- Email: [email protected]
Acceptance-based behavioral counseling
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Current Opinion in
Endocrine and Metabolic Research
Review
Acceptance-based behavioral counseling Meghan L. Butryn1,2, Christine C. Call1,2 and Jocelyn E. Remmert1,2 Abstract
Acceptance-based behavioral therapy (ABT) is a promising new approach for weight control. ABT builds upon several core strategies from standard behavioral treatment for obesity, including self-monitoring, stimulus control, goal setting, and problem solving. However, ABT acknowledges that these strategies, while necessary, are often insufficient as they may not sufficiently address uncomfortable internal experiences, including hedonic drives, emotions, and physical sensations, that may arise when one engages in weight control. ABT aims to enhance adherence to weight control by cultivating mindful awareness and acceptance of uncomfortable internal experiences, and developing willingness to persist in weight control behaviors in the service of one’s values. This theoretical model of ABT for weight control is described in detail in this review. In addition, we summarize the growing body of empirical literature, including analog studies, open-trials, and randomized controlled trials, that suggests that ABT is an efficacious weight loss intervention. Finally, we describe future research directions, including the examination of potential moderators and mediators of ABT for weight control. Addresses 1 Center for Weight, Eating, and Lifestyle Science (WELL Center), Drexel University, Philadelphia, PA, USA 2 Department of Psychology, Drexel University, Philadelphia, PA, USA Corresponding author: Butryn, Meghan L ([email protected])
Current Opinion in Endocrine and Metabolic Research 2018, -:1–5 This review comes from a themed issue on Frontiers in Obesity (22019) Edited by Paolo Sbraccia and Robert Kushner For a complete overview see the Issue and the Editorial Available online xxx
However, there is substantial variability in initial treatment response, and weight re-gain also is common [2e 7]. Efforts to continue to improve the efficacy of behavioral treatment are thus needed. Acceptance-based behavioral therapy (ABT) for obesity is a novel approach that integrates traditional behavioral skills with strategies drawn from acceptance and commitment therapy (i.e., ACT) [8,9]. In ABT for obesity, traditional behavioral skills such as selfmonitoring, stimulus control, goal setting, and problem solving are viewed as the building blocks for lifestyle modification. Participants use these strategies to make healthy eating and physical activity as easy, enjoyable, and automatic as possible. It is expected, however, that even when these traditional behavioral skills are mastered, many participants will continue to find it challenging to consistently limit calorie intake and engage in a high level of physical activity. These challenges are likely the result of attempting to counter genetic, biological, and metabolic predispositions to consume high calorie foods and conserve energy in an obesogenic environment [10e15]. The ABT model is designed to address uncomfortable internal experiences that occur during the course of lifestyle modification; these can include hedonic drives, thoughts, emotions, urges, and physical sensations that occur when making decisions about eating and exercise, or while engaging in a particular weightrelated behavior. As described in detail next, ABT 1) raises awareness (i.e., mindfulness) of uncomfortable internal experiences that occur in the context of lifestyle modification, 2) encourages participants to adopt an accepting stance towards these experiences, and 3) fosters skills for persisting in valued behavior change in the face of such discomfort.
https://doi.org/10.1016/j.coemr.2018.09.004 2451-9650/© 2018 Elsevier Ltd. All rights reserved.
Clinical approach of acceptance-based behavioral counseling for obesity
Behavioral counseling is the gold-standard, first-line treatment for obesity. In most intensive behavioral weight loss programs, average weight losses range from 8 to 10% in the first six months of treatment [1].
Acceptance-based theory has been applied to obesity treatment in a range of ways. The description in this review focuses on the model and application of ABT developed at Drexel University [8,16]. This application of ABT relies on an integration of standard behavioral treatment (SBT) skills and specific applications of acceptance-based theory to weight control. Other versions of ABT may give less attention to traditional behavioral skills, such as self-monitoring of weight and goal setting for calorie intake [17,18].
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Current Opinion in Endocrine and Metabolic Research 2018, -:1–5
Keywords Obesity, Behavioral weight loss, Lifestyle modification, Acceptancebased treatment.
Introduction
2 Frontiers in Obesity (22019)
The ABT approach discussed here shares many similarities with SBT, including group-based treatment, private measurement of weight prior to session, participant report of adherence to behavioral goals at the start of group, structured activities and guided discussion to teach weight control skills, prescriptions for calorie intake and physical activity, and homework assignments. Acceptance-based strategies are utilized to facilitate the use of skills such as stimulus control and selfmonitoring, and adherence to eating and physical activity goals. One difference between SBT and ABT for obesity is that ABT typically gives more attention to the internal experiences that form the context for behaviors. While SBToften focuses on cognitions, ABTattends to a broader range of “internal experiences” that may affect behavior, including physiological sensations, urges, and hedonic drives. A key theoretical difference between the treatments is that ABT recognizes that there are limits to the extent to which internal experiences can be modified, whereas SBT typically encourages participants to change their internal experiences, for example through cognitive restructuring, to facilitate target behaviors. ABT encourages participants to build skills for responding to internal experiences in new ways, with a focus on non-judgmental acceptance. Core acceptance-based behavioral skills
Mindful awareness of internal experiences The foundation of ABT for obesity is awareness of how internal experiences shape weight-related behaviors. The clinical approach validates that it can be difficult to tolerate the uncomfortable hedonic drives, thoughts, emotions, urges, or physical sensations that occur while one attempts to engage in healthy eating or physical activity. A key tenant of ACT generally is that individuals have a natural tendency towards experiential avoidance, which is the drive to avoid internal experiences (e.g., thoughts, feelings) that are uncomfortable. In ABT, participants develop a sense of self-compassion by recognizing that experiential avoidance is hard-wired and adaptive in most situations, and that it is natural to feel tempted to abandon lifestyle modification to diminish the accompanying discomfort. However, participants also identify ways that, in the context of weight control, experiential avoidance is maladaptive. Participants see that if they make decisions with a high level of experiential avoidance, they allow transient internal experiences to “be in charge” and direct the course of their decision-making.
when possible. For instance, stimulus control may reduce hedonic drives for tempting foods in some situations. At the same time, ABT recognizes that such strategies only have limited “workability.” Many aspects of the social and physical environments have a degree of intractability. To empower themselves to choose weight control behaviors that are most consistent with their values (discussed in detail next), participants learn to respond to internal experiences with a stance of nonjudgmental acceptance and enactment of willingness skills. Consider a participant who attends a party and engages in many “control what you can strategies,” including bringing a healthy side dish, eating a snack beforehand to limit hunger, and setting a specific calorie goal for consumption at the event. The participant may successfully use these strategies but find that at the end of the party, a dessert that he especially likes is offered, and he experiences a strong hedonic drive to eat it, despite having already consumed his allotted calories for the event. In this instance, willingness skills could be used to tolerate the urge to consume this dessert, while simultaneously engaging in a weight control behavior that is most consistent with his long-term values, such as sipping a cup of tea instead. Values clarity Values clarity is integral to the process of mindful awareness and to the use of acceptance/willingness skills. Participants reflect on many life domains (e.g., family, friendships, community, spirituality) and develop a detailed vision for what it would look like to live a full, rich, meaningful life. Participants then consider ways in which their current lifestyle, with regard to weight, eating, and physical activity, is or is not positioning them to engage in values-consistent action. Participants develop heightened awareness of their values during decision-making to determine whether a particular behavior will or will not move them towards their values. For instance, participants may recognize that healthy eating and physical activity facilitate physical fitness, energy, and longevity. These, in turn, can position individuals to more fully “live out” their values (e.g., being active with their grandchildren). Ultimately, values clarity strengthens one’s commitment to making healthy choices in the domains of eating and activity.
Efficacy of ABT for weight loss Findings from analog studies, open trials, and randomized controlled trials suggest that ABT is a promising approach to weight control that warrants additional research.
Acceptance and willingness In ABT, participants learn to adopt a “control what you can, accept what you can’t” approach to internal experiences. The first line of defense in ABT is to use traditional behavioral skills (i.e., “control what you can” strategies) to directly address sources of uncomfortable experiences so that they can be prevented or alleviated
Several analog studies have examined the impact of brief ABT interventions on eating or physical activity behaviors [19e22]. For example, in one study [19], participants with overweight body mass index (BMI) were
Current Opinion in Endocrine and Metabolic Research 2018, -:1–5
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Analog studies
Acceptance-based counseling Butryn et al.
randomized to ABT or CBT training, both focused on managing cravings, particularly for chocolate. Participants in the ABT condition reported lower cravings and consumed less chocolate than those in the CBT condition at trend-level. In another randomized analog study [22], young adult women completed a high-intensity exercise test in which they cycled until volitional exhaustion, then received brief training in either ABTor goal setting, and completed the exercise test again. Those in the ABT condition increased their exercise tolerance by 15% compared to an 8% decrease in the control group. Open trials
Several open trials have demonstrated the feasibility, acceptability, and preliminary effectiveness of ABT for weight control. For example, one 24-session, groupbased ABT intervention yielded a 12.0 kg weight loss in a sample of individuals with overweight BMIs and disinhibited eating [23], while another 12-week groupbased ABT intervention produced a weight loss of 8.1% (7.9 kg) at end-of-treatment and 10.1% (9.8 kg) at 6-month follow-up [24]. Uncontrolled studies of ABT for weight control have also been conducted with promising results in samples of cardiac patients [25] and bariatric surgery recipients [26,27] and to promote physical activity in those maintaining a weight loss [28]. Randomized controlled trials
To date, a number of randomized controlled trials (RCTs) have examined the efficacy of ABT for weight control. Several trials have investigated low-intensity ABT interventions (e.g., ABT workshops) in small samples, using no-intervention control groups. In these studies, ABTs have consistently produced superior weight control outcomes compared to controls [17,29e 33]. To our knowledge, four larger RCTs have directly compared ABT to a gold-standard SBT condition. In one study [34], 128 adults with overweight or obese BMIs were randomized to 40 weeks of group-based ABT or SBT. At end-of-treatment and 6-month follow-up, weight losses did not differ significantly by condition. However, among participants who received treatment from a weight control expert (vs. a graduate student), weight losses were greater in the ABT condition compared to the SBT condition at end-of-treatment (13.2% vs. 7.5%) and follow-up (11.0% vs. 4.8%). ABT also produced larger weight losses than SBT for participants with elevated mood disturbance, responsivity to food cues, or disinhibited eating. In a larger follow-up study (N = 190) in which all interventionists were weight control experts, participants receiving groupbased ABT had greater weight losses at end-oftreatment (12-months) than those receiving SBT (13.3% vs. 9.8%), and were more likely to achieve a 10% www.sciencedirect.com
3
weight loss by end-of-treatment (64.0% vs. 48.9% of participants) [35]. Another RCT [18] randomized participants (N = 162) with overweight/obese BMIs and high internal disinhibition (i.e., the tendency to eat in response to emotional or cognitive cues) to group-based ABT or SBT. At end-of-treatment (12-months), weight losses did not differ by condition, but at 1-year follow-up participants in ABT had regained less weight than those in SBT (4.6 vs. 7.1 kg) and were more likely to be maintaining a 5% weight loss (38% vs. 25% of participants). Another recent study [36] (N = 283) compared three group-based, 12-month treatment conditions: SBT, SBT with a focus on managing the food environment, and ABT with a focus on managing the food environment. Weight losses did not differ by condition, but race emerged as a significant moderator such that African Americans had lower weight losses than White participants in the two SBT conditions (consistent with prior research [37]), but did not differ on weight loss from White participants in the ABT condition. African Americans were also more likely to achieve a 5% weight loss in the ABT condition (80%) versus the SBT condition (57%) or the SBT condition with a food environment focus (48%).
Conclusion ABT is a promising new approach for addressing barriers to weight control. In ABT, several core strategies from SBT (e.g., self-monitoring, stimulus control, goal setting, problem solving) serve as the foundation for lifestyle modification. ABT recognizes that these traditional behavioral strategies are necessary yet insufficient for long term lifestyle modification because they do not address the uncomfortable internal experiences that arise when engaging in weight control. Thus, ABT aims to increase mindful awareness of these internal experiences, cultivate acceptance of uncomfortable internal experiences, and build willingness to persist in weight control in the service of one’s values. The research to date suggests that ABT is an efficacious weight loss intervention, with one recent RCT [35] finding that ABT produced superior weight losses to SBT and another [18] finding that ABT yielded less weight regain than SBT during a follow-up period. However, given that research in this area is limited and findings have been mixed, additional investigation is warranted. Examination of moderators is a crucial next step in order to determine whether there are certain individuals for whom either ABT or SBT is more effective. Finally, future research should examine mediators of outcome to better understand the mechanisms through which ABT produces weight losses.
Conflict of interest statement Dr. Butryn received royalties from books she has edited or authored related to acceptance-based treatment. Current Opinion in Endocrine and Metabolic Research 2018, -:1–5
4 Frontiers in Obesity (22019)
Funding This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.
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10. Lowe MR: Self-regulation of energy intake in the prevention and treatment of obesity: is it feasible? Obes Res 2003, 11: 44S–59S. https://doi.org/10.1038/oby.2003.223. 11. Church TS, Thomas DM, Tudor-Locke C, Katzmarzyk PT, Earnest CP, Rodarte RQ, Martin CK, Blair SN, Bouchard C: Trends over 5 decades in US occupation-related physical activity and their associations with obesity. PLoS One 2011, 6, e19657. https://doi.org/10.1371/journal.pone.0019657. 12. French SA, Story M, Jeffery RW: Environmental influences on eating and physical activity. Annu Rev Public Health 2001, 22: 309–335. https://doi.org/10.1146/annurev.publhealth.22.1.309. 13. Hill JO, Peters JC: Environmental contributions to the obesity epidemic. Science 1998, 280:1371–1374. https://doi.org/10. 1126/science.280.5368.1371. 14. Hill JO, Wyatt HR, Reed GW, Peters JC: Obesity and the environment: where do we go from here? Science 2003, 299: 853–855. https://doi.org/10.1126/science.1079857. 15. Wansink B: Environmental factors that increase the food intake and consumption volume of unknowing consumers. Current Opinion in Endocrine and Metabolic Research 2018, -:1–5
Annu Rev Nutr 2004, 24:455–479. https://doi.org/10.1146/ annurev.nutr.24.012003.132140. 16. Forman EM, Butryn ML: Effective weight loss: an acceptance* * based behavioral approach, clinician guide. Oxford University Press; 2016. This book provides a detailed, session-by-session guide for clinicians for administering group-based acceptance-based behavioral treatment for weight control. Theoretical underpinnings of acceptance-based behavioral treatment for obesity are explained, and experiential exercises for clinical application are included. 17. Lillis J, Hayes SC, Bunting K, Masuda A: Teaching acceptance and mindfulness to improve the lives of the obese: a preliminary test of a theoretical model. Ann Behav Med 2009, 37: 58–69. https://doi.org/10.1007/s12160-009-9083-x. 18. Lillis J, Niemeier HM, Thomas JG, Unick J, Ross KM, Leahey TM, * Kendra KE, Dorfman L, Wing RR: A randomized trial of an acceptance-based behavioral intervention for weight loss in people with high internal disinhibition. Obesity 2016, 24: 2509–2514. https://doi.org/10.1002/oby.21680. Randomized controlled trial that assigned participants with overweight or obese BMIs and the tendency to eat in response to emotional or cognitive cues (N = 162) to acceptance-based behavioral treatment or standard behavioral treatment for weight control. At end-of-treatment, weight losses did not differ by condition, but at 1-year follow-up, those in the acceptance-based condition were more likely to be maintaining a 5% weight loss (38% vs. 25% of participants). 19. Forman EM, Hoffman KL, Juarascio AS, Butryn ML, Herbert JD: Comparison of acceptance-based and standard cognitivebased coping strategies for craving sweets in overweight and obese women. Eat Behav 2013, 14:64–68. https://doi.org/10. 1016/j.eatbeh.2012.10.016. 20. Forman EM, Hoffman KL, McGrath KB, Herbert JD, Brandsma LL, Lowe MR: A comparison of acceptance-and control-based strategies for coping with food cravings: an analog study. Behav Res Ther 2007, 45:2372–2386. https://doi.org/10.1016/j. brat.2007.04.004. 21. Hooper N, Sandoz EK, Ashton J, Clarke A, McHugh L: Comparing thought suppression and acceptance as coping techniques for food cravings. Eat Behav 2012, 13:62–64. https://doi.org/10.1016/j.eatbeh.2011.10.002. 22. Ivanova E, Jensen D, Cassoff J, Gu F, Knäuper B: Acceptance and commitment therapy improves exercise tolerance in sedentary women. Med Sci Sports Exerc 2015, 47:1251–1258. https://doi.org/10.1249/MSS.0000000000000536. 23. Niemeier HM, Leahey T, Reed KP, Brown RA, Wing RR: An acceptance-based behavioral intervention for weight loss: a pilot study. Behav Ther 2012, 43:427–435. https://doi.org/10. 1016/j.beth.2011.10.005. 24. Forman EM, Butryn ML, Hoffman KL, Herbert JD: An open trial of an acceptance-based behavioral intervention for weight loss. Cognit Behav Pract 2009, 16:223–235. https://doi.org/10. 1016/j.cbpra.2008.09.005. 25. Goodwin CL, Forman EM, Herbert JD, Butryn ML, Ledley GS: A pilot study examining the initial effectiveness of a brief acceptance-based behavior therapy for modifying diet and physical activity among cardiac patients. Behav Modif 2012, 36:199–217. https://doi.org/10.1177/0145445511427770. 26. Bradley LE, Forman EM, Kerrigan SG, Goldstein SP, Butryn ML, Thomas JG, Herbert JD, Sarwer DB: A pilot study to assess feasibility, acceptability, and effectiveness of a remotelydelivered intervention to address weight regain after bariatric surgery. Surg Obes Relat Dis 2015, 11:S55. https://doi.org/10. 1016/j.soard.2015.08.523. 27. Bradley LE, Forman EM, Kerrigan SG, Goldstein SP, Butryn ML, Thomas JG, Herbert JD, Sarwer DB: Project HELP: a remotely delivered behavioral intervention for weight regain after bariatric surgery. Obes Surg 2017, 27:586–598. https://doi.org/ 10.1007/s11695-016-2337-3. 28. Butryn ML, Kerrigan SG, Arigo D, Raggio G, Forman EM: Pilot test of an acceptance-based behavioral intervention to promote physical activity during weight loss maintenance. Behav Med 2016, 44:1. https://doi.org/10.1080/08964289.2016. 1170663. www.sciencedirect.com
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29. Katterman SN, Goldstein SP, Butryn ML, Forman EM, Lowe MR: Efficacy of an acceptance-based behavioral intervention for weight gain prevention in young adult women. J Contextual Behav Sci 2014, 3:45–50. https://doi.org/10.1016/j.jcbs.2013.10.003. 30. Tapper K, Shaw C, Ilsley J, Hill AJ, Bond FW, Moore L: Exploratory randomised controlled trial of a mindfulness-based weight loss intervention for women. Appetite 2009, 52: 396–404. https://doi.org/10.1016/j.appet.2008.11.012. 31. Alberts HJ, Mulkens S, Smeets M, Thewissen R: Coping with food cravings. Investigating the potential of a mindfulnessbased intervention. Appetite 2010, 55:160–163. https://doi.org/ 10.1016/j.appet.2010.05.044. 32. Weineland S, Arvidsson D, Kakoulidis TP, Dahl J: Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT. Obes Res Clin Pract 2012, 6:e21–e30. https://doi.org/10. 1016/j.orcp.2011.04.004. 33. Butryn ML, Forman EM, Hoffman K, Shaw J, Juarascio AS: A pilot study of acceptance and commitment therapy for promotion of physical activity. J Phys Activ Health 2011, 8: 516–522. https://doi.org/10.1123/jpah.8.4.516. 34. Forman EM, Butryn ML, Juarascio AS, Bradley LE, Lowe MR, Herbert JD, Shaw JA: The mind your health project: a randomized controlled trial of an innovative behavioral treatment for obesity. Obesity 2013, 21:1119–1126. https://doi.org/10. 1002/oby.20169.
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behavioral treatment for obesity: results from the mind your health randomized controlled trial. Obesity 2016, 24: 2050–2056. https://doi.org/10.1002/oby.21601. Randomized controlled trial in which participants with overweight or obese BMIs (N = 190) were assigned to acceptance-based behavioral treatment or standard behavioral treatment for weight control. At endof-treatment (1 year), participants in the acceptance-based condition had significantly greater weight losses (13.3%) than those in the standard behavioral treatment condition (9.8%). 36. Butryn ML, Forman EM, Lowe MR, Gorin AA, Zhang F, * Schaumberg K: Efficacy of environmental and acceptancebased enhancements to behavioral weight loss treatment: the ENACT trial. Obesity 2017, 25:866–872. https://doi.org/10. 1002/oby.21813. Randomized controlled trial in which participants with overweight or obese BMIs (N = 283) were assigned to one of three 12-month treatment conditions: standard behavioral treatment, standard behavioral treatment with a focus on managing the food environment, or acceptance-based behavioral treatment with a focus on managing the food environment. Weight losses did not differ by condition, but race was a significant moderator such that African Americans lost less weight than White participants in the two standard behavioral conditions, but had similar weight losses to White participants in the acceptance-based condition. 37. Goode RW, Styn MA, Mendez DD, Gary-Webb TL: African Americans in standard behavioral treatment for obesity, 2001-2015: what have we learned? West J Nurs Res 2017, 39: 1045–1069. https://doi.org/10.1177/0193945917692115.
35. Forman EM, Butryn ML, Manasse SM, Crosby RD, Goldstein SP, * Wyckoff EP, Thomas JG: Acceptance-based versus standard
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Current Opinion in Endocrine and Metabolic Research 2018, -:1–5
ScienceDirect
Current Opinion in
Endocrine and Metabolic Research
Review
Acceptance-based behavioral counseling Meghan L. Butryn1,2, Christine C. Call1,2 and Jocelyn E. Remmert1,2 Abstract
Acceptance-based behavioral therapy (ABT) is a promising new approach for weight control. ABT builds upon several core strategies from standard behavioral treatment for obesity, including self-monitoring, stimulus control, goal setting, and problem solving. However, ABT acknowledges that these strategies, while necessary, are often insufficient as they may not sufficiently address uncomfortable internal experiences, including hedonic drives, emotions, and physical sensations, that may arise when one engages in weight control. ABT aims to enhance adherence to weight control by cultivating mindful awareness and acceptance of uncomfortable internal experiences, and developing willingness to persist in weight control behaviors in the service of one’s values. This theoretical model of ABT for weight control is described in detail in this review. In addition, we summarize the growing body of empirical literature, including analog studies, open-trials, and randomized controlled trials, that suggests that ABT is an efficacious weight loss intervention. Finally, we describe future research directions, including the examination of potential moderators and mediators of ABT for weight control. Addresses 1 Center for Weight, Eating, and Lifestyle Science (WELL Center), Drexel University, Philadelphia, PA, USA 2 Department of Psychology, Drexel University, Philadelphia, PA, USA Corresponding author: Butryn, Meghan L ([email protected])
Current Opinion in Endocrine and Metabolic Research 2018, -:1–5 This review comes from a themed issue on Frontiers in Obesity (22019) Edited by Paolo Sbraccia and Robert Kushner For a complete overview see the Issue and the Editorial Available online xxx
However, there is substantial variability in initial treatment response, and weight re-gain also is common [2e 7]. Efforts to continue to improve the efficacy of behavioral treatment are thus needed. Acceptance-based behavioral therapy (ABT) for obesity is a novel approach that integrates traditional behavioral skills with strategies drawn from acceptance and commitment therapy (i.e., ACT) [8,9]. In ABT for obesity, traditional behavioral skills such as selfmonitoring, stimulus control, goal setting, and problem solving are viewed as the building blocks for lifestyle modification. Participants use these strategies to make healthy eating and physical activity as easy, enjoyable, and automatic as possible. It is expected, however, that even when these traditional behavioral skills are mastered, many participants will continue to find it challenging to consistently limit calorie intake and engage in a high level of physical activity. These challenges are likely the result of attempting to counter genetic, biological, and metabolic predispositions to consume high calorie foods and conserve energy in an obesogenic environment [10e15]. The ABT model is designed to address uncomfortable internal experiences that occur during the course of lifestyle modification; these can include hedonic drives, thoughts, emotions, urges, and physical sensations that occur when making decisions about eating and exercise, or while engaging in a particular weightrelated behavior. As described in detail next, ABT 1) raises awareness (i.e., mindfulness) of uncomfortable internal experiences that occur in the context of lifestyle modification, 2) encourages participants to adopt an accepting stance towards these experiences, and 3) fosters skills for persisting in valued behavior change in the face of such discomfort.
https://doi.org/10.1016/j.coemr.2018.09.004 2451-9650/© 2018 Elsevier Ltd. All rights reserved.
Clinical approach of acceptance-based behavioral counseling for obesity
Behavioral counseling is the gold-standard, first-line treatment for obesity. In most intensive behavioral weight loss programs, average weight losses range from 8 to 10% in the first six months of treatment [1].
Acceptance-based theory has been applied to obesity treatment in a range of ways. The description in this review focuses on the model and application of ABT developed at Drexel University [8,16]. This application of ABT relies on an integration of standard behavioral treatment (SBT) skills and specific applications of acceptance-based theory to weight control. Other versions of ABT may give less attention to traditional behavioral skills, such as self-monitoring of weight and goal setting for calorie intake [17,18].
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Current Opinion in Endocrine and Metabolic Research 2018, -:1–5
Keywords Obesity, Behavioral weight loss, Lifestyle modification, Acceptancebased treatment.
Introduction
2 Frontiers in Obesity (22019)
The ABT approach discussed here shares many similarities with SBT, including group-based treatment, private measurement of weight prior to session, participant report of adherence to behavioral goals at the start of group, structured activities and guided discussion to teach weight control skills, prescriptions for calorie intake and physical activity, and homework assignments. Acceptance-based strategies are utilized to facilitate the use of skills such as stimulus control and selfmonitoring, and adherence to eating and physical activity goals. One difference between SBT and ABT for obesity is that ABT typically gives more attention to the internal experiences that form the context for behaviors. While SBToften focuses on cognitions, ABTattends to a broader range of “internal experiences” that may affect behavior, including physiological sensations, urges, and hedonic drives. A key theoretical difference between the treatments is that ABT recognizes that there are limits to the extent to which internal experiences can be modified, whereas SBT typically encourages participants to change their internal experiences, for example through cognitive restructuring, to facilitate target behaviors. ABT encourages participants to build skills for responding to internal experiences in new ways, with a focus on non-judgmental acceptance. Core acceptance-based behavioral skills
Mindful awareness of internal experiences The foundation of ABT for obesity is awareness of how internal experiences shape weight-related behaviors. The clinical approach validates that it can be difficult to tolerate the uncomfortable hedonic drives, thoughts, emotions, urges, or physical sensations that occur while one attempts to engage in healthy eating or physical activity. A key tenant of ACT generally is that individuals have a natural tendency towards experiential avoidance, which is the drive to avoid internal experiences (e.g., thoughts, feelings) that are uncomfortable. In ABT, participants develop a sense of self-compassion by recognizing that experiential avoidance is hard-wired and adaptive in most situations, and that it is natural to feel tempted to abandon lifestyle modification to diminish the accompanying discomfort. However, participants also identify ways that, in the context of weight control, experiential avoidance is maladaptive. Participants see that if they make decisions with a high level of experiential avoidance, they allow transient internal experiences to “be in charge” and direct the course of their decision-making.
when possible. For instance, stimulus control may reduce hedonic drives for tempting foods in some situations. At the same time, ABT recognizes that such strategies only have limited “workability.” Many aspects of the social and physical environments have a degree of intractability. To empower themselves to choose weight control behaviors that are most consistent with their values (discussed in detail next), participants learn to respond to internal experiences with a stance of nonjudgmental acceptance and enactment of willingness skills. Consider a participant who attends a party and engages in many “control what you can strategies,” including bringing a healthy side dish, eating a snack beforehand to limit hunger, and setting a specific calorie goal for consumption at the event. The participant may successfully use these strategies but find that at the end of the party, a dessert that he especially likes is offered, and he experiences a strong hedonic drive to eat it, despite having already consumed his allotted calories for the event. In this instance, willingness skills could be used to tolerate the urge to consume this dessert, while simultaneously engaging in a weight control behavior that is most consistent with his long-term values, such as sipping a cup of tea instead. Values clarity Values clarity is integral to the process of mindful awareness and to the use of acceptance/willingness skills. Participants reflect on many life domains (e.g., family, friendships, community, spirituality) and develop a detailed vision for what it would look like to live a full, rich, meaningful life. Participants then consider ways in which their current lifestyle, with regard to weight, eating, and physical activity, is or is not positioning them to engage in values-consistent action. Participants develop heightened awareness of their values during decision-making to determine whether a particular behavior will or will not move them towards their values. For instance, participants may recognize that healthy eating and physical activity facilitate physical fitness, energy, and longevity. These, in turn, can position individuals to more fully “live out” their values (e.g., being active with their grandchildren). Ultimately, values clarity strengthens one’s commitment to making healthy choices in the domains of eating and activity.
Efficacy of ABT for weight loss Findings from analog studies, open trials, and randomized controlled trials suggest that ABT is a promising approach to weight control that warrants additional research.
Acceptance and willingness In ABT, participants learn to adopt a “control what you can, accept what you can’t” approach to internal experiences. The first line of defense in ABT is to use traditional behavioral skills (i.e., “control what you can” strategies) to directly address sources of uncomfortable experiences so that they can be prevented or alleviated
Several analog studies have examined the impact of brief ABT interventions on eating or physical activity behaviors [19e22]. For example, in one study [19], participants with overweight body mass index (BMI) were
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randomized to ABT or CBT training, both focused on managing cravings, particularly for chocolate. Participants in the ABT condition reported lower cravings and consumed less chocolate than those in the CBT condition at trend-level. In another randomized analog study [22], young adult women completed a high-intensity exercise test in which they cycled until volitional exhaustion, then received brief training in either ABTor goal setting, and completed the exercise test again. Those in the ABT condition increased their exercise tolerance by 15% compared to an 8% decrease in the control group. Open trials
Several open trials have demonstrated the feasibility, acceptability, and preliminary effectiveness of ABT for weight control. For example, one 24-session, groupbased ABT intervention yielded a 12.0 kg weight loss in a sample of individuals with overweight BMIs and disinhibited eating [23], while another 12-week groupbased ABT intervention produced a weight loss of 8.1% (7.9 kg) at end-of-treatment and 10.1% (9.8 kg) at 6-month follow-up [24]. Uncontrolled studies of ABT for weight control have also been conducted with promising results in samples of cardiac patients [25] and bariatric surgery recipients [26,27] and to promote physical activity in those maintaining a weight loss [28]. Randomized controlled trials
To date, a number of randomized controlled trials (RCTs) have examined the efficacy of ABT for weight control. Several trials have investigated low-intensity ABT interventions (e.g., ABT workshops) in small samples, using no-intervention control groups. In these studies, ABTs have consistently produced superior weight control outcomes compared to controls [17,29e 33]. To our knowledge, four larger RCTs have directly compared ABT to a gold-standard SBT condition. In one study [34], 128 adults with overweight or obese BMIs were randomized to 40 weeks of group-based ABT or SBT. At end-of-treatment and 6-month follow-up, weight losses did not differ significantly by condition. However, among participants who received treatment from a weight control expert (vs. a graduate student), weight losses were greater in the ABT condition compared to the SBT condition at end-of-treatment (13.2% vs. 7.5%) and follow-up (11.0% vs. 4.8%). ABT also produced larger weight losses than SBT for participants with elevated mood disturbance, responsivity to food cues, or disinhibited eating. In a larger follow-up study (N = 190) in which all interventionists were weight control experts, participants receiving groupbased ABT had greater weight losses at end-oftreatment (12-months) than those receiving SBT (13.3% vs. 9.8%), and were more likely to achieve a 10% www.sciencedirect.com
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weight loss by end-of-treatment (64.0% vs. 48.9% of participants) [35]. Another RCT [18] randomized participants (N = 162) with overweight/obese BMIs and high internal disinhibition (i.e., the tendency to eat in response to emotional or cognitive cues) to group-based ABT or SBT. At end-of-treatment (12-months), weight losses did not differ by condition, but at 1-year follow-up participants in ABT had regained less weight than those in SBT (4.6 vs. 7.1 kg) and were more likely to be maintaining a 5% weight loss (38% vs. 25% of participants). Another recent study [36] (N = 283) compared three group-based, 12-month treatment conditions: SBT, SBT with a focus on managing the food environment, and ABT with a focus on managing the food environment. Weight losses did not differ by condition, but race emerged as a significant moderator such that African Americans had lower weight losses than White participants in the two SBT conditions (consistent with prior research [37]), but did not differ on weight loss from White participants in the ABT condition. African Americans were also more likely to achieve a 5% weight loss in the ABT condition (80%) versus the SBT condition (57%) or the SBT condition with a food environment focus (48%).
Conclusion ABT is a promising new approach for addressing barriers to weight control. In ABT, several core strategies from SBT (e.g., self-monitoring, stimulus control, goal setting, problem solving) serve as the foundation for lifestyle modification. ABT recognizes that these traditional behavioral strategies are necessary yet insufficient for long term lifestyle modification because they do not address the uncomfortable internal experiences that arise when engaging in weight control. Thus, ABT aims to increase mindful awareness of these internal experiences, cultivate acceptance of uncomfortable internal experiences, and build willingness to persist in weight control in the service of one’s values. The research to date suggests that ABT is an efficacious weight loss intervention, with one recent RCT [35] finding that ABT produced superior weight losses to SBT and another [18] finding that ABT yielded less weight regain than SBT during a follow-up period. However, given that research in this area is limited and findings have been mixed, additional investigation is warranted. Examination of moderators is a crucial next step in order to determine whether there are certain individuals for whom either ABT or SBT is more effective. Finally, future research should examine mediators of outcome to better understand the mechanisms through which ABT produces weight losses.
Conflict of interest statement Dr. Butryn received royalties from books she has edited or authored related to acceptance-based treatment. Current Opinion in Endocrine and Metabolic Research 2018, -:1–5
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Funding This manuscript did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.
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