Cover Story

In helping people manage and reduce their weight, psychologists have always tended to favor scientifically based, "whole person"-focused interventions over strict dieting, and the current treatment landscape is no different.

Many psychologists use cognitive-behavioral therapies that encourage self-monitoring, plans for eating and exercise--sometimes combined with drug regimens--and awareness in eating through mindfulness meditation.

Though similar psychological treatment strategies also have been used with children, most clinicians researching or working with youngsters prefer to emphasize prevention. They are attempting to reduce television-viewing, increase physical activity and teach parents and other adults to model healthy eating behaviors.

What follows is just a taste of the obesity treatment and prevention approaches psychologists are using with individual adults and children.

For adults

Successful weight loss in adults is often defined as at least a 10-percent reduction of initial weight that's maintained for at least one year. Weight losses at this level generally produce significant improvements in health, say experts. To help adults reap those benefits, psychologists are researching and using several different therapeutic tools.

  • Self-monitoring. One of the most effective tactics that can be used as part of cognitive-behavioral therapy (CBT) for managing and reducing weight is self-monitoring--the systematic observation and recording of target behaviors, such as reduced calorie and fat intake and increased daily exercise, says psychologist and weight-loss researcher Daniel Kirschenbaum, PhD, director of the Center for Behavioral Medicine and Sport Psychology in Chicago.

He, for example, uses an approach that emphasizes reducing fat intake to 20 grams a day, increasing exercise to more than 10,000 steps a day, and enhancing self-awareness and focus through the use of daily journals and pedometers in order to develop what Kirschenbaum calls a "healthy obsession."

"That's what athletes do," Kirschenbaum says. "Weight-controllers have to realize that they're facing a biological battle. The body's going to resist [losing weight] in a lot of ways. But the bodies of athletes resist change as well. And what successful athletes do is overcome their resistance through intensive practice, focusing, commitment and support."

In fact, several studies have found that about a quarter of weight-control success is attributable to consistent self-monitoring. In a study of 59 women and men participating in long-term cognitive-behavioral treatment for obesity, published in 1998 in Obesity Research (Vol. 6, No. 3), Kirschenbaum and psychologist Kerri Boutelle, PhD, demonstrated that unless people self-monitor at least 75 percent of the time, they may be unlikely to succeed at weight loss.

  • Accentuated CBT. For the remaining 70 percent of people for whom CBT alone is not enough, psychologists are combining CBT approaches with protein-sparing modified fasting, appetite suppressant medication, antidepressant medication and sometimes even surgery (see next page). Unlike the liquid-based diets of 20 years ago, today's modified fasting regimens call for a daily intake of 75 to 100 grams of protein--either in the form of high-quality meats or liquid protein formulas--while limiting overall calories to about 600 a day. Normal-weight adults consume about 2,000 to 2,800 calories a day.

Kirschenbaum offers a self-monitoring approach combined with a medically supervised regimen of liquid protein, sometimes used in conjunction with an appetite suppressant medication. He emphasizes the well-documented benefits, found in research that he and his colleagues have conducted, of patients' long-term commitment to such weight-management interventions in his book, "The 9 Truths About Weight Loss: The No-Tricks, No-Nonsense Plan for Lifelong Weight Control" (Henry Holt, 2000).

Others' research has also revealed benefits of using CBT approaches in conjunction with appetite suppressants. In a randomized controlled trial with adolescents, published in the Journal of the American Medical Association (Vol. 289, No. 14), psychologist Thomas Wadden, PhD, director of the Weight and Eating Disorders Program at the University of Pennsylvania School of Medicine, and colleagues Robert Berkowitz, MD, Andrew M. Tershakovec, MD, and Joanna L. Cronquist, found that adding an appetite suppressant to a family-based, behavioral weight-control program induced significantly more weight loss among the 82 13- to 17-year-old participants. Conducted from 1999 to 2002, the study assigned the participants, who had body mass indexes between 32 and 44, to receive behavioral therapy with an appetite suppressant or with a placebo.

  • Meditation. Along with its general stress-relief applications, meditation is also being studied as an intervention for weight gain and obesity, particularly for binge-eating disorder. Jean Kristeller, PhD, a psychology professor at Indiana State University, and Ruth Quillian-Wolever, PhD, clinic director and clinical health psychologist of the Duke Center for Integrative Medicine, are completing a randomized clinical trial using mindfulness meditation.

The meditation used in the study is adapted from the Buddhist contemplative tradition of vipassana--"to see things as they really are." The researchers say that, while the relaxation effects of meditation may help with how food is used emotionally, the most important aspect may be incorporating nonjudgmental awareness into eating. In fact, laboratory research on regulation of eating shows that individuals with eating problems are generally less aware of experiences of hunger and satiety cues, including taste-specific satiety and feelings of fullness.

"Rather than assuming such deficits are biologically driven," Kristeller notes, "they may be instead due to a 'disconnection' related to over-dieting or to using food primarily to meet emotional needs."

Kristeller and Quillian-Wolever have developed mindfulness exercises to heighten people's awareness of such cues--and to keep their minds focused on the current moment of eating, and nothing else. They find that these experiences are very powerful, with individuals frequently noticing changes within a few days of applying them to their eating experiences.

In 1999 pilot research involving 18 obese women, Kristeller and doctoral student Brendan Hallett, now a therapist in Salt Lake City, found that those who used the approaches reduced bingeing episodes and symptoms of anxiety and depression, and increased self-acceptance and self-control around food. Kristeller and Quillian-Wolever are now replicating the pilot study with about 150 men and women with binge-eating disorder and who weigh on average 240 pounds.

"It's OK to have chocolate, but the idea is to have a little and really enjoy it, instead of going for quantity," Quillian-Wolever says.

For children

When it comes to weight management in children, psychologists are concentrating on prevention tactics. Current research targeting overweight children or those at risk of becoming overweight--an estimated 15 percent of children, according to the U.S. Centers for Disease Control and Prevention--includes examining familial patterns of eating, establishing healthy eating behaviors and positive attitudes toward food, and reducing television-viewing. More specifically, prevention tactics psychologists are using include:

  • Positive eating messages. Encouraging positive attitudes toward eating is critical because studies have indicated that dieting and food restrictions during childhood may promote weight gain and negatively affect later eating behaviors, says psychologist Myles Faith, PhD, an assistant professor in the Weight and Eating Disorders Program at the University of Pennsylvania School of Medicine.

More important, notes psychologist Marlene Schwartz, PhD, co-director of the Yale Center for Eating and Weight Disorders, is the catch-22 in which many parents of overweight children find themselves: Though advised not to place children on such restrictive diets, they are often blamed for their children's poor eating habits.

Other parental behavior also can have a long-lasting impact on children's eating habits. In a study published in Eating Behaviors (Vol. 4, No. 3) in 2003, Schwartz and colleague Rebecca Puhl, PhD, examined self-report measures of weight and dieting history, current eating practices and recollections of rules about food while growing up among 122 adult men and women. The team found that people who said their parents used food to control their behavior were more likely to have struggles with binge eating and weight cycling as adults.

In another study, Schwartz and colleagues Eunice Chen, PhD, and Kelly Brownell, PhD, explored children's preferences for candy versus toys on Halloween in a study published in 2003 in the Journal of Nutrition Education and Behavior (Vol. 35, No. 4).

Examining seven households that offered 284 boys and girls 3 to 14 years old a choice between comparatively sized toys and candies, "We found that when given a choice, kids were just as likely to choose toys as candy," Schwartz says. "Parents often feel under a lot of pressure to use unhealthy foods for celebrations. We did this study to make the point that parents can choose to celebrate holidays without relying on unhealthy foods."

  • Involving parents. A parent's role is particularly important when it comes to children with developmental disabilities, psychologists say. That's why parents of 8- to 12-year-old children with Down syndrome will play an integral role in a pilot weight-management intervention designed by psychologist Richard Fleming, PhD, and nutritionist, Linda Bandini, PhD, both of the University of Massachusetts Medical School's Shriver Center. The population is important to target, Fleming and Bandini say, because these youngsters have a high rate of obesity and therefore may be at greater-than-average risk of developing obesity-related disorders, including heart disease and diabetes.

The team will separate 20 participants into two groups: one receiving a nutritional education program and the other the educational program plus a behavioral intervention. The behavioral intervention will include self-monitoring, stepwise goal-setting, praise and other natural rewards, and, critically, establishing daily parental support and modeling of good eating behavior.

While there will likely be challenges in working with this population, Fleming says, "I think those challenges will be balanced out by other factors that work in the kids' favor." These include parents who are often well versed in using positive behavioral interventions and youngsters who tend to be outgoing and eager to participate.

Leigh E. Rich is a writer in Denver.

Further Reading

  • Thomas, P.R. (Ed.). (1995). Weighing the options: Criteria for evaluating weight-management programs. Washington, D.C.: American Psychological Association.

  • Thompson, J.K. (Ed.) (1996). Body image, eating disorders, and obesity: An integrative guide to assessment and treatment. Washington, D.C.: American Psychological Association.

  • Thompson, J.K., & Smolak, L. (Eds.). (2001). Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment. Washington, D.C.: American Psychological Association.