Psychological and behavioural interventions

been applied in the treatment of overweight and obesity.

2.6.5.1 Behavioural therapy (BT). Behavioural Therapy (BT), as a treatment for

overweight and obesity, was developed on the premise that overweight and obesity are a result of maladaptive eating and exercise patterns, and that these could be addressed through the application of learning principles (Foster et al., 2005). Behavioural Therapy was developed to counteract the low long-term success and high attrition rates of diets. Behavioural interventions focusing on diet and exercise are deemed to be the most effective treatment for obesity (Lee, 2010; Miller, Gutschall, & Holloman, 2009). These interventions usually require 16-24 treatment sessions, over a six-month period. Such interventions are typically delivered by a multidisciplinary team, consisting of nutritionists, behavioural therapists, and exercise physiologists. The goal of behavioural interventions is to encourage healthier food choices and increased exercise. Participants are given a calorie budget of 1200- 1500 calories a day, which produce an energy deficit of between 500 and 1000 calories a day. These ratios may vary, depending on the participant’s baseline weight. The weight loss goal is between 0.5 kg and 1 kg per week. Participants are also encouraged to expend at least 1000 calories per week through exercise (Lee, 2010; Miller et al., 2009; Tate, Wing, & Winett, 2001).

Behavioural interventions encourage self-monitoring of food intake and activity levels (Lee, 2010). Participants are required to keep daily records of the time they eat, the type and amount of food eaten, and the amount of exercise done. Behavioural Therapy teaches techniques to modify eating and exercise habits, and to manipulate the home and work environments so that cues encouraging exercise are increased, and cues associated with eating are reduced. The ability to self-monitor is a strong predictor of weight loss. Interventions usually consist of face-to-face sessions, which typically result in a weight loss of 10% over a six-month period (Miller et al., 2009; Tate et al., 2001).

The involvement of family support structures is an important aspect of behavioural interventions. Family-based behavioural interventions, which include parents or significant others in the treatment process, have over the past 30 years been shown to be effective in promoting weight control and healthy habit development (Wilfley, Kolko, & Kass, 2011).

Behavioural treatments of overweight and obesity are based on classical

conditioning principles, which propose that eating is often induced by antecedent events that become inextricably linked to food intake (Stuart, 1967). Behavioural treatments aim to help the individual identify the cues that may induce inappropriate eating, and subsequently to facilitate the development of new responses to these cues (Foster et al., 2005; Wing, 2002). The treatment also aims to reinforce the adoption of positive behaviours in order to encourage a healthier lifestyle (Foster et al., 2005).

Behavioural Therapy facilitates lifestyle changes through the development of skills for achieving weight loss, and utilises a strict goal-oriented approach while

emphasising flexibility (Foster & McGuckin, 2002a; Wadden & Osei, 2002; Wilfley et al., 2011). Behavioural Therapy is based on three main premises for the

achievement of lifestyle change: it is goal-orientated, process-orientated, and focuses on making small (as opposed to large) changes (Foster et al., 2005). Behavioural Therapy seeks to set specific goals, such as going to the gym three times a week, extending the period between meals by five minutes, or reducing the number of self-critical thoughts. Secondly, the process orientation premise involves focusing treatment on actions – that is, thinking directed at how to make practical

changes, rather than merely thinking about what aspects require change (Foster et al., 2005). The emphasis is thus on problem-solving, and on an examination of factors that may hinder or help the attainment of the set goals. The third and final premise involves focusing on small changes, and is based on the learning principle of successive approximation. This theory emphasises making incremental steps to achieve a distant goal, thereby creating a foundation of small successes on which the individual can build (Foster et al., 2005).

Behavioural treatment emphasises a requirement to identify the behaviour that has led to overeating. Through examining the chain of events that results in the

overeating behaviour, Behavioural Therapy aims to identify where the modification should occur to prevent overeating (Foster et al., 2005).

Behavioural treatments teach various strategies, such as self-monitoring of food, weight, and activity levels, self-control, problem-solving, pre-planning, and relapse prevention (Wilfley et al., 2011; Wing, 2002). Other components include controlling cues associated with eating, stimulus control (restricting the home environment to encourage healthy eating behaviours), nutrition education, physical activity, slowing down meal times, and cognitive restricting (Foster et al., 2005; Wilfley et al., 2011).

Self-monitoring and physical activity have been shown to be two of the most important aspects of behavioural treatment for overweight and obesity. Parents of overweight and obese children and adolescents are encouraged to set an example by monitoring and modifying their own eating behaviours (Wilfley et al., 2011), and to utilise a rewards-based system. Rewards for successfully achieving goals associated with exchanging unhealthy eating patterns with healthy eating and increased physical activity, should be interpersonal and help encourage healthy behaviours, such as family outings (Wilfley et al., 2011). Behavioural Therapy thus focuses mainly on correcting unhealthy eating patterns and encouraging activity (Summerfield, 2001; Wilfley et al., 2011).

A large number of clinical studies have been conducted on the effects of behavioural treatments on weight loss. These treatment studies are designed to consist initially of weekly group meetings for 3-6 months, followed by maintenance-focused, biweekly meetings for 6-12 months, culminating in monthly or bimonthly meetings for a final 1- 24 months (for example, Foster et al., 2005; Wadden & Foster, 2000).

Wing et al. (cited in Foster et al., 2005) reviewed studies examining behavioural treatments for weight loss, which were conducted between 1996 and 1999. These studies demonstrated an average short-term weight loss, during the treatment phase, of 10.6% or 9.6 kg, and 8.6% or 6 kg at the 18-month follow-up. Long-term efficacy of behavioural treatments has not been established (Wing et al. cited in Foster et al., 2005).

A combination of Behavioural Therapy with diet and exercise is shown to produce greater short-term success (Wing, 2002). In their systematic review, Glenny et al. (1997) argue that combined exercise and diet programmes, which exclude a

behavioural modification programme, are as effective as diet alone. Overweight and obesity cannot simply be classified as dysfunctional eating behaviours. This is because overweight and obesity are also subject to other factors, such as genetic, metabolic, and hormonal influences. However, it is acknowledged that Behaviour Therapy provides a skill set that allows the achievement of a healthier lifestyle and weight (Foster et al., 2005). Furthermore, the healthier lifestyle promoted by therapy can improve health outcomes (Summerfield, 2001).

2.6.5.2 Cognitive-behavioural therapy (CBT). The addition of cognitive methods to

behavioural therapy intends to improve programme success and to reduce the incidence of weight regain in long-term weight management (Del Mar et al., 2009). The Cognitive Behavioural Model of overweight and obesity (Cooper & Fairburn, 2002) advocates that, with regard to the treatment of overweight and obesity, the long-term failure of behavioural interventions is a result of the neglect of the role of cognitive factors that contribute to weight regain, as well as to the relative obscurity of the treatment goals (Simos, 2008). Essentially, Cognitive Behavioural Therapy (CBT) for overweight and obesity seeks to transform the cognitive processes that maintain healthy eating and exercise behaviours, and not just to transform these behaviours in the short term (Cooper & Fairburn, 2002).

CBT techniques include psycho-education, self-monitoring, the prescription of regular eating, enabling the identification of hunger and satiety signals, stimulus control strategies (such as avoiding eating while watching television or while driving), engaging in mindful eating, identification of cues for grazing (either physical,

(including finding alternative positive activities), encouraging behaviours

incompatible with grazing (such as engaging in physical activities and identifying cognitions that promote and maintain grazing), cognitive strategies (such as

challenging maladaptive thoughts, thought restructuring and chaining, and learning how to eat high-risk foods in a safe way) (Kalodner & Delucia, 1991). CBT

techniques are thus aimed at preventing relapse.

CBT focuses on breaking negative behaviour and thought patterns. It is based on the assumption that cognition directly affects feelings and behaviours (Foster et al., 2005). For example, the negative thoughts that a dieter experiences when failing to comply with the restrictions of the diet they are engaged in, may result in feelings of worthlessness and failure, and lead to overeating. CBT aims to set realistic weight goals, to realistically monitor progress, and to correct negative thoughts resulting from a failure to meet predefined weight loss goals (Fabricatore, 2007; Foster et al., 2005).

CBT interventions include problem-solving, stimulus control, cognitive restructuring, and self-monitoring of weight, eating, and exercise (Cooper & Fairburn, 2002; Wadden & Osei, 2002; Wilfley et al., 2011). CBT does not only focus on weight loss, but targets lifestyle change through the introduction of psychological

strategies (Rapoport et al., 2000). Research (Brownell & Jeffery, 1987; Wadden & Osei, 2002; Wilson, 1994) has shown that the use of CBT has resulted in a 5-20% reduction in the initial weight of participants. However, similar to the interventions previously discussed, participants slowly return to baseline weight within five years.

A review of meta-analyses by Hofmann, Asnaani, Vonk, Sawyer, and Fang (2012) found limited research on the efficacy of CBT interventions for overweight and obesity treatment. However, preliminary research indicates support for CBT approaches when compared to no treatment. Research also demonstrates equal efficacy of CBT and other psychosocial approaches to overweight and obesity (Hofmann et al., 2012).

A study on the efficacy of CBT for treating overweight and obesity, by Grilo, Masheb and Wilson (2005), reports that CBT demonstrates efficacy for the behavioural and psychological features of Binge-Eating Disorder – a condition that is often comorbid with obesity. However, the efficacy of CBT for obesity itself is moderate and

insignificant. The high response rates that have been found for CBT as a treatment for overweight and obesity (Hofmann et al., 2012) indicate that overweight and obese people are willing to comply with this approach.

CBT has been shown to be effective in alleviating general stress and anxiety, and in decreasing depression (Hofmann et al., 2012). The ability of CBT to treat these conditions strengthens its efficacy as a treatment for overweight and obesity. This is because stress, anxiety, and depression are all reported to contribute to the

development of overweight and obesity (Dallman et al., 2003; Fulwiler et al., 2015; Goedecke et al., 2006; Luppino et al., 2010). Generally, evidence supporting the efficacy of CBT in treating overweight and obesity is strong, but scant (Hofmann et al., 2012).

2.6.5.3 Psychotherapy. It has been argued that counselling, as an intervention for

overweight and obesity, provides sustained weight loss maintenance (McTigue et al., 2003). Counselling forms part of behavioural intervention treatments, and aims to provide the skills, motivation, and external support to change eating and exercise patterns. McTigue et al. (2003) found that counselling enabled overweight and obese participants to maintain modest weight loss (3-5 kg) for a sustained period of time. The meta-analysis suggests that a more intensive counselling programme, including behavioural therapy, would achieve more success, and enable participants to sustain greater weight loss. This finding is echoed by Tsai and Wadden (2009), whose meta- analysis reveals that the use of low- to moderate-intensity physician counselling for obesity alone does not result in clinically meaningful weight loss.

Self-help peer groups and therapy post-interventions have been shown to be

effective methods of weight loss maintenance (Glenny et al., 1997). However, many participants regained weight once the maintenance programme ended. This is attributed to the abandonment of behavioural techniques taught within the therapeutic context, and the fact that extensive, long-term therapy is needed to sustain weight loss maintenance (Perri et al., 1987).

Counselling provides modest weight loss maintenance; of the available treatments for overweight and obesity, counselling provides the least harmful approach

approach because it is typically only effective as a treatment when implemented on a long-term basis. It is thus unaffordable for many people (McTigue et al., 2003).

2.6.5.4 Socio-ecological model. The Socio-ecological Model (SEM) has been

adopted as a treatment for overweight and obesity due to its focus on multiple factors impacting dietary behaviours (Townsend & Foster, 2013).

The SEM approach to overweight and obesity rests on two key concepts: the notion that behaviour affects and is affected by multiple levels of influence, and that

individual behaviour shapes and is shaped by the social environment (reciprocal causation) (Townsend & Foster, 2013, p. 1101).

Multiple behavioural drivers make up the Socio-ecological Model, and are imperative to integrate into a treatment model. These include factors within the individual/family, peer/social, community, and organisational arenas (Robinson, 2008; Wilfley et al., 2011). The SEM premise is that weight management programmes cannot be

successful if they exclude family members, peer groups, health care providers, and the community network of the individual (Wilfley et al., 2011). Social and physical environments include factors such as the levels of support and resources available to the individual to help them change to a healthier lifestyle and eating habits, and to maintain such changes.

The SEM Model is centred around examining the stimuli that may either hinder or encourage healthy eating behaviours (Wilfley et al., 2011). The results of such an examination are used as the foundation for positive behaviour change. Key areas examined in this treatment include interpersonal relationships and difficulties, and the accessibility and utilisation of healthy resources within the home, the peer network, and the community (Robinson, 2008; Wilfley et al., 2011).

This model enhances the individual’s chance of success with their weight loss as it focuses on environmental factors influencing behaviour. The SEM aims to

incorporate a supportive environment, which comprehensively deals with the multi- contextual problem of weight management (Wilfley et al., 2011). Robinson (2008) posits that the SEM, as a treatment for overweight and obesity, shows great promise because it is an integrative approach that acknowledges the multiple contributors to

the development of overweight and obesity. This model also shifts the sole responsibility for obesity from the individual to society at large.

2.6.5.5 Transtheoretical model. The Transtheoretical Model (TTM) is an

integrative, biopsychosocial model that aims to help people undertake intentional behaviour change (Summerfield, 2001). The TTM seeks to integrate key constructs from a variety of different theories in order to create a comprehensive model that can be applied to various public health interventions. This model uses “stages of change” to integrate the various concepts and principles from each of the major

psychotherapy and behavioural models. The stages of change include: (a) pre- contemplation; (b) contemplation; (c) preparation; (d) action; (e) maintenance; and (f) termination (see Prochaska, Redding, & Evers, 2013). The TTM views change as a process rather than a decision (Summerfield, 2001). TMM states that for change to occur, the individual must be ready and willing to change. Assessing the person’s readiness to change increases the likelihood that he or she will progress to the next stage of change and decreases the attrition from the treatment programme

(Summerfield, 2001).

It is hypothesised that while people may know that they need to lose weight to improve their health, this knowledge in itself is not enough to trigger change. Weight loss therefore needs to occur when an individual is ready to make that change, for the weight loss to be maintained. A mentor, or change agent, allows the person in the early stage of change (SOC) a chance to discuss concerns and to gain nutritional information, and is therefore an important factor in weight management programmes (Summerfield, 2001).

The TTM considers individual readiness to change throughout all stages of change. At the first stage of TTM, pre-contemplation, there is no intention to make a change within the next six months (Summerfield, 2001). At this stage, the individual may not have the necessary information to make the change, or they may resist making a change due to previous failure and thus lack the confidence to make another

attempt. The health belief model proposes that four strategies must be used to move from the inaction of the pre-contemplation stage to action. It is argued that an

individual must consider his or her susceptibility to the health problem, the severity of the health problem, the benefits of health action, and their perceived barriers to

health action (Summerfield, 2001). Thus, strategies targeting the pre-contemplation stage aim to determine an individual’s perceptions, and to provide feedback and information about the value of changing. This is called consciousness raising (Summerfield, 2001).

At the contemplation stage, the individual seriously considers change, and weighs the costs and benefits of engaging in change (Summerfield, 2001). Individuals begin to make small changes at the preparation stage, for example, selecting a salad as opposed to chips as a side order for a meal. At this stage, the individual is an excellent candidate for weight management programmes (Summerfield, 2001). Interventions introduced to the individual at this stage should focus on re-clarifying beliefs (self-re-evaluation), and on mobilising social support for change.

The action stage lasts approximately six months, and occurs when major changes are initiated (Summerfield, 2001). During the action stage, interventions must reinforce behaviours that encourage positive change, and build self-efficacy. Strategies at this stage include goal-setting, self-monitoring, modifying eating patterns, normalising eating, cognitive restricting, stress management, stimulus control, and building diet and activity skills (Summerfield, 2001). The sixth stage of change is maintenance, and involves applying the behaviours acquired during the action stage for at least the six months following the action stage in order for behaviour change to be sustained. This stage is concerned with preventing and coping with relapses in behaviour, and restricting detrimental environmental factors, when possible. Another weight maintenance strategy is continued participation in support groups (Summerfield, 2001). The final, ongoing phase is known as termination, which suggests that behaviour change is permanent.

Tuah, Amiel, Qureshi, Car, Kaur and Majeed (2011, p. 2) did a systematic review of the “effects of dietary interventions or physical activity interventions, or both, based on the TTM stages of change to produce sustainable (one year and longer) weight loss in overweight and obese adults”. Their review examined three studies, which had a total of 2 971 participants. Participants were allocated to either a control group or an experimental group. The control trial intervention times for each study were 9 months, 12 months, and 24 months. The use of TTM stages of change, together with

either one or both of dietary or physical interventions, was shown to be more successful than interventions that excluded TTM stages of change.

The TTM stages of change intervention resulted in a mean difference between the control group and the intervention group, of 2.1 kg at 24 months, and 0.2 kg for the interventions that excluded TTM stages of change (Tuah et al., 2011). Interventions that included TTM also demonstrated positive outcomes concerning physical activity and dietary habits: increased participation in physical activity, reduced fat intake, and increased consumption of fruit and vegetables. However, studies included in the review did not report on important health outcomes, such as quality of life, morbidity, and economic costs. The conclusions reached in this review are therefore

problematic. Furthermore, the reporting of the findings is incomplete; there are some methodological concerns, overreliance on self-reporting measures, and a lack of long-term measures to assess the sustainability of the studies. For this reason the review does not allow for any conclusive interpretations to be drawn (Tuah et al., 2011).

Johnson, Paiva, Cummins, Johnson, Dyment, Wright and Sherman (2008) investigated the benefits and efficacy of TTM-based models for the treatment of overweight and obesity. A sample of 1277 overweight or obese adults (with a BMI of 25-39) was randomly assigned to the control and TTM groups. Participants were given up to three weight management behaviours, which were assessed at 0, 3, 6,