Cognitive-behavioral therapy in addition to nutrition education is an important tool in the treatment of obesity. The goal of such an approach is to help patients make long-term changes in their eating behavior by modifying and monitoring their food intake, modifying their physical activity, and controlling cues and stimuli in the environment that trigger eating.
The commonly used components of cognitive-behavioral therapy include:
- self-monitoring (keeping food diaries and activity records);
- control of the stimuli that activate eating;
- slowing down the eating process, goal setting;
- behavioral contracting and reinforcement;
- nutrition education and meal planning;
- modification of physical activity;
- social support;
- cognitive restructuring; and
- problem-solving.
Cognitive-behavioral therapy and nutrition education programs were shown to be successful whether administered individually or in a group setting. In addition to producing comparable weight-loss results, several studies showed that the adherence rate of the participants in the group-based treatment was higher than that in the individual-based treatment.
This suggests that there are some unique characteristics of group-based treatment that contribute to a lower attrition (drop-out) rate. Thus the group-based approach seems to be more effective overall.
However, all of these clinical studies were conducted in tertiary centers by highly trained behavior therapists and dietitians. Translation to everyday practice of these methods is very difficult due the complexity of the intervention, and perhaps more importantly, due to the high cost of these programs (several hundred to thousands of dollars per month). For the low income patients this last element makes such programs even more prohibitive.
Several commercial weight loss programs have attempted to incorporate varying degrees of behavioral modification strategies into their dietary plans. Nonetheless a systematic review of the major available commercial programs in the United States reports that these programs are not successful in changing long-term nutritional patterns and behavior, probably due to the way these programs are structured. In addition, the out of pocket cost of these programs is high, ranging from a $20 enrollment fee plus $9 per week thereafter for Weight Watchers to $200 to $350 to join, plus roughly $90 per week thereafter for Jenny Craig.
The results of these studies indicate that when used appropriately, cognitive-behavioral and nutrition therapy programs produce good results. The shortcoming of these programs to date is that they are expensive and require specialized tertiary centers, and highly trained clinical staff.
We propose an intermediary alternative that will be cost–effective, evidence-based and affordable. This new program will consist of an initial six month structured small group intervention, delivered in primary care settings, by specially trained medical assistants (weight management coaches).
Medical assistants are highly versatile healthcare allied personnel, who cost less than a dietitian or behavior therapist, and most importantly are already part of the primary care team. We believe that medical assistants can be trained on-the-job, in a focused, hands-on model that will enable them to become effective in delivering a well structured cognitive-behavioral and nutritional program designed by experts in nutrition and obesity management. This intervention will be directed and overseen by the primary care physician, who will refer patients to these programs and who will follow patients as needed in the context of their co-morbidities.