Eating—A psychological dilemma

PSYCHOLOGY-BACKGROUND PAPER

Eating-A Psychological Dilemma Thomas J. Coates The woman answered the serpent, "Of the fruit of the tree in the middle of the garden, God said, 'You shall not eat nor shall you touch it, lest you die. '" But the serpent said, "No, you should not die; for God knows that when you eat of it, your eyes will be opened and you will be like God, knowing good and evil. .. Now the woman saw that the tree was good for food, pleasing to the eyes, and desirable for the knowledge it would give. She took of its fruit and ate (1).

And so the struggle began. The primordial offense involved eating. The sin chronicled as irrevocable and unforgiveable revolved around the human inability to resist the urge to consume an apparently delicious but obviously forbidden morsel offood. Humankind continues to struggle to control eating and exercise. Our ancestors worked to survive scarcity and disease. The ability to collect and retain excess fat was clearly advantageous genetically. Cold weather, recurring food shortages, and protracted illnesses might have been managed more effectively when the body could store and use fat. Contemporary society, however, provides attractive food in abundance and requires little physical work in return. Consequently, losing weight or maintaining a relatively lean body is a formidable challenge for many. How can persons be influenced to eat and exercise "appropriately"? How can persons be helped to eat only for energy needs and to select foods that enhance rather than hinder health? Psychology offers no panaceas. Psychology might offer a few suggestions or promising directions but has little to say about comprehensive or efficacious approaches to nutrition education or weight management. What can psychology tell us about nutrition education? How can psychological perspectives help us to document what we need to know using acceptable scientific methods? Emphasis in this paper has been placed on obesity because psychologists have attempted to say more about this area than many others in the field of nutrition. Psychology has offered the field of nutrition education: 1) models for explaining food choice, 2) strategies for treating obesity, 3) strategies for comprehensive nutrition education programs, and 4) strategies used in one-to-one counseling. Advancements in each of these areas are described in this paper. Most important, psychology has contributed a vigorous methodology and has highlighted what we do not know and need to find out. MODELS OF FOOD CHOICE - INTERNAL AND EXTERNAL EATING STYLES Schachter, Nisbett, and their colleagues (2-5) proposed a basic and far-reaching distinction between obese and nonobese persons. Whereas the eating behavior of normal weight persons is supposedly regulated by internal physiological cues, overweight persons' eating is hypothetically regulated by external stimuli (e.g., the sight and sound of food, the time of day). This model

THE A UTHOR is Assistant Professor, Department of Psychiatry and Behavioral Sciences, and Department of Pediatrics, The Johns Hopkins University School of Medicine; and Assistant Professor, Division of Health Education, School of Hygiene and Public Health, The Johns Hopkins University, Baltimore, MD 21205. S 34

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generated a plethora of research and has inspired a generation of treatment. The internal-external eating style distinction is part of the belief system common to dietetic practitioners. The notion appears in every introductory psychology textbook published in the last eight years (Note 1). In a typical experiment, Schachter, Goldman, and Gordon (6) examined the effects of sandwich eating on subsequent cracker eating. Subjects were lean college students and students who were overweight by 15 percent or more. Subjects were instructed to come to the laboratory in the afternoon. Some ate lunch beforehand, while others did not. All subjects were given crackers to judge for taste. The lean subjects who had eaten lunch ate fewer crackers than when they had not eaten lunch. Overweight subjects ate the same number of crackers regardless of whether or not they had eaten lunch. Food intake in situations of high or low emotion was examined in the same experiment. When fear level was low, the lean subjects ate more than did the overweight. When fear was introduced, lean subjects ate less, while overweight individuals actually ate more. These investigators have also examined the effects on overweight and normal-weight subjects of external variables such as clock time, lighting intensity, and availability and palatability of food items. When fasting during the religious holiday Yom Kippur was used as an index of internal deprivation, 83.1 percent of obese and 68.8 percent of normal-weight Jewish students fasted. This was interpreted to mean that overweight individuals got "less hungry" during the fasting period than did their normalweight counterparts (6, Note 2). A Critique. Coates (7) criticized the internal-external eating style distinction using the following points: 1 Most of the studies were conducted with middle-income to upper-income and mildly overweight college students, some of whom participated in the studies to complete course requirements (8). Samples have included both child and adultonset obese persons among whom there might be considerable difference in food intake patterns. 2 Studies have not included samples from the lower socioeconomic classes where obesity may be far more prevalent and require a different type of treatment (9, 10). 3 Most studies have been laboratory investigations. Studies in the field have produced results contrary to the hypothesis (11), or have shown nonsignificant associations between eating habits and obesity (12-14). 4 Examination of distribution statistics in studies reported by Schachter and Rodin (5) reveals considerable variability and frequent bimodal distributions. Central tendency differences, although interesting, are scarcely evidence for an "obese eating style" in the presence of such variability and bimodality. Both long-term and short-term studies reveal that persons generally are insensitive to satiety states and quite sluggish in modifying food intake in response to previous caloric consumption (15). The obese and nonobese are influenced by environmental factors such as clock time. The thesis that overweight individuals are more responsive to external food stimuli than normal-weight persons is not well supported; external responsiveness is not well correlated with degree of overweight (Note 1). VOLUME

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The ponderostat. Nisbett (16) proposed that the absolute degree of overweight cannot be used to discriminate physiological and psychological differences among persons. Rather, relative deviation from a biologically determined set point (termed the ponderostat) will provide maximum understanding of the food regulation process (17). Individual differences in adipose cell composition among the obese have been documented. Hypertrophic obese persons have a normal number of overfilled adipose cells, while hyperplastic obese persons have an overabundant number of adipose cells which mayor may not be overfilled (18-22). Hypertrophy may be related to adult-onset obesity, while hyperplasia is possibly related to early feeding experiences and juvenile-onset obesity as well as to individual differences in genetic structure. The hypothesis exists that once an excessive number of adipose cells is generated, the number remains constant. Dieting will reduce only the size of adipose cells, not their number. If the lipid content of some of these excessive cells becomes depleted-which is required if the person is to achieve and maintain a normal weight-the cells supposedly signal the central nervous system to alter feeding behavior so that the set point can be maintained. In effect, being obese is normal for the hyperplastic obese person. Nisbett (23) argued that failures to find consistent associations between externality and obesity reflected the failure to consider that many obese persons were already at their set point for body weight. Further, he hypothesized that responsiveness to external food stimuli resulted from the deprivation imposed by remaining below set point through dieting. Models of food intake control based on these speculations have been elaborated (18). These models, however, remain hypothetical. Several criticisms are noteworthy. Although there tends to be some association between the age of onset of obesity, severity of obesity, and cell number in humans (20), these data are not confirmatory, but only suggestive. A frequently confounding piece of evidence is found in the obese human who, according to medical history, became obese as an adult and yet has an excessive number of adipocytes (24). Moreover, adipose tissue signals have not been identified, and without any evidence of their existence, (or, if identified, of their function), the physiological significance of excessive cellularity remains an interesting finding whose clinical import remains to be determined. Those in clinical practice must be careful not to regard the adipose tissue hypothesis as true, confirmed, or even partially supported. We cannot afford to let the hypothesis permit us to become paralyzed in our attempts to treat a problem which seems intractable. An equally plausible hypothesis is that our interventions are impotent not because we are battling the biologically inevitable but because we have not yet developed maximally powerful treatment procedures, the means for teaching them, and the methods for ensuring their careful application over time (7). Restraint. Herman, Polivy, and colleagues (25, 26) suggested a psychological variation of Nisbett's basic model. Conscious restraint, rather than obesity or deprivation, may be correlated with externality. Herman and Mack (27) found that unrestrained females modified food intake in inverse proportion to a preload (1, 2, or 3 milkshakes), while restrained eaters who were forced to consume preloads broke their diets completely. The unrestrained females who consumed a preload reduced subsequent ice cream intakes; the restrained females increased ice cream intake following the milkshake preload. Hibscher (Note 3) replicated this effect with males. Polivy (28) found that restrained VOLUME

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subjects who perceived a preload as high calorie subsequently ate more of a standard meal than those who thought the preload to be low calorie; unrestrained subjects did the reverse. Anxious restrained eaters ate more than nonanxious restrained eaters, whereas anxiety inhibited food intake among the unrestrained (29). Restrained depressed persons tended to show weight gain, while the opposite was true for unrestrained depressed persons (30). The restraint notion, while appealing, has been criticized on several grounds: 1 Persons are classified as restrained or unrestrained on the basis of their responses to 11 items. Those falling above the median are considered restrained, while the unrestrained fall below the median. Discriminating among subjects by dividing them at the median is questionable psychologically and psychometrically (31). The median split assumes dissimilarity for persons falling on opposite sides of the median (the 49th percentile and the 57th percentile) and similarity for persons in the same side (the 51 st percentile and the 99th percentile). 2 In studies of the restraint hypothesis, response variability was high, and differences were found usually in interactions. Such variability indicates unstable estimates of the mean. Group differences are so unrepresentative of the single case that they are of little clinical value. 3 Restraint is a descriptive term. It does not, however, explain processes underlying food regulation. Primary externality and reciprocal internality. Rodin (Note 1) proposed an alternative mechanism. She and her colleagues hypothesized that external responsiveness to all stimuli may be a primary mechanism influencing eating behavior. Externality results in conscious restraint in some persons and obesity in others. In a prospective study, Rodin and Slowchower (32) observed children at an eight-week summer camp. Girls who were more responsive to all kinds of external stimuli gained the most weight in this food-rich summer camp environment. Milstein (Note 4) reported that infants of overweight parents were more externally responsive than children of normal-weight parents. These infants are now part of a longitudinal study involving inhome feeding observations to determine the relationship between infant external responsiveness, feeding behavior, and the development of obesity. Rodin (Note 1) proposed that both external and internal stimuli must be considered in studying eating patterns. The two sets of stimuli are interrelated; each will influence eating behavior depending on the stimultaneous state of other influences. External stimuli (e.g., the sight, sound, and availability of foods) must be studied in relation to internal cues such as hunger, state of the gastrointestinal tract, salivation, and insulin release. Both internal and external variables might be mediated by cognitive factors such as perceived palatability of food and desirability of maintaining weight within a specified level. If, for example, a person is presented with a favorite food, reactions could vary greatly depending on other external and internal variables. A person will respond differentially to the external stimulus, depending on other external variables (e.g., other persons, whether the person is at home or work), internal variables (how hungry the person is), and cognitive variables (when and what the person expects to eat during the rest of the day). These external food cues can also modify internal signals (e.g., salivation, hunger pangs), and internal cues can moderate the influence of external cues. The point is simple: the system is dynamic and transactional, and research models must be used that JOURNAL OF NUTRITION EDUCATION

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describe the separate and interactive effects of variables over time. This newer formulation of the externality hypothesis is appealing on several grounds. Most notably, it moves beyond the belief that a simple static and dichotomous formulation (e.g., internal vs. external) will be powerful in discriminating among persons in relation to a phenomenon as complex as obesity and food regulation. Persons are in constant interaction with the environment. Behavior at any point in time must be studied in the context of all factors determining its occurrence. Undoubtedly, the model will have flaws and will ultimately need to be replaced. In the meantime, however, it appears that our thinking has advanced beyond a simple dichotomy to the next needed level of complexity. STRATEGIES FOR TREATING OBESITY Behavior therapy. Behavior modification has prospered under the protective shield of an especially good press. The application of behavior modification to the treatment of obesity during the 1960s resulted in apparently important weight losses for persons suffering mild to moderate overweight (33). The first clinical trials supported the efficacy of behavioral treatments (34, 35). However, subsequent treatments have rarely produced weight losses exceeding those of the original studies. Worse yet, maintenance of weight loss is still elusive (36). The original behavioral approaches were based on three relatively simple propositions.

I. Because weight is the final element in a chain of responses, weight loss demands modification of the antecedent links in that chain. Antecedents involve discrete eating and exercise behaviors whose consequence might be weight gain or weight loss. The rate of eating presumably influences the amount eaten because behavior rapid eating presumably prevents persons from discriminating satiety. Rapid eaters might also be inclined to eat more food at social gatherings to harmonize their meal with persons who eat more slowly. Food choice involves habitual selection of high calorie versus low calorie foods or less healthful versus more healthful food items. Meal frequency could also influence obesity. Persons who eat the smallest number of meals per day appear to be more overweight and have higher levels of serum cholesterol, diminished glucose tolerance, and a greater prevalence of ischemic heart disease than those who eat at more frequent intervals (37). Persons who exercise regularly or who habitually use less convenient transport (e.g., stairs instead of an elevator) could be expected to use more calories than their obese counterparts. 2. Eating and exercise behaviors do not occur in isolation, but rather in a context which determines their frequency of occurrence. Antecedents to the behavior influence the frequency and intensity of these specific behaviors. Strict behavioral approaches concentrated on antecedent events in the external environment, such as the sight and smell of food, which would be observed and manipulated. With the advent of cognitive behavior therapy, studying and manipulating variables such as self-instruction (what persons say to themselves) and images (fantasies) were believed to be important and necessary in a comprehensive behavioral approach (38, 39).

3. Consequences occur following the behavior and increase or decrease the probability that they will occur again. Reinforcement increases the probability that the behavior will occur again, while punishment decreases that probability. Reward or punishment can be either social (e.g., praise) or material (e.g., monetary incentives). S 36

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Table 1: Common treatment program components in self-management of obesitya • Introduction

Learn reason for overweight. Learn importance of change in eating habits. Learn rationale for learning self-control skills.

• Self-observation

Record food intake. Record environmental and cognitive events associated with food intake.

• Cue elimination

Eat only at designated eating place and at specific times. Refuse food offers. Eliminate other activities (e.g., reading, watching television) while eating.

• Nutrition b

Discriminate food quality (i.e., protein, carbohydrate, and types of fat). Discriminate high, medium, and low calorie foods. Modify food quality. Substitute low calorie foods for high calorie foods and increase balance among food types.

• Problem solving and self-instructions

Identify and recognize problem eating situations. Learn self-verbalizations for guiding behavior in those situations. Implement and test.

• Contracting b

Set personal goals for changing eating habits. Rearrange cognitive, social, and physical environments. Select and administer personal rewards. Establish reward and point system with parents.

• Physical support

Store food out of sight and in opaque containers. Leave food platters in kitchen. Serve low calorie and high quality foods at family meals.

• Act of eating

Set fork down following each bite. Have a two-minute delay in the middle of the meal.

• Cognitive environment

Recognize "fat" thoughts (i.e., thoughts subverting motivation to use habitchange techniques). Substitute "thin" thoughts (i.e., thoughts promoting eating habit change).

• Social support b

Have family praise eating habit changes. Eliminate food talk from everyday conversation. Reduce food related interactions. Do not offer food to client.

• Food portions

Use smaller plates and bowls. Leave food on plate. Reduce amount of food taken.

• Exercise

Begin systematic exercise program. Become less "efficient" (e.g., park car far away, take stairs instead of elevator).

• Problem solving/ Maintenance b

Plan for future problem eating situations. Substitute other activities for eating. Review components and application.

aAdapted from Coates, T. J., and C. E. Thoresen. Behavior and weight change in three obese adolescents. Behavior Therapy. In press. bSessions conducted in clients' home with entire family present

Behavioral self-management. The next generation of strategies relied more directly on research in behavioral self-management. Skinner (40) noted that "self-control" occurs when persons themselves manipulate the variables of which their behavior is a function. He proposed that persons themselves can be taught specific self-control skills for use qn modifying the external or internal environment, which in turn will modify the antecedents and consequences of eating and exercise behaviors. Weight loss should result, at least theoretically. The focus on self-management influenced treatment emphasis but did little to change treatment strategy. Self-management programs were designed to help persons become aware of and modify the social and physical antecedents of eating (selfmonitoring), to self-administer rewarding consequences for VOLUME

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habit change or weight loss, or to self-administer aversive stimulation for inappropriate eating. Self-management programs began to place more emphasis on cognitive elements as well. Explicit training was introduced to help persons modify these thoughts and beliefs which interfered with adherence to weight control strategies or to administer self-reinforcing thoughts contingent on meeting weight loss or habit change goals (41). Table I presents an overview of components commonly included in behavioral self-management weight loss programs. The program has appeal. The practitioner is presented with several specific strategies presumed to be efficacious. The patient/client can choose which strategies to implement. The researcher is ecstatic because the plethora of treatment components permits endless parametric component analyses. Contrary to common belief, behavioral strategies have not been unusally efficacious. Wing and Jeffery (36) analyzed all available studies of outpatient treatments of obesity published between 1966 and 1977. As shown in Table 2, weight losses are fairly similar across treatment modalities. Figure 1 demonstrates that variability within treatment modalities was a function of the number of studies in that modality; if more studies were conducted, more variable results were reported. Follow-up data are scanty. Most treatments show some weight gain following termination of the program. Behavior therapy is the sole exception. At follow-up subjects tended to retain weight losses achieved during treatment (Table 2). Stunkard and Penick (42) reviewed results from I five-year and 10 oneyear follow-ups of studies of behavior modification for obesity. Regression toward baseline was the rule; subjects showed only minimal weight losses at the end of one year.

years old, weighed 215 pounds, stood 66" and was 72.9 percent overweight. All three were female. The treatment program was designed to teach skills for controlling eating and exercise behaviors to the adolescents and to teach parents specific procedures for supporting and encouraging their daughters' use of these skills. The adolescents met twice weekly with a therapist for a period of ten weeks during which weight loss skills were taught. The therapist met with all family members in their homes once per week during the first five weeks of the program. Subject 3, a control subject, met with the therapist on the same schedule as did the experimental subjects. She received written summaries of the weight loss skills, but did not receive specific training in these skills during treatment sessions.

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The picture is not entirely pessimistic. Some promising trends are apparent. Perhaps following some of these trends will advance us beyond our present inertia to the point where it might be possible to produce more clinically significant short-term losses and to maintain the losses over time.

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Choice of target behaviors. Coates and Thoresen (43) studied the relationship between weight losses and the behavior changes usually prescribed in behavioral programs. Subject 1 was 16 years old, 286 pounds, 65 Yz" tall, and 128.4 percent above average weight. Subject 2 was 16 years old, weighed 194 pounds, stood 62" and was 71.4 percent overweight. Subject 3 was 15

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TYPE OF THERAPY Figure 1 Comparison of weight losses from different therapeutic modalities (Source: Wing, R. R., and R. W. Jeffery. Outpatient treatments of obesity: A comparison of methodology and clinical results. International Journal of Obesity 3:261-79, 1979. Reprinted with permission.)

Comparisons of weight losses from different therapeutic modalities" Short-term

Therapy

Number of Studies

A verage Weight Loss Ib

Long-term

Percent Losing More than 20 pounds (9 kg)

Number of Studies

kg

A verage Weight Changefrom

Treatment to Follow-up Ib kg

Drug Andretic HCG Thyroid

62 4

11.2 (5.0) 17.6 (7.9)

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+ 4.0 ( 1.8)

16.9 (7.6)

20 23

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8

8.3 (3.7)

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Diet

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18.4 (8.3)

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+ 3.9 ( 1.8)

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"Data adapted from Wing, R. R., and R. W. Jeffery. Outpatient treatments of obesity: A comparison of methodology and clinical results. International Journal of Obesity 3:261-79, 1979. Reprinted with permission. VOLUME

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Trained nonparticipant observers, blind to treatment objectives and procedures, went to the homes of subjects at dinner time on four randomly selected evenings per week over a period of twelve weeks. The observers recorded foods displayed in various parts of the house and listed foods available in the cupboards, refrigerator, and freezer. During the meal, the observers recorded the kinds offoods prepared for the meal, the manner in which it was served, and client eating behaviors. Both experimental subjects experienced clinically significant weight losses (Subject I: - 21 pounds, -16.9 percent of the subject's overweight; Subject 2: - 11.5 pounds, - 10.8 percent of the subject's overweight) whereas Subject 3 experienced weight gain ( + 5 pounds, + 4.0 percent of the subject's overweight). Subjects I and 2 changed their most deviant behavior patterns. The home of Subject I was stocked with high calorie foods and meals were of high caloric density. She also ate frequently and in many locations. Behavior changes occurred in these areas, but not in eating behaviors. Subject 2 modified eating behavior (rate of eating) to lose weight. The clinical implications are important. Individual behavioral prescriptions should be based on a behavior analysis of each subject's deviant patterns. Behavioral rehearsal. Teaching persons what they must do in order to lose weight is not difficult. The millstone is encouraging dieters to perform, over a long period of time, the difficult actions needed to lose and maintain clinically significant amounts of weight. Weight loss programs generally fail to use the most efficient and powerful teaching techniques available. Bandura (44) has hypothesized that all therapies operate by inducing changes in efficacy expectations (the person's belief that he or she can execute the behavior required to produce the desired outcomes). Perceived personal efficacy determines whether persons initiate a goal-oriented action in the first place and also how much energy they will expend to continue those actions. Not all therapies are equally effective, however. Verbal persuasion, the most commonly used technique, is also the weakest in inducing changes in efficacy expectations and behavior. More powerful change methods involve those which use social modeling and guided practice to teach persons how to accomplish personal goals. Early weight loss and frequency of contact. Methods need to be found to encourage consistent performance of weight loss techniques in the natural environment over a long period of time so that weight loss can occur and people's expectations about personal efficacy will encourage them to continue using those skills. Weight loss early in a program may be especially important. Jeffery, Wing, and Stunkard (45) found that weight loss in the first 5 weeks was correlated with weight losses between weeks 6 and 20 (r = .44). Those who lost no weight in weeks I through 5 lost only 1.4 pounds during the next 15 weeks. Those who lost 10 pounds or more in weeks I through 15 lost 15.2 pounds during the next 15 weeks. The same patterns may be true for adolescents. Gross, Wheeler, and Hess (46) found in a study of 10 obese teenage girls that continued success following treatment could be predicted from weight losses achieved during the program. Daily contact may also be very motivating in helping clients to

begin and continue weight losses. Wing and Jeffery (36) found that treatments using intensive motivational procedures achieved the best weight losses. For example, subjects coming in daily to receive HCG injections lost an average of 17.6 pounds over 5 to 6 weeks. Placebo controls (daily contact plus injection with saline solution) lost an average of 14.4 pounds. S 38

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Jeffery and Wing (47,48) reported a feasible method for maintaining frequent contact with subjects. Thirty-four overweight adults were assigned to one of three groups: I) no personal contact (weekly group meeting only), 2) personal contact (group meeting plus 2 additional visits to a clinic), or 3) phone contact (group meeting plus 2 phone calls per week). Each group met once per week for 6 weeks to receive instruction in selfmonitoring, exercise, stimulus control, rate of eating, and preplanning and social support. All subjects also deposited $20.00 at the first treatment session. This was refunded at the end of treatment contingent on 100 percent adherence to the attendance requirements of their various groups. The personal contact group subjects reported weight and calories to an undergraduate assistant. Increasing the frequency of contact produced average results greater than those usually reported in behavioral weight loss studies. Mean weight losses over 5 weeks were 5.33 pounds (SD = 3.87) for no-contact subjects, 8.73 pounds (SD = 4.84) for personal-contact subjects, and 10.05 pounds (SD = 6.75) for phone-contact subjects. Contingency arrangements. Meaningful monetary deposits might also serve as motivation to adhere to weight loss regimens. Coates, Jeffery, Slinkard, Killen, and Danahar (Note 5) combined frequent contact and contingency contracts in a weight loss program for adolescents. Thirty-six adolescents (13 to 17 years old, 9 to 100 percent overweight) were taught basic weight loss skills in 10 one-hour sessions using videotape, modeling, role playing, group discussion, and reading. Overweight students were taught problem-solving skills in order to analyze their individual eating patterns; they then devised and tried out possible solutions for problems identified. All subjects were required to deposit the equivalent of 15 weeks of their allowance or 50 percent of their estimated earnings from part-time employment. Subjects in the weight loss-reward groups received deposit refunds for achieving weight loss goals of at least one pound per week. Subjects in the habit change group received refunds for keeping caloric intake below an individually established goal level. Subjects in the daily contact groups came in each morning or afternoon to receive refunds for meeting weight loss or habit change goals. Weekly contact subjects visited once per week for refunds earned. A 2 x 3 x 3 (frequency of contact reinforcement contingency trails) repeated measures analysis of variance revealed a significant trails effect (F = 10.81, df = 2/62, P < .001). Using contrast analysis, the daily contact-weight loss group was the only group to show significant changes in percent overweight from baseline to 15 weeks. Most important, this group maintained changes at the 6 month follow-up, while Ihe other group did not. Coates, Killen, Slinkard, Yasui, Ziegler, and George (Note 6) demonstrated the importance of contingency arrangements in a correspondence weight loss program. Subjects were 180 overweight (5 to 100 percent) adults age 21 to 65 years, recruited through spots on local television news, articles, and advertisements in local newspapers. Interested persons were instructed to telephone a central number where they received minimal information about the program and were invited to an orientation session. At the orientation, the rationale and procedures of the study were explained and participants were given the opportunity to join the program. Over 800 phone queries were received. About 50 percent of those calling attended the orientation meeting, and about 50 percent of these persons enrolled in the program. The ratio of female to male participants was about 5 to I. The final pool included subjects drawn from a 200-mile radius. All subjects received one lesson (about 5 pages plus a goal sheet and a set of food and activity diaries) in the mail each week VOLUME 13

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for 20 weeks. These lessons presented information on behavioral principles for weight loss, nutrition, exercise, principles of cardiovascular health, problem solving, social support, preplanning, imagery, and self-reinforcement. Participants were encouraged to set specific habit change goals each week, to set calorie goals and monitor caloric intake, to weigh daily, to post weight in a public place, and to engage family and friends to assist with weight loss efforts. Subjects were also informed that they could call or write to any member of the research staff at any time to obtain assistance or aid in problem solving. All participants were required to pay a $50 nonrefundable fee and to place $120 on deposit. The study used a 2 x 2 factorial design with factor 1 being frequency of weigh-in (every 5 weeks vs. every 10 weeks) and factor 2 being reinforcement contingency (reward for attendance at weigh-in vs. reward for weight loss). Subjects in Group 1 (weigh-in every 5 weeks; reward for weight loss) received $20 back for losing 10 pounds at each of 2 weigh-ins. Subjects in Group 2 (weigh-in every 10 weeks, reward for weight loss) received $40 back for losing 10 pounds at each of 2 weigh-ins. Subjects in Groups 3 and 4 (weigh-in every 5 or 10 weeks, respectively; reward for coming to weigh-in) received $20 and $40 back respectively for showing up to have weights taken. $20 was returned to all subjects for attending 6-month and 12-month follow-ups. Weight losses are presented in Figure 2. Although all weigh-in group changes were statistically significant (as tested by I-tests for paired comparisons), no statistically significant betweengroup differences emerged. Average weight losses were modest but promising, given the degree and intensity of subject contact. Because these procedures were relatively inexpensive and not labor-intensive, they may have implications for public health programs aimed at bringing about changes in wide segments of the population. Final determination will have to await maintenance data which is currently being collected.

Involving family members. Gam, Cole, and Bailey (49) analyzed data from the Ten-State Nutrition Survey to explore intrafamilial correlations of obesity. Parent-child fatness correlation approximated .25. A second analysis was compiled by dividing parents and children into 3 categories: lean (triceps skinfold below the 15th percentile), medium (triceps skinfold between the 16th and 84th percentiles), and obese (triceps skinfold above the 85th percentile). Children of the obese parents were significantly fatter at all ages than children of medium or lean parents. Interestingly, children of lean parents did not show the "normal" increase in fatness during adolescence. There was a decline in relative fat among males. Siblings were also quite similar. Nearly 30,000 sibling pairs were surveyed in the Ten-State project. The correlations between triceps skinfolds of siblings was .37; the correlation for subcapular skinfold was .35. Coates, Jeffery, and Wing (50) replicated these familial weight relationships in a nonclinical community sample. The correlation between mothers' and fathers' weights (r = .17) and percent overweight (r = .22) were significant but were similar in magnitude to those reported by Gam, Cole, and Bailey. Children's percent overweight did not correlate significantly with parents' percent overweight, but there was a positive correlation among first siblings. Although a genetic explanation seems an obvious hypothesis for intrafamilial fatness correlations, two analyses suggest environmental factors. First, spouses tend to be similar in triceps (r = .25) and subscapular fatfold (r = .21). When husbands are divided into the 3 fatness categories, their wives progress in fatness according to the fatness levels of their husbands. A similar relationship holds for husbands of lean, medium, and VOLUME

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Group 1: Reward 4 weigh-ins Group 2: Reward 2 weigh-ins Group 3: Reward 4 weigh-ins Group 4: Reward 2 weigh-ins

-12 -11

for 5-pound loss; for 10-pound loss: for attending weigh-in: for attending weigh-in:

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Reward for Weighing In

Figure 2 Pounds lost for each treatment group in the correspondence course weight loss study

obese wives. These relationships could be due, of course, to selective mating. Second, adopted children also resemble their foster parents in relative fatness. Gam, Cole, and Bailey (49) also analyzed data from 147 pairings of adopted children and parents from the Tecumseh project. The adopted children of lean parents were lean, and the adopted children of obese parents were obese. The fatness progression was nearly stepwise as various parental fatness combinations (lean-lean, leanmedium, and so forth) were examined. Moreover, fat pet owners tend to have fat pets (51). Again, selection, and not other variables, could be operative. Longitudinal research is needed to distinguish these alternative explanations. In light of the above data, family-based treatments might be powerful. Brownell, Heckerman, Westlake, Hayes, and Monti (52) assigned obese men and women to one of three treatment conditions. One of these consisted of subjects whose spouses agreed to participate in the treatment. Subjects and spouses in this group were trained together to model appropriate behaviors, to be supportive in noticing habit change, to assist with stimulus control procedures, to engage in alternative activities during tempting times, and to monitor the partner's behavior as well as his or her own behavior. Subjects with cooperative spouses continued to lose weight following treatment and generally maintained their weight loss at six months. Coates, Slinkard, and Killen (Note 7) combined parent involvement with a contingency arrangement in a study of overweight adolescents. Subjects were assigned to one of two treatment groups: parental involvement or no parental involvement. In addition to requiring a deposit from the participants, the program required parents in the parental involvement group to deposit an additional $95. These parents also met in separate group meetings to learn skills for helping their children lose weight. A one-way analysis of variance on changes in percent overweight was significant (F = 11.71, df = 1130, p < .001) for the adolescents whose parents were involved in their weight control activities. JOURNAL OF NUTRITION EDUCATION

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Individualizing treatments. Studies from several areas have suggested the importance of individualized assessment and treatment. The notion has always been popular and sounds appealing. Unless a useful assessment and treatment paradigm can be offered, however, the proposal is meaningless (53). Wooley and Wooley (54) attribute the failure of behavioral strategies to produce permanent losses of a large magnitude to four reasons: I) because overweight persons' food intakes are already normal, it is difficult for them to eat even less; 2) because caloric deprivation does not lead to weight loss, dieting encourages energy conservation and reduction in energy expenditure; 3) because the body is anxious to restore fat stores,

Table 3

hyperlipogenesis occurs during the refeeding period; and 4) because dieting is difficult, persons experience heightened responsivity to diet during deprivation. Wooley and Wooley classified patients along two dimensions based on their responses to dieting: primary obesity and primary hyperphagia (Table 3). Persons with primary obesity are those in whom hyperlipogenesis leads to rapid removal of nutrients from the blood stream with a consequent failure of satiety. Primary hyperphagia results from overeating unrelated to metabolic abnormalities and may result from attempts to take advantage of the stimulating properties or sensory qualities of food. In addition, persons might be high or low in arousal. Persons

Classification of patients based on their responses to dietinga

Primary Obesity

Primary Hyperphagia

High Arousal

Low Arousal

Low Arousal

High Arousal

Maintenance eating patterns Meal size

Large

Very large

Small

Large

Meal frequencies

High

Low

Very high

Average

Hunger level

High

High

Low

Low

Affective change

Well-being

Irritability

Depression, boredom

Irritability, insomnia

Type of diet breaking

Unpatterned

Evening eating

Snacking early in day

Night, weekend

Response to fasting Hunger level

Very high

Very high

Low

Affective change

Energetic

Extreme agitation

Low Euphoric

Rsponse to moderate restriction

Nervous

aSource: Wooley. S. C.• O. W. Wooley. and S. R. Dyrenforth. Theoretical. practical and social issues in behavioral treatments of obesity. Journal of Applied Behavior Analysis 12:3-25, 1979. Reprinted with permission.

I

~ ENVIRONMENT

PERSON

•

DISTAL

•

COMPETENCIES: WHAT CAN THE PERSON DO?

•

PROXIMAL

•

PERCEPTIONS

BEHAVIOR

•

PERFORMANCE - WHAT DOES THE PERSON DO?

- MODELS

- ENVIRONMENT AS PERCEIVED

- ANTECEDENTS

- BEHAVIOR AS PERCEIVED

- CONSEQUENCES

- SELF AS PERCEIVED

•

VALUES - PLACED ON PERSONAL CONDUCT. STIMULI PERCEIVED. AND CONSEQUENCES RECEIVED

•

EXPECTANCIES - STIMULUS-OUTCOME AND BEliAVIOROUTCOME EXPECTANCIES

•

BELIEFS - KNOWLEDGE. RULES FOR PERSONAL CONDUCT

Figure 3

S 40

•

EMOTIONS

•

PtiYSICAL REACTIONS AND DEPENDENCIES

A social learning/reciprocal interaction model

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with primary obesity but low arousal might be motivated to eat in order to quell hunger and to increase arousal. Large and frequent feedings will result, and hunger will be constant during dieting. Motivation to break the diet will be present at all times. Persons with primary obesity and high arousal will eat large meals to speed decreases in arousal. Hunger and agitation will be high; and the diet will be broken frequently, especially at the end of the day. Low-arousal persons with primary hyperphagia will eat for stimulation and have a large number of very small meals. Hunger will be low during dieting. High-arousal persons with primary hyperphagia will eat an average number of large meals to decrease arousal. Responses to dieting will include low hunger accompanied by nervous activity. This schema, in combination with the promising notions spelled out in the previous section, suggests three places to focus treatment. First, it may be necessary to conduct a behavior analysis of the person's current eating patterns to determine when and where eating or exercise patterns are in need of modification. Specific targets for change, along with discrete behavioral strategies (e.g., removing high caloric foods from the house), could be selected and implemented following the analysis. Detailed eating and exercise diaries could also help in the choice of targets and strategies. Second, it is necessary to establish ongoing motivational strategies to Ielp the person begin and maintain weight loss action. Spousal reinforcement, monetary incentives, and frequent contact with the therapist are three promising strategies that have emerged from the literature. Third, based on a detailed history of previous weight loss efforts and responses during treatment, persons might be classified into one of the cells in Table 3. Treatment programs to improve their prognosis could be established. Persons high in arousal, for example, might be introduced to alternative methods for reducing arousal, while those whose hunger becomes excessive might learn methods for controlling hunger. The schema may also help persons and therapists to determine a prognosis and outcome expectation so that unnecessary disappointment might be avoided.

Table 4 Examples of personal sources of influence used in selfmanagement a

Attention-Perceptual skills • Noticing and attending to relevant stimuli and not attending to irrelevant stimuli • Observing and imitating behaviors of others • Noticing and attending to rapid changes in environment Analytic skills • Remembering and retrieving specific information • Observing behavior of others and abstracting general principles to guide later behavior • Problem solving and decision making • Analyzing relationships between specific environments and probable behavior in that situation • Evaluating personal abilities to perform needed behaviors in problem situations • Analyzing relationships between personal actions and environmental consequences • Modifying beliefs about relationships between behavior environmental stimuli in relation to ongoing experience Imaginal skills • Using imagination as memory aid • Using imagination to form novel associations and ideas • Using imagination to plan and rehearse action plans Language skills • Expressing oneself in ways appropriate to situations and persons • Making and carrying out statements of intention • Expressing personal objectives and negotiating demands • Using speech to facilitate appropriate and relevant behavior in problem situations Behavioral production skills • Generating behavior appropriate to specific goals, situations, and persons

STRATEGIES FOR COMMUNITY NUTRITION

• Remembering and retrieving complex sequences of behavior

BEHAVIOR CHANGE

• Rearranging physical environment to meet specific objectives

Social learning theory. The social learning model of behavior proposes four principal sources of influence on behavior: environmental, personal, physiological, and behavioral (55, 56). The environment (in the form of models, cues to act, and consequences for action) impinges upon the person. The person evaluates the environmental influences in relation to personal competencies, perceptions, values, expectations, beliefs, emotions, and physical states. These "filters" determine what actions, if any, the person will take. Specific behaviors (e.g., smoking) also may be associated with other specific behaviors (e.g., alcohol use). Performance of a specific behavior increases the probability that the associated action also will be performed. The person's behavior, in turn, modifies the external environment and the person's variables. These set the stage for further action. Personal influence skills. Central to the social learning model is the notion that persons can influence the external environment. Personal skills (i.e., behavioral competencies) and methods of processing environmental information (e.g., thoughts, beliefs, and efficacy expectations) determine a person's behavior (Figure 3). Thus, when obese persons are taught personal influence skills, they acquire and apply behaviors with sufficient precision and frequency so as to regulate their own behavior more effectively. Table 4 summarizes some personal sources of behavior influence. Persons can notice and attend to relevant features of VOLUME

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Personal evaluating skills • Setting personal standards, evaluating personal actions, commending oneself for meeting goals • Experiencing personal dissatisfaction when goals are not met or standards are violated aAdapted from Coates, T. J., and C. E. Thoresen. Using generalizability theory in behavioral observations. Behavior Therapy 9:605-13, 1978. Reprinted with permission.

the external environment, generate a variety of possible alternative courses of action, make choices about the appropriate and effective courses of action, enact the actions chosen, and evaluate the degree to which personal actions enable them to meet preset goals. These multiple skills encourage flexibility in a person's responses to environmental, behavioral, and physiological influences; in reshaping the external environment; and in directing personal behavior. For example, increasing social, language, and negotiation skills may help adults to be more effective in learning to resist family pressure to eat and in helping families work together on health-related behaviors. As a second example, learning to evaluate one's performance in realistic terms can help a person decide what kinds of future actions will lead to personal goals attainment. JOURNAL OF NUTRITION EDUCATION

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Table 5 Variables potentially useful in producing immediate and maintained change in behavior nutrition change programs Behavioral sources of influence Specific behavior changes prescribed • Behaviors prescribed may vary in case of performance, degree of intrinsic reinforcement, and degree to which they evoke reinforcement from environment • Opportunity to practice and master target behaviors with feedback and reinforcement Environmental sources of influence Stimulus arrangements to encourage behavior change • Therapist characteristic • Behavioral models, significant others • Frequency of therapeutic contact • Involvement of family members • Involvement of peers • Prompts and reminders in natural environment • Specific goals • Displays of progress in natural environment • Fear communications Contingency arrangements • Financial or other material rewards for habit change • Social reinforcement • Vicarious reinforcement • Intermittent reinforcement • Continuing reinforcement by family members Personal sources of influence • Efficacy expectations • Basic knowledge of how to manage the disorder • Self-management skills

efficacy of performance. The opportunity to observe and practice target actions is also a critical behavioral source of influence. Environmental sources of influence include specific stimulus and contingency arrangements. While these are maintained, they are expected to encourage the needed changes in behaviors. The utility of these variables for producing and maintaining behavior change will vary according to the degree to which they can be maintained without special or unusual effort, encourage initial behavior change, and thus teach the person the skills necessary for reaching desired outcomes. Maintenance of change is not expected unless one or more sources of influence can be used consistently to promote continued use of target behaviors or strategies. Environmental influence sources should be especially efficacious in promoting lasting change. Personal sources of influence include knowledge of the disorder and methods for managing it. These are important sources of behavior change. Use of health behavior information depends upon personal motivation, personal risk, and perceived outcomes. Subject preferences may moderate outcomes. If a patient expresses preferences for specific treatment procedures or behavioral prescriptions, change and maintenance of change might be more likely than if the strategy or prescription was viewed negatively or even neutrally. Subject expectations regarding personal efficacy should mediate outcomes. Change and maintenance of change may be more likely if a person experiences success in a particular problem area or in using specific change techniques. Specific personal influence skills will influence the degree to which persons can develop and implement actions necessary for influencing their external environments. Practical therapeutic strategies. Table 6 presents specific steps for determining 1) what personal influence skills are needed and appropriate for specific problems and 2) how to arrange the environment to use personal influence strategies to reach personal objectives.

THE HEART HEALTH PROGRAM - A SOCIAL LEARNING NUTRITION CHANGE CURRICULUM

Immediate and maintained behavior change should be maximized when all sources of influence - behavioral, environmental, and personal-are employed simultaneously. For example, an ideal program for obese diabetics might 1) teach the person basic information about diabetes and its management, 2) use models and behavioral rehearsal to teach personal influence skills, 3) employ specific environmental sources of influence to promote immediate and successful behavior change, and 4) employ environmental influence sources to promote maintained behavior change and use of personal influence skills. Table 5 presents some potentially useful treatment variables derived from the model. Behavioral sources of influence provide the person with the experience of performing the target behavior under supervision. The person learns the motoric and cognitive components of the behavior and is given the opportunity to experience reinforcers potentially intrinsic to the behaviors. Behavioral sources are hypothesized as especially influential in modifying cognitive and environmental variables. Weight loss, modification of diet, and changes in activity patterns may vary in the difficulty with which they are accomplished and the degree to which they are naturally reinforced and hence maintained. In addition, whether or not the person has a choice in the focus of health behavior change may influence long-term maintenance of behavior patterns. Immediate and long-term behavior change may vary according to the choice, ease, and S 42

JOURNAL OF NUTRITION EDUCATION

The Heart Health Program is one example of a nutrition change program based on social learning principles (57). Two objectives guided the design of the Heart Health Program: 1) to increase elementary students' consumption of complex carbohydrates and to decrease their consumption of foods containing excess saturated fat, cholesterol, sodium, and sugar; and 2) to increase students' activity levels at the noon recess. We also expected to see evidence of knowledge and attitude changes for students participating in this program. The program was implemented in two elementary schools in two successive years. In each year, 3 fourth-grade classes in one school and 3 fifth-grade classes in a second school were involved. A time-series multiple baseline design was employed: lessons in the fifth-grade classes were lagged behind lessons in the fourthgrade classes. The program was developed to teach concepts and to promote significant behavior change using eight 45-minute class sessions over a four-week period. Six nutrition classes were followed by six exercise classes. The social learning/reciprocal interaction model guided the development of the overall curriculum and each specific class. Table 7 presents the principal components as they were applied in this program. As an example, the third class session introduced the concept of saturated fat and its relationship to atherosclerosis. Students first discussed items normally eaten for lunch. This was followed by an explanation of fat, the differences between saturated and VOLUME

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Table 6 Social learning strategies of change"

Strategy I - Define problem behavior • How does the problem break down into problem behaviors? • Acknowledge the behavior that needs to be changed Strategy 2- Develop and maintain commitment • Substitute more adaptive self-attributions about the nature of the problem • What "if-then" relationships do you see between certain actions and particular outcomes? • Identify and systematically anticipate several positive outcomes of your new behavior Strategy 3- Observe one's activities (self-monitoring) • What do you say to yourself about: (i) the behavior you want to change? (ii) your ability to change it? (iii) your progress? • Under what circumstances do you currently engage in the behavior you want to change? • How frequently or how much do you currently engage in the behavior you want to change? Strategy 4- Learn skills needed to enact self-management and/or target behaviors Strategy 5- Plan the environment • Establish a supportive environment: Teach family, friends, and/or associates how you would like them to help • Modify the stimuli or cues that evoke the behavior you want to change: (i) external-Rearrange your physical environment; (ii) internal- Alter undesirable internal cues such as thoughts and images • Develop a contract which specifies goals, behavior needed to attain those goals, and consequences for success and failure Strategy 6- Arrange consequences (behavioral programming) • Self-reward: (i) covert - Plan positive thoughts to follow successful actions; (ii) overt - Plan to give yourself or have someone give you a reward for success • Self-punishment: (i) covert (ii) overt aSource: Squyres, W., and T. J. Coates. A self-management approach to cardiovascular risk reduction: Management of the self and the environment. Unpublished manuscript, Johns Hopkins School of Medicine, 1980.

unsaturated fats, and usual sources of each (specify target behaviors). Food items were then divided into three parts: those containing large amounts of saturated fats, those containing predominantly unsaturated fats, and those containing relatively no fats (models). Students next divided into groups of three, inspected each others' lunches, discussed the relative amounts of fats (models) and decided how to prepare a heart healthy lunch (rehearsal). Students were given a handout to take home specifying food substitutes to decrease saturated fat content of their lunches (family involvement). Finally, each student chose a personal goal (behavioral commitment) indicating a specific food substitution to decrease the saturated fat content in his or her lunch. These goals were written on daily goal sheets which were checked by the teachers but kept by the students. Three elements of this program seemed most critical: behavioral commitment, feedback and incentives, and family involvement. Students often have difficulty translating general principles into specific behavior changes. The daily goal sheets, on which students made a written commitment to substitute specific "heart healthy" foods for foods normally in their lunches and to engage in "heart healthy" playground activities, seemed essential in promoting behavior change. Students knew precisely what had to be done to meet program goals and to earn available social rewards. VOLUME

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Table 7 Components of the Heart Health Program for elementary students"

Behavioral sources of influence Target behaviors • Students were encouraged to eat low cholesterol, low fat, low salt, and low sugar foods that they liked. • Students were encouraged to play heart healthy activities (e.g., handball, football, soccer) that they enjoyed at lunch. Behavioral rehearsal • Food taste tests were given; students were instructed in asking parents to pack specific foods in lunches, ordering heart healthy foods in restaurants, reading labels, and playing and organizing heart healthy activities. Behavioral commitment • Each day students wrote a specific food goal and a specific activity goal for the next day. Environmental sources of influence Models • Instructors were undergraduate students who practiced heart healthy eating and exercise; athletes came to class to give testimonials; outstanding students were used as models for others. Each concept or skill was modeled. Family • Families were informed of the program and asked to sign consent forms; the PTA was informed and asked to assist; handouts with simple prescriptions for change were sent home. Feedback and incentives • Outcome data were plotted and displayed during the course of the treatment; token rewards (e.g., stickers and stamps) were handed out to students who brought heart healthy lunches and exercised. Personal sources of influence • The rationale for the program and for target behavior changes was presented in a context of positive health and prevention of cardiovascular disease; competencies and efficacy was enhanced through training in the skills needed to have heart healthy foods in lunches and to play heart healthy activities at lunchtime. aAdapted from Coates, T. J., and C. P. Perry. Multifactor risk reduction with children and adolescents: Taking care of the heart in behavioral group therapy. In Behavioral group therapy: An annual review. Vol. 2. D. Upper and S. Ross, eds. Champaign, 111.: Research Press, 1980. Reprinted with permission. The feedback system, which provided students with objective information regarding their progress, seemed essential in motivating improvement. Students typically expressed amazement at how far they had progressed and also at how far they had to go in order to eat and exercise in heart healthy ways. An unplanned bonus was achieved when we presented data separately for boys and girls. The competition between the sexes was keen. The token incentive system proved to be enormously popular. Stickers, buttons, and a rubber stamp-all containing a heart (the logo of the Stanford Heart Disease Prevention Program)were used. The instructors circulated intermittently on the playground and dispensed hearts to students whose lunches contained a specified number of heart healthy food items or who were engaging in heart healthy activities. Students who earned heart stickers plastered them on lunch pails and notebooks. Students also insisted on having heart stamps on their books, papers, and hands. The tokens were important both in motivating and in cueing performance of desired actions and were especially effective when instructors appeared on the playground unannounced. The token reward system also served as a strategy to encourage behavior change at home. Heart healthy lunches, made JOURNAL OF NUTRITION EDUCATION

S 43

3.0

. 2.

School 1

'V

0

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•

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2. _______________________-::-c-_0-<-.-.....--'-=~"'-

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5 DAYS • The dotted line in each phase represents the mean for that phase, time-lagging treatment for School 2 behind School I permitted some control over extraneous factors potentially responsible for change.

Figure 4 Nutrition behavior changes for Heart Health Program Year I (Source: Coates, T. J., L. A. Slinkard, and R. W. Jeffery. Heart Healthy eating and exercise: Introducing and maintaining changes in health behaviors. American Journal ofPublic Health 71 (I): 15-23, 1981. Reprinted with permission.)

by parents or students, required students to negotiate the availability of specific food items. PTA involvement was a second method for reaching families. The PTA was encouraged to participate by calling friends and informing them of the program. Program evaluation was constructed using direct observation, paper-and-pencil measures, and phone interviews with parents. While the students were eating lunch, observers approached each student individually and wrote down the contents of his or her lunch. Following lunch, individual students were observed for a one-minute period. At each 5-second interval, the observer made a judgement regarding the student's activity level (sitting, standing, walking, climbing, running, standing still but moving upper trunk) according to pre-established operational definitions. Observer agreement, checked once weekly, was consistently high (mean percent agreement = .97, SD = 0.2). Following lunch, the observers inspected the trash and tabulated the items found. Paper-and-pencil questionnaires were administered to students before and after the classes to assess changes in knowledge, food, and activity preferences and eating at home. Foods in lunches were classified as "heart healthy" (target food items in the lessons) or "non-heart healthy." Figure 4 presents the nutrition behavior changes for the Year 1 study. At both schools the average daily number of heart healthy foods in students' lunches increased during the program, remained high following the program, and remained above baseline levels when follow-up data were collected. The postprogram data were collected at the end of the spring term. Follow-up data were collected in the fall following summer vacation. Students increased in knowledge and in reported performance for heart healthy foods and activities after the program. These results were maintained at follow-up. This initial experience led the researchers to revise the program so that it would be taught in six lessons. Each lesson contained a basic concept about the cardiovascular system, food targets, goal selection, taste tests, and reinforcement and feedback. The revised Heart Health Program was evaluated using a time-series design with time-lagged controls with 3 fourth-grade

S 44

JOURNAL OF NUTRITION EDUCATION

classes at one school, 2 fifth-grade classes at a second school, and an untreated control unit at the second school. As shown in Figure 5, Groups 1 and 2 changed significantly, while the control class did not. The significance ofthe Heart Health Program lies in its application of behavioral principles within the context ofregular educational programs to promote behavior change among all students. Because the program worked with groups of students rather than with individuals, program effects may have been enhanced. Undoubtedly, students modeled and reinforced changes in fellow students. Moreover, the Heart Health Program demonstrated the potential efficacy of using in-school programs to promote family change. Both student and family change were essential in ensuring the maintained changes we observed at follow-up.

TREATING THE COMMUNITY If the proposition is that the person's macroenvironments and microenvironments are especially important in influencing ongoing behavior then it follows that efficacious nutrition education and behavior change must involve these environmental variables. Sustained behavior change may require an environment which continues to cue and reinforce desirable patterns of behavior. In modifying any widespread pattern such as obesity or eating practices, both the environment and the individual may require clinical attention to produce clinically significant maintained change. Community-based interventions can be simple and yet have widespread effects. Brownell, Stunkard, and Albaum (58) observed persons in three public locations where stairs and escalators were adjacent to one another. They found that the obese used stairs significantly less frequently than nonobese persons. A sign placed near the base of the stairs to encourage stair use increased stair use by both obese and nonobese persons. Zifferblatt, Wilbur, and Persky (59) attempted to modify food choices in the employee cafeteria at the National Institute of Health by using playing cards. Employees received cards which offered messages about heart healthy eating each day the employees went through the food line. The cards could be turned in VOLUME

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Base Line

are being planned under the direction of H. Blackburn of the Laboratory of Physiological Hygiene at the University ofMinnesota; under the direction of A. Stunkard of the Department of Psychiatry at the University of Pennsylvania; and in Rhode Island under the direction of R. Carleton of Brown University.

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Days 2 4 6 8 10 1214 1618 2022242628303234363840 Weeks 1 2 3 4 5 6 7 8 9 Figure 5 Nutrition behavior changes for revised Heart Health Program (Source: Coates, T. J., and C. Perry. Multi-factor risk reduction with children and adolescents: Taking care of the heart in behavioral group therapy. In Behavioral group therapy: An annual review. Vol. 2. D. Upper and S. Ross, eds. Champaign, Ill.: Research Press, 1980. Reprinted with permission.) periodically for prizes for standard poker hands (e.g., three of a kind). During the eight-week intervention period, skim milk purchases increased and dessert and bread sales declined. Average number of calories purchased per day per person fell significantly. Some evidence of maintenance was provided during a ten-week follow-up. The Stanford Three-Community Study attempted behavior change for a total community (60,61). The objective was to promote changes in cardiovascular risk factors (blood pressure, tobacco use, serum cholesterol) through behavior change strategies. A quasi-experimental design was used in which one community served as a no-treatment control while treatment was applied to two other communities. The two treatment communities both received a multimedia campaign. An intensive face-to-face instruction program was also conducted in one of the communities for participants whose blood pressure or lipid levels placed them in a high risk category. The media campaign alone resulted in significant knowledge and behavior change. The intensive treatment program increased risk factor reductions for those participants judged initially to be high risk for cardiovascular disease. The objectives and scope of this research have been broadened into the Stanford Five City Multifactor Risk Reduction Program, which is currently underway in California. Community organization, health professional education, direct adult instruction, and programs in the schools will be added to a mass media campaign. Knowledge and behavior changes are expected to lead to changes in cardiovascular risk factors, which in turn are expected to lead to reduction in morbidity and mortality due to cardiovascular disease. Similar community-based programs VOLUME

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One-to-one or group counseling or education are commonly used to transmit nutrition information or to promote behavior change. All theories of counseling and therapy agree that counselor/educator behavior can promote positive outcomes. A positive counselor-client relationship seems to be a necessary but not sufficient precondition for change. Counselor actions can help the client formulate a specific action plan and implement it outside of the treatment setting (62). Russell, Insull, and Probstfield (63) developed a series of facilitative analysis/strategy skills for use by adherence counselors in the Coronary Primary Prevention Trial. Facilitative skills are designed to promote rapport between client and counselor, to promote self-disclosure by the client, and to avoid premature and hasty problem identification. Analysis and strategy skills are designed to help counselor and client develop a target problem, complete a behavior analysis, and develop and implement a plan for change. The American Heart Association and the National Heart, Lung and Blood Institute have also developed an outline of counseling strategies which parallel those developed by the Coronary Primary Prevention Trial Group but provide more specific information about goal and strategy development (64). Both outlines provide a framework for organizing and planning individual counseling sessions. However, promoting behavior change over a long period of time for the majority of persons involves manipulation of more variables than can be accomplished effectively in the one-to-one counseling framework. NEXT STEPS Where do we go from here? Can psychology make any contribution to nutrition education and nutrition behavior change? The tone of this paper has been critical; paradigms that promised to deliver on the basis of clever rhetoric and simple experiments (or experiments by the same experimenter and his or her progeny) have failed to withstand the test of replication. Behavior therapy continues to produce modest weight losses of short duration. Psychology, however, has not failed. Simply because psychologists have not delivered us into the promised land of skim milk and slim people does not mean that psychology has offered nothing to the nutrition education enterprise. Quite to the contrary, several contributions are noteworthy and important. What have we learned? I. We now know more about what we do not know. We know, for example, that the obese and nonobese are not necessarily different from each other in their responses to external and internal stimuli, eating style, characteristic home environment, amount of food they eat, and eating behavior in public situations. We know that complex methods will be needed to account for obese-normal differences. How and why they differ remains for future theory and research. 2. We know obesity will not be explained by simple dichotomous models. Obesity is a complex and perplexing state. To reduce its cause to simple formulations such as restraint, externality, or eating styles had great initial appeal but little empirical yield. We know that a transactional model which attempts to account for obesity in terms of interaction of internal JOURNAL OF NUTRITION EDUCATION

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and external variables is an important step forward in this research. 3. We have learned that obesity will not be treated easily. Obesity is refractory. Behavior modification was ushered in under a rhetorical promise and suffered from good press for far too long. The limits of the approach have finally been recognized so that we can move ahead to improve treatment and maintenance strategies. 4. Lecture and education lead to little behavior change. Many obese persons already know what to do in order to lose weight. Most persons know what kinds of foods they should be eating. Sustained behavior change is the elusive key. 5. Ongoing environmental support seems essential for immediate and sustained behavior change. Simply working with a person in an office may be relatively ineffective in helping that person to change. Attention is needed to the ways in which the environment can be structured to encourage immediate change and sustain those changes over time. Programmatic efforts may be more cost-effective than individual counseling contacts. 6. Programmatic and community-based approaches may yield substantial and cost-effective changes. The individualized counseling approach is easy to manage for one individual counselor or educator. Because the external environment appears enormously powerful, however, relatively greater yield might be obtained from programmatic environmental change efforts. Resources are always limited. Allocation of effort should be made on the basis of greatest expected yield. 7. An ideal weight loss/nutrition change program, based on the social learning model, might a) teach basic information, b) use models and behavior rehearsal, and c) employ environmental supports for immediate and sustained behavior change. 8. Specific counselor actions and strategies may be necessary, but not sufficient, conditions for change. Studies of counselorclient interchanges have identified specific counselor actions that facilitate report, problem identification, and strategy development and implementation. These can help in the process of client change but are not substitute for other change strategies. 9. We know more about how to find out what we know and do not know. Clinical practice in fields such as nutrition education often thrive on belief and tradition rather than the results of objective studies. The application of psychology to the field of nutrition has resulted in notable advances in research methods, measurement techniques, and psychotherapy research in general. Placebo controls, objective measures, component analyses, and long-term follow-ups have been developed in the attempt to improve weight loss programs. Even though advances in weight loss programs have not been notable in recent years, important improvements in research methods have been made in evaluating weight loss programs. Research methods: What have we learned? I. The research setting is not irrelevant. Information about behavior obtained under anyone set of conditions may not provide valid estimates of behavior under other conditions (65). Eating behavior is a prime example. Information derived from nutritional surveys of obese people has yielded the conclusion that overweight and obese persons eat no more than normalweight persons. Yet studies in metabolic wards have usually found that obese persons have larger caloric intakes than normal-weight persons (66). Studies of the internality-externality hypothesis have yielded the conclusion that the obese tend to eat more than the nonobese under certain stimulus conditions in the laboratory (5). ColI, Meyer, and Stunkard (67) found that S 46

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caloric content of food choice was influenced most strongly by food site. Tests of externality hypothesis have not been replicated in the natural environment (68). Results from anyone research setting cannot be used to provide definitive conclusions about any hypothesis related to eating or physical state. 2. The method of measurement is important. Studies of childhood obesity have found that obese children eat no more than their nonobese peers, but that the obese are far less active than normal-weight children. The conclusions, however, are based on self-report or parent report (69-71). Different patterns of results emerge when different measures are used. Waxman and Stunkard (72) observed obese children at home and at school. Siblings at home and peers at school served as normal-weight comparisons. The obese were far less active at home and equally active at school. The obese consumed more calories at lunch and at dinner than did the nonobese. Unexamined claims. 1. Juvenile onset obesity leads to a proliferation of fat cells, dooming the person to a life of overweight. The hypothesis is intriguing, but definitive empirical outcomes are lacking. Juvenileonset obesity mayor may not be correlated with excess fat cells, and excess fat cells mayor may not be associated with increased difficulty in losing weight. Because of its far-reaching and potentially damaging clinical implications, the position should be regarded as a hypothesis until definitive experiments can be completed.

2. Rapid weight loss results in regained weight while slow weight loss does not. Most weight losses, regardless of the speed with which they occur, are followed by weight gains (53). Fasting has been associated with clinically significant weight loss in adolescents (45), and success in weight loss programs has been correlated with losses experienced in the first week of the program (36). 3. Treatment should focus on changing eating behaviors, not on weight loss. The reported relationship between behavior change and weight loss among adults has been supported only weakly in several empirical studies. Only three studies have shown that eating behaviors were modified in behavioral treatment programs (34, 73, 74). BrownelI, Stunkard, and Albaum (58) point out that these studies' conclusions were based on a single self-report by the subjects, who may have been biased in their answers. Other studies using more comprehensive measures have not demonstrated relationships between behavior and weight changes (45, 52). Using direct observation, Coates and Thoresen (75) found correlations between behavior change and weight loss, but behavior changes were not uniform across subject. There is no single obese eating style in need of modification. Obese persons may be overweight for a variety ofreasons, one of which might be specific eating behaviors. Effective treatment programs may need to promote change directly and simply in those relevant activities. Questions that need to be answered. No paper would be complete without a statement of future direction and critical needs. The list could be quite long; four needs are listed so that their particular importance can be highlighted.

1. We still need to learn how to motivate persons for shortterm and long-term behavior change. Motivation is the key. Money, social support, family involvement, and intensive contact do help to sustain motivation. Community-based programs may be necessary to provide ongoing cultural support. How to VOLUME

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supply motivation in efficient and cost-effective ways remains problematic. 2. Maintenance is the therapeutic challenge of the next decade. We can help persons lose weight for short periods of time, but we are not yet even remotely successful in helping persons maintain weight losses. 3. How can emotions be integrated into a theoretical framework? Theories of nutrition behavior change are cognitive and presume that food choices are logical and rational. Little acknowledgement has been given to emotional factors that predispose a person to eat or exercise, emotional changes that occur following eating, and the multiple emotional and social functions that food serves in almost every society (76). Next to nothing is known about how to help persons manage and modify emotions that are related to eating and obesity. 4. How can pleasure be integrated into a theoretical framework? Theoretical formulations have emphasized environmental, physiological, cognitive, and cultural factors influencing eating and exercise. But persons do eat and exercise for pleasure as well. Eating may be a primary source of pleasure for many persons. Integrating pleasure into a theoretical frame and learning how to modify preferences or to supply equally potent sources of pleasure could promote one of the most important advances in nutrition education. Specific psychological approaches have produced plentiful writing but few definitive answers. Nonetheless, the psychological approach has been influential. Psychological perspectives have influenced the development of treatments of obesity and have promoted more rigorous evaluation of these procedures. Psychological methods have been important in providing some promising directions and in indicating what we do not yet know. This latter accomplishment may be psychology's most important contribution to nutrition education. 0 ACKNOWLEDGEMENT

Preparation of this manuscript was supported in part by Grant no. 1-R23-HL242927 from the National Heart, Lung and Blood Institute. NOTES

1 Rodin, J. Has the internal external distinction outlived its usefulness in obesity research? Paper presented at the meetings of the American Psychological Association, San Francisco, 1979. 2 Goldman, R. The effects of the manipulation of the visibility of food in the eating behavior of obese and normal subjects. Ph.D. dissertation, Columbia Univeristy, 1968. 3 Hibscher, J. D. The effect of free fatty acid and preload level on the subsequent eating behavior of normal weight and obese subjects. Ph.D. dissertation, Northwestern University, 1974. 4 Milstein, R. M. Responsiveness in newborn infants of overweight and normal weight parents. Ph.D. dissertation, Yale University, 1978. 5 Coates, T. J. et al. Frequency of contact and contingent reinforcement in weight loss, lipid change, and blood pressure reduction with adolescents. Behavior Therapy. In Press. 6 Coates, T. J. et al. Losing weight by mail and money: Weight loss in a correspondence course program. Presented at the meeting of the Association for the Advancement of Behavior Therapy, San Francisco, 1979. 7 Coates, T. J., L. A. Slinkard, and J. Killen. Weight loss with adolescents: Efficacy of parent involvement, frequent contact and reinforcement for weight loss. Presented at the meeting of the Association for the Advancement of Behavior Therapy, San Francisco, 1979. LITERATURE CITED

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