Acceptance and Commitment Therapy for Weight Loss Maintenance

| March 1, 2021

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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.

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