Healthy Weight Maintenance Boosted by Habit

Military parents join ranks

To achieve durable change and sustained weight loss, kids need a lot of buttressing, a lot of outside support, and what’s more, they need the right kind of support. Anything that sounds like nagging will be rebuffed and have the opposite effect from what was intended.

The far future is hard enough to deal with, but for kids even the near future is too long to wait for the benefits of good behavior. Self-discipline and impulse control are difficult even for grownups. Kids who have developed a trust bond with the world can get behind delayed gratification and self-binding.

When the trust bond is broken or has never had a chance to exist, everything becomes exponentially more difficult. If a child has been led to believe that a sled will be under the Christmas tree and the sled doesn’t show up, why should he believe anything a grownup says about the future?

That was a relatively benign example. For many kids, life is far more precarious and tenuous than we can comfortably acknowledge. The sociological term is “unreliable environment,” and millions of kids live in chaotic environments that are unreliable every single day, in myriad ways. If only a magic wand could be waved to guarantee that all parents everywhere would be loving, fair, consistent, dependable, and supportive. If only.

Automaticity

Cognitive behavioralists have found that after an active period of family-based intervention, healthful new behaviors are maintained by extended contact and duration. In the family, helping a kid sustain weight loss over the long term can be an emotional minefield. Any juncture where a decision must be made is an opening for potential strife. A method that doesn’t involve discussion, or even thinking, could be a plus.

When Dr. Denise Wilfley set out to work on successful interventions to reduce childhood obesity, she saw the necessity to “make the healthy choice the easy choice,” in the words of journalist Erin Fults, who wrote:

To determine the most effective weight control strategy, Wilfley’s team must evaluate the contexts in which children and families live and work to both maximize the prompts for healthy behaviors and minimize the prompts for unhealthy ones. Her team uses a novel socio-environmental approach that builds on the “traffic light” plan, color-coding foods and opportunities for physical activities in a user-friendly manner. Families are encouraged to go for healthy GREEN foods and activities, exercise caution around YELLOW foods and activities, and stop and plan how to limit unhealthy RED foods and activities.

Habit can work either for or against a person, and the trick is to make automaticity a positive trait. What if there were a really simple way to shop for weight loss-friendly foods, without the need for decision-making? This is what the traffic-light system implies. Can such an elementary concept really make a difference?

Next: a closer look at the traffic light labeling system.

Your responses and feedback are welcome!

Source: “Dr. Denise Wilfley: Successful Interventions for Curbing Pediatric Obesity,” NIH.gov, 11/23/11
Image by U.S. Army

Maintaining Social Facilitation

Today is the first day of the rest of your life

The first study to focus on pediatric long-term weight control using the socio-ecological model was conducted by Dr. Denise Wilfley. The basis is cognitive behavioral therapy. The research team concluded that, even after a successful weight loss program has been completed, it is essential to focus on a child’s social ecology via continued contact and interaction. In this paradigm,

The treatment targets extend beyond the individual to incorporate a supportive environment, which more comprehensively addresses the multi-contextual problem of weight control…. Involving the family, peers, healthcare providers, and community network is crucial.

The overall goal is to make it easy for kids to choose healthful alternatives, by bringing the maximum possible number of other people in on the action. Most important of all, of course, are the immediate family members, blood-related or not, who share the domestic headquarters.

Last time we discussed how Dr. Wilfley’s team would work with children ages 7 to 11 and their families, during the initial four-month behavioral weight loss treatment. SFM stands for social facilitation maintenance, which is the object of the subsequent eight-month program, working to maintain whatever weight loss had been achieved. This group of researchers also observed the built environment in which each child would continue to live.

One of the tenets of SFM is that intervention steps should be built in at all levels of existence whenever possible. It does indeed take a village to raise a child, and a village is made up not only of other people but of physical objects and structures both large and small. For instance, if the “village” contains convenience stores and fast-food joints on every corner, that will be a problem for some people. For a child trying to stay within healthy-living parameters, it’s truly a “bad neighborhood” and he or she needs more support than another child who lives, for instance, in a rural area.

In these matters, society is limited in what it can do. Common sense says, take the kid out of the bad neighborhood, or legislate to make the neighborhood less bad. These are both huge undertakings, and we live in a free country. Many kinds of damage can’t be stopped by fiat, so parents and health care professionals are stuck with the only available alternative, treating victims one by one.

Learning to make healthy choices isn’t hard, but new behaviors have to be practiced repeatedly until they become ingrained. In the areas of weight loss and addiction treatment, almost anyone can achieve positive, and even spectacular, results in the short term. The “long run” is what counts. When someone experiences that flush of victory, too often attention is then turned away – including the person’s own attention. It is all too easy to slip back into old ways.

Dealing with this inevitable letdown and the temptation to backslide is difficult enough for adults, who are expected to be equipped with at least a partial set of life skills. For a child, a day seems like a week and a week seems like a year, and the concept of a year is ungraspable. For those who are trying to hang in there and maintain, the old saying “Today is the first day of the rest of your life” has special meaning.

Your responses and feedback are welcome!

Source: “Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents,” NIH.gov, 04/01/12
Source: “Dr. Denise Wilfley: Successful Interventions for Curbing Pediatric Obesity,” NIH.gov, 11/23/11
Image by apasciuto

Molding the Social Environment

Faith & six topping pizza 083

We have seen that cognitive behavioral therapy comes in several flavors and that it can be quite successful in promoting behavioral change by breaking negative behavior cycles and restructuring harmful patterns. Appetitive traits are vulnerabilities linked to eating behavior, and these vulnerabilities can slow progress or cancel it out altogether.

One problem can be a person’s impaired responsiveness to internal satiety signals — the signals that say “You have been fed, now stop eating.” Another appetitive trait is extreme responsiveness to external food cues. When the ice cream truck drives slowly by with its tinkly music, she or he gets up and starts fishing in the pockets for change. Pair up extreme responsiveness to external food cues with extreme impulsivity, and you’ve got a person whose arm does not need to be twisted one little bit.

“High motivation to eat” is a tough one, the grand-daddy of all appetitive traits. Possibly the only thing that can replace it is an even higher motivation toward something else. Here’s the problem with helping a person switch to a higher motivation track: the satisfaction of eating is a known quantity, a dependable reward, and a proven consolation for the pains of life. A 6-year-old knows what he likes. Even with a known commodity, delayed gratification is a difficult concept to master.

One marshmallow now seems like a much better deal than two marshmallows tomorrow. When he has never experienced the joy of winning a basketball game or dating a prom queen, change is a very, very hard sell. The idea that he should quit drinking soda pop for the sake of some incomprehensible far-future goal is just ludicrous. And even when people, children or adults, do the work and make changes, backsliding and recidivism are right around the corner. Far too often, change doesn’t last.

We are told that appetitive traits arise from both genetic and environmental influences, and that the environment includes both the built environment and the social environment — in other words, the world. Negative influences are everywhere, in the family, among a child’s peers, at school, in the media, and in the larger community. Fortunately, some health care professionals possess a skill set whose purpose is to change the social environment.

One such person is Denise Wilfley, Ph.D., a professor of psychiatry, medicine, pediatrics, and psychology at Washington University in St. Louis. Wilfley knows that elements of the built environment “may determine which families particularly need weight loss maintenance treatment and how much of it.” She headed a team consisting of basic and behavioral scientists, urban design experts, and public health professionals to determine what should follow a four-month, family-based behavioral weight loss treatment.

Working with kids in the 7- to 11-year range, they evaluated the built environment to objectively assess environmental factors and determine the most effective ways to help children stay on track. They came up with an eight-month program called social facilitation maintenance, or SFM. Journalist Erin Fults writes:

The goal of the SFM intervention is to make the healthy choice the easy choice by building social support and routines for healthy behaviors across the home, peer, and community environments…. Such a change for a child requires that family members are also on board.

Next: More about enforcing long-term weight loss.

Your responses and feedback are welcome!

Source: “Dr. Denise Wilfley: Successful Interventions for Curbing Pediatric Obesity,” NIH.gov, 11/23/11
Image by James Emery

Obesity and the Social Environment

Food table patchwork cloth

In the field of sociology, the social environment pretty much includes everything that isn’t nature. In the field of psychology, here is one definition:

Social environment of an individual is the culture that he or she was educated and/or lives in, and the people and institutions with whom the person interacts…. A given social environment is likely to create [a] feeling of solidarity among its members, who are more likely to keep together, trust and help one another and think in similar ways.

For most people, the general social environment is subdivided into several compartments, which may include home, school, work, church, and so on. Some say the social environment is only made up of one’s peers; others say it’s everyone a person ever meets. As Childhood Obesity News has noted, the social environment is also said to include everything created and made by humans, from interstate highways to cupcakes with squiggles on top, which also fit into the definition of the built environment.

Yes, it is confusing, especially the difficult task of discovering where seemingly inextinguishable appetitive traits come from. No matter how good a person’s weight-control program might be, and no matter how much success she or he might have for six months or a year, the sad truth is that appetitive traits will spring up again and again. For many people, long-term weight control is like the unicorn, an elusive creature often heard of but never seen. “I lost 150 pounds and gained back 100” is a story too often told.

The plot thickens

Why? Because we have appetitive traits that just don’t want to quit. But why? Because we live in the natural world, and also in the built environment, and also in the social environment. The famous “Marshmallow Experiment” has inspired much thought. Prof. Richard Aslin, of the University of Rochester, said, “This study is an example of both nature and nurture playing a role.”

The roots are so difficult to sort out because the environment exerts an influence on the development of appetitive traits, one of which is over-response to environmental influences. Many important relationships are uncharted because previous studies were not designed to track them. For instance, most studies that might have been useful started too late in childhood for researchers to adequately trace causal relationships.

The inadequacy of previous studies is a favorite topic among researchers in this field. Dr. Mia A. Papas of the University of Maryland School of Medicine led a team that created a meta-study, obtaining data from several fairly comparable studies. The shortcomings:

Several methodological issues were of concern, including the inconsistency of measurements of the built environment across studies, the cross-sectional design of most investigations, and the focus on aspects of either diet or physical activity but not both…. Only one of the 20 studies examined differences in the built environment-obesity association by race/ethnicity.

Since in many cases the built environment is so intractable, this exerts more pressure on the social environment to be the factor that adapts and changes. Immediately a problem arises. The social environment is made up of people, and if there is one thing they don’t like, that thing is change. Luckily, and appearing in the next post, experts have the job of figuring out how to change the social environment.

Your responses and feedback are welcome!

Source: “Social Environments,” Wikia.com, undated
Source: “The Built Environment and Obesity,” OxfordJournals.org, 05/28/07
Image by regan76

Obesity and the Built Environment

Temptations

Why can’t some children resist temptation? Why can’t most of them understand that it’s better to have a larger reward later than a smaller reward now? Why is it that, for some kids, whatever goes in the eyes (like a TV commercial for junk food) also goes into the mouth? Appetitive traits arise from both genetic and environmental influences. A National Institutes of Health report on appetitive traits in children says:

In this paper we describe the results of new studies using behavioural tests and psychometric questionnaires in large samples to show that individual variation in these appetitive traits relates to body weight throughout the distribution. We also describe twin studies and genetic association studies supporting a strong genetic component to appetite.

It might be useful to have a notion of what psychologists and social scientists mean by “built environment” and “social environment,” which are often set in opposition to each other, although closer examination reveals a fuzzy borderline. Dr. Mia A. Papas, of the University of Maryland School of Medicine, is a pediatrician concerned with the many ways in which diet, exercise, and the environment interact. She says:

The built environment encompasses a range of physical and social elements that make up the structure of a community and may influence obesity…. [T]he environment can be thought of as “all that is external to the individual,” with the term “built environment” encompassing aspects of a person’s surroundings which are human-made or modified, as compared with naturally occurring aspects of the environment.

But wait, isn’t the built environment assumed to be a separate phenomenon, in contrast to the social environment? Yet here is a scientist saying that social elements are part of the built environment, and the real contrasting element is the natural world of soil, plants, rocks, and weather.

Dr. Papas goes on to enumerate ways in which the built environment impacts human health. What happens when we always walk on cement and never on grass? What about those thousands of chemicals we absorb every day? The built environment also encompasses more tangible things, such as “housing, urban development, land use, transportation, industry, and agriculture.” The “food desert” concept, for instance, comes under the heading of the built environment.

Dr. Papas led a meta-study whose team first scoured through hundreds of scientific abstracts to find articles about suitable studies whose data, taken together, would clarify some points. They ended up with 20 applicable studies, but only three concerned children. (The great majority chose subjects from among adolescents and/or adults.) From this scant evidence they formed a not very surprising conclusion: Younger children are more influenced by their immediate environment, and teens are more influenced by the larger built environment.

Where it gets complicated

Often, the built environment can’t be changed. In other cases, it can be changed at great trouble and expense, including participation from the social environment in the form of, for instance, protest groups who have their own reasons for not wanting the built environment altered in that particular way. Before exerting influence to change some part of the built environment, it’s important to understand why it matters, and to hold a reasonable degree of certainty that the change will actually have some impact on childhood obesity.

Researchers look, for instance, at children’s proximity to fast food joints and/or health food retailers. They ask how the kids get to and from school. They also look at the proximity of parks and open spaces where kids can engage in physical activity. Dr. Papas’s team found that kids in poor neighborhoods live closer to playgrounds, which should be something to cheer about. It certainly sounds good on paper.

But therein lies the trouble with a lot of studies. The factors they try to measure, and the problems that arise when the researchers have to line up data from studies conducted by various individuals from different institutions at different times, and fit it together somehow — it gets kind of crazy. We can count the number of playgrounds in a neighborhood, but what if no children play there, because the park is a hangout for gang members? The measurement becomes meaningless. This is the sort of conundrum that can make these studies so frustratingly uninformative.

Your responses and feedback are welcome!

Source: “Appetitive traits in children. New evidence for associations with weight and a common, obesity-associated genetic variant,” NIH.gov, 07/25/09
Source: “The Built Environment and Obesity,” OxfordJournals.org, 05/28/07
Images by theimpulsivebuy

CBT and Appetitive Traits

Yella Mella Macra

Childhood Obesity News has been looking at the different varieties of cognitive behavioral therapy. The biggest stumbling block, in these or any modalities, is longevity. Something may work for six months or a year, or while attention is focused on the problem – in other words, as long as meetings with a therapist continue. The difficulty is that, left to their own devices, many patients will revert to their old ways.

In the long term, what messes things up is the difficulty of extinguishing appetitive traits. Whether these traits are inborn or developed in the earliest stages of life, to counteract them it is necessary to cultivate really strong, enduring new habits. The National Institutes of Health website mentions this in connection with the ways in which people respond differently to the “obesogenic environment,” saying, “One plausible mechanism for this variation is the early expression of appetitive traits.”

These appetitive traits are specific vulnerabilities linked to eating behavior and physical activity preferences. One vulnerability is impaired satiety responsiveness, the failure to recognize and respond to internal “enough”signals. Another appetitive trait is high responsiveness to external food cues, encapsulated in the old saying, “I can resist anything except temptation.” This is one reason why corporations are under fire for the way in which they advertise products to children. The temptation-resistance mechanisms of little kids are undeveloped, and they don’t have the wisdom or life experience to recognize flagrant nonsense when they see it.

“High motivation to eat” is an appetitive trait, which was characterized in the old days simply as “gluttony” and categorized as one of the seven deadly sins. Then there is impulsivity, which manifests in the inability to postpone an immediate reward, even if a greater reward is promised for the future.

Remember a much-cited study from the 1970s, the “Marshmallow Test”? Kids were given a choice between one marshmallow now, or two marshmallows in a few minutes. Some figured out clever ways to restrain themselves, and a follow-up study showed that the self-binders did better on their SAT scores and had more success in avoiding recreational drugs.

More recently, University of Rochester researchers wanted to know more about the rational process involved in making decisions when the stakes are short-term versus long-term rewards.

Doctoral candidate Celeste Kidd was lead author of the study, and the co-author was Dr. Richard Aslin, who teaches brain and cognitive sciences. Kidd references the children’s “belief about the practicality of waiting,” though it is unlikely that children so young could identify or verbalize such a belief. But from a very young age, we have all internalized beliefs about the practicality of waiting and about many other things, even if we can’t articulate them.

The Marshmallow Test revisited

The experimenters set up a mini-world in which a child is offered the chance to use a small, grungy set of crayons now, or a splendid set of art supplies in a little while. Some wait for the better art supplies. But this isn’t the experiment, yet. This is only the setup. Pretend you’re a kid who dutifully waited for the fancy set of markers, only to be told by an apologetic grownup that the nice art supplies can’t be found, but you can still color your picture with the grungy crayons.

An innate sense of unfairness kicks in. Even if you can’t clearly articulate your thoughts, they go something like, “Wait a minute. I met the challenge, I was good, I waited. And now I don’t get the reward? To heck with that. When the next opportunity comes to have a small reward now or a big reward later, I’m gonna be a YOLO kind of kid, and delayed gratification can go jump in a lake. Carpe diem!”

And then the researchers did the marshmallow test, and found out that the kids who had been disappointed about the art supplies were less likely to opt for delayed gratification in the marshmallow test. The trust bond had been broken, and now they knew they lived in an unreliable environment, one in which promises are not always kept and virtue is not always rewarded. They went for one marshmallow now instead of two marshmallows later. Celeste Kidd says:

Delaying gratification is only the rational choice if the child believes a second marshmallow is likely to be delivered after a reasonably short delay.

Dr. Aslin adds:

If they’re in an environment in which long-term gain is very rare, well then it makes perfect sense for them to behave impulsively, because that’s going to maximize their reward.

Your responses and feedback are welcome!

Source: “Appetitive traits and child obesity: measurement, origins and implications for intervention,” NIH.gov, 08/20/08
Source: “Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents,” NIH.gov, 04/01/12
Source: “The Marshmallow Study Revisited,” Rochester.edu, 10/11/12
Image by flattop341

Varieties of Cognitive Behavioral Therapy

[plastic toy man speaking to computer: "So this operating system... Does it tell you to do things?"]]

In the short term, many obesity interventions achieve an encouraging degree of success, but a year or five years later, a follow-up shows a different picture. As Childhood Obesity News has described, cognitive behavioral therapy or CBT is designed to promote behavioral change by breaking negative cycles of behavior and restructuring harmful patterns. To fulfill the needs of the all-important long term, a program must support behavior maintenance over time, and minimize the incidence of relapse. To do all that, it must somehow extend its sway beyond the individual and include other domains — the family, peer network, and community.

CBT is such a useful therapeutic modality that it has evolved into another stage, characterized as “enhanced” and identified by the acronym CBT-E. About two-thirds of the clients who opt for it are said to have benefited, at least in the short term. It aims to change maladaptive behaviors and negative pathology, and especially to teach strategies for the prevention of relapse. The Counselling Directory defines CBT-E as a “transdiagnostic” treatment, describing it as:

…an approach comprehensive enough to be applied irrespective of differential diagnosis and appropriate for the mixed patterns of difficulties that people with eating disorders typically experience over time…. It is a structured, tailored form of one-to-one talking therapy in which you and your therapist work together as a team. It focuses on helping you change your eating behaviours now and in the future (it does refer to the past but does not centre on it).

CBT-E was created to address the roots of an eating disorder, whether it manifests as insufficient eating, as in anorexia nervosa, or excessive eating, as in binge eating disorder. That is the “transdiagnostic” part. In addition, the therapy developed branches. In CBT-Ef, the “f” stands for “focused.” It targets the eating disorder psychopathology, and is considered the “default” version.

Then there is CBT-Eb, where the “b” stands for “broad.” It addresses the same issues and also incorporates additional focus on external factors. The directory explains:

In particular, patients with low self-esteem, poor mood-regulation strategies, high interpersonal problems, and high levels of clinical perfectionism are well-suited for CBT-Eb, in which these four core features are targeted.

In any case, 20 weekly outpatient sessions are usually recommended, stretching over five months. Anorexia nervosa seems to be a tougher case, with 40 weekly sessions recommended. The roots of eating disorders are found among the individual’s core beliefs, especially those related to the over-evaluation and control of the person’s weight and body shape. These unhealthy core cognitions or beliefs are what cause maladaptive cognitive and behavior patterns, and those patterns maintain the eating disorder in whatever form it takes. A succinct definition that sums it all up can be found in the “Eating Disorders Glossary”:

Cognitive behavioral therapy (CBT) and Enhanced Cognitive behavioral therapy (CBT-E): A relatively short-term, symptom-oriented therapy focusing on the beliefs, values, and cognitive processes that maintain the eating disorder behavior. It aims to modify distorted beliefs and attitudes about the meaning of weight, shape and appearance which are correlated to the development and maintenance of the eating disorder.

Your responses and feedback are welcome!

Source: “What are CBT-BN, CBT-BED and CBT-E?” CounsellingDirectory.org.uk, 08/08/13
Source: “Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents,” NIH.gov, 04/01/12
Source: “Eating Disorders Glossary,” feast-ed.org, undated
Image by Mark Anderson

Cognitive Behavioral Therapy: Family-Based or Not?

[close-up of scale]

In the areas of weight management and eating disorders in kids and teens, several different components are involved. Negative behavior cycles need to be broken, and patterns need to be restructured. Some behaviors need to be eliminated, and others put in their place. Equally important is the long-term maintenance of both elements — the permanent extinction of some behaviors and the perpetual repetition of others. If all this can be accomplished, the likelihood of relapse is minimized.

Two major problem categories are anorexia nervosa (AN) and bulimia nervosa (BN). Cognitive behavioral therapy achieved some early successes with those. Basically, all eating disorders have something in common — a constant concern with food, eating, and weight. AN and BN are about the obsessive need to eat less and weigh less. Even though it seems on the surface to be the diametrical opposite, BED or binge eating disorder leading to obesity comes from the same roots – constant concern with food, eating, and weight. BED is included, along with some other diagnoses, in a category dubbed EDNOS, or “eating disorder not otherwise specified.”

It looked promising

Ten years ago, the United Kingdom’s Health Development Agency (using sources from everywhere) issued a report called The Management of Obesity and Overweight. Authored by Caroline Mulvihill and Robert Quigley, the report was subtitled “An analysis of reviews of diet, physical activity and behavioural approaches.” Among many other useful explorations of the literature, it offered a comparison between behavioral modification programs that were family-based and those that were not family-based. Reviewing family-based modalities that had been tried so far, the researchers wrote:

These programmes included behaviour modification, dietary and exercise education, with a mix of sessions involving the child, parent(s) and, in some cases, the entire family. The review concluded that while some findings appear promising, the small size of some of the studies and the disparate nature of the interventions mean there is ‘at present insufficient evidence to recommend any specific programme’.

Although family-based programs were regarded favorably, there was not at the time enough solid evidence for the authors to recommend any specific one. They also looked at reports about behavior modification programs without parental involvement – well, one, actually, because that’s all they could find in the literature, and it involved kids from 9 to 19 years of age. The report says:

This compared a three-part cognitive–behavioural ‘obesity-training’ programme combined with a calorie-reduced diet and an exercise programme, against a group that received the same diet and exercise component but received muscle relaxation training instead of the psychological component. The intervention lasted for six weeks. Both groups significantly reduced their percentage overweight over the course of a year. No statistically significant differences were found between the two treatment groups.

Progress

Almost a decade later, the U.S. National Institutes of Health issued a report titled Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents. Despite the development of successful treatment programs, relapse and non-recovery still were prominent occurrences. In fact, AN patients were noteworthy for dropping out before the end of the structured treatment programs, and because of non-completion, could not even be counted in the relapse vs. non-relapse statistics.

Family-based behavioral treatment for obesity still looked promising because of short-term successes, but once the intervention was over, patients would revert to old behaviors and gain weight. Families are especially crucial because for the most part children and youth cannot avoid living with them. For a kid, the family home and the people in it are the most significant and influential features of the environment, and if they don’t change, the outcome of any intervention that involves only the child is apt to be dismal. The report puts it this way:

The persistence of weight-related problems may occur because environmental stimuli, which had fostered the previously learned, maladaptive behaviors, have not been modified.

This is reminiscent of a famous quotation attributed to Albert Einstein (though he probably didn’t say it), the one about how doing the same thing over and over again, and expecting different results, is the definition of insanity.

Your responses and feedback are welcome!

Source: “The Management of Obesity and Overweight,” Prevenzione PDF, October 2003
Source: “Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents,” NIH.gov, 04/01/12
Image by kpspap95

Cognitive Behavioral Therapy for Eating Disorders

[top ten fitness facts related to the benefits of exercise on the brain, stress and energy levels, and overall health]

The National Institutes of Health website offers a succinct definition of Cognitive Behavioral Therapy and its usefulness:

CBT is the most established psychological treatment for BN (bulimia nervosa) and BED (binge eating disorder), with demonstrated efficacy over pharmacological and other psychological therapeutic options. The goal of treatment is to identify, monitor, and tackle the cognitions and behaviors that maintain the disorder while heightening the motivation for change.

CBT is said to have “accumulated one of the largest bodies of research evidence in any psychological field.” Its techniques have been around for at least 20 years, subjected to constant refinement, and adapted to more and more situations, as it becomes clear that the various types of eating disorders are fundamentally more alike than different.

There was a period when a lot of attention centered around AN (anorexia nervosa), BN, and EDNOS. Actually about 70% of problems came under the last heading, which stands for “eating disorder not otherwise specified,” including not only binge eating but other behavior patterns close to, but not exactly aligned with, the official descriptions of AN and BN. What they all have in common is the patient’s constant preoccupation with food and body weight, along with the potential for alleviation by CBT which, while not universally successful, seems to be the best hope so far.

Another trait shared by all eating disorders is the possibility of permanent damage to the individual’s health, which is also true of obesity. Since the explosion of the childhood obesity epidemic, the world is full of children who have joined the risk pool for developing serious lifelong conditions like metabolic syndrome, Type 2 diabetes, and heart disease. Obese kids are also in danger of going too far in the opposite direction and sliding into other kinds of eating disorders like AN or BN.

As Childhood Obesity News has discussed, there seems to be a set of core cognitions (or what Dr. Bryan P. Walsh simply calls unhealthy beliefs) associated with the risks that obesity brings. They are “body dissatisfaction, dietary restriction, overvaluation of weight and shape, negative affect, and low self-esteem,” according to researchers in the CBT field.

The National Obesity Observatory in the United Kingdom has identified four major areas that must be addressed — behavioral, biological, psychological, and social. Experts there arrived at the conclusion that it is more effective to concentrate on psychological factors than to focus specifically on weight loss.

In both Britain and the U.S., there are not enough practitioners to go around, so entrepreneurial professionals are busy modifying CBT into a self-help modality available via electronic devices. Overweight youth are best served by interventions whose behavioral components modify both activity and diet. The NIH website says parents take an active role in this:

Parents are also encouraged to utilize a behavioral reward system, in which successful goal completion (e.g., weight loss, reduced caloric intake, increased physical activity) is reinforced with rewards that are interpersonal and/or promote healthy behavior (e.g., family outings, bike riding, ice skating).

The page also discusses family intervention strategies, centered around self-monitoring and stimulus control, which is a fancy way of saying “don’t keep potato chips and ice cream in the house.” Since parental success with weight control is a strong predictor of success in the kids, parents are strongly urged to step up and be excellent role models.

Your responses and feedback are welcome!

Source: “Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents,” NIH.gov, 04/01/12
Source: “What are CBT-BN, CBT-BED and CBT-E?” CounsellingDirectory.org.uk, 08/08/13
Image by trutherbot

Behavioral Economics and School Lunches

[graphic of people being served at a cafeteria]

When a human is unhappy with the way things are going, three courses of action are possible: change other people (usually frustratingly futile), change oneself (difficult to varying degrees), or change the environment. Sometimes modifying the environment can be astonishingly effective, as a science called behavioral economics has shown when applied to school lunches.

School districts across the country are caught between a rock and a hard place. The meals they provide have to meet nutritional standards, which often means spending more money. If the food is so unfamiliar that kids don’t even want to try it, or if they try it and don’t like it, the school loses money. When schools have to discontinue the popular items that kids are willing to pay for, they lose even more money. But David R. Just and Brian Wansink, writing for Choices magazine, explain how this problem can be managed:

By using tools that will both increase the sales of more nutritional foods and decrease the sales of less nutritional foods, behavioral tools can achieve nutritional goals while having a minimal impact on the bottom line.

What tools are they talking about? Simple rearrangement, for one. The authors describe a Minnesota school where kids waiting to pay for their lunches had ample leisure time to contemplate an array of chips, snacks, and desserts. Placing such attractive nuisances at the checkout station is a familiar tactic used by grocery stores to encourage impulse buying. But in a school cafeteria setting, it is inappropriate and counterproductive. So Just and Wansink moved the junk food and placed fruit in that location, which increased not only the amount of fruit the kids bought, but the amount of it they actually ate.

At a middle school in New York state, moving the salad bar had a noticeable effect on the popularity of salads, and not just because of the novelty. Salad sales remained strong. Changing the physical environment can also help to discourage the consumption of high-calorie, low-nutrition items. Research has shown that keeping the lid of an ice cream freezer closed can cut ice cream sales to students in half.

The basics

This method of helping kids develop good eating habits employs two simple principles: reactance and self-attribution. Reactance stems from a natural resentment against coercion, inspiring a spirit of rebellion that does not bode well for long-term behavioral change. Sure, we can stop kids from eating cookies at lunch by refusing to offer them, but the heavy-handed approach only guarantees the consumption of more cookies after school. It’s more effective in the long run to tuck the cookie machine away in a lightly trafficked area of the building. If soda vending machines have to be present, they too should be exiled to an out-of-the-way spot.

Self-attribution is the dignity of making one’s own decisions, and parenting courses emphasize its importance even with very young children. “Do you want some corn for supper?” might be met with resistance. “Which would you rather have — corn or peas?” is a question that can produce amazing results. The child is so jazzed about having a choice, and making a choice, that the reality of eating a vegetable is of secondary importance. It works for older kids, too. When a school rule requires a kid to put a vegetable on the plate, only about a third of those vegetable servings actually get eaten. When there are two or more choices of vegetable, the likelihood of actual consumption increases. The authors write:

[T]he object of using behavioral economics in school lunch rooms is to guide choices in a way that is subtle enough that children are unaware of the mechanism. These subtle changes often have the advantage of being relatively cheap and easy to implement…. To preserve choice, we will necessarily have to allow some individuals to purchase items that are less nutritious. But we can make these choices less convenient or less visible.

Find out more about these theories and their implementation at SmarterLunchrooms.org.

Your responses and feedback are welcome!

Source: “Smarter Lunchrooms: Using Behavioral Economics to Improve Meal Selection,” ChoicesMagazine.org, undated
Image by Joe McKendry

Childhood Obesity News | OVERWEIGHT: What Kids Say | Dr. Robert A. Pretlow
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