Preventing relapse after weight loss.

The Epidemic of Obesity

Overweight and obesity are now recognized to be epidemic in the Western world. Overweight and obesity, in combination with physical inactivity, are risk factors for multiple chronic medical conditions which include diabetes mellitus, hypertension, cardiovascular disease, pulmonary disease, and orthopedic injuries, all of which may be debilitating or life-threatening. Approximately 300,000 deaths each year in the US are attributed to obesity and an equal number to physical inactivity (1). The psychosocial morbidity and mortality is likely to be high but harder to quantify. Data from industrialized western countries, and now even industrialized regions of China, demonstrate increasing prevalence of obesity and overweight. In the US, approximately 64% of the adults qualify as overweight/obese, with some population subgroups having a prevalence of over 70% (2). Twenty-eight percent of US children are overweight with another 14% obese. Five percent of the population qualifies as morbidly obese, roughly doubling from 1989 to the present (2).

The commonly accepted definitions are from the International Obesity Task Force of the World Health Organization which in 1998 successfully urged universal adoption. Body mass index (BMI) is used as the measure, and is defined as kilograms of body weight divided by the body surface area in meters squared. Overweight is defined as a BMI of 25 to 29.9; obesity is defined as a BMI of greater than 30, and morbid obesity as a BMI of 40 or greater (1).

The literature is replete with approaches to weight loss management. Serdula's article (3) is an excellent starting point. Tsai's review of major commercial weight loss programs is helpful. Various diet + exercise + medication plans have been reviewed, and in short, they can all be found to be effective for short-term weight loss, usually with a nadir at six months. The thornier problem is how to maintain the weight loss. The NIH Task Force found that sustained weight loss after one year was less than 5% (4). This is a common observation among physicians and lay people. Other common observations are the yo-yo dieting and large swings in body weight, also known as weight cycling, which risk injury to the client. Finally, we should note the exception to diet-induced weight loss. Since the NIH consensus statement in 1992, bariatric surgery is now recommended for the morbidly obese (BMI>40) or BMI>35 if there are significant comorbidities.

Stages of Change

The challenge, then, is to integrate an effective relapse prevention strategy into a weight management program. First, consider the client who enters a weight management program. A common model for understanding motivation and timing for making a major change in life is the Stages of Change Model developed by Prochaska and DiClemente (Table 1) who studied patterns in smokers who were or were not making smoking cessation efforts. The stages are Precontemplation, Contemplation, Preparation/Determination, Action/Willpower, Maintenance, and Relapse. A seventh stage has been suggested by Kern, Transcendence, a stage reached when Maintenance has been sustained to the point that relapses are unthinkable. The significant point here is that movement from stage to stage is made from an internal locus of control, i.e. permanent change will not be imposed by another, and that clients cycle and recycle from stage to stage. For example, a client may move from Maintenance due to a severe stress to a Relapse, at which time he may need to resume from the Contemplation stage. This model may be quite different from the AA model in which the client never is assumed to reach the Transcendence stage. The client must always believe himself to be impaired ("I am an alcoholic"), and the addiction is controlled not cured.

The Stages of Change Model has been modified by inclusion of Processes of Change (Table 2) which are ten processes used by the client in moving through the Stages. Prochaska lists these as: Consciousness Raising, Self-Reevaluation, Self-Liberation, Counterconditioning, Stimulus Control, Reinforcement Management, Helping Relationships, Dramatic Relief, Environmental Reevaluation, and Social Liberation. Different processes are used at different stages (5) as shown in Table 3. This new fusion is the Transtheoretical Model of Health Behavior Change and is applied to a smoking cessation with success by tailoring counselor responses to stages and processes as identified on a questionnaire (6). This is an attempt to better understand the movement of the client through the various Stages of Change.

More recently, King (7) notes a distinction between "the processes that underlie the initiation of a new behavior" and the "maintenance of an initiated change in behavior." Compare the high outcome expectations of a change with the satisfaction of the new situation, e.g. lower weight and a more active or perhaps a more restrictive lifestyle. King ends by warning about setting initial expectations too high.

Expectations

A cornerstone of a successful weight loss program is realistic weight-loss goals. Serdula suggests an initial goal of 10% of body weight over six months. Achievement of this goal "can significantly reduce obesity-related conditions" (3). Wadden (8) notes than "many obese individuals, however, are not interested in modest weight losses," and even after being counseled to expect to lose 10% of their weight, they continued to expect to lose 20% to 30%. Wadden also found that although the weight loss averaged 10% to 16%, the majority of his clients were satisfied with that result. It is important to teach clients that even mild loss will be helpful in reducing the risk of developing comorbid conditions or in facilitating their treatment (9).

Who Succeeds

After reviewing successful weight loss maintainers, Elfhag finds an association "with more initial weight loss, reaching a self-determined goal weight, having a physically active lifestyle, a regular meal rhythm including breakfast and healthier eating, control of over-eating and self-monitoring of behaviors" (10). Other factors include "an internal motivation to lose weight, social support, better coping strategies and ability to handle life stress, self-efficacy, autonomy ... and overall more psychological strength and stability" (10). Risks for "weight regain include a history of weight cycling, disinhibited eating, binge eating, more hunger, eating in response to negative emotions and stress, and more passive reactions to problems" (10). Specifically, depression or depressed mood is a major risk factor and is the precipitating factor in half of relapses.

What is clear is that obesity/overweight is a chronic illness (11). Timmerman (12) notes in dieters that perceived deprivation and preoccupation with food are not closely related to actual calorie or fat intake. Phelan also found that after major weight loss, "that recovery from even minor weight regain was rare" (13).

Relapse Prevention Strategies

What strategies can be employed to prevent relapse? First, with regard to definition, "lapse" is often described as a slip or a mistake, whereas "relapse" is defined as a resumption of old behaviors (14). Foreyt (15) list five strategies: Relapse Prevention Training (Cognitive-Behavioral Training), Therapist Contact, Peer Groups, Aerobic Exercise, Social Influence to which we may add Behavioral Therapy. What are the causes of relapse? Prochaska notes stress or more correctly, distress, anxiety, or depression. Turner notes that many overweight people have "lifestyles unbalanced with much work and little pleasure" (16).

Cognitive-Behavioral training involves "cognitive methods to help patients adopt a more healthful diet and modify attitudes about eating and body image" (17). A therapist and client partner in focusing on client attitudes and beliefs, set achievable goals, and assist in modifying behaviors. The cognitive aspect relates to discussion of the client's thoughts, beliefs, assumptions and his/her expectations. The goal of the therapist in a group or individual setting is to work with these to bring the client to adopting realistic perceptions and assumptions, forming a reasonable plan, and setting achievable goals. The behavioral aspect relates to the therapist and client looking at reinforcing appropriate behaviors, learning a skill set which will contribute to increasing appropriate behaviors, and rewarding helpful behaviors and extinguishing non-helpful behaviors. The mix of the two aspects will depend on the nature of the client.

Behavior Therapy focuses on "changing behavior related to eating and physical activity and involves self-monitoring, stimulus control, improving nutrition, and contracting to promote a reward system" (17). The most common techniques include self-monitoring (especially with a diary) to teach body awareness. Wisotsky includes a sample diary page in her article. Stimulus control means new routines to limit access to high calorie meals. For example, eliminate such foods from the home or work environment. A behavior contract system with a reward system can be designed by the client with the therapist. The client, when he identifies a high-risk situation, needs to apply an adequate coping response to prevent the "abstinence violation" which may lead to relapse (14).

Peer Groups, especially with a facilitator have been found to be helpful. These can be organized by the health care provider or may include other standing groups, i.e. Overeater's Anonymous (www.oa.org). This organization may or may not be helpful. Of course, the peer group may well be the friends or family who enlist in a weight loss and maintenance program with the client. Groups of three or more friends compared to groups of solo participants were more successful in completing treatment (95% vs. 76%) and in maintaining their weight loss (66% vs. 24%) per Dr Rena Wing (18). Epstein notes excellent results in weight loss and maintenance of weight loss when a parent and child are both in a program (19). More examples of parent-child programs are evident, e.g. Kidshapers, a multimodality program organized by All Childrens Hospital--University of South Florida, which combines education and exercise programs with parents and children attending.

Therapist contact means specifically prolonged therapist involvement. Perri (20) notes that a full year of biweekly (every two weeks) therapist contact resulted in significantly more long-term weight loss (35% vs. 6%) than a control group which received only 20 weeks. In these sessions, participants were taught the problem-solving model of obesity management:

(a) Orientation (developing an appropriate coping perspective) -- Problems are a normal part of managing your weight, but they can be dealt with effectively.

(b) Definition or specifying the problem and goal behaviors -- What is the particular problem facing you right now? What is your goal in this situation?

(c) Generation of Alternatives (i.e., brainstorming potential solutions) -- The greater the range of possible solutions you consider, the greater your chances of developing an effective solution.

(d) Decision Making (i.e., anticipating the probable outcomes of different options) -- What are the likely short- and long-term consequences of each of your options?

(e) Implementation and Evaluation (i.e., trying out a plan and evaluating its effectiveness) -- What solution plan are you going to try and how will you know if it works?

Turner speaks more simply about cognitive restructuring to turn negative thoughts into positive alternatives. For example, rather than "I've been working on this for so long that I shouldn't be making mistakes," shift the thought to "Even people who have been working on behavior change for a long time make mistakes. Making mistakes is part of the learning process" (16). The essential point is to not blame the patient yet help them take responsibility for their own health (16). Baker (21) makes the point to not be judgmental and notes that the obese deal with harsh vocabulary which often equates obesity with sinfulness, and blames the client for yielding to temptation and indulgence.

Exercise programs or increased physical activity have been found to be an effective supplemental tool in weight loss and maintenance of weight loss. Multiple papers have demonstrated this finding. One paper reported that "76% of individuals who used exercise during a weight loss period maintained their weight loss, whereas only 36% of those who did not use exercise during the weight loss period were able to maintain their weight" (9). McGuire found that of the individuals who maintained a 10% weight loss for an average of five years, most used exercise as part of their weight loss program (22). Besides the caloric expenditure of exercise, other behaviors associated with exercise may be beneficial and account for the improvement. Exercise may be associated with changes in eating patterns, continued contact with groups, and compliance with weight loss regimens (9). Not to be overlooked is that "improved well-being and enhanced self-esteem produced by physical activity generalize to other areas of life and lead to improved dietary adherence" (1). Several authors note improvement in self-esteem and perhaps perceived self-efficacy from exercise programs. Sorensen in a year-long study which had three arms, i.e. diet only, exercise only, and diet plus exercise, found that "exercise led to more positive self perceptions of physical mastery and ability" (1).

A review of the literature reveals that most authors recommend multimodality therapy, and most recommend continued therapist contact for maintenance of weight loss (11,23,24,25). The Trevose Program maintained contact up to 60 months with "two-year weight loss 19% of initial weight and at five-year it was 17%" (11). Jeffrey notes the above and suggests further investigation of 1) how to keep the obese in long-term treatment, 2) the natural history of intentional weight loss and the multiple contributing psychosocial factors, 3) energy intake and expenditure, 4) behavioral phenotypes within the obese population, 5) the role of behavioral preferences in obesity and its treatment (e.g. for energy-dense foods), 6) why outcomes are better for preadolescents than adults, 7) the effect of physical activity and social support on weight loss, 8) the link from lab research to new models of behavior control to that of applied research, 9) new and safer effective medications, and 10) the integration of medications into effective programs of weight control (26).

Additionally, contact with clients may be better quantified or characterized by use of questionnaires. Both Pratt (27) and Cioffi (28) have published studies of questionnaires to identify reasons for attrition from a weight loss program. Similarly, Prochaska used a questionnaire completed by mail or computer to track progress of smokers in a cessation program. Prochaska notes that the questionnaire was used to define where the client is in the stages model and therefore the counselor can offer a better directed therapy (6).

Conclusions

In summary, although weight loss programs are medically indicated, and an effective relapse prevention plan should be included in the program, there is no general consensus on a particular plan. Below, however, are common threads found throughout the literature:

1. Encourage enrollment of groups--clients do better if enrolled with small groups of friends and family, their peers.

2. Encourage participation and support of significant others and families.

3. Initiate therapist contact early on to examine motivations, thought processes, and set appropriate goals (see Table 7).

4. Programs should be multimodality with inclusion of physicians, dietitians, therapists, and trainers.

5. Frequent meetings should be programmed to increase client compliance and participation.

6. Physical activity program should be included and may well be a major source of the psychosocial benefits which increase and maintain success.

7. Lapses and relapses should be expected and managed as learning opportunities for the client, to attempt to prevent a major relapse or withdrawal from the program (see Tables 4, 5, and 6).

8. Therapy contact, individual or group, should be every two weeks or more often and should extend to at least one year.

9. Cognitive-Behavioral approaches should be used as the model for discussion of problems with the clients.

10. The Transtheoretical Model with stages and processes are useful guides for formulating tailored messages to each client.

11. Questionnaires used by the therapist directly, mailed, or by Internet may be used to track status of clients, or to identify clients at risk of relapse.

12. Look for depression or depressed mood as a major risk factor for relapse.

REFERENCES

1. Bouchard C, ed. Physical Activity and Obesity, 1st Ed. Champaign, IL. Human Kinetics, 2000.

2. Ogden CL. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA 2006; 295: 1549-1555.

3. Serdula MK, et al. Weight loss counseling revisited. JAMA 2003; 289: 1747-1750.

4. Albert M, Spanos C, Shikora S. Morbid obesity: the value of surgical intervention. Clin Fam Pract 2002; 4(2).

5. Prochaska J. In search of how people change: applications to addictive behaviors. Am Psychol 2002; 1102-1114.

6. Prochaska J. The transtheoretical model of health behavior change. Am J Health Promot 1997; 12(1): 38-48.

7. King CM, el al. The challenge study: theory-based interventions for smoking and weight loss. Health Educ Res: Theory & Pract 2002; 17: 522-530.

8. Wadden TA, et al. Great Expectations: "I'm losing 25% of my weight no matter what you say." J Consult Clin Psychol 2003; 71: 1084-1089.

9. Anderson J, et al. Long-term weight maintenance after an intensive weight-loss program. J Am Coll Nutr 1999; 18: 620-627.

10. Elfhag K, Rossner S. Who succeeds in maintaining weight loss? Int Assoc Study Obes: Obes Rev 2005; 6: 67-85.

11. Latner JD, et al. Effective long-term treatment of obesity: a continuing care model. Int J Obes 2000; 24: 893-898.

12. Timmerman GM, Gregg EK. Dieting, perceived deprivation, and preoccupation with food. West J Nurs Res 2003; 25: 405-418.

13. Phelan S. Recovery from relapse among successful weight maintainers. Am J Clin Nutr 2003; 78: 1079-1084.

14. Brownell K. The LEARN Program for Weight Management, 10th ed. Dallas, TX: American Health Publishing Company, 2004.

15. Foreyt J, Goodrick GK. Evidence for success of behavior modification in weight loss and control. Ann Intern Med 1993; 119(7): 698-701.

16. Turner L, Wang M, Westerfield RC. Preventing relapse in weight control: a discussion of cognitive and behavioral strategies. Psychol Rep 1995; 77: 651-656.

17. Wisotsky W, Swencionis C. Cognitive-behavioral approaches in the management of obesity. Adol Med: State Art Rev 2003; 14(1): 37-48.

18. Wing R, Jeffrey R. Benefits of recruiting participants with friends and increasing social support for weight loss and maintenance. J Consult Clin Psychol 1999; 67(1): 132-138.

19. Epstein L. Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol 1994; 13(5): 373-383.

20. Perri M. Relapse prevention training and problem-solving therapy in the long-term management of obesity. J Consult Clin Psychol 2001; 69(4): 722-726.

21. Baker R. On sin, symptom substitution and simplicity: a response to preventing relapse in weight control. Psychol Rep 1996; 78: 680-682.

22. McGuire M. Behavioral strategies of individuals who maintain long-term weight loss. Obes Res 1999; 7: 334-341.

23. Glenny AM. The treatment and prevention of obesity: a systematic review of the literature. Int J Obes 1997; 21: 715-737.

24. Perri M. The maintenance of treatment effects in the long-term management of obesity. Clin Psychol: Science and Pract 1998; 5(4): 526-543.

25. Baum J, Clark H, Sandler J. Preventing relapse in obesity through posttreatment maintenance systems: comparing the relative efficacy of two levels of therapist support. J Behav Med 1991; 14(3): 287-301.

26. Jeffery R. Long-term maintenance of weight loss: current status. Health Psychol 2000; 19(1): 5-16.

27. Pratt C. Development of a screening questionnaire to study attrition in weight-control programs. Psychol Rep 1989; 64: 1007-1016.

28. Cioffi J. Factors that enable and inhibit transition from a weight management program: a qualitative study. Health Educ Res 2002; 17(1): 19-26.

Katrina Wells is a student-athlete (triathlon, tennis) interested in science and a career in medicine. Thomas Wells, MD, is a general surgeon and avid but slow athlete (triathlon, ultramarathon) with special interests in exercise physiology and preventive medicine.

Questions or feedback for the author may be directed to [e-mail].

By Katrina M. Wells and Thomas D. Wells, MD

Table 1 Prochaska and DiClemente's Stages of Change Model

Stage of
Change           Characteristics              Techniques

Pre-             * Not currently considering  * Validate lack of
  Contemplation  change: "Ignorance is        readiness
                 bliss"                       * Clarify: decision is
                                              theirs
                                              * Encourage re-eval of
                                              current behavior
                                              * Encourage self-
                                              exploration, not action
                                              * Explain and personalize
                                              the risk
Contemplation    * Ambivalent about change:   * Validate lack of
                 "Sitting on the fence"       readiness
                 * Not considering change     * Clarify: decision is
                 within the next month        theirs
                                              * Encourage evaluation of
                                              pros and cons of behavior
                                              change
                                              * Identify and promote
                                              new, positive outcome
                                              expectations
Preparation      * Some experience with       * Identify and assist in
                 change and are trying to     problem solving re:
                 change: "Testing the         obstacles
                 waters"                      * Help patient identify
                 * Planning to act within     social support
                 1 month                      * Verify that patient has
                                              underlying skills for
                                              behavior change
                                              * Encourage small initial
                                              steps
Action           * Practicing new behavior    * Focus on restructuring
                 for 3-6 months               cues and social support
                                              * Bolster self-efficacy
                                              for dealing with obstacles
                                              * Combat feelings of loss
                                              and reiterate long-term
                                              benefits
Maintenance      * Continued commitment to    * Plan for follow-up
                 sustaining new behavior      support
                 * Post-6 months to 5 years   * Reinforce internal
                                              rewards
                                              * Discuss coping with
                                              relapse
Relapse          * Resumption of old          * Evaluate trigger for
                 behaviors: "Fall from        relapse
                 grace"                       * Reassess motivation and
                                              barriers
                                              * Plan stronger coping
                                              strategies

Table 2 Titles, Definitions, and Representative Interventions of the
Processes of Change

Process              Definitions and Interventions

Consciousness        Increasing information about self and problem:
  Raising            observations, confrontations, interpretations,
                     bibliography
Self-Reevaluation    Assessing how one feels and thinks about oneself
                     with respect to a problem: value clarification,
                     imagery, corrective emotional experience
Self-Liberation      Choosing and commitment to act or belief in ability
                     to change: decision-making therapy, New Year's
                     resolutions, logotherapy techniques, commitment
                     enhancing techniques
Counterconditioning  Substituting alternatives for problem behaviors:
                     relaxation, desensitization, assertion, positive
                     self-statements
Stimulus Control     Avoiding or countering stimuli that elicit problem
                     behaviors: restructuring one's environment (e.g.,
                     removing alcohol or fattening foods), avoiding high
                     risk cues, fading techniques
Reinforcement        Rewarding one's self or being rewarded by others
  Management         for making changes: contingency contracts, overt
                     and covert reinforcement, self-reward
Helping              Being open and trusting about problems with someone
  Relationships      who cares: therapeutic alliance, social support,
                     self-help groups
Dramatic Relief      Experiencing and expressing feelings about one's
                     problems and solutions: psychodrama, grieving
                     losses, role playing
Environmental        Assessing how one's problem affects physical
  Reevaluation       environment: empathy, training, documentaries
Social Liberation    Increasing alternatives for nonproblem behaviors
                     available in society: advocating for rights of
                     repressed, empowering, policy interventions

Prochaska J. In search of how people change: applications to addictive
behaviors. Am Psychol 2002; p. 1108.

Table 3 Stages in Which Particular Processes of Change are Emphasized

Precomtemplation  Contemplation  Preparation  Action  Maintenance

* Consciousness Raising
* Dramatic Relief
* Environmental Reevaluation
  * Self-Reevaluation
    * Self-Liberation
      * Reinforcement Management
      * Helping Relationships
      * Counterconditioning
      * Stimulus Control

Prochaska J. The transtheoretical model of health behavior change. Am J
Health Promot 1997; 12(1): p. 43.

Table 4 Lapse Prevention

1. Distinguish Lapse, Relapse, and Collapse
2. Identify High Risk Situations
3. Outlast the Urge
4. Use Alternate Activities

Brownell K. The LEARN Program for Weight Management, 10th ed. Dallas,
TX: American Health Publishing Company, 2004.

Table 5 Incompatible Activities to Eating

Walk the Dog           Play a Board Game
File Coupons           Ride a Bike
Go to a Movie          Brush Your Teeth
Call a Friend          Read This Manual!
Shop for Plants        Frame Some Pictures
Take a Shower          Refinish Furniture
Listen to Music        Play Music
Take a Drive           Knit a Sweater
Read a Romantic Book   Work in a Garden
Read a Sexy Book       Visit a Museum
Go to the Zoo          Buy a Gift
Buy a New Magazine     Plan a Vacation
Kiss Somebody          Paint a Picture
Wash the Car           Buy Tickets
Kiss Somebody Again    Work on a Hobby
Write a Letter         Visit a Neighbor
Get Some Exercise      Donate to Charity
Look at a Photo Album  Imagine Being Thin

Prochaska J. The transtheoretical model of health behavior change. Am J
Health Promot 1997; 12(1): p. 43.

Table 6 Coping With Lapse

Step 1: Stop, Look, and Listen
Step 2: Stay Calm
Step 3: Renew Your Diet Vows
Step 4: Analyze the Lapse
Step 5: Take Charge Immediately
Step 6: Ask For Help

Brownell K. The LEARN Program for Weight Management, 10th ed. Dallas,
TX: American Health Publishing Company, 2004.

Table 7 Summary of Ways to Help Clients in a Weight-Maintenance Program

* Properly screen the client prior to beginning a weight-control
  program.
* Assist the client in enlisting and using social support.
* Help the client develop, initiate, and maintain an exercise program.
* Assist the client in behavioral monitoring.
* Help the client develop behavioral self-control practices.
* Assist the client in developing cognitive coping abilities.
* Help the client to adopt realistic expectations.
* Assist the client in developing an attitude of ownership and
  responsibility.
* Facilitate the client's development of self-efficiency and self-
  acceptance.
* Educate the client regarding the distinctions between lapse and
  relapse.
* Help the client develop and practice strategies for coping with high-
  risk situations.
* Assist the client in developing a balanced lifestyle that includes
  positive pleasurable situations.