Clinical Implications for the Treatment of
Gary D. Foster
FOSTER, GARY D. Clinical implications for the treatment
of obesity. Obesity. 2006;14(Suppl 4):182S–185S.
Combining Behavior and Biology
This conference has underscored the magnitude and com-
plexity of the obesity problem across the globe (1). Efforts
to effectively prevent and treat obesity must be grounded in
a precise understanding of etiology and pathophysiology.
Although the fundamental energy imbalance is well known,
the myriad of factors that affect that imbalance are less well
understood (2). In addition, obese person are quite hetero-
geneous both behaviorally and biologically, making one
size fits all treatments less likely to succeed in the long term.
Given the complex and refractory nature of obesity, it is
useful to employ treatment strategies that attempt to address
both the biology and behavior of obesity. This conference
has focused on the considerable science around the regula-
tion of food intake, including the brain, the gut, and beyond
(3–7). These systems are complex and, unfortunately, for
weight reduction purposes, redundant. Therefore, efforts to
trick the physiological system are likely to be subject to
habituation, compensation, and/or adaptation.
As Mela (7) suggests, consumers are eager for products
that manage hunger, although it is less clear what is meant
by hunger (8). It may be internally mediated by going long
periods without eating or more externally driven by multiple
triggers associated with eating (sight, smell, activities and
emotions, places). Attempts to develop products or agents
that modify the internal milieu are best complemented by
behavioral strategies that seek to manage the multiple ex-
ternal prompts to eat more and move less. The remainder of
this paper will describe the principles of behavior treatment
and its efficacy.
Behavioral treatment is based largely on principles of
classical conditioning, which posit that eating is often
prompted by antecedent events (i.e., cues) that become
strongly linked to food intake (9). Behavioral treatment, as
described below, helps patients identify cues that trigger
inappropriate eating (and activity) and learn new responses
to them (10,11). Treatment also seeks to reinforce (or re-
ward) the adoption of positive behaviors, while also reduc-
ing the aversiveness associated with some types of behavior
In the last 20 years, cognitive therapy also has been
incorporated in the behavioral treatment of obesity. The
underlying assumption of cognitive therapy is that thoughts
(or cognitions) directly affect feelings and behaviors (12).
Negative thoughts frequently are associated with negative
outcomes, as in the case of a male, who overeats, tells
himself he has blown his diet, and then proceeds to eat triple
the original amount because of feelings of disgust and
despair. With cognitive therapy, patients learn to set realis-
tic goals for weight and behavior change, to evaluate their
success in modifying eating and activity habits, and to
correct negative thoughts that occur when they do not meet
their goals (11,13,14). Cognitive interventions for weight
management are based on those developed for the treat-
ments of depression and anxiety (15,16).
Behavioral treatment has several distinguishing charac-
teristics (17). First, it is goal-directed. It specifies very clear
goals in terms that can be easily measured. This is true
whether the goal is walking four times a week, lengthening
meal duration by 10 minutes, or decreasing the number of
self-critical comments. Specific goals facilitate a clear as-
sessment of success.
Second, treatment is process-oriented. It is more than
helping people to decide what to change (i.e., eating, activ-
ity, thinking habits); it is helping them identify how to
change (13). Thus, once a goal is specified, patients are
encouraged to examine factors that will facilitate or hinder
Center for Obesity Research and Education, Temple University, Philadelphia, Pennsylvania.
Address correspondence to Gary Foster, Center for Obesity Research and Education, Temple
University, 3223 North Broad Street, Suite 175, Philadelphia, PA 19140.
Copyright © 2006 NAASO
182S OBESITY Vol. 14 Supplement July 2006
goal achievement. In cases in which the desired behavior is
not implemented, problem-solving skills are used to identify
new strategies to overcome barriers. In this view, successful
weight management is based on skills that can be learned
and practiced, in the same manner that an individual can
learn to play the piano through frequent practice. Skill
power, not will power, is the key to success.
Third, the behavioral approach advocates small rather
than large changes. This is based on the learning principle of
successive approximation in which incremental steps are
taken to achieve more distant goals. Making small changes
gives patients successful experiences on which to build
rather than attempting drastic changes that are typically
The behavior change process is facilitated through the use
of a variety of problem-solving tools. The behavior chain, a
typical chain of events that lead to an unwanted behavior
like overeating, is one of the tools commonly used in
treatment (11,18). By examining the cues and events that
lead up to an overeating episode, one can identify areas
where modifications in behavior can be made to break the
chain of events and prevent an overeating episode from
occurring in the future. This tool can be used to extinguish
conditioned responses that have been established over time
with repeated pairing. For example, if a patient has identi-
fied television watching as part of the sequence of events
leading up to an overeating episode, limiting eating to a
more appropriate location (i.e., table in the kitchen or dining
room) can be an effective strategy for weakening the asso-
ciation between eating and television watching. The more
often the patient refrains from eating in front of the televi-
sion, the less likely that television watching will automati-
cally trigger food intake.
The Behavioral Package
Behavioral treatment usually includes multiple compo-
nents such as keeping food and activity records (i.e., self-
monitoring), controlling cues associated with eating (i.e.,
stimulus control), nutrition education, slowing eating, phys-
ical activity, problem solving, and cognitive restructuring
(i.e., cognitive therapy) (10,11). These components com-
prise the behavioral package, which has been summarized in
manuals such as the LEARN Program for Weight Manage-
ment 2000 (11). Studies have shown that two components,
self-monitoring (19,20) and physical activity (21,22), are
consistently associated with better weight control, short and
long term, respectively. Surprisingly, there is little empirical
evidence to support the use of stimulus control, problem
solving, or cognitive restructuring, either because the nec-
essary studies have not been conducted or negative results
were obtained. Further research clearly is needed to identify
the most potent components of the package and additional
interventions that might be added (such as body image
therapy) (23). In the interim, researchers and practitioners
probably will continue to use the behavioral package be-
cause it is well validated, as a whole, and different patients
are drawn to different components of the intervention.
Short-Term Results of Behavioral Treatment
A large number of clinical studies have been conducted
examining the effects of behavioral treatment on weight
loss. The research has ranged in length from 3 weeks (24) to
?10 years (25). The typical design of most behavioral
treatment weight loss studies is group meetings weekly for
the initial treatment phase (?3 to 6 months), biweekly
(every other week) meetings for the maintenance phase (6 to
12 months), and monthly or bimonthly for the later phases
of the study (12 to 24 months) (25–28). Wing et al. (10)
reviewed several behavioral weight loss studies from 1996
to 1999, which resulted in a mean short-term weight loss of
9.6 kg during the treatment phase (21 weeks) and 6.0 kg
during follow-up (18 months). Several more recent studies
have been published from 2000 to 2006, which have pro-
duced similar results (26,29–34). Maximum weight losses
are usually achieved during the initial phases of the re-
search. Average weight losses were 10.7 kg after 6 months.
Short-term weight loss averages ?9.1 kg after 1 year. This
indicates an average of 1.6-kg weight regain during the
follow-up phase (26,29–34).
Strategies for Augmenting Outcomes
Although behavioral treatment provides individuals with
a set of skills to handle barriers to eating healthy and being
active, overcoming barriers is a difficult endeavor, particu-
larly in a fast-paced environment that encourages consump-
tion of large portions of tasty, low-cost foods and promotes
sedentary behavior. A healthy lifestyle requires significant
planning, proficiency in making healthy choices and esti-
mating portion sizes, and diligence in monitoring caloric
intake and activity, all of which take time to develop and
maintain. As such, strategies for simplifying and making
this process more practical have been investigated and are
described below. In general, these strategies provide struc-
ture and reduce or eliminate time spent planning and deci-
Jeffery et al. (35) examined the impact of food provision
on weight loss outcomes. Individuals who received food
along with standard behavioral treatment lost more weight
at 6, 12, and 18 months (?10.1, ?9.1, and ?6.4 kg) than
those who received standard behavioral treatment alone
(?7.7, ?4.5, and ?4.1 kg). Wing et al. (36) conducted a
follow-up study to determine whether the food provision
itself or the limited dietary decision making affected weight
loss outcome. Weight loss was greater in groups that re-
Clinical Implications for the Treatment of Obesity, Foster
OBESITY Vol. 14 Supplement July 2006183S
ceived food or menus compared with the group that re-
ceived standard behavioral treatment at 6 and 18 months;
however, no differences in weight loss were observed be-
tween the groups that were provided food and the group that
received menus and grocery lists.
Similar findings are observed in studies that compare
meal replacements (37–40) or prepackaged entrees (41,42)
with self-selected diets. These studies suggest that replacing
two of three meals with a liquid and/or solid meal replace-
ment or at least two meals with a portion-controlled entre ´e
result in greater weight loss than traditional self-selected
diets and an improved nutrient intake profile (i.e., decreased
dietary fat intake and improved micronutrient intake) with
the exception of fiber intake, which may be low if diets
using meal replacements are not supplemented with high-
fiber foods (43). Although some weight regain is observed
over time, a greater reduction in weight is observed even up
to 4 years in individuals receiving meal replacements (38).
Based on a meta-analysis by Heymsfield et al. (44), indi-
viduals consuming meal replacements lose ?7% to 8%
body weight, whereas those on a standard self-selected diet
lose 3% to 7% body weight at 1 year. It is unclear, however,
whether meal replacements are superior to other structured
weight loss approaches that provide menus and recipes.
Noakes et al. (43) found similar decreases in weight in
individuals using meal replacements (9.0 kg or ?9.4% body
weight) and following structured diets (9.2 kg or 9.3% body
weight) for 6 months (43). These findings suggests that
guidance in making food choices and/or determining por-
tion size may improve compliance to a dietary plan and
make following an energy-restricted diet easier.
Combining behavioral and pharmacological treatments
creates synergies to address internal and external modula-
tors of food intake. Wadden et al. (45) recently reported that
behavioral treatment combined with pharmacotherapy pro-
duced greater weight loss than drug alone. Moreover, higher
doses of behavioral treatment (in terms of treatment inten-
sity and frequency) produced greater weight losses than
lower doses (45,46). In addition, across both pharmacolog-
ical and non-pharmacologic treatments, higher rates of self-
monitoring (kept food records) were associated with greater
weight loss (45,35). As more safe and effective anti-obesity
agents become available in prescription and over-the-
counter settings, we can hopefully learn how to best couple
behavioral and pharmacological treatments.
The serious, complex, and refractory nature of obesity
requires treatments that are based on a precise understand-
ing of etiology at the individual level. Although our under-
standing of etiology has progressed during the last decade,
especially on the physiological side, our fund of knowledge
is insufficient to target treatments based on individual het-
erogeneity. In the meantime, it is optimal to combine ap-
proaches that seek to alter the internal milieu with those
than modify the external environment such as behavioral
treatments at the individual level and public health policy at
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