Promoting healthy weight with "stability skills first": a randomized trial

Obesity is a precursor to significant health consequences such as heart disease and diabetes, yet modest weight losses of 5–10% of initial weight produce clinically significant improvements in cardiovascular disease risk factors (Diabetes Prevention Program Research Group, 2002; Stevens et al., 2001; Wing & Jeffery, 1995). Although behavioral weight-loss interventions effectively produce modest weight losses in the short term, defined as 5–10% of initial weight in six months (Wadden, Crerand, & Brock, 2005), long-term maintenance remains elusive. Overweight and obese individuals typically give up the lifestyle and self-regulatory changes they have made during a weight-loss program—such as healthy eating, physical activity, and vigilant record keeping—and regain 30–50% of the weight loss within one year after the program ends (Barte et al., 2010; Jeffery et al., 2000). Maintenance interventions based on a ‘continued care’ perspective rely on active intervention and staff contact over time to sustain skills learned during weight loss, such as record-keeping and problem-solving skills (Perri & Corsica, 2002; Svetkey et al., 2008; Wadden et al., 2005). Although often highly successful at improving weight-loss maintenance when intervention and staff contact are in place, these maintenance interventions may only delay rather than prevent weight regain (Perri & Corsica, 2002; Wadden et al., 2005). Discouragingly, individuals leaving interventions with active maintenance components typically regain weight at the same rate as individuals leaving weight-loss programs without such maintenance components, sometimes regaining weight even before maintenance contact ends (Perri & Corsica, 2002; Perri et al., 2001; Wadden et al., 2005). Whereas these results could be interpreted as providing even stronger support for a continued care perspective, there may be additional skills that must be mastered for long-term weight maintenance. These skills may be independent from those needed for losing weight (King et al., 2002; Rothman, 2000; Sciamanna et al., 2011), but are not currently being incorporated into interventions. We hypothesized that individuals who want to successfully maintain a weight loss may need to proactively focus on weight “stability,” that is how to keep themselves at a stable and steady weight (Kiernan et al., 2005; Kiernan, Goldberg, & Durkin, 2003; Kiernan, Goldberg, Kirkpatrick, & Raymond, 2000). Consequently, they may need to learn a set of “stability skills” that optimizes satisfaction with the immediate day-to-day experience of engaging in lifestyle and self-regulatory habits. These skills include learning how to eat a healthy diet in appropriate portion sizes and be more physically active without feeling deprived or dissatisfied (relative deprivation theory; Kruglanski & Mayseless, 1990) and learning how to regulate or “fine-tune” the balance between their eating, activity, and weight with the minimum effort and attention necessary (limited resources theory; Baumeister, Bratslavsky, Muraven, & Tice, 1998). In addition, individuals may be more successful if they learn these stability skills before initiating weight loss, thus, capitalizing on initial motivation, providing a mastery experience for weight stability, and increasing perceived self-efficacy for maintaining a stable weight in the future (social cognitive theory; Bandura, 1986). This randomized trial examined whether learning a novel set of stability skills before losing weight improved long-term weight management, i.e., during a 12-month follow-up period after intervention sessions and staff contact had ended. Overweight/obese women were randomly assigned to one of two 6-month interventions that differed in the content and order of the maintenance modules. In Maintenance First, women participated first in an 8-week weight stability skills maintenance module, then in a standard 20-week behavioral weight-loss program. In Weight Loss First, women participated first in a standard 20-week behavioral weight-loss program, then in an 8-week problem-solving skills maintenance module. Thus, Maintenance First (a multi-component approach) differed in two important ways from Weight Loss First (a standard care approach). The Maintenance First condition consisted of both novel content (learning a set of stability skills designed to optimize day-to-day satisfaction with lifestyle and self-regulatory habits) and a novel order (placing a maintenance module before a weight loss program). In this trial, we hypothesized that women randomized to Maintenance First would regain less weight over the 12-month follow-up than women randomized to Weight Loss First.