Elsevier

Eating Behaviors

Volume 10, Issue 3, August 2009, Pages 146-151
Eating Behaviors

Problem solving, treatment adherence, and weight-loss outcome among women participating in lifestyle treatment for obesity

https://doi.org/10.1016/j.eatbeh.2009.03.005Get rights and content

Abstract

Objective

This study examined whether improvements in problem-solving abilities mediate the relation between treatment adherence and weight-loss outcome in the behavioral treatment of obesity.

Method

272 women (mean ± SD age = 59.4 ± 6.2 years, BMI = 36.5 ± 4.8) participated in a 6-month lifestyle intervention for obesity. Body weight and problem-solving skills (as measured by the Social Problem Solving Inventory—Revised) were assessed pre- and posttreatment. The completion of self-monitoring logs during the intervention served as the marker of treatment adherence.

Results

At posttreatment, participants lost 8.4 ± 5.8 kg, an 8.8% reduction in body weight. Changes in weight were associated with increased problem-solving skills and with higher levels of treatment adherence. Improvements in problem-solving skills partially mediated the relation between treatment adherence and weight-loss outcome. Moreover, participants with weight reductions ≥ 10% demonstrated significantly greater improvements in problem-solving skills than those with reductions < 5%.

Discussion

Improvements in problem-solving skills may enable participants to overcome barriers to adherence and thereby enhance treatment-induced weight losses.

Introduction

Problem solving is the process by which a person works to develop adaptive solutions for difficult problems encountered in everyday life (D'Zurilla & Nezu, 1999). Studies have linked deficits in problem-solving abilities to a host of psychological conditions, including anxiety (Dugas, Gagnon, Ladouceur, & Freeston, 1998) and depression (Frye and Goodman, 2000, Marx and Schulze, 1991, Nezu, 1985). Impairments in problem-solving skills have also been associated with difficulties coping with chronic illnesses (Bodehnheimer, Lorig, Holman, & Grumbach, 2002), including diabetes (Elliot, Shewchuk, Miller, & Richards, 2001), chronic pain (Kerns, Rosenberg, & Otis, 2002), and multiple sclerosis (Pakenham, 2001). Further, problem-solving therapy (PST), a cognitive–behavioral intervention focused on teaching of specific skills to improve adaptive coping, has been shown to be beneficial in multiple contexts, including smoking cessation, marital therapy, and the treatment of mood disorders (Arean et al., 1993, D'Zurilla and Nezu, 1999, Nezu and Perri, 1989, Nezu and D, 1989, Nezu et al., 1989).

Recent studies have demonstrated that PST may be particularly beneficial in promoting treatment adherence. From a PST perspective, adherence problems can be viewed as stemming from difficulties with motivation (e.g., ambivalence about one's goals or participation in treatment) or with a specific skill deficit in overcoming barriers and obstacles related to adherence (e.g., limited resources or a lack of social support for change) (Nezu, Nezu, & Perri, 2006). Problems with motivation or difficulties addressing treatment barriers often exacerbate one another. For example, in the treatment of obesity, a participant's lack of motivation to engage in the behaviors required to induce weight loss (e.g., regular exercise) may undermine his or her efforts to address barriers to behavioral change (e.g., wearing a pedometer, finding a workout partner, investigating low-cost gyms, etc). PST is designed to address both the negative motivational set and the behavioral skill deficits needed to overcome barriers to adherence (Nezu et al., 2006). Indeed, two recent studies conducted with children and adolescents have demonstrated that PST can effectively enhance adherence to treatment protocols (Kazdin and Whitley, 2003, Spirito et al., 2002).

Few studies have examined the use of PST within the context of lifestyle treatment for obesity, although PST is often used to guide clinical decision-making by interventionists (Perri, Nezu, & Viegener, 1992). For example, interventionists may utilize problem-solving techniques to guide their interactions with participants who report significant challenges. Participants may also be explicitly taught problem-solving techniques in order to address barriers to treatment adherence. However, although problem-solving techniques are frequently taught to participants in weight-management programs, few studies have examined the impact of PST on weight loss when it is used as the primary mode of intervention.

Indeed, only one investigation to date has evaluated the impact of PST on lifestyle treatment for obesity. In a study by Perri et al. (2001) that focused on the weight maintenance phase of treatment, 80 obese women were randomized to receive one of three year-long extended care conditions following participation in a 5-month behavioral treatment (BT) intervention for obesity: Relapse Prevention Training (RPT), Problem-Solving Therapy (PST), or a BT only condition that involved no extended care treatment. No significant differences in weight losses were observed between participants in the RPT and BT only conditions or between participants in the RPT and PST conditions. However, results demonstrated that participants in the PST condition evidenced significantly greater weight losses as compared to participants in the BT only condition. Further, a significantly greater percentage of participants in the PST intervention achieved weight losses greater than 10% as compared to the BT only participants (35% versus 6%, respectively). PST participants also demonstrated significantly greater adherence to key behavioral weight management strategies taught during the intervention. Adherence to behavioral strategies was a partial mediator of the treatment condition effect, such that the long-term success of participants in the PST condition was partially accounted for by their better adherence to these strategies (Perri et al., 2001). Rates of attrition and attendance in the 12-month extended care conditions (RPT and PST) were equivalent, and at the final follow-up, 83%, 71%, and 66% of participants were assessed in the BT only, RPT, and PST conditions, respectively. This study suggests that problem-solving skills, as well as adherence to behavioral weight-loss strategies, are significantly associated with long-term weight loss maintenance.

The aim of the present study was to investigate the association between problem-solving skills and weight loss outcome in the initial phase of obesity treatment. Specifically, we examined whether improvements in problem-solving abilities mediated the relation between adherence and weight loss outcome. We also examined changes in problem-solving abilities among participants who achieved differing degrees of weight loss. We hypothesized that increased problem-solving skills would mediate the relation between treatment adherence and weight loss outcome, and that participants with large weight reductions would evidence greater improvements in problem-solving abilities when compared to participants with moderate or small weight reductions.

Section snippets

Participants

Participants were healthy but sedentary women (ages 50–75) from medically underserved rural areas who volunteered to take part in a study examining the effects of a lifestyle intervention for obesity (Perri et al., 2008). The highest rates of obesity in the U.S. are observed among women ages 50–69 (Flegal, Carroll, Kuczmarski, & Johnson, 1998), leading the World Health Organization (WHO) to emphasize the need for weight loss and physical activity interventions designed for obese women in this

Statistical analyses

Pearson product-moment correlations were used to investigate the association between change from baseline to six months in problem solving (SPSI summary scores), weight change (measured by change in BMI) and treatment adherence (number of records completed). In addition, a semi-partial correlation was used to examine the unique effect of change in problem solving on weight loss after controlling for baseline SPSI scores. Pearson product-moment correlations were also used to assess the

Demographics

Participants were 298 women, ages 50 to 75 years, who were taking part in a six-month intervention that occurred prior to randomization for a clinical trial. Only women with recorded weights at baseline and at six months, and who completed the Social Problem Solving Inventory—Revised (SPSI-R) at each of these assessments were included in the present study (N = 272). At the start of the program, participants weighed an average of 95.6 kg ± 14.7 (BMI = 36.5 ± 4.8). A complete listing of baseline

Discussion

The results in this study showed that improvements in problem-solving skills served as a partial mediator of the relation between treatment adherence and weight change following lifestyle treatment for obesity. Improvements in problem-solving skills were significantly associated with weight change, and larger weight reductions were linked to higher levels of treatment adherence. These findings suggest that the impact of increased adherence to the intervention on weight loss was partially

Acknowledgement

This research was supported by grant R18HL73326 from the National Heart, Lung and Blood Institute.

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