Behavioral treatment of obesity: thirty years and counting

Beginning with the purely theoretical extrapolation of Skinnerian principles to changing eating behavior in 1962, behavioral treatment has since become the principal means of managing mild to moderate obesity. Over the years treatments have become longer and more intensive, often being combined with aggressive Very Low Calorie Diets. Weight loss has been correspondingly greater. Yet a fundamental problem noted from the outset has remained: the inexorable pattern of relapse irrespective of diverse attempts to improve long-term maintenance. Although most patients maintain weight loss for at least a year, five year follow-ups have shown that virtually everyone returns to their baseline weight. The health effects of this pattern of loss and regain are unknown, but should not necessarily be judged to be harmful. Reactions to the long-term ineffectiveness of weight control treatment have varied. Whereas some critics have called for an end to treatment, proponents have suggested that innovative maintenance strategies can be devised, and that subtypes of obesity more amenable to behavioral treatment can be identified. It is argued here that an understanding of the mechanisms that cause or at least maintain obesity should determine treatment. This premise makes it unlikely that behavioral treatments can be improved, but rather points to the direct modification of the biological processes that regulate body weight. Cognitive-behavioral treatment is effective in reducing binge eating and other maladaptive behavior associated with obesity. It can potentially improve nutrition and increase physical activity, resulting in significant health benefits if not weight loss.