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1.  From Morbid Obesity to a Healthy Weight Using Cognitive-Behavioral Methods: A Woman's Three-Year Process With One and One-Half Years of Weight Maintenance 
The Permanente Journal  2012;16(4):54-59.
Background: Obesity is a national health problem regularly confronting medical professionals. Although reduced-energy (kilocalorie [kcal]) eating and increased exercise will reliably reduce weight, these behaviors have been highly resistant to sustained change.
Objective: To control eating using theory-based cognitive-behavioral methods that leverage the positive psychosocial effects of newly initiated exercise as an alternate to typical approaches of education about appropriate nutrition.
Method: A woman, age 48 years, with morbid obesity initiated exercise through a 6-month exercise support protocol based on social cognitive and self-efficacy theory (The Coach Approach). This program was followed by periodic individual meetings with a wellness professional intended to transfer behavioral skills learned to adapt to regular exercise, to then control eating. There was consistent recording of exercises completed, foods consumed, various psychosocial and lifestyle factors, and weight.
Results: Over the 4.4 years reported, weight decreased from 117.6 kg to 59.0 kg, and body mass index (BMI) decreased from 43.1 kg/m2 to 21.6 kg/m2. Mean energy intake initially decreased to 1792 kcal/day and further dropped to 1453 kcal/day by the end of the weight-loss phase. Consistent with theory, use of self-regulatory skills, self-efficacy, and overall mood significantly predicted both increased exercise and decreased energy intake. Morbid obesity was reduced to a healthy weight within 3.1 years, and weight was maintained in the healthy range through the present (1.3 years later).
Conclusion: This case supports theory-based propositions that exercise-induced changes in self-regulation, self-efficacy, and mood transfer to and reinforce improvements in corresponding psychosocial factors related to controlled eating.
PMCID: PMC3523938  PMID: 23251120
2.  Supported Exercise Improves Controlled Eating and Weight through Its Effects on Psychosocial Factors: Extending a Systematic Research Program Toward Treatment Development 
The Permanente Journal  2012;16(1):7-18.
Background: Behavioral weight-loss treatments have been overwhelmingly unsuccessful. Many inadequately address both behavioral theory and extant research—especially in regard to the lack of viability of simply educating individuals on improved eating and exercise behaviors.
Objective: The aim was to synthesize research on associations of changes in exercise behaviors, psychosocial factors, eating behaviors, and weight; and then conduct further direct testing to inform the development of an improved treatment approach.
Methods: A systematic program of health behavior-change research based on social cognitive theory, and extensions of that theory applied to exercise and weight loss, was first reviewed. Then, to extend this research toward treatment development and application, a field-based study of obese adults was conducted. Treatments incorporated a consistent component of cognitive-behaviorally supported exercise during 26 weeks that was paired with either standard nutrition education (n = 183) or cognitive-behavioral methods for controlled eating that emphasized self-regulatory methods such as goal setting and caloric tracking, cognitive restructuring, and eating cue awareness (n = 247).
Results: Both treatment conditions were associated with improved self-efficacy, self-regulation, mood, exercise, fruit and vegetable consumption, weight, and waist circumference; with improvements in self-regulation for eating, fruit and vegetable consumption, weight, and waist circumference significantly greater in the cognitive-behavioral nutrition condition. Changes in exercise- and eating-related self-efficacy and self-regulation were associated with changes in exercise and eating (R2 = 0.40 and 0.17, respectively), with mood change increasing the explanatory power to R2 = 0.43 and 0.20. Improved self-efficacy and self-regulation for exercise carried over to self-efficacy and self-regulation for controlled eating (β= 0.53 and 0.68, respectively).
Conclusions: Development and longitudinal testing of a new and different approach to behavioral treatment for sustained weight loss that emphasizes exercise program-induced psychosocial changes preceding the facilitation of improved eating and weight loss should be guided by our present research.
PMCID: PMC3327117  PMID: 22529754
3.  Relationship of Exercise Volume with Change in Depression and Its Association with Self-Efficacy to Control Emotional Eating in Severely Obese Women 
Introduction. Exercise may improve one's perceived ability to control overeating related to negative emotions through psychological pathways such as reduced depression; however, the volume required is unclear. Methods. Severely obese women (N = 88) participated in a 24-week exercise and nutrition treatment incorporating self-regulatory skills training, and were assessed on depression, self-efficacy, self-regulatory skills usage, weight, and waist circumference, at baseline and treatment end. Results. Subjects completing low-moderate (40–149.9 minutes/week) and public health (≥150 minutes/week) volumes of exercise had significant and similar reductions in depression scores. No significant changes were found for those completing <40 minutes/week. For all subjects aggregated, depression change was significantly related to change in self-efficacy to control emotional eating; however, this relationship was completely mediated by changes in self-regulatory skill usage. When changes in depression, self-efficacy, and self-regulatory skills usage were entered into multiple regression equations as predictors, only self-regulatory skill changes explained significant unique portions of the overall variance in weight and weight circumference change. Discussion. Exercise of less than half the public health recommendation was associated with depression improvement, with no dose-response effect. Changes in depression, self-efficacy, and self-regulation may be salient variables to account for in behavioral weight-loss treatment research.
doi:10.4061/2011/514271
PMCID: PMC3226245  PMID: 22135751
4.  Behaviorally Supported Exercise Predicts Weight Loss in Obese Adults Through Improvements in Mood, Self-Efficacy, and Self-Regulation, Rather Than by Caloric Expenditure 
The Permanente Journal  2011;15(1):23-27.
Background: The relationship of exercise to weight loss, beyond minimal caloric expenditures possible in obese and deconditioned individuals, requires clarification.
Objective: We assessed whether changes in theory-based psychological variables associated with participation in an exercise treatment extended to psychologically based predictors of controlled eating and weight and waist-circumference reductions.
Methods: A group of 137 adults with severe obesity (mean body mass index, 42.2 kg/m2) volunteered for an exercise-support and nutrition-education treatment of 26 weeks' duration that was based on social cognitive theory. Exercise- and eating-related measures of mood, self-regulation, and self-efficacy were obtained at baseline and at treatment end, along with weight, waist circumference, and exercise volume. Analyses were also conducted separately for women participants only (n = 102).
Results: Treatment-induced changes in total mood disturbance, self-regulatory skill usage for exercise, and exercise self-efficacy were significantly related to changes in self-efficacy to control emotional eating, self-regulatory skill usage for controlled eating, and overall self-efficacy for controlled eating, respectively (p < 0.001). Changes in the eating-related measures significantly predicted changes in weight and waist circumference with adjusted R2 values from 0.15 to 0.21 and 0.28 to 0.30, respectively (p < 0.001). Post-hoc testing indicated a strong negative correlation between exercise completed and weight change (r = −0.62); however, only 12.4% of the observed weight change was accounted for through associated caloric expenditures.
Conclusion: Exercise may support weight loss primarily through psychological rather than physiological pathways. Although the models tested were viable, additional modifiable variables may further strengthen the prediction of weight and waist-circumference change and benefit weight-loss theory and treatment outcomes.
PMCID: PMC3048629  PMID: 21505614
5.  Effects of 12- and 24-Week Multimodal Interventions on Physical Activity, Nutritional Behaviors, and Body Mass Index and Its Psychological Predictors in Severely Obese Adolescents at Risk for Diabetes 
The Permanente Journal  2010;14(3):29-37.
Background: Although 7% of US adolescents have impaired fasting glucose, a precursor of type 2 diabetes, research has suggested that few interventions for obese adolescents at risk for diabetes have been effective. Therefore, pediatricians seek effective behavioral treatments for referral for this age group.
Objective: We wanted to determine the effects of two different durations of nutritional and exercise treatments on changes in nutrition, physical activity, body mass index (BMI), and psychological predictors of BMI change in overweight and obese adolescents at risk for type 2 diabetes.
Methods: We obtained data from 64 pediatrician-referred patients with diabetes risk factors (mean age, 14.1 years; BMI, ≥99th percentile.) Study participants were assigned to nutrition and exercise treatments for 12 weeks (n = 35) or 24 weeks (n = 29). A specific weight-loss goal was given only for the 24-week group.
Results: Both treatments demonstrated significant within-group changes over 12 weeks in days per week of physical activity of at least 60 minutes, physical self-concept, general self, and overall mood. However, they failed to demonstrate significant 12-week increases in fruit and vegetable intake, decreases in sweetened-beverage consumption, or decreases in BMI. Between-group differences were found only in mood changes in favor of the 12-week treatment. In the 24-week treatment, BMI change from week 12 to week 24 was significantly better than corresponding normative data (d = 0.37). Physical self-concept, general self, and mood scores at week 12 explained a significant portion of the variance in BMI change (R2 = 0.13, p = 0.04).
Conclusion: Nutrition education alone may be insufficient for nutrition behavior change. Behavioral treatment lasting longer than 12 weeks and having a specific weight-loss goal may be useful for BMI improvements, and attention to participants' self-concept and mood may be important treatment considerations.
PMCID: PMC2937842  PMID: 20844702
6.  Changes in Theory-Based Psychological Factors Predict Weight Loss in Women with Class III Obesity Initiating Supported Exercise 
Journal of Obesity  2010;2010:171957.
Background. Psychological factors' effect on weight loss is poorly understood, in general, and specifically in the severely obese. Objective. To examine whether a behavioral model based on tenets of social cognitive and self-efficacy theory will increase understanding of the relationship between exercise and weight loss. Methods. Fifty-one women with severe obesity participated in a 24-week exercise and nutrition information treatment and were measured on changes in psychological factors and exercise attendance. Results. A significant portion of the variance in BMI change (adjusted for number of predictors) was accounted for by the behavioral model (R2adj = 0.23). Entry of exercise session attendance only marginally improved the prediction to 0.27. Only 19% of the weight lost was directly attributable to caloric expenditure from exercise. Conclusions. Findings suggest that participation in an exercise program affects weight loss through psychological pathways and, thus, may be important in the behavioral treatment of severe obesity.
doi:10.1155/2010/171957
PMCID: PMC2911610  PMID: 20700411
7.  Weight Loss and Psychologic Gain in Obese Women—Participants in a Supported Exercise Intervention 
The Permanente Journal  2008;12(3):36-45.
Background: Physical activity is a predictor of maintained weight loss; however, causal mechanisms are unclear. Behavioral theories suggest that associated psychologic changes may indirectly affect weight loss.
Objective: We sought to test the association of a behaviorally based exercise support protocol (The Coach Approach [CA]), with and without a group-based nutrition education program (Cultivating Health), with adherence to exercise and changes in physiologic and psychologic factors, and to assess theory-based paths to weight and body-fat changes.
Setting: The study took place in YMCA wellness centers.
Study subjects: Study participation was open to formerly sedentary obese women.
Design: Study participants were randomly assigned to the CA Only (CA; n = 81), The CA Plus Cultivating Health (CA/CH; n = 128), or the control (n = 64) group. We contrasted dropout and attendance rates and changes in self-efficacy (SE), physical self-concept (PSC), total mood disturbance (TMD), body areas satisfaction (BAS), and select physiologic factors during a six-month period. We also analyzed proposed paths to weight loss.
Results: The CA and CA/CH groups had significantly lower exercise dropout rates (χ2 = 44.67, p < 0.001) and higher attendance rates (F = 10.02; p < 0.001) than the control group did. Improvements in body fat, body mass index (BMI), and waist circumference were significant for only the CA and CA/CH groups. Significant improvements in TMD, PSC, and BAS scores were found for all groups, with effect sizes greater in the groups incorporating the CA protocol. Within the five paths assessed, entry of changes in TMD and BAS scores into multiple-regression equations, along with SE and PSC scores, increased the explained variance in exercise session attendance from 5% (p = 0.01) to 16% (p < 0.001). Exercise session attendance was significantly associated with changes in body fat (r = −0.41; p < 0.001) and BMI (r = −0.46; p < 0.001).
Conclusion: Counseling based on social cognitive and self-efficacy theory may increase exercise adherence and improve variables indirectly related to weight and body-fat reductions. Although decreases in body fat and BMI were obtained, they appeared less pronounced than psychologic improvements. Additional research on interrelations of physical activity, psychologic factors, and weight change is warranted for development of obesity treatments.
PMCID: PMC3037122  PMID: 21331208
8.  Relationship of Initial Self-Regulatory Ability with Changes in Self-Regulation and Associated Fruit and Vegetable Consumption in Severely Obese Women Initiating an Exercise and Nutrition Treatment: Moderation of Mood and Self-Efficacy 
An emphasis on increasing self-regulation is an alternate to nutrition education, which has had poor results in the behavioral treatment of obesity. Although appropriately designed weight-loss treatments may enhance one’s self-regulatory ability to control eating, whether improvements are moderated by psychosocial factors such as initial self-regulatory skills use, self-efficacy to control eating, and mood is unknown. Severely obese women (BMI 35-50 kg·m-2) were randomized into 26-week treatments of exercise supported by cognitive-behavioral methods paired with either nutrition education (n = 114) or cognitive-behavioral methods applied to controlled eating (n = 121). Improvement in self-regulation for controlled eating was 36.9% greater (p < 0.01) for the group incorporating cognitive-behavioral methods for controlled eating. Change in self-regulation was significantly associated with self-regulation at baseline (β = -0.33). Both mood and self-efficacy for controlled eating significantly moderated this relationship. Increased self-regulation was associated with both increases in fruit and vegetable consumption and fruit and vegetable intake at treatment end. The present findings increase our understanding of psychosocial variables associated with increased self-regulatory skills usage and improvements in eating that, after replication, may be used to improve the effects of behavioral weight-loss treatments.
Key pointsInitial self-regulatory abilities do not appear to affect improvements in self-regulation for eating, however direct training in behavioral skills are predictors of change.The relationship of self-regulation improvements and improved eating is significant, and affected by mood and self-efficacy in women with obesity.Instruction in behavioral skills such as cognitive restructuring and relapse prevention is associated with better improvements in eating than typical methods of nutrition education.Cognitive-behavioral methods for exercise may be paired with cognitive-behavioral methods for eating to maximize longer-term effects on eating behaviors.
PMCID: PMC3761514  PMID: 24149553
Behavioral treatment; cognitive-behavioral; health psychology; obesity treatment; self-regulation
9.  LETTERS: OBESITY BEHAVIOR CHANGE 
The Permanente Journal  2011;15(1):91.
PMCID: PMC3048653  PMID: 21505637
10.  Relations of self-regulation and self-efficacy for exercise and eating and BMI change: A field investigation 
Objectives
This study aimed to assess relations of self-regulatory skill use with self-efficacy for exercise and appropriate eating, and the resulting change in weight associated with participation in a nutrition and exercise treatment supported by cognitive-behavioral methods.
Methods
Adults with severe obesity (N = 95; mean BMI = 40.5 ± 3.9 kg/m2) participated in a 6-month exercise and nutrition treatment emphasizing self-regulatory skills. Changes in self-regulatory skills usage, self-efficacy, overall mood, and BMI were measured. Relations of changes in self-regulatory skill use and self-efficacy, for both physical activity and appropriate eating, were assessed, as was the possibility of mood change being a mediator of these relationships. Indirect effects of the variables associated with the present treatment on BMI change were then estimated.
Results
For both exercise and appropriate eating, changes in self-regulation were associated with self-efficacy change. Mood change partially mediated the relationship between changes in self-regulation for appropriate eating and self-efficacy for appropriate eating. Self-efficacy changes for physical activity and controlled eating, together, explained a significant portion of the variance in BMI change (R2 = 0.26, p < 0.001). The total indirect effect of the treatment on BMI change was 0.20.
Conclusion
Findings suggest that training in self-regulation for exercise and eating may benefit self-efficacy and weight-loss outcomes. Thus, these variables should be considered in both the theory and behavioral treatment of obesity.
doi:10.1186/1751-0759-4-10
PMCID: PMC2941739  PMID: 20815891
11.  Relations of Self-Appraisal and Mood Changes with Voluntary Physical Activity Changes in African American Preadolescents in an After-School Care Intervention 
There is an increasing prevalence of overweight in preadolescents that predicts physical problems over the lifespan. Physical inactivity has been implicated as an associated factor, with African American youth being at an increased risk. Based on social cognitive theory, and proposed correlates of physical activity in youth, changes over 12 weeks in measures of self-appraisal (general self, physical appearance, physical self-concept, exercise barriers self-efficacy) and mood (tension, vigor), and their relations with voluntary physical activity changes, were assessed within an after-school care physical activity intervention. Participants were volunteers recruited from children already registered for a 12-week segment of YMCA after-school care. The treatment group consisted of 146 African American preadolescents with the control group comprised of 123 African American preadolescents who were scheduled to receive the program during the next sequence that it was offered. Results indicated the intervention group reported significantly more positive self-appraisals, reduced tension, and enhanced vigor. Bivariate and multiple regression analyses indicated that when each of the 4 self-appraisal and 2 mood factors were simultaneously entered into a regression equation, 36% of the variance in voluntary physical activity was explained. Findings support the treatment's association with theoretically based correlates of physical activity in the present sample, and suggest directions for physical activity interventions for youth.
Key pointsSocial cognitive theory offers a framework for understanding correlates of physical activity in youth.This study suggests that it is possible for a convenient physical activity intervention, led by after-school care counselors with minimal training, to improve participants' self-perceptions, mood, and voluntary physical activity.Improvements in self-perceptions and mood appeared to be significantly associated with increased free-time physical activity in African American 8- to 12-year-olds.This study's findings may lead to a better understanding of physical activity promotion in youth, and foster improvements in physical activity curricula.
PMCID: PMC3761451  PMID: 24149459
Physical activity; exercise; body mass index; youth; health behavior

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