Everyone, welcome to the session, Behavioral Therapy and Weight Management. My name is Karl Nadelsky, and I'll be serving as your moderator today. We'll be hearing a great lecture from Dr. Kelly Allison on this critically important and fundamental subject of behavioral therapy. Dr. Allison is a professor of psychology at the Perelman School of Medicine at the University of Pennsylvania and director of the Center for Weight and Eating Disorders. She received her undergraduate degree from the University of Notre Dame, then her master's and PhD from Miami University. Dr. Allison's research interests include the timing of eating, night eating syndrome, binge eating disorder, and the role of weight and eating behaviors on reproductive health. She was also engaged in studies on bariatric surgery outcomes and clinical trials for weight and disordered eating. She has over 150 peer-reviewed papers, reviews, and chapters in these areas. For the audience, please place your questions in the Q&A during the talk so that we have them ready at the end. Thanks for attending this session, and here's Dr. Allison. Hello, everyone. Thanks so much for inviting me to give this talk, behavioral therapy and weight management. I'm happy to begin, and I look forward to your questions at the end. So we're going to review the role of behavioral weight management in healthcare practices and how this can be done and how effective it is. Then we're going to consider some important background information and ways of approaching weight management in a medical setting that you want to consider before diving into the actual behavioral weight management sessions. And then we'll talk about the specifics of how to deliver an intensive behavioral therapy in the context of a medical practice. So let's just think initially about the role, and I'm sure you are all familiar with the Diabetes Prevention Program, but this is really the program that our intensive behavioral therapy is based on. And so it's just good to have a refresher of the origins of this. And so we know, you know, it's been 20 years, but this was really the first study to show how effective lifestyle counseling could be in reducing weight, but also in reducing conversion from prediabetes to diabetes. So in this trial, over the course of four years, the Lifestyle Modification Program produced a 31% reduction in conversion from prediabetes to full diabetes. And in comparison to placebo, it produced a 58% reduction. So that was really quite impressive. And several studies obviously now have used similar programs, including the Look Ahead Trial, which also was a program of weight loss in older adults with diabetes. And these are the materials that our current intensive behavioral therapy is based on that I'll talk about a little bit later. So the other important thing to note in a medical care setting is what are the roles of intensive behavioral therapy? And then what are the roles of a medication therapy for obesity management? They each play a part. And so if we think about intensive behavioral therapy, this really modifies external environment. So we wanna reduce exposure to food so that cravings are not as strong. We want to change cues that are present in the environment that might cue us to eat certain foods. So that might, and also things that we pair eating those foods with, like eating in front of the TV, we might wanna switch up those behaviors so those cues change. We wanna increase dietary restraint. And of course we wanna increase physical activity. So these are all things around us that we focus on with intensive behavioral therapy. With pharmacotherapy, that really helps modify the internal environment by reducing hunger, reducing food preoccupation, increasing satiation, and in some cases, decreasing nutrient absorption. So the question becomes, do these things work in an additive way or do they work independently? And we do have some data to show that they can work additively. We look in this trial though, in particular of loraglitide, this was combined with moderate intensive behavioral therapy about one session per month of weight management. And it looks over the course of one year. And we do see that behavioral weight management produces some weight loss. So with the placebo, there was about three kilograms of weight loss over the course of a year. But with loraglitide on board, that difference was greater, about 5.6 kilos over the course of the, I'm sorry, the difference between the treatments was 5.6 kilos in the loraglitide groups, both with prediabetes and regular glycemia levels. There was an 8.4 kilo loss. So we do see that these things can work together to add benefit. In this trial, and I'll spend a little bit of time on this trial because this is where we will be taking our intensive behavioral therapy program from, the goal of this trial from our center was really to test the intensive behavioral therapy as outlined by the Centers for Medicaid and Medicare. And so I'll tell you the results and then I'll tell you the components, but there were three groups with 50 participants in each group. And we can see that the intensive behavioral therapy group over the course of one year lost 6% of their body weight. And both loraglitide groups lost about 11.5% of their body weight. These loraglitide groups, the group in blue, have loraglitide plus the intensive behavioral therapy program. And this bottom group here, I guess that's like violet color, also had meal replacements to use to make sure that they really were reducing their calories. And we'll talk more about the role of meal replacements. But at one year, both of the loraglitide groups were very similar and significantly different from the intensive behavioral therapy group. And there was an excellent retention in this study, which is good for us to be able to draw some conclusions about sticking with the therapy and what the outcomes can be. But for the purposes of this talk, this first point becomes very important. 44% of those who had the intensive behavioral therapy did lose at least 5% of their body weight. And we know that a five to 10% reduction in body weight can really help with glucose control and improve lipids and cardiometabolic factors. And so oftentimes that is enough to help somebody reduce their dose of their medication or get them off of a medication. So while adding on the loraglitide did improve those outcomes, if that's not an option, and medication is not an option for various reasons, money, side effects, other issues, then certainly a sizable percentage of those who received this intensive behavioral therapy can also be successful. Sorry about that. And we also know that people who attend more of the sessions are also more successful. So those who completed all of the sessions lost an average of almost 10% of their baseline weight compared to those who attended about half of their sessions who lost about 3.5% of their baseline weight. The actual sessions consisted of 21 brief sessions of intensive behavioral therapy. In brief, meaning 15 minute counseling sessions delivered by primary care physicians. We also, in this study, included ancillary staff, which is also covered in the Medicare and Medicaid provisions. This included nurse practitioners and dieticians. And so we see that it can produce meaningful weight loss. And then I don't know how many of you are in primary care versus specialty care, but the idea would be in delivering such a program, you could seek reimbursement. So before diving into intensive behavioral therapy for your patients, there really are some things to consider. And I think you'll hear about some of these things in other talks during this conference as well. So let's just consider how we interact with folks with higher weights. And this was a particular study where vignettes were presented to 122 primary care physicians with the complaint of having two migraines a week for the past two years. And the variables that were changed from vignette to vignette were BMI level and sex. So the three BMI levels that were presented in these vignettes were a BMI of 23, 30, and 36. And then the physicians were asked what procedures would you do? And so with rising BMI, a higher percentage of physicians said that they would refer to a psychologist. And keep in mind, this was for the same presenting problem. And the time that the physicians would spend with the patients also decreased. And so it is difficult to think about ourselves as interacting with people in different ways, but time and time again, this is just one example. The data are there to show that we do treat patients with higher weight in different ways for similar presenting problems and tend to pathologize their problems more. Just again, something to keep in mind as you're interacting with patients in your own practices. And words do matter. So the way we describe somebody's weight also has an impact and has an impact on how much the rest of whatever you're telling your patient sinks in. So in this particular trial or study, it was piggybacked on a trial in primary care practices for weight loss of 390 participants. This was, as it's in a lot of our trials, it was mostly women. So 80% women, about 60% white, about 35% black, mean age of about 50. And they were asked what, with these terms, how desirable are these terms for your healthcare providers to use in describing your excess weight? So weight was the most acceptable. And in these past few years, terms of persons of higher weight or persons living in larger bodies, these are all terms that are coming more and more into the nomenclature that are more acceptable, certainly, than the clinical term of obesity. So we, as providers, are used to using the word obesity. It's a disease, it's classified in that way, it's a clinical term, but it's a very sensitive word for a lot of people. And so it may not have the impact that we want it to have, right? It could actually have a very negative impact and make people feel shamed and then not want to engage. They may feel already defeated. So it is really important to just try to use more neutral language, such as weight or your BMI, or your excess weight, and really try to stay away from the terms that are towards the bottom of this graph. The other important thing before diving into behavioral weight loss is to really consider disordered eating and the role that that may have in your interactions with your patients and their success or struggles with weight management. And it's really important to know that persons of all weights can have disordered eating. In higher weight individuals, binge eating disorder is likely the most common, but certainly they can also have bulimia nervosa and night eating syndrome, which is waking up at night to eat at least twice per week and or having a shift in your calories such that you're consuming at least a quarter of your intake after the evening meal. So those would be the most common forms of eating disorders that we would see in persons of higher weight. And we wanna be careful because caloric restriction can increase binge eating and night eating and bulimia nervosa if it's not done in a structured way. So we wanna make sure people are eating regularly throughout the day and not skipping meals and then having that loss of control eating that then makes them feel even worse and builds a really damaging pattern. So that's why it's important to make sure that how we're asking them to eat is done in a structured way so that they feel empowered by it and not that they're so restricted that they end up having these loss of control episodes. And people with binge eating and night eating syndrome can still be part of these weight loss programs but really their symptoms should be monitored. And in the preferred scenario, if at all possible, they should also be receiving psychotherapy for their disordered eating. So one example of this, I work with our great team of reproductive endocrinologists in particular, Anusha Dokharis here at Penn. And we've done several studies of weight management and just looking at disordered eating in Dr. Dokharis's patients with PCOS. So in this particular study, we examined 148 women with PCOS and 106 women who were just at their regular routine GYN appointments. And we wanted to get an idea of the prevalence of disordered eating in between those two populations. So we administered the eating disorder examination questionnaire, the night eating questionnaire, a measure of general distress. And that was the hospital anxiety and depression scale and a health related quality of life scale. That was so we can get a sense of more general measures as well. So when we look at the eating disorder examination questionnaire, there are four subscales and a global scale. And we can see that the women with PCOS had elevated global scores as well as elevated subscale scores on every subscale, restraint, shape, concerns, weight concerns and eating concerns. So in general, disordered eating pathology was significantly higher in our PCOS women. And so when we look at specific criteria for eating disorders, we can see that in the past month, the women with PCOS had reported three and a half binge episodes per month and the controls reported just under two per month and compulsive exercise was more common as well. And the women with PCOS has compared to the controls. The criteria for meeting full binge eating disorder is one episode per week on average over three months. And so this is just below that threshold of about one episode per week. So actually pretty high for a sample that isn't specifically presenting for eating disorders treatment. And then we can also see the prevalence of the different eating disorders in the two populations. And this did not reach significance likely due to the numbers, but you can see a trend, especially for binge eating disorder and the occurrence of any eating disorder towards women with PCOS being more likely. But in general, this was done with a survey. So these numbers should be taken with a grain of salt. Interviews typically provide lower prevalence estimates, but still we're seeing about 20%, over 20% of our participants having some sort of eating disorder. So in general, we see that women with PCOS are at that increased risk of elevated eating disorder examination scores and that further those elevated eating disorder examination scores were associated with worse mood, worse levels of anxiety, higher BMI and worse quality of life scores. So it's just something that we definitely need to monitor. And one example of this, in one of our weight loss trials with women with PCOS, I was seeing a graduate student presenting for weight management. She had had a previous history of bulimia nervosa. We did accept her into the study and she really did struggle with logging, her intake regularly. She was often eating foods that were provided like pizza and whatnot in her study labs and not excessive amounts, but it was just still a struggle, right? To adhere to all of the guidelines that we know help people be successful with weight management. And her rate of weight loss was very slow and she did start to binge and purge again. And so at that point, we had to stop her from the weight loss trial and get her into treatment for her bulimia symptoms. And so this is really important to note, right? If you don't ask about these things, you're not going to know about them and somebody could actually be doing even more damage psychologically and even physically if you're not aware of that. So what do you do? You really should be screening for eating disorders if you are before people start behavioral weight loss. And so there are some measures that are pretty easy to use. The eating attitudes test is a 26 item questionnaire. The questionnaire for eating and weight patterns is really quite valid measure that we often use in our bariatric surgery patients and their pre-surgery assessments. And then there's two really brief ones that can be used in primary care. The eating disorder screen for primary care or ESP and the SCOF. So with these latter two measures, a cutoff score of two seems to maximize sensitivity for both of them. And so I'm giving you these examples right here. They're just four items. The ESP is, are you satisfied with your eating patterns? Do you ever eat in secret? The second question, does your weight affect the way you feel about yourself? The third, have any members of your family suffered with an eating disorder? And four, do you currently suffer with or have you ever suffered in the past with an eating disorder? So a response of two or more would certainly trigger a response of saying, yes, let's talk further and see what else is going on. And should we get you further support for disordered eating before diving into behavioral weight loss? The second, the staff, is five questions. Do you make yourself sick because you feel uncomfortably full? Do you worry you have lost control over how much you eat? Have you recently lost more than one stone? This obviously came from England. So that translates into 14 pounds in a three month period. And do you believe yourself to be fat when others say you're thin, or would you say that food dominates your life? So again, two or more on this would also be a positive indicator for further follow-up for disordered eating. And so what happens if you get a positive, what do you do? I really think it's a value to develop relationships with behavioral healthcare providers and nutritionists for collaborative treatment. In these cases, you can also consider medications that might show efficacy for treating the eating disorder symptoms as well as weight. And so things like agents like tapiramate might be appropriate for helping with both. There are several studies that is off-label for tapiramate helping with bulimia nervosa and binge eating disorder. And other newer agents such as GLP-1 inhibitors also may be helpful with binge eating disorder. There's some emergent literature on that. You could promote a wide range of treatment outcomes and not focus just solely on the number on the scale. And this would include metabolic and functional goals, pain-related goals, moving around more, less out of breath, and not just weight. And then follow guidelines for step care weight management. So if BMI is below 27, we don't recommend use of weight loss medications. And again, we don't want to over pathologize weight if it's not accompanied by comorbidities at the lower ends of that weight spectrum. So what is recommended for guidelines for, sorry, for the US Preventive Task Force recommendations for weight loss with behavioral approaches? So if there's no hypertension, dyslipidemia, abnormal blood glucose levels, you really do wait to a BMI of 30 to provide a referred to intensive behavioral counseling. And there's discretion at lower BMI. Again, you want to make sure that someone's not presenting with eating disorder pathology before you make that decision of what you're going to recommend. If they have hypertension and or dyslipidemia, that does reduce to the overweight range of providing intensive behavioral counseling. And if abnormal blood glucose levels are diabetes, then it could also be applied to people in the quote unquote normal weight range. And so the guidelines that I mentioned previously with the intensive behavioral therapy, the Centers for Medicare and Medicaid Services will cover intensive behavioral therapy for obesity with the following guidelines. So month one would be weekly 15 minute counseling sessions. Months two through six would be every other week counseling sessions. And then if they lose at least three kilos by month six, they would be eligible for coverage for an additional six months of these brief behavioral treatments. And they would occur monthly. The coverage stops, however, if they don't lose at least three kilos by six months. And again, if you're in a specialist's office, I understand these might not apply and you're probably looking for other ways to cover these services, but they can be helpful. So let's do turn our attention to what is behavioral, what does this look like in a practice? So I call your attention to this article from my colleagues, Tom Wadden, Adam Tsai, Jenna Trenary. They have published in this article published in obesity, there's a link to the actual sessions of the intensive behavioral therapy that they tested in several previous trials. So I provided the link here. I'm sure we can get that link to you somehow too during the discussion, but at your fingertips, you have the actual handouts and sessions that are provided. And it is modeled on the CMS 14 to 15 brief individual counseling visits over six months. So these are the first six months topics that are covered just to kind of give you an idea. It orients people to the program, orients them to how many calories they'll be aiming for, how to keep track, how to make these healthy eating decisions, strategies for grocery shopping, increasing activity, how to avoid or deal with triggers for overeating, how to manage eating out, all of the things that end up being super important in helping someone gain momentum and continue with their weight loss goals. So the key elements of any behavioral weight management program are these three. So first would be behavioral modification. And we're gonna talk about each of these in detail. The second would be increased physical activity. And the third would be caloric restriction. So let's just start with caloric restriction. So when we think about the typical behavioral weight loss program, we are, I'm gonna talk about this in regards to calories, and I'll tell you why in a moment. We typically think about 12 to 1500 calories per day for women, and those starting under 250 pounds, or about 1500 to 1800 calories a day for men, and those starting over 250 pounds. This can be modified as necessary, particularly if someone's presenting with an extremely high BMI. For example, I saw a patient, we'll call him John. He presented after seeking bariatric surgery at a starting weight of 522 pounds. His HbA1c was over 11, and he had sleep apnea and a multitude of other cardiometabolic problems. He was referred for behavioral weight loss to manage his weight and have some weight loss, and manage his diabetes before he would be considered at a safer risk level for bariatric surgery. So we did not start him on a 1200 calorie per day diet. Over time, he reduced and finally settled at a level of about 2500 calories per day, and this produced quite a bit of weight loss. Over time, he lost about 80 pounds with the initial treatment, and then I didn't see him in a while, and then he did lose some more weight on his own before seeking my services again when he had finally decided, approximately seven years later, to finally have bariatric surgery. He also had a lot of anxiety about actually having the surgery. And I think some things to consider about John, and that may also be present in your patients, he did have depression and anxiety symptoms. So these certainly were barriers, in that they often drove him to eat as a means of feeling better. He also had binge eating disorder, and he was prone to eating quite a bit of his intake at night. So all of these things, I ended up folding into my treatment of him that may not be able to be folded in in a medical care practice. And so in those cases, you could certainly continue to provide the behavioral weight management, but you may find that he would need further services from a psychologist or counselor to deal with the psychiatric comorbidities. Because once we had plans in place for both with cognitive behavioral therapy for the eating disorder and anxiety and depression, he was able really to do quite well with his weight loss and his HbA1c dropped to seven, which was fantastic. And just, he felt so much better and his quality of life improved more generally. So these are all things to consider when we think about that initial starting caloric range. We also wanna encourage self-weighing. So certainly when they're coming into your office, you do wanna get a weight. And again, you wanna be sensitive to this. You do wanna be encouraging when they step on this scale or when you see someone else in your office is doing the weighing when you see the results. And then you wanna encourage them, especially if they're not coming in weekly to see you, to be weighing at home. And we say anywhere between one day a week to once per week. And so this can vary. Some people are very sensitive and get very upset about their weight. If they see it too often and become obsessed, we don't want them on and off the scale all day long. We really just want them to do it once in the morning, take it as a piece of data to inform their efforts that day and then move on. So if somebody really struggles with just doing it in that way that frequently, then we might just say, just do it once a week and at least get the data once per week. Coming back to why I'm talking about calories and kind of the general lower fat diet that's typically promoted in this intensive behavioral therapy, in part it is due to the food density, right? The clark density of foods. And so proteins and carbohydrates generally have four calories per gram of food and fat has about nine calories per gram. So people, this has been shown in lots of studies, tend to eat the same net weight of food day in and day out. And so if you can provide them more grams of food in per sitting, and it looks the same on the plate, but it's fewer calories, they're gonna do better with feeling satisfied psychologically at least. As well as filling wise, if you have a lower fat diet, and this seems to be more sustainable for a wide range of people, which is why it's promoted. But it's not to say that other approaches don't work, certainly they can. And so this was an earlier study, but it's been borne out time and time again, that most approaches do produce similar amounts of weight loss. And even we can add in the fact that And even we can add to this, there have been several reviews recently of a hot topic, one that I've been quite interested in as well, is time restricted eating or intermittent fasting that head to head with this typical behavioral weight loss program, they produce similar amounts of weight loss. So it's not that you can't promote those to your patients, it's just that you really wanna kind of think more in a precision medicine kind of way, like what can people adhere to longer term? Because whatever they can adhere to longer term is what you want them to be doing, because most of these diets are gonna produce similar amounts of weight loss. So how do we improve that adherence to a low calorie diet? That's kind of the crux of this, right? So part of it would be adding structure. We know structure enhances weight loss maintenance and initial weight loss, and there's just less room for error, that's why it works. And why is this? Well, when we look at studies of doubly labeled water, we can kind of understand exactly how many calories per day people are consuming. So if you have them keeping track and logging their intake each day, and then compare the results from the doubly labeled water of how many calories they were actually consuming in a day, everybody underestimates how much we're eating. So dieticians on average in these studies underestimated by about 10%, persons in the quote unquote normal weight range underestimated by about 20%, and persons with higher weight underestimated by even more, by about 30 to 50%. So it's just, it's human error. We are not good at estimating how many calories we're eating. So in that, you know, with that in mind, we really do wanna help our folks do well. So old fashioned weighing and measuring definitely still works. You can, there's more advanced scales now that can provide calorie information, which is handy, as well as the weight of the foods. Oftentimes we promote using, you know, lots of fun little containers as you see here. This is often, you know, what we promote in our bariatric patients as well. Get back to those tiny containers so that you know exactly how much you're eating, and you're not just taking a handful out and kind of guesstimating, because that handful tends to drift over time, right? And ends up getting bigger and bigger and bigger. The use of portion controlled meals or snacks is important. So for, you know, we really would encourage replacing one to two meals a day in that weight loss phase. We know that it enhances weight loss. And this doesn't have to be just shakes. When people think about meal replacements, typically they think about, you know, some kind of shake, but it could also be a pre-portioned meal, whether it's frozen or fresh in some ways. And that just means like, you know exactly how much you're getting. You don't have to put that food on your plate yourself. And again, perhaps underestimate how much you're putting on your plate. And these decisions come at us all day long. So the fewer decisions we have to make about portion control, the more successful we're going to be in adhering to our calorie goals. And also when we see something as a serving, like in a pre-packaged meal, we see that as a whole. So psychologically, there's a lot of data around this that if we see something as a whole, we think about that as a serving. So no matter how much we put on our plate, we see that as a serving. So if we have something that's pre-portioned, that also helps us feel more satiated through these psychological mechanisms than if we were trying to estimate and do that on our own. So again, this is an old study, but it has a nice graph that illustrates the point. And I'll show you more recent data in a second. But when standard behavioral therapy was used in this particular study, they lost about just under eight kilos initially with weight regain over time to about four kilos. But when you had standard behavioral therapy plus a meal plan or plus food provision, they lost about 12 kilos at six months and about eight, just under eight at 18 months. So it really does make a difference to provide that structure. This is the more recent study, but it didn't have a nice figure, so it's pretty busy. But the point of this study, when looking at the percentage of patients who lost 5%, at least 5% of their weight or at least 10% of their weight over the course of the trial, we see that in all cases, the meal replacement diet, there were various iterations of how much support was provided with that meal replacement diet versus a standard behavioral diet. But in all cases, those who received the meal replacements were more likely to achieve those 5% and 10% weight losses. So it really does help our patients to not have as many choices, to really meet those calorie goals day in and day out. Okay, so the next part would be physical activity to our tripartite approach to behavioral weight management. Most adults, the recommendation would be engaging in 150 to 300 minutes of moderately vigorous physical activity per week. And in general, to reduce comorbidities, that would be at least 30 minutes of moderate intensity activity in most days of the week. To prevent unhealthy waking, up to 60 minutes. And to sustain weight loss, unfortunately it goes up even more, about 60 to 90 minutes. It does get tough once your body is in that reduced calorie state or that reduced weight state to maintain your weight. And that's why the recommendations for activity to maintain are higher. Oops, wrong way, sorry. So what does this look like? We really do, instead of becoming just weekend warriors, which increases the risk for injury, we do encourage making it a habit and spreading it out over the course of the week. We want people to start slowly. So in typically, if they're not doing anything, we recommend a 10 minute walk, five days a week. Just get them out there moving until, and then adding onto that each week. And that is exactly what's detailed in that intensive behavioral therapy protocol. We want to increase their heart rate to a point where they can talk, but they can't sing. Again, this is a guideline that's in those original diabetes prevention program materials that have been used across tons of studies now. That's just a nice rubric that they can use without having to measure their heart rate. But certainly with all of the smart watches that we have now they can also easily measure their heart rate if that's available to them. So we want to make sure that they're getting to the point of cardiovascular activity. We want them to be safe, stretch regularly. Definitely want them to have the right shoes and equipment to prevent injuries, because if they get injured, they are not going to want to go back out there and do this. That's super important. And a simple brisk walk will do. So if they don't like to do anything else, that's fine. Bouts of at least 10 minutes are shown to be additive. So as long as they get their heart rate up for at least 10 minutes at a time, they would be meeting that 30-minute recommendation. they don't have to do it all at once. And it can also be done incorporating it into increased lifestyle activity. So studies have compared this, right? If we provide a gym membership to people and we are asking them to meet the same minutes of physical activity per week versus not providing that gym membership and asking them to fit in these minutes of activity throughout the day in minimum bouts of 10 minutes, we see that they do equally well and perhaps the lifestyle activity over time is a little bit more easier to keep going. This just missed significance. So those either way is fine is the bottom line message. Some people prefer the gym, great, fine. And hopefully as we come out of COVID, fingers crossed, people can get back to that who really prefer that. But if they don't like that, certainly they can do lifestyle activity, engage in Zoom, whatever things they wanna do at home. And we also know that exercise alone produces pretty minimal weight loss unless you're jogging 20 miles per week, unfortunately. In and of itself, exercise isn't gonna be the bulk of your weight loss. It really does come down to the caloric restriction. It certainly helps and it helps build your lean muscle mass as you're losing weight. And it needs to be there as part of the bigger package, but in and of itself, it's not going to produce most of the weight loss. Okay, and so in our final time, let's spend these minutes looking at the behavioral modification piece. I like to call this the how piece. How do we get people to change those behaviors to really be successful long-term? And we've done this in groups, we've done this individually. And so certainly, we've been talking a lot about these mini individual sessions, which is fine, but if your practice wants to do a group-based treatment, that also can be great. And people often draw encouragement from each other. And this can be virtual even. We're doing a lot of these groups virtually these days. So the skills that are taught, there are both cognitive skills and behavioral skills. So behaviorally, self-monitoring is super important. We'll talk about that. And then stimulus control. You can think about this as like environmental engineering of food and activity cues. Those are the two behavioral elements. And then problem-solving and challenging negative thoughts and stress management are the cognitive elements. Self-monitoring is really the single best predictor of weight loss in our behavioral studies. It does help increase awareness of your protein intake, your calorie intake, and other nutritional information. And it just provides feedback in the moment so that you can plan the rest of your meals for the day. Again, I want people to think about this as data, right? If they end up going out and eating more than they realized they were going to eat out or that they planned for, okay, please do still write it down so that over the next couple of days, you can cut back just a little bit and not end up skipping meals and end up getting into a cycle that you can't get out of. We really want to think about this as like a bank account, right? Over the course of the week, you want to be at a deficit of about 3,500 calories to lose a pound. We trust that age-old adage, but generally that is the idea. And so if they overdo it one day, we don't want them to think that all is lost. We want them to think about, okay, let me be pragmatic about this. How can I plan out my next few days to take this into account? Many apps are now available and many allow sharing, right? So that providers and staff in your office could review those if they share their apps with their logging with you. These are just some examples of programs that people use and in bariatrics, also one that we use is Baritastic. But there's lots of these and people like different ones. Generally, I want them to use the ones they feel comfortable with because that's what they will use. And that's super important. We also know that, again, as people use self-monitoring more, they have more success. So in this particular study, and again, this is borne out time and time again, this is kind of a classic, but those over 18 weeks, this was in pounds, those who monitored the most, who were in that top quartile lost 31 pounds as compared to those who monitored the least and gained about nine pounds. So as much as people can log the better, if they're not gonna log every day, try to get them to log at least a few days a week to still try to have that perspective in mind so that they really do have an idea of how many calories they're eating more often than not. And then behavioral elements, the stimulus control becomes important. You wanna identify eating and activity related cues. So if they always sit down with a bag of pretzels in front of the TV, you wanna think that through, right? So you wanna have them plan out their evening snack and not just take the whole bag, measure out their portion, enjoy it. And then when they're done, declare the kitchen closed, right? Shut the light off. How many of us keep our light on in the kitchen all night long? After that, only water or tea or something like that, but have them brush their teeth. Make sure there's no candy dish sitting there staring at them while they're sitting there trying to watch TV. Or social support is often helpful. Maybe they say, hey, let's go for a walk during the time that I would usually have that snack so that they're not sitting there just thinking about the eating. Or maybe they don't sit in the favorite chair. Maybe they switch it up so that they don't have that same behavior and response reaction going on. And yes, definitely ask for help within the household to see how they can kind of engineer the household, throwing out foods that they may not like, and then just thinking about where they're eating, but also where their food is located. So do they have fruit sitting on the counter or do they have a package of cookies on the counter? You know, these things are very important for success long-term in choosing those lower calorie options. And so, you know, these are the things that we kind of want to prevent. And these are the things with environmental engineering and stimulus control that we want to promote. Make sure it's easy for them to remember to work out, easy for them to remember to grab the lower calorie foods. And then with problem solving, we want to think through what barriers could get in the way of our patients' plans, you know, for portion control, being active, keeping their food environment supportive. And we want to help generate options for addressing those barriers so they'll have a likelihood of success. So for example, like if my family wants to eat out at a restaurant, you know, I would promote looking up a menu online to see what you're going to eat. And then once they serve it, I want a box right away to get it off my plate so it's not sitting there staring at me. And, you know, that begets eating more. You're going to nibble here, nibble there. And maybe next time I'll be the one to choose the restaurant, right? To give me more of a chance to have a wider variety of options. Often with our patients planning bariatric surgery, as well as those coming for weight loss, you know, if there are certain restaurants that their families like to eat at regularly, then it's worth their time to really sit down, look at the menus that they offer, and at each place, choose the two or three options that fit best in their dietary approach. So this way, if they're in a hurry, if they're starving, if they don't have time to sit down and plan out and their family says, hey, we're going here, they know already, okay, these are the two or three options that I can choose from at this restaurant. Which one do I want tonight? That way they're not feeling like they have to eat completely differently from the rest of their family or that they're completely blowing it if they go out. It gives them more of a sense of normalcy and hopefully sustainability for the longterm of their eating choices. And then stress reduction. We want to, you know, again, these are laid out within the sessions, examine how our patient's time is distributed each day. Are there periods of time that the patient can engage in some self-kindness and stress reduction, which then can reduce those triggers for stress-related and emotional eating. And you want to help people problem-solve difficult situations that particular stressors, you know, possibly could be solved for longer-term relief. Are they having ongoing conflict with a work colleague? Okay, so maybe it's worth spending some time talking with, communicating with other people on the job or their boss, or getting a plan in place for, you know, how to blow off steam if it's not readily, if there's a solution not readily available. Or maybe they want to think about, sorry, longer-term solutions and think about different jobs. Maybe something like this can raise some of those bigger issues to help them be, have a better quality of life and better health in general. And then finally, use of social support and communication are very important. They're making big changes. Families, friends, coworkers, all of those people have influence on what we eat and how we're active. Often people still are, you know, provide food peer pressure. Come on, I made this just for you. Aren't you going to have some? These are messages we hear all day long. And so we want people to communicate and have strong boundaries so that people know that they mean no if they're asked, do you want to order out? Or do you want to, you know, go to this movie and have a bunch of popcorn? Maybe they want to establish new routines of going for a hike or just having coffee or something like that instead. And you just want to make sure they're giving consistent messages so that over time those food peer pressure behaviors are extinguished and they stop pushing food on them. And maybe you just help ask people around your house to help with some of the chores and some of the food prep so that you have more time to plan and really be successful with your goals. All of these things really can matter. And so we want people to get specific about this and really write out their plan. And again, these tools are all provided in that intensive behavioral therapy program of worksheets and how to help people graph these things out and be very intentional so that they can be successful long-term with their weight management. And then your part is to provide that accountability after setting the goals, you really want to follow up so that they know somebody is going to be asking and that they'll be able to problem solve some of these things over time. We are people, we all like to have that reinforcement. So in general, there is a role for healthcare providers to deliver the intensive behavioral therapy. There can be many barriers. And so using the program can be helpful for extra support in how to deliver this. Be mindful of your person first language and check your biases at the door. This can be tougher than we realize. And also be sure to screen for disordered eating so appropriate therapy or support can be accessed as needed. And just thanks to my colleagues at the Center for Weight and Eating Disorders especially Tom Wadden and Jenna Trenary. And my email is here if you do outside of this want to send me any further follow-up questions. Thank you. Thank you. Thank you. Hi everyone. Our moderator is having some technical issues. So I will just jump in and answer some of the questions that have been posed in the chat. Thank you so much for attending. And thanks again for the organizers for inviting me. So some of the questions, I did see that somebody had trouble accessing the sessions and that it's, they said there was a login and password required. I did access that all through my library. For the article to the journal obesity. So I suppose if someone does not have access to that journal that I wasn't aware of that, that they might not be able to download that. Please feel free to email me and I will do my best to try to get those sessions out to you. Sorry about that. Okay. So Dr. Agrawal asks, what apps or online resources do you recommend to patients for behavioral therapy to improve adherence to lifestyle changes? So some of them I did name. I have no financial ties with any of these apps or approaches, but we often use MyFitnessPal, just the free version of it. For bariatrics, we use Baritastic. People like all different ones. Some of them like the one that comes with a Fitbit. Some people like that it all is linked together with their activity. So really I try to encourage people to use whatever they like the best, but certainly MyFitnessPal is the one that we tend to use the most. Do I see Dr. Nadolski back on? I am back on. All right. Did you already answer the question on Noom? No. It kind of fits in with your last answer, but somebody wants to know about your experience with Noom. And I have some patients who have used Noom with some success and it's been promoted by at least one of the pharmaceutical companies too. Yeah. I mean, it's based on these same behavioral principles. I have not, my one concern is I had signed up just as a dummy patient and it can sometimes, I feel like, give you too low of a calorie count. And I think that could be with any of these behavioral programs. And so I think you want to be in communication with your patients about what is recommended through some of these programs. Because I think sometimes the algorithms may not be quite right. And you don't want somebody struggling with a starting point that may be unrealistic. So that would be my caveat, but a program like Noom uses these very same behavioral principles. And so technically would be a strong program. And WW as well, they've been around for a long time. They also use these very behavioral principles. There have been several studies that examine outcomes. They've shared their data. They've really wanted people to be out there looking at outcomes with their products as well, their approaches. And so I think those are pretty strong programs to recommend to your patients as well. Yeah. And sort of in line with those thoughts is the question, again, from Dr. Agarwal, I don't think you touched on this yet, the virtual behavioral therapy sessions. That actually goes in line with one of the thoughts I had to discuss too, is how to implement this pragmatically with patients in the real world, in a clinic. It's hard to do weekly and then every other week, face-to-face sessions. And obviously that's geared more towards primary care anyways. And we obviously are a group of endocrinologists, many of us who specialize in obesity medicine. I happen to have, I'm lucky to have dieticians and a psychologist involved. I'd like to have an exercise physiologist, but not everyone has that. And we went virtual right now and for the past year. So how about virtual behavioral therapy? We would encourage people to use virtual platforms. We've seen attendance rates go way up with the use of virtual sessions. And so the other thing to think about, dieticians would be an ideal source if you can have them bill under you for these services. We've also trained other ancillary staff such as medical technicians or nurses to deliver some of these protocols. And you have to pick the right staff, right? Who are interested in this and you think have good people skills and are very sensitive around these issues. But in several of our primary care site studies, we trained other office staff to deliver these. So that could be an option, right? If you don't have multidisciplinary staff that could deliver them, like a psychologist or nutritionist. Yeah, great. They likely should be trained though, well, by somebody who knows first, obviously. That's the caveat. Yeah, all right. Well, I'm not seeing, unless you see a lot of other questions from the audience, it appears. So I'll ask you something else from my personal thoughts. What's your experience with really personalizing your exercise or non-exercise activity, prescription to patients? So you had some slides on starting the habit and that's exactly what I think most of us do. Just start a 10 minute walking habit, et cetera. I'm a shield for resistance training. I want everyone to lift weights, progress in their volume, intensity, time, et cetera. And in combination with things like walking, do you have any experience really helping to personalize therapy and any tips on that? I do think it's, we always ask how much do you like exercise or not? And just start with that as you're saying and try to have people really experiment and see if there is a niche that they can fall into. And even if they hadn't tried it before, I think obviously some people are afraid to try new things like that. So we definitely try to maintain a list of accessible gyms or gyms, if it's low income gyms that they might be able to have some financial assistance for. And really try to think out of the box, have a dog, right? If that's gonna help them walk more, what equipment can they have at home if they are not a gym person? I think we'd really try to problem solve all of these things just to make it happen as you're saying. Right on. Well, that's all the time we have for today's session. Thank you so much for participating.

Behavioral Therapy

Weight Management

Karl Nadelski

Dr. Kelly Allison

Lifestyle Counseling

Intensive Behavioral Therapy

Medication Therapy

Disordered Eating

Virtual Behavioral Therapy