Childhood Obesity Research
Experience and research shows Wellspring works
Wellspring's fitness and weight loss program is based on decades of scientific research, the work of renowned Dr. Daniel Kirschenbaum, and continued studies on Wellspring participants that demonstrate our program's effectiveness for initial and long-term weight loss success.
In 1958, Albert Stunkard summarized the results of the previous 30 years of research in the area of obesity: "Most obese persons will not stay in treatment for obesity. Of those who stay in treatment, most will not lose weight, and of those who do lose weight, most will regain it."
Fortunately, more modern methods using cognitive-behavioral therapy, very low-fat diets, pedometers to promote increased activity and related techniques produce much better outcomes. So while in the review from 1958 reported by Stunkard, only 1% of people treated for weight problems lost 40 pounds or more, recent reviews show that approximately 90% of people treated using the best of the current techniques lose at least 20 pounds and 50% lose 40 pounds or more.
Consequently, Wellspring's approach to changing the behavior and lifestyles of students has a long and solid scientific basis. The highlights of this scientific foundation - outlined below - illustrate some of the key developments in the history of the treatment of weight problems among children, teenagers, and adults. This scientific foundation has allowed Wellspring to incorporate every major approach demonstrated by research to be effective in treating excess weight in adolescents and its complications.
- Ferster and associates (1962). Ferster and colleagues showed how principles of learning established in laboratory and field studies could be applied to treating problems such as obesity. They showed that weight problems can be viewed as a function of learned behavior (learned problems in eating) that could be unlearned and replaced by new habits. More specifically, they showed how principles such as stimulus control, shaping, chaining and reinforcement could help people learn new, more effective ways of eating and exercising.
- Stuart (1967). Stuart showed through a series of case studies that the principles of learning when applied to changing eating habits could lead to very successful outcomes: averages of more than 30 pounds of weight loss in overweight adults.
- Brownell and associates (1978). Brownell and colleagues demonstrated that rallying the support of interested spouses can lead to better long-term weight loss than treatments that do not target family members.
- Self-regulatory (self-control) theories of Bandura (1968,1977), Kanfer & Karoly (1972), Carver & Scheier (1981,1990), Kirschenbaum (1987)**, Mischel (1968, 1973,2004) . These researchers showed how principles associated with goal-setting and the notion of a "feedback loop" can apply to changing self-regulated habits. Their research and formulations demonstrated, for example, that the process of self-monitoring (systematic observation and gathering of information about targeted behaviors) is necessary for successful weight control.
- Wadden and associates (1985-2004). Wadden and colleagues showed that the use of a very low-calorie diet (VLCD) can accelerate weight loss for many people.
- Epstein (1990). Epstein and associates showed that children treated with a cognitive-behavioral and family-based approach maintained substantial improvements in weight over a ten year follow-up period compared to comparison and control conditions.
- Perri (1992). Harvey-Berino (2004). Perri and colleagues demonstrated that longer treatments produce better outcomes and that the content of the treatment matters less than expected. As long as the treatment promotes focusing on the problem (and self-monitoring), weight controllers often benefit from frequent contact with therapists and others who help them concentrate on this aspect of life. Harvey-Berino and associates showed that maintaining contact with therapists via the Internet helped "participants sustain comparable weight loss over 18 months compared to individuals who continued to meet face-to-face."
* Healthy Living Academies Advisory Board Member
** Healthy Living Academies Clinical Director
Data Monitoring and Tracking
In this same spirit, Wellspring evaluates the effectiveness of the Wellspring program every year. Students and parents complete standardized questionnaires that assess such factors as mood, self-esteem and satisfaction/dissatisfaction with weight. We also collect data about height and weight throughout a camper's time at Wellspring, and at follow-up periods of three months, six months, and one year after camp. Other measures will be taken during camp to evaluate the process of change, such as consistency of self-monitoring (record keeping pertaining to eating and physical activity).
Wellspring Camps: Rationale and Approach
The World Health Organization recently declared that obesity has become a global epidemic (World Health Organization, 1998). This epidemic has revealed itself most dramatically in the accelerating rate of excess weight among America's children: a 183% increase (6% to 15%) in just the past three decades (Ogden, Flegal, Carroll, & Johnson, 2002). Millions of overweight teens now face a high probability of a lifetime of compromises, in health, social-psychological well-being, and vocational opportunities (Ebbeling, Pawlak, & Ludwig, 2002).
The proliferation of obesity among teenagers and its likely consequences do not, by themselves, mandate the development of boarding schools exclusively focused on helping overweight teens. If these teens could be helped enough by outpatient educational or counseling programs, more intensive treatments wouldn't be warranted. However, the evidence from the best extant programs leaves much room for improvement.
Leonard Epstein and his colleagues have tested family based cognitive-behavioral treatment (CBT) programs for many years and found some positive effects, even in an extraordinary 10-year follow-up (Epstein, Valoski, Wing, & McCurley, 1990). Yet, the average child who received the best of those interventions remained 34% overweight at the follow-up, with those who received other variations on the family-based CBT approach faring significantly worse. More recently, my colleagues and I examined the efficacy of a long-term multidisciplinary intervention (e.g., CBT, nutritional education, physical therapy for explicit exercise training) for low income morbidly obese adolescents (Kirschenbaum, Germann, Rich, & O'Koon, 2004). At a 2-year follow-up, only 10% of the 150 participants demonstrated clinically significant improvements in their Body Mass Indexes (BMIs; i.e., equivalent to a reduction from initial weight of 5% or more).
The search for improved long-term outcomes may come from the following equation:
SELF-CONTROL + EXTERNAL CONTROL = WEIGHT CONTROL.
Consideration of each element in this equation suggests important implications for all health professionals who help people lose weight.
Extremely consistent self-monitoring (systematic observation and recording of target behaviors) is necessary for effective weight control (Baker & Kirschenbaum, 1993). More specifically, Figure 1 shows that among adult participants in a long-term CBT program, only those who self-monitored very consistently (virtually every day) lost weight during the holiday season (Thanksgiving through New Years Day, Baker & Kirschenbaum, 1998). This finding was replicated in a second and similar study (Boutelle & Kirschenbaum, 1998). Additional research has shown that even among those weight controllers who generally self-monitored everything they ate and their activity levels, when they self-monitored inconsistently (i.e., missing a day or two per week) they lost less than half of their usually weekly average of 1-2 pounds per week (Baker & Kirschenbaum, 1998). In other research, those who self-monitored most consistently during the first weeks of professionally conducted programs lost more weight at 1-2 year follow-ups (Wadden, Berkowitz, Vogt, Steen, Stunkard & Foster, 1997). Related findings have been obtained with obese adolescents as the subjects of the self-monitoring studies (e.g., Kirschenbaum, Germann & Rich, 2004; Saelens & McGrath, 2003).
Self-regulatory theories indicate that self-monitoring impacts self-evaluation and that when attributions, expectations, and other conditions are right, self-monitoring serves as the central element of effective self-control (e.g., Baumeister, Heatherton & Tice, 1994; Carver & Scheier, 1990; Kanfer & Karoly, 1972). Another way of summarizing the role of self-monitoring (Kirschenbaum, 2000) is to suggest that it can improve weight control by:
- increasing salience of goals;
- improving commitment to change;
- increasing feelings of control;
- increasing understanding of eating and activity patterns;
- increasing understanding of, and ability to focus on, the details;
- promoting more positive moods.
Highly consistent self-monitoring may even help weight controllers develop "healthy obsessions" (Kirschenbaum, 1987, 2000). This healthy obsession may produce anxiety when the usual patterns of eating, exercising, and self-monitoring are not followed. This anxiety, in turn, could create motivation to decrease it by maintaining effective self-regulated habits.
During the middle ages, a group of Portuguese monks realized that they were growing too large for standard frocks. They collectively decided to do something about their expanding waistlines. Their simple solution was to change the size of the door to the kitchen/dining room. They made the door so small that only slim monks could fit through it. Without access to vending machines, cars, and any other sources of food, this piece of external regulation had to work - and it did.
This true story suggests a direction for intervention when standard educational and behavior change techniques prove too limited for too many people: external regulation. Changing the availability of temptations and other stimulus control techniques have been shown to help alcoholics, cigarette smokers, and weight controllers (Epstein, Paluch, Kilanowski, & Raynor, 2004; Kirschenbaum, 1987; Marlatt & Gordon, 1985).
Also, successful self-control of eating and activity depends on the ability to manage various stressors. Roy Baumeister, Todd Heatherton and their associates (1994) have shown that many self-regulated behaviors deteriorate when stressors overwhelm "self-regulatory strength." In other words, if the demands of the external environment become excessive, self-regulated tasks become less important. For example, what if a weight controller had to work longer hours because her business might fail if she didn't put in the extra effort? Would she have the same time and energy for self-monitoring and exercising and making good decisions about eating? If weight controllers have too many demands relative to their coping skills, they may discontinue attending group sessions, abandon self-monitoring, decrease exercising, and eat based more on convenience without enough thought about quality.
We know that getting spouses and families to help create less tempting and more facilitating environments can help weight controllers somewhat, some of the time. Such family support produces relatively weak effects, however (Black, Glaser, & Kooyers, 1990; McClean, Griffin, Toney, & Hardeman, 2003). Families have difficulty creating environments that are totally committed to promoting aggressive and effective weight control. A totally facilitating environment would build in prompts to exercise, to walk rather than ride, to stay active rather than passive, and to eat in a controlled way. It would also limit the exposure to high fat and excessive amounts of food. It would also have readily available specialized nutritional and behavioral education and therapy. The world's first schools for overweight teens, developed by Healthy Living Academies, attempt to provide exactly that kind of completely facilitative environment (see healthylivingacademies.com).
Implications for "Diet Camps"
This analysis suggests that a maximally effective summer camp for overweight teens would take several steps to ensure that consistent self-monitoring becomes the norm and that the environment facilitates the development of the requisite healthy obsession.
For example, at Wellspring New York, young women are in a controlled environment on the campus of Paul Smith's College in the Adirondacks. The facilities provide for a extraordinarily wide range of physical and athletic activities, and the food plan focuses on very low fat but very appealing meals and snacks. A multidisciplinary staff, including dietitians, counselors, cognitive-behaviorally oriented therapists and medical personnel, embrace the mission of the Camp in various programs and meetings. The same is true at all Wellspring programs.
Wellspring also actively pursues the self-control aspect of the equation: self-control + external control = weight control. Campers have four cognitive-behavior therapy sessions per week with camp therapists. These sessions include establishing specific goals pertaining to eating and activities, reviewing self-monitoring and journaling entries, as well as the developing "super-normal" focusing and stress management skills. Campers carry their self-monitoring/journaling booklets with them, and these booklets are required for entry into the dining hall.
All foods in the dining hall are labeled for nutritional content and prompts for self-monitoring/journaling are provided toward the end of each mealtime. In addition, entrée and snack portions are controlled, but students have to exert self-control (and monitor) portions of extra ("uncontrolled") items at every meal (e.g., fruit and fat-free yogurt at breakfast; salads and soups at lunches and dinners). Family workshops and an Internet-based self-monitoring after-care program for at least three months are also key elements that should promote both self-control and external control after students return home.
Baker, R.C., Kirschenbaum, D.S. (1993). Self-monitoring may be necessary for successful weight control. Behavior Therapy, 24, 377-394.
Baker, R.C., Kirschenbaum, D.S. (1998). Weight control during the holidays: Highly consistent self-monitoring as a potentially useful coping mechanism. Health Psychology, 17, 367-70.
Baumeister, R.F., Heatherton, T.F., Tice, D.M. (1994). Losing control: How and why people fail at self-regulation. San Diego: Academic Press.
Black, D.R., Glaser, L.J., Kooyers, K.J. (1990). A meta-analytic evaluation of couples weight-loss programs. Health Psychology, 9, 330-347.
Boutelle, K.N., Kirschenbaum, D.S. (1998). Further support for consistent self- monitoring as a vital component of successful weight control. Obesity Research, 6, 219-224.
Carver, C.S., Scheier, M.F. (1990). Origins and functions of positive and negative effect. A control-process view. Psychological Review, 97, 19-35.
Ebbeling, C.B., Pawlak, D.B., Ludwig, D.S. (2002). Childhood obesity: Public health crises, common sense cure. Lancet, 360, 473-82.
Epstein, L.H., Valoski, A., Wing, R.R., McCurley, J. (1990) Ten-year follow-up of behavioral, family-based treatment for obese children. Journal of the American Medical Association, 264, 2519-23.
Epstein, L.H., Paluch, R.A., Kilanowski, C.K., & Raynor, H.A. (2004). The effect of reinforcement or stimulus control to reduce sedentary behavior in the treatment of pediatric obesity. Health Psychology, 23, 371-380.
Kanfer, F.H., & Karoly, P. (1972). Self-control: A behavioristic excursion into the lion's den. Behavior Therapy, 3, 398-416.
Kirschenbaum, D.S. (1987). Self-regulatory failure: A review with clinical implications. Clinical Psychology Review, 7, 77-104.
Kirschenbaum, D.S. (2000). The 9 truths about weight loss: The no-tricks, no-nonsense
plan for lifelong weight control. New York: Holt.
Kirschenbaum, D.S., Germann, J.N., Rich, B.H., O'Koon, J.C. (2002). Long-term evaluation of a multi-disciplinary treatment of morbid obesity in low income minority adolescents: La Rabida Children's Hospital's FitMatters program. Pediatrics (under review).
Marlatt, G.A., & Gordon, J.R. (Eds.). (1985). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors. N.Y.: Guilford.
McClean, N., Griffin, S., Toney, K., & Hardeman, W. (2003). Family involvement in weight control, weight maintenance and weight loss interventins: A systematic review of randomized trials. International Journal of Obesity, 27, 987-1005.
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Salaens, B.E., & McGrath, A.M. (2003). Self-monitoring adherence and adolescent weight control efficacy. Children's Health Care, 32, 137-152.
Wadden, T.A., Berkowitz, R.I., Vogt, R.A., Steen, S.N., Stunkard, A.J., Foster, G.D. (1997). Lifestyle modification in the pharmacologic treatment of obesity: A pilot investigation of a potential primary care approach. Obesity Research, 5, 218-26.
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