OBESITY 0889-8529/96 $0.00 + .

20

BEHAVIORAL THERAPY
FOR OBESITY
Donald A. Williamson, PhD, and Lori A. Perrin, PhD

Behavioral approaches have been widely adopted as an effective treatment

strategy for the management of obesity. The earliest descriptions of behavioral
strategies for obesity were published over 30 years ago.", 30 The approach was
initially called behavior modification. Later, the term behavioral therapy was used to
describe essentially the same procedures. More recently, strategies to alter thought
processes, attitudes, and emotions have been added to traditional be-havioral
approaches. This set of techniques is called cognitive-behavior therapy. All of these
approaches share the same basic goals-modification of eating and exercise to yield
"lifestyle behavior change."
Evidence of the widespread acceptance of behavioral treatment approaches for
obesity is seen in the fact that virtually all commercial weight management
programs, for example, NutriSystems and Weight Watchers, include a behavior
modification component. Recent recommendations of a government panel on the
problem of obesity emphasized lifestyle behavior change as the first and most
important step in the treatment of obesity.Z0In this article, we review the evolution
of research on behavior management approaches for obesity and describe current
research findings concerning the effectiveness of this approach.

HISTORICAL PERSPECTIVE

Ferster and colleagues" and Stuart30 were the first researchers to apply
behavioral treatment methods to obesity. In his seminal report, Stuart described the
application of the principles of learning to the modification of eating habits, nutrient
intake, and activity/exercise. Stuart described the treatment of ten obese subjects
using an individualized approach. Two of the ten subjects dropped out of treatment.
Of the remaining eight subjects, all lost more than 9 kg, and three

From the Pennington Biomedical Research Center (DAW, LAP) and the Psychological
Services Center, Department of Psychology (DAW), Louisiana State University, Baton
Rouge, Louisiana

ENDOCRINOLOGY AND METABOLISM CLINICS OF NORTH AMERICA

VOLUME 25 * NUMBER 4 - DECEMBER 1996 943

944 WILLIAMSON & PERRIN

lost more than 18 kg. At that time, obesity was generally considered to be an
intractable medical Therefore, the impressive results of Stuart’s initial uncontrolled
clinical report were received with considerable enthusiasm. In 1972 Stuart and
Davis31published a behavioral treatment manual entitled, Slim Chunce in a Fat
World, which described the behavioral approach in more detail.
Over the next few years, enthusiasm for behavioral therapy for obesity
increased.2 During the 1970s, behavioral treatment was generally administered in
small groups of six to ten persons using a schedule of one therapeutic meeting per
week for about 12 to 16 weeks. This protocol yielded average weight loss of about 4
to 5 kg.4,45
As research on behavioral therapy progressed, studies with measurement of weight
at long-term follow-up (1 to 5 years) were p ~ b l i s h e d .These~,~~reports indicated
that most obese persons treated with behavioral therapy regained much of the weight that
had been lost during active treatment. The publication of these findings led to tests of
strategies which promoted maintenance of weight loss over extended periods of time after
behavioral treatment. Weight maintenance strategies which were tested included the
inclusion of family mem-bers in treatment, booster sessions, longer treatment periods,
telephone contacts to facilitate lifestyle changes, and financial reinforcement strategies.
Most recently, research has focused on methods which yield increasingly larger
amounts of weight loss for longer periods of time. This research has investigated the
effectiveness of combining behavioral therapy with very low calorie diets and with
appetite suppressant medications.

BEHAVIORAL TREATMENT STRATEGIES

Basic Philosophy and Theory

Behavioral therapy is based on the basic principles of learning. These princi-ples

have been established through many studies of the processes by which animals and
humans learn habits, develop expectancies about the consequences of behavior, and
change behavior in response to new environmental demands? In applying these
principles to obesity, one must first link behavior to the biologic basis of obesity.
Most behavioral programs conceptualize obesity as being determined by positive
energy balance whereby the person consumes more energy via eating than is
expended by basal metabolic needs and activity. Weight loss occurs when there is
negative energy balance whereby total energy consumed exceeds total energy
expenditure. The relationships between eating and caloric intake and between activity
and caloric expenditure are illustrated in Figure 1. The behavioral targets of
behavioral therapy for obesity are de-creased eating and increased activity. According
to behavioral theory, appetitive behaviors such as eating are reinforced and
strengthened by the inherent he-donic qualities of food and by the reduction of
hunger.z,43 The negative conse-quences of overeating, that is, weight gain, are
delayed and thus have less impact than the immediate positive and negative
reinforcers of taste and reduc-tion of hunger. Exercise, especially for obese persons,
is inherently aversive in that it produces fatigue, discomfort, and is often
inconvenient; yet, in the long-term, it yields fitness, weight loss, and improved health.
Therefore, increased activity through exercise often leads to immediate negative
consequences and substantially delayed positive consequence^.^^ The net result is
that basic motiva-tional principles such as reinforcement and punishment promote
increased eating and decreased activity which results in gradual weight gain and, ulti-
 BEHAVIORAL THERAPY FOR OBESITY 945

Weight - Total energy Total energy

-
change - intake expenditure

energy

t
Figure 1. Relationship between energy balance, behavior, and the behavioral targets of
behavior therapy.

mately, chronic obesity. These habits are presumed to be conditioned to various

environmental and biologic cues so that unhealthy habits, for example, eating in
response to watching television or resting rather than exercising after work, are
strengthened over time. The goals of behavioral therapy are to alter these habits through a
systematic lifestyle change program. Behavior management programs are thus designed
to modify eating and exercise habits gradually so that negative energy balance is
achieved and loss of body weight occurs. An implicit assumption of the original
behavioral philosophy was that once the person’s lifestyle habits were modified, they
would be maintained by naturally occurring reinforcers, for example, satisfaction with
lower weight and greater stamina. Current data suggest that biologic factors related to
energy regulation may be more powerful than naturally occurring reinforcers, which has
led to treatment methods which combine behavioral and pharmacologic treatment

Stimulus Control

Stimulus control of behavior refers to the influence of antecedent conditions on

eating.’ For example, riding home from work could set the occasion for snacking, or
watching sports events on television could become associated with drinking beer or
soft drinks. Procedures for modifying stimulus control involve altering the
antecedents for problematic behavior, such as overeating or inactiv-ity, and
developing stimuli which prompt and facilitate healthy behavior. Table 1 provides a
list of specific stimulus control techniques. These techniques are applied on an
individualized basis as indicated by initial assessment of the presence and absence of
healthy and unhealthy eating and exercise habits3’

Reinforcement

In behavioral theory, reinforcement refers to the process by which the frequency

and intensity of behavior are strengthened by its consequences.’ Behaviors that are
strengthened by positive consequences are positively rein-forced; behaviors that
remove or avoid aversive consequences are negatively reinforced. Therefore,
overeating is positively reinforced by pleasant taste and
946 WILLIAMSON & P E M N

Table 1. BEHAWOR THERAPY TECHNIQUES FOR TREATING PATIENTS WITH

OBESITY
Stimulus control techniques
Eat three meals per day.
Eat at approximately the same time and place at each meal.
Eat while seated at table.
Eliminate distractions from enjoying food.
Place foods on small plate.
Slow pace of eating by placing utensil(s) on table between bites.
Pause at the end of meal to evaluate satiety level.
Avoid purchasing problematic foods.
Do not serve high-calorie condiments.
Clear plates directly into garbage.
Serve foods in small quantities.
Do not consume second servings.
Reinforcement techniques
Reward changes in behavior, not changes in weight.
Do not reward behavior by eating food.
Select tangible reinforcers, such as money or clothing.
After completing a behavioral goal, immediately receive reward.
Self-monitoring
Monitor antecedent conditions for eating and exercise.
Monitor nutrient intake.
Monitor exercise/energy expenditure.
Monitor emotional antecedents for eating.
Monitor hunger before and after eating.
Behavioral contracting
Specify clearly defined behavioral goals.
Specify time frame for achieving behavioral goals.
Gradually change habits to achieve final target.
Set realistic goals.
Establish contract for behavior change, not weight change.
Social support
Select a supportive partner.
Educate partner about how to help you.
Thank your partner for his or her support.
Make specific requests.
Let partner help with difficult tasks.

negatively reinforced by the reduction of hunger. It is essentially impossible to alter

these natural reinforcement contingencies other than by strategies which reduce
feelings of hunger, for example by not skipping meals or by taking appetite
suppressant medications. For this reason, reinforcement strategies are typically used
to modify the pattern of eating and exercise habits. Eating three meals per day at
approximately the same times and places might be reinforced by the attainment of $5
per day for a clothing allowance to be used once the person has reached a lower body
weight. Suggestions for the application of reinforcement strategies are provided in
Table 1.

Self-Monitoring

Most behavioral therapy programs for obesity recommend self-monitoring of

eating and exercise habits. The purposes of self-monitoring are (1) increasing
awareness of habits, (2) assessment of eating and exercise habits, and ( 3 )assess-
 BEHAVIORAL THERAPY FOR OBESITY 947

ment of the person's motivation to comply with the treatment ~ r o g r a mSelf.~-

monitoring of eating generally involves recording the types of foods and amounts
consumed, environmental emotional antecedents of eating, the time of day, social
factors surrounding eating, and levels of perceived hunger before and after
eating.43Table 1 summarizes the basic principles for self-monitoring. These
principles can be applied to exercise/activity and social support as well.

Behavioral Contracting

Behavioral contracting is used to integrate the concepts of stimulus control and

reinforcement to modify eating and exercise habits.& Behavioral contracts are
written agreements developed by the obese patient, therapist, and other group
members. A typical contract specifies a goal for gradual behavior change, such as
eating three meals per day, and the reward for meeting the behavioral goal. The
behavior therapist has a very important role in successful implementa-tion of the
behavioral contract. First, contracts must be individualized and clearly stated.
Second, the behavior therapist must gradually alter the behavioral goals so that they
can be realistically achieved and ultimately lead to significant behavior change over
the course of treatment. Finally, the behavior therapist must be skillful in helping the
obese patient solve problems which interfere with the achievement of behavioral
goals. In Table 1, additional useful tips for the effective use of behavioral contracts
are provided.

Social Support

In their test, Slim Chance in a Fat World, Stuart and Davis3' describe how to
reprogram the social environment to promote the modification of eating and exercise
habits. They suggest that the patient identify one friend or family member who can
provide social support and reinforcement for behavior change. In Table 1, we present
several principles to guide the effective employment of a social support agent in the
treatment of obesity. Behavioral therapy programs for obesity have typically enlisted
social support in one of two ways: (1) the patient personally trains and educates the
support person, or (2) the support person actively participates in treatment by attending
therapy sessions, monitor-ing the patient's behavior, altering his or her own eating and
exercise habits, and providing reinforcement for behavior change.

Weight Maintenance Strategies

With the discovery that the regaining of weight following treatment is very
common, behavioral researchers turned their attention to strategies directed at relapse
prevention and long-term therapeutic contact.

Relapse Prevention
Strategies that are designed to identify at-risk situations for relapse are identified
throughout behavioral treatment. Toward the end of the formal treat-ment period,
patients are trained to engage in actions which prevent relapse, such as assertively
refusing fattening foods at a party. When small lapses occur,
948 WILLIAMSON & PERRIN

patients are trained to use problem-solving strategies to prevent a small lapse from
developing into a full relapse.44

Booster Treatments
Perri and colleaguesz1,z4, 25 reported on a series of studies which examined
strategies directed at weight maintenance. These approaches included the use of
booster sessions and telephone contact after the end of formal treatment and
substantial increases in the overall length of treatment.

EFFECTIVENESS OF BEHAVIORAL THERAPY

Progress has been made in the effectiveness of behavioral treatments, partic-

ularly during the past decade.5,45 In early studies, weight losses were approxi-mately
1 pound per week in behavioral programs lasting approximately 8 weeks. These
programs primarily focused on modifying eating habits. Current programs are more
comprehensive in nature and have added cognitive restruc-turing and increased
emphasis on exercise and social support to the traditional behavioral weight loss p r ~
g r a mAverage.~ weight loss has increased from 3.8 kg in 1974 to 8.8 kg in 1995.
Over this sample period, the average length of treatment increased from 8.4 to 20.7
weeks. Table 2 provides a summary of behavioral studies from 1974 to 1995 in the
following journals: Addictive Behau-iors, Behavior Therapy, Belzaviour Research
and Therapy, and the Journal of Consulting and Clinical Psychology. Because of the
declining number of studies examining behavioral therapy alone, we chose to include
studies combining behavioral therapy with very low calorie diets.
The literature shows that weight loss increases with length of treatment.
However, the average weight loss per week has remained fairly constant at 0.5
kg/week. Therefore, the increase in total weight loss in recent studies seems to be the
result of longer treatment. In a meta-analysis of behavioral treatment studies, Bennetr
found that greater weight loss was associated with treatment duration, hours of
therapist contact, therapist experience, use of a rigorous diet,

Table 2. SUMMARY OF RESEARCH ON BEHAVIORAL THERAPY FOR OBESITY

(1974 TO 1995)
1991-1995

Parameter 1974 1978 1984 1985-1987 1986-1990 BT BT + VL'

Number of studies 15 17 15 13 5 3 4
Sample size 53.1 53.1 54.0 71.3 71.6 97.3 114.5
Initial weight (kg) 73.4 87.3 88.7 87.2 91.9 93.3 104.5
Weeks of treatment 8.4 10.5 13.2 15.6 21.3 20.7 21.1
Weight loss (kg) 3.8 4.2 6.9 8.4 8.5 8.8 22.0
Loss per week (kg) 0.5 0.4 0.5 0.5 0.4 0.5 1.1
Percent attrition 11.4 12.9 10.6 13.8 21.8 17.0 24.0
Weeks of follow-up 15.5 30.3 58.4 48.3 53.0 43.0 71.0
Loss at follow-up 4.0 4.1 4.4 5.3 5.6 7.9 12.1

BT = behavioral therapy; VL = very low calorie diet.

'Behavioral therapy plus very low calorie diet was included because much of the behavioral therapy
for obesity includes a very low calorie diet.
Data from 7974 to 7990 from Wadden TA, Vanltailie TB: Treatment of the Seriously Obese Patient.
New York, Guilford Press, 1992.
 BEHAVIORAL THERAPY FOR OBESITY 949

the use of exercise during therapy sessions, family involvement, and the provi-sion
of drugs.
Several studies have reported impressive weight loss using behavioral ther-apy. In a
study using monetary contracting, average weight losses in the group reported on by Jeffrey
and co - w~rkers'~were 13 kg. Other ~ t u d i e s ' ~have,~~ , ~ ~ reported average weight
losses ranging from 12 to 14 kg. In all of these studies, intensive behavioral therapy
programs were employed.
Recently, researchers have begun to study the occurrence of binge eating in
obese persons. Approximately 30% of all obese patients seeking treatment meet the
diagnostic criteria for binge-eating disorder as described by Spitzer and
colleagues.2RSeveral studies have found that obese individuals who binge eat
respond poorly to weight loss treatment.', 15, l6 Cognitive behavioral treatment has
been shown to be effective treatment for binge-eating disorder without a weight loss
emphasis." Agras and co-workers' suggested that binge eating should be decreased
or eliminated before beginning weight loss treatment.
Several studies have found that social support can be used to promote the
maintenance of weight 46 Epstein and co-workers'" compared a group attended by
both child and parent in which both were reinforced for behavior change and weight
loss, a child group in which child behavior change was reinforced, and a nonspecific
control group which reinforced families for atten-dance to groups. The children in
the child and parent group showed significantly greater decreases in the percentage
of overweight at 5-year and 10-year follow-up in comparison with children in the
nonspecific control group. Children in the child only group were midway between
the parent and child group and the nonspecific group but did not differ from either of
the other two groups. Perri and co-workersZ4examined the effects of peer support on
long-term weight maintenance by using behavioral therapy plus a "buddy group." In
the buddy group, regular meetings were held in which the group members weighed
in, supported each other for their success, and used problem-solving strategies to
manage life stressors. Patients in the buddy group maintained 4.5 kg of an original
6.1 kg loss. Patients who received behavioral therapy without the buddy group
maintained only 0.4 kg of an original 5.6 kg weight loss. In a study of the effect of
involving spouses as support agents, Murphy and colleagues" found that such
intensive involvement of marital partners resulted in an average weight loss of 7.2
kg. At 2-year follow-up, only the program with intense involvement of spouses was
associated with maintenance of weight loss. Over the course of 2 additional years of
follow-up, these subjects regained most of the weight they had lost, however.IR
Behavioral programs are effective for mildly obese persons, but the average
weight loss produced by these programs is not sufficient for moderately or seriously
obese persons. Consequently, behavior therapists have recently at-tempted to
increase weight losses by increasing the length of treatment and by combining
behavioral therapy with other treatment modalities such as pharma-cotherapy and
very low calorie diets.36

LENGTH OF TREATMENT AND WEIGHT LOSS

As noted previously, increasing the duration of behavioral therapy has been

associated with increased weight loss. Craighead and co-workersXtreated patients
for 26 weeks using a behavioral program and reported average weight
losses of 10.8 kg. Wadden and S t ~ n k a r reported~ ~ average weight losses of 14
kg after 26 weeks of behavioral treatment. Perri and co-workersZs reported
950 WILLIAMSON & PERRIN

average weight losses of 13.5 kg at the end of 20 weeks and an additional 2.25 kg
(total of 15.75 kg) after an additional 26 weeks of bimonthly meetings. In a 52-week
controlled trial of behavioral treatment, patients lost 11.9 kg after 26 weeks and 2.5
kg (total of 14.4 kg) in the following 26 ~ e e k s . These3~ long-term studies suggest
that there may be an upper limit to the average weight loss produced by behavioral
therapy of about 10 to 15 kg. The majority of weight loss seems to occur in the first 6
months of treatment, with weight loss tapering off in the following months.

BEHAVIORAL THERAPY AND VERY LOW CALORIE DIETS

Very low calorie diets (usually, about 600 kcal per day), which are carefully
designed to minimize body protein loss, have been shown to produce safely the most
rapid rates of weight loss possible.6,39The development of very low calorie diets
was an outgrowth of fasting (total starvation) and a desire to achieve larger and more
rapid weight loss than with conventional diets. Very low calorie diets generally
produce average weight losses of about 15 to 20 kg for 12 weeks of treatment.27, 36, 39
The primary problem associated with very low calorie diets is the regain of
weight after completion of the diet. Several studies have compared very low calorie
diets with and without behavioral therapy.z7,37, 38, 47 The addition of behavioral
therapy during the active treatment period did not yield significant weight loss above
that associated with very low calorie diets alone; however, over the course of follow-
up periods ranging from 1 to 5 years, the addition of behavioral therapy was
associated with a slower rate of regaining weight. One study found that 32% of
patients in the behavioral therapy plus very low calorie diet group maintained weight
loss at 1-year follow-up as compared with 5% of persons in the group receiving only
a very low calorie diet.37In a study compar-ing behavioral therapy, a very low
calorie diet, and behavioral therapy plus a
very low calorie diet, Wadden and S t ~ n k a r reported~ ~ average weight losses of
14, 14, and 19 kg, respectively, after 6 months of treatment. Thus, the behavioral
therapy plus very low calorie diet group had the best initial results. However, at 18-
month follow-up, weight losses were 9.4 kg for the behavioral therapy group and
12.8 kg for the behavioral therapy plus very low calorie diet group. The very low
calorie diet group regained the greatest amount of weight, main-taining a 4.6-kg loss
at 18 months. At 3-year follow-up, average weight losses were 4.8 kg for the
behavioral therapy group, 3.8 kg for the very low calorie group, and 6.5 kg for the
behavioral therapy plus very low calorie diet group.4O There were no differences
among groups at 5-year follow-up.37
Wing and c o - w ~ r k e r sreported~~ similar results. They compared a 20-week
behavioral therapy program with a behavioral therapy plus very low calorie diet
program and found that the behavioral therapy group averaged 10.1 kg of weight loss
as compared with an average weight loss of 18.6 kg for the behav-ioral therapy plus
very low calorie group. No group differences were found at 1-year follow-up,
however. Based on these studies, very low calorie diets when used in combination
with behavioral techniques seem to produce superior initial weight losses. The
addition of behavioral therapy did not enhance the mainte-nance of weight loss over
several years of follow-up, however.

BEHAVIORAL THERAPY AND PHARMACOTHERAPY

The first drug treatment for obesity, thyroid hormone, was introduced in 1893
and was widely used until after World War 11. Amphetamines became
 BEHAVIORAL THERAPY FOR OBESITY 951

available pharmalogically in the 1930s and were found to produce weight loss by
reducing appetite. Pharmacotherapy using amphetamines was the principal drug
treatment during the 1 9 5 0 ~Amphetamines.~~ were associated with drug
dependence in many individuals and rapid regain of weight following the
termination of medication. For these reasons, pharmacotherapy for obesity was
essentially abandoned until the last 15 years.
Recently, behavioral programs have been combined with contemporary anorectic
medications such as, nonamphetamines. In a recent study, the effects of behavioral
therapy combined with caffeine and ephedrine were examined.3s Results indicated
average weight losses of 16 kg for the behavioral therapy and ephedrine plus caffeine
group, 14 kg for behavioral therapy plus ephedrine, 11 kg for behavioral therapy plus
caffeine, and 13 kg for the placebo group. In a 6-month treatment study, behavioral
therapy, fenfluramine, and behavioral ther-apy plus fenfluramine groups were
compared? Results indicated average weight losses of 10.8, 14.4, and 15.3 kg,
respectively. One-year follow-up data indicated that the fenfluramine group regained
8.1 kg, the behavioral therapy plus fenfl-uramine group, 10.8 kg, and the behavioral
therapy group, only 1.8 kg. It was concluded that patients who had received
fenfluramine regained weight far more rapidly after treatment than those who had
received only behavioral therapy; thus, adding fenfluramine compromised the effects
of behavioral ther-apy. In a later study, Weintraub4’ examined the combination of
fenfluramine, phentermine, and behavioral therapy. Short-term results indicated that
patients in the fenfluramine and phentermine plus behavioral therapy group lost more
weight in comparison with the placebo plus behavioral therapy group. Weight loss
was sustained for 3.5 years as long as patients remained on the combination of drugs.
Long-term results indicated that weight was regained after drug withdrawal. These results
are similar to the findings of Craighead and col-leagues.* Based on current research
findings, long-term use of fenfluramine and phentermine leads to long-term maintenance.
The addition of behavioral therapy to active medication does not prevent regaining weight
after medication is withdrawn, however.

PROBLEM OF POST-TREATMENT WEIGHT GAIN

The main problem associated with all treatments of obesity is a slow return to
baseline weight after the treatment intervention ends.I2 In a review of the literature,
Wadden and Bell36found that from 25% to 55% of subjects regained their weight at
48-week follow-up. Longer follow-up periods of 3 to 5 years also show a general
return to baseline weights.’ It has become increasingly apparent that obesity cannot
be treated with an acute-care model in which patients attend treatment meetings for
15 to 25 weeks and then are asked to maintain their new
behavioral skills and weight losses forever on their Instead, obesity must be treated
as a chronic disease, similar to hypertension, and should be treated with ongoing
medical and behavioral therapy.
Strategies that are effective for weight loss may not be effective for weight
maintenance. Although individuals losing weight are taught to restrict markedly their
diets (avoid fattening foods), they are not taught how to eat normal foods in
moderation, a habit which is needed for long-term weight maintenance. The ability
to lose weight is reinforced by others. Maintenance of weight loss fre-quently is not
reinforced. In fact, dieters tend to forget about their accomplish-ments, as do their
family members.36Wadden and BelPh advocate a two-step approach for weight
maintenance. The basic strategy consists of keeping a
952 WILLIAMSON & PERRIN

diet diary, exercising regularly, and recording and charting weight. Relapse
prevention includes having the skills to respond immediately to an over-eating or
small-weight-gain crisis.
Dieters are vulnerable to the abstinence violation effect in which the dieter feels
guilt and despair for having engaged in what he or she perceives as inappropriate
eating beha~i0r .Guiltl~ and despair from this violation lead to a loss of self-efficacy
or perceived ability to be in control of weight and eating habits. Consequently, long-
term maintenance programs need to focus on teach-ing cognitive behavioral
strategies for coping with dietary lapses before they become relapses. Identifying
high-risk situations before they occur and devising strategies for handling these
situations are critical for long-term successful weight maintenance. Dieters need to
have an arsenal of problem-solving tech-niques; they also need to have easy access to
return to treatment if they need to do so. Often, these lapses and relapses occur once
treatment has ended; conse-quently, they are embarrassed to return to treatment.
Perri and colleagueszzz4.-26 conducted a series of studies examining weight loss
maintenance strategies. Subjects receiving 20 weeks of behavioral treatment without
maintenance were compared with subjects receiving the same 20 weeks of treatment
followed by 1 year of biweekly maintenance meetings. At 1 year follow-up, the
subjects who received the year of maintenance sessions main-tained weight loss by
the end of treatment; the group without maintenance meetings regained 50% of their
weight loss. Perri and co-workersZ5found that patient-therapist contact was
associated with the maintenance of weight loss, and that the content of the
maintenance meetings was less important than the therapeutic contact at the
meetings.
Research suggests that it is unrealistic to treat obesity as a short-term problem.
Instead, obesity should be regarded as a chronic disease needing long-term ongoing
treatment.”, 45

CONCLUSION

Behavioral therapy for obesity has been established as an effective treatment

method for weight loss. Like most other therapeutic modalities for obesity, behavioral
therapy does not lead to long-term maintenance of weight loss. While participants are
enrolled in behavioral therapy programs, they generally lose weight and maintain the
weight loss. When they withdraw from treatment, they generally regain the weight
gradually that was lost. These research findings suggest that behavioral therapy might
be especially useful for the following purposes:
1. In a stepped-care treatment approach for obesity: behavioral therapy may be
useful for moderately obese persons who have failed to lose excess weight without
professional assistance.
2. A problem with pharmacotherapy for obesity is that most persons do not want
to take anorectic drugs for the remainder of their lives. Behav-ioral therapy could be
used to assist them in maintenance of weight loss while withdrawing from
medication. If weight gain occurs, the person could reinitiate medication, lose weight,
and try again. Those persons who do not maintain weight without medication would
eventually be-come more accepting of this reality and would most likely agree to take
anorectic drugs for extended periods of time.
3. For persons who are able to maintain weight loss, behavioral therapy
 BEHAVIORAL THERAPY FOR OBESITY 953

support groups could be established to provide the social and therapeutic

support needed for long-term (i.e,, life-time) success. Major treatment centers
would need to facilitate the creation of these support groups at very low or no
cost. In this manner, obesity could be treated as a long-term chronic illness as
opposed to an acute disease.

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Address reprint requests
to
Donald A. Williamson, PhD
Department of Psychology
Louisiana State University
Baton Rouge, LA 70803