california state university, northridge behavior
TRANSCRIPT
CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
BEHAVIOR MODIFICATION AND WEIGHT LOSS
A thesis submitted in partial satisfaction of the requirements for the degree of Master of Science in
Home Economics
by
Carolee Blumin
May, 1982
The Thesis of Carolee Blumin is Approved:
Patricia Beals, M.S.
Lillie M. Grossman, Dr.P.H.
Ann R. Stasch, Ph.D. Committee Chairperson
California State University, Northridge
ii
ACKNOWLEDGMENTS
The author would like to express appreciation to Dr. Ann R.
Stasch, Committee Chairperson. Her warmth and understanding were as
much a part of this project as were her knowledge, guidance and
support.
Sincere appreciation is also extended to Dr. Lillie M. Grossman
and Mrs. Patricia Beals for their guidance and cooperation in preparing
this thesis.
The author is also indebted to Nancy Imazu of Maxicare for her
cooperatton during the data-gathering process.
A special note of thanks goes to Irene Goldman for her skillful
typing of the many drafts.
iii
TABLE OF CONTENTS
ACKNOWLEDGMENTS
LIST OF TABLES
LIST OF FIGURES .
ABSTRACT
Chapter
1. INTRODUCTION ....
Purpose of Study
Justification .
Objectives ..
Null Hypotheses ..
Assumptions
L imitations .
Definitions
2. REVIEW OF LITERATURE
Etiology of Obesity
Resistance to Weight Reduction
History of Behavior Modification
Techniques of Behavior Modification .
Case Studies
3~ PROCEDURES . . .
4. RESULTS AND DISCUSSION
Attrition
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Page
iii
vi
vii
. viii
1
1
1
2
2
2
3
3
5
5
7
10
12
17
20
25
27
Weight Loss and Maintenance ..
Booster Sessions .....
Tecpnique Preference and Use
5. SUMMARY AND CONCLUSIONS .
Recommendations
SELECTED BIBLIOGRAPHY
APPENDICES . . . . .
A. Letter of Permission ....
B. Data Collection Devices ..
C. Preliminary Data .... .
D. Chi-Square Analysis .... .
v
Page
28
32
33
37
38
40
43
44
46
49
56
LIST OF TABLES
Table
l. Weight Control Class Schedule .
2. Group Identification
3. Group Attendance and Percent of Attrition
4. Percent of Participants Losing Specified Amounts of Weight .......... .
5. Average Amount of Weight Lost per Person During 9-Week Course .....
6. Monthly Weight Loss During Course ...
7. Weight Loss During Maintenance Period
8. Preference Order and Actual Use of Techniques
9. Profile of Group A
10. Profile of Group B
11. Profile of Group C
12. Profile of Group D
13. Profile of Group E
14. Frequency Distribution of Participants Using Specific Techniques During Maintenance
15. Chi-Square Analysis .
, 16. Chi-Square Analysis
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Page
23
26
27
28
29
31
31
36
50
51
52
53
54
55
57
58
LIST OF FIGURES
Figure Page
1. Relationship Between Attrition Rate and Weight Loss Quring Course 30
vii
ABSTRACT
BEHAVIOR MODIFICATION AND WEIGHT LOSS
~
Carolee Blumin
Master of Science in Home Economics
The purpose of this study was to determine the effects of a
behavior modification course on maintenance of weight reduction after
treatment. Specific aspects have included the rate of loss at three
month intervals for one year, preference for the techniques, and actual
home use of the techniques following completion of the course. Infor
mation on attrition rate and attendance at booster sessions has also
been included. Chi-square was performed to determine significant
differences on weight losses and time of year that dieting began.
Sixty-two participants were interviewed by telephone to gather
information about weight maintenance, home use of techniques and
booster session attendance. Evaluation forms filled out at the end
of the course by each subject were used to tabulate the most- and
least-liked techniques.
The course was taught at a health maintenance organization
viii
located in the Los Angeles area and spanned nine weeks.
Results of this study showed that a low level of success had
been maintained over a period of twelve months.
ix
Chapter l
INTRODUCTION
Purpose of the Study
The purpose of this study was to determine if dieters who com
pleted a course in behavior modification were able to maintain weight
loss over a period of time. It was also the purpose of this study to
determine which techniques the dieters have continued to use on their
own.
Justification
Obesity has been found to be a major health hazard. Research
has indicated between forty and eighty million Americans to be obese.
Social, sexual and occupational roles have been threatened by being
overweight. Eighty-seven percent of the people treated for obesity
received temporary or no relief. Doctors, psychologists, nutritionists
and other experts in the field have had little to offer in the way of
help for these people. However, behavior modification techniques have
been changing this picture. With concentration focused on overt be
havior, studies have shown that behavior modification has successfully
reduced body weight regardless of the cause (0 1 Leary and Wilson, 1975).
The kinds of techniques that were effective in this study have
been defined with the hope that others who read this will have gained
insight into the weight reduction process.
1
Objectives
The objectives of this study were as follows:
1. The assessment of the rate of weight loss of dieters at
three month intervals of time following their participation in a course
in behavior modification and weight reduction.
2. The tabulation of techniques dieters reported using at
three month intervals of time following their participation in a course
in behavior modification and weight reduction.
3. The determination of the best-liked and the least-liked
techniques of behavior modification.
Null Hypotheses
The null hypotheses of this study were as follows:
1. There is no significant difference between weight lost \,,
during a behavior modification tfeatment program and weight lost during
maintenance periods.
2. There is no significant difference between the weight lost
as a result of treatment in a behavior modification course and the time
of year that treatment began.
Assumptions
The following assumptions were made in developing this study:
1. People who needed or wanted to lose weight were interested
in changing their eating behavior.
2. Participants answered questions honestly.
Limitations
The limitations of this study were as follows:
1. This study represented the results produced by only one
therapist.
2. This study represented members of the particular organiza
tion studied.
Definitions
1. Behavior Modification- a system of techniques based on
learning principles used to change observable behavior.
2. Obesity - considered to exist when an individual has ex
ceeded his or her ideal weight by 20 percent or more.
3. Therapist - one who teaches the behavior modification
techniques to others.
4. Learning Theory - based on facts obtained from experiments
in the laboratory. The three theories are (1) conditioning, based on
the forming of habits; (2) cognition, based on the act of knowing; and
(3) humanism, based on the need to express creativity.
5. Classical Conditioning - the simplest kind of learning based
on the stimulus-response experiments performed by Pavlov.
6. Operant Conditioning - a system based on reward and punish-
ment in order to encourage subjects to act in a more desirable way.
7. Overt Behavior- behavior which can be seen and measured.
8. Cognitive Domain - the area of knowledge and awareness.
9. "Booster" Session - a follow-up meeting with the therapist
after treatment has been completed; a method of fostering continued
motivation in the subject.
10. Weight Maintenance - the ability to keep weight off once
it has been lost.
11. Maintenance- any specified period of time following treat
ment for weight reduction.
I '
Chapter 2
REVIEW OF LITERATURE
Etiology of Obesity
\ ~ ) ~ Genetics, metabolism, physiology and environment have all been
implicated in obesity. Research also found evidence relating obesity ;:y• .... __ ~ '}
to socio-cultural factors, ~ocio-economic status: social mobility and
'ethnic variables {O'Leary and \~ilson, 1975).
Craddock {1973) cited studies with identical twins showing a
high correlation for body weight despite envirqnmental differences, \
thus supporting the genetic viewpoint. Other cited studies (Craddock,
1973) that supported this hereditary factor have found that the weights
of adopted children showed n,o correlation with the weights of the .
adopting parents wh i 1 e the weights of other ch i1 d ren corre 1 a ted we 11
with their natural parents. Stunkard (1980) expressed caution in making
statements concerning studies about twins and adopted children due to
conflicting evidence and questionable sampling methods. However, he/
made clear the fact that genes play a significant role in obesity.
Several factors in theHenvironment have been shown to be in-
valved in the etiology of obesity. Some studies"showed that overfeeding
in the first years of life led to increases in the number of fat cells •.
Supposedly, the individual will then have acquired a tendency to accumu
late fat easily. By the same studies, overfeeding in the later years
produced evidence of increases only in the size of already existing fat
ce 11 s (Craddock, 1973). Newer .evidence, .however, has suggested that
5
r···· \
this correlation may not hold up under the more advanced·cell detection
methods being used today (Stunkard, 1980). Regardless of these incon
sistencies, the powerful influence of the environment on obesity has
been documented~ D~i1LE!~~il'19_~~-~it~, social pressures of eating, and
eating to relieve depression have all been included in a long list of
environmental influences (Craddock, 1973).
Further evidence of the environment control of obesity has
come from surveys that showed obesity to "run in families." When both
parents were obese, 80 percent of the offspring were obese. When only
one parent was obese, 40 percent of the offspring were obese. When
neither parent was obese, only 10 percent of the offspring were obese
(Leitenberg, 1976).
Research has shown metabolism and physiology to be rare but not
l unknown causes of obesity. Malfunction of the hypothalmic area of the
j ~ n, pi !_ui_taz_g~_and and ad~~~~~~~~;~; h~~~ precipitated obesity.
( HX!'!~-~~-~I_i~~-!-~.rll ~_f1d thyroid defir:=j"~~~~ have been known to do the same '-- (Craddock, 1973).
Nutrition Newsletter (1981) carried an article on recent work
concerning the role of brown fat and its ability to waste energy in the
form of heat. This concept has gained acceptance as a factor in the
metabolic contra 1 of weight. t,~-rd
Social and ethnic factors have been documented by many re-
searchers who showed that in the United States obesity has decreased
with upward mobility while different patterns have emerged in other
countries (Craddock, 1973). Because obesity has proven to be a social
definition, its incidence has taken on a different significance within
6
social structures (LeBow, 1981). Work done in the area of social and
ethnic influence in the control of obesity has suggested that under
standing the social determinants may be more important than under
standing the physiological determinants. Since obesity has been shown
to be in part a function of lifestyle, treatment may be enhanced if
approached from that position (Stunkard, 1980).
Resistance to Weight Reduction
Regardless of the cause of obesity, it has been established
that a reduction in caloric intake has ultimately caused a reduction in
body weight. Despite this simple unalterable fact, treatment has failed
to help most people lose and maintain weight loss for more than a year.
Jordan (1973) offered one explanation for this. Obese individ
uals, like normal-weight individuals, exhibited certain physiological
symptoms while dieting. These symptoms included a lowered pulse rate
and a lowered basal metabolic rate. In addition, all subjects became
irritable, preoccupied with food and often depressed. All lost weight,
but returned to their previous weights when dieting was discontinued.
According to Jordan (1973), these have been identified as symptoms of
stress and he suggested that this indicated an equilibrium at work con
trolling energy balance. Once the body established this, it became
extremely resistant to change. Jordan (1973) described experiments in
overfeeding in an attempt to produce obesity in normal weight individ
uals. Once the overfeeding stopped, subjects returned to their normal
eating patterns and pre-experimental weights. However, if overfeeding
were to continue for several years, Jordan (1973) has suggested that
the body would establish a new equilibrium. He further suggested that
if the time required to achieve this can be established, then programs
can be set up to allow a new equilibrium to be established at intervals
during the dieting process. Limited knowledge of these metabolic pro
cesses has hampered effective treatment by this method. LeBow (1981)
supported this theory when he chose to include Jordan's equilibrium
theory in his discussion on the breakdown of weight maintenance.
Conversely, Conrad (1954) maintained that if a patient, given
sufficient motivation, failed to lose weight on a reduced calorie diet,
emotional maladjustment should be suspected. Since it has been estab
lished that the primary function of food has been to sustain life by
fulfilling metabolic needs, food intake beyond that need was then
thought to be taken for emotional reasons. A compilation of reasons
has been reported as follows: (1) to reduce anxiety, (2) to gain
acceptance and security, (3) to influence others, (4) response to depri
vation, (5) protection against illness, (6) a sign of success, (7) method
of expressing hostility, (8) an excuse to avoid maturity, (9) represen
tation of pregnancy, (10) identification with fat parent, (11) defense
against sexuality, (12) manifestation of low self-image, and (13) a form
of self-punishment (Babcock, 1948; Bayles and Ebaugh, 1950; Conrad,
1954).
A study conducted at the Cornell University School of Nutrition
(Young et al., 1955) showed a close relationship between emotional sta
bility and success in weight reduction. Patients who appeared to have
emotional problems were advised to seek appropriate counseling prior to
attempting a weight reduction program lest it should compound the al-
ready existing problems.
Despite the various theories concerning obesity, evidence still
has shown that the only way to lose body fat has been by the establish
ment of negative energy balance. Reduced calorie intake was considered
the primary means of producing this negative balance and behavior modi
fication was significantly more effective than alternate methods in
producing weight reduction on a short-term basis. However, the test of
successful treatment of obesity has been considered to be the mainten
ance of weight loss over time and behavior modification programs have
not met this criterion any better than have alternative programs. The
advantages of behavioral treatment--low cost, efficient, ease of dis
semination, no adverse side effects--have led researchers to believe
that this approach should be researched (Stunkard, 1980).
Researchers have been slow to make unprecedented claims due to
the lack of long-term follow-up data, inconsistency in reporting sta
tistical data, attrition rate of subjects involved in research projects,
and lack of continued motivation of subjects. Merritt (Bray, 1980:111)
has stated that, "weight maintenance after weight reduction is unproven
for any therapy. "
Some suggestions for improved research have included making
follow-up an integral part of the design and asking subjects to commit
themselves. Evidence has shown that frequent contact or "booster 11
sessions with the therapist reduced attrition rate. Although booster
sessions showed inconsistent results, well-timed and spaced sessions
were beneficial (Stunkard, 1980)~
The goal of all behavior modification has been to help individ-
uals learn how to control and influence their own environments, both
social and physical. The future of behavior modification has been con
sidered certain even if somewhat unpredictable. The pervasive theme of
treatment has continued to be that of self-control, self-instruction,
self-monitoring, self-evaluation, self-reinforcement and self-selection
of standards (Sjoden et al., 1979).
History of Behavior Modification
The origins of behavior modification have been traced back to
the works of Freud and his medical model which focused its treatment on
identifying and resolving underlying causes for observed behavior.
General dissatisfaction with this unscientific approach gave
way to the Pavlovian view that mental disease was a disruption of the
normal process of behavior and that treatment should have directed it
self at the modification of the disruption. Pavlov subsequently
developed the process called classical conditioning and introduced a
systematic program into the study of behavior. In this way behavior
became directly measurable rather than left to the Freudian method of
interpretation of impressions (Franks, 1969).
As human behavior became more and more subjected to scientific
inspection, the principles of behaviorism were developed by John B.
Watson, the father of behaviorism in America. Watson believed that
psychology should have used experimental techniques and often took
the position that the mind did not exist. Although his work was first
published in the 1920s, little else followed until the late 1950s
(Erwin, 1978; Franks , 1969) .
Out of behaviorism grew the techniques of behavior modification.
Work on the principles and procedures of behavior modification was done
almost simultaneously by J. Wolpe in South Africa, who developed the
foundations of the clinical practice; by H. J. Eysenck in England, who
described the .. modern learning theory 11; and by B. F. Skinner in America,
who applied the principles of operant conditioning to human problems
(0 1 Leary and Wilson, 1975).
Wolpe formed what became known as the 11 behavioral·group ... This
group evaluated current status and research on behavior therapy, con
sidered methodological problems and made recommendations. Eysenck
based his learning theory on the works of Pavlov and other theorists.
His work was in accordance with the more scientific approach as an
alternative to psychotherapy (Agras et al., 1979). Skinner•s operant
conditioning based its treatment on the use of reward and punishment
to modify behavior (Kazdin, 1978).
No clear, concise and accepted definition of behavior modifica
tion has been made and this has led to much misunderstanding about its
use and misuse. Mehrabian (1978) described behavior modification as a
technique that focused on changing specific observable behaviors that
can readily be measured and assessed as to the effectiveness of the
change. Kazdin (1978:1) defined behavior modification as 11 the applica
tion of experimental findings from psychological research for the pur
pose of altering behavior. The applications are directed toward
eliminating debilitating behavior and enhancing human functioning ...
Earlier work with prisoners and mental patients gave rise to the
mistrust and hostility felt by the general public as people began to see
behavior modification techniques as controlling and manipulating. A
threat to personal freedom became a reality as questions arose about
who decided "good" and "bad" behaviors (Leitenberg, 1976).
Behavior modification originated for the treatment of abnormal
behaviors. Correction of inappropriate behaviors, rather than their
underlying causes, was the focus of this new approach. Principles of
learning theory became the backbone for breaking maladaptive behaviors
(Sjoden et al., 1979). More recent research has been incorporating
thought, images and feelings and finding them to be powerful influences
(O'Leary and Wilson, 1975; Williams et aT., 1976).
The development of behavior modification, then, has been attri
buted to a dissatisfaction with the traditional, but unscientific,
psychoanalytical method. This prompted the rise of behaviorism which
led directly to the learning theories and eventually to a set of pre
scribed techniques for successful behavior changes.
Techniques of Behavior Modification
"Most obese persons will notstay in treatment for obesity. Of
those who stay in the treatment most will not lose weight and of those
who do lose weight, most will regain it" (O'Leary and Wilson, 1975:330).
The above statement made by Albert J. Stunkard, a leader in re
search on obesity, has typified the general findings of weight control
programs. However, researchers and therapists alike have reported that
behavior modification techniques have been changing that picture~~-
da ~_,___Qgha v j or modi f_i c~JjQrL.ll9c~LRJ:QY~TL.:trtJle~ .. the~mQ.s.t_,SJJ.c.c,ass_fuJ~
approach to weight reduction (Leitenberg, 1976; O'Leary and Wilson, ~.........___·--~~~---"···-----~-- ~"""~~ ~,._....,._..,_
"'""--.,..~ .......... """--~
,, '
1975; Sjoden et al., 1979; Williams et al., 1976; Bray, 1980).
The techniques were developed on the premise that behavior was
the way in which a person learned to cope with life situations. Pro-
ponents of behavior ~~~!~~~,_<:~~~~~~~ ~~y~~~~~2~n~,~~~~e~~,~~~t.--~\'l,~~n~~eh~~iQ!',""~ .....,.______~~--~ ------ - ~--~---- __ , - -~
changes were sustained long e!!Ql:lgh,",,attitudes~and,.fegli_!l,gs ~Jso e:ha!!g~d. -.._,~ .. ·~-- ··- --·"'"'•' " -.. -·- ._-.-~--·<•····· --~·-·~·~-~-.---·~----~-·~-----~·
to become consistent with ~he new ~~~~yiQ!:~ (Mehrabi an, 1978) .
Although several learning models were presented in the litera
ture, operant conditioning has been the major focus of behavior modifi-----~---~--·---·-~-----~-,__,--~·--~~-~~-----~<-~--- -- ___ ...,~:-...... ~-......-..-----~---~-~-··- ~--· -----·· .. -···· ····--~····-·--···-~----~-------- ,._, _______ ~--~----~---- -·~"~~
cation. The basis of operant condLI:tPJli~ngw~~JL~yst~m of reward and •· • '"•><:-.ch<~-·;.c"'~"'-"''"'""""~""""'"•'·"~"'"-•''0-'""·'~"'"''',.._.-•·····.,,·•- · '·· · · " - · ' ·' ··• •··- ,< -- •• ,.,_,_,-, •• , __ ,, •• ,_,._,,"-'·"",-·.
punishment, alternately called positive and negative reinforcers
(Mehrabian, 1978).
Sherman (1973) described a sequence of six basic steps that
have been helpful in planning operant conditioning. They were as
follows: (l) state the general problem; (2) identify the behavioral
objective; (3) develop behavioral measures; (4) make observations;
(5) make necessary alterations in plan; and (6) monitor the results.
Although there has been some variation among researchers (Erwin,
1978; Franks, 1969; Leitenberg, 1976; O'Leary and Wilson, 1975; Sjoden
et al., 1979), most programs have employed one or more of the following
generally recognized and accepted techniques.
Self-monitoring. This record-keeping technique has urged sub- ,
jects to record behaviors and food intake, thus allowing the subject t~ see what behaviors and feelings have prompted eating.
Self-reward and self~punishment~ These techniques have sought~~·~ to find ways in which the subjects can reward or punish themselves in ·~
order to maintain newly formed behaviors. Monetary rewards and fines
have become popular.
Social reinforcement. This technique has focused its attentionX;
on educating family and friends so that they may help to perpetuate ~
appropriate behavior in the natural environment.
>Goal-setting. This technique has been conducive to weight los~
when realistic, short-term goals were set.
Nutrition counseling. Evidence has suggested that this kind o~~~
counseling should be included in order to prevent weight loss at the ex-Vf
pense of essential nutrients.
Aversion therapy. This technique has made use of releasing un
pleasant odors or administering electric shocks while eating. The imag
ination has also been used extensively in creating unpleasant thoughts.
Desensitization. This technique has been used to reduce
threatening situations by use of an anxiety hierarchy and relaxation
techniques.
Modeling. This technique has attempted to change behavior by :}! the subject witness the performance of another person. ~
\ having
Self-control. This form of operant conditioning has been used
to teach the individual to depend on him- or herself rather than on a
therapist. Signed contracts have become a popular device.
Group·therapy. This kind of therapy has used many different
techniques to reinforce favorable behavior changes through a social
setting.
Stimulus control. This technique has tried to make the subject
aware of cues associated with eating, such as the clock, a specifi~ room, reading, television, boredom, etc.
Exercise counseling. Inactivity has been described as a main
component of overweight. Nevertheless, according to LeBow (1981) many
of the obese were unreceptive to activity programs because_they con
sidered exercise to be work. In further descriptions of the exercise
component, LeBow (1981) cited studies that have shown that those
dieters who exercised lost 35 percent more fat than the diet-only sub
jects. He also cited a study that showed that increasing calorie ex
penditure through exercise protected the body from undesirable lean
body tissue loss.
No technique has proven effective by itself. While the most
effective combination has not been defined, much success has still
been recorded.
It has become possible for dieters to pursue a behavior modifi-~-.. -----~-~~,.....~--"'·-·-~~~----··-«··-~ •"<->.--'"''~">"'•'-"-'-" -·_o--~0"!'"•--~~"<••"c-~F'"-•'"~"""~'"--•~o.~,...-......... ~.g,_~~~,.-,~.~-..-·v~,-"'"~.~·~=-.~-,;·,~-·-•-,-,·o•~·-.~••o,..-•'C""~.,...,~ .. -~·-· .. ,~>
cation approach to weight loss without first seeking out the help of - --·--·--~·---·· ........ ,,,. '"""""""""""""'" ~-· "'"'"""'"'""""-·-····-···-::,.
a thera~-~~~~ ·-<Several books have appeared on the market as self-help --~.c---,_~-"~-- .. ---'-"
and programmed learning of the techniques.
In keeping with behavior modification theory, Jordan, et al.
(1976} have written a book encouraging readers to take charge of their
own weights by taking responsibility for their own eating behaviors.
Techniques, directed at changing inappropriate behaviors, were
described.
15
Ferguson (1976) put into book form a ten-week behavior modifi
cation program complete with explanations, activities and blank forms
to be filled out by the dieter. The activities were all geared toward
discovering and changing established habits that Je_Q to~ overweight .. - -.-f>'<><>--'•·_._,.~8·•~'""'_.,.~-....~~-'~··>·~·M• ''> o
----~·'--' -·--······-"'····-···------·-·--····-·---· ·•->='·•Pr .. ,, •• ..,.~.-·
Arenson (1978) also put into book form a behavior modification
program. She, too, included explanations, activities and forms.
Again, the dieter was encouraged to take charge by discovering problem
areas and changing behavior patterns in such a way as to produce sue-
cess in weight loss and maintenance.
All three of these books (Arenson, 1978; Ferguson, 1975; Jordan
et al., 1976) have stressed record-keeping or self-monitoring as a key -------~--···--··-~-••·-----·~--.~---.~,_,_,-__...,..~._.,.....,.,._~~._.....,-~. ~~""'"'""'"'""~"-_,-,"<.••-c-.>.-..,_..,-...-.,.,_'<0<__,--.-'-'"'S)'""'-~~·--""~-,.~~<.~,~~.,....,.~-,.r"'~~"~-""""'
ti ve in a 11 owing the dieter to see trends and R~~1:~.rn.~~--th.c:tt.b.!t or.~Q~,.
may not have been aware of before. Only when these eating behavior
patterns were documented co~:Jlg_J.b.f:!.,{!J.~:tgr_ J~~9J'! .. ~.<?.lll.~~e changes.
Cue elimination, preplanning and energy use were all part of
the Arenson (1978) and Ferguson (1975) programs. The dieter was in-
structed to eat in only one place, to avoid simultaneous activity when
eating, to keep food out of sight and to break behavior chains that
signal eating. In so doing, dieters were helped to eliminate outside
influences that had become unconscious eating cues. Preplanning was
a technique advocated to eliminate impulsive and emotional eating. It
limited the dieter to only that food which was planned for that day.
Energy use or exercise was considered an important part of weight re
duction programs. In moderation it has been known to reduce appetite
(Ferguson, 1975) and to help maintain negative energy balance. Energy
use suggestions focused mostly on ways to increase walking throughout
the day.
Arenson (1978) based her program mostly on record-keeping and
writing exercises that helped dieters to discover themselves. Her
thesis was that in order to achieve lasting success, one must become
aware of the whole self in order to assume responsibility for one's
own behavior.
Case Studies
It has only been since the late 1960s that behavior modifica
tion has been applied to the treatment of obesity. Surveys of original
research work done in the area of behavior modification for weight loss
have revealed an incomplete picture. Although all studies resulted in
a weight loss, the long-term results of weight loss maintenance have
not been made clear. In addition, only very few experiments have
studied the comparative effects of the various techniques (Jordan and
Levitz, 1973).
One researcher reported that both professional and experienced
therapists produced greater weight losses in behavior modification pro
grams than lay therapists. Further studies found evidence that charac
teristics of the therapist had a major influence on the success of the
program (Stunkard, 1980).
Aversion therapy captured the attention of several researchers.
Foreyt and Kennedy {l97l) successfully produced weight loss in six sub
jects by pairing favorite foods with noxious odors. Five of the sub
jects had maintained and even increased their weight loss at the end of
I I
48 weeks. Some credit for this success was given to the experimenter
patient relationship and was emphasized as an effective component of
the study.
A second study (Meyer and Crisp, 1964) using electric shocks to
inhibit eating of favorite foods, showed this to be effective only if
the subject actually experienced the shocks. Avoiding the food in
order to avoid the shock did not produce behavior changes or weight
loss.
Three separate studies (Levitz and Stunkard, 1974; Penick
et al., 1971; Stunkard, 1972) comparing the effectiveness of behavior
modification in group settings all resulted in similar conclusions.
Those groups in which behavior modification techniques were applied
averaged more weight loss and longer maintenance of that loss than did
subjects participating in groups without the use of behavior modifica
tion techniques.
When comparing the effectiveness of behavior modification tech
niques between group therapy and individual therapy, McCann and Trulson
(1955) concluded that neither the individual nor the group therapy pro
gram was effective over a three-year period.
Stuart (1967) and Hall (1972) both experimented with self
control techniques of reward and punishment. When these techniques
were applied both with and without the interaction of a therapist, the
therapist-controlled subjects were more successful.
A study by Mahoney et al. (1973} involving self-reward, self ...
punishment and self-monitoring techniques revealed that theself-reward
subjects lost significantly more weight.than either oftheother two
groups.
While behavior modification techniques have been shown to be
successful in causing individuals to lose pounds, the long-term picture
has been discouraging and this led one group of researchers (Young et
al., 1955:1115) to conclude that, "In the end the only real answer to
the problem of obesity is prevention ...
Blouin (1977:535) reinforced this statement when he said,
11 research and therapy results to date indicate that prevention and
not treatment is the only road to true success in curing obesity."
1;:7
Chapter 3
PROCEDURE
A study.was conducted to determine results of a behavior modi
fication class for weight reduction. Classes were taught at a prepaid
health maintenance organization in Northridge, California.
Participants were either self- or doctor-referred and each was
given a choice of group or individual counseling. The course consisted
of nine weeks with the same therapist teaching the class at each of the
meetings. The complete course was offered in January, April, July and
October. Booster sessions were offered monthly after completion of the
course. Groups were identified as A, B, C, D and E according to their
starting date. A participant was considered to have completed the
course if he or she attended at least six meetings. This study eval
uated the progress of participants that had completed the course one
year ago. Others had completed the course nine, six, and three months
before, respectively. Finally, an evaluation of participants' progress
immediately following completion of the course was made. Statistical
analyses by chi-square were done in order to test the null hypotheses.
The following is a description of the content of the course.
At the beginning of each class meeting, all participants were
weighed and their weight recorded on a form. Dieters were expected to
keep daily food diaries for the entire nine weeks and were always en
couraged to share their dieting experiences with the whole group.
The first class consisted of information gathering and an
20
orientation of what to expect from the course. The main topic for the
week pertained to habit awareness. Homework designed for this purpose
was for dieters to begin food diaries and to prepare a map showing all
the eating places of their respective homes and work places.
The second class meeting dealt with food cue elimination and
non-food rewards. Each dieter was asked to make a list of that which
triggered eating for him or her and then to make a decision on how
these cues could be eliminated or changed. Secondly, participants were
encouraged to indulge in activities, other than eating, that made them
feel good. These were non-food rewards.
The third class meeting emphasized positive dieting and
learning to eat slowly. As one positive approach, dieters were asked
to make diet plans for themselves. Techniques, such as putting uten
sils down between bites, were taught for the purpose of prolonging the
eating process.
The fourth class meeting dealt with testaurant eating and be
havior chains. The discussion centered around preplanning activities
that have been shown to encourage good eating habits. Secondly,
dieters were taught how to break a behavior chain that resulted in
inappropriate eating.
The fifth class meeting discussion centered on self-sabotage
and emotional overeating. The dieter who practiced self~sabotage was
the one who found excuses for eating. In order to eliminate this, the
dieter was asked to identify those situations and then to make a com
mitment to change that kind of behavior. The first step towards
eliminating emotional overeating, dieters were told, was a matter of
'- I
identification.
The sixth class meeting concentrated on the elimination of
impulsive eating. Dieters were again reminded of the importance of
preplanning as a means to eliminate impulsive eating.
The seventh class meeting ~mphasized the importance of energy
use through regular exercise. Hints on how to increase energy use
during the course of a normal day were discussed.
The eighth class meeting dealt with the importance of the
positive influence of others on continued success. Therefore, dieters
were asked to actively enlist the support of at least one person. Main
taining good food habits was also stressed.
The week between the fifth and the sixth class meeting had
been designated as a maintenance week. The purpose of this week was
to give the participants a chance to experience being on their own.
Any problems or questions arising during this week were presented and
discussed. The inclusion of this maintenance week brought the total
time of treatment to nine weeks. (See Table 1.)
Table l
Weight Control Class Schedule
Week Topic Homework
l Habit Awareness Begin food diary Eating place map
2 Food cue elimination Food out of sight Non-food rewards Eat in one place
When eating, only eat
3 Positive dieting Practice diet plan Eating slowly Utensils down
4 Restaurant meals Practice meals Behavior chains Use alternate activities
for eating
5 Preventing 11 Self- Plan for preventing sabotage 11 sabotage
Overeating and emotions
6 No class Maintenance check list
7 Planning to prevent Plan one meal/day impulsive eating Prepare shopping list
Plan for restaurant~ parties
8 Energy Use Plan for activity More cue elimination Cue eliminations
9 Positive influence of Enlist support of friend or others loved one
Maintaining good habits
The combination of techniques used throughout this course in
volved (1) self-monitoring, (2) self-reward, (3) social reinforcement,
(4) nutrition counseling, (5) modeling, (6) stimulus control, {7) self
control, (8) group therapy, (9) goal setting, and (10) exercise. For
example: keeping of food diaries was a form·of self-monitoring; using
non-food rewards involved self-reward; sharing experiences and en
listing support of a friend were both considered social reinforcement;
nutrition and exercise counseling were present throughout the lectures;
modeling was used by the therapist to demonstrate homework activities;
elimination of eating cues was a part of stimulus control; self-control
was encouraged by individual decision making; group therapy, rather
than individual counseling, was the chosen form of presentation; and
each dieter was encouraged to set realistic goals of weight loss
expectancy.
Each of these broad categories consisted of many specific
techniques. The following list of items was used in this program:
(l) sharing experiences, (2) keeping food diaries, (3) keeping food out
of sight, (4) eating in one place, (5) putting utensils down, (6}
eating without doing another activity, (7) enjoying non-food treats,
(8) following splurge allowances, (9) substituting one food for another
or another activity for eating, (10) eating smaller portions, (ll)
breaking behavior chains, (12) restaurant eating, (13) fast food ideas,
(14) preplanning, and (15) exercising.
In order to obtain information, participants were telephoned
and asked the questions indicated on thecollective device. The data
obtained in this manner and from the evaluation forms were tabulated,
organized and reported.
Chapter 4
RESULTS AND DISCUSSION
After the completion of telephone interviews with sixty-two
subjects who had been involved in a behavior modification and weight
reduction program, the data were tabulated, compiled and organized
according to several different factors and relationships. These in--
eluded attrition rate, weight reduction during the nine-week course,
maintenance of weight loss at three, six, nine and twelve month inter-
vals, attendance at booster sessions and the most~ and least-liked
Collectively, the groups consisted of twelve men and fifty
women. The ages ranged from sixteen to sixty-two with an average age
of forty years.
Since all participants had been interviewed by telephone, the
reliability of self-report has been the basis for all results and con
clusions.
Subjects were grouped according to the starting date oftreat-
25
ment. Each of the five groups consisted of a distinct and unique set
of subjects. Since it was not possible to follow a single group for
any length of time, separate groups were selected to represent the
stated intervals of time. Group A began the nine-week course in
October of 1981. No follow-up data was collected on this group. Group
A represented only the results of the course itself. Group B began the
course in July of 1981. A three-month follow-up interview was done to
obtain information on current weight, booster session attendance and
current use of behavior modification techniques. Groups C, D and E
were treated the same as Group B. The starting date for Group C was
April of 1981 and ·represented a six-month interval between the course
and the follow-up interview. Group D began in February of 1981 and
represented a nine-month interval. GroupE began in October of 1980
and represented a twelve-month interval. (See Table 2.)
Table 2
Group Identification
Group Starting Date Time Interval
A October 1981 No follow-up
B July 1981 3 months
c April 1981 6 months
D January 1981 9 months
E October 1980 12 months
p .
Attrition
Attrition rates for the various groups studied are presented
in Table 3.
Group
A
B
c
D
E
Table 3
Group Attendance and Percent of Attrition
Subjects Subjects Entered Finished
39 13
44 18
30 16
25 9
20 6
Percent of Attrition
67
59
47
64
70
The average attrition rate for all groups combined was 61.4±9
percent. Attrition rates of from 20 to 80 percent have been reported
by Levitz and Stunkard (1974}.
According to Levitz and Stunkard (1974.) a major problem in any
obesity treatment program has been the number of patients who have
dropped out of treatment. This attrition rate has seriously biased
the results of treatment since studies have shown that the poor weight
losers have dropped out at a higher rate than the more successful
dieters. Therefore, a lower attrition rate has meant that the less
successful dieters have remained in the program.
- -·-~--- - --;,------ --~-::;------
Weight Loss and Maintenance
Penick et al. (1971) have reported that 25 percent or less of
obese persons will have lost as much as twenty pounds as a result of
treatment and only 5 percent will have lost as much as forty pounds.
Weight loss to date of all subjects has shown that 17 percent have
lost more than twenty pounds but less than forty pounds and 3 percent
have lost more than forty pounds.
Weight Loss
More than 20 pounds
More than 40 pounds
Table 4
Percent of Participants Losing Specified Amounts of Weight
Treatment Groups A through E
17
3
Average in Literature
(Penick et al., 1971)
25
5
Since Penick et al. (1971) did not identify the element of
time, the results in Table 4 should be considered general rather than
specific.
During the nine-week course, Group A subjects lost an average
of nine pounds per person. Group B subjects lost an average of seven
pounds per person. Three B subjects had been pregnant during the
course and were omitted from calculations of weight loss as a result
of treatment and during the weight maintenance period. They have,
however, been included in all other tabulations. Another subject
moved and was not interviewed. Group C subjects lost an average of
twelve pounds per person. Two of the C subjects had moved and were
not interviewed. Group D subjects lost an average of eleven pounds
per person. Group E subjects lost an average of five pounds per person.
One subject had been pregnant during the course and was not included in
weight lost as a result of treatment or in weight maintenance calcu
lations.
Table 5
Average Amount of Weight Lost Per Person During 9-Week Course
Weight Loss in Pounds
A
9
B
7
Group
c
12
0 E
ll 5
The relationship between attrition rate and weight loss on an
average per person basis has been documented by Levitz and Stunkard
(1974). They described a pattern of decreasing weight loss with de
creasing attrition rate. This study, however, produced results that
were directly opposite. With decreasing weight loss there had been
an increase in attrition rate. (See Figure 1.) This discrepancy may
have originated in group size. This study dealt with small groups.
Levitz and Stunkard (1974) have not specified this variable.
---- ---~-~-------;_.--
100 95 90 85 80 75
1::: 70 0
65 ...... ..j..) ...... 60 s.. ..j..) 55 ..j..)
50 c::(
4- 45 0
40 ~
35 30 25 20 15 10 5 0
1
E
. . . B .·• . . ...
A .... •·•·•·•·· •. D
·J¥•;o . . . . :.c
2 3 4 5 6 7 8 9 10 11 12 13 14 15
Weight Loss in Pounds
Figure 1
Relationship Between Attrition Rate and Weight Loss During Course
Weight maintenance was compared for Groups B, C, D and E.
Group A represented only the weight loss that occurred during the
course. In order to compare the progress made by dieters during the
maintenance periods, Tables 6 and 7 have been prepared. Table 6 shows
the average weight loss per person on a monthly basis for the nine-week
course. Table 7 shows the weight losses that occurred during the main
tenance periods.
Because each group represented a unique set of dieters, it was
important to compare the losses on a monthly basis. In this way, a set
of figures emerged that showed a clear picture of the weight loss
pattern.
Weight Loss in Pounds
No. of months
Table 6
Monthly Weight Loss During Course
Group
A B c
4 3 5
Table 7
Weight Loss During Maintenance Periods
B
since treatment 3 began
Pounds lost si nee treatment 10 began
Pounds lost 3.3 per month
Average for all groups (Mean±S.D.)
D E
5 2 3.8±2.8
c D E
6 9 12
22 13 6
3.6 1.4 .5
The data in Table 7 shows that with increasing length of time,
weight losses decreased. Some dieters had already begun to increase \
their body weights. Similar results have been reported in the litera-
ture by other researchers, who noted the discouraging results of weight
reduction programs (McCann and Trulson, 1955; Levitz and Stunkard, 1974;
Young et al., 1955). However, this study has shown that treatment was
still effective at a low level after a twelve-month interval. The
longer range picture of these dieters has yet to be recorded.
When subjected to statistical testing by chi-square, there was
no significant difference between the weight lost during the course and
weight lost during the maintenance periods. The null hypothesis has
been accepted. There was, however, a significant difference at the .01
level between the weight lost as a result of the treatment and the time
of year that treatment began. The null hypothesis has been rejected.
The groups representing starting times in January and April exhibited
the highest weight losses while the groups starting in July and October
produced significantly less weight losses. Therefore, it can be sug
gested that the months after the beginning of the year, but prior to
the start of summer, may be conducive to dieting while the summer and
fall months may be considered a less effective time to diet.
Booster Sessions
Booster sessions designed to enhance continued motivation after
treatment have not shown consistent results. Stunkard (1980) cited
studies that have shown both favorable and unfavorable results. He
suggested that booster sessions were helpful only if they were
scheduled at strategic times for the participants. Prearranged ses
sions have not generally coincided with critical stress periods in
dieting.
Twenty of the 46 eligible subjects attended at least onebooster
session. This represented a 41 percent return of subjects during the
maintenance period. However, calculations showed that the twenty sub
jects who had attended at least one booster session had lost an average
of sixteen pounds per person while the subjects who had not attended
any booster sessions had lost thirteen pounds per person. All subjects
reported that the booster sessions were of help to them.
Technique Preference and'Use
The most-liked of the techniques used during the nine-week
course as reported by all groups are listed in Table 8 in order of
decreasing preference. Also the actual use of these techniques during
maintenance is presented in the same table for comparison with the
stated preferences.
This tabulation has shown that the social aspects of sharing
experiences played a major role in this treatment program. Stuart and
Mitchell (Stunkard, 1980) reported that the social aspects of health
care have probably been rooted in the earliest days of human civiliza
tion. Individuals who share common problems have traditionally met the
challenge with varying degrees of social organization. This technique
of sharing experiences has slipped to the eleventh position on the
scale of maintenance use~ Subjects reported that upon leaving the
group they no longer had anyone with whom to share their experiences.
Those subjects who had continued treatment through the booster ses
sions reported using those sessions to share experiences. Lack of
transportation, inconvenient scheduling of sessions, and forgetfulness
were given as reasons for non-attendance at the booster sessions.
Preplanning of meals and food intake was the second most-liked
technique, but had slipped to the ninth position of actual use during
maintenance. Explanations offered by subjects to account for this
indicated that its association with record-keeping techniques may have
influenced a dislike for preplanning methods.
Keeping food out of sight and eating in only one location of
the home or office were the third and fourth most-liked techniques
during the course and had actually risen to the first and second places
of techniques used during maintenance. One explanation for the ratings
received by these two techniques may have been due to their close re
lationship to cue elimination. Many subjects had spoken of eating for
reasons other than hunger. Sight of food and physical location of self
were both able to trigger eating in these individuals.
A large number of subjects commented on the self-awareness that
had come about as a result of applying the techniques, especially the
keeping of a diary. Most reported a dislike for keeping the diary, but
also acknowledged its importance. This technique placed fifth in the
list of preferences, but had slipped to last place in the list of tech
niques being used for weight maintenance.
Exercising was listed as the least~ liked technique but had
risen to the seventh place in the list of maintenance techniques being
used. The rest of the techniqu~s fall somewhere in between with
varying degrees of exchanges in order of preference and use. Comments
regarding the breaking of behavior chains indicated that this had been
done for the most part during the course and so had not needed further
attention. Fast food and restaurant eating techniques were not appli
cable to many subjects as they had decided not to eat out.
The philosophy of the therapist who conducted the course had
been one of positiveness and reward. No form of punishment was evi
dent in her methodology. This positive approach prompted subjects to
comment on the positive feelings that they had enjoyed throughout the
course.
Table 8
Preference Order and Actual Use of Techniques
Preference in Maintenance use Order descending order Order in descending order
1 Sharing experiences 1 Food out of sight 2 Preplanning 2 One location 3 Food out of sight 3 Smaller portions 4 One location 4 Subs ti tuti ons 5 Keeping diaries 5 Splurge allowance 6 Substitution 6 Non-food treats 7 Smaller portions 7 Exercising 8 Behavior chains 8 Restaurants 9 Restaurants 9 Preplanning.
10 Only eat 10 Only eat 11 Utensils down 11 Sharing experiences 12 Splurge allowance 12 Behavior chains 13 Fast foods 13 Fast foods 14 Non-food treats 14 Utensils down 15 Exercising 15 Keeping diaries
Chapter 5
SUMMARY AND CONCLUSIONS
The effectiveness of behavior modification in the treatment of
obesity was assessed in sixty~two subjects. All participants had been
either self- or doctor-referred and were given a choice of group or
individual counseling. All participants had voluntarily chosen the
group setting and received the same treatment by the same therapist.
The initial success for each group during the nine-week course
was encouraging, but losses decreased with the passage of time. How
ever, twelve months after treatment in a behavior modification pro
gram, a low level of success was still evident.
Statistical testing by chi-square showed that there was no
difference between the amount of weight lost during the course and the
amount of weight lost during the maintenance periods. Chi-square
analysis showed that dieters lost significantly more weight during the
first half of the year than they did during the second half of the yea~
A number of other statistics were presented as a result of
analysis of the data. The average attrition rate for all groups com
bined was 61.4±9 percent. Seventeen percent had lost more than twenty
pounds; 3 percent had lost more than forty pounds; and the average
number of pounds lost per person during the nine-week course was
8.8±3.7 pounds. Thirty--two percent had attended at least one booster
session. All ~participants reported that theyhad been helped further
by the sessions and had lost more·weight per person than those who had
37
not attended any booster sessions.
The most-liked technique was the sharing of experiences while
the least-liked was exercising. The most-used technique during main
tenance was keeping food out of sight while the least-used was the
keeping of diaries.
The treatment of obesity has been the subject of an over
whelming number of books and articles. A common feature of all weight
reduction programs has been their general ineffectiveness over time.
Although each treatment program has had some success with some individ
uals, the reasons for this success have not yet been identified.
There has been a real need for further study in methods of
weight reduction and the effect on long-term maintenance. There has
also been a real need for wide-spread educational programs aimed at
the prevention of obesity. Evidence has suggested that prevention may
be the only real cure for obesity.
This study was an investigation of several aspects of a be
havior modification treatment program. It was done with the hope that,
combined with the results of other research, these results would have
value to others using this form of treatment
Recommendations
Results of this study have prompted recommendations as follows:
1. Since it has been shown that behavior modification programs
do successfully help individuals lose weight, the problem of regain
during maintenance has arisen. Therefore, booster sessions should be
further researched in an effort to gain maximum and effective use of
them.
2. Methods of lowering attrition rate, such as requiring a
deposit, need to be studied for their effectiveness.
3. Many different techniques have been taught and used during
treatment. In order to determine effective combinations, more research
on actual techniques used at home should be conducted.
4. This study has raised the question of a possible relation
ship between record-keeping techniques and weight loss. This question
should receive special attention from researchers.
5. Since individuals begin treatment either as self-referred
or doctor-referred dieters, this variable should be investigated.
6. The time of year that treatment begins should be investi
gated for its effect on the success of weight loss.
SELECTED BIBLIOGRAPHY
Books
Agras, W. Stewart, Alan E. Kazdin, and G. Terrance Wilson. Behavior TheraPY: Toward an Applied Clinical Science. San Francisco: Freeman, 1979.
Arenson, Gloria. How to Stop Playing the Weighting Game. Los Angeles: Transformation Publications, 1978.
Bray, ·George A. Obesity: Compari ti ve Methods of Weight Contra 1 . Westport: Technomic, 1980.
Craddock, Dennis. Obesity and its Management. London: Churchill Livingston, 1973.
Erwin, Edward. Behavior TheraPY:· Scientific, Philosophical, and Moral Foundations. London: Cambridge University Press, 1978.
Ferguson, James M. Learning to Eat:· Behavior Modification for Weight Control. Palo Alto, California: Bull, 1975.
Franks, Cyril t1. Behavior Therapy: Appraisal and Status. New York: McGraw-Hi 11 , 1969.
Jordan, Henry A., Leonard S. Levitz, and Gordon M. Kimbrell. Eating is Okay! New York: New American Library, 1976.
Kanfer, Frederick H., and Jeanne S. Phillips. Learning Foundations of Behavior Therapy. New York: John Wiley, 1970. ·
Kazdin, Alan E. History of Behavior Modification: Experimental Foundations of Contemporary Research. Baltimore: University Park Press, 1978~
LeBow, Michael D. Weight Control: The Behavioral Strategies. New York: John Wiley, 1981.
Leitenberg, Harold, ed. Handbook of Behavior Modification and Behavior Therapy. New Jersey: Prentice Hall, 1976.
Mehrabian, Albert. Basic.Behavior·Modification. Vol. 9. New York: Human Sciences Press, 1978.
O'Leary, Daniel K., and G. Terrance Wilson. Behavior Therap': Application and Outcome. New Jersey: Prentice Hall, 19 5.
40
Sherman, A. Robert. Behavior Modification: Theory and Practice. Monterey, California: Brooks/Cole, 1973.
Sjoden, Pre-Olow, Sandra Bates, and WilliamS. Dockens III, eds. Trends in Behavior Therapy~ New York: Academic Press, 1979.
Stunkard, Albert J., ed. Obesity~ Philadelphia: Saunders, 1980.
Williams, Ben J., Sander Martin, and John P. Foreyt, eds. Obesity: Behavioral Approaches to Dietary Management~ New York: Brunner/Mazel, 1976.
Periodicals
Babcock, C. G. Food and Its Emotional Significance. Journal of the American Dietetic Association, 24 (May 1948) 390-393.
Bayles, S., and F. G. Ebaugh. Emotional F&ctors in Eating and Obesity. Journal of the American Dietetic Association, 26 (June 1950) 430-34.
Blouin, B. B. Diet and Obesity. Journal •of the·American Dietetic Association, 70 (1977) 535.
Conrad, S. W. Resistance of the Obese to Reducing. Journal of the American Dietetic Association, 30 (June 1954). 581-88.
Foreyt, J. P., and W. A. Kennedy. Treatment of Overweight by Aversion Therapy. Behavior Research ·and • Therapy, 9 ( 1971) 29~34 •.
Grinker, J. Behavioral and Metabolic Consequences of Weight Reduction. Journal of the American Dietetic Association·; 62 (January 1973) 30-4.
Hall, S.M. Self-control and Therapist Control in the Behavioral Treatment of Overweight Women. BehaviOr Research and Therapy, 10 (1972) 59-68.
Hertzler, A. A. Obesity~- Impact of the Family. Journal of• the· American Dietetic Association, 79· (November 198)) 525-30.
Jordan, H. A. In defense of Bodyweight~ · Journal of· the American· Dietetic-Association; 62 (January 1973) 17 .. 21 ~ · _
Jordan, H. A .. , and L. S. Levitz. Behavior Modi-fication in a Self-Help Group. Journal of the•American Dfetetic •Asscidatton, 62 (January 1973) 27:..9 ~
41
Levitz, L. S., and A. J. Stunkard. A therapeutic Coalition for Obesity: Behavior Modification and Patient Self-Help. American Journa 1 of Psychiatry, 131 :4 (Apri 1 197 4) 423-26.
Mahoney, M. J., N. G. M. Moura, and T. C. Wade. Relative Efficacy of Self-Reward, Self-Punishment, and Self-Monitoring Techniques for Weight Loss. Journal of Consulting and Clinical Psychology. 40:3 (1973) 404-07.
McCann, M., and M. F. Trulson. Long-Term Effect of Weight-Reducing Programs. Journal of the Americari·Dietetic Association, 31 (November 1955) 1108 ... 10.
Meyer, V., and A. H. Crisp. Aversion Therapy in Two Cases of Obesity. Behavior Research and Therapy, 2 (1964) 143-47.
Nutrition Newsletter, Sunmer 1981, pp. 3-9.
Penick, S. B., R. Filion, S. Fox, and A. J. Stunkard. Behavior Modification in the Treatment of Obesity. Psychosomatic· Medicine, 33:1 (January-February 197l) 49-55.
Stuart, R.B. Behavioral Control of Overeating. Behavior·Research and Therapy, 5 (1967) 357-65.
Stunkard, A. J. New Therapies for the Eating Disorders; Behavior Modification of Obesity and Anorexia Nervosa. Archives of General Psychiatry, 26 (May 1972) 391-98.
Young, C. M., N. S. Moore, K. Berresford, B. M. Einset, and B. G. Waldner. The Problem of the Obese Patient. Journal of the American Dietetic Association, 31 (November 1955) llll-15. ·
APPENDICES
43
APPENDIX A
Letter of Permission
44
maxi care
August 20, 1981
To Whom It May Concern:
Carolee Blumin has permission to telephone
Maxicare members at Northridge Medical Group who have completed our weight control course. I
understand that she has developed a questionnaire which will enable her to gain information for
research leading to a masters degree.
Sincerely,
~~~ Erica Frand, M.P.H. Director, Health Education
Cot7HJtate Office 11833 HAWTHORNE BLVD. HAWTHORNE, CA 902SO (213) 973-5400 A FI!DIRALLY QUAUFIID HEALTH MAINTENANCE ORGANIZATION
Melling Address 445!1 WEST 117th ST.
HAWTHORNE, CA 902SO
45
46
p •
APPENDIX B
Data Collection Devices
Evaluation Data Collection Form
Starting date ____ _
Number of subjects entering class ____ _
Number of subjects completing class ____ _
Most liked aspect of class
Least liked aspect of class
Subject
1 2 3 4 5 6 7 8
Starting Weight.
Group ____ _
Ending Weight
"TI
Telephone Data Collection Form·
Starting Date -------Name -----------
Starting Height------
Group·--------
Phone No.
Ending Weight ·------
1. What is your current weight?~-----
2. Which, if any, of the following techniques are you still using?
1. Sharing experience ____ 9. Substitution
2. Diaries 10. Sma 11 portions ~-
3. Out of sight _ 11. Behavior chains
4. One place_ 12. Preplanning ____
5. Utensils down 13. Exercise
6. Only eat_ 14. Fast food·
7. Non-food 15. Restaurant eating --...--.
8. Splurge
3. How many 11 Booster Sessions" have you attended?
4. Have these sessions helped you to tontinue using the techniques?
5. Have these sessions helped you to continue to lose weight and/or maintain your weight loss?
Comments:
48
APPENDIX C
Pre 1 imi nary Data
!>U
Table 9
Profile of Group A
Starting End of Subject Weight Course Weight
1 174 167
2 160 152
3 162 159
4 214 208
5 142 130
6 188 177
7 140 135
8 205 190
9 159 151
10 208 197
11 92 88
12 287 269
13 172 170
o.JI
Table 10
Profile of Group B
. Starting End of Maintenance Attendance at Subject Weight Course Weight . Wei ght ... 3 mas .. Booster Sessions
1 238 222 216 Yes
2 144 138 Moved
3 162 160 Miscarried No
4 147 139 138 No
5 252 243 231 Yes
6 160 164 Pregnant No
7 247 226 220 No
8 128 126 126 No
9 198 189 190 No
10 206 202 201 Yes
11 145 143 140 Yes
12 187 190. Pregnant No
13 170 166 159 Yes
14 130 127 126 Yes
15 212 213 213 No
16 122 116 116 Yes
17 138 133 135 Yes
18 163 145 145 No.
Table 11
Profile of Group C
Starting End of Maintenance Attendance at Subject Weight Course Weight Weight-6 mos. Booster Sessions
1 202 198 187 No
2 159 140 Moved
3 164 151 140 No
4 150 146 145 No
5 235 215 178 No
6 289 262 225 Yes
7 155 136 124 Yes
8 254 238 220 Yes
9 196 189 1g6 No
10 210 195 190 Yes
11 136 133 125 No
12 170 157 169 No
13 238 226 Moved
14 130 119 113 Yes
15 166 163 153 Yes
i6 125 118 108 No
Table 12
Profile of Group D
Starting End of Maintenance Attendance at Subject Weight Course Weight Weight-9 mos. Booster Sessions
1 179 172 174 No
2 160 150 150 No
3 228 224 226 No
4 193 186 183 Yes
5 157 134 150 No
6 287 280 260 No
7 301 280 280 Yes
8 202 190 180 Yes
9 140 132 124 Yes
54
Table 13
Profile of Group E
Starting End of Maintenance Attendance at Subject Weight Course Weight Weight-12 mos. Booster Sessions
1 144 147 Pregnant No
2 220 217 204 No
3 174 170 180 Yes
4 159 142 142 Yes
5 108 109 102 No
6 152 149 155 No
Table 14
Frequency Distribution of Participants Using Specific Techniques During Maintenance
Techniques Groups
B N=l6 c N=l4 D N=9 No. % No. % No. %
Sharing experiences 6 38 5 36 3 33 Diaries 2 12 5 36 0 0 Food out of sight 15 94 8 57 6 66 One place 15 94 7 50 5 56 Utensils down 2 13 4 29 2 22 Only eat 6 38 4 29 4 44 Non-food 8 50 5 36 7 77 Splurging 11 69 6 43 3 33 Subs ti tuti ons 14 88 8 57 4 44 Small portions 13 81 9 64 6 66 Behavior chains 8 50 4 29 3 33 Preplanning 4 25 7" 50 4 44 Exercise 6 38 7 50 6 66 Fast foods 8 50 3 21 2 22 Restaurants 10 63 4 29 5 56
E N=5 No. %
1 20 1 20 3 60 2 40 1 20 2 40 1 20 2 40 2 40 1 20 0 0 2 40 2 40 0 0 1 20
Total No.
15 8
32 29 9
16 21 22 28 29 15 17 21 13 20
%
34 18 72 66 20 36 48 50 64 66 34 39 48 30 45
0"! 0'!
APPENDIX D
Chi-square Analysis
56
57
Table 15
Data for Null Hypothesis No. 1
Groups
B c D E Totals
Course losses 0 7 12 11 5 35
E 6.9 13.8 9.8 4.5
D . 1 -1.8 1.2 .5
o2 .01 3.24 1.44 .25
D2/E .0014 .235 . 147 .055
Maintenance losses 0 10 22 13 6 51
E 10.1 20.2 14.2 6.5
D -.1 1.8 -1.2 -.5
02 .01 3.24 1.44 .25
D2/E .0009 .160 . 101 .038
Totals 17 34 24 11 86
Chi-square - .7383
Criterion value .01 - 11.345
No statistical difference
Table 16
Data for Null Hypothesis
A B
0 9 7
E 8.8 8.8
D .2 -1.8
02 .04 3.24
D2/E .0045 .0368
Chi-square- 18.15
Criterion value .01 - 13.28
.01 level of significance
Groups
c
12
8.8
3.2
10.24
1.163
58
No. 2
D E Total
11 5 44
8.8 8.8 44
2.2 -3.8
4.84 14.44
.55 16.4