Elsevier

Nutrition

Volume 32, Issues 7–8, July–August 2016, Pages 904-909
Nutrition

Pilot study
A comparison of a behavioral weight loss program to a stress management program: A pilot randomized controlled trial

https://doi.org/10.1016/j.nut.2016.01.008Get rights and content

Highlights

  • The stress management program produces sustained changes in stress level.

  • Because stress-induced caloric intake may be a risk factor for weight regain, a combination of the behavioral weight loss and stress management approach is suggested.

  • The behavioral weight loss program produced greater weight loss than the stress management program.

Abstract

Objectives

This study compared a behavioral weight loss program (BWL) with a stress management-based program, Emotional Brain Training (EBT), on weight loss, blood pressure, depression, perceived stress, diet, and physical activity.

Methods

Subjects with a body mass index (BMI) of >28 and <45 kg/m2 were recruited in Lexington, Kentucky in January 2014 and randomized to BWL or EBT for a 20-week intervention. Of those recruited, 49 participants were randomized to EBT or BWL. Randomization and allocation to group were performed using SPSS software. Weight, blood pressure, depression, perceived stress, dietary intake, and physical activity were measured at baseline, 10 week, and 20 week. Linear models for change over time were fit to calculate 95% confidence intervals of intervention effects.

Results

BWL produced greater changes in BMI than EBT at both 10 (P = 0.02) and 20 wk (P = 0.03). At 10 wk, both EBT and BWL improved BMI, systolic blood pressure, depression and perceived stress (P < 0.05). BWL also improved diastolic blood pressure (P = 0.005). At 20 wk, EBT maintained improvements in BMI, systolic blood pressure, depression, and perceived stress while BWL maintained improvements only in BMI and depression (P < 0.05).

Conclusions

BWL produced greater weight loss than EBT; however, EBT produced sustained improvements in stress, depression, and systolic blood pressure. A combination of the two approaches should be explored.

Introduction

The phrase “obesity epidemic” has become common in the United States [1]. This focus on weight has led to a weight loss industry estimated to be a $60 billion per year business [2]. Current efforts at curbing the obesity epidemic are not working, as obesity rates continue to climb [3]. While initial weight loss is possible for many through the use of behavioral weight loss techniques [4], long-term maintenance of weight loss remains difficult for many [5], [6], [7], [8], [9], [10]. National data indicate that only 37% of individuals are able to maintain at least a 5% weight loss, and only 17% maintain a weight loss of 10% for a period of one year [11]. Data from the National Weight Control Registry indicate that those who are successful with weight maintenance consume a low-calorie diet and exercise regularly [12]. However, for many, weight maintenance does not occur, likely because these behaviors are not maintained.

A National Institutes of Health (NIH) working group to improve weight loss maintenance published a report in early 2015 [13]. The working group concluded that, “no approach has worked to change the overall pattern on weight loss and regain.” The current standard in obesity treatment, behavioral weight loss, involves a dietary and exercise prescription with encouragement to self-monitor behaviors. The NIH working group proposed that these behavioral programs fail at producing weight loss maintenance because participants have decreasing adherence to the prescribed treatment of decreased calories and increased exercise; however, they concede that attempts to remedy this problem with adherence to treatment have not been effective [13], [14]. The group then proposed that habitual eating behaviors that led to the state of obesity, possibly “involving dopamine signaling in the brain,” may be responsible for returning to old behaviors and difficulty in maintaining weight loss [13].

Chronic and acute stress have been linked to consumption of foods high in sugar and/or fat, often referred to as “emotional eating” [15], [16], [17]. Stress is one activator of the dopaminergic (DA) system and has an impact on food intake through the hypothalamic-pituitary-adrenal (HPA) axis. Specifically, recent evidence in humans suggests a direct link from the hypothalamus into the dorsal and ventral striatum, brain regions associated with reward and satiety [18], [19]. Highly palatable foods, such as those high in sugar and fat, increase extracellular dopamine, thus increasing the perception of reward [20], [21]. Furthermore, recent evidence suggests that appetite-regulating hormones, such as ghrelin and glucagon-like peptide-1 (GLP-1) activate reward neurocircuitry, enhancing motivation for rewarding stimuli [22]. Interestingly, studies have shown that individuals who chronically consume high-fat, high-sugar diets show similar adaptations in limbic dopamine function as individuals who chronically abuse drugs [23], [24]. While the link between stress regulation of the HPA and limbic reward centers is still not clearly understood, it suggests a possible mechanism by which stress can govern food intake, resulting in obesity. Furthermore, it provides grounds to suggest that stress management techniques may help to “reset” the neurochemical regulation of food intake, resulting in more maintainable weight-loss interventions [19], [20].

Despite the connection between stress and eating behaviors, there has been little research on the use of stress management to improve weight loss. Christaki et al. evaluated the efficacy of an 8-wk stress management program for weight loss in a small sample of adults and found that participants in the stress management group lost significantly more weight than the control group but did not experience greater improvements in perceived stress [25]. In another 12-wk weight loss program augmented with stress management techniques, the authors found it to produce a trend in greater weight loss and lower cortisol levels than the control group [26]. Research by Mellin et al. found improvements in weight, blood pressure, and depression when adolescents and adults were treated with a stress reduction program [27], [28]. The skills taught in the early version of this stress reduction program were further developed by modifying the stress-management tools to be consistent with the neurophysiology of self-regulation. The program is now known as the Emotional Brain Training (EBT) program. EBT encourages mindfulness and improvements in lifestyle behaviors but focuses on cognitive and emotional strategies for managing stress. The strategies used in the program have been developed based on brain physiology (Table 1). An earlier version of the EBT program has been shown in two small previous studies to produce changes in weight, blood pressure, perceived stress, and depression [29], [30].

The objective of the present study was to compare the EBT program to a behavioral weight loss program (BWL) on weight and secondary outcomes, over the course of 20 wk.

Section snippets

Methods and materials

This was a parallel, randomized controlled clinical trial. Participants were randomized to a behavioral weight loss program (BWL; n = 25, 51%) or a stress management program (EBT; n = 24, 49%). The University of Kentucky Medical Institutional Review Board approved the study protocol and all participants provided written informed consent.

Statistical analysis

This was an exploratory analysis of a new strategy, EBT; therefore, a sample size calculation was not possible. The analysis presented is for completers only (n = 45). All analyses were performed using SAS software (version 9.3, 2010, SAS Institute Inc., Cary, NC, USA). Descriptive statistics were used to characterize participants. Continuous variables were compared using two-sample t tests if the normality assumption held or Wilcoxon rank-sum test otherwise. The normality of the variables was

Sample

A total of 49 participants signed consent forms and attended the baseline assessment and at least one group session. The completion rate was 94% at 10 wk and 92% at 20 wk (Fig. 1). The participants were 82.2% female and 82.2% Caucasian. The average age was 45.0 ± 7.9 y and the average BMI was 36.5 ± 4.6 kg/m2, which is in the obese range. Blood pressure was slightly elevated at baseline for both groups. The average CES-D score was 10.4 ± 9.8 for the EBT group and 7.5 ± 6.4 for the BWL group.

Discussion

This pilot study sought to compare a stress management program and a BWL. Both groups lost a statistically significant amount of weight; however, BWL produced greater weight loss than EBT at 10 and 20 wk. A greater percentage of BWL participants also achieved a clinically significant (≥5%) weight loss than EBT participants [35]. However, the effect size for the difference between groups was small (d = 0.3).

Weight loss in the BWL group was comparable to that seen in similar length studies, while

Conclusions

In the short term, BWL is superior at producing weight loss to the EBT program. However, in this short study, the EBT program had a small but significant impact on weight and a significant sustained impact on blood pressure, perceived stress, and depression. Because of the difficulty in maintaining weight loss through traditional methods and the connection between stress and obesity, further exploration of the EBT program in a larger, more diverse sample over a longer period of time is needed.

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    Kelly Webber secured the grant funding, conducted the study, and drafted and refined the manuscript. Lindsey Mayes administered the behavioral intervention, collected data, and contributed to writing the background section. Erin Casey contributed to the introduction and background sections of the manuscript and completed the references for the manuscript. Yuriko Katsumata conducted the statistical analysis and prepared Tables 2 and 3. Laurel Mellin created Table 1. Trial Registration at www.clinicaltrials.gov #NCT02023515. Funding NHLBI grant #1 R56 HL116517- 01 A1 and support provided by National Center for Advancing Translational Sciences (UL1 TR000117). Dr. Laurel Mellin is the founder of Emotional Brain Training.

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