1. Behavior Strategies in Diet Control The Challenge and the Cure Dr Abeer Al Saweer Consultant Family Physician, Diabetologist Kingdom of Bahrain

2. Learning Objectives To appreciate the importance of lifestyle modification in the control of the diabetes epidemic. To overview the different modalities of behavior therapy. To understand the role of behavior therapy in diet control and thus in diabetes control.

3. Introduction Diabetes Mellitus is “one of the most psychologically and behaviorally demanding of the chronic medical illnesses”. Cox and Gonder-Frederick,1992

4. Research about diabetes has changed from imparting knowledge about the cause and treatment to diabetes self-management.” (Clement 1995)

5. What are Behavioral Strategies? Strategies, based on behavioral change theories which provide patients/clients with tools for overcoming barriers to compliance with dietary or exercise therapy.

6. Evidence Statement: (A) No one behavior therapy appeared superior to any other in its effect on weight loss; rather, multimodal strategies appeared to work best and those interventions with the greatest intensity appeared to be associated with the greatest weight loss. Do Behavior Strategies work?

7. Do Behavior Strategies work? Strongly Evident: (B) Programs that combine diet, exercise, and behavior modification have been shown to be most effective over the short term. The NIH Guidelines reported that behavior strategies in diet and physical activity produced wt losses of approximately 10% in 4-12 months. 0

8. Common Theories Relevant to Understanding Human Behavior Educational and Behavioral. Health Belief Model. Theory of Planned Behavior. The Wheel of Change. Conflict Theory. Cognitive Dissonance Theory. Operant Learning.

9. History of Behavioral Therapy First applied in the late 1960's and early 1970's. Initial programs were 10-weeks in length. Produced weight losses 4.5 kg.

10. History of Behavioral Therapy Parameters 1970s1980s1990s Length of treatment (wks) 101427 Wt Loss (kg) 4.07.69.7 Length of F/U (wks) 225364 Loss at F/U (kg) 4.04.85.6

11. Theoretical origin of Behavior approach Eating and exercise behaviors are related to body weight. Behavior can be changed by environmental cues before or after the behavior.

12. Components of Behavior strategies Assess Behavior. Change contributors. Change consequences/Reinforcers.

13. Common Components of Behavioral therapy in diet Control SSet realistic goals. SSelf-monitoring. CCognitive restructuring and Problem Solving. SStimulus control. SSocial support. RRelapse prevention.

14. Self-monitoring Involves the systematic observation and recording of target behaviors. Daily food and physical activity (PA) records for the first two weeks. After which to complete food records at least two days per week and one weekend, & continue to record the frequency and duration of exercise.

15. Stimulus control A process which involves identifying and modifying environmental cues that are associated with overeating and inactivity (Changing antecedents and consequences or reinforcers).

16. Stress management techniques. Environmental changes to control cue eating and PA habits.

17. Cognitive Restructuring Involves identifying and modifying maladaptive thoughts and advising more positive self-statements to assist in behavior change.

18. Social Support Studies show that persons with higher levels of social support tend to be more successful at achieving and maintaining weight loss.

19. What current strategies look like? Conducted in groups of 15 individuals. Two co-therapists. Weekly treatment meetings for 6 months and biweekly or monthly meetings for the remainder of the year to two years.

20. What current strategies look like? Continued contact is an important component of the maintenance program. Recently there have been efforts to deliver behavioral treatment programs via television or the Internet.

21. What do strategies contain? Standardized. Group sessions include a private weigh-in, review of self-monitoring records, and presentation of the week lesson. Assignments are given and reviewed next week.

22. Dietary prescriptions in behavioral programs Energy Intake. Macronutrient intake. Food provision and structured meal plans.

23. Support for Healthy Eating Ongoing support for long term behavior change. One approach is to continue treatment contact over longer period. Another approach is to involve the spouse. Another one is to involve friends. Incentives.

24. Tailoring Treatment to Individual subgroups Ethnicity. Binge eating Disorders. Media-based interventions for wt loss.

25. Preventing Weight Gain Wt gain prevention in young adults. Wt gain prevention at time of pregnancy. Wt gain prevention at menopause.

26. Performance Objectives Behavioral approaches are used to help patients make long-term changes in their eating. Behavioral approaches stress monitoring of dietary intake and modifying the cues and reinforcers in the environment. Better results have been achieved with longer periods of treatment contact and more structured approaches.