Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Introduction

Behavioral approaches to weight control are recommended as the treatment of choice for overweight and moderately obese adults. The goal of these approaches is to help participants make healthy, permanent changes in their eating and exercise behaviors, and thereby achieve long-term weight loss and maintenance.

In this chapter, we will describe the history of behavioral approaches to obesity and the key components of these approaches. We will then review the results that can be achieved in these programs and the health benefits that occur. Finally, the chapter will discuss current and future efforts to both improve the outcomes of these approaches and extend their reach to large numbers of overweight/obese adults.

History

First Generation: Behavior Therapy

Behavior therapy began in the 1960s as a response to the current state of psychosocial clinical interventions, which was dominated by psychoanalytic approaches. Research and adherence to empirical findings was lacking. The first generation of behavior therapy aimed to establish basic behavioral principles and applied technologies that were well specified and subject to rigorous scientific testing [1]. Traditional behavior therapy was based largely on social learning theory, focused on direct, overt behavior change, and many of its techniques comprise modern day standard behavioral treatments, including self-monitoring, stimulus control, and goal setting.

Second Generation: Cognitive Behavior Therapy

Clinicians became aware over time of the limitations of first generation behavior therapy. Primary among these concerns was an inadequate account of, and technology to address, cognition. Behavior therapy’s focus on manipulating observable contextual variables naturally led to a de-emphasizing of private experiences (such as thoughts and feelings). In response, clinicians began documenting patterns of clinical phenomena, such as the occurrence of poor mood, self-focused judgmental thoughts, and a lack of goal-directed behavior. Soon after, techniques targeting cognitive and emotional change were added to clinical interventions, giving rise to Cognitive Behavior Therapy (CBT). A number of cognitive and emotional change techniques remain widely used in evidenced-based treatments today [2], many of which are present in standard weight loss interventions, including: (a) identifying negative, automatic thoughts and replacing them with more useful, reality-based thinking, (b) challenging cognitive distortions, (c) restating problems in behavioral terms, (d) distraction, and (e) self-soothing techniques.

Cognitive change techniques were a departure from the roots of behavior therapy as these techniques were being developed on clinical theories as opposed to well-established basic behavioral processes. Thoughts and feelings were being treated as independent variables—the causes of behavior. This had the unintended effect of making many of these working cognitive theories unfalsifiable. Cognitive change techniques have been shown to be useful as a part of larger CBT packages, however they have shown little to no incremental utility when examined in large dismantling studies [3]. More recent evidence suggests the possibility that attempts to control cognition can be detrimental [4].

Third Generation: Acceptance and Mindfulness

The third generation of behavior therapy returned to traditional roots by re-emphasizing basic behavioral principles. Language and cognition is now seen as a learned operant and its manifestation determined by a learning history and current contextual factors (emphasis placed back on the environment). From this perspective, thoughts and emotions are no longer seen as independent variables, but instead dependent variables. This led to a proliferation of new techniques that focus on changing the function of thoughts and emotions, as opposed to changing them in form or frequency [5]. These techniques are frequently called mindfulness and acceptance-based, and are found in treatments such as Acceptance and Commitment Therapy [6], Dialectical Behavior Therapy [7], and Mindfulness-Based Cognitive Therapy [8] among others. Acceptance and mindfulness-based strategies have been added to many weight control packages and are just recently being evaluated empirically [9, 10].

Overview of Behavioral Weight Loss Treatment

Format

Behavioral treatment is typically delivered once weekly to groups of 10–15 individuals. Group treatment has been shown to be superior to individual care [11]. After an initial weight loss period of 4–6 months, there may be an extended treatment, or maintenance, phase that lasts 6–12 additional months, usually at a reduced contact rate of 1–2 times per month. Treatment sessions are 60–90 min in duration and the format is typically closed (meaning individuals start at the same time and remain in the same group throughout treatment). Each session includes a private weigh in, review of material and homework from the prior session, and then presentation of new lesson material (following a structured written protocol).

Interventionists

Groups are typically run by co-leaders or multidisciplinary teams. Interventionists are most frequently nutritionists, exercise physiologists, and behavior therapists. Interventionist education level varies by setting from master’s to doctoral level.

Focus

The primary focus of behavioral weight loss treatment is to improve dietary and physical activity behavior patterns. Specific recommendations and empirical support for nutrition and exercise educations strategies are reviewed elsewhere in this book. The behavioral approach, however, assumes that providing information about diet and activity may be important and helpful to individuals, but it is not sufficient for establishing behavior change. Behavioral treatment programs focus on teaching individuals strategies for changing unhealthy behavior patterns by addressing the variables that are leading to inappropriate eating and sedentary activity.

Behavioral Weight Loss Strategies

Self-Monitoring

The systematic recording of body weight, caloric intake, and physical activity is the foundation of behavioral weight loss treatment. Self-monitoring allows individuals to assess their progress toward treatment goals and to receive feedback on the adequacy of their goal-directed behaviors. Throughout treatment, individuals keep a daily record of food intake and physical activity, allowing both the individual and the group leader to see if target behaviors are improving, deteriorating, or remaining the same. Individuals typically record all food and beverages consumed along with the calories for each item, and sometimes additional information, like the number of fat grams. Individuals also record their daily weight and number of minutes engaged in moderate intensity physical activity. Daily records are used as a clinical tool during sessions and group leaders often provide written feedback after a more thorough review in between sessions. Adherence to self-monitoring has been demonstrated to be significantly associated with success at both weight loss and maintenance [12, 13]. Recent research suggests that using a smart-phone (or similar device) increases self-monitoring and can improve weight control [14, 15].

Goal Setting

Setting clear goals for caloric intake and physical activity provide structure and direction for individuals. Behavioral weight loss interventions are designed to produce a weight loss of 1–2 lb per week, with an overall target of a 7–10 % reduction from baseline weight. To accomplish this, participants are prescribed a daily calorie goal between 1,200 and 1,800 cal (depending on the starting weight of the individual), and a weekly exercise recommendation that starts low (e.g., 20–50 min) and works up to a goal of 250 min per week of moderately intense physical activity by about 6 months. Individuals are also encouraged to set additional behavioral goals. Behavioral weight loss treatment promotes the use of SMART goals (see Table 13.1). When setting a new goal, individuals are encouraged to carefully consider factors such as how, when, and where the behavior will be completed. Goal setting is used in conjunction with self-monitoring to keep track of both short- and long-term goal achievement progress. Although goal setting has not been systematically studied within the paradigm of weight loss treatment research, research suggests that it can contribute to behavior change in general [16].

Table 13.1 SMART goals
Full size table

Problem Solving

Problem solving is a process through which individuals can address barriers to change. Individuals are taught to use a systematic process for solving problems that includes describing the problem in detail, brainstorming potential solutions, making an action plan, and evaluating the effectiveness of the chosen strategy. This process can be repeated as many times as is necessary to successfully address a specific barrier. A key point of emphasis is teaching individuals how to analyze chains of behavior and identify multiple potential points of intervention within these chains. For example, an individual might skip lunch, receive some criticism from their boss, feel stressed and upset, come home tired and hungry, go right to the kitchen, see cookies on the counter, and finally eat a lot of cookies. Table 13.2 shows several links in this behavioral chain and possible problem-solving solutions at each point in the chain.

Table 13.2 Problem solving ways to interrupt a behavioral chain
Full size table

Stimulus Control

Environmental factors, such as plate size and shape, food packaging, socializing, and distraction play a role in overeating [17]. Thus, a key strategy to promote weight loss is creating an environment more conducive to healthy eating and physical activity. Stimulus control principles are used to reduce cues for unhealthy eating and sedentary behavior and increase cues for healthy eating and activity. For example, placing equipment for physical activity (e.g., walking shoes or exercise equipment) in a prominent place in the house can help remind individuals to become more active during the day. Reducing exposure to tempting foods, by removing them from the house or putting them on a difficult to reach shelf, should reduce the consumption of those foods. Washing and preparing fresh fruits and vegetables can lead to healthier snacking choices. Although individuals do not have complete control over their environments, they can often enact meaningful environmental change at home and work.

Strategies for Addressing Cognitive and Emotional Barriers

Cognitive and Emotional Change Strategies

According to the cognitive behavior model, thoughts and feelings can be triggers for maladaptive behavior (e.g., excessive eating, sedentary behavior). For example, an individual may have the thought “I’ll never lose the weight” and then stop exercising and monitoring their food intake. The process of cognitive restructuring involves identifying maladaptive thoughts, labeling these thoughts, and replacing them with a more rational thought. For example the thought “I’ll never get the weight off” can be replaced with the thought that “I may have had a difficult week, but I can recover from this slip.” Another strategy would be to challenge the thought, for example by stating “There are times when I’ve lost weight and I’ve already lost 15 lb in this program.” Other techniques include thought-stopping (breaking a negative thinking chain) and distraction (focusing on something else, for example a to-do list).

Emotional change techniques focus on reducing a problematic emotion, such as stress. Individuals can be taught systematic relaxation skills in which they learn how to progressively relax their muscles, one muscle group at a time. Self-soothing is taught as a way to change mood by engaging in non-eating pleasurable events (e.g., taking a bath or a walk). Another strategy is seeking social support from friends or family members. These techniques have been a part of evidenced-based behavioral weight loss treatment packages for years; however they have never been systematically evaluated as components.

Mindfulness and Acceptance Strategies

Excessive attempts to change thoughts and feelings can lead to maladaptive behavior [4]. Mindfulness and acceptance strategies are an alternative to cognitive and emotional change. Mindfulness techniques teach individuals to notice their thoughts as simply thoughts by training the ability to watch the process of thinking. For example, one might imagine their thoughts as leaves on a stream and envision them floating by. Mindfulness allows individuals to experience a distance between themselves and their thoughts, allowing for more behavioral flexibility (i.e., thoughts no longer need to be responded to/fought with because they are seen as just thoughts).

Acceptance strategies teach individuals how to behave consistently with their values and goals even when unwanted emotions are present. Behavioral repertoires tend to narrow in the presence of difficult emotions. For example, when individuals experience stress, they may stop doing things that matter but take effort, like monitoring calories, exercising, engaging social relationships, and instead engage in a narrow set of behaviors, such as eating and isolation, in an attempt to feel better. The goal of acceptance work is repertoire expansion. The main technique is exposure, though not for the purpose of emotion reduction, but rather to practice sitting with discomfort and also practice making positive behavioral choices in the presence of discomfort. For example, individuals may be taught in session how to notice and experience deprivation by mindfully focusing on different aspects of the emotional experience without pushing it away. Later they are asked to practice this in their natural environment in the presence of tempting foods. An additional acceptance strategy is orienting to the cost of avoidance. For example, if an individual uses food as a way to reduce stress in the short-term, they are encouraged to note the long-term costs of being unwilling to experience stress over the long-term (e.g., weight gain, disease, low energy). Recent studies have shown the potential for adding these techniques to behavioral weight loss interventions [9, 18].

Motivational Interviewing

Motivational Interviewing (MI) is a therapeutic approach that focuses on helping individuals work through ambivalence about behavior change. In a MI approach there is generally no direct attempt to confront irrational or maladaptive beliefs, address denial, or to convince or persuade [19]. Instead, the goal is to help clients think about and express their own reasons for and against change and how their current behavior or health status affects their ability to achieve their own values and goals. MI interventionists use reflective listening skills and positive affirmations to help motivate individuals to change their behavior without telling them what to do. Other core MI techniques include allowing the client to interpret information, rolling with resistance, building discrepancy (between statements made by the individual, their behavior, and their core values), and eliciting self-motivational statements [19].

In a standard behavioral approach, interventionists provide education and goals. Individuals may be told about the risks of being overweight and the benefits of weight loss, given specific calorie intake and exercise targets, and instructed to self-monitor their behavior. In contrast, a MI approach would first elicit the person’s understanding and information needs, then provide this in a more neutral manner, followed by allowing space for the individual to express what this means for them, with a question like, “How do you make sense of all this?” MI assumes that individuals are more likely to make behavior changes that they identify and commit to, as opposed to being told what to do. A number of studies have shown that MI can produce improvements in diet and physical activity (e.g., [20, 21]).

Outcomes Achieved in Current Behavioral Programs

The strategies described above are utilized in combination in standard behavioral weight loss programs to help participants change their eating and exercise behaviors. The efficacy of these standard programs has been evaluated in a wide variety of trials. Most of these behavioral weight loss studies are conducted in a single clinical site, with approximately 100–200 participants who are followed for up to 2 years. Reviewing these studies, Wing [22] showed (Fig. 13.1) that these studies typically produce initial weight losses of approximately 10 kg, with maintenance of an 8 kg weight loss at 1–2 year follow-up. These studies have carefully evaluated many of the specific strategies used in behavioral treatment, and have included randomized trials comparing different approaches to changing dietary intake [23], physical activity [24, 25], and motivation [26, 27].

Fig. 13.1
figure 1

Weight loss outcome in behavioral treatments from 1990 to 2000. Reprinted from Wing, R.R., Behavioral approaches to the treatment of obesity, in Handbook of Obesity: Clinical Applications, G. Bray and C. Bouchard, Editors. 2008, Informa Health Care USA, Inc.: New York

Full size image

Using the findings from these trials, there have been several multi-center studies in which a standard behavioral weight loss intervention was used in all clinical sites and the health impact of the intervention was evaluated. These studies are described in detail below as they provide an excellent way to showcase the format, content, and results of current behavioral approaches.

The Diabetes Prevention Program (DPP)

The goal of DPP was to determine if an intensive lifestyle intervention could reduce the risk of developing diabetes in individuals with impaired glucose tolerance (IGT). A total of 3,000 overweight/obese individuals with IGT were recruited at 27 clinical sites and randomly assigned to receive the lifestyle intervention, metformin (a medication used to treat diabetes) or placebo. The lifestyle intervention was developed centrally and all counselors, who were typically master’s level nutritionists, received training in the administration of the intervention. The intervention was conducted individually and involved a 16-session core curriculum delivered over 16–24 weeks, followed by ongoing group and individual contact. The goal was to help participants achieve and maintain at least a 7 % weight loss. To achieve this, changes in both diet and activity were stressed. The dietary intervention focused primarily on decreasing fat intake and participants were assigned both a fat gram goal and a calorie intake goal. Physical activity was gradually increased to a goal of 150 min/week of moderate intensity activity such as brisk walking. Participants recorded their intake and exercise daily throughout the core curriculum, and were encouraged to record as needed during maintenance. The lessons used in DPP are available on the DPP website (http://www.bsc.gwu.edu/dpp/lifestyle/dpp_part.html) and focus on the key behavior change strategies, such as stimulus control, changing cognitions, and problem solving.

Participants who received the behavioral intervention achieved an average of 6.9 ± 4.5 % (6.5 ± 4.7 kg) weight loss at the end of the 16 session core curriculum and maintained a weight loss of 4.9 ± 7.4 % (4.5 ± 7.6 kg) at 3.2 year follow-up. Fifty percent of participants achieved the 7 % weight loss goal initially and 38 % at final follow-up [28]. The study was stopped at that time because these weight losses, although modest, were effective in reducing the risk of developing diabetes by 58 % relative to placebo [29]. The lifestyle intervention was also twice as effective as metformin. A follow-up of the DPP, conducted after year 10, showed that although the weight losses in the intensive lifestyle intervention no longer differed significantly from placebo or metformin, the impact on development of diabetes remained highly significant [30].

Based on the success of DPP, another larger trial was launched to examine the long-term health effects of intensive lifestyle intervention in individuals who were overweight or obese and had already developed type 2 diabetes. In this study, called Look AHEAD, 5,145 individuals were recruited at 16 centers and randomly assigned to intensive lifestyle intervention (ILI) or a control group, referred to as Diabetes Support and Education (DSE). The design [31], rationale for the specific components of the lifestyle intervention [32] and the initial and longer term results have been published previously [33–35]. In brief, the lifestyle intervention in Look AHEAD was implemented primarily in groups, with 3 group meetings and 1 individual session during each of the first 6 months, and 2 group meetings and 1 individual session for months 7–12. Subsequently the frequency of contact was decreased, but an effort was made to have contact with each participant at least monthly for years 1–4 and every 3 months in later years.

The intervention was very similar to DPP, with the following modifications [32]. Participants were encouraged to lose 10 % of their body weight and then maintain this. The dietary intervention focused more on reducing caloric intake, since lowering total calories is recognized as more important for weight loss than is the macronutrient composition of the diet. To help participants achieve this caloric reduction, meal plans and meal replacement products were provided to participants for use initially for two meals per day and later for one meal per day. The physical activity goal was increased to 175 min per week based on recent evidence that higher levels of physical activity were important for weight loss maintenance [36]. The lessons used in Look AHEAD are available on the Look AHEAD website (http://www.lookaheadtrial.org/).

On average, participants in the ILI group lost 8.7 % at 1 year, compared to 0.7 % in DSE. Although the ILI group had a gradual weight regain between years 2 and 4, their weight then plateaued and they maintained weight losses of 6.0 % (vs 3.5 %in DSE) at a median of 9.6 year follow-up (Fig. 13.2). These outcomes were better than seen in DSE at each time point.

Fig. 13.2
figure 2

Changes in weight during 10-year follow-up in the Look AHEAD Trial. From Wing, R.R., et al. Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes. N Engl J Med, 369(2): pp. 145–54. Copyright © (2013) Massachusetts Medical Society. Reprinted with permission

Full size image

The weight losses achieved in Look AHEAD had important health benefits. The ILI group had greater improvements in glycemic control, while requiring less use of insulin, and better improvements in systolic blood pressure with less hypertensive medications. HDL cholesterol improved more in ILI than DSE, but the DSE group had lower levels of LDL-C during the study, due to their greater use of statins. Despite these positive effects on cardiovascular risk factors, the ILI did not reduce the risk of cardiovascular morbidity and mortality. However, it did lead to a large number of other health benefits. Patients in ILI had greater improvements in sleep apnea [37], urinary incontinence [38], and sexual dysfunction [39], reported less depressive symptoms [40] and better physical quality of life [41], and maintained better physical function over time [42].

Variability in Outcome and Demographic and Behavioral Predictors of Success

Although the average weight losses in behavioral weight loss programs are quite good, the outcome for any individual patient is extremely variable; some participants lose little or no weight whereas others are very successful. This has led to efforts to identify predictors of treatment outcomes. Ideally, those would be characteristics that could be assessed easily at baseline and indicate who should be enrolled. Unfortunately there are no baseline variables that have such predictive value [43].

Several variables have been identified that relate to group differences in outcomes, but none are strong enough to determine which individuals will be most successful. For example, older individuals typically do better in behavioral weight loss programs than younger ones [28, 44]. This was noted in both DPP and Look AHEAD. Moreover, older individuals have been shown to attend more treatment sessions and adhere better to both the diet and physical activity recommendations [44]. In contrast, young adults have been shown to drop out of treatment more frequently and to achieve poorer outcomes [45]. However, not all older individuals will be successful and vice versa.

Behavioral weight loss programs have also reported ethnic differences in outcomes; initially, African Americans lose less weight than whites in these trials [46], but when followed long-term, there are no differences in outcomes by ethnicity [44].

Although behavioral programs are often recommended for those who are moderately obese, more intensive approaches, involving pharmacotherapy or surgery, are suggested for heavier patients. However, severely obese patients actually do quite well in behavioral programs. Using data from Look AHEAD [47], Unick and colleagues reported that severely obese participants in the lifestyle intervention group lost as much or more weight than others who were less overweight and had similar changes in CVD risk factors through 4 years.

Psychological factors at baseline, for example depression, binge eating, and emotional eating have been inconsistent predictors of outcome. In the largest study to address this, Look AHEAD found no effect of Beck Depression Scores on weight loss or maintenance, but the mean levels of BDI scores in this trial was quite low [40]. In clinical settings, both depression and binge eating have been related to poorer weight loss outcomes [48]. Participants who report eating in response to negative emotions have been shown to perform less well in some studies when treated with standard behavioral weight loss [9] and may be particularly appropriate for intervention strategies including Acceptance and Commitment Therapy [49].

The strongest predictor of outcome in a behavioral weight loss program is the success during the initial weeks of the intervention [43]. Several studies have shown that those who lose the most weight during the intensive phase of the intervention are far more likely to be successful long-term compared to those who perform less well initially. For example, in DPP, comparisons of those who did or did not achieve the 7 % weight loss goal at the end of the initial 6 months showed that those who were initially successful were three times more likely to also achieve this goal at the end of the study (3.2 years) [28]. The same can be shown with even earlier weight loss; weight loss in the first month of the program predicts outcomes over the entire program [50]. This information should be used clinically to determine whether to provide rescue efforts to those who are doing poorly after 4 weeks or to consider referring these individuals to alternative treatment approaches.

The variable that is most consistently related to long-term outcome in behavioral weight loss programs is physical activity. Jakicic [51, 52] has conducted several retrospective analyses showing that women in behavioral weight loss programs who report greater than 200 min of physical activity at 6, 12, and 18 months have better long-term outcome than those reporting lower levels of activity. Physical activity is important for increasing caloric expenditure, but may also facilitate weight loss through psychological mechanisms and direct effects on hunger and intake.

Maintenance of Weight Loss

The biggest problem in the treatment of obesity at this time is the problem of long-term maintenance of weight loss. As seen in the weight loss graph from Look AHEAD (Fig. 13.2), participants in intensive lifestyle programs tend to gradually regain their weight over time. To address this concern, researchers have conducted both observational studies of successful weight losers and randomized trials evaluating specific maintenance strategies.

The largest study of successful weight loss maintainers is the National Weight Control Registry (NWCR) [53]. Currently the registry has over 10,000 members, all of whom lost >30 lbs (mean = 30 kg) and have kept it off >1 year (mean = 5 years). In a number of publications, the NWCR members were noted to continue to consume a low calorie, low fat diet, maintain high levels of physical activity, and remain vigilant about their diet, exercise, and weight [53, 54]. Approximately 36 % of these individuals report weighing themselves every day and an additional 42 % report weighing at least once per week [12]. The majority eat breakfast every day and watch very little television [55, 56].

Recently, data were reported for almost 2,900 Registry members who had reached 10 years of follow-up as members [57]. These members reported losing 31.3 kg initially. On average, they had kept off 23.8 kg at 5 years and 23.1 kg at 10 years. Weight regain was curvilinear, with the greatest weight regain during the initial year of follow-up and decreasing each subsequent year. Eighty-seven percent were still maintaining at least 10 % weight loss at year 10. The magnitude of weight regain was greater in those who at entry into the NWCR had lost the most weight and in those with shorter duration of maintenance. Keeping weight off for at least 2 years was related to better long-term success. In addition, weight regain was strongly associated with decreased adherence to the behaviors associated with successful weight loss maintenance. Those who had decreases in physical activity, restraint, and self-weighing frequency or increases in dietary intake of fat or disinhibition regained more weight than those who maintained these behaviors. The best maintenance was seen in those who maintained all of these behaviors, and failure to maintain each of the other behaviors contributed additional to the amount regained.

Findings from the NWCR were used as the basis for a randomized trial testing the efficacy of these strategies to individuals who had recently lost weight as a means of helping them maintain their weight loss. Wing et al. [58] randomly assigned 314 individuals who had lost at least 10 % within the past 2 years to either a newsletter control group, or to a face-to-face or Internet intervention condition. The two interventions were identical in content, and differed only in the delivery system. Both interventions taught participants to self-regulate their behavior by weighing themselves daily and using the weight information to determine if changes in diet and physical activity were needed. This study found that both intervention groups were less likely than the control group to regain >5 lbs over 18 months, but only the face-to-face group differed from the control group in the absolute magnitude of weight regain. In addition, decreases in physical activity and increases in depressive symptoms, disinhibition, and hunger were related to weight regain in all groups [59]. In contrast, increased frequency of self-weighing was protective only in the two intervention groups, which had been taught how to use the information from the scale to self-regulate eating and activity behaviors.

Individual trials and a meta-analysis have provided strong evidence that continuing to see participants over the long-term is critical for successful weight loss maintenance [60]. Other randomized trials have shown that social support [26] and financial contingencies based on group performance [61] can improve weight loss maintenance. Recently, there has been evidence that adding variety to a maintenance program may improve long-term results [62].

Dissemination

Lifestyle interventions, with regular face-to-face group or individual sessions, are expensive to implement and time-consuming for participants. Therefore, efforts have been made to provide these approaches in more cost-effective formats. Several studies have suggested that providing behavioral weight control via regular phone calls is very effective for treatment and maintenance [63, 64]. Delivering the program via the internet has also been successful [65]. The best weight losses in internet programs are seen when the components of standard behavioral approaches are delivered via the internet. For example, a key component is for participants to have goals for their weight, eating and activity, and to self-monitor these behaviors, and submit these data at least weekly. Feedback on the extent to which the goals were accomplished is a critical component, but this feedback can be provided either by live therapists or even through automated feedback [66]. Given the prevalence of obesity, it is important to continue to develop treatment approaches that can be implemented cost-effectively.

Conclusion

This chapter has highlighted the progress that has been made in the behavioral treatment of obesity. With current programs, participants can be expected to lose approximately 7–10 % of their body weight at 1-year, which has an important health impact. The challenge for the field lies in the development of strategies to improve the maintenance of weight loss and to extend the reach of behavioral treatments.