Overview of Talk

1. Weight control: Should we be helping obese individuals change themselves or change their food environment? Michael R. Lowe Drexel University and The Renfrew Center Philadelphia, PA Presentation at the Center for Health, Intervention and Prevention, University of Connecticut, Storrs, Conn., December 8, 2010

2. Overview of Talk • Behavioral treatment of obesity and the self-control model upon which it is based • Rationale for changing focus of treatment from “changing the individual” to nutritional and environmental change • Development of the “Nutritrol” program • Preliminary studies

3. Behavioral treatment of obesity and the self-control model upon which it is based • Behavioral treatment is current standard of care for non-medical treatment of obesity • Represents significant improvements over previous approaches to treatment • Produces medically significant weight losses over 6-12 months • Associated with substantial health improvements as shown in Diabetes Prevention Program • Weight regain usually begins shortly after treatment ends; most weight loss is regained in 3-5 years

4. OBESITY Behavioral treatment of obesity and the self-control model upon which it is based SelfMonitoring ProblemSolving CognitiveRestructuring ContingencyManagement SocialSupport StimulusControl StressManagement Wadden and Foster. Med Clin North Am 2000:84:441. Figure from www.obesityonline.org

5. Behavioral treatment of obesity and the self-control model upon which it is based • Many are attempting to modify behavioral treatment to improve its long-term effectiveness • e.g., lengthen treatment, provide post-treatment continued contact, enhance social support, add internet support • But 3 decades of such research has done little to improve long-term outcome • I argued (Lowe, 2003) that biological and nutritional research on obesity, and limitations of self-control interventions, indicate that our paradigm needs to change

6. Behavioral treatment of obesity and the self-control model upon which it is based • Assumption of BT is that because there are so many potential sources of overeating – • Negative affect, social pressure, negative thinking, eating in many situations, weakened motivation, fear of success, etc. • Best approach is to try to treat them all • I suggested that the number of targets, the great difficulty of modifying them permanently and the lack of focus on the foods in the environment made the task nearly impossible

7. Behavioral treatment of obesity and the self-control model upon which it is based • Argued that of the factors affecting body mass that are potentially controllable, most powerful ones are in the environment, not within individuals (knowledge, attitudes, beliefs) • Use of term “potentially controllable” important in regard to those who do achieve long-term successful weight loss • The fact that a small proportion of formerly obese individuals achieve long-term success does not mean we know how to produce that outcome in the vast majority of individuals who can’t achieve it on their own

8. Behavioral treatment of obesity and the self-control model upon which it is based • A final issue with the behavioral model: Assumption that food is a relatively inert stimulus (unlike provocative stimuli involving sex, money, alcohol) • Began with Stuart’s (1967) original behavior modification approach, which viewed obesity as resulting from faulty learning and bad habits • It has become increasingly clear that palatable food is much more similar to sex or money than it is to other potentially bad habits (watching too much TV, procrastination, etc.)

9. Behavioral treatment of obesity and the self-control model upon which it is based • Increasingly appears that palatable foods are highly provocative, even before they are first tasted • Thus the mere existence of such foods may not simply set the stage for over-consumption, but may play a major role in provoking over-consumption • Recent neuroimaging research by Stice and others supports this possibility

10. Development of the Nutritrol Program • Stands for “nutritional control of body weight” • Nutritrol rationale is threefold: 1. The various qualities of food that have helped create the obesity epidemic (portion size, energy density, etc.) can be “reverse engineered” to promote weight control • Primary goal is not to teach improved self-control skills, but to focus on helping people change their “personal food environments” to minimize the need for self-control • Overweight individuals are key agents of change in their personal food environments – rather than the targets of change

11. Components of the Nutritrol Program • Psycho-education to refocus participants from the problem being “in” them to in the food environment • Review research findings on: • the effect of the food environment on appetite and eating • The impact of implicit (as well as explicit) food stimuli • How over-consumption of palatable foods (and the overweight that results) may make resisting the food environment even more difficult • Self-control as a limited resource

12. Components of the Nutritrol Program • Early on weight loss is emphasized using traditional behavioral procedures • Nutritrol principles covered early; then specific nutritional changes are gradually introduced and continue for several months • Emphasis of Nutritrol is more on preparing for maintenance than increasing weight loss

13. Components of the Nutritrol Program • Participants perceptions of being “good or bad,” “on or off the program”, motivated are not motivated are reframed: • Ultimate question is whether they are making the specific changes in food purchasing, pre-portioning, preparation methods, etc. to change their “personal food environment” • Goal of Nutritrol is to save at least 300 calories per day while eating about the same volume of food as prior to weight loss • Evidence indicates that volume of food eaten per day – not • calories consumed – is regulated and difficult to change

14. Components of the Nutritrol Program • Bulk of program is based on nutritional research focusing on changes designed to facilitate long-term control of energy intake. • Starting around week 10, consists of about 20 more weeks of: • didactic material on why the specific nutritional change is beneficial • group discussion and questions • most importantly – specific assignments to make changes in meals, snacks, food purchases, ingredients, food portioning, etc.

15. Components of the Nutritrol Program • Nutritional research has identified several characteristics of foods that, in laboratory and in some intervention studies, facilitate control of energy intake: • Reduce the energy density of the diet • Increase use of portion size strategies, especially for foods high in energy density • Consume certain “danger” foods only outside the home • Increase consumption of foods low in energy density

16. Components of the Nutritrol Program • Purchase and consume more high-protein/low fat foods (for satiety value) • Increase variety of low-energy dense foods (e.g., fruits) and decrease variety of high-energy dense foods (e.g. desserts) • Increase foods high in fiber • Take advantage of products with sugar or fat substitutes

17. Components of the Nutritrol Program • Initial data on components of Nutritrol program • Rolls has shown that a program focusing on reducing energy density of the diet produces weight losses comparable to behavioral programs • In our initial study, which focused only on energy density, compared a behavioral plus reduced energy density program with two other groups • Got non-significantly better weight loss – and maintenance of weight loss for 6 months – than two comparison condition

18. “Primary Care” Study – Examination of Meal Replacements and Reduced-ED Diet • Obese primary care patients randomly assigned to behavior therapy plus MR or behavior therapy plus reduced-ED diet in 2 X 2 design • Weight loss/maintenance treatment for one year • Followed by two years of follow-ups • Preliminary results:

20. Thanks!