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Behavioral controls for achieving weight loss in the severely retarded
.I. Behav.
Thu.
& Exp.
Psychiat.
Vol. 6, pp. 27-29.
PergamonPress,1975. Printedin Great Brimin.
BEHAVIORAL CONTROLS FOR ACHIEVING WEIGHT LOSS IN THE SEVERELY RETARDED* JOHN
PAUL
and JIM T. PARKS
FOREYT
Florida State University Summary-A weight loss program for severely retarded adults based on behavioral controls consisted of: (1) a manual for parents of retardates, (2) colored tokens to represent food groups, (3) monetary payments for weight lost, and (4) dai!y weighings. Despite very limited intellectual capacities, subjects were able to develop new eatmg behaviors resulting in weight losses that
were maintained
at follow-up. of 26; subject 2 was 19, weighed 161, with an I.Q. of 35; subject 3 was 21, weighed 126, and had an I.Q. of 30.
Nurnberger and Levitt (1962), Stuart (1967, 1971), Stuart and Davis (1972), Harris (1969), Harris and Bruner (1971), Stunkard, Levine and Fox (1970), Penick et al. (1971), Stunkard (1972), Wollersheim (1970) and others have developed weight loss programs based on behavioral controls. Although these techniques are successful with many subjects, they require considerable re-education of eating habits and development of self-control behaviors, and have not been systematically applied to obese retarded subjects. This report describes an adaptation of these behavioral techniques, especially Stuart and Davis (1972), for use with three severely retarded adults. The program was designed to help these obese subjects achieve an initial weight loss and to teach them new eating habits to maintain their losses. FERSTER,
Apparatus A manual by J.T.P. entitled “A guide for parents of an
overweight so; or daughter” was iiven to the parents of each subiect. Subiects used colored tokens in a elastic box to a>count fir all food eaten daily. A phydcian’s balance beam scale was used to weigh subjects. Procedure
Baseline weights were taken for 13 weeks, subjects being weighed each morning at the Training Center and the weight posted on a large chart. No instruction in weight loss was given during this period, but the subjects were told that they would be helped to lose weight later. The treatment program consisted of: (1) a weight loss manual for the parents, (2) colored tokens for the subjects to help make them aware of their daily food intake, (3) a payment of 50# per week for a weekly weight loss of at least 1 lb, and (4) daily weighings. The parents met with the investigator and staff members from the center to discuss the program. The manual the parents received was written in simple, easy to understand language and included short chapters on the cause of weight changes, eating habits, importance of a balanced diet, how their daughters were to use the colored tokens, helpful hints about weight loss, sample low calorie recipes, etc. Its main purpose was to help the parents establish behavioral controls over eating in the home and understand a basic weight loss program. Each parent was contacted at least once a month and encouraged to telephone at any time help was needed. The colored tokens in plastic boxes had a threefold purpose. First, they served as a means of communication between the center and the home about the amount and kinds of food eaten each day. Second, they served as a guide for a balanced diet and third, they eliminated the need for counting calories.
METHOD SuOjects The subjects, three severely retarded women attending a daycare training facility for retardates, were identified as obese by an examining physician and were more than 10 per cent above their best weight as defined by the New Weight Standards for men and women (Metropolitan Life Insurance Company, November-December, 1959). Each subject agreed to participate in the program and permission was also obtained from the subjects’ parents. Subject 1, 36-yr-old, weighed 243 lb, and had an I.Q.
*Requests for reprints should be addressed to John Paul Foreyt, Baylor College of Medicine, Fondren and Brown Building #B 202,6516 Bertner, Houston, Texas 77025. 27
28
JOHN PAUL FOREYT and JIM T. PARKS
Servings in the var-ious food groups (meats, vegetables, fruits etc.) based on the food exchanges from Stuart and Davis (1972), were used rather than require subjects to count calories, a task far beyond the capacities of these women and some of their parents. The colored tokens represented the different food groups: red tokens for meats, green for cooked vegetables, yellow for breads, cereals, an>d some vegetables such as beans or potatoes, orange for fruits, white for milk or milk products, and brown for miscellaneous foods such as oils and sweets. The plastic boxes had two compartments, in one of which the appropriate number of different colored tokens was placed in the morning, and moved to the other compartment as the various foods were eaten during the day. The tokens served as an estimate of what had already been eaten and the amount and types of food that could still be eaten that day. This communication was necessary since the subjects ate a snack and lunch at the center and the rest of iheir meals at home. Each subject was also paid SO@per week during the ll-week treatment period for weekly weight losses of at least 1 lb.
RESULTS Average weight loss for subjects at the end of the 11 week treatment period was 8.5 lb, with subject 1 losing 10 lb; subject 2,11 lb; and subject 3,4.5 lb. Average weight loss for subjects at the end of the 29-week follow-up period was 15.2 lb, with subject 1 losing 21.5 lb; subject 2, 18.75 lb; and subject 3, 5.75 lb. Figure 1 presents the weekly mean weight change in pounds for the three subjects during 13-week baseline, 1 l-week treatment, and 29week follow-up.
FIG. 1. Mean weight change in pounds per week for the three subjects during 13 week baseline, 11-week treatment, and 29-week follow-up.
DISCUSSION All three subjects lost weight during the llweek program, as expected. Each continued to lose during the 29-week follow-up period when they were no longer paid 5Oe per week for weight losses. Observations by the investigator, the center’s staff, and reports from parents suggested that each of the program’s four components was important to the subjects, but the order of importance differed. The manual was a useful means of giving the parents the information needed to implement the program and provided a reference source to help them as questions arose. It also lessened the need for lengthy meetings with the parents. The family of subject 2 particularly used the manual extensively and the whole family began changing their eating habits. Subject 2’s mother and sister lost several pounds during this period. Subject 3’s family also made considerable use of the manual. The boxes of tokens were important and helpful to all subjects. They were carried to the center and home again each day and served as an easy way to communicate with the parents concerning the amount and types of foods which had been eaten at the center each day. The subjects seemed proud to carry their boxes with them. The importance of the money varied according to the economic situation of the home, with those from poorer homes more concerned with money. The slower rate of weight loss during the follow-up period, when payments were no longer made, suggests that some kind of monetary reinforcer is useful at least initially when starting a weight loss program. Subject 1 maintained her rate of loss during follow-up, even though she showed the most interest in being paid during treatment. Daily weighing appeared to be of equal importance to subjects since they all wanted to be weighed immediately after arrival at the center and have it posted on the chart. Staff attention and verbal praise for lost weight enhanced the desirability of the weighings. It is
BEHAVIORAL
CONTROLS
FOR ACHIEVING
WEIGHT
doubtful that the subjects understood the numerical amounts involved, but they knew that losing weight was an accomplishment to be proud of and would tell other staff members when their weight was down. The relationship of the subjects with the investigator and their classroom instructor was very important. Verbal praise and encouragement were generously given and apparently were quite reinforcing. Subjects were eager to report weight loss to the one who had not weighed them. Subjects also frequently made statements such as “I didn’t eat my bread” or “I didn’t eat any cake today”. An area of particular concern was how much subjects could learn about food choices and to what extent they could become self-monitoring, since all were classified as functioning within the range of severe mental retardation. The subjects did not attain complete control of the mechanics of the program but did control some eating behaviors. They all gradually began voluntarily to refuse snacks of sweetrolls and doughnuts. During afternoon breaks, they bought only “diet colas” even though other drinks were available. They also quit buying candy and potato chips from the center’s store. In addition to applying their learning to their eating behavior, the subjects also learned to verbalize somewhat the requirements of weight loss. For example, when a new trainee said he wanted to lose weight, the instructor would ask subject 1 to tell him how to do it. Subject 1 answered, “Eat less. Can’t have no cokes, no candy, no cake, no ice cream, no potato chips”. When asked how to eat fried chicken, subject 1 said, “Take the skin off first”, During the follow-up period, subjects continued to carry the token boxes, weigh each morning, and eat together at the center. Parents
LOSS IN THE SEVERELY
RETARDED
29
reported that they were continuing to rely on the manual even though the investigator gradually withdrew from active participation in the program. Although it is difficult to ascertain just how much the subjects have learned, observation of their changed eating habits at the center and reports from parents indicate that there has been some knowledge gained and some selfcontrol instituted. This adaptation of a program to gain behavioral control of obesity in retarded subjects by working with them and with those individuals who control portions of the subjects’ lives appears to have a good chance of success. Further research is needed to identify the most effective components of a weight loss program for retardates. REFERENCES
FERSTERC. B., NURNBERGERJ. I. and LEVITTE. B. (1962) _ ’ The control of eating, J. Math. 1, 87-109. HARRIS M. B. (1969) Self directed DroPram for weipht control: a pi& stuhy, J. abnorn;. &ycohol. 74,263-270. HARRIS M. B. and BRUNERC. G. (1971) A comparison of a self-control and a contract procedure for weight control, Behav. Res. & Therapy 9, 347-354. Metropolitan Life Insurance Company (1959) New weight standards for men and women, Stat. Bull. 40, l-4. PENICK S. B., FILION R., Fox S. and STUNKARDA. J. (1971) Behavior modification in the treatment of obesity, Psychosom. Med. 33, 49-55. STUART-R. i. (1967) Behavioral control of overeating, Behav. Res. & Therapy 5, 357-365. STUARTR. B. (1971) A three-dimensional program for the treatment of obesity, Behav. Res. & Therapy 9.177-186. STUARTR. B. and DAVISB. (1972) Slim Ch&c~ in a Fat World, Research Press. Chamoaien. Illinois. STUNKA~D A. J. (1972)’ New theyaiies for the eating disorders, Archs gem Psychiat. 26,391-398. STUNKARDA. J., LEVINE H. and Fox S. (1970) The management of obesity: patient self-help and medical treatment, Arrhs Int. Med. 125, 1067-1072. WOLLERSHEIM J. P. (1970) Effectiveness of group therapy based upon learning principles in the treatment of overweight women, J. ubnorm. Psychol. 76,462-474.
Thu.
& Exp.
Psychiat.
Vol. 6, pp. 27-29.
PergamonPress,1975. Printedin Great Brimin.
BEHAVIORAL CONTROLS FOR ACHIEVING WEIGHT LOSS IN THE SEVERELY RETARDED* JOHN
PAUL
and JIM T. PARKS
FOREYT
Florida State University Summary-A weight loss program for severely retarded adults based on behavioral controls consisted of: (1) a manual for parents of retardates, (2) colored tokens to represent food groups, (3) monetary payments for weight lost, and (4) dai!y weighings. Despite very limited intellectual capacities, subjects were able to develop new eatmg behaviors resulting in weight losses that
were maintained
at follow-up. of 26; subject 2 was 19, weighed 161, with an I.Q. of 35; subject 3 was 21, weighed 126, and had an I.Q. of 30.
Nurnberger and Levitt (1962), Stuart (1967, 1971), Stuart and Davis (1972), Harris (1969), Harris and Bruner (1971), Stunkard, Levine and Fox (1970), Penick et al. (1971), Stunkard (1972), Wollersheim (1970) and others have developed weight loss programs based on behavioral controls. Although these techniques are successful with many subjects, they require considerable re-education of eating habits and development of self-control behaviors, and have not been systematically applied to obese retarded subjects. This report describes an adaptation of these behavioral techniques, especially Stuart and Davis (1972), for use with three severely retarded adults. The program was designed to help these obese subjects achieve an initial weight loss and to teach them new eating habits to maintain their losses. FERSTER,
Apparatus A manual by J.T.P. entitled “A guide for parents of an
overweight so; or daughter” was iiven to the parents of each subiect. Subiects used colored tokens in a elastic box to a>count fir all food eaten daily. A phydcian’s balance beam scale was used to weigh subjects. Procedure
Baseline weights were taken for 13 weeks, subjects being weighed each morning at the Training Center and the weight posted on a large chart. No instruction in weight loss was given during this period, but the subjects were told that they would be helped to lose weight later. The treatment program consisted of: (1) a weight loss manual for the parents, (2) colored tokens for the subjects to help make them aware of their daily food intake, (3) a payment of 50# per week for a weekly weight loss of at least 1 lb, and (4) daily weighings. The parents met with the investigator and staff members from the center to discuss the program. The manual the parents received was written in simple, easy to understand language and included short chapters on the cause of weight changes, eating habits, importance of a balanced diet, how their daughters were to use the colored tokens, helpful hints about weight loss, sample low calorie recipes, etc. Its main purpose was to help the parents establish behavioral controls over eating in the home and understand a basic weight loss program. Each parent was contacted at least once a month and encouraged to telephone at any time help was needed. The colored tokens in plastic boxes had a threefold purpose. First, they served as a means of communication between the center and the home about the amount and kinds of food eaten each day. Second, they served as a guide for a balanced diet and third, they eliminated the need for counting calories.
METHOD SuOjects The subjects, three severely retarded women attending a daycare training facility for retardates, were identified as obese by an examining physician and were more than 10 per cent above their best weight as defined by the New Weight Standards for men and women (Metropolitan Life Insurance Company, November-December, 1959). Each subject agreed to participate in the program and permission was also obtained from the subjects’ parents. Subject 1, 36-yr-old, weighed 243 lb, and had an I.Q.
*Requests for reprints should be addressed to John Paul Foreyt, Baylor College of Medicine, Fondren and Brown Building #B 202,6516 Bertner, Houston, Texas 77025. 27
28
JOHN PAUL FOREYT and JIM T. PARKS
Servings in the var-ious food groups (meats, vegetables, fruits etc.) based on the food exchanges from Stuart and Davis (1972), were used rather than require subjects to count calories, a task far beyond the capacities of these women and some of their parents. The colored tokens represented the different food groups: red tokens for meats, green for cooked vegetables, yellow for breads, cereals, an>d some vegetables such as beans or potatoes, orange for fruits, white for milk or milk products, and brown for miscellaneous foods such as oils and sweets. The plastic boxes had two compartments, in one of which the appropriate number of different colored tokens was placed in the morning, and moved to the other compartment as the various foods were eaten during the day. The tokens served as an estimate of what had already been eaten and the amount and types of food that could still be eaten that day. This communication was necessary since the subjects ate a snack and lunch at the center and the rest of iheir meals at home. Each subject was also paid SO@per week during the ll-week treatment period for weekly weight losses of at least 1 lb.
RESULTS Average weight loss for subjects at the end of the 11 week treatment period was 8.5 lb, with subject 1 losing 10 lb; subject 2,11 lb; and subject 3,4.5 lb. Average weight loss for subjects at the end of the 29-week follow-up period was 15.2 lb, with subject 1 losing 21.5 lb; subject 2, 18.75 lb; and subject 3, 5.75 lb. Figure 1 presents the weekly mean weight change in pounds for the three subjects during 13-week baseline, 1 l-week treatment, and 29week follow-up.
FIG. 1. Mean weight change in pounds per week for the three subjects during 13 week baseline, 11-week treatment, and 29-week follow-up.
DISCUSSION All three subjects lost weight during the llweek program, as expected. Each continued to lose during the 29-week follow-up period when they were no longer paid 5Oe per week for weight losses. Observations by the investigator, the center’s staff, and reports from parents suggested that each of the program’s four components was important to the subjects, but the order of importance differed. The manual was a useful means of giving the parents the information needed to implement the program and provided a reference source to help them as questions arose. It also lessened the need for lengthy meetings with the parents. The family of subject 2 particularly used the manual extensively and the whole family began changing their eating habits. Subject 2’s mother and sister lost several pounds during this period. Subject 3’s family also made considerable use of the manual. The boxes of tokens were important and helpful to all subjects. They were carried to the center and home again each day and served as an easy way to communicate with the parents concerning the amount and types of foods which had been eaten at the center each day. The subjects seemed proud to carry their boxes with them. The importance of the money varied according to the economic situation of the home, with those from poorer homes more concerned with money. The slower rate of weight loss during the follow-up period, when payments were no longer made, suggests that some kind of monetary reinforcer is useful at least initially when starting a weight loss program. Subject 1 maintained her rate of loss during follow-up, even though she showed the most interest in being paid during treatment. Daily weighing appeared to be of equal importance to subjects since they all wanted to be weighed immediately after arrival at the center and have it posted on the chart. Staff attention and verbal praise for lost weight enhanced the desirability of the weighings. It is
BEHAVIORAL
CONTROLS
FOR ACHIEVING
WEIGHT
doubtful that the subjects understood the numerical amounts involved, but they knew that losing weight was an accomplishment to be proud of and would tell other staff members when their weight was down. The relationship of the subjects with the investigator and their classroom instructor was very important. Verbal praise and encouragement were generously given and apparently were quite reinforcing. Subjects were eager to report weight loss to the one who had not weighed them. Subjects also frequently made statements such as “I didn’t eat my bread” or “I didn’t eat any cake today”. An area of particular concern was how much subjects could learn about food choices and to what extent they could become self-monitoring, since all were classified as functioning within the range of severe mental retardation. The subjects did not attain complete control of the mechanics of the program but did control some eating behaviors. They all gradually began voluntarily to refuse snacks of sweetrolls and doughnuts. During afternoon breaks, they bought only “diet colas” even though other drinks were available. They also quit buying candy and potato chips from the center’s store. In addition to applying their learning to their eating behavior, the subjects also learned to verbalize somewhat the requirements of weight loss. For example, when a new trainee said he wanted to lose weight, the instructor would ask subject 1 to tell him how to do it. Subject 1 answered, “Eat less. Can’t have no cokes, no candy, no cake, no ice cream, no potato chips”. When asked how to eat fried chicken, subject 1 said, “Take the skin off first”, During the follow-up period, subjects continued to carry the token boxes, weigh each morning, and eat together at the center. Parents
LOSS IN THE SEVERELY
RETARDED
29
reported that they were continuing to rely on the manual even though the investigator gradually withdrew from active participation in the program. Although it is difficult to ascertain just how much the subjects have learned, observation of their changed eating habits at the center and reports from parents indicate that there has been some knowledge gained and some selfcontrol instituted. This adaptation of a program to gain behavioral control of obesity in retarded subjects by working with them and with those individuals who control portions of the subjects’ lives appears to have a good chance of success. Further research is needed to identify the most effective components of a weight loss program for retardates. REFERENCES
FERSTERC. B., NURNBERGERJ. I. and LEVITTE. B. (1962) _ ’ The control of eating, J. Math. 1, 87-109. HARRIS M. B. (1969) Self directed DroPram for weipht control: a pi& stuhy, J. abnorn;. &ycohol. 74,263-270. HARRIS M. B. and BRUNERC. G. (1971) A comparison of a self-control and a contract procedure for weight control, Behav. Res. & Therapy 9, 347-354. Metropolitan Life Insurance Company (1959) New weight standards for men and women, Stat. Bull. 40, l-4. PENICK S. B., FILION R., Fox S. and STUNKARDA. J. (1971) Behavior modification in the treatment of obesity, Psychosom. Med. 33, 49-55. STUART-R. i. (1967) Behavioral control of overeating, Behav. Res. & Therapy 5, 357-365. STUARTR. B. (1971) A three-dimensional program for the treatment of obesity, Behav. Res. & Therapy 9.177-186. STUARTR. B. and DAVISB. (1972) Slim Ch&c~ in a Fat World, Research Press. Chamoaien. Illinois. STUNKA~D A. J. (1972)’ New theyaiies for the eating disorders, Archs gem Psychiat. 26,391-398. STUNKARDA. J., LEVINE H. and Fox S. (1970) The management of obesity: patient self-help and medical treatment, Arrhs Int. Med. 125, 1067-1072. WOLLERSHEIM J. P. (1970) Effectiveness of group therapy based upon learning principles in the treatment of overweight women, J. ubnorm. Psychol. 76,462-474.