Acceptance-Based Versus Standard Behavioral
Treatment for Obesity: Results from the Mind
Your Health Randomized Controlled Trial
Evan M. Forman
, Meghan L. Butryn
, Stephanie M. Manasse
, Ross D. Crosby
, Stephanie P. Goldstein
Emily P. Wyckoff
, and J. Graham Thomas
Objective: To evaluate the efficacy, as well as potential moderators and mediators, of a revised acceptance-
based behavioral treatment (ABT) for obesity, relative to standard behavioral treatment (SBT).
Methods: Participants with overweight and obesity (n5190) were randomized to 25 sessions of ABT or
SBT over 1 year. Primary outcome (weight), mediator, and moderator measurements were taken at base-
line, 6 months, and/or 12 months, and weight was also measured every session.
Results: Participants assigned to ABT attained a significantly greater 12-month weight loss (13.3% 6
0.83%) than did those assigned to SBT (9.8% 60.87%; P50.005). A condition by quadratic time effect
on session-by-session weights (P50.01) indicated that SBT had a shallower trajectory of weight loss
followed by an upward deflection. ABT participants were also more likely to maintain a 10% weight loss
at 12 months (64.0% vs. 48.9%; P50.04). No evidence of moderation was found. Results supported
the mediating role of autonomous motivation and psychological acceptance of food-related urges.
Conclusions: Behavioral weight loss outcomes can be improved by integrating self-regulation skills that are
reflected in acceptance-based treatment, i.e., tolerating discomfort and reduction in pleasure, enacting
commitment to valued behavior, and being mindfully aware during moments of decision-making.
Obesity (2016) 24, 2050–2056. doi:10.1002/oby.21601
Behavioral weight loss interventions produce weight losses averaging
about 5% to 8% at the end of a 12-month intervention (1). While these
outcomes are robust, a substantial proportion of participants do not
achieve clinically significant benefits, and participants lose consider-
ably less weight than individuals whose adherence to dietary prescrip-
tions is ensured via a controlled environment (2,3). The suboptimal
outcomes of behavioral weight control programs are primarily attrib-
utable to an inability to meet and/or maintain prescribed dietary intake
and physical activity goals, i.e., to inadherence (4,5).
Adherence to healthy eating and physical activity goals depends on the
ability to self-regulate in the face of biological predispositions (e.g., a
drive to consume high-calorie food) and the pervasive cues (e.g., the
presence of food, television, cravings, anxiety, boredom) that facilitate
overeating and sedentary behavior (6). Standard behavioral interventions
for weight loss do not intensively focus on developing skills that teach
individuals how to override drives and urges for pleasure or comfort,
which may help explain why most individuals lose less weight than
desired. Given the pervasive obesogenic food environment, urges and
desires to consume calorie-dense, palatable food likely persist for most
individuals seeking weight loss.
Acceptance-based behavioral interventions infuse behavioral treat-
ment with strategically chosen self-regulation skills that are adapted
primarily from Acceptance and Commitment Therapy (ACT) (7) but
also from Dialectical Behavior Therapy (8) and Relapse Prevention
for Substance Abuse (9). These self-regulation skills include an
Department of Psychology, Drexel University, Philadelphia, Pennsylvania, USA. Correspondence: Evan M. Forman (email@example.com)
Neuropsychiatric Research Institute, Fargo, North Dakota, USA
Department of Psychiatry and Behavioral Science, University of North Dakota School of
Medicine and Health Sciences, Fargo, North Dakota, USA
Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown
University, Providence, Rhode Island, USA.
See commentary, pg 2029.
Funding agencies: The Mind Your Health project was funded by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (award R01
DK095069) (to EMF).
Disclosure: EMF and MLB report authorship of books on acceptance-based approaches, published by New Harbinger and Oxford University Press. RDC reports
personal fees from Health Outcome Solutions, outside the submitted work. The other authors declared no conflict of interest.
Author contributions: EMF, MLB, RDC, and JGT designed the study. EMF, MLB, SMM, SPG, and EPW collected data. RDC and SMM conducted data analysis. EMF, MLB,
SMM, SPG, and EPW wrote the initial draft of the paper. All authors were involved in revising the paper and had final approval of the submitted and published versions.
Clinical trial registration: ClinicalTrials.gov identifer NCT01854320.
Received: 2 March 2016; Accepted: 1 June 2016; Published online 27 September 2016. doi:10.1002/oby.21601
2050 Obesity |VOLUME 24 | NUMBER 10 | OCTOBER 2016 www.obesityjournal.org
CLINICAL TRIALS AND INVESTIGATIONS
ability to tolerate uncomfortable internal states (e.g., urges, cravings,
and negative emotions) and a reduction of pleasure (e.g., choosing
to exercise instead of watch TV), behavioral commitment to clearly
defined values (which is posited to increase motivation to persist in
difficult weight control behaviors), and metacognitive awareness of
decision-making processes (6,10). This collection of skills is meant
to facilitate adherence to behavioral recommendations for weight
loss despite the challenges posed by biological predispositions and
cues that push individuals to engage in unhealthy behaviors (or
nonbehaviors) that impede weight control.
Treatments based on acceptance-based principles have shown prom-
ise in analog studies [e.g., abstaining from craved, high-calorie foods
(11,12)] and uncontrolled trials (13-16). Several randomized con-
trolled trials also provide support. In one study, individuals complet-
ing a self-selected weight loss program who were randomized to an
ACT-based 1-day workshop intervention continued to lose weight in
the months that followed, whereas those randomized to a wait list
control experienced weight regain (17). In another trial, women
randomized to ACT-based workshops lost more weight than partici-
pants assigned to a control condition (18). In addition, university
students at risk for weight gain assigned to 8 h of acceptance-based
behavioral intervention experienced weight loss, but those assigned
to a control exhibited weight gain (19).
Only one published trial to date has compared acceptance-based
behavioral treatment (ABT) of obesity to a gold standard behavioral
weight loss intervention. The Mind Your Health (MYH) project (20)
randomized 128 participants with overweight or obesity to receive
30 sessions of group-based ABT or standard behavioral treatment
(SBT) over the course of 40 weeks. Both interventions included the
core components of behavioral treatment, e.g., prescriptions for
calorie intake and physical activity, self-monitoring of food intake,
stimulus control, and problem solving. At post-treatment and at a
6-month follow-up, the advantage of ABT was only statistically
significant for participants who received the treatment from weight
loss experts (vs. student trainees) and for participants with particular
vulnerabilities to internal and external cues for overeating, i.e.,
mood disturbance, elevated responsivity to food cues, and high
disinhibition. For example, in the expert-led groups, mean ABT
weight loss at follow-up was 11% versus 4.8% for SBT. Participants
with greater baseline depressive symptomology lost 11.2% of body
weight in ABT versus 4.6% in SBT.
Despite the promise demonstrated in early studies of ABT for weight
control, a number of questions remain unanswered. First, virtually all of
the evidence supporting ABT for weight control comes from analog
studies, open trials, or trials with a weak control; only one randomized
controlled trial comparing ABT with a gold standard treatment exists at
this time. Moreover, the original MYH trial obtained reliable evidence
for the superiority for ABT over SBT only under certain conditions.
Additional investigation is needed to establish whether ABT confers a
benefit over SBT when delivered by experienced clinicians and to
ensure that the previous effect was not attributable to idiosyncratic
effects of clinicians in the MYH trial. Furthermore, the findings that the
benefit of ABT are more pronounced among those with specific vulner-
abilities requires replication in a sample that receives the treatment
from experienced clinicians. In addition, clinician and supervisor feed-
back indicated that the ABT protocol was problematic in certain regards
(e.g., a missing unifying framework, sometimes lacking integration of
acceptance and behavioral skills, overemphasis on tolerating
discomfort and not enough on tolerating reduction of pleasure), thus
raising the possibility that a revised protocol would produce better
results. Finally, initial evidence suggested that the ability to accept psy-
chological experiences of reduced pleasure and discomfort related to
food choices mediated the effect of ABT. However, no previous study
has examined whether the values component of ABT also mediates the
effect of ABT for weight control. Thus, it is necessary to test whether
these postulated unique mechanisms of action underlie ABT.
In order to investigate the questions posed above, this study random-
ized 190 participants with overweight or obesity to either a standard
behavioral or an acceptance-based behavioral weight loss intervention.
Both interventions were delivered in 25 group sessions over 1 year and
were delivered by experienced weight control clinicians. We hypothe-
sized that ABT would produce greater weight loss at 12 months com-
pared with SBT, and, consistent with previous findings, the effect of
ABT would be most pronounced for those with the particular vulner-
abilities described above (i.e., mood disturbance, responsivity to food
cues, and disinhibited eating). Lastly, we hypothesized that food-
related psychological acceptance and autonomous motivation would
mediate the effect of ABT given that these are posited to be two of the
central mechanisms of action of the treatment.
Participants (n5190) had a body mass index (BMI) between 27
and 50 kg/m
and were between 18 and 70 years of age. Participants
were excluded if they had a medical or psychiatric condition that
limited their ability to comply with the behavioral recommendations
of the program or posed a risk to the participant during weight loss,
were unable to engage in the program’s exercise plan, changed the
dosage of weight-affecting medication within the past 3 months,
were pregnant or planned to become pregnant during the study
period, had lost more than 5% of their weight in the past 6 months,
or met criteria for binge eating disorder.
Recruitment for this study was conducted in four waves of 38 to 45
participants (making up approximately four treatment groups). Poten-
tial participants were recruited through referrals from local primary
care physicians and advertisements in newspapers and radio stations.
Initial screens for eligibility were conducted via telephone. Partici-
pants who appeared eligible were invited for two in-person appoint-
ments to complete screening and baseline assessment procedures. All
participants provided informed consent. Once enrolled, participants
were randomly assigned to SBT (n590) or ABT (n5100). Random-
ization was stratified by gender and ethnicity. Assessments were com-
pleted at months 0 (baseline), 6 (midpoint), and 12 (post-treatment).
See Figure 1 for a CONSORT diagram. The study protocol was
approved by the Drexel University Institutional Review Board.
Participants attended 25 treatment groups in total. Treatments were
manualized and groups were held weekly for 16 sessions, biweekly
for 5 sessions, monthly for 2 sessions, and bimonthly for 2 sessions.
Treatment was delivered in 75-minute, small (10-14 participants),
closed-group sessions. Groups typically consisted of brief individual
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check-ins (35 min), skill presentation, and a skill building exercise.
If a participant was absent from group, a 20-minute individual
makeup session was scheduled to cover material that was missed.
Interventionists were doctoral-level clinicians with an average of 4.8
years of experience delivering behavioral weight loss treatment. All
interventionists delivered an equal number of SBT and ABT groups.
Trainees functioned as group co-leaders.
Treatment. Shared treatment components. Behavioral com-
ponents of both treatments (e.g., daily self-monitoring of calorie
intake, prescriptions for a balanced-deficit diet and physical activity,
stimulus control, problem solving) were similar to those used in Look
AHEAD and the Diabetes Prevention Program protocols (21,22). See
Table 1 for a description of components for all treatments.
SBT-only components. Components of SBT not included in ABT
were introduction of the traditional cognitive-behavioral model, which
indicates that changing the content of one’s thoughts can produce behav-
ior change; cognitive restructuring; building self-efficacy and positive
self-esteem; and learning to cope with food cravings through distraction.
Acceptance-based treatment components. The ABT materi-
als [For the full clinician and participant manuals, see Forman & Butryn,
2016 (23, 24)] were adapted from those used in the first clinical trial test-
ing the MYH protocol, i.e., MYH I, which themselves represented a syn-
thesis of traditional behavioral weight loss treatment and several ABTs,
i.e., Dialectical Behavior Therapy (8), Marlatt’s Relapse Prevention
Model (9), and especially ACT (25). The ABT sessions used for this
study largely emphasized the following principles: (1) participants must
choose goals that emanate from freely chosen, personal life values (e.g.
living a long and healthy life; being a present, loving, active grand-
mother); (2) participants must recognize that, in the context of the obeso-
genic environment, weight control behaviors will inevitably produce dis-
comfort (urges to eat, hunger, cravings, feelings of deprivation, fatigue)
and a reduction of pleasure (choosing an apple instead of ice cream,
choosing a walk instead of watching TV); and (3) participants will
Figure 1 CONSORT diagram.
TABLE 1 Components of standard behavioral (SBT) and acceptance-based (ABT) behavioral treatments
Shared components of SBT and ABT Included only in SBT Included only in ABT
Nutritional education, 1,200- to 1,800-calorie goal
(depending on weight and personal preferences)
Physical activity education, gradual increases up to Identification of cognitive Mindful decision-making training
250 min per week of aerobic activity distortions
Setting specific, reasonable, actionable, and time-limited
goals related to eating or activity behavior
Cognitive restructuring Psychological acceptance of and
willingness to experience less
pleasurable or comfortable states
Self-monitoring of caloric intake and physical activity
Stimulus control (e.g., removal of problematic foods from home/work)
Behavior analysis (e.g., reviewing factors leading to
a lapse in eating or activity goals)
Relapse prevention (e.g., identifying triggers for overeating/
sedentary behavior, creating plan for small weight gains)
Problem solving (e.g., identifying barriers to healthy eating and
activity and developing solutions to overcome)
Social support (e.g., communicating needs, building positive support)
Obesity An RCT of Acceptance-Based Behavioral Treatment Forman et al.
2052 Obesity |VOLUME 24 | NUMBER 10 | OCTOBER 2016 www.obesityjournal.org
benefit from increased awareness of how cues impact their eating and
Based on feedback from clinicians and clinicians’ supervisors, the
MYH I manual was adapted in several ways. For example, a “Control
What You Can and Accept What You Can’t” framework was used to
orient participants to the aspects of their experience that can and
should be directly modified (their personal food environment and their
behaviors) and those aspects of their experience which are not under
voluntary control (e.g., thoughts, emotions, urges) and towards which
direct attempts to control will result in wasted effort or even paradoxi-
cal magnification. Acceptance-based skills were also more tightly inte-
grated within behavioral weight loss principles by framing behavioral
skills and challenges within the context of ABT. For example, partici-
pants who avoided self-weighing were taught to be willing to accept
difficult thoughts (“I am never going to lose this weight”) and emo-
tions (shame) while simultaneously stepping on the scale. (In contrast,
the SBT condition would help participants recognize the maladaptive
thinking style producing the thought, and utilize cognitive restructur-
ing to reduce shame and produce a more adaptive behavioral choice.)
Additionally, acceptance of loss of pleasure (the ability to make the
less hedonically rewarding choice, like an apple instead of ice cream
after dinner) and willingness to choose a behavior despite internal
experience were emphasized while acceptance of aversive experience
(e.g., the ability to accept the experience of a craving for ice cream)
Treatment fidelity. Group sessions were audio recorded and four
psychologists (including EF and MLB) independently rated 25% of
sessions on a scale of 1 (poor) to 10 (perfect) adherence to each sec-
tion of the specific session manual. Likewise, avoidance of treat-
ment contamination was rated from 1 (total) to 10 (no) contamina-
tion. Neither rating differed by condition (Ps50.83, 0.79). Any
adherence issues noted were immediately addressed in ongoing
Outcomes. Weight loss (taken at each session and all assessment
points) was measured with the participant in street clothes (without
shoes) using a standardized SecaV
Rscale accurate to 0.1 kg. Height
was measured with a stadiometer to establish BMI (kg/m
Mediators (measured at baseline and midpoint). Autonomous
regulation of health behaviors was measured with the Treatment Self-
Regulation Questionnaire. The 15-item Treatment Self-Regulation
Questionnaire has adequate reliability (a50.76-0.93; current sample
a50.71-0.74) and predicts health behaviors such as fruit and vegeta-
ble intake, exercise, and smoking cessation (26). Psychological accep-
tance of food cravings was measured using the 10-item Food Craving
Acceptance and Action Questionnaire (FAAQ), which has adequate
reliability (a50.93; current sample a50.58-77) and validity (27).
Moderators (measured at baseline). Mood disturbance was
assessed via the Beck Depression Inventory-II, a 21-item self-report
measure with excellent internal consistency and validity (current sample
a50.88) (28). Susceptibility to food cues was measured using the
15-item Power of Food Scale. The Power of Food Scale has adequate
reliability (a50.81-0.91; current sample a50.93) and predictive valid-
ity (29,30). The 20-item Disinhibition subscale of the Eating Inventory,
which has good reliability (a50.91; current sample a50.79) and
validity (31-33), was used to measure disinhibited eating.
Treatment groups were compared on demographic and clinical char-
acteristics at baseline using a v
test for categorical variables and
independent sample t-tests for continuous measures. The primary
and secondary outcomes were percent of initial body weight lost at
post-treatment (12 months), and reaching 10% weight loss at post-
treatment, a well-established marker of success in behavioral weight
loss interventions (34). Means and effects are reported 6standard
error (not standard deviation) of the mean.
All outcome analyses were based on an intention-to-treat (21,22)
approach, and were conducted in SPSS version 23. Missing data
were imputed using maximum likelihood estimation to account for
the dependencies of missingness on other variables in the dataset.
We repeated analyses using only data from those who completed
assessments; results were equivalent, and so are not reported. Treat-
ments were compared using a general linear mixed model, which
included an autocorrelation term to account for serial dependency
among within-person observations based on a first-order autoregres-
sive component. Two time points (mid- and post-treatment) were
included in the model reflecting percent of baseline weight lost. The
secondary outcome was evaluated using logistic regression. Modera-
tors were examined in separate (grand-mean centered) models via
the addition of a main effect for moderator and a moderator 3treat-
ment condition interaction term. We also compared treatment groups
on the trajectories of session-by-session weight, with time (i.e.,
week) as the independent variable, using a mixed-effects model with
linear, quadratic, and cubic effects.
Hayes boostrapping simple mediation analyses PROCESS macro for
SPSS (35) evaluated whether changes from baseline to mid-treatment
in psychological acceptance and autonomous motivation mediated the
effect of treatment condition on 12-month weight loss. As a check,
we repeated mediation analyses using residualized change scores from
baseline to mid-treatment in psychological acceptance of food-related
urges and cravings; results were equivalent, and so are not reported.
TABLE 2 Baseline sample characteristics
Mean SD Mean SD tdfP
Age 51.61 9.97 51.67 10.16 0.04 188 0.97
Body mass index 36.50 5.41 37.40 6.21 1.06 188 0.29
BDI 7.10 6.07 8.07 6.77 1.04 188 0.30
PFS 41.06 12.41 41.67 13.76 0.32 184 0.75
EI-DIs 8.06 2.50 8.01 2.52 20.14 184 0.89
FAAQ 40.23 7.53 37.97 6.40 22.20 184 0.03
TSRQ-AM 6.46 0.73 6.55 0.53 0.92 184 0.36
BDI, Beck Depression Inventory; EI-Dis, Eating Inventory–Disinhibition subscale;
FAAQ, Food Acceptance and Action Questionnaire; PFS, Power of Food Scale;
TSRQ-AM, Treatment Self-Regulation Questionnaire-Autonomous Motivation.
Original Article Obesity
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The sample was 82.1% female, and primarily Caucasian (70.5%;
African American: 24.7%; Asian: 1.1%; Hispanic: 3.7%) with a
mean age of 51.64 60.73 years and mean starting BMI of 36.93 6
. The groups were equivalent in gender (v
df 51, P50.97) and ethnicity (v
51.05, df 53, P50.79), and
on all outcome and process measures at baseline with the exception
of higher FAAQ scores in ABT (Tables 2 and 3).
Attendance and attrition
Treatment attendance (with inclusion of makeup sessions) was in excess
of 84% of expected sessions, and there were no differences between the
two treatments in terms of the average number of sessions attended
521.26 65.85, M
520.88 65.46; t(189) 520.46, P5
0.65). Overall, 84.2% of the ABT participants and 85.6% of SBT partic-
ipants attended the majority (i.e., 18 or more) of the 25 scheduled groups
50.07, df 51, P50.79). A total of 142 participants (74%) com-
pleted the mid-treatment assessment and 149 participants (78%) com-
pleted the post-treatment assessment.
ABT yielded a significantly greater percent weight loss than did SBT
across mid- (M
512.9% 60.83, M
510.3% 60.87) and post-
513.3% 60.83, M
59.8% 60.87; b53.44
SE 51.21, P50.005; Figure 2). No time by treatment condition inter-
action was evident (b520.92, SE 50.71, P50.20). Additionally,
ABT participants were more likely (64.0%) than SBT participants
(48.9%) to reach 10% weight loss at 12 months [Wald v
df 51, P50.04, OR 51.86, 95% CI (1.04-3.23)]. Given differences
in FAAQ between groups at baseline, we repeated outcome analyses
with FAAQ as a covariate, and results were equivalent.
Session-by-session weight change is depicted in Figure 3. Nonlinear
analyses revealed a condition by time quadratic effect (b50.003,
SE 50.001, P50.01). Specifically, SBT showed a shallower trajec-
tory of weight loss compared with ABT with upward deflection
(weight regain) by 12 months, while ABT maintained weight losses
through 12 months.
After adding a main effect for moderator and a moderator 3treat-
ment condition interaction term to the general linear model, no evi-
dence was detected for the moderating effects of depressive symp-
toms (b520.18, SE 50.19, P50.28), susceptibility to food cues
(b520.02, SE 50.09, P50.58), or disinhibited eating (t
20.97, b520.48, SE 50.49, P50.69).
The superior effect of ABT (relative to SBT) on 12-month weight loss
was mediated by psychological acceptance of food-related urges and
51.55, SE 50.55, 95% CI (2.65-7.81)] and autono-
mous motivation [b
50.47, SE 50.33, 95% CI (0.03-1.37)].
TABLE 3 Mediator variable descriptive statistics
ABT SBT ABT SBT
Mean SD Mean SD df t P Mean SD Mean SD
FAAQ 40.23 7.53 37.97 6.40 184 22.20 0.03 51.03 9.02 43.70 6.99
TSRQ-AM 6.46 0.73 6.55 0.53 184 0.92 0.36 6.77 0.35 6.59 0.53
FAAQ, Food Acceptance and Action Questionnaire; TSRQ-AM, Treatment Self-Regulation Questionnaire-Autonomous Motivation.
Figure 2 Percent weight change by treatment condition over time.
Figure 3 Session-by-session percent weight change, with time modeled as the
Obesity An RCT of Acceptance-Based Behavioral Treatment Forman et al.
2054 Obesity |VOLUME 24 | NUMBER 10 | OCTOBER 2016 www.obesityjournal.org
During the 12-month treatment period, participants who were random-
ized to ABT demonstrated significantly greater weight loss than those
who received SBT. In particular, SBT weight loss was 9.8%, whereas
ABT weight losses were 13.3%, which represents a clinically signifi-
cant 36% improvement. In addition, the likelihood of maintaining a
10% weight loss at 12 months was one-third greater for ABT, i.e.,
64% versus 49% for SBT. A strength of the study is that the superior-
ity of ABT cannot be credited to disappointing SBT results. In fact,
SBT weight losses and weight loss maintenance through the reduced-
contact 6- to 12-month period were better than is typically reported
(36), perhaps due to differences in delivery of the intervention (e.g.,
continuous accountability around food records and the use of experi-
enced PhD-level clinicians). Thus, we can say with confidence that
participants in ABT were able to achieve weight losses meaningfully
greater than is typical with lifestyle modification (1,3). These findings
are consistent with a large body of literature demonstrating that ABT
can produce clinically significant weight losses (13,14,16,18,37,38).
Moreover, this study, while one of the first of its kind, offers prelimi-
nary evidence that weight control outcomes can be improved by infus-
ing behavioral treatments with skills related to acceptance of discom-
fort and reduced pleasure, clarification of and commitment to life
values, and mindful decision-making.
The advantage of ABT over SBT was more pronounced in this study
relative to the first MYH Trial. Several potential explanations exist for
this difference including the use of experienced clinicians (who could
perhaps better integrate behavioral and ABT-specific skills), and the
fact that the revised ABT protocol focused more on general willingness
and accepting a loss in pleasure, and less on coping with emotional dis-
tress, cravings, and hunger. These same changes to treatment focus
may have been responsible for improving the efficacy of ABT for all
participants, such that the benefit of ABT was no longer limited to a
subset of participants as it was in the previous trial (20).
This study replicated the results of the original MYH Study (20) in that
changes from baseline to 6 months in food-related psychological
acceptance mediated the effect of condition on weight loss. Addition-
ally, it extended this work by detecting a mediating role of autonomous
motivation, which is consistent with other research demonstrating that
higher amounts of autonomous motivation early in weight loss treat-
ment are predictive of greater total weight loss (39,40). These findings
support the theory underlying ABT, which proposes that participants
are better able to adopt and maintain changes in weight control behav-
iors (such as meeting a daily calorie goal) if they learn specialized
Our session-by-session analyses indicated that the advantage of ABT
became increasingly evident starting about session 16 (also week 16;
see Figure 3), i.e., when treatment frequency transitioned to biweekly
(and eventually, monthly and bimonthly). It is possible that ABT
enhances skills or characteristics (e.g., autonomous motivation) that
augment participants’ ability to better sustain weight control behaviors
(and thus prevent weight regain) even when the frequency of group
sessions lessens and external accountability diminishes. Future
research should continue to investigate the ideal number of weekly ses-
sions before transitioning to less frequent sessions.
This study has several limitations. Perhaps most importantly, assess-
ments were not available after treatment contact ended.
Generalizability is another concern given that treatment to motivated
participants was delivered by expert clinicians who were trained and
supervised by the treatment developers. Future studies could examine
outcomes under conditions that more closely resemble typical clinical
care, e.g., a community setting, with lower intensity interventions
delivered by nonpsychologists. Outcomes might also have been
affected by the choice of BMI ceiling, participant attrition, and vari-
ability in makeup sessions experienced. Finally, additional research
must be conducted to better understand ABT mechanisms of action,
for instance by using a more comprehensive battery (including behav-
ioral measures). In conclusion, study results suggest that the efficacy
of behavioral weight loss treatment can be improved by integrating
self-regulation skills that are reflected in ABT models. Learning to tol-
erate discomfort or reduction in pleasure, enact commitment to valued
behavior, and be mindfully aware during moments of decision-making
may position participants to adhere to recommendations for lifestyle
modification in the face of powerful biological and environmental
challenges. This is the first randomized clinical trial to demonstrate
that ABT for obesity produced greater weight losses than the gold
standard, traditional form of behavioral treatment. Discovering ways
to improve the efficacy of behavioral therapy is a key priority in the
obesity treatment field; as such, the clinical and research impact of
these findings is notable.O
C2016 The Obesity Society
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