Home Health Eating Disorders and Obesity
Treatment Approaches Targeting Weight Loss in Overweight and Obese Youths
On the basis of the theories we have described and the premise that longterm energy imbalances result in excess weight gain, several treatments have been developed to target weight loss and aberrant eating patterns in overweight and obese youths. In this section, we review two treatments for weight reduction in overweight and obese youths and provide a case example for behavioral weight loss for pediatric obesity, the current gold- standard treatment for weight loss in children. Last, we review a treatment for aberrant eating patterns that specifically targets binge eating and EAH. As behavioral specialists, counselors play a crucial role as the primary providers of these treatments in a variety of settings including schools, mental health agencies, and community agencies and organizations.
Behavioral Weight Loss for Pediatric Obesity
Family-based behavioral treatment for weight loss is a family intervention to reduce weight in obese youths. It is delivered to both parents and children and combines nutrition education and exercise with behavior therapy techniques (Epstein, 1996). Behavioral weight loss is a conglomerate of several empirically supported strategies, including parents as active participants in treatment (Epstein, McCurley, Wing, & Valoski, 1990), providing exercise in addition to diet (Epstein, Wing, Penner, & Kress, 1985), providing mastery criteria for behavior change (Epstein, McKenzie, Valoski, Klein, & Wing, 1994), problem solving (Epstein, Paluch, Gordy, Saelens, & Ernst, 2000), and reducing sedentary behaviors (Epstein, Paluch, Gordy, & Dorn, 2000; Epstein, Valoski, Kalarchian, & McCurley, 1995). In addition, this treatment protocol includes separate parent and child groups and individual one-on-one meetings for goal setting and problem solving (Epstein, 1996). Changes in behavior are conceptualized and taught as lifestyle changes and healthy habit acquisition as opposed to a diet. The program encourages healthy weight loss behaviors, primarily enacted by parents so as to avoid resistance and excessive responsibility on the part of the child. Ten-year longitudinal data have shown that one third of children treated with this modality are no longer overweight in adulthood (Epstein, Valoski, Wing, & McCurley, 1990, 1994). Data have also suggested that children who participate in this program do not have an increase in ED symptoms (Brownell & Rodin, 1994; Epstein, Paluch, Saelens, Ernst, & Wilfley, 2001).
Behavioral weight loss typically consists of 20 sessions that take place over the course of a 6-month period. The first 16 sessions occur weekly, and the remaining 4 sessions occur biweekly. Sessions consist of hour-long separate parent and child groups that take place simultaneously. In addition to attending the group, each family participates in a family coaching session facilitated by a behavioral coach. The coaching session focuses on setting specific, tailored goals and monitoring and reviewing progress. Group sessions are differentiated by topic and include didactics, experiential learning, and goal setting for parents, whereas the focus in childrens groups is on experiential learning and skills acquisition through the use of developmental appropriate games and activities. Both coaching sessions and group sessions are typically provided by counselors and psychologists with some knowledge or expertise in the area of eating and weight issues. Behavioral weight loss treatments are generally sponsored by and held in medical settings including large hospital organizations and university medical schools. Schools and community agencies are also ideal locations at which to hold these treatments because they may be the most effective way to reach and target overweight and obese youths.
Parental competence is achieved by providing education on dietary information and energy expenditure as they relate to energy balance. Families are taught that the primary inputs contributing to weight loss are caloric intake and physical activity. This principle is taught in the context of what is referred to as the “energy balance,” where families learn that to lose weight, an individual must expend more energy than he or she takes in. Correspondingly, the goals of treatment are to increase physical activity and reduce caloric intake.
Families are provided with a child-friendly dietary classification system, referred to as the traffic light diet, in which foods are classified by color (red is stop, yellow is slow down, green is go) on the basis of energy density and sugar and fat content. For example, a bag of potato chips is considered a red food because of its high fat content, whereas air-popped popcorn is considered green because of its low fat and sugar content. The traffic light diet is intended to assist families in making food choices that are compatible with weight loss. In addition to learning to classify foods, families learn appropriate portion size, how to count calories, and caloric guidelines for both adults and children.
Additionally, families are taught to increase their physical activity and decrease sedentary activity. Increases in physical activity are achieved through planned physical activity (i.e., going for a run) or lifestyle activity (walking to school). Additionally, screen time is decreased outside of homework needs. Interventionists use the behavioral technique, successive approximation, to assist families to meet designated physical activity goals over the course of the first five weeks of treatment. Parents are shaped to a goal of 60 minutes per day, and children are shaped to a goal of 90 minutes per day.
Behavior Modification Strategies
Parents learn a variety of behavior modification strategies to promote healthy behaviors in their children. In addition to learning behavioral strategies to be implemented at home, behavioral strategies are used within the context of treatment to facilitate weight loss and the promotion of healthy eating and activity habits.
Self-monitoring. All group members receive weekly self-monitoring booklets in which daily dietary intake and physical activity are recorded. Both parents and children complete these booklets, which are then reviewed with their behavioral coach. Families are instructed to keep track of caloric intake, number of foods from each color category, physical activity, and sedentary activity on a daily basis. As one of the primary predictors of weight loss, self-monitoring by participants is highly encouraged and time is spent identifying barriers and problem solving to increase the likelihood of successful monitoring.
Goal setting. To increase healthy behaviors such as physical activity and reduce unhealthy behaviors such as the consumption of red foods, behavioral coaches set goals with each family that are tracked and reviewed on a weekly basis. Goals are set for the following components of treatment: daily calorie consumption, minutes of physical activity, minutes of sedentary activity, number of red foods consumed, and number of fruits and vegetables consumed. Parents are responsible for keeping track of whether their child met his or her goals, and goals are reviewed in behavioral coaching sessions on a weekly basis.
Positive reinforcement. To promote healthy behaviors and motivate children, a behavioral reward system is used in which children earn points for engaging in healthy behaviors and losing weight. Parents are taught to implement the reward system and keep track of their child's progress on a weekly basis. Generally, children have small, medium, and large rewards that can be earned on the basis of the number of points that they have obtained. In addition to rewards, parents are also taught to practice praising behaviors in an effort to reinforce healthy behaviors.
Stimulus control. Parents are taught to limit stimuli that promote unhealthy behaviors by restructuring their home environments to reduce the availability of unhealthy foods and reduce the availability and visibility of healthy foods. Parents are advised to eliminate unhealthy foods from the home and increase the accessibility of healthy foods, such as fruits and vegetables. For example, one parent who did not feel comfortable throwing away red foods decided to store them on the highest shelf of her pantry. Every Sunday, she also began cutting up fruits and vegetables and storing them in single-size portions at eye level in her refrigerator so that her child would be more likely to grab these on returning home from school. (For a session-by-session example, please see Table 15.1.)
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