A white woman, age 48 years, with morbid obesity (BMI of 43.1 kg/m2
) initially wanted to change her sedentary lifestyle into a physically active one. A later goal (after 4 months of maintaining regular exercise) was to reduce her weight by half by also modifying her diet. Her physician supported those goals and communicated their links to improvements in her health. She joined a YMCA in the southeastern US that incorporated a standardized cognitive-behavioral protocol based on tenets of social cognitive theory and self-efficacy theory11
(The Coach Approach). This protocol previously had demonstrated success at reducing the typically high rates of dropout from newly initiated exercise.15
The Coach Approach has been fully described elsewhere.15
To summarize briefly, it consists of six 1-hour sessions over 6 months that address an array of self-regulatory and self-management skills (eg, productive self-talk, self-reward, preparing for specific barriers, recovery from lapses). Long-term goals are identified, documented, and broken down into process-oriented short-term goals where ongoing progress is tracked graphically. Behavioral contracting is also used when specific expectations (eg, “increase weekly cardiovascular exercise from 60 to 90 minutes”) are agreed on and formalized. A proprietary computer program serves to standardize the process.
The certified wellness specialist who facilitated the woman's one-on-one Coach Approach appointments continued meetings every 4 to 6 weeks beyond its completion to facilitate and support changes in eating behaviors, as well as to revise exercise modalities and volumes. Common themes throughout the meetings were as follows: 1) using self-regulatory skills (productive self-talk, self-reward, etc), 2) building self-efficacy (ie, feelings of ability and mastery) around health behavior change, 3) improving mood (eg, anxiety, depression, fatigue, vigor), and 4) logging all exercises completed via another computer program (FitLinxx, Shelton, CT) and logging consumption of food and associated kcal in a personal journal. According to the theoretical basis of the behavior-change processes, self-regulatory skills were intended to address common barriers that challenge maintained exercise and appropriate eating (eg, discomfort, social pressure). Taking long-term goals (eg, “lose 50 lb [22.7 kg] within 1 year”), breaking them down into short-term process goals (eg, “have soup prior to a meal to curb hunger”; “participate in at least 1 group exercise class each week”), and viewing progress through constant logging of corresponding data were intended to promote self-efficacy. Exercise alone, sometimes supplemented with mind-body modalities (eg, tai chi, yoga), was intended to improve both short-term and long-term mood.
The 4 months of exercise before the subject initiated energy reduction would theoretically enable a transfer of exercise-related improvements in self-regulation skills, self-efficacy, and mood to attain and sustain improvements in eating behaviors and a maintained healthy weight. More specifically, improved self-talk and feelings of behavioral control would transfer from adapting to exercise to adapting to controlled eating, whereas exercise-induced mood changes would improve emotional eating. Daily goals for energy intake were modified approximately every 3 months on the basis of current weight. For example, when the woman's weight was 118 kg (Month 1), the daily goal was 1800 kcal. When her weight was 68 kg (Month 30), the goal was 1300 kcal. Guidelines were followed to reduce daily energy intake between 500 and 1000 kcal below the projected energy requirement for weight maintenance, but not below 1200 kcal.16
Data available for our analyses were derived from physician records; the FitLinxx exercise recording device; and the personal food log, which also included responses to items on self-regulation, self-efficacy, and mood initiated within The Coach Approach (adapted from validated inventories). Responses to these items ranged from 1 to 10, with 1 denoting an extreme negative response (eg, not at all; never
) and 10 denoting an extreme positive response (eg, extremely; often
). Weekly self-weighing was cross-checked with physician records for accuracy. Recording of energy intake and expenditure was cross-checked with validated calorie conversion tables, which adjusted for the present weight.17
The 6-month Coach Approach treatment was included in the YMCA membership, and a fee for the additional individual meetings was paid by the subject.