oac

M.

ta K

wling

4 Jan

were stepped-up to more intensive treatment when poor prog-

ress toward weight loss or maintenance goals was detected.

investigation exam-

T Corresponding author. Department of Psychology, Bowling Green

Journal of Psychosomatic ResearchState University, Bowling Green, OH 43403, USA. Tel.: +1 419 372 9405;

fax: +1 419 372 6013.range of disease severity (i.e., overweight to super obese;

[24]). In a stepped-care (SC) approach to treatment,

patients are transitioned to more intensive treatments when

less intensive treatments prove to be insufficient [2]. By

beginning with a less intensive treatment, the likelihood of

some patients receiving unnecessary treatment is reduced.

SC approaches have been formulated for a variety of medical

conditions, including weight management [49]. Applying

an SC approach to the treatment of obesity represents one

attempt to efficiently allocate treatment resources.

Although there has been increased emphasis on providing

individualized treatment (e.g., Diabetes Prevention Pro-

gram; [14]), in most weight loss investigations, treatment

innovations are commonly provided to all participants

regardless of need. Investigations that provide systematic

therapeutic supplements for individuals who are having

difficulty losing or maintaining weight loss are limited. Yet,

a prompt therapeutic response to unsatisfactory progress

during or following treatment may be necessary to circum-

vent poor treatment outcome across a number of psycho-

logical and behavioral domains, including weight loss

[1517]. In the current investigation, eligible participantsreported greater physical activity and greater improvements in

Keywords: Obesity; Stepped-care; Treatment; Weight loss; Diet

Introduction

Obesity may soon replace smoking as the number one

cause of preventable death [1]. Effective management of the

obesity epidemic is likely to require cost-effective, time-

efficient, minimally intrusive treatments across the entire0022-3999/05/$ see front matter D 2005 Elsevier Inc. All rights reserved.

doi:10.1016/j.jpsychores.2005.06.060

E-mail addre1 Authors contributed equal effort to this manuscript.D 2005 Elsevier Inc. All rights reserved.

Over the past several decades, behavioral approaches

have been the treatment of choice for mild to moderate

obesity [1013]. In most behavioral weight loss programs

(BWLPs), participants struggling with weight loss difficul-

ties are commonly provided informal individual assistance.in the BWLP+SC lost significantly more weight and body fat,evidence superior treatment outcomes when compared with a

BWLP without SC (BWLP). Methods: Forty-four obese,

sedentary adults were randomly assigned to a BWLP+SC [i.e.,

problem-solving therapy (PST)] or a BWLP. Results: Participants

maintenance (through 12 months posttreatment) compared with

BWLP participants matched on SC eligibility [BWLP (SC

matched)]. Conclusion: BWLP+SC may improve treatment

outcomes and participant motivation to achieve preestablished

weight loss goals.Applying a stepped-care appr

Robert A. CarelsT, Lynn Darby, HollyJessica Harper1, Mary E. Kaplar1, Kris

Bowling Green State University, Bo

Received 2

Abstract

Objective: In a stepped-care (SC) approach to treatment, more

intensive interventions are implemented when less intensive

interventions prove to be insufficient. It was hypothesized that

a behavioral weight loss program with SC (BWLP+SC) wouldh to the treatment of obesity

Cacciapaglia1, Olivia M. Douglass1,

onrad1, Sofia Rydin1, Karin Tonkin1

Green, OH 43403, United States

uary 2005

diet, and were more likely to achieve their within-treatment

weight loss goals than BWLP participants. Participants in the

BWLP+SC who received PST (BWLP+SC [PST]) also evidenced

superior treatment outcomes including superior weight loss

59 (2005) 375383did not include aTo our knowledge, the only prior

ining an SC approach to weight lossss: rcarels@bgnet.bgsu.edu (R.A. Carels).

control group of participants who did not receive SC [18].

Therefore, conclusions about the effectiveness of a SC

approach to weight loss are limited. In this investigation, a

randomized SC weight loss intervention was evaluated.

Problem-solving therapy (PST; [19,20]) was administered

in individual sessions concurrent with the BWLP when

participants failed to achieve preestablished weight loss

goals. While problem solving occurs in most BWLPs,

participants are not commonly taught formal problem-

solving skills. PST has been used effectively to help

participants reach behavioral change goals in numerous

contexts, including weight loss [1827]. It was hypothesized

that BWLP+SC participants who received additional coun-

seling (BWLP+SC [PST]) would evidence superior treatment

outcomes when compared with BWLP participants matched

on treatment eligibility (BWLP [SC matched]).

In BWLP+SC, the failure to achieve weight loss goals

resulted in tangible consequences (i.e., additional counsel-

ing); there were no equivalent consequences in the BWLP. It

was reasoned that the tangible consequence of additional

counseling would enhance goal importance [28] in BWLP+

SC participants and that receiving PST would contribute to

superior treatment outcomes. Therefore, it was hypothesized

Midwestern university. Participants were included if they

were (a) obese (BMI N30 kg/m2), (b) sedentary, and (c)nonsmokers. Participants were excluded if they had (a) past

or current cardiovascular disease, (b) musculoskeletal prob-

lems that would prevent participation in moderate physical

activity, or (c) insulin-dependent diabetes or impaired fasting

glucose (blood glucose N110 mg/dl). All participantsreceived medical clearance from their physician.

To reduce attrition, participants provided a US$100

deposit, which was refunded following completion of the

program. The deposit was waived for four participants

because of financial considerations. Additionally, program

completion was emphasized during recruitment and partic-

ipants were promptly contacted after missed sessions.

Study design

Participants were randomly assigned to the BWLP (n=23)

or BWLP+SC (n=21) prior to the intervention (see Fig. 1 for

randomization, attrition, and SC eligibility). At pre- and

posttreatment, participants completed assessments of body

weight and fat, physical activity, cardiorespiratory fitness,

R.A. Carels et al. / Journal of Psychosomatic Research 59 (2005) 375383376Forty-four obese, sedentary adults were recruited through

local newspaper advertisements and campus email at athat BWLP+SC participants would evidence superior treat-

ment outcomes when compared with BWLP participants.

Methods

ParticipantsFig. 1. Randomization, attritand nutrition. In addition, weight assessments were com-

pleted at 1, 2, 4, 6, and 12 months posttreatment. During the

intervention, participants made daily recordings of the

calories that they expended from activity (see Caltrac

accelerometers below) and the duration of planned physical

activity. The program was administered in 75-min weekly

sessions in closed groups of 712 participants. Participants in

the BWLP+SC groups were eligible for additional counseling

in addition to the weekly BWLP if they failed to meet their

preestablished weight loss goals (see Stepped Care below).ion, and SC eligibility.

hosomInterventions

Behavioral weight loss program

The 20-session (24 weeks including holidays) BWLP was

based on the LEARN program [29], a comprehensive, em-

pirically supported approach to weight management [30,31].

The primary goals of the intervention were to achieve gradual

weight loss, increase physical activity, and progressively

decrease energy and fat intake through permanent lifestyle

changes. Additional information on the LEARN program

can be found at www.thelifestylecompany.com.

Stepped care

Performance-based criteria dependent on progress toward

preestablished weight loss goals were used to determine

stepped-up treatment for participants in the BWLP+SC

groups. Based on recommendations from the NHLBI [3], a

minimum end-of-treatment weight loss goal of 8% of total

body weight was established. In addition, all participants

received moderate (12%) and ambitious (16%) weight loss

goals. The bambitiousQ goals were established by examiningthe weight loss of successful participants in prior BWLPs

[32,33]. The bmoderateQ goals represent the midpointbetween the bminimumQ and bambitiousQ weight loss goals.

During the program, eligibility for SC was assessed

during four preestablished weight loss assessments. Partic-

ipants were stepped-up if they did not meet the following

percent body weight loss goals: (a) N 1% by Week 3; (b)N1% between the 3rd and 6th weeks; (c) N2% between the6th and 12th weeks; or (d) N2% between the 12th and 18thweeks. The SC eligibility criteria were designed to promote

gradual weight loss without creating excessive demands on

the participants. Therefore, a participant did not have to

bmake-upQ weight loss from a previously unsuccessfulassessment period.

Posttreatment weight assessments were conducted at 1, 2,

4, 6, and 12 months. BWLP+SC participants were eligible

for additional SC counseling if they regained greater than

1% of their body weight during the first 6 months following

treatment. There was no treatment contact during posttreat-

ment months 6 through 12.

Participants eligible for SC received PST based on the

five-stage problem-solving method of DZurrila et al.

[19,34]. The five stages include (1) orientation, (2)

definition, (3) generation of alternatives, (4) decision

making, and (5) implementation and evaluation. Eligible

participants met weekly with a clinical psychology

doctoral student for 45- to 60-min individual sessions

and received a brief problem-solving manual (available

upon request). The overall goals of the PST were to (a)

teach the PST approach, (b) identify and remediate any

problem-solving skill deficits, and (c) apply PST to

participants problems and evaluate the outcomes. PST

was discontinued when a weight loss goal was met in a

subsequent assessment, unless the participant requested

R.A. Carels et al. / Journal of Psyccontinuation of treatment.Measures

Cardiorespiratory fitness

To determine VO2 max, each participant completed a

submaximal graded exercise test [35], using the modified

Balke protocol walking on a treadmill [36]. Heart rate via a

12-lead EKG was recorded at the end of each stage. The test

was discontinued if any test termination criteria, as described

by ACSM, were present during the test [35]. Maximal

oxygen consumption was predicted from the regression

equation for the relationship between submaximal VO2and heart rate at one or more submaximal work loads [35].

Four participants failed to complete fitness testing.

Physical activity questionnaire

To assess leisure-time physical activity, each participant

completed the Paffenbarger Physical Activity Questionnaire

(PPAQ) at pre- and posttreatment [37]. This questionnaire

has been used in numerous research investigations [38].

Four participants failed to complete the PPAQ.

Caltrac accelerometer and physical activity logs

Participants recorded daily calories expended in physical

activity from Caltrac accelerometers in a daily activity diary

[39]. Participants also recorded the type and duration of

daily planned physical activity in a daily activity diary. One

participant failed to complete a physical activity diary.

Body weight and body composition

Body weight was measured using a digital scale (BF-

350e; Tanita, Arlington Heights, IL) to the closest 0.1 lb,

and height was measured in inches to the closest 0.5 in.

using a standard height rod. Body fat was obtained using

leg-to-leg bioelectrical impedance (BF-350e; Tanita). Leg-

to-leg bioelectrical impedance analysis correlates highly

with body composition estimates utilizing underwater

weighing in obese participants [40].

Dietary assessment

Participants recorded food intake over 4 days (2 week-

days, 2 weekend days) at baseline and posttreatment. Oral

and written instructions on food measurement estimation,

measurement demonstrations, and sample diaries were

provided to the participants. Estimates for total calories,

calories from fat, saturated fat, carbohydrates, and protein

were derived using Nutribase 2001 Professional Nutrition

software (Phoenix, AZ). Eight participants failed to com-

plete dietary assessments.

End of treatment evaluation

The effect of receiving weight loss goals on behavior

was assessed using six items. All questions were rated on a

five-point scale (1=not at all; 3=somewhat; 5=extremely).

Participants were asked whether they found the goals (1)

motivating, (2) too ambitious, (3) too easy, or (4)

atic Research 59 (2005) 375383 377beneficial. In addition, participants were asked whether

analyses were repeated for BWLP+SC (PST) versus

Pb.01], treadmill time [F(1,34)=37.92, Pb.01], andestimated VO2 max [F(1,34)=38.00, Pb.01]. Increasesin leisure time physical activity were significantly greater

in the BWLP+SC compared with the BWLP [F(1,34)=

2.67, P=.05].

Daily physical activity diary data were computed to

indicate (a) the daily calories expended in response to

physical activity (i.e., accelerometers) and (b) the minutes

per week of time spent in planned physical activity.

Although compared with BWLP participants, BWLP+SC

participants engaged in an additional 38.4 min/week of

planned physical activity, there were no significant differ-

ences between the BWLP+SC and BWLP participants in the

hosomBWLP (SC matched). Because the BWLP+SC was

hypothesized a priori to have superior treatment outcomes

when compared with the BWLP, one-tailed significance

tests (Pb.05) were employed.

Results

Demographics and baseline differences

Forty of 44 participants completed the investigation (20

BWLP+SC; 20 BWLP). There were no differences between

the groups on baseline demographic factors, weight, body

fat, or physical activity (see Table 1). In addition,

BWLP+SC (PST) versus BWLP (SC matched) did not

differ on demographic factors, weight, body fat, or physical

activity. Participants who were eligible for PST during

treatment attended, on average, 5.9 PST sessions (S.D.=5.1;

range, 213).

SC eligibility

During treatment, four weight assessments were con-

ducted to determine eligibility for SC. Significantly more

BWLP participants did not meet their minimum weight loss

goals during at least one weight assessment (n =14)

compared with BWLP+SC participants [n=7; v2(40)=5.02, Pb.05]. In addition, by the end of treatment,significantly more BWLP+SC participants (n=12) met their

minimum 8% weight reduction goal compared with thethey (5) appreciated or (6) resented receiving the weight

loss goals. For BWLP+SC participants, their thoughts and

feelings regarding individual counseling were assessed

using five items. Participants were asked whether the

potential for individual counseling resulted in them feeling

(1) anxious, (2) supported, or (3) resentful. In addition,

participants were asked whether (4) they worked hard to

avoid or (5) they appreciated the opportunity to receive

individual counseling.

Data analysis

Baseline differences between treatment groups were

assessed using one-way ANOVA and chi square. Chi-

square analyses were used to compare BWLP and

BWLP+SC participants who achieved (1) their minimum

weight loss goals during the four assessments and (2) a

final minimum weight loss goal of 8% of total body

weight. Pre- and posttreatment effects were evaluated

using a two-way, repeated-measures ANOVA with treat-

ment group as the between-group factor. In addition,

weight changes at 6 and 12 month post-BWLP were

evaluated with a two-way, repeated-measures ANOVA

with treatment group as the between-group factor. All

R.A. Carels et al. / Journal of Psyc378BWLP participants [n=6; v2(40)=3.64, P=.05].Changes in body weight and body fat

There were significant pre- to posttreatment decreases in

percent body fat [F(1,38)=57.41, Pb.01] and body weight[F(1,38)=88.14, Pb.01]. Compared with participants in theBWLP, BWLP+SC participants lost significantly more body

fat [F(1,37)=2.92, Pb.05] and weight [F(1,38)=2.85,Pb.05; see Table 2 and Fig. 2].

The BWLP+SC (PST) participants were compared with

the BWLP (SC matched) participants. There were signifi-

cant pre- to posttreatment decreases in percent body fat

[F(1,19)=27.32, Pb.01] and body weight [F(1,19)=28.07,Pb.01]. Compared with the BWLP (SC matched) partic-ipants, the BWLP+SC (PST) participants lost significantly

more body fat [ F (1,19) = 4.85, Pb.05]. AlthoughBWLP+SC (PST) participants lost an additional 5.6 lb

compared with the BWLP (SC matched) participants, the

difference was not statistically significant [F(1,19)=1.50,

P=ns]. The small number of BWLP+SC (PST) (n=7) or

BWLP (SC matched) participants (n=14) likely resulted in

diminished power and increased Type II error. An exami-

nation of effect sizes indicated a moderate to large effect

size (Cohens d=.60) for weight loss favoring the

BWLP+SC participants (see Table 3 and Fig. 3).

Physical activity and cardiorespiratory fitness

There were significant increases from pre- to posttreat-

ment in leisure time physical activity [F(1,34)=8.76,

Table 1

Demographic characteristics

BWLP+SC BWLP Total

Demographics n % n % n %

Gender (female) 18 85.7 21 91.3 39 88.6

Race (Caucasian) 17 80.9 22 95.7 39 88.6

Income bUS$30,000 7 33.3 10 43.4 17 38.6College degree 5 23.8 9 39.1 14 31.8

M S.D. M S.D. M S.D.

Age 45.5 10.6 48.3 7.9 47.0 9.3

atic Research 59 (2005) 375383duration of weekly planned physical activity or total calories

expended due to physical activity throughout the program. groups on the duration of weekly planned physical activity

Table 2

Overall changes from pre- to posttreatment BWLP+SC vs. BWLP on treatment outcomes

BWLP with SC BWLP

Pre Post Difference Pre Post Difference

Participants M (S.D.) M (S.D.) M (S.D.) M (S.D.) M (S.D.) M (S.D.) Overall change (%)

Body weight and fat

Body fat (%) 45.0 (6.3) 40.9 (6.5) 4.1 (1.5) 44.3 (4.2) 41.7 (6.1) 2.6 (3.6)T 7.6TTWeight (lb) 228.2 (38.4) 207.1 (32.6) 21.1 (11.2) 214.1 (35.1) 199.5 (38.0) 14.6 (12.8)T 8.1TTPhysical activity and fitness

Paffenbarger (kcal/week) 498 (515.2) 1388 (975) +890 (698) 653 (699) 910 (1192) +257 (1453)T +98.7TTVO2 max (ml/kg

1 min1) 28.8 (6.4) 33.2 (6.3) +4.4 (4.2) 28.3 (6.1) 33.4 (6.4) +5.1 (5.0) +16.8TTTreadmill (s) 551 (269) 737 (249) +186 (173) 535 (237) 742 (277) +207 (205) +36.5TTNutrition

Total calories 2043 (427) 1475 (202) 568 (368) 2165 (651) 1676 (625) 489 (512) 25.1TT% Carbohydrates 47.1 (8.7) 51.7 (5.7) +4.6 (8.4) 49.8 (9.2) 51.2 (7.9) +1.5 (10.0) +6.2TT% Protein 15.4 (3.2) 18.4 (3.1) +3.0 (4.4) 16.1 (5.2) 16.5 (3.2) +0.4 (4.5) +10.1TT% Fat 37.5 (6.5) 29.9 (5.4) 7.6 (7.7) 34.1 (5.8) 32.3 (8.5) 1.7 (7.8)T 13.1TT% Saturated fat 9.4 (2.4) 7.0 (1.8) 2.4 (2.5) 8.9 (3.0) 8.8 (3.1) 0.1 (3.2)T 14.1TT

T Pb.05, BWLP+SC vs. BWLP (between groups).TT Pb.05, pre- vs. posttreatment (within subject).

R.A. Carels et al. / Journal of Psychosomatic Research 59 (2005) 375383 379An examination of effect sizes indicated a moderate to large

effect size (Cohens d=.65) for planned physical activity

favoring the BWLP+SC participants.

BWLP+SC (PST) were compared with the BWLP (SC

matched) participants. There were significant increases from

pre- to posttreatment in leisure time physical activity

[F(1,17)=3.37, Pb.05], treadmill time [F(1,17)=18.79,Pb.01], and estimated VO2 max [F(1,17)=16.42, Pb.01].BWLP+SC (PST) participants increased their leisure time

physical activity significantly more than did the BWLP (SC

matched) participants [F(1,17)=5.67, Pb.05; see Table 3].However, there was no significant difference between theFig. 2. Weight loss in the BWor total calories expended due to physical activity through-

out the program. Again, examination of effect sizes

indicated a moderate to large effect size (Cohens d=.67)

for planned physical activity, favoring the BWLP+SC

participants (additional 40.6 min/week of planned physical

activity; see Table 3).

Caloric and nutritional intake

From pre- to posttreatment, average daily caloric intake

[F(1,28)=39.9, Pb.01] and percentage of daily energyderived from fat [F(1,28)=11.17, Pb.01] and saturatedLP+SC vs. the BWLP.

Table 3

Pre- to posttreatment changes for BWLP+SC who received PST vs. BWLP participants matched on SC eligibility on treatment outcomes

BWLP with SC BWLP

Pre Post Difference Pre Post DifferenceOverall

Participants M (S.D.) M (S.D.) M (S.D.) M (S.D.) M (S.D.) M (S.D.) change (%)

Body weight and fat

Body fat (%) 45.5 (7.9) 42.1 (8.0) 3.4 (1.2) 45.4 (4.1) 44.1 (4.2) 1.3 (2.0)T 5.1TTWeight (lb) 222.2 (30.2) 207.5 (20.5) 14.7 (13.4) 219.3 (37.5) 210.2 (37.0) 9.1 (7.4) 5.0Physical activity

and fitness

Paffenbarger

(kcal/week)

555 (583) 1782 (1362) +1227 (994) 848 (766) 689 (995) 159 (1249)T +70.8TT

VO2 max

(ml/kg1 min1)27.4 (7.7) 32.9 (5.5) +5.5 (5.4) 27.8 (6.4) 31.3 (6.3) +3.5 (3.7) +14.4TT

Treadmill (s) 443 (279) 701 (171) +258 (240) 500 (233) 662 (275) +162 (162) +39.0TTNutrition

Total calories 2044 (377) 1335 (127) 709 (353) 2221 (624) 1905 (568) 316 (490) 23.6TT% Carbohydrates 44.2 (16.3) 48.1 (7.4) +3.9 (12.7) 49.2 (9.7) 48.9 (5.3) 0.3 (10.0) +1.8% Protein 15.8 (5.8) 20.6 (3.6) +4.8 (7.2) 15.6 (6.0) 15.4 (2.9) 0.2 (4.9) +7.6% Fat 40.0 (10.8) 31.3 (4.9) 8.7 (6.3) 35.1 (4.9) 35.7 (5.7) +0.6 (7.7)T 5.8TT% Saturated fat 9.9 (3.6) 7.5 (1.6) 2.4 (2.5) 8.6 (2.1) 9.5 (3.0) +0.9 (3.0)T 1.1T Pb.05, BWLP+SC vs. BWLP (between group).TT Pb.05, pre- vs. posttreatment (within subject).

R.A. Carels et al. / Journal of Psychosomatic Research 59 (2005) 375383380fat [F(1,28)=5.78, Pb.05] decreased significantly (seeTable 2). The percentage of daily energy derived from

carbohydrates [ F (1,28) = 3.20, Pb.05] and protein[F(1,28)=4.42, Pb.05] increased significantly. Comparedwith the BWLP participants, the BWLP+SC participants

evidenced greater decreases in percentage of daily energy

from fat [F(1,28)=4.35, Pb.05] and saturated fat intake[F(1,28)=4.52, Pb.05].

Again, the BWLP+SC (PST) were compared with the

BWLP (SC matched) participants. From pre- to posttreat-Fig. 3. Weight loss in the BWLP+SC (PST) vs. thement, average daily caloric intake [F(1,12)=16.4, Pb.01]and the percentage of daily energy derived from fat

decreased significantly [ F (1,12) = 3.53, Pb.05; seeTable 3]. Compared with the BWLP (SC matched)

participants, BWLP+SC (PST) had greater decreases in

percentage of daily intake from fat [F(1,12)=4.51, Pb.01]and saturated fat [F(1,12)=3.80, Pb.05; see Table 3].Examination of effect sizes indicated a large effect size

(Cohens d=.84) for reduced daily calorie intake favoring

the SC participants who received PST.BWLP participants matched on SC eligibility.

End of program evaluation

The effect of receiving weight loss goals was assessed at

the end of treatment. In general, participants found the goals

to be motivating (M=3.8; S.D.=1.2), beneficial (M=3.9;

S.D.=1.0), and they appreciated receiving the goals (M=4.0;

S.D.=1.1). Participants disagreed with the statement that the

goals were too ambitious (M=1.5; S.D.=0.7) or easy

(M=1.9; S.D.=0.9). No significant differences emerged

between the BWLP+SC and BWLP participants, or

between BWLP+SC (PST) and BWLP (SC matched)

participants on the perception of goals. Finally, compared

with BWLP+SC (PST) or BWLP (SC matched) partici-

through the end of the no treatment contact period, compared

with BWLP (SC matched) participants, BWLP+SC (PST)

participants lost significantly more weight [F(1,17)=2.89,

P=.05]. In fact, BWLP+SC (PST) participants weighed less,

while BWLP (SC matched) participants weighed more than

their baseline weights (see Table 4 and Figs. 2 and 3). When

examining all participants, compared with BWLP partic-

ipants, BWLP+SC participants did not have significantly

better weight maintenance during the maintenance phase, the

maintenance and no treatment contact phases combined, or

baseline through the end of the no treatment contact period.

hs

(S.E

(15

(10

differ

R.A. Carels et al. / Journal of Psychosomatic Research 59 (2005) 375383 381pants, participants who did not or were not eligible to

receive PST reported that they found the weight loss goals

more motivating [F(1,35)=8.60, Pb.01] and beneficial[F(1,35)=9.79, Pb.01].

Attitudes regarding PST were assessed for BWLP+SC

participants. In general, participants reported that they

appreciated (M =4.1; S.D.=1.3) and felt supported

(M=4.1; S.D.=1.2) by the opportunity for PST. They

denied feeling anxious (M=1.8; S.D.=1.3) or resentful

(M=1.7; S.D.=1.2) about the potential for PST. Participants

reported working bsomewhat Q hard to avoid PST (M=2.5;S.D.=1.4). Individuals who did or did not receive PST did

not significantly differ in their attitudes toward indi-

vidual PST.

Weight loss maintenance

Thirty-six participants completed the final follow-up

assessment. Nine BWLP+SC participants and 10 BWLP

participants were eligible for SC during the first 6 months

following treatment (i.e., maintenance phase). Participants

who were eligible for PST attended, on average, 4.2 sessions

(S.D.=3.5; range, 212) during the maintenance phase.

Compared with BWLP (SC matched) participants,

BWLP+SC (PST) participants regained significantly less

weight during the maintenance phase [F(1,17)=7.04,

Pb.01], as well as the maintenance and no treatment con-tact phases combined [F(1,17)=3.21, Pb.05]. From baseline

Table 4

Body weight at posttreatment, as well as 6 and 12 months follow-up

Participants

BWLP with SC: received PST (n=11)

Posta 6 months 12 mont

M (S.E.) M (S.E.) M

Body weight

Weight (lb) 203.5 (12.3)T,TT 208.6 (13.1) 218.3

BWLP with SC (n=18)

Weight (lb) 209.2 (8.6) 209.8 (9.6) 219.2

a Small differences in posttreatment weights among Tables 24 reflect

T Pb.05, BWLP+SC vs. BWLP (change from post to 6 months).

TT Pb.05, BWLP+SC vs. BWLP (change from post to 12 months).BWLP: matched on PST eligibility (n=10)

Posta 6 months 12 months

.) M (S.E.) M (S.E.) M (S.E.)

.2) 211.1 (12.94)T,TT 222.6 (13.7) 230.5 (14.4)

BWLP (n=18)

.0) 198.1 (8.6) 202.1 (9.6) 205.6 (10.0)

ences secondary to attrition (n=4).Discussion

An SC approach to treating obesity represents one attempt

to efficiently allocate treatment resources. BWLP+SC (PST)

participants lost significantly more body fat, reported greater

physical activity and greater decreases in dietary fat and

saturated fat, and evidenced superior weight maintenance

than BWLP (SC matched) participants. While not statisti-

cally significant, during treatment, BWLP+SC (PST) partic-

ipants lost 5.6 lb more weight, reduced their total calorie

consumption by 393 more kcal, and participated in 40.6 min/

week more planned physical activity than BWLP partic-

ipants. In each case, moderate to large effect sizes were

observed (Cohens d=.6084). These findings are consistent

with previous research, which has shown that PST can

effectively help people lose weight and maintain weight loss

[21,22,27]. PST may improve participants ability to think

more creatively about their weight-related challenges, to

develop tangible plans to remediate current difficulties, and

may provide them with skills that are generalizable to future

weight loss difficulties [21].

When examining all participants in both treatment groups,

BWLP+SC participants lost more weight and body fat during

treatment than did BWLP participants. BWLP+SC partic-

ipants also reported greater physical activity and greater

decreases in the consumption of dietary fat and saturated fat

than BWLP participants. Finally, compared with BWLP

participants, BWLP+SC participants were more likely to

Participants who struggle to maintain posttreatment weight

loss appear to benefit from additional therapeutic contact

hosomachieve their within-treatment minimum weight loss goals

including a final weight loss goal of 8%.

The better treatment outcomes in the BWLP+SC were

attributable, at least in part, to the superior performance of

the participants receiving PST. However, when compared

with BWLP participants, twice as many BWLP+SC

participants achieved their minimum weight loss goals

during treatment. These findings are notable because all

participants were given identical weight loss goals. In

addition, BWLP and BWLP+SC participants reported no

differences in how motivating, ambitious, easy, or beneficial

they found the goals, or whether they appreciated or

resented receiving the goals. These findings suggest that

the implications for not meeting weight loss goals may have

influenced the BWLP+SC participants in a manner that they

could not fully appreciate or that was not captured in the

posttreatment evaluation.

Goal research clearly demonstrates that goals can

favorably enhance performance ([28]; including weight loss

outcomes; [41]) and goal importance is known to facilitate

goal attainment [28]. Because the BWLP+SC participants

goals had tangible consequences, these preestablished goals

may have become more important. BWLP+SC participants

may have increased their effort, felt greater accountability,

or maintained a greater focus on their weight loss goals. For

example, in the posttreatment evaluation, participants

reported that they bsomewhat Q worked hard to avoid PST.Alternatively, the potential for additional PST may have

resulted in participants feeling additional support. Again, the

posttreatment evaluations indicated that participants appre-

ciated and felt supported by the opportunity for PST.

Knowing that additional PST was available if they

experienced significant difficulties may have enhanced

self-efficacy for program success in BWLP+SC participants.

On the other hand, some participants may have perceived

receiving PST as punitive. After all, failing to meet weight

loss goals had tangible consequences, such as additional

meeting times for PST sessions. Therefore, the possibility of

PST may have served as an aversive stimulus, negatively

reinforcing high levels of program compliance. However, in

the posttreatment evaluation, participants generally denied

that the potential eligibility for PST resulted in them feeling

anxious or resentful. The impact of failing to meet weight

loss goals in the BWLP without SC condition is not known.

During the maintenance phase, all participants received

identical weight maintenance goals (regain b1% total bodyweight). While not statistically significant, from baseline

through the end of the no-treatment contact period,

BWLP+SC participants maintained a 5-lb greater weight

loss than BWLP participants. These findings are encourag-

ing, given the struggle of BWLP participants to maintain

weight loss. When comparing BWLP+SC (PST) with

BWLP (SC matched) participants, BWLP+SC (PST)

participants had significantly better weight maintenance

and superior weight loss over the course of treatment and

R.A. Carels et al. / Journal of Psyc382follow-up. In fact, from baseline to 12 months posttreat-during the critical weight loss maintenance period.

Weight maintenance difficulties following treatment are

common [42]. In this investigation, over one-half of the

participants had difficulty achieving their weight mainte-

nance goal during the first 6 months following treatment. In

addition, no differences in goal attainment were observed

between the BWLP+SC and BWLP participants, despite the

possibility of additional counseling for BWLP+SC partic-

ipants. These findings suggested that many participants in

BWLPs might benefit from posttreatment therapeutic

contact to encourage weight loss maintenance.

Although the findings in this investigation suggest that a

SC approach to weight loss had a favorable effect on

treatment outcomes, these conclusions should be viewed

tentatively. The modest sample size and the small number of

individuals who participated in PST suggest that replication

with a larger, more diverse sample is warranted. Multiple

statistical tests may have increased the likelihood of Type I

error. However, a clear pattern of results favoring the

BWLP+SC group emerged and the moderate to large effect

sizes (Cohens ds=.50.70) suggest that the relationships

were robust. Nevertheless, while the reliability of the findings

may be more susceptible to disconfirmation upon replication,

the essential interpretability and importance of the findings

remain unchanged. In addition, it is unclear whether the

observed benefits in those who received SC were due to PST

or simply a function of the additional therapeutic contact or

whether those in the BWLP+SC group had better treatment

outcomes because their goals had tangible consequences (i.e.,

PST). Future research would benefit from a comparison of

PST to a nondirective therapeutic contact condition or an

alternative treatment approach (e.g., motivational interview-

ing). Because the same team of therapists carried out all

treatments, therapist bias favoring the SC treatment cannot be

ruled out. Finally, the observed changes in dietary intake in

this study are based on self-report data, which are susceptible

to considerable underreporting [43].

Cost-effective treatments are needed to effectively

manage the obesity epidemic [24]. An SC approach offers

a potentially cost-effective approach to treating individuals

exhibiting a poor response to treatment. The promising

results from the current investigation suggest that the

application of SC principles to the treatment of obesity

may have considerable merit.

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Applying a stepped-care approach to the treatment of obesityIntroductionMethodsParticipantsStudy designInterventionsBehavioral weight loss programStepped care

MeasuresCardiorespiratory fitnessPhysical activity questionnaireCaltrac accelerometer and physical activity logsBody weight and body compositionDietary assessmentEnd of treatment evaluation

Data analysis

ResultsDemographics and baseline differencesSC eligibilityChanges in body weight and body fatPhysical activity and cardiorespiratory fitnessCaloric and nutritional intakeEnd of program evaluationWeight loss maintenance

DiscussionReferences