Acceptance and Commitment Therapy for Weight Loss Maintenance
This activity has expired.
Tracy Martinez, RN, BSN, CBN
Tracy Martinez, RN, BSN, CBN, is Program Director of Wittgrove Bariatric Center in Del Mar, California.
A Message from the Department Editor
Dear Colleagues:
I am thrilled to present this month’s continuing education article, titled “Acceptance and Commitment Therapy for Weight Loss Maintenance” by two outstanding authors. Dale Bond, PhD, is a leading researcher in the bariatric surgical population and Jason Lillis, PhD, is a leading ACT-for-weight-loss research scientist and coauthor of Acceptance and Commitment Therapy and The Diet Trap.
Acceptance and commitment therapy (ACT) can help patients achieve weight loss, weight maintenance, and an increase in physical activity. This relatively new behavioral therapy is clearly and concisely described in this exceptional article.
I hope you enjoy it as much as I did and will share it with your fellow nurses and integrated team members.
Please send me your comments and ideas for future articles so we can build a collaborative platform for ongoing education.
Stay safe and healthy.
My best to you,
Tracy Martinez, RN, BSN, CBN
by Jason Lillis, PhD, and Dale Bond, PhD
Drs. Lillis and Bond are with the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University/The Miriam Hospital Weight Control and Diabetes Research Center in Providence, Rhode Island.
Funding: No funding was provided.
Disclosures: The authors have no conflicts of interest relevant to the content of this article.
ABSTRACT: Bariatric surgery is the most effective treatment for obesity, however weight loss maintenance can still be a problem for a significant number of patients. Acceptance and commitment therapy (ACT) teaches skills that directly impact key areas that can cause struggle for patients over the long-term, such as dealing with hunger and motivation deficits. ACT has been shown to improve weight loss, weight loss maintenance, and physical activity, and can be delivered in low-intensity formats, giving it high potential for use with postsurgery patients. Preliminary evidence supports further study of ACT for use in this population.
KEYWORDS: Acceptance, mindfulness, obesity, bariatric surgery, weight loss, weight loss maintenance
Bariatric Times. 2021;18(3):10–14
Bariatric Surgery and Weight Loss Maintenance
While durability of surgical weight loss is superior compared to behavioral and pharmacological treatments,1–3 significant weight regain is common.4–7 Almost half (47.8%) of patients regain at least 10 percent of their maximum weight lost during the year after reaching their nadir weight, while two-thirds (67.3%) of patients regain 20 percent of their maximum weight lost five years after nadir.6 Weight regain can cause reemergence of comorbidities and quality of life impairments and create need for more intensive and costly treatments.5,7,8
Several behavioral and psychosocial issues that underlie the challenge of weight regain are often inadequately addressed in typical postsurgical care. For many, but not all, patients, the first year after bariatric surgery (i.e., “honeymoon period”) carries a risk to perceive the postoperative journey as “easy”—weight loss is rapid, following the diet is “easier” due to limited hunger and ability to consume larger amounts of food, mood and quality of life improves, and adopting regular physical activity might not seem necessary or worthwhile given rapid weight loss.9 However, the honeymoon doesn’t last forever, and many patients might be unprepared to deal with the end of the honeymoon and the harder work ahead to maintain initial successful outcomes.
A number of issues undermine adherence to behaviors recommended to optimally maintain postoperative outcomes. Food intake gradually increases after surgery.10 A recent study found that perception of hunger and satiety do not differ for postsurgery patients who maintain versus regain a significant amount of weight, raising the possibility that tolerance, as opposed to absolute level, of hunger could be a factor in weight regain.11
Many postsurgery patients have low levels of physical activity,12–15 which is a predictor of weight regain.16 Research suggests that bariatric patients’ low activity levels can be attributed in large part to low motivation in general and low autonomous motivation specifically.17–19 Weight loss after all treatments, including bariatric surgery, induces metabolic and hormonal adaptations (e.g., changes in hypothalamic neuropeptide expression, insulin, leptin, and resting energy expenditure) that create an “energy gap” where appetite and energy intake are elevated but energy expenditure is suppressed, thus driving weight regain.20,21 Thus, higher physical activity is critical to counter many of these adaptations and narrow the energy gap via increases in not only energy expenditure, but factors such as leptin and insulin sensitivity and satiety signaling.21
Despite weight regain being a common and serious problem,7 with clear behavioral intervention targets, there is limited availability of adjunctive evidence-based interventions to help bariatric patients modify behaviors that protect against weight regain.22
Acceptance and Commitment Therapy
Acceptance and commitment therapy (ACT) is a newer-generation cognitive behavioral intervention23 that was originally designed as a transdiagnostic mental health treatment approach, but it has since been adapted and widely utilized as a behavioral health intervention.24 ACT uses mindfulness, acceptance, and values processes to effect clinically meaningful behavior change. It has broad support for producing meaningful behavior change in physical health-related domains (e.g., smoking cessation, chronic pain)24,25 and has shown promise for improving weight loss and maintenance, including after bariatric surgery.26–30
ACT for Weight Loss Maintenance
An ACT approach to weight-loss maintenance builds on standard behavioral treatment, which typically includes education (e.g., energy balance, calories, portions, nutrition labels, cardiovascular exercise), goal setting, self-monitoring (e.g., calories, weight, exercise minutes), and environmental change strategies. The primary role of ACT strategies is to foster long-term adherence to healthy lifestyle changes by providing targeted, robust methods to address barriers to persisting with lifestyle changes.
A key target of ACT is reducing internal change efforts—attempts to change unwanted thoughts, feelings, or bodily sensations when doing so is ineffective and can cause harm, referred to as experiential avoidance or psychological inflexibility.25,31,32 ACT aims instead to increase tolerance of, and willingness to experience (i.e., acceptance of), unwanted thoughts, emotions, bodily sensations.
The rationale for this approach is that negative internal experiences cannot be fully managed or avoided while attempting to manage one’s weight. The environment bombards individuals with food stimuli through advertising, storefronts, and social engagements, making it impossible to shield oneself from potential triggers for food cravings and overeating.33–35 Likewise, for most people, life involves stressful periods, if not chronic stress, which has been linked to eating.36–43 In addition, weight-based stigma is pervasive and can be debilitating, often resulting in persistent negative thoughts and beliefs about one’s general worth and abilities.44,45 Finally, metabolic changes following weight loss, such as reduced metabolic mass, changes in metabolic efficiency, and increased hunger46–50 contribute to an increased psychological burden of engaging in weight management.51 Thus, negative internal experiences are unavoidable. Highly palatable food and sedentary activities can provide short-term pleasure, comfort, or relief from these experiences, and thus alternative strategies are necessary to help patients maintain a healthy lifestyle while coping.
Another key target of ACT is increasing values-consistent behavior—behavior linked to long-term goals and personally meaningful values as identified by the patient (i.e., not prescribed by the interventionist). ACT aims to align weight management behaviors with personal values, increase awareness of behavior-value congruence, and thus facilitate an increase in day-to-day satisfaction of engaging in healthy behaviors (i.e., they become more autonomously motivated).
The rationale for this approach is that motivation to persist with weight management is different from the motives that prompt initial weight loss.52 Initial weight loss has rewards ranging from physical and mood improvements, to a sense of accomplishment with decreasing scale numbers, to positive social feedback. In contrast during maintenance, these rewards plateau or drop off53–61 and are accompanied by mental fatigue62–64 and reduced pleasure;65–67 and thus, taking into account metabolic adaptations, the cost-benefit ratio of continuing weight management efforts can shift negatively.52,62,63,68 In short, weight loss maintenance is associated with significant erosion of motivation to persist with weight management and requires powerful, autonomous motivators to help counteract this process. This can be even more true of patients who undergo bariatric surgery, as there is a common perception that the surgery is doing much of the work initially. Autonomous motivation has been shown to mediate long-term weight loss69 and has a strong influence on the maintenance of behavior change more generally.70–72
ACT Clinical Examples
ACT utilizes a combination of didactic presentation, metaphors, and experiential exercises/in-vivo skills training to teach core skills. The intervention is typically highly interactive and shaped by the specific struggles and motivations identified by the specific group of patients. The following are examples of how ACT can be utilized to facilitate weight loss maintenance.
Acceptance of thoughts. Acceptance is the active and open embrace of thoughts without ineffective attempts to change or control them. The goal is to teach patients how to recognize common unhelpful thoughts, including thoughts that focus on short-term comfort-seeking at the expense of one’s health goals (e.g., “Never mind your goals—you deserve a treat!”), self-critical thoughts (e.g., “I will always fail”), and more general rationalizations (e.g., “It’s too hot/cold/early/late to exercise”), and allow those thoughts to be present without acting on them. For example, patients might be instructed to identify an unwanted, personally relevant thought (e.g., “I’m too weak to do this”) and to reflect on the characteristics of the thought, as opposed to the content—how familiar it is, how old it is, how automatically it shows up in difficult situations. Patients may then complete a guided imagery exercise in which they imagine passively watching their thoughts float by like clouds in the sky, training the skill of looking at their thoughts, as opposed to being caught up in them. Again, the goal is to de-emphasize the importance of any content in the thought and instead focus on the process of thinking and how one can get stuck on thoughts. Finally, patients may practice imagining and “hearing” such thoughts come from various noncredible avatars, such as an indulgent grandmother or an overly critical drill sergeant. These mindfulness-based acceptance skills, with practice, allow patients to become more aware of, and distanced from, thoughts that tend to trigger unhealthy behaviors, which helps facilitate greater acceptance of thoughts.
Acceptance of emotions/sensations. Just like with thoughts, acceptance of emotions is the active and open embrace of these experiences without ineffective attempts to change or control them. The goal is to teach patients how to be more mindful of their emotional states, label them appropriately, make room or allow them to ebb and flow naturally without acting to reduce or control them. A key initial area of focus is highlighting the limits of emotional change strategies. For example, patients are asked to walk through a previous incident when they responded to stress or another negative emotion by eating and/or engaging in sedentary behavior, in an attempt to feel better (e.g., I was stressed after work, so I ordered pizza). They identify the chain of ever-increasing negative emotional and thought content that follows such behavior (e.g., “after I ate the pizza, I felt guilty, disgusting, and weak”), and also the strong tendency to re-engage in unhealthy behavior for short-term comfort (e.g., “so I watched TV all night and ate some ice cream”). Each unhealthy behavior starts a new chain, with all the “new” negative emotions and thoughts that follow from that behavior.
Patients are also taught how the intensity of food cravings rises and falls over time and how to curiously observe how cravings are experienced in the body. The metaphor of surfing waves in the ocean can be used to illustrate this concept, and patients may practice with a food craving exposure exercise using a personally tempting food. Patients are guided through a series of mindful observation experiences (e.g., notice the color, size, shape, texture, etc… of the object; notice the smell; As you do that, notice what you feel in your body…where…how it is changing…trace it with your mind, etc…). The goal is to practice sitting with and observing a craving without acting on it.
Similar exposure-like activities are utilized to address emotions such as stress, boredom, deprivation, and sadness. Patients are trained in mindful awareness and acceptance-labeling emotions, identifying parts of the body in which they are localized, observing different aspects of them (e.g., intensity, perceived weight), observing how the experience of them evolves over time. Again, the goal is openness, nondefensiveness, and tolerance of emotions. Patients are also engaged in discussions about how accepting uncomfortable feeling states does not necessarily mean they like them or want to have them, but rather reflects a willingness to experience these emotions as sometimes inevitable parts of the human experience. Education is provided about how decreasing struggle with emotions, and increasing acceptance of and willingness to experience these states, will allow individuals to focus their energy on their behaviors and to act more consistently with their values regardless of the particular thoughts or feelings that are present in these moments.
Values. The primary goal of values skills is to identify patient core values, anchored by self-identified desired qualities of action (e.g., being kind, supportive, engaged, or productive), in specific domains that matter to them (e.g., work, family, friendships, community, and parenting), and to link those values to health behavior change efforts. For example, a patient might identify “Being a caring and present mother” as a core value. Values are described metaphorically as directions, like traveling east, with behaviors either moving toward (e.g., spending time playing with child) or away from (e.g., using social media on phone in the presence of child) the stated value. In any moment of any day, one can “orient” to their valued direction and identify a behavior that would help move them toward their personal value. Patients are then asked to identify ways in which health behavior change can empower values-consistent behavior. For example, losing weight and increasing physical activity could provide increased energy and mood regulation. This might allow for increased stamina for active participation in play sessions with children (i.e., greater participation in values-consistent activities), and also limit the irritability that fuels parent–child conflict (i.e., improved quality of interactions in valued relationships).
Values strategies include free-writing, group discussion, and guided imagery exercises used to uncover core values. For example, participants can be asked to write a letter to themselves from 10 years into the future, reflecting back on everything they had done that was deeply important to them. Or patients might be asked to “stand and declare” a core value and articulate and detail a set of commitments to that value for short, medium, and long-term horizons to the interventionist and peers. In addition, patients set values-based goals, implement action plans linked to values, and evaluate the degree to which their behavior is consistent with their values.
ACT in Practice
ACT has typically been integrated with standard behavioral treatment when targeting weight loss. ACT has also been utilized in an add-on model when targeting weight loss maintenance, which has some inherent benefits and potential applicability to postsurgery care. ACT can have a significant impact on health outcomes when administered in brief formats26,73–75 in part due to extensive in vivo practice of skills25 that build on each other and make concentrated doses ideal.23,25 Although ACT has been delivered in single-contact formats, it is more typical to use a multi-session format (e.g., 1 longer + 2 shorter sessions).25,26,73,74,76,77 The use of a low-intensity model has the potential to improve cost effectiveness and portability compared to current maintenance interventions—which often last 12 to 36 months with frequent face-to-face contact78—and would present a low burden addition to postoperative care.
In addition, ACT intervention effects have been observed after treatment is discontinued,25,79 including in the area of weight loss maintenance,25 suggesting that ACT provides skills that remain useful even after the withdrawal of intervention support. The extended impact of ACT makes it ideally suited for a weight loss maintenance intervention for postbariatric surgery.
An additional consideration for the application of ACT to bariatric care and its utility for assisting with weight loss maintenance is the optimal timing of delivery. While most patients regain at least some of the weight they lost, a recent study showed that a majority of patients experienced clinically significant weight regain (≥20% of maximum weight loss) within two years of reaching their nadir weight.6 While ACT can likely be effective for both helping patients to prevent or reverse significant weight regain, it could be more efficient and clinically advantageous to prevent, versus stop significant regain. This important question warrants future study.
Review of ACT Literature
Several randomized trials have demonstrated the benefit of integrating ACT methods with standard behavioral weight loss treatment for producing initial weight loss;27,28,80–83 however, in this section, we will highlight studies relevant to weight loss maintenance and the potential for using ACT with patients who have undergone bariatric surgery.
Studies with nonsurgical samples. A pilot RCT examined the efficacy of ACT for weight maintenance in a sample of participants (N=84) who had recently completed a weight loss program.26 Participants received a single session ACT workshop (5 contact hours) or were assigned to a wait-list and asked to continue their current strategies for managing weight. The workshop included ACT methods focused on reducing experiential avoidance and increasing acceptance. No traditional weight influencing interventions were taught (e.g., dietary changes, exercise, self-monitoring, etc…), although it is likely that participants had encountered some exposure to these strategies prior to the study (e.g., about half of participants reported utilizing Weight Watchers). At three-month follow-up, a significantly higher proportion of the ACT participants had maintained or lost weight and overall ACT participants had lost an additional 1.6 percent of their body weight compared to a 0.3 percent gain for the control condition26 and reductions in experiential avoidance mediated changes in weight.
A small RCT was conducted with 102 patients with overweight or obesity who lost weight (>5% of starting weight) during a three-month online behavioral weight loss program (mean=10% WL) who were randomly assigned to attend a five-hour workshop focusing on a) ACT, b) self-regulation (SR), or c) no workshop (Control).84 All groups received three months of weekly email follow-up. Both ACT (-7.2%) and SR (-4.2%) had significantly better WL from baseline to 24 months than Control (-1.1%); however, notably, WLM from months 12 to 24 was better in ACT than SR (regain of +2.5 vs. +5.7kg, respectively).
A systematic review and meta-analysis of seven ACT-based physical activity (PA) interventions showed a significant, small-to-moderate effect on PA.85 The authors of this manuscript pilot-tested a one-time, 5-hour, ACT-based workshop with weekly email feedback for three months, which produced mean moderate-to-vigorous physical activity (MVPA) from 17.5 minutes/day at baseline to 28.7 minutes/day at three months (going from insufficiently active [<150 min/wk] to active [>200 min/wk]).86 Given emerging evidence suggesting that high levels of PA could help prevent postsurgical weight regain,15,87–89 and the well documented insufficient PA levels in postsurgery patients,12–15 using ACT to target increases in PA for patients who undergo bariatric surgery could present a compelling avenue of treatment development.
Studies with surgical samples. A proof-of-concept, pilot RCT was conducted on patients who had undergone bariatric surgery (N=39) over a six-week intervention period.90 Patients received either care as usual or care as usual with two sessions of ACT and limited online support. Results showed that patients who received ACT reduced eating disordered behaviors and body dissatisfaction, and increased quality of life and acceptance of weight-related thoughts and feelings compared to the usual care group.
Bradley et al29,30 completed two, small pilot studies testing the feasibility, acceptability, and short-term efficacy of an acceptance-based intervention (drawn largely from ACT) for postoperative weight gain. The first study was a single-arm trial (N=8) that provided a 10-week, group-based intervention for individuals who had regained at least 10 percent of postoperative weight loss. Results showed the intervention to be feasible and acceptable, and over the 10-week intervention period participants lost an average of 3.58 percent of their body weight, indicating that not only did the intervention prevent weight gain, but it also helped them begin to lose weight again.29 The second study tested a similar 10-week intervention, this time delivered via online modules, for individuals who were at least 1.5 years postoperative and had experienced weight gain (N=20), again in a single-arm design. Weight gain was reversed, as the sample showed a mean weight loss of 5.1 percent at the end of the intervention and maintenance of weight loss at three-month follow-up.30 Although both studies had a small sample size and only short-term assessment, they show the potential for continuing to develop and test ACT methods in this area.
Summary and Future Directions
ACT is a robust intervention approach with support for use in weight management and emerging support for use targeting weight loss maintenance and increased PA. In addition, ACT can be potent in low contact interventions, is easily portable as an add-on approach, and demonstrates the potential to have effectiveness beyond the intervention period, thus making it potentially well suited for use with patients who have undergone bariatric surgery. Further development and larger scale trials are needed to establish efficacy in the area of postbariatric surgery care.
References
- Courcoulas AP, Belle SH, Neiberg RH, et al. Three-year outcomes of bariatric surgery vs lifestyle intervention for Type 2 diabetes mellitus treatment: a randomized clinical trial. JAMA Surg. 2015;150:931–940.
- Cotugno M, Nosso G, Saldalamacchia G, et al. Clinical efficacy of bariatric surgery versus liraglutide in patients with Type 2 diabetes and severe obesity: a 12-month retrospective evaluation. Acta Diabetol. 2015;52:331–336.
- Arterburn DE, Johnson E, Coleman KJ, et al. Weight outcomes of sleeve gastrectomy and gastric bypass compared to nonsurgical treatment. Ann Surg. 2020 Mar 13. Online ahead of print.
- Courcoulas AP, Christian NJ, Belle SH, et al. Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity. JAMA. 2013;310:2416–2425.
- Courcoulas AP, King WC, Belle SH, et al. Seven-year weight trajectories and health outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study. JAMA Surg. 2018;153:427–434.
- King WC, Hinerman AS, Belle SH, et al. Comparison of the performance of common measures of weight regain after bariatric surgery for association with clinical outcomes. JAMA. 2018;320:1560–1569.
- Cohen RV, Cummings DE. Weight regain after bariatric/metabolic surgery: a wake-up call. Obesity (Silver Spring). 2020;28:1004.
- Jirapinyo P, Abu Dayyeh BK, Thompson CC. Weight regain after Roux-en-Y gastric bypass has a large negative impact on the Bariatric Quality of Life Index. BMJ Open Gastroenterol. 2017;4:e000153.
- Lynch A. “When the honeymoon is over, the real work begins:” Gastric bypass patients’ weight loss trajectories and dietary change experiences. Soc Sci Med. 2016;151:241–249.
- Giusti V, Theytaz F, Di Vetta V, et al. Energy and macronutrient intake after gastric bypass for morbid obesity: a 3-y observational study focused on protein consumption. Am J Clin Nutr. 2016;103:18–24.
- Vieira FT, Faria S, Dutra ES, et al. Perception of hunger/satiety and nutrient intake in women who regain weight in the postoperative period after bariatric surgery. Obes Surg. 2019;29:958–963.
- King WC, Chen JY, Bond DS, et al. Objective assessment of changes in physical activity and sedentary behavior: pre- through 3 years post-bariatric surgery. Obesity (Silver Spring). 2015;23:1143–1150.
- Afshar S, Seymour K, Kelly SB, et al. Changes in physical activity after bariatric surgery: using objective and self-reported measures. Surg Obes Relat Dis. 2017;13:474–483.
- Crisp AH, Verlengia R, Ravelli MN, et al. Changes in physical activities and body composition after Roux-Y gastric bypass surgery. Obes Surg. 2018;28:1665–1671.
- Herman KM, Carver TE, Christou NV, Andersen RE. Keeping the weight off: physical activity, sitting time, and weight loss maintenance in bariatric surgery patients 2 to 16 years postsurgery. Obes Surg. 2014;24:1064–1072.
- Mundi MS, Lorentz PA, Swain J, et al. Moderate physical activity as predictor of weight loss after bariatric surgery. Obes Surg. 2013;23:1645–1649.
- Zabatiero J, Smith A, Hill K, et al. Do factors related to participation in physical activity change following restrictive bariatric surgery? A qualitative study. Obes Res Clin Pract. 2018;12:307–316.
- Dikareva A, Harvey WJ, Cicchillitti MA, et al. Exploring perceptions of barriers, facilitators, and motivators to physical activity among female bariatric patients: implications for physical activity programming. Am J Health Promot. 2016;30:536–544.
- Peacock JC, Sloan SS, Cripps B. A qualitative analysis of bariatric patients’ post-surgical barriers to exercise. Obes Surg. 2014;24:292–298.
- MacLean PS, Wing RR, Davidson T, et al. NIH working group report: innovative research to improve maintenance of weight loss. Obesity (Silver Spring). 2015;23:7–15.
- Foright RM, Presby DM, Sherk VD, et al. Is regular exercise an effective strategy for weight loss maintenance? Physiol Behav. 2018;188:86–93.
- Sarwer DB, Heinberg LJ. A review of the psychosocial aspects of clinically severe obesity and bariatric surgery. Am Psychol. 2020;75:252–264.
- Hayes SC, Strosahl K, Wilson KG. Acceptance and commitment therapy: an experiential approach to behavior change. New York: The Guilford Press; 1999.
- Gloster AT, Walder N, Levin ME, et al. The empirical status of acceptance and commitment therapy: a review of meta-analyses. J Contextual Behav Sci. 2020;18:181–192.
- Hayes SC, Luoma JB, Bond FW, et al. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44:1–25.
- Lillis J, Hayes SC, Bunting K, Masuda A. Teaching acceptance and mindfulness to improve the lives of the obese: a preliminary test of a theoretical model. Ann Behav Med. 2009;37:58–69.
- Niemeier HM, Leahey T, Reed KP, et al. An acceptance-based behavioral intervention for weight loss: a pilot study. Behav Ther. 2012;43:427–435.
- Forman EM, Butryn ML, Juarascio AS, et al. The mind your health project: a randomized controlled trial of an innovative behavioral treatment for obesity. Obesity. 2013;21:1119–1126.
- Bradley LE, Forman EM, Kerrigan SG, et al. A pilot study of an acceptance-based behavioral intervention for weight regain after bariatric surgery. Obes Surg. 2016;26:2433–2441.
- Bradley LE, Forman EM, Kerrigan SG, et al. Project HELP: a remotely delivered behavioral intervention for weight regain after bariatric surgery. Obes Surg. 2017;27:586–598.
- Bond FW, Hayes SC, Baer RA, et al. Preliminary psychometric properties of the Acceptance and Action Questionnaire-II: a revised measure of psychological inflexibility and experiential avoidance. Behav Ther. 2011;42:676–688.
- Hayes SC, Strosahl K, Wilson KG, et al. Measuring experiential avoidance: a preliminary test of a working model. Psychological Record. 2004;54:553–578.
- Llewellyn C, Wardle J. Behavioral susceptibility to obesity: gene-environment interplay in the development of weight. Physiol Behav. 2015;152:494–501.
- Lowe MR, Butryn ML, Didie ER, et al. The Power of Food Scale. A new measure of the psychological influence of the food environment. Appetite. 2009;53:114–118.
- Cohen DA. Obesity and the built environment: changes in environmental cues cause energy imbalances. Int J Obes. 2008;32:S137–1S42.
- Simpson JA, Rholes WS. Adult attachment orientations, stress, and romantic relationships. In: Devine P, Plant A, eds. Advances in Experimental Social Psychology, Vol. 452012:279–328.
- Bayram N, Bilgel N. The prevalence and socio-demographic correlations of depression, anxiety and stress among a group of university students. Soc Psychiatry Psychiatr Epidemiol. 2008;43:667–672.
- Torres SJ, Nowson CA. Relationship between stress, eating behavior, and obesity. Nutrition. 2007;23:887–894.
- Smyth JM, Heron KE, Sliwinski MJ, et al. Daily and momentary mood and stress are associated with binge eating and vomiting in bulimia nervosa patients in the natural environment. J Consult Clin Psychol. 2007;75:629–638.
- Chandola T, Brunner E, Marmot M. Chronic stress at work and the metabolic syndrome: prospective study. BMJ. 2006;332:521–524A.
- Gutman LM, McLoyd VC, Tokoyawa T. Financial strain, neighborhood stress, parenting behaviors, and adolescent adjustment in urban African American families. J Res Adolesc. 2005;15:425–449.
- Cavanaugh MA, Boswell WR, Roehling MV, Boudreau JW. An empirical examination of self-reported work stress among US managers. J Appl Psychol. 2000;85:65–74.
- Kyriacou C, Sutcliffe J. Teacher stress – prevalence, sources, and symptoms. Br J Educ Psychol. 1978;48:159–167.
- Puhl RM, Heuer CA. Obesity stigma: important considerations for public health. Am J Public Health. 2010;100:1019–1028.
- Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity. 2009;17:941–964.
- Leibel RL, Rosenbaum M, Hirsch J. Changes in energy-expenditure resulting from altered body-weight. N Engl J Med. 1995;332:621–628.
- Rosenbaum M, Hirsch J, Gallagher DA, Leibel RL. Long-term persistence of adaptive thermogenesis in subjects who have maintained a reduced body weight. Am J Clin Nutr. 2008;88:906–912.
- Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. 2011;365:1597–1604.
- Cummings DE, Weigle DS, Frayo RS, et al. Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery. N Engl J Med. 2002;346:1623–1630.
- Hall KD, Sacks G, Chandramohan D, et al. Obesity 3 quantification of the effect of energy imbalance on bodyweight. Lancet. 2011;378:826–837.
- MacLean PS, Wing RR, Davidson T, et al. NIH Working Group Report: innovative research to improve maintenance of weight loss. Obesity. 2015;23:7–15.
- Kwasnicka D, Dombrowski SU, White M, Sniehotta F. Theoretical explanations for maintenance of behaviour change: a systematic review of behaviour theories. Health Psychol Rev. 2016;10:277–296.
- Foreyt J, Goodrick GK, Gotto AM. Limitations of behavioral treatment of obesity: review and analysis. J Behav Med. 1981;4:159–174.
- Jeffery RW, Kelly KM, Rothman AJ, et al. The weight loss experience: a descriptive analysis. Ann Behav Med. 2004;27:100–106.
- Perri MG, Lauer JB, Yancey DZ, et al. Effects of peer support and therapist contact on long-term weight-loss. J Consult Clin Psychol. 1987;55:615–617.
- Anton SD, Foreyt J, Perri MG. Preventing weight regain after a weight loss. In: Bray GA, Bouchard C, eds. Handbook of Obesity. Boca Raton, FL: Taylor and Francis Group; 2014:145-66.
- Curtis B, Hayes R, Fehnel S, Kolotkin RL. Assessing the impact of weight loss among obese individuals with Type 2 diabetes (T2DM). Obesity. 2009;17:S152-S.
- Faulconbridge LF, Wadden TA, Rubin RR, et al. One-year changes in symptoms of depression and weight in overweight/obese individuals with Type 2 diabetes in the Look AHEAD Study. Obesity. 2012;20:783–993.
- Wing RR. Behavioral approaches to the treatment of obesity. In: Bray GA, Bouchard C, eds. Handbook of Obesity. Boca Raton, FL: Taylor and Francis Group; 2014:131–144.
- Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of Type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393–403.
- Jeffery RW, Drewnowski A, Epstein LH, et al. Long-term maintenance of weight loss: current status. Health Psychol. 2000;19:5–16.
- Karfopoulou E, Mouliou K, Koutras Y, Yannakoulia M. Weight loss methods in relation to weight maintenance status: focus groups results. Ann Nutr Metab. 2013;63:1296.
- McKee H, Ntoumanis N, Smith B. Weight maintenance: self-regulatory factors underpinning success and failure. Psychol Health. 2013;28:1207–1223.
- Wang J, Shih PC, Carroll JM. Life after weight loss: design implications for community-based long-term weight management. Computer Supported Cooperative Work. 2015;24:353–384.
- Barnes AS, Goodrick GK, Pavlik V, et al. Weight loss maintenance in African-American women: focus group results and questionnaire development. J Gen Intern Med. 2007;22:915–922.
- Bertz F, Sparud-Lundin C, Winkvist A. Transformative lifestyle change: key to sustainable weight loss among women in a post-partum diet and exercise intervention. Matern Child Nutr. 2015;11:631–645.
- Sarlio-Lahteenkorva S, Rissanen A, Kaprio J. A descriptive study of weight loss maintenance: 6 and 15 year follow-up of initially overweight adults. Int J Obes. 2000;24:116–125.
- Engstrom M, Forsberg A. Wishing for deburdening through a sustainable control after bariatric surgery. Int J Qual Stud Health Well-being. 2011;6(1).
- Teixeira PJ, Carraca EV, Marques MM, et al. Successful behavior change in obesity interventions in adults: a systematic review of self-regulation mediators. BMC Med. 2015;13.
- Deci EL, Ryan RM. The “what” and “why” of goal pursuits: human needs and the self-determination of behavior. Psychological Inquiry. 2000;11:227–268.
- Deci EL, Ryan RM. Intrinsic motivation and self-determination in human behavior. New York: Plenum; 1985.
- Deci EL, Ryan RM. Self-determination theory: a macrotheory of human motivation, development, and health. Can Psych. 2008;49:182–185.
- Gregg JA, Callaghan GA, Hayes SC, Glenn-Lawson JL. Improving diabetes self-management through acceptance, mindfulness, and values: a randomized controlled trial. J Consult Clin Psychol. 2007;75:336–343.
- Bond FW, Bunce D. The role of acceptance and job control in mental health, job satisfaction, and work performance. J Appl Psychol. 2003;88:1057–1067.
- Butryn ML, Forman E, Hoffman K, et al. A pilot study of acceptance and commitment therapy for promotion of physical activity. J Phys Act Health. 2011;8:516–522.
- Bond FW, Bunce D. Mediators of change in emotion-focused and problem-focused worksite stress management interventions. J Occup Health Psychol. 2000;5:156–163.
- Dindo L. One-day acceptance and commitment training workshops in medical populations. Curr Opin Psychol. 2015;2:38–42.
- Dombrowski SU, Knittle K, Avenell A, et al. Long term maintenance of weight loss with non-surgical interventions in obese adults: systematic review and meta-analyses of randomised controlled trials. BMJ. 2014;348.
- Gifford EV, Kohlenberg BS, Hayes SC, et al. Acceptance-based treatment for smoking cessation. Behav Ther. 2004;35:689–705.
- Forman EM, Butryn ML, Hoffman KL, Herbert JD. An open trial of an acceptance-based behavioral intervention for weight loss. Cog Behav Pract. 2009;16:223–235.
- Forman EM, Butryn ML, Manasse SM, et al. Acceptance-based versus standard behavioral treatment for obesity: results from the Mind Your Health randomized controlled trial. Obesity. 2016;24:2050–2056.
- Forman EM, Manasse SM, Butryn ML, et al. Long-term follow-up of the Mind Your Health Project: acceptance-based versus standard behavioral treatment for obesity. Obesity. 2019;27:565–571.
- Lillis J, Niemeier HM, Thomas JG, et al. A randomized trial of an acceptance-based behavioral intervention for weight loss in people with high internal disinhibition. Obesity. 2016;24:2509–2514.
- Lillis J, Wing RR. Using novel behavioral interventions to improve long-term weight loss: a randomized trial comparing acceptance and commitment therapy and self-regulation for weight loss treatment seeking adults with overweight and obesity. Annual meeting of the Association for Contextual Behavioral Science. Dublin, Ireland 2019.
- Pears S, Sutton S. Effectiveness of acceptance and commitment therapy (ACT) interventions for promoting physical activity: a systematic review and meta-analysis. Health Psychol Rev. 2020:1–26.
- Lillis J, Schumacher LM, Bond, DS. Preliminary evaluation of a one-day acceptance and commitment therapy workshop for increasing moderate-to-vigorous physical activity in adults with overweight or obesity. Int J Behav Med. In Press.
- Josbeno DA, Kalarchian M, Sparto PJ, et al. Physical activity and physical function in individuals post-bariatric surgery. Obes Surg. 2011;21:1243–1249.
- Amundsen T, Strommen M, Martins C. Suboptimal weight loss and weight regain after gastric bypass surgery-postoperative status of energy intake, eating behavior, physical activity, and psychometrics. Obes Surg. 2017;27:1316–1323.
- Hanvold SE, Vinknes KJ, Loken EB, et al. Does lifestyle intervention after gastric bypass surgery prevent weight regain? A randomized clinical trial. Obes Surg. 2019;29:3419–3431.
- Weineland SM, Arvidsson D, Kakoulidis T, Dahl J. Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT. Obes Res Clin Pract. 2012;6(1):e1–e90.
Category: Past Articles, Review