Conceptual Articles
Acceptance and Commitment Therapy for weight control: Model, evidence, and future directions

https://doi.org/10.1016/j.jcbs.2013.11.005Get rights and content

Highlights

  • Outlines the ACT approach to weight control and compares to the standard behavioral approach.

  • Presents models for integrating ACT with current gold standard weight loss intervention.

  • Reviews current evidence for using ACT for weight control.

  • Describes potential obstacles for integrating ACT and standard interventions.

  • Identifies significant empirical questions that remain unanswered.

Abstract

Behavioral weight loss programs achieve substantial short-term weight loss; however attrition and poor weight loss maintenance remain significant problems. Recently, Acceptance and Commitment Therapy (ACT) has been used in an attempt to improve long-term outcomes. This conceptual article outlines the standard behavioral and ACT approach to weight control, discusses potential benefits and obstacles to combing approaches, briefly reviews current ACT for weight control outcome research, and highlights significant empirical questions that remain. The current evidence suggests that ACT could be useful as an add-on treatment, or in a combined format, for improving long-term weight loss outcomes. Larger studies with longer follow-up are needed as well as studies that aim to identify how best to combine standard treatments and ACT and also who would benefit most from these approaches.

Introduction

Behavioral weight loss programs, which include diet and exercise recommendations supplemented by basic behavioral therapy skills training, are effective at producing an average weight loss of 8–10% over 6 months (Butryn et al., 2011, Wadden et al., 2007). However participants regain about a third of lost weight within the first year, and by 5 years more than half of participants have returned to or exceeded their baseline weight (Butryn et al., 2011, Jeffery et al., 2000, Perri, 1998). Furthermore, despite often rigorous screening methods, clinical trials show attrition rates above 30% (e.g. Honas et al., 2003, Teixeira et al., 2004).

Treatment innovation has been lacking. The primary approach to improving effectiveness has been to extend the length of treatment, which seems to only delay weight regain (Middleton et al., 2012, Perri et al., 1989). Another approach has been to study successful maintainers and recommend strategies that they use (e.g. Klem, Wing, McGuire, Seagle, & Hill, 1997); however studying successful maintainers has not resulted in improved long-term effectiveness of, or adherence to, behavioral weight loss interventions.

Predictors of attrition include binge eating, psychological distress, body-image dissatisfaction, and poor quality of life (Teixeira et al., 2004). Risk factors for weight regain include psycho-social stressors, disinhibition, emotional or stress eating, depression, and feelings of food-related deprivation (Elfhag and Rossner, 2005, Wing and Phelan, 2005). Broadly speaking, coping with difficult or unwanted cognitive and emotional experiences seems to play a vital role in predicting long-term weight loss success.

Recent developments in mindfulness and acceptance-based interventions provide a potential avenue for treatment development. Often referred to as third-generation behavioral approaches, mindfulness and acceptance-based interventions seek to change one's relationship to unwanted thoughts, feelings, or bodily sensations, as opposed to trying to change or control them (Hayes, 2004). Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is one of the most widely used third generation interventions and is empirically supported for a range of psychological and behavioral problems, including anxiety, depression, chronic pain, and smoking cessation, among others (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Third generation interventions have been growing in popularity and have broad empirical support (e.g. Hayes, Masuda, Bissett, Luoma, & Guerrero, 2004); however weight control interventions have been slow to adopt these newer methods.

In this article we make a case for using ACT in weight control interventions. We compare and contrast the standard behavioral and ACT approaches to weight control, and discuss the relative fit of the two approaches as well as barriers to integration. Finally, we identify research questions that need to be answered in order to better understand if, and to what degree, ACT processes can contribute to better long-term weight control.

Section snippets

The standard behavioral approach to weight control

The model for standard behavioral treatment (SBT) for obesity stems from Learning Theory, which suggests that a behavior can be modified by altering the context in which it occurs (i.e. changing the antecedents or consequences of a behavior of interest; Wing, 1998). SBT aims to reduce maladaptive behaviors (e.g. high calorie diet; sedentary behavior) and replace with and reinforce healthy behaviors (e.g. reduced calorie diet; exercise) by teaching a variety of first generation behavior therapy

The ACT approach to weight control

ACT comes from the same tradition as SBT, with a shared focus on modifying behavior by changing the context in which it occurs. While both approaches aim to foster engagement in healthier behavior, ACT makes different assumptions about the etiology of behaviors that contribute to obesity, and thus focuses on different mechanisms in treatment.

ACT methods are based on Relational Frame Theory (RFT; Hayes, Barnes-Holmes, & Roche, 2001), a basic science model of language and cognition. RFT research

Differences between ACT and SBT

One of the differences between ACT and SBT is that ACT does not supply a priori goals to treatment. In SBT, the overarching treatment goal is to lose weight or prevent weight gain. In ACT, the overarching treatment goal is effective living, defined as behaving consistent with one's personal values. The individual in treatment defines the values. From an ACT perspective, values are desired qualities of action, and thus weight loss itself cannot be a value. However healthy living often relates to

Support for using ACT for weight control

In this section we review two studies that used only ACT methods to target weight control. Other studies that have used ACT/SBT combined methods will be reviewed later. There is empirical support for using ACT methods to target weight-related issues, such as body image dissatisfaction (Pearson, Follette, & Hayes, 2012), disordered eating patterns (Juarascio, Forman, & Herbert, 2010), physical activity (Butryn, Forman, Hoffman, Shaw, & Juarascio, 2011), reactivity to food cravings (Forman et

Potential benefits of combining approaches

Weight loss and weight maintenance benefits could be improved by providing foundational SBT work to give the individual the tools necessary to achieve their caloric and exercise goals, and adding the ACT approach to target the underlying barriers while enhancing motivation for adherence. ACT targets psychological flexibility, which, by definition, provides the individual with the ability to deal with new challenges as they show up. This could improve adherence to weight loss programs and

Support for using combined methods

In an open trial of an acceptance-based behavioral intervention for weight loss using SBT strategies from the LEARN program (Brownell, 2004) as well as acceptance-based strategies including distress tolerance, mindfulness and commitment enhancement, participants lost an average of 6.6% of their body weight from baseline through posttreatment and continued to lose weight from posttreatment to a 6 months follow up (9.6%; Forman, Butryn, Hoffman, & Herbert, 2009). Additionally, participants noted

Potential models for combining SBT and ACT

We will outline three potential models for integrating SBT and ACT while noting that there may be other effective models for integration.

The model that has been tested in the literature is the fully integrated model. In this model, SBT is taught, virtually unchanged, from session 1 to somewhere between session 4–12. This allows the basic SBT skills of diet, exercise, self-monitoring, goal setting, and stimulus control to be taught and reinforced, with large initial weight loss the primary goal.

Potential obstacles to combining ACT and SBT

When designing interventions, it is useful to understand the structural and philosophical differences that could make it difficult to integrate ACT and SBT.

The most obvious conflict between ACT and SBT is the overarching treatment goal. A purely ACT intervention would not organize treatment around producing changes in weight. A purely SBT approach usually does just that by encouraging regular, sometimes daily weighing at home, weekly weigh-ins before group meetings, and periodic graphical

Research agenda

SBT is effective over 6–9 months and is easy to deliver in group format, thus a major focus of the research agenda should be determining whether ACT adds utility beyond what can be achieved in SBT that warrants the additional training that would be required to deliver ACT elements competently. This question will ultimately be answered by testing different models of integration against relevant control groups in randomized trials, but careful laboratory studies testing different mixed methods on

Weight loss as experiential avoidance

Many of the questions about using ACT and integrating it with SBT relate to a core question: Is losing weight a form of experiential avoidance? Of course the answer will be “it depends,” but we believe it is useful to think this issue through, as it will have implications for developing and testing intervention protocols.

Thought of as a continuum, on one side could be an individual who is highly motivated by having enough energy to keep up and play with her children, participate in activities

Summary

ACT has shown promise for improving long-term weight control outcomes in pilot interventions testing both stand-alone ACT and integrated SBT+ACT interventions. However philosophical and structural differences exist between ACT and SBT, requiring thoughtful decision-making when constructing intervention protocols. Future research should focus on efficacy, the added utility of ACT methods, intervention formats, identifying populations that would most benefit from ACT, and interventionist training.

References (34)

  • A. Pearson et al.

    A pilot study of Acceptance and Commitment Therapy as a workshop intervention for body dissatisfaction and disordered eating attitudes

    Cognitive and Behavioral Practice

    (2012)
  • K. Tapper et al.

    Exploratory randomised controlled trial of a mindfulness-based weight loss intervention for women

    Appetite

    (2009)
  • T.A. Wadden et al.

    Lifestyle modification for the management of obesity

    Gastroenterology

    (2007)
  • R.R. Wing et al.

    Long-term weight loss maintenance

    American Journal of Clinical Nutrition

    (2005)
  • Y. Barnes-Holmes et al.

    Relational frame theory: A post-Skinnerian account of human language and cognition

    Advances in Child Development and Behavior

    (2001)
  • K.D. Brownell

    The LEARN program for weight management

    (2004)
  • M.L. Butryn et al.

    A pilot study of acceptance and commitment therapy for promotion of physical activity

    Journal of Physical Activity and Health

    (2011)
  • Cited by (78)

    • Can peer-tutored psychological flexibility training facilitate physical activity among adults with overweight?

      2021, Journal of Contextual Behavioral Science
      Citation Excerpt :

      Moreover, ACT helps to decrease fusion with one's own thinking patterns and explanations for avoiding physically active occasions (Kangasniemi et al., 2015) by raising awareness of tiredness and self-judgment (Sairanen, 2016, p. 25). From a long-term perspective, when ACT is applied together with behavior change techniques (Michie et al., 2013), such as goal setting and problem solving, it may provide an effective way to conduct weight loss maintenance (Lillis & Kendra, 2014; Forman & Butryn, 2015). Previous reviews have shown that ACT can improve disease self-management and lifestyle (Graham et al., 2016; Yildiz, 2020).

    View all citing articles on Scopus
    View full text