Implications for Treating Obesity
By Daniel S. Kirschenbaum, Ph.D.
Northwestern University Medical School
Healthy Living Academies

The World Health Organization recently declared that obesity has become a global epidemic. This epidemic has revealed itself most dramatically in the accelerating rate of excess weight among America’s children: a 183% increase (6% to 15%) in just the past three decades. Millions of overweight teens now face a high probability of a lifetime of compromises, in health, social-psychological well-being, and vocational opportunities.

The proliferation of obesity among teenagers and its likely consequences do not, by themselves, mandate the development of boarding schools exclusively focused on helping overweight teens. If these teens could be helped enough by outpatient educational or counseling programs, more intensive treatments wouldn’t be warranted. However, the evidence from the best extant programs leaves much room for improvement.

Leonard Epstein and his colleagues have tested family based cognitive-behavioral treatment (CBT) programs for many years and found some positive effects, even in an extraordinary 10-year follow-up. Yet, the average child who received the best of those interventions remained significantly overweight at the follow-up (34%), with those who received other variations on the family-based CBT approach faring significantly worse. More recently, my colleagues and I examined the efficacy of a long-term multidisciplinary intervention (e.g., CBT, nutritional education, physical therapy for explicit exercise training) for morbidly obese adolescents. At a 2-year follow-up, only 10% of the participants demonstrated clinically significant improvements in their Body Mass Indexes (BMIs; i.e., equivalent to a reduction from initial weight of 5% or more).

The search for improved long-term outcomes may come from the following equation: SELF-CONTROL + EXTERNAL CONTROL = WEIGHT CONTROL. Consideration of each element in this equation suggests important implications for all health professionals who help people lose weight.

Self-Control

Extremely consistent self-monitoring (systematic observation and recording of target behaviors) is necessary for effective weight control. More specifically, research has shown that even among those weight controllers who generally self-monitor everything they eat and their activity levels, when they self-monitor inconsistently (i.e., missing a day or two per week) they lose less than half of their usually weekly average of 1-2 pounds per week. In two different studies, my colleagues and I found that only highly consistent self-monitors lose any weight during the holiday season (Thanksgiving to New Years Day). In other research, those who self-monitor most consistently during the first weeks of professionally conducted programs lose more weight at 1-2 year follow-ups.

Self-regulatory theories indicate that self-monitoring impacts self-evaluation and that when attributions, expectations, and other conditions are right, self-monitoring serves as the central element of effective self-control. As presented in my book, The 9 Truths About Weight Loss, self-monitoring improves weight loss by:

• increasing salience of goals;
• improving commitment to change;
• increasing feelings of control;
• increasing understanding of eating and activity patterns;
• increasing understanding of, and ability to focus on, the details;
• promoting a more positive mood.

In other words, highly consistent self-monitoring helps weight controllers develop “healthy obsession.” A healthy obsession produces anxiety when the usual patterns of eating, exercising, and focusing are not followed. This anxiety creates motivation to decrease it by maintaining effective self-regulated habits.

External Control

During the middle ages, a group of Portuguese monks realized they were growing too large for standard frocks. They collectively decided to do something about their expanding waistlines. Their simple solution was to change the size of the door to the kitchen/dining room. They made the door so small that only slim monks could fit through it. Without access to vending machines, cars, and any other sources of food, this piece of external regulation had to work – and it did.

This true story suggests a direction for intervention when standard educational and behavior change techniques prove too limited for too many people: external regulation. Changing the availability of temptations has been shown to help alcoholics, cigarette smokers, and weight controllers. Also, successful self-control of eating and activity depends on the ability to manage various demands of life (stressors). Roy Baumeister, Todd Heatherton and their associates have shown that many self-regulated behaviors deteriorate when strong demands (i.e., stressors) overwhelm “self-regulatory strength.” In other words, if the demands of the external environment become excessive, self-regulated tasks become less important. For example, what if a weight controller had to work longer hours because her business might fail if she didn’t put in the extra effort? Would she have the same time and energy for self-monitoring and exercising and making good decisions about eating? If weight controllers have too many demands relative to their coping skills, they may discontinue attending group sessions, abandon self-monitoring, decrease exercising, and eat based more on convenience without much thought about quality.

We know that getting spouses and families to help create less tempting and more facilitating environments can help weight controllers somewhat, some of the time. Yet, many obese teenagers may well benefit from living in an environment that is completely dedicated to promoting aggressive and effective weight control. This environment would build in prompts to exercise, to walk rather than ride, to stay active rather than passive, and to eat in a controlled way. It would also limit the exposure to high fat and excessive amounts of food. It would also have readily available specialized nutritional and behavioral education and therapy. Wellspring Academies (formerly Academy of the Sierras) provides exactly this kind of environment.

In summary, this analysis suggests the following things for weight loss counselors:

• Make highly consistent self-monitoring a target of intervention, every bit as important as weight loss.
• Promote self-monitoring by: (a) showing weight controllers the evidence documenting the crucial role of self-monitoring in weight loss; (b) increasing contact with weight controllers who falter in their consistency of self-monitoring [via more sessions, email, sending letters, telephone booster sessions]; (c) “prime” self-monitoring by filling in missing information as best you can during each session; (d) encourage journaling in addition to self-monitoring.
• Use various methods of enhancing external controls that could support weight loss. For example, it may help for some weight controllers to move into a city, in which walking naturally increases, rather than continue to live in a suburb that requires long commutes. Recommending weight loss camps, residential treatment, or even extended vacations that were oriented to activity (e.g., bike trips) could also prove useful or necessary for some weight controllers.