Bulldog Weight Loss The Role of Behavioral Modification in Weight Management

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

Behavior Modification Ideas for Weight Management

Weight management involves adopting a healthy lifestyle that includes a knowledge of nutrition and exercise, a positive attitude and the right kind of motivation. Internal motives such as better health, increased energy, self-esteem and personal control increase your chances of lifelong weight management success.

Remember to have realistic goals and think long-term success. Believe in yourself and you can do it. The following information will give you ideas to help you meet your goals.

Control Your Home Environment

• Eat only while sitting down at the kitchen or dining room table. Do not eat whilewatching television, reading, cooking, talking on the phone, standing at the refrigerator orworking on the computer.
• Keep tempting foods out of the house don't buy them.
• Keep tempting foods out of sight. Have low-calorie foods ready to eat.
• Unless you are preparing a meal, stay out of the kitchen.
• Have healthy snacks at your disposal, such as small pieces of fruit, vegetables, canned fruit, pretzels, low-fat string cheese and nonfat cottage cheese.

Control Your Work Environment

• Do not eat at your desk or keep tempting snacks at your desk.
• If you get hungry between meals, plan healthy snacks and bring them with you towork.
• During your breaks, go for a walk instead of eating.
• If you work around food, plan in advance the one item you will eat at mealtime.
• Make it inconvenient to nibble on food by chewing gum, sugarless candy or drinkingwater or another low-calorie beverage.
• Do not work through meals. Skipping meals slows down metabolism and may result in overeating at the next meal.
• If food is available for special occasions, either pick the healthiest item, nibble on low-fat snacks brought from home, don't have anything offered, choose one option and have a small amount, or have only a beverage.

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Control Your Mealtime Environment

• Serve your plate of food at the stove or kitchen counter. Do not put the serving disheson the table. If you do put dishes on the table, remove them immediately when finishedeating.
• Fill half of your plate with vegetables, a quarter with lean protein and a quarter withstarch.
• Use smaller plates, bowls and glasses. A smaller portion will look large when it is in a little dish.
• Politely refuse second helpings.
• When fixing your plate, limit portions of food to one scoop/serving or less.

Daily Food Management

• Replace eating with another activity that you will not associate with food.
• Wait 20 minutes before eating something you are craving.
• Drink a large glass of water or diet soda before eating.
• Always have a big glass or bottle of water to drink throughout the day.
• Avoid high-calorie add-ons such as cream with your coffee, butter, mayonnaise and salad dressings.

Shopping

• Do not shop when hungry or tired.
• Shop from a list and avoid buying anything that is not on your list.
• If you must have tempting foods, buy individual-sized packages and try to find a lower-calorie alternative.
• Don't taste test in the store.
• Read food labels. Compare products to help you make the healthiest choices.

Preparation

• Chew a piece of gum while cooking meals.
• Use a quarter teaspoon if you taste test your food.
• Try to only fix what you are going to eat, leaving yourself no chance for seconds.
• If you have prepared more food than you need, portion it into individual containers and freeze or refrigerate immediately.
• Don't snack while cooking meals.

Eating

• Eat slowly. Remember it takes about 20 minutes for your stomach to send a message to your brain that it is full. Don't let fake hunger make you think you need more.
• The ideal way to eat is to take a bite, put your utensil down, take a sip of water, cut your next bite, take a bit, put your utensil down and so on.
• Do not cut your food all at one time. Cut only as needed.
• Take small bites and chew your food well.
• Stop eating for a minute or two at least once during a meal or snack. Take breaks to reflect and have conversation.

Cleanup and Leftovers

• Label leftovers for a specific meal or snack.
• Freeze or refrigerate individual portions of leftovers.
• Do not clean up if you are still hungry.

Eating Out and Social Eating

• Do not arrive hungry. Eat something light before the meal.
• Try to fill up on low-calorie foods, such as vegetables and fruit, and eat smaller portions of the high-calorie foods.
• Eat foods that you like, but choose small portions.
• If you want seconds, wait at least 20 minutes after you have eaten to see if you areactually hungry or if your eyes are bigger than your stomach.
• Limit alcoholic beverages. Try a soda water with a twist of lime.
• Do not skip other meals in the day to save room for the special event.

At Restaurants

• Order la carte rather than buffet style.
• Order some vegetables or a salad for an appetizer instead of eating bread.
• If you order a high-calorie dish, share it with someone.
• Try an after-dinner mint with your coffee. If you do have dessert, share it with two or more people.
• Don't overeat because you do not want to waste food. Ask for a doggie bag to take extra food home.
• Tell the server to put half of your entree in a to go bag before the meal is served toyou.
• Ask for salad dressing, gravy or high-fat sauces on the side. Dip the tip of your forkin the dressing before each bite.
• If bread is served, ask for only one piece. Try it plain without butter or oil. At Italianrestaurants where oil and vinegar is served with bread, use only a small amount of oiland a lot of vinegar for dipping.

At a Friend's House

• Offer to bring a dish, appetizer or dessert that is low in calories.
• Serve yourself small portions or tell the host that you only want a small amount.
• Stand or sit away from the snack table. Stay away from the kitchen or stay busy ifyou are near the food.
• Limit your alcohol intake.

At Buffets and Cafeterias

• Cover most of your plate with lettuce and/or vegetables.
• Use a salad plate instead of a dinner plate.
• After eating, clear away your dishes before having coffee or tea.

Entertaining at Home

• Explore low-fat, low-cholesterol cookbooks.
• Use single-serving foods like chicken breasts or hamburger patties.
• Prepare low-calorie appetizers and desserts.

Holidays

• Keep tempting foods out of sight.
• Decorate the house without using food.
• Have low-calorie beverages and foods on hand for guests.
• Allow yourself one planned treat a day.
• Don't skip meals to save up for the holiday feast. Eat regular, planned meals.

Exercise Well

• Make exercise a priority and a planned activity in the day.
• If possible, walk the entire or part of the distance to work.
• Get an exercise buddy. Go for a walk with a colleague during one of your breaks, go to the gym, run or take a walk with a friend, walk in the mall with a shopping companion.
• Park at the end of the parking lot and walk to the store or office entrance.
• Always take the stairs all of the way or at least part of the way to your floor.
• If you have a desk job, walk around the office frequently.
• Do leg lifts while sitting at your desk.
• Do something outside on the weekends like going for a hike or a bike ride.

Have a Healthy Attitude

• Make health your weight management priority.
• Be realistic. Have a goal to achieve a healthier you, not necessarily the lowest weight or ideal weight based on calculations or tables.
• Focus on a healthy eating style, not on dieting. Dieting usually lasts for a short amount of time and rarely produces long-term success.
• Think long term. You are developing new healthy behaviors to follow next month, in a year and in a decade.