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Recommendations Summary

AWM: Multiple Behavior Therapy Strategies 2014

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    AWM: Multiple Behavior Therapy Strategies

    For weight loss and weight maintenance, the registered dietitian nutritionist (RDN) should incorporate one or more of the following strategies for behavior therapy: 

    • Self monitoring: Strong evidence shows that for adults who need or desire to lose weight or for adults who are maintaining body weight following weight loss, self-monitoring of food intake improves nutrition-related outcomes related to weight loss and weight maintenance
    • Motivational interviewing: Research demonstrated that motivational interviewing significantly enhanced adherence to program recommendations and improved targeted diet-related outcomes including glycemic control, percentage of energy intake from fat, fruit and vegetable intake and weight loss
    • Structured meal plans and meal replacements and portion control: Research reports that the use of various types of meal replacements or structured meal plans was helpful in achieving health and food behavior change and strong evidence documents a positive relationship between portion size and body weight
    • Goal-setting: Clients' active participation in selecting and setting goals led to the selection of a goal from the area that could use the most improvement and the goal that was most personally appropriate
    • Problem-solving: Studies based on the use of problem-solving strategies resulted in improvements in key outcome measures, including maintenance of weight loss and in subjects with diabetes, was linked to improvements in fat consumption, self-efficacy and physical activity.

    Rating: Strong
    Imperative

    AWM: Consider Use of Additional Behavior Therapy Strategies

    For weight loss and weight maintenance, the RDN may consider using the following behavior therapy strategies: 

    • Cognitive restructuring
    • Contingency management
    • Relapse prevention techniques
    • Slowing the rate of eating
    • Social support
    • Stress management
    • Stimulus control and cue reduction.
    These strategies are not well researched and there is limited evidence demonstrating their effectiveness.

    Rating: Fair
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      None.

    • Potential Costs Associated with Application

      Costs of medical nutrition therapy (MNT) sessions vary, however MNT sessions are essential for improved outcomes.

    • Recommendation Narrative

      From the Nutrition Counseling Project

      • Three RCTs (two positive-quality and one neutral-quality) provide evidence that self-monitoring of food intake improves nutrition-related outcomes related to weight loss (Boutelle et al, 1999; Tate et al, 2003) and compliance with renal diets (Milas et al, 2002). Three observational studies of neutral quality revealed that clients enrolled in cognitive behavioral weight-loss programs that were successful in losing weight were significantly more consistent with self-monitoring (Baker et al, 1998; Mattfeldt-Beman et al, 1999; Streit et al, 1991).
      • Four RCTs (three positive-quality and one neutral-quality) assessed the efficacy of various types of meal replacement or structured meal plan strategies, as compared to self-selected diets in middle aged-adults and found the use of various types of meal replacements or structured meal plans helpful in achieving health and food behavior change in middle-aged adults (Wing et al, 1996; Metz et al, 1997; Ditschuneit et al, 1999; Flechter-Mors et al, 2000; Ashley et al, 2001; Ditschuneit and Flechter-Mors, 2001). Additional research is needed to determine if benefits derived from temporary use of these behavioral strategies can be sustained over time.
      • Two positive-quality (one RCT and one meta-analysis) and one neutral-quality RCT found monetary rewards or reinforcement had no treatment effect (Jeffery and Wing, 1995; Fuller et al, 1998; Paul-Ebhohimhen and Avenell, 2007)
      • Two positive-quality RCTs, one in overweight and obese women and the other in post-menopausal women with diabetes, utilized interventions that incorporated problem-solving strategies (Perri et al, 2001; Glasgow et al, 2004). In both studies, use of problem-solving strategies resulted in improvements in key outcome measures, including maintenance of weight loss and in subjects with diabetes, was linked to improvements in fat consumption, self-efficacy and physical activity. 
      • One highly intense lifestyle change study found social support was helpful and four traditional lifestyle change programs did not find it helpful (Wing et al, 1991; Wing et al, 1999; Barrera et al, 2002; Barrera et al, 2006; Toobert et al, 2007). The definition of social support has evolved to include multiple dimensions of social support measured pre- and post-treatment. Two RCTs conducted in the 1990s manipulated social support and found no significant treatment effect. In an RCT published in 2006, multiple dimensions of social support were measured pre- and post-treatment and use of social resources was shown to mediate intervention effects on physical activity, fat consumption and HgA1C change. Additional studies are needed to measure impact of social support interventions on outcomes.
      • One positive-quality RCT found a 30-minute motivational interviewing session, based on self-selected diabetic self-management goals, followed by three 10-minute phone calls at one week, three weeks and seven weeks, was significantly more effective than usual care in reducing dietary fat intake and increasing physical activity at one year in 100 adults with type 2 diabetes (Clark et al, 2004). A positive-quality RCT showed similar results regarding the value of clients' self-selected behavior change goals and demonstrated the effectiveness of goal-attainment training in realizing dietary improvements (Berry et al, 1989). One neutral-quality observational study found 422 clients with diabetes who used computer technology to self-select a behavior-change goal in an area of diet or exercise and received brief (eight to 10 minutes) counseling related to the goal, were successful in reducing fat intake two months later (Estabrook et al, 2005). Clients' active participation in selecting and setting goals led to the selection of a goal from the area that could use the most improvement and the goal that was most personally appropriate.
      • One neutral-quality RCT assessed the additive effect of a cognitive restructuring component to a 10-week strictly behavioral weight-loss program in 63 middle-aged overweight subjects and found no significant difference between the treatment group and control group in any physiological, behavioral or cognitive measures at baseline, post-treatment and at three-month follow-up (DeLucia and Kalodner, 1990). Additional research is needed on the isolated effect of cognitive restructuring as part of a behavioral intervention on nutrition-related outcomes. 
      • Four RCTs of positive quality assessed the effect of motivational interviewing as an added component to cognitive-behavioral programs [three studies (Smith et al, 1997; Bowen et al, 2002; West et al, 2007)] or a self-help intervention (Resnicow et al, 2001) and found motivational interviewing significantly enhanced adherence to program recommendations and improved targeted diet-related outcomes including glycemic control, percentage of energy intake from fat, fruit and vegetable intake and weight loss.

      From the 2010 Dietary Guidelines Advisory Committee (DGAC) Nutrition Evidence Library (NEL) Evidence-Based Systematic Reviews

      • What is the relationship between diet self-monitoring and body weight?
        • Strong evidence shows that for adults who need or desire to lose weight or who are maintaining body weight following weight loss, self-monitoring of food intake improves outcomes.
      • What is the relationship between portion size and body weight?
        • Strong evidence documents a positive relationship between portion size and body weight.

    • Recommendation Strength Rationale

      • The eight Conclusion Statements from the Nutrition Counseling project in support of this recommendation received the following grades:
        • What is the evidence that the behavioral strategy of self-monitoring, used as a component of a behavioral program, will result in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade I
        • What is the evidence that the behavioral strategy of meal replacements or structured meal plans, used as a component of a behavioral program, will result in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade I
        • What is the evidence that the behavioral strategy of reward and reinforcement (contingency management), used as a component of a behavioral intervention, will result in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade I
        • What is the evidence that the behavioral strategy of problem-solving will result in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade II
        • What is the evidence that the behavioral strategy of social support will result in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade II
        • What is the evidence that the behavioral strategy of goal-setting will result in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade II
        • What is the evidence that the behavioral strategy of cognitive restructuring will result in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade III
        • What is the evidence that Motivational Interviewing, used as an adjunct to a cognitive-behavioral program, results in health or food behavior change in adults counseled in an outpatient or clinic setting? Grade I
      • The Conclusion Statements for Energy Balance and Weight Management, Food Environment and Dietary Behaviors in support of this recommendation both received a grade of Strong.

    • Minority Opinions

      Consensus reached.