Bulldog Obesity Overcoming Behavioral Challenges to Weight Loss
Behavioral weight loss programs are effective, but where to find them?
The US Preventive Services Task Force (USPSTF) is a team of volunteer experts from various primary care medicine and nursing fields. They identify big medical problems, review the research, and translate it into action plans (called practice recommendations) for doctors like me.
Just this fall, they tackled obesity, with the goal of identifying effective ways we in primary care can help people to lose weight.
And it's not about aesthetics. This is about disease prevention, especially diabetes, high blood pressure, and heart disease, which are particularly associated with obesity.
They were NOT looking at surgeries or other procedures, only research trials involving either behavioral or medication-based weight loss programs.
The task force analyzed 89 behavioral weight loss program trials from all over the world, and these included participants of both genders as well as many racial and ethnic groups, with ages between 22 and 66, and body mass index between 25 and 39.
What was involved in a behavioral weight loss program?
The programs studied lasted between 12 and 24 months, and involved at least 12 sessions (face-to-face, group meetings, or web-based). A variety of specialists were involved (behavioral therapists, psychologists, registered dietitians, exercise physiologists, lifestyle coaches, as well as physicians) who provided counseling on basics like nutrition, physical activity, and self-monitoring, as well as psychological components like identifying obstacles, planning ahead, problem solving, and relapse prevention. Email, telephone, and/or peer support were typically included. Basically, these are intensive programs that focus on lasting diet and lifestyle change.
And intensive diet and lifestyle programs work well for weight loss. Participants had significant weight loss compared to controls, averaging between 1 and 20 pounds, with an average weight loss of 5 pounds overall, and were more likely to have lost 5% of their total body weight at 12 to 18 months. Thirteen trials looked at diabetes risk, and pooled results showed that participants had a significantly lower risk of developing diabetes.
Here's the most important part: the risks of participating in these studies were minimal. This is a major plus to behavioral interventions: no side effects or drug complications.
How did behavioral programs compare with medications?
That is considerably different from studies featuring weight loss medications. Thirty-five studies looking at a variety of medications (like liraglutide, lorcaserin, naltrexone and bupropion, orlistat, and phentermine-topiramate) had stringent inclusion criteria and high dropout rates. Why? Because of the many medical contraindications of some of these medications, and the side effects, some quite serious.
Yes, the medication studies demonstrated significant weight loss, ranging from 2 to 13 pounds. But in the end, the USPSTF has to weigh effectiveness as well as potential risks, and they concluded that "intensive, multicomponent behavioral interventions in adults with obesity can lead to clinically significant improvements in weight status and reduce the incidence of type 2 diabetes among adults with obesity and elevated plasma glucose levels [] and that the harms of intensive, multicomponent behavioral interventions (including weight loss maintenance interventions) in adults with obesity are small to none."
Basically, intensive behavioral programs aimed at lasting lifestyle changes work well for weight loss, and are extremely low-risk to boot.
So where can you sign up for such programs?
Okay, here's where the gap between science and practice comes in.
Few of these behavioral weight loss programs exist, and not everyone meets the criteria for insurance to cover them. So for most people, unless they can afford to pay out of pocket, these programs are only available through research studies.
For example, the Diabetes Prevention Program (DPP) is an excellent intensive lifestyle change behavioral weight loss program that has been studied for literally decades and works very well. It's a year-long commitment including 22 learning sessions (in-person or online) and frequent contact with a lifestyle coach. Insurance will cover this program for people who have a BMI over 25 and a confirmed diagnosis of prediabetes. Not diabetes, only prediabetes. The DPP curriculum is available for free on the Centers for Disease Control (CDC) website. Anyone could establish a program.
But a program has to meet a lot of requirements over a significant amount of time before it's officially recognized by the CDC, and insurance companies won't cover a program until it's recognized by the CDC. Even then, reimbursement rates can vary. As a result, there aren't many of these programs up and running, but there are some. To find a recognized DPP program in your state or online, check out the CDC's registry.
Many hospitals offer less intensive, shorter behavioral lifestyle change programs, but these are pay-out-of-pocket and generally cost upwards of $500.
What can you do if you can't access a behavioral weight loss program?
You can work with your doctor and create your own program by consulting with relevant specialists (for example, a nutritionist, personal trainer, and therapist), following your own progress (for example, at the doctor's office or using an app), and arranging your own peer support (ask friends and family to join you on your health journey, or join a group like Weight Watchers). I have had patients who have succeeded in making lasting lifestyle changes including weight loss using this approach.
Mobile phone apps are a relatively new but promising tool. In one 2015 research review, studies of various weight loss phone apps, used for six weeks to nine months, showed a significant average weight loss of 2.2 pounds. Some free, widely available apps include MyFitnessPal, Lose It, Noom, Weight Watchers, and Fooducate (note that these were not necessarily the ones studied in that review article).
I am hopeful that soon, guidelines-based intensive lifestyle change programs will become more widely accessible to everyone who needs this support.
Resources
There are books that can help you. I have written an evidence-based book expressly for self-guided diet and lifestyle change, Healthy Habits for Your Heart.
But my book is not the only one; other quality examples address behavioral factors for lasting lifestyle change:
Disease-Proof by David Katz, MD, MPH
The Spectrum by Dean Ornish, MD
Eat, Drink, and Be Healthy by Walter Willet, MD, DrPH
Smart at Heart (for women) by Malissa Wood, MD, FACC
Weight loss
Weight loss: 6 strategies for success
Follow these proven strategies to reduce your weight and boost your health.
By Mayo Clinic StaffHundreds of fad diets, weight-loss programs and outright scams promise quick and easy weight loss. However, the foundation of successful weight loss remains a healthy, calorie-controlled diet combined with increased physical activity. For successful, long-term weight loss, you must make permanent changes in your lifestyle and health habits.
How do you make those permanent changes? Consider following these six strategies for weight-loss success.
1. Make sure you're ready
Long-term weight loss takes time and effort and a long-term commitment. While you don't want to put off weight loss indefinitely, you should make sure you're ready to make permanent changes to eating and activity habits. Ask yourself the following questions to help you determine your readiness:
- Am I motivated to lose weight?
- Am I too distracted by other pressures?
- Do I use food as a means to cope with stress?
- Am I ready to learn or use other strategies to cope with stress?
- Do I need other support either from friends or professionals to manage stress?
- Am I willing to change eating habits?
- Am I willing to change activity habits?
- Do I have the time to spend on making these changes?
Talk to your doctor if you need help addressing stressors or emotions that seem like obstacles to your readiness. When you're ready, you'll find it easier to set goals, stay committed and change habits.
2. Find your inner motivation
No one else can make you lose weight. You must undertake diet and exercise changes to please yourself. What's going to give you the burning drive to stick to your weight-loss plan?
Make a list of what's important to you to help you stay motivated and focused, whether it's an upcoming vacation or better overall health. Then find a way to make sure that you can call on your motivational factors during moments of temptation. You might want to post an encouraging note to yourself on the pantry door or refrigerator, for instance.
While you have to take responsibility for your own behavior for successful weight loss, it helps to have support of the right kind. Pick people to support you who will encourage you in positive ways, without shame, embarrassment or sabotage.
Ideally, find people who will listen to your concerns and feelings, spend time exercising with you or creating healthy menus, and share the priority you've placed on developing a healthier lifestyle. Your support group can also offer accountability, which can be a strong motivation for sticking to your weight-loss goals.
If you prefer to keep your weight-loss plans private, be accountable to yourself by having regular weigh-ins, recording your diet and exercise progress in a journal, or tracking your progress using digital tools.
3. Set realistic goals
It may seem obvious to set realistic weight-loss goals. But do you really know what's realistic? Over the long term, it's smart to aim for losing 1 to 2 pounds (0.5 to 1 kilogram) a week. Generally to lose 1 to 2 pounds a week, you need to burn 500 to 1,000 calories more than you consume each day, through a lower calorie diet and regular physical activity.
Depending on your weight, 5% of your current weight may be a realistic goal, at least for an initial goal. If you weigh 180 pounds (82 kilograms), that's 9 pounds (4 kilograms). Even this level of weight loss can help lower your risk of chronic health problems, such as heart disease and type 2 diabetes.
When you're setting goals, think about both process and outcome goals. "Walk every day for 30 minutes" is an example of a process goal. "Lose 10 pounds" is an example of an outcome goal. It isn't essential that you have an outcome goal, but you should set process goals because changing your habits is a key to weight loss.
4. Enjoy healthier foods
Adopting a new eating style that promotes weight loss must include lowering your total calorie intake. But decreasing calories need not mean giving up taste, satisfaction or even ease of meal preparation.
One way you can lower your calorie intake is by eating more plant-based foods fruits, vegetables and whole grains. Strive for variety to help you achieve your goals without giving up taste or nutrition.
Get your weight loss started with these tips:
- Eat at least four servings of vegetables and three servings of fruits daily.
- Replace refined grains with whole grains.
- Use modest amounts of healthy fats, such as olive oil, vegetable oils, avocados, nuts, nut butters and nut oils.
- Cut back on sugar as much as possible, except the natural sugar in fruit.
- Choose low-fat dairy products and lean meat and poultry in limited amounts.
5. Get active, stay active
While you can lose weight without exercise, regular physical activity plus calorie restriction can help give you the weight-loss edge. Exercise can help burn off the excess calories you can't cut through diet alone.
Exercise also offers numerous health benefits, including boosting your mood, strengthening your cardiovascular system and reducing your blood pressure. Exercise can also help in maintaining weight loss. Studies show that people who maintain their weight loss over the long term get regular physical activity.
How many calories you burn depends on the frequency, duration and intensity of your activities. One of the best ways to lose body fat is through steady aerobic exercise such as brisk walking for at least 30 minutes most days of the week. Some people may require more physical activity than this to lose weight and maintain that weight loss.
Any extra movement helps burn calories. Think about ways you can increase your physical activity throughout the day if you can't fit in formal exercise on a given day. For example, make several trips up and down stairs instead of using the elevator, or park at the far end of the lot when shopping.
6. Change your perspective
It's not enough to eat healthy foods and exercise for only a few weeks or even months if you want long-term, successful weight management. These habits must become a way of life. Lifestyle changes start with taking an honest look at your eating patterns and daily routine.
After assessing your personal challenges to weight loss, try working out a strategy to gradually change habits and attitudes that have sabotaged your past efforts. Then move beyond simply recognizing your challenges plan for how you'll deal with them if you're going to succeed in losing weight once and for all.
You likely will have an occasional setback. But instead of giving up entirely after a setback, simply start fresh the next day. Remember that you're planning to change your life. It won't happen all at once. Stick to your healthy lifestyle and the results will be worth it.
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Dec. 07, 2021- Hensrud DD, et al. Ready, set, go. In: The Mayo Clinic Diet. 2nd ed. Mayo Clinic; 2017.
- Duyff RL. Reach and maintain your healthy weight. In: Academy of Nutrition and Dietetics Complete Food and Nutrition Guide. 5th ed. John Wiley & Sons; 2017.
- Losing weight: Getting started. Centers for Disease Control and Prevention. http://www.cdc.gov/healthyweight/losing_weight/getting_started.html. Accessed Nov. 15, 2019.
- Do you know some of the health risks of being overweight? National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/health-topics/weight-control/health_risks_being_overweight/Pages/health-risks-being-overweight.aspx. Accessed Nov. 15, 2019.
- 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Journal of the American College of Cardiology. 2014; doi:10.1016/j.jacc.2013.11.004.
- 2015-2020 Dietary Guidelines for Americans. U.S. Department of Health and Human Services and U.S. Department of Agriculture. http://health.gov/dietaryguidelines/2015/guidelines. Accessed Nov. 15, 2019.
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