 and I welcome everybody again to our evening lecture series on clinical nutrition and obesity. Tonight we are fortunate to have Dr. Rena Wing from the University of Pittsburgh with us to give a presentation entitled behavioral approaches to the treatment of obesity and type 2 diabetes. Dr. Wing has been a long time, I won't say how long, but an investigator dealing primarily with the behavioral and psychological approaches to the treatment of various diseases, but especially in the area of obesity and diabetes. She is a member of our National Task Force on Prevention and Treatment of Obesity and is past president of the Society of Behavioral Medicine. This past year she has been the principal investigator on our recently awarded obesity nutrition research center at the University of Pittsburgh and as a result of that is actually pulling together a lot of other individuals that are in the Pittsburgh community to help work on the problem of obesity and obesity prevention. And we'd like to go ahead and welcome her and have her give her presentation. It's a great pleasure to be here today and speak with you on the topic of behavioral approaches to obesity and diabetes. My goal today is to try to show you some of the changes that we've made in this area recently. I'm going to try to document some of the changes that have occurred between the 1980s and the 1990s as we move into this decade. What are we doing now in the way of behavioral treatments of obesity? Before I begin my talk, though, I think it's important to make sure that you have some understanding of what is a behavioral treatment for obesity and what were the kinds of treatments that were being done in the 1980s. The basic premise of a behavioral approach to obesity are two-fold. First, we assume that by changing behaviors, in this case eating and exercise behaviors, we will be able to change somebody's body weight. And secondly, we assume that these behaviors, these eating and exercise behaviors, are controlled by the environment the person lives in, by the antecedents or cues in the environment that set the stage for eating, such as the sight and smell of a food, and by the reinforcers that come after eating and lead to its recurrence, such as the good taste of an apple pie. Our hypothesis is that if we can change these antecedents and consequences, we can change the behavior. Now to accomplish this, to try to change these behaviors and change the antecedents and consequences, what we do is we develop behavioral treatment programs. These usually involve weekly group meetings for 10 to 20 weeks, and then periodic follow-up maybe two or three times per year. One of the major techniques we use in a behavioral treatment program is a technique called self-monitoring, which is just a fancy word for saying keeping a diary of your eating and exercise behaviors. Now we want to focus on someone's behavior, as I said, they're eating and exercise, so we want a way to make patients in our program aware of their current eating and exercise habits, and of changes they might make, more positive changes. And we do this by asking people to write down everything they eat and the calories in those foods. And pretty quickly, patients start to see patterns in their eating and exercise behavior, and we as part of the therapy can help them change those patterns. Now as soon as you start writing down your eating and exercise behavior, people want to have a goal, what should they be eating? What should they be doing for exercise? So we set goals as part of the behavior program. And usually the goal we set for caloric intake in our program is for patients to eat about 1200 to 1500 calories a day. And usually the goal we set for exercise is a goal of walking about two miles a day on each of five days in the week. And later if you want I can talk with you more about why we set those specific goals. But then as part of the behavioral treatment program, what we do is we help patients learn to arrange the antecedents in the environment and the consequences to help them establish new, better, more appropriate eating and exercise behaviors. So for example, a very simple behavioral technique would be to instruct patients to take the high calorie foods out of their home so that the high calorie foods are not sitting there as a cue to eat them. And rather to go to the grocery store and buy carrots and celery, wash them, prepare them, keep them visible in the refrigerator so that the low calorie foods cue them to eat the low calorie foods. And we also work to change the consequences or the reinforcers with techniques such as self-reinforcement strategies where patients are taught that if they follow their diet, able to eat within their calorie goal for three or four days, then they might reinforce themselves by treating themselves to a new book that they wanted or a new blouse or some type of tangible reward. Now, I think one thing that I want you to realize is that behavior modification, when it works, can really work and we can sometimes be extremely successful. And what I thought I would do is show you a case of an individual patient that we treated who was a 55-year-old man with type 2 diabetes. And when he first came to us, we asked him to write down all the foods that he had been eating and to figure out the calories in it. This is what I mean by self-monitoring. So we asked him to write down what he had eaten the day before. And this is what he ate. He started out his breakfast with orange juice and then coffee and then an English muffin with some butter. Then he had some jam, sausage links, eggs, hash browns. For lunch, he had hot sausage, meatball, pineapple. He knew enough to throw in a diet drink. He then had hot sausage, meatballs, lasagna, wine and remembered to have that diet drink again for dinner. For a total over the course of the day of 2,822 calories and what's most striking is that 57% of those calories were from fat. Now we treated this gentleman in a 20-week behavioral program, taught him to monitor his intake, taught him healthier eating habits and particularly helped him try to change his amount of fat he was eating. These are his results at the end of the 20-week program. Again, we asked him to record his intake for a day. Now he was starting off his day with pineapple and coffee. We would have liked him to eat a little more for breakfast but that's what he chose to eat. Then for lunch, he had pasta, marinated vegetables, pineapple again. For dinner, he had pasta. He cooked his pasta. It looks like he was sort of making a cream sauce. He cooked it with 2 tablespoons of margarine, milk, flour and cheese. I think the poor guy was so hungry at this point that he was eating the flour but we figured as long as it was high fiber it would be all right for him. Then he had shrimp, scallops and crab for dinner for a total of 1,424 calories, so about half as much as what he used to eat and now only 28% of those calories were coming from fat. I don't show you this as a model diet by any means. I show you this just to show you the magnitude of changes that some individuals make and the types of foods they're eating and the quantity of foods they're eating. If you make such dramatic changes like that in your behavior you would expect it would translate into weight loss and sure enough it did for this gentleman. Here was his weight loss over the 20 week program and you can see he reduced from 250 pounds at the beginning of the program to closer to 200 pounds by the end of the 22 weeks of the program. Let me just point out to you that his weight loss is very nice and steady over that program. The next slide shows his fasting blood sugar. He was a type 2 diabetic and his fasting blood sugar when he started the program was very, very high. His fasting blood sugar was 350. Normal fasting blood sugars would be about 140 or less and you can see that within about 2 weeks in the program, 3 weeks maybe, this gentleman close to normalized his blood sugar. So even though his weight loss was coming down very steadily like this his blood sugar had a dramatic initial decrease. This is typical of what we see in type 2 diabetics and has led us and some of our research to be very interested in the effects of caloric restriction independent of weight loss on blood sugar control in type 2 diabetics. And you can see over the course of the rest of the program his blood sugars came down even further but the vast majority of improvement occurred immediately. Now the program ended after 20 weeks and we asked him to come back at 6 months in a year to see how he was doing and here you can see that this gentleman did a very nice job of maintaining his weight loss. He was 260 initially then 199. He got it down a little further to 187 at 6 months and kept it like that at one year follow-up. Now I want to show you his percent of ideal body weight. He'd gone from 65% over ideal body weight to about 24% over ideal body weight. We usually define obesity as by anything over 20% above ideal body weight. So even at this end of this program this gentleman would still be considered overweight or obese but this amount of weight loss markedly improved and in fact normalized his blood sugar control shown here is a measure of long term blood sugar control called hemoglobin A1 and in our laboratory non-diabetic levels of hemoglobin A1 run from about 5.1 to 7.1 and something under 7.1 would be like a non-diabetic and you can see that from here, from here on this individual had normal blood sugar control. So one point I'd like to make from this case study is that behavior modification approaches can be very, very successful and when they work in a type 2 diabetic they can produce not only weight loss but marked improvements in glycemic control and the other point I'd like to make is that these individuals do not have to reduce to ideal body weight even modest weight losses can have a dramatic impact. Now unfortunately not all my patients or any therapist patients do as well in a behavioral treatment program as this gentleman did and in fact in an average weight loss program when I average my results across all my patients what we usually find is about a 20 pound weight loss in 20 weeks and we find that patients maintain a weight loss of about 11 pounds at the one year follow up so clearly more modest than what this gentleman did but what I want to point out to you is that even oh that stuck slide again well this slide will come out in a second but what I want to point out is that even these modest weight losses of 10, 20, 30 pounds can have marked effects on it's the one right after that can have marked effects on glycemic control and on lipids in type 2 diabetic patients what's going to be shown on this slide in a minute is that individuals who lose just 15 to 30 pounds have significant long term improvements in their fasting blood sugar their insulin their HDL cholesterol the good cholesterol and several other parameters so here we go is people who lose just 15 to 30 pounds and maintain that at a year have significant long term improvements in fasting blood sugar, insulin, triglycerides and HDL which is the good cholesterol and you would want it to go up and these individuals just losing that amount of weight makes it go up significantly all those changes are even better if patients lose more weight if they lose 30 plus pounds but even losing 15 to 30 is very important clinically and statistically for these individuals I think that's an important message for those of you who treat obese type 2 diabetic patients these individuals do not have to get to ideal body weight just modest weight losses which would be much more reachable for them will produce long term improvements in these parameters now these are really the concept of the behavioral program as we were doing it in the 80s and at the end of the 80s and these were really the types of results we were getting and points we were establishing now as we've moved into the 90s we've made a few changes in our concepts about behavior modification approaches that I'd like to share with you because I think you're going to see new programs using these new concepts first of all in our old programs such as shown here our patients were treated for 20 weeks and then we assumed they learned everything and they could do it on their own and stopped seeing them and what we found was that patients regained their weight except for these unusual cases like the one I showed you now what we have done is we have moved to a chronic disease model of obesity we have realized that obese people have a chronic disease just like hypertensives do and that they are going to need to be in long term ongoing treatment just the way you would treat hypertensives for a long term you don't put a hypertensive on medication for 20 weeks take them off and expect their blood pressure to stay down a year later but that's the model we've used thus far in obesity treatment we treated patients for 20 weeks hoped they would learn everything and could do it on their own forever we find that they cannot do that and we now realize that these patients need to remain in treatment perhaps for the rest of their lives there have been several studies that have used this long term model of treatment that it's much more successful than the old model this is one such study a study by Michael Perry what he did was recruited a group of overweight patients and randomly assigned them to one of five groups this group up here called BT received a standard behavioral program such as I was describing from the 80s they were seen weekly for 20 weeks and then they weren't seen any longer you can see they lost weight nicely and then when they stopped seeing these individuals they regained their weight and as I said before they lose about 20 pounds and then they regain and they've maintained about 10 pounds typical behavioral program now these four groups were all you treated using this chronic disease model in which they continue to come for treatment every other week for the full 18 months of the study and you can see that all four of those other groups did much better throughout this period than this group did now Dr. Perry studied exactly what kind of contact they should have the C group just received contact they just came every other week to the groups the C plus A group came and actually did aerobic exercise the C plus S group came and actually participated in some social support programs like buddy systems and the C plus A plus S had contact and aerobic exercise social support and you can see when you put them all together it was a little better than the others but actually these treatment groups did not differ significantly from each other so it appears that the most important thing was just seeing these patients for long periods of time now another thing that has changed in our approach to weight loss is that we're going beyond just telling people how to change the antecedents and consequences in their environment to help them change their home environment we've argued that we could probably get better results if we didn't just tell people what to eat but if we actually gave them the food that they should eat so we've actually studied food provision and similarly we argued that we would probably get better results if we didn't just tell people to pat themselves on the shoulder when they did a good job eating and exercising appropriately but rather if we could actually financially reward them for doing a good job so pay them to lose weight we studied these two approaches and asked the question whether providing subjects with the food there to eat would improve outcome and whether paying subjects to lose weight would improve outcome to study this what we did was we recruited 200 individuals 202, 100 males 100 females who were 37 years of age weighed 89.8 kilograms for about 200 pounds and they had a body mass index of 31 so they're mildly overweight relatively young individuals these individuals were put in five different treatment approaches one was a control group that got no treatment they were just told we'll see you again at 6 months and if you will follow your weight at that time the standard intervention group was given a standard behavioral program where they were taught to self monitor their intake and their exercise they were encouraged to eat a low calorie, low fat diet to increase the amount of exercise particularly walking that they were doing and they came in to see us every single week for the first 20 weeks and then they had monthly meetings for the next 18 months and weekly weigh-ins throughout next group got the exact same behavioral treatment plus in addition every time we came into a weekly meeting we gave them a box of food and in that box of food was there five breakfasts for the week and five dinners for the week all pre-packaged and arranged for them so there would be a little note in there saying Monday morning you are to have one box of Cheerios it will be provided in the box one container of skim milk and it would be there a banana and a container of orange juice everything would be in the box and we would tell them exactly how many calories and how much fat they were eating same thing for dinner and we often use lean cuisines for dinner weight watchers frozen foods for dinner or we would pre-package something like a chicken breast plus some frozen peas plus some rice and set it up all in the correct portions for them at different calorie goals depending on their initial body weight now they got that food every single week for 18 months now this group got the same standard behavioral program they didn't get any food but they got paid to lose weight every week if they came in and lost weight they could earn up to 25 dollars a week depending on how much weight they lost or maintained so over the course of a year you could earn quite a bit of money 25 dollars a week by getting your weight down and keeping it down and this group got the standard behavioral program plus the box of food plus the money and all these treatments were continued for 18 months now these were the results of that study the group that got no treatment the control just stayed about the same in their weight they didn't gain much they didn't lose much the standard behavioral program lost some weight and then regained some and the standard behavioral plus money is sitting right there on top those two lines are right together so giving the money didn't help at all these are the two groups that were given the food one's given just the food and one's given the food plus money there's no evidence that adding the money helped but what you see dramatically is that the two groups given the food have much better weight losses than the groups that were not given the food at every single time period we studied now unfortunately the food provision didn't make perfect weight maintenance would have been nicer if they came down a weight loss and kept it down they didn't but at every time period we studied they had significantly better weight losses than the groups that were not given the food now we investigated possible mechanisms whereby this food provision might be helping with weight loss and we found that the individuals who were getting the food had better attendance they would come to the treatment meetings because they wanted to get this food they did more of this self-monitoring they kept their diaries religiously in part because we made it easier for them to keep their diaries because we told them how many calories were in the foods we gave them we found that giving them the foods that they were to eat led to greater reductions in dietary fat so they ate what we were giving them was healthier and it also produced greater knowledge of calories by giving them the food showing them about portions they learned more information about calories and actually did better on knowledge tests about calories so we think for all these reasons that the food provision was working to produce better weight losses and we feel strongly that this type of more intensive more direct behavioral approach is going to be an important way of producing better weight losses in our patients now in moving to the 90s one of the other things that we have been doing is looking at the combination of behavior modification and very low calorie diets and we've been comparing those results to programs that are behavior modification alone now by very low calorie diets what I mean are diets usually of about 400 calories a day that are either taken as liquid formulas or as lean meat, fish and fowl these are diets similar to what you've heard about commercially in programs such as Optifast in our study with these very low calorie diets what we did was we recruited obese type 2 diabetic patients and randomly assigned them to one of two groups one group got a standard behavioral treatment program with a balanced 1200 to 1500 calorie a day diet throughout the 20 weeks and all during maintenance this group was given behavior modification and a very low calorie diet they ate 1200 to 1500 calories initially then for 8 weeks they used a very low calorie diet 8 out of the 20 weeks then we gradually increased their food back to 1200 to calories and then during maintenance they had the same diet so the only difference between these two groups was in this 8 week period of very low calorie diet now you would expect that this group would have a better weight loss initially because they've eaten less if you look from here to here they've had a period where they only ate 400 calories whereas this group was eating 1200 to 15 throughout so that's almost expected that initially this group would do better the important question to us is what happens out here does getting better initial weight losses help out here or not and that's really the question we were trying to ask now Dr. Tom Wadden asked that question with a group of non-diabetic obese individuals he had three groups in his study he had one group that got a very low calorie diet without the behavior modification at all those patients lost weight and rapidly regained it consequently I think that approach using a very low calorie diet without any behavior modification is not one that has remained popular at all it is not one that we even chose to study and I think most people are not using that approach in fact almost all the commercial programs that use very low calorie diets use it in combination with behavior modification when you look at the other two groups of Wadden studies this is the group that was getting the behavior modification only and this is the group getting behavior modification and a very low calorie diet and as you can see initially the very low calorie diet group lost more weight as I said you would expect and out here they lost somewhat more weight too but this was actually not a statistically significant difference between those two groups so you would conclude looking at this data that at one year follow up they really didn't differ in long term weight loss now how did my type 2 diabetics that really were done exactly the same as this how did my type 2 diabetics look well here's their weight losses and again very much the same pattern initially being treated with the behavior modification in VLCD now I should point out mine is behavior modification and VLCD versus behavior modification or behavior therapy alone when you use the combination I got much better initial weight losses but these patients regained the weight and at one year follow up there was absolutely no significant difference between the two so I think from these data you would have to conclude that in terms of weight loss the use of the very low calorie diet is not warranted why make patients do this if it doesn't produce long term weight loss however when we looked at our type 2 diabetics blood sugar control the story was very different here we found both initial and particularly long term improvements in blood sugar control for those individuals who have been treated with the very low calorie diet something about that period of strict dieting of almost fasting seemed to produce a long term impact on their blood sugar control now in moving to the 90s we began to ask about using very low calorie diets in the context of long term treatment programs and we developed a new study design where we would use a very low calorie diet initially you can't keep someone on a very low calorie diet on 400 calories for the rest of their lives or for the whole year of treatment so if we want to go to a chronic disease model with very low calorie diets how could you use them we thought maybe one way to use them would be to use them intermittently put people on it for a while take them off it for a while put them back on it for a while in hopes of getting a new burst of weight loss and perhaps a new improvement in blood sugar then take them off it for a while so on off on off was our thinking and we compared that to a chronic disease behavioral treatment model where people came in every single week for a full 48 weeks for a full year of treatment so both groups come weekly this group stays on this diet throughout this group has two periods of very low calorie diet again we wanted to know what would happen for weight loss and blood sugar control this slide shows the weight losses by the way I'm showing these weight losses now in kilograms it's a little confusing I know in my slide some of them are pounds some are kilograms what I think about that is to think of kilograms you multiply 2.2 to get the fact of pounds but what you can see here just looking at the pattern is that the group given the very low calorie diet which is shown here in the filled in circles had significantly better weight losses during the first bout of the very low calorie diet they then maintained their weight losses now this is the second bout of the very low calorie diet you can see they lost almost no weight the second time we've analyzed that very carefully and we can show that that failure to lose weight the second time results completely from poor adherence to the diet the second time patients went on it the first time they loved it the first time they came off of it all during this time they cried to go back on they were so eager to go back on when they got back on they found it very hard to adhere the second time and it produced very little weight loss and then this is the last three months of the program where you can see some regain this is the standard behavioral program that came in weekly and was on 1,000 to 1,500 throughout they lost weight initially and they maintained their weight losses fairly well over the remainder of the year however in this study there is a significant difference in long term weight loss the behavioral group lost about 10 kilograms at the end of the year study about 20 pounds whereas the very low calorie diet lost about 14, 14 and a half kilograms closer to 30 pounds and that was a statistically significant difference so in this particular study there was some evidence that the use of the two very low calorie diets did improve weight loss but not tremendously so and most of that improvement was due to this first VLCD with very little effect of the second now what about the blood sugar results well again I'm showing you hemoglobin A1 this measure of long term blood sugar control and again you can see that this fasting the very low calorie diet shown here with the dark the filled in circles produced dramatic improvements in their blood sugar control far greater than the improvements initially in the behavioral program but then over time the behavioral program kind of catches up so that over those latter months of the program the two groups are having actually comparable changes in their blood sugar what's striking here is that both groups have very nice changes in their hemoglobin A1 and the really at the end is no difference between the two groups although the mean blood sugar of the very low calorie diet group throughout the year of treatment does turn out to be statistically different from the mean blood sugar of the BT group so again some slight evidence that the very low calorie diet group may improve blood sugar not as dramatic as I saw in my first study and again most of this impact seems to be from that first very low calorie diet now at this point when I've done these two studies I think my conclusion would really be that very low calorie diets do show some promise in the treatment of type 2 diabetic patients we need to study how better to use them I'm not sure that this intermittent format was the best way to go and I think we need to study other approaches to using very low calorie diets either intermittently or in relationship to different periods like when a person starts to regain their weight might be a good time to put them on a very low calorie diet I think we need to be creative to use very low calorie diets at the moment my data would suggest that it's mostly the first bout of VLCD that may be helping people and as I say I think it really we need to figure out how to use these very low calorie diets as part of a long term treatment program now we also have begun to ask about the combination of very low calorie excuse me, about the combination of low fat diets in combination with calorie restriction most of the studies I've shown you thus far we just told people to cut down their calories eat a thousand to fifteen hundred calories a day and we didn't focus very much on how much fat individuals were eating well clearly I'm sure you're all aware of the recent literature that's arguing that cutting back on fat may also be an important part of helping individuals lose weight that fat may be fattening in and of itself and that it may be important for individuals not just to cut back their calories but to actually decrease the percentage of the calories that's coming from fat plus fat would have the cutting down fat would have the added benefit of helping to protect against coronary heart disease so we asked another question from our type 2 diabetics which was does use of a low fat diet less than 20% of calories from fat improve outcome compared to a calorie restriction alone we randomly assigned our type 2 diabetics to one of two groups one group worked just on cutting back their calories they were instructed to eat 1000 to 1500 calories a day with less than 30% of their calories from fat but we didn't put a lot of emphasis on the fat we had them self monitor only their calories so they would write down what foods they'd eaten and figure out how many calories were in that food but not how much fat and that takes the emphasis off of the fat we compared that to a group that was doing calorie restriction plus fat restriction same number of calories but this group was asked to come down to 20% of their calories from fat and they were actually asked to focus on the amount of fat they were eating by writing down not only the calories in every food but also the number of grams of fat in every food that they ate and they had a goal not only for calories but also for how much fat they should eat each day now these are our weight losses at the end of the 16 week program and you can see that the group that was doing fat and calorie restriction had significantly better weight loss as about 9 kilogram weight loss compared to about a 5 kilogram weight loss in the group that's doing calorie restriction only the group, both groups had significant improvements in their hemoglobin A1 but there were no differences between the two groups this is the calorie restriction group at beginning and after 16 weeks this is the fat and calorie at beginning and after 16 weeks they both come down but they both come down the same amount we also show the comparable types of things at one year follow up again the group that was given the fat and calorie restriction maintained their weight losses better at the end of the one year treatment program so we feel that there is some benefit to combining fat and calorie restriction one of the reasons we were very interested in doing this study in type 2 diabetics is that there's been some recent studies arguing against low fat diets in the treatment of type 2 diabetics because when you put individuals on low fat it means you're putting them on a high carbohydrate diet some of these studies have argued that a high carbohydrate diet for type 2 diabetics can result in worsening in their lipids and their glycemic control however these previous studies have all used weight maintaining regimens they've tried to keep individuals a constant weight and look to see the effect we felt that the question should be addressed within a calorie restriction model within a weight loss model and we find with using weight loss, calorie restriction that adding the fat restriction helps with weight loss as I've shown and has no negative effects on lipids or on glycemic control in the type 2 diabetics so we feel that we should continue to look at the use of low fat diets in combination with calorie restriction in the treatment of type 2 diabetics now I think another change of the 90s has been an increased recognition of the importance of exercise in combination with diet in the treatment of obesity the importance of exercise comes out numerous different studies and in all kinds of studies this is one study which was a retrospective study by a woman named Susan Cayman that Cayman did was to study three groups of individuals one group of individuals were controls they were normal weight controls who had never been overweight another group were a group of people who had successfully lost weight and maintained their weight loss and the third group was a group of overweight people who lost weight but then relapsed and she looked at what distinguished these three groups and one of the best variables to distinguish them was in terms of how much exercise they did individuals who were normal weight and individuals who maintained their weight loss successfully both reported about almost 100% of those individuals both reported doing regular exercise that is exercising at least three times a week 30 minutes each time whereas the relapser is only about 40% of them reported doing that much exercise there have been many other studies that have shown much the same thing that one of the best predictors of who is going to relapse is those individuals who stop exercising or never start exercising seem to be most vulnerable to regain their weight whereas those individuals who keep exercising seem to be the ones who keep off their weight and this has also been shown in experimental studies where you randomly assign people to diet or exercise groups this is a very busy slide where all these horrible lines are wondering what's going on let me make it simple for you there are four different diets used here and the four diets are used with exercise and without exercise these four up here are the four diets used without exercise and these four down here are the four diets used with exercise and what you can see very dramatically is it didn't matter what the diet was all the groups that didn't get exercise regained their weight and all the groups that got exercise kept it off much better suggesting that whether or not someone given exercise as part of the program may be much more important than anything we do in the diet now we've done similar kinds of studies with our type 2 diabetic patients and again we show importance of exercise in our study we randomly assign some patients to work on diet only and some to work on diet plus exercise and as you can see here diet plus exercise had significantly better weight losses at 10 weeks, 20 weeks and at one year follow up this is one of the old studies where we saw people weekly here and then stopped singing them and you can see there's a lot of regain although this group did do better we are now studying what happens if you keep people coming in and exercising with you all through here can we keep this line down those are some of the kinds of new directions for the diabetic disease model with the realization that exercise is important now if you look at a study like this and you look at the one before and you say diet plus exercise works better than diet only the question becomes why why is this combination of diet plus exercise effective for long term weight loss there's several possible explanations one is that diet and exercise work additively that by diet you get some caloric restriction some change in calorie balance if you exercise you get an increase in caloric expenditure so you get greater change in greater caloric deficit overall you add the two together another possibility is it's not just additive it's synergistic maybe there's something about putting people on a diet getting them to lose weight quickly that helps them stick to an exercise program and maybe there's something about exercise that helps people stick to a diet now we've been looking at those kinds of questions and we've been looking at them within the context of a new study that we're doing this is a study with individuals who are overweight and also have a family history of diabetes these are adults and they all have a parent one or two parents with diabetes the individuals I'm studying are adults but they don't yet have diabetes but they're overweight they have a parent with diabetes so they would be at high risk of later developing diabetes and we're trying to see if we can intervene to help reduce their risk of diabetes and we're intervening with four different approaches one is not to give them any treatment another is to use a diet another is to use exercise and another is to look at diet plus exercise we've only started this study so I don't have results to tell you yet but there has been some interesting data that suggests maybe why diet plus exercise works better than diet or exercise alone and that comes from the finding that something about the combination of diet plus exercise seems to make people much more adherent to the treatment that we're trying to get them to do now in this case I have people in an exercise program who are being asked to come and exercise with me at least twice a week I have three exercise sessions for them to choose from but they're to come two out of three times the diet plus exercise group is likewise told to come and exercise with me two times out of three sessions a week so they have the exact same requests for how much exercise they should do this group also is told to diet now if you think about a behavioral approach you might think that asking someone to work on diet plus exercise would be a lot might be a lot of changes and they might do less well at either change but actually our data suggests just the opposite we find that the people who are asked to do diet and exercise actually are more adherent to the exercise program they come to more of these prescribed exercise sessions that group attended about 85% of the prescribed exercise sessions compared to only about 60% in the patients who were just told to work on their exercise so we think one of the reasons that diet plus exercise may be particularly useful for patients is it may get them involved in the whole program maybe what they like best and may create more of an involvement and they may do both parts of the program more enthusiastically now this shows the same data in another way this just looks at the weekly attendance at each of these exercise sessions per week and shown here are the diet plus exercise groups and shown here are the exercise only groups and you can see that attendance goes up and down in part that's due to things such as the weather but you can see that throughout the exercise only group has lower rates of attendance this is the percent of the patients who are attending throughout the exercise only group does poorer now this week we said to the people instead of just walking with us let's go and join a big event that they're having downtown in Pittsburgh and what they were doing was inviting the stealers to come and walk so that week you had a chance of going and walking with the stealers and look what happens everybody comes the diet and exercise and the exercise only group has very good attendance but it quickly falls off when they realize the stealers aren't around anymore and you can see by the even this week 11 of the program attendance clearly in the exercise group is worse than in the diet plus exercise but you can see that even here our attendance is only 55% of the patients are attending both of the exercise sessions so clearly as you develop long term exercise programs even though exercise is very important for weight loss you can see what one of the major problems is which is getting people to adhere to the exercise long term we feel that one of the things that we need to be doing as behaviorists is studying new approaches to increase exercise adherence since exercise seems to be an important part of the weight loss package so in conclusion I think we've made progress in the behavioral treatment of obesity and the application of these principles to the treatment of the obese type 2 diabetic patients and I show you some of my own data to illustrate some of the progress that's been made in the last 10 years this is the progress I made over the 10 year period and the treatment of type 2 diabetics from my first study to my 8th study I doubled my weight loss during my initial treatment and I caused almost a quadrupling of my effect at the one year follow up now a lot of that difference relates to the treatments that I'm telling you about today the use of longer term chronic disease approaches the emphasis on diet plus exercise in this case we didn't use low fat diets but I think if you added low fat diets and perhaps very low calorie diets to the treatment package you might even do better so I think there is progress clearly the results are still modest but I think I hope you've seen that even modest weight losses of this type are very important for the type 2 diabetic patients and I think there are some things for us to be considering as we move into the 90s and do new treatment approaches one is that I really think we need to be treating obesity as a chronic disease and developing long term interventions now the questions that's going to hit us as researchers and as therapists is how do you get patients to stay in these programs long term we know that they need to stay there but it's very difficult to get patients to agree to come weekly for two years, three years, four years but I think that's what they're going to need we also need to know what do you do in these treatment groups if you're seeing patients weekly for four years what do you do, there's not that much you can tell them every single week what should you be doing with them at each of these meetings and how can you prevent them how can you see if they're about to relapse and how can you prevent that relapse I also think we're going to be needing to be showing you here such as providing food to patients using intermittent very low calorie diets using structured exercise programs using low-fat diets and I think if we can combine these more intense approaches with a chronic disease model maybe we'll be able to improve our results still further in the rest of this decade thank you I'd be happy to answer questions $2,500 where does it stand? it's actually interesting we debated a long time about the magnitude of the money it is possible that $25 wasn't enough and that one approach to a research project would be to see I believe there is an amount of money that you should be able to pay people and control that behavior I think there's another problem though with the way we had to set up that study and the way we did set it up we were paying people for weight loss or weight maintenance really these are behavioral programs and our focus really should be on behavior what we really want to be paying people for is changing their behavior the problem is that we can't get good measures of people's behavior I can't go and find out how much you ate or how much exercise you did so one need we have in this field is to get some good measures of intake and $25 if used appropriately maybe enough we're actually finding that even smaller amounts of money actually a lottery system may be very useful in manipulating exercise behavior and that may be because what we're actually doing is rewarding patients for attending exercise sessions there we're looking at a behavior attending and I know whether the people attend or not because I'm right there to check them using my reinforcement more related to the behavior that may be the problem one possibility is that the magnitude of the money wasn't enough another potential problem is that what I was giving the money for was the wrong thing let me see if I can point out the changes first of all in all my current programs we now have not only calorie monitoring but fat monitoring that's number one the exercise prescription is probably quite similar the probably the biggest change in mine and other people's behavioral treatment program is the emphasis on relapse prevention techniques Marlat and Gordon type of approaches we spend a lot of time with individuals explaining to them that relapse is something that's inevitable that lapses are inevitable that we need to use these lapses as learning experiences and help them identify when lapses are occurring and what they can do to treat those lapses so I think that's probably the biggest addition my definition of a binge the definition I use of a binge really comes from the DSM-3 criteria for bulimia nervosa which is I'm going to block in the exact wording of it but it's a large amount of food and the large amount of food has to be large not only by the patient's standards but by an experimenter's standards and with that large amount of food the ingestion of a large amount of food there's a frequency criteria so that has to occur at least two times a week every week or over the past three months and the other thing is that it has to be associated with a feeling of loss of control so it's all those criteria but basically what we are doing when we work with binge eating and the obese individuals is we are using the definition of a binge that has been used to date in the bulimia nervosa literature and will be recommended now in the DSM-4 criteria for binge eating disorder yes, I actually in all of my studies have not gone beyond the 12 to 18 months oh actually that's a lie and I didn't mean to lie I'll tell you about one in a second in fact I'll tell you about it right now in this trim study I showed you where the trim is when we provided the food I only showed you that through 18 months and follow up what we did after 18 months was we stopped everything we stopped giving them the food we stopped giving them the treatment we stopped giving them the money stopped everything what do you guess happened to the weights went back up and that's exactly what happened now my question is it was going back up you could see it was even going back up with the giving of the food in the treatment I don't know if I had kept that going for 30 months if it would have helped to mitigate that we just didn't do that one thing I do know is if you stop it it doesn't work yes I did not talk about combination therapies combining behavioral treatments and pharmacotherapy and I did not talk about pharmacotherapy separately just in interest of time but let me address the question the question really was about the wine trough study the wine trough study used a combination of drugs used phentermine and fenfloramine in combination in the treatment of obese patients plus all the patients on the drug were also given behavior modification and what he found was that the combination of behavior modification and the two drugs together produced very nice maintenance of the weight losses the weight losses were not tremendous they were relatively modest but they were well maintained over time the group that was given behavior modification and the placebo did not lose as much weight at all and did not maintain their weight as well he I don't have the numbers directly in front of me but he kept them on this as a double blind study initially then after a while took them off the double blind single blinded it and changed some of the treatments so it's hard really I think to look at his four year data but the initial phase of the program was successful it clearly needs a long term trial and I think that that trial really should be a trial of the combination of combination drugs plus behavior modification now we've also been doing some work with behavior modification in combination with Prozac Loven which is the lily drug that's used for depression but has also been shown to produce weight loss and I have had some positive results of the combination of behavior modification and Prozac in the treatment of obese patients I was I have significant effects with that drug it worked quite well for me with behavior modification however I was part of a large study and across all the centers in the study it did not work well I was the only one though really doing behavior modification with the drug so I think again that's another drug that might deserve more study with behavior modification without behavior modification it's different treatment approaches so I very much think that the area of anorectic drugs is a very interesting one to study A as a treatment alone but B in combination with diet and exercise interventions I think we're going to have to go with combination approaches good observation ok and it's actually fascinating if you take 200 people and you lay out individual plots what you see is that almost everyone starts going up around 6 months 6 months, 7 months, 8 months very interesting because they all start going up at 6 months, 7 months, 8 months almost regardless of how much weight they've lost which to me I think many people would say oh you hit your set point and your biological set point makes you start going back up I have more problem with that explanation because it seems to be more related to length of time in the program that it does to actual weight loss it doesn't seem to be how far down do you get the person it seems to be something about 6 months and I'm actually quite interested in that I mean I think it's you know I think people may sustain their activities for about 6 months, 20 weeks and in fact I've been sort of interested in looking at things like chess clubs and finding out how long do people stay in chess clubs and do they have trouble at around 20 weeks you know is there something about how long we will adhere to a new behavior and it's down about how long these groups are sort of interesting and after that they get boring so the answer is I don't know you are correct in your perception whether that is a behavioral type of problem sort of due to boredom whether it is a physiological thing that they've lost enough weight that they're you know having trouble maintaining it I really don't know yes up the top well let me let me answer you in two ways okay first of all let me answer you a little bit about individualization our program is actually fairly individualized in the sense that we set individual calorie goals so that's why I always gave you a range the calorie goals might be between 1,000 and 1,500 but that is individualized depending on the individual patient depending on their weight other things about them how much weight they're losing etc the selection of foods by the patient is totally individualized so that we give them a calorie goal but we teach them to use that calorie goal as they would like and to eat the foods that they would like so some patients eat very small breakfasts and big lunches and no dinners and others eat you know much smaller lunches and you know big dinners they eat different types of foods the guy I showed you was eating a lot of shrimp and pasta other patients might eat something totally different the exercise too is totally individualized we work on a calorie based exercise program so we tell people how many calories you should get in exercise but we show them how you can get that same expenditure by skiing or by walking or by biking or etc so there is a fair amount of individualization in the program now the second aspect of your question had to do with intrinsic versus extrinsic motivation and we actually are moving more and more to the feeling that you may need more extrinsic motivation for a longer period of time that the intrinsic motivation may come over time but it may not come for many many individuals and that the best way to produce long-term weight loss in a large group of people may be to keep the external motivation there yes very good question not at all my assumption and we try to deal with that in several ways and again I don't think we've been as good about that as we should let me tell you how we try to do it when we're looking at self-monitoring records and we're working with an individual on their diet what we're very interested in having them do when I talk about antecedents controlling the eating one of the things we want to know is what are the antecedents let's say this woman mentioned a binge okay what are the antecedents related to a binge is it fights with your husband is it positive what are the social situations what are the things going on in your life that are directly related to your eating we approach other things in the person's life in the context of looking at those things as cues for eating now I think one of the things that behavioral approaches have not done and again I would think may be part of the wave of the future just as I'm talking about combining behavioral approaches with drug approaches I think there may be some combinations with other psychotherapeutic approaches for example interpersonal therapy is being talked about interpersonal therapy has been shown to be quite useful in the treatment of normal weight bulimia nervosa and I know some people who are starting to apply it to the treatment of the obese binge eater interpersonal therapy totally does not talk about food at all it deals with other interpersonal aspects of the person's life and perhaps again it shouldn't be interpersonal versus behavioral therapy maybe it should be combinations of the two so I think we'll be moving more and more into some of those domains just let me say one other thing that I think is very interesting in this regard we know that people lose weight we know that around six months people have problems we know that people relapse one of the things that we can't do is we have a lot of trouble studying the relapse process finding out what else is going on in their life and the reason we can't do those studies I mean I keep setting up to do them etc is patients won't quote-unquote won't let us do them what happens is when people start to regain the weight they get very defensive they don't want to talk to me they feel like I'm going to yell at them even though I'm not going to yell at them I just want to help them and have them help me learn about the problem but they are not at that point eager to share information about what is happening so what happens is at the point where it would be most helpful to learn what is going on patients withdraw from our programs they say it's not working I don't want to be in your program anymore we try to see them individually and often they will not come so that's been a problem in this field I was looking to you for the answer for that I think it's going to be a very I don't know I mean I don't know the answer what I hope that researchers will do is two things I guess what I really hope is to go out and do tremendous studies with gigantic sample sizes with no idea what they're doing this is an area where I would very much like to see some smaller studies not looking at long term weight loss but looking at shorter term adherence acceptance type of variables I think we don't know what to do we don't know what is going to be the most effective program so I think we need to be starting to study that in a small way first as I look at the data African American women in particular what strikes me is the low activity level so I think clearly one important aspect of the treatment program for minority women is going to be exercise and the question is going to be coming back to individualization how do you individualize it what types of activity programs will be most appealing to African American women I also think the food provision model may be a useful one because that may provide some education meaning to African Americans and other groups of individuals who may not be as familiar with what are good low fat choices what are appropriate serving sizes so I think those may be some models but I really would argue that we need to try some things in relatively small scale and see what works Box you send home constantly putting less and less in the box oh that would be so mean I put a little to begin with no I haven't thought about that I've thought about a lot of things with the box and I am doing a lot of work with it one of the things we're doing with the box right now is we're using it we're allowing people to select the times of the year that they want it we found that when you gave it to people every single week for 18 months if you remember what happened it sort of lost its effectiveness worked real well and sort of lost its effectiveness one of the questions we have is maybe if you let people use it at the points where they needed it they could use it very effectively that's an approach that's been used in the pain control literature people are often given access to pain control medications and they have the freedom to individually control when they want to take those pain medications they have found in those studies that people often use less pain medication in that setting and they have less pain the medication works better because they can use it when they really want it and that's been one of our thoughts with the food box is I don't know what periods of your of your next year what periods are going to be bad for you but often people will go through periods of their lives get crazy their mothers in the hospital or their children are all home and life gets crazy and we think that maybe if we can convince them to ask us to bring the box to them at that point in time that that's when it might be useful you wouldn't have to think about your food for that next month it's a busy crazy month I'm running to the hospital to see my mother all the time there's food all there for me and it's the right food and I wouldn't have to go to the grocery store during those days so that's one of our thinking you know to use with the box I think it's an interesting approach we think we think that it has some potential and we are sort of interested in seeing how it applies to even lipid lowering I mean other approaches the original idea for the food box actually came out of the diet heart study which was a large trial to get individuals to eat less dietary fat and what they found there was if you had a food provision center sort of a grocery store where there were low fat meats available that people did better and that's the same concept if you make this very available to people it seems to do better and I think the question is you know how do you use it and what different diet problems might it be helpful for yes I'm sorry most of mine are volunteers yes well I'll answer you in both ways yes they answer an ad I guess you would say they're motivated however they also usually come with the message from there when I contact their physician to ask permission tell them I'm going to treat them and most physicians write me back letters saying good luck this patient is the most difficult patient in the world I'm so glad she's coming to you so it's a mixed blessing yes right was it in New England Journal yes the question is how do I explain the under-reporting of intake and the over-reporting of exercise and I think I would answer you in a couple of ways first of all I think it's actually extremely difficult to accurately report what you eat even if you get trained therapists people totally committed to doing it and you really stop them and say well didn't you nibble anything today like when you were cooking a food didn't you put anything in your mouth and say oh yeah I did I tasted that stew I was cooking well it's no place in their diary I think it is actually extremely difficult we eat so many times in the day so often unconsciously sort of you know not really thinking and not sitting down so I think it's actually very difficult to accurately record one's intake and exercise and I think that that problem is probably worse in people who are eating a little more chaotically that if you sit down and you eat breakfast at breakfast time lunch at lunch time probably a little easier to do it than if you tend to be a nibbler or tend to you know eat more erratically now in that study that was a relatively small sample I don't know if those people were eating more erratically or not but those would be the kinds of things I would expect leading to under-reporting I think some of it is purposeful under-reporting I think some of it is accidental under-reporting I think it comes from all different things but my classic example was a woman who came to me a patient who came in was self-monitoring and she came in and she said Dr. Wing I had a terrible terrible week this week I ate everything and I said well let me look at your book let's look through it together and I looked the first day and I said this doesn't look so bad you had an eclair today she said well I left out one thing I left out the S, eclairs and I said well what do you mean she said well there were six of them okay well that's a little little distortion okay I was very interested too in the six month syndrome especially in the slide that showed the very low calorie diets you got beautiful weight loss the first second but what you didn't get was the return of weight couldn't you say the same thing about behavioral therapy it works great for three months, four months but then it stops working because it seems to me in some of your studies you didn't stop at six months you continued behavioral therapy and they still keep and they start going back up you're right so one of the questions that we are asking now is it seems to do better if you keep them in but you're right it doesn't stop it from going up so just keeping people in there forever doesn't seem enough one of the questions is what we need variety and I don't know do you put people on a diet program for the first six months then after six months you say okay keep working on your diet but we're not going to talk diet here at all we're just going to do exercise we're going to turn this into an exercise group for the next six months then for months 12 to 18 do you do something totally different now do you put them on a VLCD is it just sort of a variety type of thing that we have to do to keep people interested what you hear from patients is in all the years I have worked in obesity I have never heard a patient say to me that after six months I got too hungry that hunger was the cue I've never ever heard I hear much more things like it became too much of a pain in the neck other things in my life became more important this was happening in my life that was happening in my life I couldn't devote the attention to this I don't have an answer to this I don't have a solution but the feeling I have is that we can devote attention to one thing only for so long and it's like for six months people can attend real real hard on this diet but then after six months it loses that excitement that interest that it's no longer their primary focus and once you take weight loss out of the primary focus it seems like you go back to your old habits and it becomes you know it's not ingrained yet so it goes back to the old habits I think you have to keep it in primary focus and I don't know how you do that that's my hypothesis we're ahead with it excuse me an OA or AA AA well you asked an excellent question and it's not a simple one for me to answer in a minute but clearly we know that hypertensives are put on treatment regimens for the rest of their lives and if you look at the adherence among hypertensives many of them do not adhere very well they take their medications some of the time but not all the time many of them self-medicate they take it when they feel like their blood pressure is up compliance in general there's a major problem many of these things do show erosions actually many of the addictive disorders show problems around three to six months so it's in that period where you start getting the relapses so there does seem to be a general curve I thought you were actually heading in another direction too which is to say that we also need to be looking at other approaches like AA, OA other approaches where people stay in them long term they stay in certain things a long long time why will they keep attending meetings and then try to build on that in our treatment programs and those are exactly the kinds of thinking we're doing at the moment one last question I mean I do let me answer you in two ways okay every study I do is different so I have profiles from each study when I'm doing my type 2 diabetics when I'm doing my obese bingers I mean I have many different kinds of studies and they all have slightly different profiles that the obese patients do have high rates particularly the obese diabetics do have high rates of depression throughout the literature there's been evidence of sexual abuse but it seems to be no higher in obese individuals or in eating disorder individuals than in the rest of the population the important thing though is that for the most part these psychological variables have not been associated with long term success or failure you know for the most part I'm unable to tell who is going to do well in our treatment program and who isn't this is really one of the frustrating areas that we can ask you know take a whole group of 100 people put them in a treatment program we know some of them are going to do well some of them are not going to do well we can give them all kinds of psychological tests but we cannot predict using those psychological tests so far at least who is going to end up doing well in our treatment program we really don't have a good handle on that and that may be that we're talking about predicting who is going to do well in a year or two years and it may be that all these things change that somebody's at one point they weren't depressed or their life was not chaotic but a year later things have changed it may be that what happens out here is not going to predict but really we have not at the moment identified good predictors certain sociological variables I'm not quite sure what things you're thinking of but one of the things that we have found is obese individuals who have an overweight spouse so the spouse they live with as a sociologist if you're thinking of something like that does seem to be related to poorer long term outcome there's been some data in the childhood obesity looking at number of children in the family with larger numbers of children in the family being a negative predictor none of these are very strong predictors though in some of the studies ethnicity is a predictor we have been less successful so far in most of our studies with African-Americans individuals and that may be going back to the question earlier maybe that we haven't developed the correct programs for those individuals we have some variables but there's nothing real powerful that I can really I can't look at 10 people coming in and saying you you and you are going to do well I want to treat you I know aren't going to succeed in this program just tell me I'm happy to keep answering questions two more two more, okay let me just tell you how we deal with that and basically the literature sort of the social psychological literature would argue that what you want for behavior change is kind of a medium level of fear and a very clear action plan of what to do to prevent something okay if you make someone if they don't have any fear then maybe they won't change behavior and if they have too much fear they're going to be paralyzed and they won't change behavior and if you give them a little bit of fear and you don't tell them what to do you just tell them that heart disease is scary but you don't tell them how to make changes that's not going to help them much either so I mean basically I would say that's our goal is to instill a little, a medium amount of fear but not to panic the people so clearly when we work with our type 2 diabetics one of the things we do is we have lectures and discussions of what is type 2 diabetes what are the complications that these come in and present but it is not done with horror slides here's the worst that could happen with you okay the other thing I just should say to you and it wasn't directly you just made me think of it as you asked your question I don't want to give you the idea that we teach these behavioral programs by saying to people you eat a thousand to fifteen hundred calories and that's the only explanation we spend a lot of time these are really very I would call them intellectual programs in the sense that we spend a lot of time explaining to them why that calorie goal why weight loss is only going to be two pounds a week why you're not going to see bigger weight losses than that why it's impossible to lose ten pounds overnight we spend a lot of time discussing things like there's no magic food that you know eating twenty grapefruits a day is not going to work and sort of dispelling all these diet myths that people come in with a great deal of time we actually show them the scientific data we show them studies results and things like I showed you today and explain to them well here's what the science is showing here's why a low-fat diet might be helpful to you so there really is an intellectual rationale presented to each part of the program I just couldn't do it with you today because it would take me twenty weeks like it takes me to do with them yes the biggest problem with over readers the question is what do I think of over readers anonymous and the biggest problem with over readers anonymous for me is that they do not believe in weighing patients so they cannot provide me with weight loss data nor do they approach it as sort of a scientific group not that I think everyone has to be a scientist but it would be very helpful to the field if they would be willing to weigh their patients and their members and then let me know what I do because we need such data we need to know if this is an effective approach but to me an effective approach for obesity should be one that produces weight loss and so I would like to see what the weight loss results are the closest to that I know of are some experimenters who are trying to quote sort of mimic over readers anonymous programs in their offices and do it as a treatment so that then they can study it because we can't study it outside so they're bringing it in just stand here and answer any other questions but why don't you just come up individually and ask me them at this point okay okay thank you Reena and again in the back of the room there is a sign up sheet for the dieticians for their CEUs and evaluation form for any physicians that want to get CME credits the next lecture will be June 16th with a provocative title living without dieting by John Ferret