LETTERS: OBESITY BEHAVIOR CHANGE

Abstract

Dear Editors and Readers, I thank the editors for this opportunity to respond to Vincent Felitti, MD's comments on our article: Effects of 12- and 24-Week Multimodal Interventions on Physical Activity, Nutritional Behaviors, and Body Mass Index and its Psychological Predictors in Severely Obese Adolescents at Risk for Diabetes,1 for which I was the primary author. Although I wholeheartedly agree with Dr Felitti that providing basic education, alone, has not made even a dent in the obesity problem, I also have concerns with several of his statements made in his Letter to the Editor, which appeared in the Fall 2010 issue. Some issues may have their basis in my being a behavioral scientist (focused on health behavior change) within the emerging field of health psychology. For example, his concern that we, “and with many others,” lack focus on “Why these children became obese …” seems to be indicative of a common criticism of behaviorists who, admittedly, are more concerned with obtaining sustained behavioral changes than dwelling on possible underlying psychological factors. Many within our discipline believe that, in our quest for large-scale changes in health behaviors (within an epidemic of obesity and sedentarism), it is an inefficient use of our resources to seek out nuanced personal psychosocial factors that may or may not lead us to effecting changes. Rather, we seek to uncover meaningful patterns in psychological variables that may be used to reliably advance desired behavioral changes, with an eye on disseminating evidence-based treatments based on those findings to the many, rather than a few. In the real world, such interventions may best be delivered through referrals to trusted community organizations (eg, YMCAs), considering the reality of time restrictions that physicians are under. Dr Felitti also stated that we “avoid exploration” of constructs such as “self-concept, general self, and overall mood,” but just the opposite is true. This article is just one of dozens of peer-reviewed reports that I have authored in which we used established behavioral models (here, social cognitive theory as developed by Albert Bandura) to derive treatments that focus on predictors of sustained improvements.2–6 Other researchers skillfully continue this quest through similar scientific means. For example, behavioral theory (specifically, self-efficacy theory) suggests that individuals feel an improved sense of accomplishment, self-concept, and self-efficacy when they perceive that they can make meaningful progress while applying themselves to a task they see as worthwhile. This leads to sustained health behavior changes. Thus, treatments following self-efficacy theory may incorporate systems where long-term goals are broken down to short-term goals. As a reasonable plan of action is facilitated and adhered to, and incremental progress is documented, feelings of self-efficacy emerge. Unfortunately, left on their own, people typically set lofty goals, get disappointed by slow progress, and relapse to their original behaviors. Although it is true that we have little knowledge of “Why” one person complies while most do not, we have been able to systematically empower the skills needed for sustained change—and that's quite worthwhile. Another example of this is when we teach self-regulatory skills such as positive self-talk, cognitive restructuring, and thought stopping. Although we do not know why negative self-statements emerge and undermine progress, we feel that a primary focus should be to teach how to realign self-talk when it becomes unproductive. In the treatment referred to in our article, a computer program was used to help in the large-scale dissemination of these and other behavioral methods. I hope that this letter serves to clarify our perspective in designing the research and interpreting its findings. It is true that although the behavioral methods used succeeded in increasing the severely obese adolescents' physical activity levels (just as theory predicted), the nutrition education portion failed to obtain much change. As mentioned in the Discussion section, we are preparing to better apply behavioral theory to the nutritional portion of the treatment in the future. In fact, through studies such as the one focused on here, we recently found that, when administered properly: A) exercise-induced mood change is associated with reduced emotional eating, B) self-regulation skills learned in an exercise context “generalize” to self-management for controlled eating, and C) self-efficacy derived from persistence with an exercise program carries over to confidence in sustaining improved eating. It stands to reason that our future weight management efforts build upon these findings. Such is the nature of applied research. I hope that, ultimately, behavioral science will gain the trust of the medical community so that, as a team, we may contribute to the large-scale prevention and treatment of physical inactivity and overeating behaviors. To be of best service to society, we must efficiently use our resources, effectively incorporate the most current knowledge base of our fields, and accept the responsibility to facilitate meaningful health behavior changes.