Prevencin de la recada despus de la prdida de peso.

"\"\\\"\\\\\\\"21. Baker R. On sin, symptom substitution and simplicity: a
response to preventing relapse in weight control. Psychol Rep 1996; 78:

\\\\\\\\n\\\\\\\\n\\\\\\\\nThe literature is replete with approaches to weight lossmanagement. Serdula's article (3) is an excellent starting point.Tsai's review of major commercial weight loss programs is helpful.Various diet + exercise + medication plans have been reviewed, and inshort, they can all be found to be effective for short-term weight loss,usually with a nadir at six months. The thornier problem is how tomaintain the weight loss. The NIH Task Force found that sustained weightloss after one year was less than 5% (4). This is a common observationamong physicians and lay people. Other common observations are the yo-yodieting and large swings in body weight, also known as weight cycling,which risk injury to the client. Finally, we should note the exceptionto diet-induced weight loss. Since the NIH consensus statement in 1992,bariatric surgery is now recommended for the morbidly obese (BMI>40)or BMI>35 if there are significant comorbidities.\\\\\\\\nStages of Change

\\\\\\\\n\\\\\\\\n2. Ogden CL. Prevalence of overweight and obesity in the United
States, 1999-2004. JAMA 2006; 295: 1549-1555.

\\\\\\\\n\\\\\\\\nWhat strategies can be employed to prevent relapseh First, with
regard to definition, \\\\\\\\\\\\\\\"lapse\\\\\\\\\\\\\\\" is often described as a slip or
a mistake, whereas \\\\\\\\\\\\\\\"relapse\\\\\\\\\\\\\\\" is defined as a resumption of old
behaviors (14). Foreyt (15) list five strategies: Relapse Prevention
Training (Cognitive-Behavioral Training), Therapist Contact, Peer
Groups, Aerobic Exercise, Social Influence to which we may add
Behavioral Therapy. What are the causes of relapseh Prochaska notes
stress or more correctly, distress, anxiety, or depression. Turner notes
that many overweight people have \\\\\\\\\\\\\\\"lifestyles unbalanced with much
work and little pleasure\\\\\\\\\\\\\\\" (16).

\\\\\\\\n\\\\\\\\n10. Elfhag K, Rossner S. Who succeeds in maintaining weight lossh
Int Assoc Study Obes: Obes Rev 2005; 6: 67-85.

\\\\\\\\n\\\\\\\\n(d) Decision Making (i.e., anticipating the probable outcomes of
different options) -- What are the likely short- and long-term
consequences of each of your optionsh

\\\\\\\\n\\\\\\\\n24. Perri M. The maintenance of treatment effects in the long-term
management of obesity. Clin Psychol: Science and Pract 1998; 5(4):

\\\\\\\\n\\\\\\\\nWho Succeeds

\\\\\\\\n\\\\\\\\nThe challenge, then, is to integrate an effective relapse
prevention strategy into a weight management program. First, consider
the client who enters a weight management program. A common model for
understanding motivation and timing for making a major change in life is
the Stages of Change Model developed by Prochaska and DiClemente (Table
1) who studied patterns in smokers who were or were not making smoking
cessation efforts. The stages are Precontemplation, Contemplation,
Preparation\\\\\\\\\\\\\\\/Determination, Action\\\\\\\\\\\\\\\/Willpower, Maintenance, and Relapse. A
seventh stage has been suggested by Kern, Transcendence, a stage reached
when Maintenance has been sustained to the point that relapses are
unthinkable. The significant point here is that movement from stage to
stage is made from an internal locus of control, i.e. permanent change
will not be imposed by another, and that clients cycle and recycle from
stage to stage. For example, a client may move from Maintenance due to a
severe stress to a Relapse, at which time he may need to resume from the
Contemplation stage. This model may be quite different from the AA model
in which the client never is assumed to reach the Transcendence stage.
The client must always believe himself to be impaired (\\\\\\\\\\\\\\\"I am an
alcoholic\\\\\\\\\\\\\\\"), and the addiction is controlled not cured.

\\\\\\\\n\\\\\\\\n5. Frequent meetings should be programmed to increase client
compliance and participation.

\\\\\\\\n\\\\\\\\n10. The Transtheoretical Model with stages and processes are useful
guides for formulating tailored messages to each client.

\\\\\\\\n\\\\\\\\nA review of the literature reveals that most authors recommend
multimodality therapy, and most recommend continued therapist contact
for maintenance of weight loss (11,23,24,25). The Trevose Program
maintained contact up to 60 months with \\\\\\\\\\\\\\\"two-year weight loss 19%
of initial weight and at five-year it was 17%\\\\\\\\\\\\\\\" (11). Jeffrey notes
the above and suggests further investigation of 1) how to keep the obese
in long-term treatment, 2) the natural history of intentional weight
loss and the multiple contributing psychosocial factors, 3) energy
intake and expenditure, 4) behavioral phenotypes within the obese
population, 5) the role of behavioral preferences in obesity and its
treatment (e.g. for energy-dense foods), 6) why outcomes are better for
preadolescents than adults, 7) the effect of physical activity and
social support on weight loss, 8) the link from lab research to new
models of behavior control to that of applied research, 9) new and safer
effective medications, and 10) the integration of medications into
effective programs of weight control (26).

\\\\\\\\n\\\\\\\\n8. Therapy contact, individual or group, should be every two weeks
or more often and should extend to at least one year.

\\\\\\\\n\\\\\\\\n(c) Generation of Alternatives (i.e., brainstorming potential
solutions) -- The greater the range of possible solutions you consider,
the greater your chances of developing an effective solution.

\\\\\\\\n\\\\\\\\n6. Physical activity program should be included and may well be a
major source of the psychosocial benefits which increase and maintain

\\\\\\\\n\\\\\\\\n2. Encourage participation and support of significant others and

\\\\\\\\n\\\\\\\\n(a) Orientation (developing an appropriate coping perspective) --
Problems are a normal part of managing your weight, but they can be
dealt with effectively.

\\\\\\\\n\\\\\\\\n16. Turner L, Wang M, Westerfield RC. Preventing relapse in weight
control: a discussion of cognitive and behavioral strategies. Psychol
Rep 1995; 77: 651-656.

\\\\\\\\n\\\\\\\\nA cornerstone of a successful weight loss program is realistic
weight-loss goals. Serdula suggests an initial goal of 10% of body
weight over six months. Achievement of this goal \\\\\\\\\\\\\\\"can significantly
reduce obesity-related conditions\\\\\\\\\\\\\\\" (3). Wadden (8) notes than
\\\\\\\\\\\\\\\"many obese individuals, however, are not interested in modest
weight losses,\\\\\\\\\\\\\\\" and even after being counseled to expect to lose
10% of their weight, they continued to expect to lose 20% to 30%. Wadden
also found that although the weight loss averaged 10% to 16%, the
majority of his clients were satisfied with that result. It is important
to teach clients that even mild loss will be helpful in reducing the
risk of developing comorbid conditions or in facilitating their
treatment (9).

\\\\\\\\n\\\\\\\\n1. Encourage enrollment of groups--clients do better if enrolled
with small groups of friends and family, their peers.

\\\\\\\\n\\\\\\\\n4. Programs should be multimodality with inclusion of physicians,
dietitians, therapists, and trainers.

\\\\\\\\n\\\\\\\\n8. Wadden TA, et al. Great Expectations: \\\\\\\\\\\\\\\"I'm losing 25%
of my weight no matter what you say.\\\\\\\\\\\\\\\" J Consult Clin Psychol 2003;
71: 1084-1089.

\\\\\\\\n\\\\\\\\nIn summary, although weight loss programs are medically indicated,
and an effective relapse prevention plan should be included in the
program, there is no general consensus on a particular plan. Below,
however, are common threads found throughout the literature:


\\\\\\\\n\\\\\\\\nQuestions or feedback for the author may be directed to

\\\\\\\\n\\\\\\\\nThe Stages of Change Model has been modified by inclusion of
Processes of Change (Table 2) which are ten processes used by the client
in moving through the Stages. Prochaska lists these as: Consciousness
Raising, Self-Reevaluation, Self-Liberation, Counterconditioning,
Stimulus Control, Reinforcement Management, Helping Relationships,
Dramatic Relief, Environmental Reevaluation, and Social Liberation.
Different processes are used at different stages (5) as shown in Table
3. This new fusion is the Transtheoretical Model of Health Behavior
Change and is applied to a smoking cessation with success by tailoring
counselor responses to stages and processes as identified on a
questionnaire (6). This is an attempt to better understand the movement
of the client through the various Stages of Change.

\\\\\\\\n\\\\\\\\nAfter reviewing successful weight loss maintainers, Elfhag finds an
association \\\\\\\\\\\\\\\"with more initial weight loss, reaching a
self-determined goal weight, having a physically active lifestyle, a
regular meal rhythm including breakfast and healthier eating, control of
over-eating and self-monitoring of behaviors\\\\\\\\\\\\\\\" (10). Other factors
include \\\\\\\\\\\\\\\"an internal motivation to lose weight, social support,
better coping strategies and ability to handle life stress,
self-efficacy, autonomy ... and overall more psychological strength and
stability\\\\\\\\\\\\\\\" (10). Risks for \\\\\\\\\\\\\\\"weight regain include a history of
weight cycling, disinhibited eating, binge eating, more hunger, eating
in response to negative emotions and stress, and more passive reactions
to problems\\\\\\\\\\\\\\\" (10). Specifically, depression or depressed mood is a
major risk factor and is the precipitating factor in half of relapses.

\\\\\\\\n\\\\\\\\n15. Foreyt J, Goodrick GK. Evidence for success of behavior
modification in weight loss and control. Ann Intern Med 1993; 119(7):

\\\\\\\\n\\\\\\\\n20. Perri M. Relapse prevention training and problem-solving
therapy in the long-term management of obesity. J Consult Clin Psychol
2001; 69(4): 722-726.

\\\\\\\\n\\\\\\\\nTherapist contact means specifically prolonged therapist
involvement. Perri (20) notes that a full year of biweekly (every two
weeks) therapist contact resulted in significantly more long-term weight
loss (35% vs. 6%) than a control group which received only 20 weeks. In
these sessions, participants were taught the problem-solving model of
obesity management:

\\\\\\\\n\\\\\\\\n7. Lapses and relapses should be expected and managed as learning
opportunities for the client, to attempt to prevent a major relapse or
withdrawal from the program (see Tables 4, 5, and 6).

\\\\\\\\n\\\\\\\\n11. Questionnaires used by the therapist directly, mailed, or by
Internet may be used to track status of clients, or to identify clients
at risk of relapse.

\\\\\\\\n\\\\\\\\n23. Glenny AM. The treatment and prevention of obesity: a
systematic review of the literature. Int J Obes 1997; 21: 715-737.

\\\\\\\\n\\\\\\\\n22. McGuire M. Behavioral strategies of individuals who maintain
long-term weight loss. Obes Res 1999; 7: 334-341.

\\\\\\\\n\\\\\\\\n7. King CM, el al. The challenge study: theory-based interventions
for smoking and weight loss. Health Educ Res: Theory & Pract 2002;
17: 522-530.

\\\\\\\\n\\\\\\\\nCognitive-Behavioral - green coffee bean max acai bogota - training involves \\\\\\\\\\\\\\\"cognitive methods to
help patients adopt a more healthful diet and modify attitudes about
eating and body image\\\\\\\\\\\\\\\" (17). A therapist and client partner in
focusing on client attitudes and beliefs, set achievable goals, and
assist in modifying behaviors. The cognitive aspect relates to
discussion of the client's thoughts, beliefs, assumptions and
his\\\\\\\\\\\\\\\/her expectations. The goal of the therapist in a group or individual
setting is to work with these to bring the client to adopting realistic
perceptions and assumptions, forming a reasonable plan, and setting
achievable goals. The behavioral aspect relates to the therapist and
client looking at reinforcing appropriate behaviors, learning a skill
set which will contribute to increasing appropriate behaviors, and
rewarding helpful behaviors and extinguishing non-helpful behaviors. The
mix of the two aspects will depend on the nature of the client.

\\\\\\\\n\\\\\\\\n3. Initiate therapist contact early on to examine motivations,
thought processes, and set appropriate goals (see Table 7).

\\\\\\\\n\\\\\\\\nPeer Groups, especially with a facilitator have been found to be
helpful. These can be organized by the health care provider or may
include other standing groups, i.e. Overeater's Anonymous
( This organization may or may not be helpful. Of course,
the peer group may well be the friends or family who enlist in a weight
loss and maintenance program with the client. Groups of three or more
friends compared to groups of solo participants were more successful in
completing treatment (95% vs. 76%) and in maintaining their weight loss
(66% vs. 24%) per Dr Rena Wing (18). Epstein notes excellent results in
weight loss and maintenance of weight loss when a parent and child are
both in a program (19). More examples of parent-child programs are
evident, e.g. Kidshapers, a multimodality program organized by All
Childrens Hospital--University of South Florida, which combines
education and exercise programs with parents and children attending.

\\\\\\\\n\\\\\\\\n1. Bouchard C, ed. Physical Activity and Obesity, 1st Ed.
Champaign, IL. Human Kinetics, 2000.

\\\\\\\\n\\\\\\\\n12. Timmerman GM, Gregg EK. Dieting, perceived deprivation, and
preoccupation with food. West J Nurs Res 2003; 25: 405-418.

\\\\\\\\n\\\\\\\\n3. Serdula MK, et al. Weight loss counseling revisited. JAMA 2003;
289: 1747-1750.

\\\\\\\\n\\\\\\\\nBy Katrina M. Wells and Thomas D. Wells, MD

Table 1 Prochaska and DiClemente's Stages of Change Model

Stage of
Change Characteristics Techniques

Pre- * Not currently considering * Validate lack of
Contemplation change: \\\\\\\\\\\\\\\"Ignorance is readiness
bliss\\\\\\\\\\\\\\\" * Clarify: decision is
* Encourage re-eval of
current behavior
* Encourage self-
exploration, not action
* Explain and personalize
the risk
Contemplation * Ambivalent about change: * Validate lack of
\\\\\\\\\\\\\\\"Sitting on the fence\\\\\\\\\\\\\\\" readiness
* Not considering change * Clarify: decision is
within the next month theirs
* Encourage evaluation of
pros and cons of behavior
* Identify and promote
new, positive outcome
Preparation * Some experience with * Identify and assist in
change and are trying to problem solving re:
change: \\\\\\\\\\\\\\\"Testing the obstacles
waters\\\\\\\\\\\\\\\" * Help patient identify
* Planning to act within social support
1 month * Verify that patient has
underlying skills for
behavior change
* Encourage small initial
Action * Practicing new behavior * Focus on restructuring
for 3-6 months cues and social support
* Bolster self-efficacy
for dealing with obstacles
* Combat feelings of loss
and reiterate long-term
Maintenance * Continued commitment to * Plan for follow-up
sustaining new behavior support
* Post-6 months to 5 years * Reinforce internal
* Discuss coping with
Relapse * Resumption of old * Evaluate trigger for
behaviors: \\\\\\\\\\\\\\\"Fall from relapse
grace\\\\\\\\\\\\\\\" * Reassess motivation and
* Plan stronger coping

Table 2 Titles, Definitions, and Representative Interventions of the
Processes of Change

Process Definitions and Interventions

Consciousness Increasing information about self and problem:
Raising observations, confrontations, interpretations,
Self-Reevaluation Assessing how one feels and thinks about oneself
with respect to a problem: value clarification,
imagery, corrective emotional experience
Self-Liberation Choosing and commitment to act or belief in ability
to change: decision-making therapy, New Year's
resolutions, logotherapy techniques, commitment
enhancing techniques
Counterconditioning Substituting alternatives for problem behaviors:
relaxation, desensitization, assertion, positive
Stimulus Control Avoiding or countering stimuli that elicit problem
behaviors: restructuring one's environment (e.g.,
removing alcohol or fattening foods), avoiding high
risk cues, fading techniques
Reinforcement Rewarding one's self or being rewarded by others
Management for making changes: contingency contracts, overt
and covert reinforcement, self-reward
Helping Being open and trusting about problems with someone
Relationships who cares: therapeutic alliance, social support,
self-help groups
Dramatic Relief Experiencing and expressing feelings about one's
problems and solutions: psychodrama, grieving
losses, role playing
Environmental Assessing how one's problem affects physical
Reevaluation environment: empathy, training, documentaries
Social Liberation Increasing alternatives for nonproblem behaviors
available in society: advocating for rights of
repressed, empowering, policy interventions

Prochaska J. In search of how people change: applications to addictive
behaviors. Am Psychol 2002; p. 1108.

Table 3 Stages in Which Particular Processes of Change are Emphasized

Precomtemplation Contemplation Preparation Action Maintenance

* Consciousness Raising
* Dramatic Relief
* Environmental Reevaluation
* Self-Reevaluation
* Self-Liberation
* Reinforcement Management
* Helping Relationships
* Counterconditioning
* Stimulus Control

Prochaska J. The transtheoretical model of health behavior change. Am J
Health Promot 1997; 12(1): p. 43.

Table 4 Lapse Prevention

1. Distinguish Lapse, Relapse, and Collapse
2. Identify High Risk Situations
3. Outlast the Urge
4. Use Alternate Activities

Brownell K. The LEARN Program for Weight Management, 10th ed. Dallas,
TX: American Health Publishing Company, 2004.

Table 5 Incompatible Activities to Eating

Walk the Dog Play a Board Game
File Coupons Ride a Bike
Go to a Movie Brush Your Teeth
Call a Friend Read This Manual!
Shop for Plants Frame Some Pictures
Take a Shower Refinish Furniture
Listen to Music Play Music
Take a Drive Knit a Sweater
Read a Romantic Book Work in a Garden
Read a Sexy Book Visit a Museum
Go to the Zoo Buy a Gift
Buy a New Magazine Plan a Vacation
Kiss Somebody Paint a Picture
Wash the Car Buy Tickets
Kiss Somebody Again Work on a Hobby
Write a Letter Visit a Neighbor
Get Some Exercise Donate to Charity
Look at a Photo Album Imagine Being Thin

Prochaska J. The transtheoretical model of health behavior change. Am J
Health Promot 1997; 12(1): p. 43.

Table 6 Coping With Lapse

Step 1: Stop, Look, and Listen
Step 2: Stay Calm
Step 3: Renew Your Diet Vows
Step 4: Analyze the Lapse
Step 5: Take Charge Immediately
Step 6: Ask For Help

Brownell K. The LEARN Program for Weight Management, 10th ed. Dallas,
TX: American Health Publishing Company, 2004.

Table 7 Summary of Ways to Help Clients in a Weight-Maintenance Program

* Properly screen the client prior to beginning a weight-control
* Assist the client in enlisting and using social support.
* Help the client develop, initiate, and maintain an exercise program.
* Assist the client in behavioral monitoring.
* Help the client develop behavioral self-control practices.
* Assist the client in developing cognitive coping abilities.
* Help the client to adopt realistic expectations.
* Assist the client in developing an attitude of ownership and
* Facilitate the client's development of self-efficiency and self-
* Educate - - the client regarding the distinctions between lapse and
* Help the client develop and practice strategies for coping with high-
risk situations.
* Assist the client in developing a balanced lifestyle that includes
positive pleasurable situations.
\\\\\\\\n\\\\\\\\nThe commonly accepted definitions are from the International
Obesity Task Force of the World Health Organization which in 1998
successfully urged universal adoption. Body mass index (BMI) is used as
the measure, and is defined as kilograms of body weight divided by the
body surface area in meters squared. Overweight is defined as a BMI of
25 to 29.9; obesity is defined as a BMI of greater than 30, and morbid
obesity as a BMI of 40 or greater (1).

\\\\\\\\n\\\\\\\\n28. Cioffi J. Factors that enable and inhibit transition from a
weight management program: a qualitative study. Health Educ Res 2002;
17(1): 19-26.

\\\\\\\\n\\\\\\\\nTurner speaks more simply about cognitive restructuring to turn
negative thoughts into positive alternatives. For example, rather than
\\\\\\\\\\\\\\\"I've been working on this for so long that I shouldn't
be making mistakes,\\\\\\\\\\\\\\\" shift the thought to \\\\\\\\\\\\\\\"Even people who
have been working on behavior change for a long time make mistakes.
Making mistakes is part of the learning process\\\\\\\\\\\\\\\" (16). The
essential point is to not blame the patient yet help them take
responsibility for their own health (16). Baker (21) makes the point to
not be judgmental and notes that the obese deal with harsh vocabulary
which often equates obesity with sinfulness, and blames the client for
yielding to temptation and indulgence.

\\\\\\\\n\\\\\\\\n12. Look for depression or depressed mood as a major risk factor
for relapse.

\\\\\\\\n\\\\\\\\n25. Baum J, Clark H, Sandler J. Preventing relapse in obesity
through posttreatment maintenance systems: comparing the relative
efficacy of two levels of therapist support. J Behav Med 1991; 14(3):

\\\\\\\\n\\\\\\\\n5. Prochaska J. In search of how people change: applications to
addictive behaviors. Am Psychol 2002; 1102-1114.

\\\\\\\\n\\\\\\\\nAdditionally, contact with clients may be better quantified or
characterized by use of questionnaires. Both Pratt (27) and Cioffi (28)
have published studies of questionnaires to identify reasons for
attrition from a weight loss program. Similarly, Prochaska used a
questionnaire completed by mail or computer to track progress of smokers
in a cessation program. Prochaska notes that the questionnaire was used
to define where the client is in the stages model and therefore the
counselor can offer a better directed therapy (6).

\\\\\\\\n\\\\\\\\n(b) Definition or specifying the problem and goal behaviors -- What
is the particular problem facing you right nowh What is your goal in
this situationh

\\\\\\\\n\\\\\\\\n9. Cognitive-Behavioral approaches should be used as the model for
discussion of problems with the clients.

\\\\\\\\n\\\\\\\\n4. Albert M, Spanos C, Shikora S. Morbid obesity: the value of
surgical intervention. Clin Fam Pract 2002; 4(2).

\\\\\\\\n\\\\\\\\n19. Epstein L. Ten-year outcomes of behavioral family-based
treatment for childhood obesity. Health Psychol 1994; 13(5): 373-383.

\\\\\\\\n\\\\\\\\nRelapse Prevention Strategies

\\\\\\\\n\\\\\\\\n9. Anderson J, et al. Long-term weight maintenance after an
intensive weight-loss program. J Am Coll Nutr 1999; 18: 620-627.

\\\\\\\\n\\\\\\\\nWhat is clear is that obesity\\\\\\\\\\\\\\\/overweight is a chronic illness (11).
Timmerman (12) notes in dieters that perceived deprivation and
preoccupation with food are not closely related to actual calorie or fat
intake. Phelan also found that after major weight loss, \\\\\\\\\\\\\\\"that
recovery from even minor weight regain was rare\\\\\\\\\\\\\\\" (13).

\\\\\\\\n\\\\\\\\n18. Wing R, Jeffrey R. Benefits of recruiting participants with
friends and increasing social support for weight loss and maintenance. J
Consult Clin Psychol 1999; 67(1): 132-138.

\\\\\\\\n\\\\\\\\n6. Prochaska J. The transtheoretical model of health behavior
change. Am J Health Promot 1997; 12(1): 38-48.

\\\\\\\\n\\\\\\\\n11. Latner JD, et al. Effective long-term treatment of obesity: a
continuing care model. Int J Obes 2000; 24: 893-898.

\\\\\\\\n\\\\\\\\n14. Brownell K. The LEARN Program for Weight Management, 10th ed.
Dallas, TX: American Health Publishing Company, 2004.

\\\\\\\\n\\\\\\\\nKatrina Wells is a student-athlete (triathlon, tennis) interested
in science and a career in medicine. Thomas Wells, MD, is a general
surgeon and avid but slow athlete (triathlon, ultramarathon) with
special interests in exercise physiology and preventive medicine.

\\\\\\\\n\\\\\\\\n26. Jeffery R. Long-term maintenance of weight loss: current
status. Health Psychol 2000; 19(1): 5-16.

\\\\\\\\n\\\\\\\\n\\\\\\\\nMore recently, King (7) notes a distinction between \\\\\\\\\\\\\\\"theprocesses that underlie the initiation of a new behavior\\\\\\\\\\\\\\\" and the\\\\\\\\\\\\\\\"maintenance of an initiated change in behavior.\\\\\\\\\\\\\\\" Compare thehigh outcome expectations - green coffee bean max jakarta - of a change with the satisfaction of the newsituation, e.g. lower weight and a more active or perhaps a morerestrictive lifestyle. King ends by warning about setting initialexpectations too high.\\\\\\\\nExpectations

\\\\\\\\n\\\\\\\\n13. Phelan S. Recovery from relapse among successful weight
maintainers. Am J Clin Nutr 2003; 78: 1079-1084.

\\\\\\\\n\\\\\\\\nBehavior Therapy focuses on \\\\\\\\\\\\\\\"changing behavior related to
eating and physical activity and involves self-monitoring, stimulus
control, improving nutrition, and contracting to promote a reward
system\\\\\\\\\\\\\\\" (17). The most common techniques include self-monitoring
(especially with a diary) to teach body awareness. Wisotsky includes a
sample diary page in her article. Stimulus control means new routines to
limit access to high calorie meals. For example, eliminate such foods
from the home or work environment. A behavior contract system with a
reward system can be designed by the client with the therapist. The
client, when he identifies a high-risk situation, needs to apply an
adequate coping response to prevent the \\\\\\\\\\\\\\\"abstinence violation\\\\\\\\\\\\\\\"
which may lead to relapse (14).

\\\\\\\\n\\\\\\\\n The Epidemic of Obesity\\\\\\\\nOverweight and obesity are now recognized to be epidemic in the
Western world. Overweight and obesity, in combination with physical
inactivity, are risk factors for multiple chronic medical conditions which include diabetes mellitus, hypertension, cardiovascular disease,
pulmonary disease, and orthopedic injuries, all of which may be
debilitating or life-threatening. Approximately 300,000 deaths each year
in the US are attributed to obesity and an equal number to physical
inactivity (1). The psychosocial morbidity and mortality is likely to be
high but harder to quantify. Data from industrialized western countries,
and now even industrialized regions of China, demonstrate increasing
prevalence of obesity and overweight. In the US, approximately 64% of
the adults qualify as overweight\\\\\\\\\\\\\\\/obese, with some population subgroups
having a prevalence of over 70% (2). Twenty-eight percent of US children
are overweight with another 14% obese. Five percent of the population
qualifies as morbidly obese, roughly doubling from 1989 to the present

\\\\\\\\n\\\\\\\\n(e) Implementation and Evaluation (i.e., trying out a plan and
evaluating its effectiveness) -- What solution plan are you going to try
and how will you know if it worksh

\\\\\\\\n\\\\\\\\n17. Wisotsky W, Swencionis C. Cognitive-behavioral approaches in
the management of obesity. Adol Med: State Art Rev 2003; 14(1): 37-48.

\\\\\\\\n\\\\\\\\nExercise programs or increased physical activity have been found to
be an effective supplemental tool in weight loss and maintenance of
weight loss. Multiple papers have demonstrated this finding. One paper
reported that \\\\\\\\\\\\\\\"76% of individuals who used exercise during a weight
loss period maintained their weight loss, whereas only 36% of those who
did not use exercise during the weight loss period were able to maintain
their weight\\\\\\\\\\\\\\\" (9). McGuire found that of the individuals who
maintained a 10% weight loss for an average of five years, most used
exercise as part of their weight loss program (22). Besides the caloric expenditure of exercise, other behaviors associated with exercise may be
beneficial and account for the improvement. Exercise may be associated
with changes in eating patterns, continued contact with groups, and
compliance with weight loss regimens (9). Not to be overlooked is that
\\\\\\\\\\\\\\\"improved well-being and enhanced self-esteem produced by physical
activity generalize to other areas of life and lead to improved dietary
adherence\\\\\\\\\\\\\\\" (1). Several authors note improvement in self-esteem and
perhaps perceived self-efficacy from exercise programs. Sorensen in a
year-long study which had three arms, i.e. diet only, exercise only, and
diet plus exercise, found that \\\\\\\\\\\\\\\"exercise led to more positive self
perceptions of physical mastery and ability\\\\\\\\\\\\\\\" (1).


\\\\\\\\n\\\\\\\\n27. Pratt C. Development of a screening questionnaire to study
attrition in weight-control programs. Psychol Rep 1989; 64: 1007-1016.