From an ACT perspective, many of the psychological factors related to weight control that were discussed previously can be grouped into three categories:

• Persistence in the face of difficult emotions and thoughts or distress tolerance
• Cognitive rigidity
• Motivational factors

Persistence: Individuals who have difficulty maintaining weight loss typically report or have been found to eat in response to stress and other negative affective states, such as hopelessness, helplessness, anger, anxiety, or boredom. From an ACT perspective, this can be seen as a problem with persistence or distress tolerance. The ACT theory of psychopathology suggests that attempts to change or eliminate unwanted private experiences (experiential avoidance) result in a narrow set of behavioral responses. In this case, the presence of uncomfortable or undesirable emotions consistently occasions eating for comfort. The problem is that the short-term effects of reducing negative affect have little or no impact on an individual’s long-term ability to face discomfort and lead a healthy, vital life. Each instance strengthens the relationship between uncomfortable emotion and avoidance. In a sense, the individual becomes less able to deal with uncomfortable emotions over time and eating is required more and more as a coping response.

Rigidity: Individuals who have difficulty maintaining weight loss typically report or have been found to adhere to rigid thinking patterns and rigid control of eating behaviors. Unsuccessful maintainers frequently adhere to dichotomous “all or nothing” thinking, viewing a minor misstep as a total failure or discounting any gains that fall short of some imagined ideal as meaningless. These individuals are prone to alternating between total restriction of desirable foods and a complete lack of weight controls all together. From and ACT perspective, this can be viewed as cognitive fusion. Cognitive fusion refers to situations in which behavior is excessively regulated by verbal rules and is insensitive to direct experiences. Individuals may be responding to verbal formulations, such as, “I had cake therefore I blew it, so what’s the point” or, “I only lost 15 pounds. I’ll never get to where I want to be.” These private events are experienced as literal truth, not as experiences that can be noticed while not being believed nor disbelieved. Individuals respond as though this is a true state of affairs and engage in behaviors that are inconsistent with a healthy, vital life.

Motivational factors: Individuals who have difficulty maintaining weight loss typically report attempting to lose weight in response to pressure from friends, family members, or health professionals as opposed to personal reasons, such as caring for oneself, wanting to be more healthy, or less activity restriction. From an ACT perspective, this can be seen as a form of rule-governance called pliance. Pliance occurs when individuals engage in behaviors in an attempt to please others or “be good” (Hayes, Strosahl et al., 1999). When this function dominates over direct, personal experiences of what works, problems can occur. These externally based contingencies are often not enough to maintain behavior outside the presence of the contextual variables (e.g. family member telling them they are doing a good job). Given the lifelong nature of maintaining weight, it is unlikely that excessive pliance could be a successful long-term behavioral approach. From an ACT perspective, individuals do not need to engage in behaviors consistent with weight maintenance in order to be praised by others; they can do them as an expression of chosen personal values (also called augmenting) and doing what works in regard to those values (also called tracking). In this respect, weight maintenance behaviors are less rigid and are more likely to be tied to the direct contingencies necessary for success.

Motivation, then, can be viewed primarily as a values issue. People are often not connected to their values. It is possible that there is frequently a disparity between what people want in their lives and what they are actually doing. This disparity can be painful to contact, thus relegating the issue of values to the background. Acceptance and defusion can help create a context where this disparity can be noticed without attachment to the painful private events that can accompany this connection. From an ACT perspective, then, values work involves goal setting/ attainment and the willingness to say/ know what is truly wanted. This involves the ability to recognize and be in contact with the disparity between what is desired and what is currently being done.

The ability to cope with stress has been associated with weight maintenance. Individuals who were described as having poor coping skills, or a poor ability to manage internal or external demands that are appraised as stressful, have been show to regain weight when confronted with stressful life events (S. Byrne, Cooper, & Fairburn, 2003; Gormally & Rardin, 1981; Gormally, Rardin, & Black, 1980; Grilo, Shiffman, & Wing, 1989). People who regain lost weight tend to eat in response to the presence of negative emotional states or use food to regulate their mood; a phenomenon often referred to as emotional eating (S. Byrne et al., 2003; Ganley, 1989). Obese people who have difficulty losing or keeping off weight have been shown to use food as a source of comfort and satisfaction (Castelnuovo-Tedesco & Schiebel, 1975), eat after difficult interpersonal situations (Hockley, 1979), and eat in response to hopelessness, helplessness, anger, anxiety, or boredom (Hudson & Williams, 1981; Rotmann & Becker, 1970). Motivational factors have also been associated with weight maintenance. Successful weight maintainers have been found to be motivated to lose weight for more personal reasons as opposed to pressures from family, friends, or medical professionals (Ogden, 2000). It appears that when a person is intrinsically motivated, and weight loss is tied to meaningful outcomes other than just losing weight, patients tend to be more successful in keeping weight off. Self-efficacy has been also been associated with weight maintenance. Self-efficacy can be described as a belief in one’s capability to produce desired outcomes in one’s life. Related, individuals who respond to overeating episodes passively tend to regain weight more than those who respond actively (Jeffery et al., 1984). The key difference seems to be that active responders somehow do not get stuck when confronted with adversity. Rigid versus flexible control of eating behavior has been associated with weight regain. Rigid control is characterized by dichotomous ‘all or nothing’ thinking and alternating periods of severe restriction and no weight control efforts. Flexible control is characterized by a ‘more or less’ approach, a long-term outlook, and the inclusion of desired foods at moderate amounts (Westenhoefer, 2001). Despite the literature findings, potentially important psychological variables are rarely targeted in clinical trials of comprehensive weight loss programs or program components. Many interventions lack a psychological component altogether (for a review, see Avenell et al., 2004).

Outcome Studies: Weight Maintenance

• Lillis, J., Hayes, S. C., Bunting, K., & Masuda, A. (2009). Teaching acceptance and mindfulness to improve the lives of the obese: A preliminary test of a theoretical model. Annals of Behavioral Medicine, 37, 58-69.

• Forman, E. M., Butryn, M. L., Hoffman, K. L., & Herbert, J. D. (2009). An open trial of an acceptance-based behavioral intervention for weight loss. Cognitive and Behavioral Practice, 16(2), 223-235.

• Tapper, K., Shaw, C., Ilsley, J., Hill, A. J., Bond, F. W., & Moore, L. (2009). Exploratory randomised controlled trial of a mindfulness-based weight loss intervention for women. Appetite, 52, 396–404.

• Niemeier, H. M., Leahey, T., Palm Reed, K., Brown, R. A., & Wing, R. R. (2012). An acceptance-based behavioral intervention for weight loss: A pilot study. Behavior Therapy, 43, 427-435.

• Katterman, S. N., Goldstein, S. P., Butryn, M. L., Forman, E. M., & Lowe, M. R. (2014). Efficacy of an acceptance-based behavioral intervention for weight gain prevention in young adult women. Journal of Contextual Behavioral Science, 3, 45-50.

• Nourian, L., & Aghaei, A. (2015). Effectiveness of Acceptance and Commitment Therapy on the body mass index in women afflicted with obesity. Iranian Journal of Psychiatric Nursing, 3, 11-20.

• Berman, M., Morton, S., & Hegel, M. (2016). Uncontrolled pilot study of an acceptance and commitment therapy and health at every size intervention for obese, depressed women: Accept yourself. Psychotherapy, 53(4), 462-467.

• Bradley, L. E., Forman, E. M., Kerrigan, S. G., Goldstein, S. P., Butryn, M. L., Thomas, J. G., ... & Sarwer, D. B. (2017). Project HELP: a remotely delivered behavioral intervention for weight regain after bariatric surgery. Obesity surgery, 27(3), 586-598.

Micro/Component Studies: Weight Maintenance

• Lillis, J. (2008). Acceptance and Commitment Therapy for the treatment of obesity-related stigma and sustained weight loss. Unpublished doctoral dissertation. University of Nevada, Reno.

• Lillis, J., Thomas, J., Niemeier, H., & Wing, R. (2017). Exploring process variables through which acceptance-based behavioral interventions may improve weight loss maintenance. Journal of Contextual Behavioral Science, 6(4), 398-403.

• Forman, E. M., Hoffman, K. L., McGrath, K. B., Herbert, J. D., Brandsma, L. L., & Lowe, M. R. (2007). A comparison of acceptance- and control-based strategies for coping with food cravings: An analog study. Behaviour Research and Therapy, 45, 2372-2386.

98 participants with chocolate cravings were exposed to a CBT-based protocol and an ACT-based protocol or no instructions and required to carry chocolate with them of for two days. Those more impacted by food related cues ate less and had fewer cravings in the ACT condition.

• Sairanen, E., Lappalainen, R., Lapveteläinen, A., & Karhunen, L. (2012). Perceptions, motives, and psychological flexibility associated with weight management. Journal of Obesity & Weight Loss Therapy, 2(135).

• Weineland, S., Arvidsson, D., Kakoulidis, T., & Dahl, J. (2012). Acceptance and commitment therapy for bariatric surgery patients, a pilot RCT. Obesity Research & Clinical Practice, 6(1), e21-e30.

• Forman, E. M., Hoffman, K. L., Juarascio, A. S., Butryn, M. L., & Herbert, J. D. (2013). Comparison of acceptance-based and standard cognitive-based coping strategies for craving sweets in overweight and obese women. Eating Behaviors, 14, 64-68.

• Sairanen, E., Lappalainen, R., Lapveteläinen, A., Tolvanen, A., & Karhunen, L. (2014). Flexibility in weight management. Eating behaviors, 15(2), 218-224.

• Sairanen, E., Tolvanen, A., Karhunen, L., Kolehmainen, M., Järvelä, E., Rantala, S., Peuhkuri, K., Korpela, R., & Lappalainen, R. (2015). Psychological Flexibility and Mindfulness Explain Intuitive Eating in Overweight Adults. Behavior Modification, 39(4), 557-579.

Measurement Development: Weight Maintenance

• Lillis, J., & Hayes, S. C. (2008). Measuring avoidance and inflexibility in weight related problems. International Journal of Behavior Consultation and Therapy, 4(4), 348-354.

• Lillis, J., Luoma, J. B., Levin, M. E., & Hayes, S. C. (2010). Measuring Weight Self‐stigma: The Weight Self‐stigma Questionnaire. Obesity, 18(5), 971-976.

• Sandoz, E. K., Wilson, K. G., Merwin, R, M. & Kellum, K. K. (2013). Assessment of body image flexibility: The Body Image-Acceptance and Action Questionnaire. Journal of Contextual Behavioral Science, 2, 39-48.

• Palmeira, L., Cunha, M., Pinto-Gouveia, J., Carvalho, S., & Lillis, J. (2016). New developments in the assessment of weight-related experiential avoidance (AAQW-Revised). Journal of Contextual Behavioral Science, 5(3), 193-200.

Psychological Flexibility and Weight Maintenance

• Ciarrochi, J., Sahdra, B., Marshall, S., Parker, P., & Horwath, C. (2014). Psychological flexibility is not a single dimension: The distinctive flexibility profiles of underweight, overweight, and obese people. Journal of Contextual Behavioral Science, 3, 236-247.

Physical Activity and Weight Maintenance

• Mutikainen, S., Föhr, T., Karhunen, L., Kolehmainen, M., Kainulainen, H., Lappalainen, R., & Kujala, U. (2015). Predictors of increase in physical activity during a 6-month follow-up period among overweight and physically inactive healthy young adults. Journal of Exercise Science and Fitness, 13 (2), 63-71. 

Body Image and Weight Maintenance

• Pearson, A. N., Follette, V. M. & Hayes, S. C. (2012). A pilot study of Acceptance and Commitment Therapy (ACT) as a workshop intervention for body dissatisfaction and disordered eating attitudes. Cognitive and Behavioral Practice, 19(1), 181-197.

• Rafiee, M., Sedrpoushan, N., & Abedi. M. R. (2014). The effect of Acceptance and Commitment Therapy on reducing anxiety symptoms and body image dissatisfaction in obese women. Journal of Social Issues & Humanities, 2 (1), 187-190.

• Timko, C. A., Juarascio, A. S., Martin, L. M., Faherty, A., & Kalodner, C. (2014). Body image avoidance: An under-explored yet important factor in the relationship between body image dissatisfaction and disordered eating. Journal of Contextual Behavioral Science, 3(3), 203-211.

• Webb, J. B. (2015). Body image flexibility contributes to explaining the link between body dissatisfaction and body appreciation in White college-bound females. Journal of Contextual Behavioral Science, 4, 176-183.

Obesity has been referred to as a dangerous epidemic and one of the most important public health challenges of the 21st century. The sharp increase in obesity has contributed to increases in related conditions, causing a sizeable economic cost burden for health providers and funding agencies. The 2002 estimated U.S. cost burden for obesity was $92.6 billion (Finkelstein, Fiebelkorn, & Wang, 2003).

It has been shown that marketplace food portions have increased in size since the 1970’s(Young & Nestle, 2002). People have been eating out more (K. Ball, Brown, & Crawford, 2002), food industry marketing has increased, and larger numbers of new products are being introduced (Gallo, 1990). Most Americans are sedentary. Technological advances have led to an increase in use of computers, cars, elevators, and televisions, with subsequent decreases in athletic activities including walking and bicycling.

Obese people also face discrimination resulting in external consequences. A recent review of the literature found evidence of obesity discrimination at every stage of the employment cycle (Roehling, 1999). Negative attitudes regarding obesity are widespread, socially acceptable, and develop as early as three years of age (Falkner et al., 1999; Puhl & Brownell, 2003a).

Well controlled, comprehensive weight loss programs often achieve substantial weight loss results with low rates of attrition. However weight maintenance has been a significant problem in the literature. Typically, half the weight lost is regained in the first year following treatment, and by 3-5 years posttreatment, 80% of patients have returned to or exceeded their pretreatment weight (Perri, 1998; Wadden et al., 1989; Wing, 1998).