A comparison of a self-control and a contract procedure for weight control

Technology-based versus in-person deposit contract treatments for promoting physical activity

Deposit contracts involve participants depositing their own money and earning it back contingent on behavior change. Deposit contracts are empirically supported treatments for promoting health behavior, but they have a history of poor uptake. We compared the effectiveness and acceptability of technology-based versus in-person deposit contracts for promoting physical activity with 12 individuals. Participants' daily step counts were monitored using Fitbits across 6 weeks, and treatment preferences were assessed at the end of the study. The 2 types of treatments were equally effective in increasing physical activity, but the technology-based deposit contracts were preferred by most participants. Most participants also reported that their preference was related to convenience. Technology-based implementation may be one way to improve deposit contract uptake, while maintaining similar effectiveness compared to in-person procedures.

The challenge of keeping it off, a descriptive systematic review of high-quality, follow-up studies of obesity treatments

The aim of this systematic review is to answer the question: Is substantial, stable, and long-term weight loss a viable goal for adults with obesity? To answer this question, we conducted a broad systematic search of non-surgical and non-pharmacological obesity treatment studies with the following strict criteria: (a) minimum 3-year follow-up, (b) 5% body mass lost, (c) no continued interventions in the follow-up-period, (d) prospective design, and (e) less than 30% attrition from the start of the follow-up period. While the search revealed a very large number of published articles, only eight studies met the inclusion criteria. Several of the nonincluded studies report a majority of participants achieving satisfactory weight loss and little regain, especially among studies with continued interventions during the follow-up period. In contrast, the eight high-quality studies included in this study demonstrate a trend of weight regain towards pretreatment baseline. This review concludes that the majority of high-quality follow-up treatment studies of individuals with obesity are not successful in maintaining weight loss over time. The results suggest that excess weight can be lost but is likely regained over time, for the majority of participants.

Rational-Emotive Therapy: Research Data That Supports The Clinical and Personality Hypotheses of RET and Other Modes of Cognitive-Behavior Therapy

This article examines 32 important clinical and personality hypotheses of rational-emotive therapy (RET) and other modes of cognitive-behavior therapy and lists a large number of research studies that provide empirical confirmation of these hypotheses. It concludes that (1) a vast amount of research data exists, most of which tends to confirm the major clinical and personality hypotheses of RET; (2) this data keeps increasing by leaps and bounds; (3) RET hypotheses nicely lend themselves to experimental investigation and therefore encourage a considerable amount of research; (4) researchers have not yet tested some of the major RET formulations and could do so with profit to the field of psychotherapy and personality theory.

Accelerating Dissertation Writing: Case Study

In an application of Zimmerman's productive avoidance technique, to accelerate dissertation writing, an S who had postponed writing her dissertation for 2 yr. deposited $50 in cash with E. Five dollars was returned each week to S contingent on 5 pages of writing being submitted; otherwise the money was mailed to a church organization S intensely disliked. After the eighth week a draft was complete, and S's committee requested only minor revisions; treatment was suspended. As revisions had not been made 6 wk. later, contingencies were reinstated. A complete final draft was finished within a week.

Cholesterol Reduction among Volunteers in a Health Promotion Project

Behavioral contracting was used with moderate success as a primary intervention strategy in an urban clinic-based health promotion program designed to reduce serum cholesterol. Of the 223 adults screened, 144 had high serum cholesterol. One hundred and eighteen attended an interpretation/education session, and 51 participants agreed to sign a behavioral contract. Among those who signed contracts, adherence to American Heart Association dietary guidelines was significantly related to serum cholesterol changes. Eleven of the 46 adults who returned for the six-month clinical assessment reduced their cholesterol levels to recommended levels.

Weight loss intervention adherence and factors promoting adherence: a meta-analysis

BACKGROUND

Adhering to weight loss interventions is difficult for many people. The majority of those who are overweight or obese and attempt to lose weight are simply not successful. The objectives of this study were 1) to quantify overall adherence rates for various weight loss interventions and 2) to provide pooled estimates for factors associated with improved adherence to weight loss interventions.

METHODS

We performed a systematic literature review and meta-analysis of all studies published between January 2004 and August 2015 that reviewed weight loss intervention adherence.

RESULTS

After applying inclusion and exclusion criteria and checking the methodological quality, 27 studies were included in the meta-analysis. The overall adherence rate was 60.5% (95% confidence interval [CI] 53.6-67.2). The following three main variables were found to impact adherence: 1) supervised attendance programs had higher adherence rates than those with no supervision (rate ratio [RR] 1.65; 95% CI 1.54-1.77); 2) interventions that offered social support had higher adherence than those without social support (RR 1.29; 95% CI 1.24-1.34); and 3) dietary intervention alone had higher adherence than exercise programs alone (RR 1.27; 95% CI 1.19-1.35).

CONCLUSION

A substantial proportion of people do not adhere to weight loss interventions. Programs supervising attendance, offering social support, and focusing on dietary modification have better adherence than interventions not supervising attendance, not offering social support, and focusing exclusively on exercise.

The Role of External Variables in Self-Reinforcement

The present paper reviews self-reinforcement research in behavior modification. This research suggests that a wide range of responses can be altered, including classroom deportment, academic performance, and studying as well as eating behaviors, smoking, nail-biting, and others. A major area of debate in the self-reinforcement literature is the extent to which external influences contribute to or account for behavior changes usually attributed to self-control. Without embracing a particular conceptual position, examination of the research suggests that several external variables might contribute to self-reinforcement procedures. These variables are rarely acknowledged in investigations as possible sources of influence and include a history of external control in the experiment, criterion setting for the response, self-monitoring, surveillance of the self-reinforcement process, instructional sets, and direct reinforcement or punishment contingencies for the self-reinforcing response or the target behavior. Investigation of these variables will help enumerate both the conceptual basis of self-reinforcement and reveal procedures to enhance the effects of self-reinforcement as a behavior modification technique.

Behavioral Contracting in an Urban Health Promotion Project

A health promotion project involving 223 participants was conducted by the Department of Family Medicine at Wayne State University in Detroit, Michigan. Participants were screenedforfive cardiovascular riskfactors: blood lipids, obesity, smoking, blood pressure and physical fitness; they were reassessed at six-month and two-year intervals. Following the initial screening, participants were asked to meet with the project health educator to sign one or more "behavioral contracts" to make behavior or life-style changes designed to improve risk factor status. Individual and group interventions were provided to all interested clients. Of the individuals screened, 179 of the 223 returned for at least one health counseling session. Contractors were most successful in improving exercise habits and making dietary changes to reduce cholesterol. These changes were reflected in improved treadmill performance and significant reductions in serum cholesterol. Smokers and the overweight showed poor success rates, few smokers were willing to sign a smoking cessation contract, and there was a high dropout ratefrom weightcontrol counseling.

The importance of community consultation and social support in adhering to an obesity reduction program: results from the Healthy Weights Initiative

BACKGROUND

Few community-based obesity reduction programs have been evaluated. After 153 community consultations, the City of Moose Jaw, SK, Canada, decided to initiate a free comprehensive program. The initiative included 71 letters of support from the Mayor, every family physician, cardiologist, and internist in the city, and every relevant community group including the Heart and Stroke Foundation, the Canadian Cancer Society, and the Public Health Agency of Canada.

OBJECTIVE

To promote strong adherence while positively influencing a wide range of physical and mental health variables measured through objective assessment or validated surveys.

METHODS

The only inclusion criterion was that the individuals must be obese adults (body mass index >30 kg/m(2)). Participants were requested to sign up with a "buddy" who was also obese and identify three family members or friends to sign a social support contract. During the initial 12 weeks, each individual received 60 group exercise sessions, 12 group cognitive behavioral therapy sessions, and 12 group dietary sessions with licensed professionals. During the second 12-week period, maintenance therapy included 12 group exercise sessions (24 weeks in total).

RESULTS

To date, 243 people have been referred with 229 starting. Among those who started, 183 completed the program (79.9%), while 15 quit for medical reasons and 31 quit for personal reasons. Mean objective reductions included the following: 31.0 lbs of body fat, 3.9% body fat, 2.9 in from the waist, 2.3 in from the hip, blood cholesterol by 0.5 mmol/L, systolic blood pressure by 5.9 mmHg, and diastolic blood pressure by 3.2 mmHg (all P<0.000). There were no changes in blood sugar levels. There was also statistically significant differences in aerobic fitness, self-report health, quality of life measured by Short Form-36, and depressed mood measured by Beck Depression Inventory-II (all P<0.000). Independent risk factors for not completing the program were not having a family member or friend sign a social support contract (odds ratio 2.91, 95% confidence interval 1.01-8.34, P=0.047) and lower education (odds ratio 2.90, 95% confidence interval 1.20-7.03, P=0.018).

CONCLUSION

Comprehensive obesity reduction programs can be effective when there is extensive consultation at the community level and social support at the individual level.

A theoretically grounded systematic review of material incentives for weight loss: implications for interventions

BACKGROUND

Providing material incentives for weight loss is a class of intervention strategies that has received considerable attention; however, the effectiveness of this class of strategies is uncertain. Attending to distinctions among incentive strategies may clarify our understanding of prior work and inform the design of future interventions.

PURPOSE

A theoretical framework is proposed that distinguishes between four classes of incentive strategies and is used to organize randomized controlled trials of material incentives for weight loss.

METHODS

A systematic literature review was conducted.

RESULTS

Findings were mixed with regards to the overall efficacy of material incentives for weight loss. Three of the four proposed incentive categories are represented in the literature. Heterogeneous methods were used across studies rendering comparisons between studies difficult.

CONCLUSIONS

Definitive conclusions about the usefulness of material incentives for weight loss could not be drawn. A theoretically grounded approach to designing and testing incentive strategies is encouraged.

Financial incentives and weight control

This paper reviews research studies evaluating the use of financial incentives to promote weight control conducted between 1972 and 2010. It provides an overview of behavioral theories pertaining to incentives and describes empirical studies evaluating specific aspects of incentives. Research on financial incentives and weight control has a history spanning more than 30 years. Early studies were guided by operant learning concepts from Psychology, while more recent studies have relied on economic theory. Both theoretical orientations argue that providing financial rewards for losing weight should motivate people to engage in behaviors that produce weight loss. Empirical research has strongly supported this idea. However, results vary widely due to differences in incentive size and schedule, as well as contextual factors. Thus, many important questions about the use of incentives have not yet been clearly answered. Weight-maintenance studies using financial incentives are particularly sparse, so that their long-term efficacy and thus, value in addressing the public health problem of obesity is unclear. Major obstacles to sustained applications of incentive in weight control are funding sources and acceptance by those who might benefit.

Systematic review of the use of financial incentives in treatments for obesity and overweight

Nine studies met the criteria for inclusion in this systematic review of randomized controlled trials of treatments for obesity and overweight involving the use of financial incentives, with reported follow-up of at least 1 year. All included trials were of behavioural obesity treatments. Justification of sample size and blinding procedure were not mentioned in any study. Attrition was well described in three studies and no study was analysed on an intention to treat basis. Participants were mostly women recruited through media advertisements. Mean age ranged from 35.7 to 52.8 years, and mean body mass index from 29.3 to 31.8 kg m(-2). Results from meta-analysis showed no significant effect of use of financial incentives on weight loss or maintenance at 12 months and 18 months. Further sub-analysis by mode of delivery and amount of incentives although also non-statistically significant were suggestive of very weak trends in favour of use of amounts greater than 1.2% personal disposable income, rewards for behaviour change rather than for weight, rewards based on group performance rather than for individual performance and rewards delivered by non-psychologists rather than delivered by psychologists.

Improving health professionals' management and the organisation of care for overweight and obese people

BACKGROUND

Obesity is increasing throughout the industrialised world. If left unchecked it will have major implications for both population health and costs to health services. Health professionals have a key role to play in tackling the obesity problem, but little is known about how they may be encouraged to work more effectively with overweight and obese people.

OBJECTIVES

The main objective was to determine whether health professionals' management or the organisation of care for overweight and obese people could be improved.

SEARCH STRATEGY

We searched the specialised registers of the Cochrane Effective Practice and Organisation of Care Group (May 1997), the Cochrane Depression, Anxiety and Neurosis Group (August 1997), the Cochrane Diabetes Group (August 1997), the Cochrane Controlled Trials Register (September 1997), MEDLINE to January 1998, EMBASE to December 1997, Cinahl (1982 to November 1997), PsycLit (1974 to December 1997), Sigle (1980 to November 1997), Sociofile (1974 to October 1997), Dissertation Abstracts (1861 to January 1998), Conference Papers Index (1973 to January 1998), Resource Database in Continuing Medical Education. We also hand searched seven key journals and contacted experts in the field.

SELECTION CRITERIA

Randomised trials, controlled before-and-after studies and interrupted time series analyses of providers' management of obesity or the organisation of care to improve provider practice or patient outcomes. We addressed three a priori comparisons and a fourth post hoc comparison. 1. Interventions aimed at improving health professionals' management or the delivery of health care for overweight/obese patients are more effective than usual care. 2. Interventions aimed at redressing negative attitudes and related practices towards overweight/obese patients are more effective than usual care. 3. Organisational interventions designed to change the structure of services for overweight/obese people are more effective than educational or behavioural interventions for health professionals. 4. Comparisons of different organisational interventions.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Twelve studies were included involving more than 393 providers and 3392 patients. Four studies were identified for comparison 1. Three were professional-oriented interventions (the use of reminders and training) and the fourth was a study of professional and organisational interventions of shared care. No studies were identified for comparisons 2 or 3. Eight studies were identified for post hoc comparison 4. These compared either the deliverer of weight loss interventions or the setting of interventions. The included studies were heterogeneous and of generally poor quality.

REVIEWER'S CONCLUSIONS

At present, decisions about improving provision of services must be based on the evidence of patient interventions and good clinical judgement. Further research is needed to identify cost effective strategies for improving the management of obesity.

Patient compliance behavior: the effects of time on patients' values of treatment regimens

Present medical models of treatment compliance have not addressed the role that time plays in the perception of a treatment regimen's costs and benefits. This paper re-evaluates the role of time in understanding compliance behavior. Models from the economic and psychological literature are used to demonstrate that the 'discounting effect' associated with future events, and the 'sunk cost effect' associated with past events may have a direct and predictable impact on the patient's values in health care choices. This article suggests that when the effects of time are incorporated into expectancy models of compliance behavior (such as the Health Belief Model) the resulting predictions are supported by numerous findings in the compliance literature, many of which were previously unaccountable by these expectancy models. From this finding an explanation is derived for the variable results of educational and attitudinal change programs upon compliance behavior, the success of patient contracts, the sudden occurrence of preference reversals in health care choices, and the 'confusing' effect of treatment cost on treatment adherence. This paper also introduces to the compliance literature the concept of a treatment's 'time adjusted rate of return', and speculates upon how this concept may be used to understand the relationship between a treatment's 'desirability' or its ability to motivate a person to start the treatment, and its 'resistance' or its capacity to help a person to finish the treatment once it has begun. It proposes that changes in the temporal distribution of a treatment's benefits and costs can improve the treatment's desirability and resistance, and that a treatment's time adjusted rate of return can be used to allocate more efficiently the effort that providers spend monitoring patient compliance.

Contingency contracting to enhance patient compliance: a review

Researchers and practitioners have expressed considerable interest in contingency contracting as a promising intervention strategy for enlisting patient cooperation, particularly with regard to long-term treatment regimens. After brief examination of the theoretical background, the authors summarize advantages of contracting, describe elements essential to the development of a contract, and enumerate those ingredients in the contracting process thought to be critical for achieving optimal results. They review relevant research efforts in terms of their designs, methods, target and contracted health-related behaviors, contingencies employed, and initial and follow-up results. On the basis of this review, current issues regarding contingency contracting are raised, and practical considerations for large-scale application are noted along with recommendations for future research.

Does patient education in chronic disease have therapeutic value?

A pool of 320 articles on patient education were screened to select controlled experiments in chronic disease where the dependent variables included (a) compliance with therapeutic regimen, (b) physiological progress of patients or (c) long-range outcome. Thirty such articles were found; and the magnitude of experimental effects of patient education were calculated using an empirical form of integrating research findings known as meta-analysis. Summary of all experimental effects showed patient education most successful in altering compliance (average improvement = 0.67 sigma over control, p less than 0.05). However, average improvements in physiological progress (0.49 sigma) and health outcome (0.02 sigma) were also statistically significant (p less than 0.01 and p less than 0.05, respectively). Efforts to improve health by increasing patient knowledge alone were rarely successful. Behaviorally-oriented program, often with special attention to changing the environment in which patients care for themselves, were consistently more successful at improving the clinical course of chronic disease.

Strategies for enhancing patient compliance

Patient noncompliance is a substantial obstacle to the achievement of therapeutic goals. This paper reviews a number of practical interventions with demonstrated efficacy in enhancing patient adherence, including (1) improving patients' levels of information concerning the specifics of their regimens, reinforcing essential points with review, discussion, and written instruction, and emphasizing the importance of the therapeutic plan, (2) taking clinically appropriate steps to reduce the cost, complexity, duration, and amount of behavioral change required by the regimen and increasing the regimen's convenience through "tailoring" and other approaches, (3) obtaining a compliance-oriented history of the patient's prior experiences and present health beliefs and, where necessary, employing strategies to modify those perceptions likely to inhibit compliance, (4) improving levels of patient satisfaction, particularly with the provider-patient relationship, (5) arranging for the continued monitoring of the patient's subsequent compliance to treatment, (6) increasing staff awareness of the magnitude and determinants of the noncompliance phenomenon and attempting to develop an "active influence orientation" in each member of the health care team, (7) using such techniques as patient-provider contracts to involve the patient in therapeutic decisions and in the setting of treatment objectives and creating incentives (through rewards and reinforcements) for achieving these objectives, (8) arranging for as much continuity of provider (and other staff) as possible, (9) establishing methods of supervising the patient, including involvement of the patient's social support network, and (10) involving fully the assistance of all available health care providers, assigning specific roles and responsibilities for activities directed at improving adherence to treatment.

The effect of contract witnessing on motivation and weight loss in a weight control program

To investigate the impact which commitment has on the achievement of behavioral-change goals in a weight control program, a behavioral contracting process was used. One-hundred six adult volunteers were randomly identified as treatment or control group members and co-participated in a four-week, eight-hour, behavioral self-management weight control program. As part of homework assignments, all participants were provided with three take-home contracts which were to be returned either signed by the participant only (control group with baseline commitment) or by the participant and at least one friend, relative, or peer (treatment group with enhanced commitment). Analyses of comparable treatment and control group members shows the treatment group holding significantly stronger behavioral intentions 10 to 15 weeks after the program ended and losing weight at a significantly faster rate. Implications for program planning, implementation, and evaluation are discussed.

Personality and morbid obesity. Implications for dietary management through behavior modification

Psychological investigations have failed to reveal a distinct personality type or psychodynamic conflict pattern in moderately and massively obese persons. Many of the psychological problems noted in the obese such as anxiety, depression, and poor self-esteem seem to be the result of, rather than the cause of, the obese state. Morbidly obese persons share an addictive behavior pattern that is also seen in persons with other types of addictions. The extent of their obesity points to the strong substance abuse component of the eating disorder. Behavior modification programs aimed at changing problematic eating patterns and teaching self-management skills in relation to food consumption have been moderately successful and have been shown to result in a mean post-treatment weiht loss of seven to 16 pounds. However, the majority of morbidly obese persons will not lose enough weight to make this an effective treatment program for them.

Predicting successful weight loss after treatment

Conducted two 8-week behavioral self-control weight reduction groups to investigate the relationship between locus of control and success at weight reduction (N = 49 female Ss). Mean weight losses were significant at post-treatment and after a 3-month and 18-month follow-up. There was no significant difference in weight loss between internals and externals at post-treatment, but internals maintained a significantly greater weight loss than externals at the follow-ups. These results are discussed with regard to self-control behavior.

Exercise prescription: a clinical trial

To assess the effectiveness of physician prescribed exercise, health education, and patient self-monitoring, 124 firefighters were medically screened and randomly allocated to a control and two treatment groups. Physiologic and reporting methods were employed to assess adherence to regular exercise at three months and six months after the initial exercise prescription. Addition of a health education program significantly improved compliance over that achieved by a physician consultation. Self-monitoring did not produce a further increase in compliance. Improvement in the treatment groups was limited to three months after prescription; at six months, the treatment and control populations had similar exercise patterns.

Preferred versus nonpreferred treatment and self-control training versus determination raising as treatments of obesity: a pilot study

Of 12 overweight women half received 10 wk. of self-control training and the rest received an equal period aimed at increasing determination to lose weight. Half of each treatment group had expressed a preference for the type of treatment they received and half for the other type of treatment. Both groups lost a statistically significant amount of weight, and at a 3-mo. follow-up there was still a significant weight loss. Follow-up at 6 mo. on 9 of the 12 original subjects indicated both groups regained much of their lost weight. There was no evidence that either type of treatment or receiving one's preferred type of treatment was related to weight loss.

II. In vivo self-control training

2 groups of 9 overweight women received 12 sessions of self-control training in the presence of fattening foods. In one group self-control was followed by eating a low-calorie food. Results were compared with 2 control groups. Weights for 12 wk. pretreatment and 12 and 24 wk. posttreatment were collected. Only the group receiving self-control training and a substitute low-calorie food lost significant average weight (—8.89 lb.) during treatment. Subject differences between groups preclude firm identification of the reason for this. By 24 wk. posttreatment an average 7.33 lb. had been regained. Comparable studies indicating success with group behavior therapy have either no or inadequate follow-up, or other shortcomings. There is no reliable evidence to date that group behavior therapy will result in permanent weight loss.