Analyzing Technology-Supported Acceptance and Commitment Therapy for Obesity

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By Zoey Dangleman

 

Technology-Supported Acceptance and Commitment Therapy for Obesity

The obesity epidemic in the United States has become increasingly concerning in recent years. Approximately 34 percent of American adults are obese and with that comes an increased risk for numerous chronic conditions.1 Current efforts to address this issue include healthy lifestyle changes, behavioral weight loss programs, medication, medical devices, and surgery.2 However, there has been difficulty in producing and maintaining substantial weight loss with current methods.1 However, one emerging method that has yielded promising results is Acceptance and Commitment Therapy (ACT).

ACT is a mindfulness-based behavioral therapy that combines experiential exercises and values-guided behavioral interventions in order to “create a rich and meaningful life” while managing the unpleasant private experiences (urges, thoughts, memories, etc) that will inevitably accompany it.3 This challenges principles of Western psychology, which often attempts to “cure” individuals of such experiences through the pursuit of healthy normality, or the concept that humans are by nature psychologically healthy. ACT instead aims to shift how one perceives these experiences, teaching that they are harmless and transient events. This approach has been successful in achieving symptom reduction, unlike traditional or Western methods that attempt to suppress such symptoms, which actually results in more negative experiences.4 Other mindfulness-based interventions, like Mindfulness-Based Stress Reduction (MBSR) and Mindfulness-Based Cognitive Therapy (MBCT), are manualized treatment protocols that are designed for the treatment of specific symptoms like stress and depression. ACT is more dynamic and can be individualized to the needs and preferences of those being treated. Traditionally, ACT is administered in person and includes group sessions, as well as individual or personal instruction.3

As mentioned previously, ACT is effective in addressing obesity, along with other clinical conditions. There have been several systematic reviews that have explored the current findings concerning ACT’s effects on weight management, as well as the psychological well-being of obese individuals. Iturbe et al. solely analyzed randomized controlled trials and found that ACT was able to enhance overall psychological well-being through improvements in quality of life and reductions in psychological distress, weight-related stigma, body dissatisfaction, and self-criticism.5 ACT’s effect on actual weight loss is more limited, with several reviews finding a mixture of results regarding differences in weight between ACT and non-ACT groups.5,6 There were inconsistencies in whether the intervention resulted in significant weight loss, both in immediate and long-term follow-up. However, across all studies there was a reduction in weight-related psychological difficulties,5 which has been shown to be significantly correlated with weight changes.7 Overall, ACT has been found to be effective in treating psychological aspects of obesity and partially in addressing weight loss. However, more studies are necessary in order to meet Hill’s criteria of strength and consistency for establishing causal inference.

Recently, there have been attempts to explore technology-supported ACT (i.e. ACT delivered either entirely or partially through technology, such as the telephone, internet, or smartphone) to increase the accessibility of the intervention. This has come both as a result of the COVID-19 pandemic, which exacerbated the need for virtual healthcare delivery,8 and also because the traditional in-person delivery of ACT can be a treatment barrier for those unable to attend weekly clinic appointments. Technology-supported ACT has the potential to be an effective treatment option for the obese as those with chronic health conditions often have difficulty making necessary behavioral modifications,9 struggle with poor overall well-being,10 and are often limited in terms of mobility and time due to their conditions.11 This literature review hopes to explore the measures and methods by which technology-supported ACT can influence obesity and its related issues, discuss the strengths and weaknesses of existing studies, and consider potential avenues for future research.

 

Discussion

There have been several preliminary studies on technology-supported ACT, but the interventions, presented and examined in these studies, have all differed. A pilot study of a web-based intervention that combined intuitive eating and ACT was conducted in a single-arm intervention study measuring eating behavior, psychological flexibility, quality of life, BMI, as well as the usage and acceptability of the intervention.12 The intervention “Mind, Body, Food” was web-based and included intuitive eating principles13 and ACT-based skills. Questionnaires were used to collect data on all outcomes besides BMI, which was measured by a trained research assistant. While BMI is commonly used in most studies related to obesity research,14 it is not necessarily the most reliable measurement as it fails to distinguish between body fat and lean body mass, nor does BMI account for differences in body fat percentages between genders.15 The questionnaires used (EDE-S for disordered eating, IES-2 for intuitive eating, AAQ-II for ACT, SF-12v2 for quality of life), however, were all reported to have strong reliability and validity. The findings of this study illustrated that it was effective in stopping or preventing binge eating, decreasing psychological inflexibility, and increasing general mental health by the 3-month follow-up. There were no significant changes in BMI, although there was an inverse relationship between changes in intuitive eating and changes in BMI (r=.43, P=.03). This reflects the findings of another study which determined ACT encouraged intuitive eating by enhancing one’s ability to continue with valued activities even through negative private experiences related to weight.16 This study by Boucher et. al also found an inverse relationship between psychological inflexibility and intuitive eating scores.12 While this study was strengthened by the fact that it observed mechanisms by which ACT was able to influence obesity – such as through increasing intuitive eating – there were numerous limitations: lack of a comparison group, lack of a long-term follow-up, and a small non-diverse sample (40 females). Future research that explores this program should do so in a randomized-controlled trial RCT with a wider sample size and longer follow-up periods to address Hill’s criteria of consistency and biological gradient for causal inference. 

Another pilot study of a different intervention, ACT telephone coaching, compared the intervention to standard behavioral therapy (SBT) in a randomized control trial, examining weight (both scale-reported and self-reported), treatment satisfaction and quality, and mediators of weight loss.17 The ACT telephone coaching was adapted to have the same number (25) and timing of sessions as the group program, which had previously been found to be an effective intervention for weight loss.18 A preliminary diary study with interviews was conducted with a sample of 10 to examine the receptivity of this beta intervention, and its findings showed that the ACT exercises were believed to be helpful, specifically with accepting cravings and focusing on values-driven food choices and physical activity. After making minor adjustments based on diary feedback, the primary study of the intervention was conducted. Results from the primary study indicated that ACT was more effective than SBT, with 38 percent of the ACT group experiencing 10 percent or more scale-reported weight loss versus 32 percent at the 12-month outcome (similar differences were also seen at the 3 and 6-month outcomes). Both treatments scored similarly in satisfaction with assigned treatment (90 percent for ACT v. 36 percent for SBT) and perception that assigned treatment was useful for weight loss (96 percent v. 87 percent) although ACT scored slightly higher in both categories. As for mediators, there was a significant effect on valued living in ACT compared to SBT (57 percent v. 35 percent) and the percentage of those who lost 10 percent or more body weight was higher for those above the median in acceptance of food cravings than those below (22 percent v. 18 percent). This aligns with the theoretical model of ACT for weight loss that has been observed in other studies.18,19 The results of this study are strengthened by a relatively diverse sample (106 participants from 32 states, 42 percent male, 34 percent minority, 52 percent had some college education or less), and its inclusion of objective measurements such as scale-reported weight. Furthermore, it accounted for confounding variables by time-matching the interventions and double-blinding the study. The reliability of the study is also relatively high as its findings are consistent with prior randomized controlled trials RCTs of in-person ACT. Limitations of this study are consistent with those of most pilot trials, which is a lack of power, as well as a lack of long-term follow-up which would be useful in understanding the impact on weight loss relapse. Future research could include diet and physical activity measures as process data that predict weight loss outcomes. The author of this study, Bricker, is currently working on a study that addresses limitations in a fully powered RCT with a longer-term follow-up.

Despite differences in delivery, the mechanisms by which technology-supported ACT can potentially affect obesity are the same as traditional ACT. A study done by Reijonen et al.20 analyzed an RCT that compared ACT in-person, ACT via mobile, and a no-intervention control.21 The rationale behind this study was that the core principles of ACT would influence eating behavior through intuitive eating, cognitive restraint, eating competence, and motivation regulation. Eating behavior was measured using several scales (IES, TFEQ-R18, HTAS, ecSI 2.0, REBS) that have all been validated thoroughly, and food intake and diet were similarly measured using the Index of Diet Quality. Perceived stress was measured with the Perceived Stress Scale, another validated measure. The findings of this study illustrated that the ACT-based interventions were effective in bringing positive changes to eating behavior with reductions in emotional eating and reward-based eating behaviors. These results were more prominent in the face-to-face group than in the mobile group. However, there were no subsequent changes seen in the participants’ diet, which led to suggestions for the inclusion of nutrition education in ACT interventions aimed at addressing obesity. Perceived stress has previously been associated with poor eating behaviors,22 and both ACT interventions improved several features associated with such behavior regardless of baseline stress level. While the ACT in-person intervention consistently performed better than the mobile intervention, that could be because the in-person intervention demands more accountability due to the nature of its delivery. A major strength of this study is that it is solely focused on ACT without the inclusion of other interventions (such as intuitive eating education), allowing for the examination of mechanisms solely associated with ACT. The study also had a relatively long follow-up (9 months) which allows for a greater understanding of the lasting impacts of ACT. The generalizability of the study is limited due to the primary female sample size and the fact that it focused on obese individuals with psychological distress. This study also didn’t measure weight changes, although the outcomes measured are often found in studies on obesity and are associated with weight change. Further studies are necessary to examine the effects of ACT-based skills specifically focused on diet. 

 

Conclusion

Preliminary research has shown promising results for technology-supported ACT in addressing obesity and related behaviors. Many of the studies are in the pilot stages, and there have been none that have examined the same intervention. More fully powered RCTs are necessary in order to establish a consistent association and determine a causal relationship. However, it is important to note that there has been a relatively significant amount of research that has found in-person ACT to be favorable in addressing obesity, and so this paper is simply meant to explore whether such results can be translated to technology-supported ACT. Further studies must be conducted in order to determine which form of technology-supported ACT (telephone, web-based, mobile app, etc) is most effective. These studies should include larger, more diverse sample populations, as well as longer follow-up times and more sophisticated measures of weight. Future research should also focus on which mode is most accessible and cost-effective, as one of the primary drivers for technology-supported ACT is to address gaps in healthcare access.

 

References

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Zoey Dangleman