight loss.

Use of the Causal Chain

As an extension of the research, a revised model is proposed in this article using a causal chain design.⁴² A causal chain is an explanatory process in which behaviors and psychosocial factors are posited to exist in ordered schemas. Such schemas should be congruent with accepted theory, and both predictor and mediator variables might be expected to be affected by a treatment.⁴² Hardeman and colleagues^43p767 suggested that causal modeling presents a fresh opportunity for the development and testing of health behavior-change interventions, which they assert, “remain at an early stage.” In the proposed causal chain model, key tenets of social cognitive theory,^44,45 self-efficacy theory,⁴⁶ and self-regulation theory^47,48 are incorporated. Accordingly, there is an expectation that increased self-regulation will predict perseverance through lifestyle barriers, improved self-efficacy will foster persistent goal striving, and enhanced mood will generate a positive and reinforcing psychological climate that facilitates behavioral progress.²⁸ Research is also incorporated on the generalization of self-regulation and self-efficacy across health-related tasks^35,38,49 (here, exercise to healthier eating). In addition to providing an overall “shape” to the model, this theory-based emphasis additionally restricts the plethora of relationships possible among those and other variables.⁵⁰ It furthermore limits probative analyses and statistically capitalizing on chance that are, unfortunately, common in applications of structural equation modeling.⁵¹ Although often of minimal concern to the practitioner, resolution of these methodologic issues is of considerable import for the validity of an emergent model.

In the present synthesis of research, although the inevitability of idiosyncratic differences across individuals with obesity is acknowledged, a somewhat deterministic view is incorporated that might ultimately enable numerous individuals to finally be helped through standardization of methods arising from relationships in a sound predictive model. Because the use of multiple experiments to explain aspects of a causal chain has been viewed as optimal⁴² and identified as effective within a context of dietary change,⁵² those processes formed the basis of the present model’s systematic development. This was a unique advantage. Far from being an intellectual exercise that is common in research-orientated abstractions, the overall goal of the model being proposed is clear: To create a structure in which evidence-based methods facilitate meaningful improvements in both exercise and healthy eating behaviors that are reliably sustained.

Focus on Real-World Applicability

Although some research posits matching treatments to causal models,⁵³ the present concern was the development of a causal chain model in the presence of field-based treatments. This course of action allowed generalization to the real world to be maximized. Here, a fundamental aim was to seek an understanding of “active ingredients” of treatment effects⁵⁴ so that processes might be accordingly developed, prioritized, and timed. This practical use of theory and the extant research has been cited as a gap in weight management intervention research concerned with long-term effects.¹³ Additionally, considering that a further aim of this research was to support effects that have sometimes been defined as separate (ie, initial weight loss vs sustaining lost weight), the model discussed here reflects this. The extensive research literature on the transtheoretical model⁵⁵ supports the approach of accounting for psychosocial effects on behaviors that are based on distinct stages (eg, development of a behavior vs maintenance of that behavior). Because what might be the most important aspect, that is, maintenance of behavioral change, has typically been omitted in related research,^2,13 that matter received equal attention to the essential task of establishing initial changes.⁵⁶ Given this, marked attention was devoted to accounting for the transfer of the psychosocial conditions enabling short-term weight loss to those facilitating maintained loss (and accompanying reductions in health risks).⁵⁷

Model Description

A newly developed causal chain model is outlined that takes into account the following: 1) the need for an innovative treatment direction, 2) research demonstrating that exercise is the strongest predictor of sustained weight loss, 3) demonstrated relationships between psychosocial correlates of exercise and eating improvements, and 4) the need to address weight loss and weight loss maintenance as distinct issues. The model is conveyed in 2 interrelated parts: A weight loss phase (initial 6-9 months after treatment initiation) and a weight loss maintenance phase (beyond 6-9 months after treatment start). For ease of interpretation, components of the chain are denoted as “segments,” which are primarily delineated through their predictor variables. As mentioned previously, the model is derived from research completed in the presence of behavioral treatments. More specifically, those treatments had 2 components. One component was based on our 23-year program of research that has focused on cognitive-behavioral exercise adherence methods.^26,58 The component focused on eating behavior change had various versions during the last 12 years. In all cases, a pairing of exercise and eating behavior change support transpired, and emphases were placed on developing domain-specific self-regulatory skills and self-efficacy while leveraging changes in mood. Associated improvements in those psychosocial variables were supported across adult sample types,^{26,27,29,32-36,41,59-64} and in children⁶⁵ and adolescents with obesity.⁶⁶ Figure 1 shows the model, and the next section presents a rationale for the model’s component relationships.

Relationships Embedded in the Model

At its basic level, the new causal chain model proposes that under behavioral treatment conditions, psychosocial predictors of increased exercise will be associated with parallel psychosocial changes related to eating behaviors during the weight loss phase. These are associated with reductions in unfavorable eating behaviors and weight during that period. The targeted psychosocial improvements from the weight loss phase will then transfer to maintained weight loss during the weight loss maintenance phase. The proposed mediation-based segments, relationships bridging those segments (eg, carryover of psychosocial changes from exercise to eating contexts), and moderators of relationships are described here, supported by a pointed representation of their associated research findings through provided references. At a fundamental level, model-based predictions are supported by both Bandurian^44-46 and self-regulation^47,48 theory, with additional confirmation from the many cited studies.

In segment 1 of the model (top left in Figure 1) during the weight loss phase, increased exercise is predicted by increased exercise-related self-regulation through (ie, mediated by) associated improvements in exercise self-efficacy.³⁶ As suggested by Gendolla and Brinkman⁶⁷ and supported by treatment research in the present realm,⁶⁸ one’s initial mood is predicted to moderate the exercise self-regulation®physical activity relationship.

In segment 2, change in exercise behavior serves as the predictor variable. Its association with improved mood is posited to be through improved exercise self-efficacy.⁶⁹ This is supported by research suggesting that most exercise-induced change in mood is induced via improvements in feelings of accomplishment (ie, self-efficacy) rather than often-posited biochemical changes.^70,71 Leading into segment 3, exercise self-regulation change is proposed to carry over to eating-related self-regulation, change in exercise self-efficacy is posited to carry over to eating-related self-efficacy change,^34,35,72 and change in mood is a proposed moderator of the change in eating self-regulation®positive eating behavior change relationship.^67,73 

In segment 3, the relationship between changes in eating-related self-regulation and positive eating behaviors is proposed to be mediated by change in eating-related self-efficacy.³⁶ In the related research, the decision to enter positive vs unfavorable eating behaviors in segment 3 was influenced by the stronger relationships of self-regulation with positive eating behaviors previously identified.⁷⁴ However, this was somewhat arbitrary, and the significant interrelationship is addressed in the account of segment 5.

Part of segment 4 is represented with dashed lines where change in emotional eating enters the model. This is because of a lack of clarity on whether the effect of mood change on eating behavior encompasses the construct of “emotional eating” or not. The reader is left to judge this nuance in terminology. However, assuming that it is a distinct construct, the prediction of negative mood change’s effect on change in positive eating behavior is proposed to be mediated by emotional eating change.^61,68

Leading into segment 5, it is contended that increased emotional eating will predict increases in unfavorable eating behaviors.⁷⁵ In this segment, the effect of increased positive eating behaviors on weight loss is proposed to be mediated by a reduction in unfavorable eating.⁷⁵ This portion of the model is supported by research suggesting that the positive eating behavior of increased fruit and vegetable consumption affects the diet as a whole,⁷⁶ including reducing unfavorable eating behaviors such as the intake of sweets,^61,77 and its effects on weight^39,78 in a behavioral treatment context.

Supported by recent findings,⁵⁷ in segment 6, the increases in eating-related self-regulation over the weight loss phase are purported to increase eating-related self-regulation into the weight loss maintenance phase through eating-related self-efficacy changes attained in the weight loss phase.^62,79 Research findings also suggest that the transfer of early increases in eating-related self-regulation to their longer-term improvements is associated with the degree of treatment attention provided to self-regulatory skills development (vs more customary activities related to nutritional advice).^62,64 The association of increased self-efficacy developed through feelings of ability derived from self-regulating through barriers was addressed earlier, in segments 1 and 3.

In segment 7, the prediction of weight loss sustained over the weight loss maintenance phase by the eating-related self-regulation changes during that period is proposed to be moderated by the degree of negative mood present in the weight loss maintenance phase. The research on mood’s effect on self-regulation⁶⁷ was again the basis of that proposition, which was also adequately supported in the present context.^39,68 Also supported was that the effect of the aforementioned moderation by mood during the weight loss maintenance phase is, in turn, affected by exercise amounts completed during that phase.³⁹ Because it remains unclear what volume of exercise is required to sustain exercise-induced improvements in mood, both its mean value and change during the weight loss phase is presently being investigated. With formerly sedentary adults, our preliminary findings suggest that 3 moderate exercise sessions per week are adequate.

Model-Based Treatment Directives

Success or failure with weight loss can often be synopsized via the constant “battle” of immediate gratification from unhealthy eating and avoiding physical exertion vs longer-term (already known) health benefits from regular exercise and controlled eating. Put in behavioral terms, the management of one’s environment to minimize challenges and of personal capabilities/perceptions to counter persistent barriers is where theory meets effective treatment application.⁸⁰ With that in mind and remaining in this article’s intended parameters, treatment facets are proposed on the basis of the causal chain model and its supporting data as well as the field-based treatment context in which those data were acquired (Table 1).

Assessing Generalizability

Assessment of outcomes and additional decomposition of effects requires further testing across sample types (eg, ages, sexes, ethnicities, medical disorders beyond excess weight, pre/post bariatric surgery, degrees of overweight/obesity, degrees of physical mobility, using pharmacotherapies, with psychiatric/psychological disorders), and treatment administration formats (eg, group, individual, face-to-face, electronically supported, manual based). Although an aim of the predictive model is large-scale applicability across individuals with excess weight, it is also possible that, after further study, adjustments by subgroups will be indicated. However, any such treatment alterations should be evaluated against the advantages (eg, logistical, cost) of a single standardized protocol applicable across venues capable of supporting its widespread dissemination (eg, community health centers, YMCAs, health maintenance organizations).

Limitations and Strengths

The clear advantage in the development of the proposed model was our nearly continuous compilation of relevant data since 1997. This was made possible because the associated treatment components were operationally embedded in a large community-based organization concerned with changing health behaviors and improving health risks. This provided a unique opportunity for our sustained and systematic program of field-based inquiry. However, given the behavioral nature of the proposed causal chain, it is beyond the present scope to propose interrelationships between behavioral and physiologic factors regarding weight change. Hence, although controlled eating will be associated with reduced body weight because of an overall reduction in energy intake,^39,76 analyses of possible relationships such as the effect of increased exercise on body composition and resting metabolic rate, and increases in consumption of fruits and vegetables on lean body mass, should be attended to in future research.

Strengths of the model, including some based on methodologic aspects, include the following:

•  Findings that used a lagged variable approach, in which gains observed over an earlier temporal period predicted longer-term changes in outcome variables,^81,82 were prioritized. That condition addresses possible reciprocal relationships (and directionality opposite from expectations) among incorporated factors.

•  Where mediators and moderators are included in the causal chain, actual determinants of targeted gains were clarified and could also be accordingly addressed in treatment applications. That could beneficially drive both the timing and prioritization of intervention components. Also, such sequencing allowed an outcome variable in one area of the causal chain to serve as a predictor in a subsequent section.

•  Variables selected for inclusion in the model were reasonably malleable. For example, although factors such as educational level and socioeconomic status might predict (covary with) behaviors associated with reduced weight, if emergent interventions are to be pertinent across demographic groups, accounting for such in the model would not be practically useful.

•  Following from a goal of applicability, the dynamic processes in interventions were represented by change (gain) scores. Although cross-sectional research is (too) common in the area of health behavior change,⁸³ data that characterize change best reflect both dynamic intervention effects and their impacts in a sequence of associations, ultimately leading to improvements in exercise and eating, their maintenance, and associated changes in weight.⁸⁴ 

•  Although the basis of the causal chain design emanates from seminal principles of mediation analysis,⁸⁵ recent extensions of those tenets that do not require a predictor and outcome variable to initially demonstrate a significant bivariate relationship⁸⁶ were also incorporated in the guiding research.

CONCLUSION

Predictive models on the effects of exercise on weight loss through psychosocial processes have been scarce. Exceptions are Baker and Brownell,²⁸ who proposed that exercise affects the relations of psychological mechanisms (eg, body image, coping) and physiologic mechanisms (eg, resting metabolic rate, appetite) that foster weight control, and our own earlier research positing interactions between physical activity-related and eating-related self-regulation and self-efficacy, and mood.^26,27 Rather, what has been available in the area are studies limited by 1) cross-sectional analyses, 2) post hoc interpretations of relationships among variables, 3) a lack of decomposition of treatment effects, 4) an irrelevance of short-term findings, and 5) a lack of generalizability of results to applied settings. Even the emerging research on the phenomenon of coaction (ie, taking action on one treated behavior increasing the probability of taking action on a second behavior) related to weight management has not yet proposed a causal framework.⁸⁷ Also, the few investigations testing sequential applications of exercise and nutrition intervention components have been limited by a lack of decomposition of effects through potential mediators, failure to assess impacts on overweight and obesity, and an absence of intention-to-treat formats (ie, having self-select biases).^88,89 Given their design limitations, some studies simply presumed that effects carry over from exercise to eating improvements, without identifying possible mechanisms.^38,90

The model proposed in this article addresses many of those limitations while also being the first explanatory paradigm found to focus on weight loss and weight loss maintenance as separate issues, as is suggested by much of the pertinent scientific literature.^{2,3,11-13,25,31} Its well-defined annotation of relevant variables and their interrelationships addresses summary suggestions from the recent National Institutes of Health working group charged with providing suggestions for future research on improving maintenance of weight loss such as, “Clear constructs with better definitions are needed to improve our understanding of how the homeostatic, hedonic, and cognitive mechanisms that underlie eating and activity-related behaviors influence body weight regulation.”^2p12 Practical considerations were also attended to through the model’s ability to inform intervention. Ultimately, if physicians and other health care professionals can be armed with targeted health behavioral change methods emerging from the proposed model, and they are supported through alliances with other professionals that are tailored to addressing sustained change in the same theoretically sound manner, chances for gaining control over obesity-related behaviors and outcomes are likely to increase exponentially. Many will agree that the realization of such a partnership between the behavioral science, medical professional, and wellness communities is considerably past due.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgments

The author acknowledges the ongoing support of evidence-based applications of exercise adherence and weight management processes provided him by the administration and staff of the YMCA of Metro Atlanta, Atlanta, GA, along with consistent intellectual contributions from a select few academicians dedicated to theory-based translational behavioral medicine. The research yielding the proposed model was influenced by numerous studies we conducted in the US, Canada, United Kingdom, and Italy; intervention evaluations provided by the National Institutes of Health/National Cancer Institute, Bethesda, MD; and individuals with positions ranging from health promotion professional and physician to facility operations specialist and research methodologist. Appreciation is especially afforded the participants and practitioners involved in the associated research program, which continues.

Author Affiliations

¹ YMCA of Metropolitan Atlanta, GA

Corresponding Author

James J Annesi PhD, FAAHB, FTOS, FAPA (jamesa@ymcaatlanta.org)

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Keywords: adherence, behavioral medicine, evidence-based, health education, integrative medicine, Lifestyle Medicine, nutrition, obesity, preventive, weight