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Behavioral Therapy for Obesity

by Tammy Worth

If you struggle with obesity, you know how hard it is to lose weight. But obesity is a serious medical condition that often requires medical help for you to be successful in losing weight and keeping it off.

Unfortunately, obesity—meaning a body mass index (BMI) of 30 or higher—is challenging to treat. Even in large-scale, well-known clinical interventions, people often don’t hit their target weight-loss goals. And among people able to lose weight, nearly half regain it within five years. That’s troublesome since obesity is associated with such health concerns as heart disease, diabetes, high blood pressure, joint problems, cancer, and disability.

Updated weight-loss guidance

The U.S. Preventive Services Task Force (USPSTF), a panel of medical experts who evaluate scientific evidence and make recommendations about preventive health care, reviewed the clinical evidence on interventions for weight loss and weight-loss maintenance to determine which strategies are the safest and most effective for people who are obese. The task force focused on nonsurgical practices, such as drug therapy and methods to help modify behavior, that primary care doctors can offer to patients who are obese, either by providing it themselves or referring patients to a specialist. The revised recommendations appeared in September 2018 in JAMA: The Journal of the American Medical Association.

In its recommendation statement, the USPSTF concluded—as they had in their original 2012 recommendation—that the most effective way for people with a BMI of 30 or higher to lose weight is by engaging in intensive behavioral therapy.

What is behavioral therapy?

Behavioral therapy is based on the concept that people have learned unhealthy behaviors, such as poor diet habits and inactivity, which play a role in weight gain. The therapy focuses on changing those behaviors.

Behavioral therapy typically has several components to help you:

  • Improve your diet and increase your physical activity
  • Set realistic goals
  • Self-monitor with tools like pedometers and food diaries
  • Identify your weight-loss challenges
  • Develop problem-solving techniques to overcome those challenges
  • Control or eliminate the factors that trigger unhealthy eating
  • Build strategies to maintain your weight loss over time

The cost of behavioral therapy varies but is often paid for by Medicare and some private health insurers.

Types of behavioral therapy interventions

Behavioral therapy interventions come in several forms. They can be group or individual sessions held one to four times a month. Interventions can also be provided by way of platforms like smartphone apps, phone consults, or web-based self-monitoring. The number of sessions and the length of programs vary.

Most programs evaluated by the USPSTF lasted one to two years, with patient sessions averaging once a month. Many trials combined a weight-loss program followed by a weight-loss maintenance program. Behavioral therapists, psychologists, dietitians, lifestyle coaches, and other health care providers typically conduct the sessions.

In-person treatment isn’t always available locally, particularly for people living in rural areas, where the burden of obesity is greatest. But the options of electronic and phone interventions make behavioral therapy more accessible. Such remote interventions can also make the therapy more accessible for people with disabilities and older adults.

What About Drugs for Obesity?

In its latest recommendations, the U.S. Preventive Services Task Force found drug therapy to be less effective for long-term weight loss than behavioral therapy, mainly because research on medications isn’t strong enough to make a comparison.

Measuring success

The USPSTF couldn’t determine whether one form of behavioral therapy was better than the others because of the wide range of interventions—and not all patients respond to the therapy in the same way. The task force suggests that the therapies with the greatest weight-loss benefit involved 14 or more face-to-face sessions (group or individual) over six months.

The average weight loss among those who used behavioral therapy in the studies the USPSTF evaluated was between one and 20 pounds. Those not in therapy lost between three and 12 pounds. The intervention participants also had a lower risk of developing diabetes than the control group and were more likely to have maintained a loss of 5 percent of their initial weight a year later.

However, an editorial accompanying the guidelines reported that individuals on average regain one-third of their weight a year after therapy ends, and nearly half return to their original weight within five years.

Though the USPSTF recommends behavioral therapy as a first-line treatment, there’s no quick fix to lose weight, as evidenced by those who eventually regained their weight. Research shows that people who succeed tend to be effective at monitoring their food intake and exercise, lose weight at a steady pace, and regularly take part in a weight-loss program.

This article first appeared in the January 2019 issue of UC Berkeley Health After 50.

Also see What's Behind the Obesity Epidemic and 18 Keys to Healthy Weight Loss.