Weight management is much more complex than maintaining proper caloric intake based on a metabolic calculation. If losing weight were that easy, first world countries wouldn’t have the obesity epidemic that they presently do. While nutrition science is of utter importance in one’s health, people eat for far more reasons than just basic nourishment. Sociological, psychological, and biological factors all play significant roles on eating patterns. These factors can contribute to one’s health or contribute to disordered eating. According to the USDA’s Dietary Guidelines for 2015-2020, 2/3 of United States adults are overweight or obese and 1/2 of United States adults have preventable chronic diseases including conditions “related to poor quality eating patterns”(1). The SLiM program, founded in the United Kingdom, has demonstrated effectiveness in helping people lose excess weight(2).
SLiM, Specialist Lifestyle Management, is a group nutrition intervention class that meets 6 sessions over 6 months. The SLiM program is part of a multidisciplinary approach for severe and complex obesity. The three main objectives of the program are to provide education on obesity, achieve >5% weight loss, and increase self-management of obesity. The first session teaches clients about goal setting, self-monitoring, healthy eating, and daily living activity ideas(2). The second session educates clients on energy balance, macronutrient calories, including a regular eating schedule opposed to grazing, menu planning, and healthy cooking methods. The third session introduces behavior modification (e.g. increasing fruits and vegetable intake), conscious eating, and thoughts and feelings surrounding eating behaviors. The fourth through sixth sessions include portion and serving size education, reading food labels, grocery shopping approaches, and working on self-esteem(2).
Contrary to traditional weight loss strategies, no calorie counting is involved in the SLiM program. So how does one reduce calorie consumption without counting calories? With changing how one thinks about food. The SLiM program emphasizes nutrition education and cognitive-behavioral therapy to increase healthy thinking patterns around food. Methods of the SLiM study include an evaluation of 828 severe or complex obese patients with a >35 body mass index as well as a comorbidity such as diabetes or >40 body mass index. Half of the patients enrolled in the program completed the program. Weight loss outcomes were measured at 3 and 6 months. The data was analyzed using the Intention to Treat principle which randomly allocated patients to treatment groups through a 48 month time period. The SLiM program’s preliminary results found nearly 80% of participants who completed the program lost weight and also improve glycemic control in diabetic patients. Deeming the program an effective method to support weight loss efforts as part of a medical team approach.
Cognitive-Behavioral therapy are two different therapies, cognitive therapy and behavioral therapy, combined(3). Cognitive therapy focuses on awareness of one’s self-talk and learning to replace destructive or defeating self-talk with constructive self-talk. The SLiM program applies cognitive therapy with cognitive restructuring such as encouraging the clients to change negative beliefs to more positive beliefs(2). For example, if a client slips on their diet, they may call themselves a failure and give up. Instead, they should replace this thought with deciding it’s not a huge deal and to try again. Problem-solving skills are also developed during cognitive therapy. In the SLiM program, problem-solving strategies are discussed including navigating future potential setbacks. Behavior therapy includes identifying a stimulus that triggers the behavior (in this case, eating). This is known as Classical Conditioning. The SLiM therapy includes considering factors of external and internal triggers such as boredom, hearing the sound of the fridge opening, or making their children a snack. The behavior modification in the program teaches distraction techniques to avoid excess eating. Rewards and consequences are also considered in behavior therapy and are known as Operant Conditioning. The SLiM program encourages clients to celebrate progress with non-food rewards to maintain motivation(3).
The SLiM program also contain other aspects of behavior modification models. The Health Belief Model addresses perceived barriers(3). A strategy of the SLiM program offers techniques to help control perceived hunger, a barrier to change. In the Transtheoretical Stages of Change Model, the path to behavior change is organized into stages from no change (precontemplation) all the way to maintaining their change (maintenance)(3). Some clients of SLiM’s preliminary study dropped out before completing the program which could be explained by the precontemplation stage of the Transtheoretical Model since they weren’t ready or willing to stick with the 6 month program. The maintenance stage is implemented in the program by giving the clients thinking tools around food. For example, discouraging the use of absolute terms such as “failure” to prevent relapse. According to the Social Cognitive Therapy Model, self-regulation is a primary intervention strategy which involves the development of goal setting and self-monitoring(3). Self-monitoring skills are practiced in the SLiM program when the clients are assigned homework to keep a daily diary of eating patterns and the moods and triggers leading up to eating.
The SLiM program is considered highly effective as a method of weight loss support therapy that doctors and dietitians can recommend and utilize for their patients. Encompassing the cognitive aspects of behavior change, the thinking that occurs around food and eating, into a nutrition intervention is simply vital to successful behavior change. SLiM would fit well in an outpatient hospital setting as part of specialist obesity management. Dietitians would do well to promote or implement the SLiM program myself due to the profound implications of cognitive-behavior therapy and the other aspects of behavior change models included in SLiM. People are thinking beings, and dysfunctional behavior patterns such as disordered eating often start long before the client meets the nutritionist. Assuming that a quick delivery of nutrition information is effective is shortsighted and likely fruitless for clients struggling to change long-standing eating patterns. The SLiM program intervenes more precisely where the disordered eating originates, in one’s thinking.
References
1. USDA. Dietary Guidelines. http://DietaryGuidelines.gov. Accessed January 15, 2017.
2. Brown A, Gouldstone A, Fox E, et al. Description and preliminary results from a structured specialist behavioural weight management group intervention: Specialist Lifestyle Management (SLiM) programme. BMJ Open 2015:5:e007217. Doi:10.1136/bmjopen-2014-007217.
3. Bauer KD, Liou D, Sokolik CA. Nutrition Counseling And Education Skill Development. 2nd ed. Belmont, CA: Cengage Learning.