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. Author manuscript; available in PMC: 2012 Dec 31.
Published in final edited form as: J Behav Med. 2009 Dec;32(6):503–509. doi: 10.1007/s10865-009-9221-8

Successful weight loss with self-help: A stepped-care approach

Robert A Carels 1,✉, Carissa B Wott 2, Kathleen M Young 3, Amanda Gumble 4, Lynn A Darby 5, Marissa Wagner Oehlhof 6, Jessica Harper 7, Afton Koball 8
PMCID: PMC3533369  NIHMSID: NIHMS286688  PMID: 19521759

Abstract

In a stepped-care approach to treatment, patients are transitioned to more intensive treatments when less intensive treatments fail to meet treatment goals. Self-help programs are recommended as an initial, low intensity treatment phase in stepped-care models. This investigation examined the effectiveness of a self-help, stepped-care weight loss program. Fifty-eight overweight/obese adults (BMI ≥ 27 kg/m2) participated in a weight loss program. Participants were predominately Caucasian (93.1%) and female (89.7%) with a mean BMI of 36.6 (SD = 7.1). Of those completing the program, 57% of participants (N = 21) who remained in self-help maintained an 8% weight loss at follow-up. Participants who were stepped-up self-monitored fewer days and reported higher daily caloric intake than self-help participants. Once stepped-up, weight loss outcomes were equivalent between individuals who remained in self-help compared to those who were stepped-up. Individuals who were stepped-up benefited from early intensive intervention when unsuccessful at losing weight with self-help.

Keywords: Weight loss treatment, Obesity, Stepped-care, Self-help

Introduction

Given the scope of the obesity epidemic, the chronic nature of the condition, and the cost of professional care, cost-effective, time-efficient, minimally intrusive treatments will likely be required to effectively manage the obesity epidemic. In a stepped-care (SC) approach, patients are transitioned to more intensive treatments when less intensive treatments are insufficient, thereby reducing the likelihood that some patients will receive unnecessary treatment (Haaga 2000). Stepped-care approaches have been developed for treatment of a variety of conditions, including weight management (Abrams 1993; Carels et al. 2005, 2007; NHLBI 1997; Expert Panel on Detection 2001; Sobell and Sobell 2000; Wadden et al. 2002).

Similarly, given the scope of the obesity epidemic, self-help programs, with or without guidance, may be the only financially viable approach to the wide-spread treatment of obesity (Latner 2001). Self-help refers to any treatment or approach that views the person receiving help as the main agent of change in achieving their behavioral change goals (Latner and Wilson 2007). Self-help programs do not preclude the use of manuals, commercial products, technology, supportive peers, or professional assistance (Latner and Wilson 2007). Self-help weight loss programs have shown promise (Butryn et al. 2007; Latner 2001) and are often a recommended low intensity treatment for initial weight loss efforts in stepped-care models (Wadden et al. 2002). In fact, approximately one-third of the successful dieters in the National Weight Control Registry appear to be self-guided dieters who lost weight on their own (Butryn et al. 2007; Latner 2001). Nevertheless, some individuals require a more intensive treatment that provides greater support and/or accountability than what is provided in a self-help approach.

While stepped-care approaches are generally successful in aiding weight loss (Black 1987; Black and Threfall 1986; Carels et al. 2005, 2007; Wadden et al. 2002), they have, at times, produced mixed (Polley et al. 2002) or null results (Carels et al. 2008c). Simply providing participants with a higher intensity treatment is not always sufficient to encourage successful weight loss. For example, in a recent self-help program, individuals who evidenced weight loss difficulties during 12 weeks of self-help failed to lose weight after being stepped-up to more intensive treatment (Carels et al. 2008c). Thus, developing and utilizing effective stepped-up treatments is also critical.

Research suggests that the “obesogenic” nature of the nation’s current eating and physical activity environment is fueling the obesity epidemic (e.g., Brownell and Horgen 2004; Lowe 2003; Nestle 2004). Interventions are needed to teach individuals how to modify their own personal food and physical activity environments to promote healthy eating and an active lifestyle. Micro-/individual-level changes may be necessary to counteract the deleterious impact of the obesogenic environment. One promising treatment approach is to help obese individuals modify their personal eating and physical activity environments in order to reduce exposure to “obesogenic” cues and increase exposure to “healthy” cues (Carels et al. 2008a).

While modifying an individual’s personal eating and physical activity environment is likely to improve weight loss treatment outcomes, environmental modification alone may be insufficient to produce successful weight loss. Self-monitoring of energy intake and expenditure, long considered a cornerstone of behavioral weight loss programs, is likely to greatly contribute to successful weight loss outcomes. In fact, consistent self-monitoring is associated with superior weight loss treatment outcomes (Baker and Kirschenbaum 1998; Carels et al. 2008b) and weight loss maintenance (Wing and Hill 2001).

Informed by the self-help study noted earlier (Carels et al. 2008c), this investigation chose to: (1) step-up participants to intensive treatment more rapidly (i.e., 6 vs. 12 weeks to diminish extended demoralization), and (2) emphasize personal environmental modification to combat the “obesogenic” culture. In this investigation, all participants began an 18 week self-help weight loss program. Participants unable to lose 2.5% of their body weight during the first 6 weeks of the program using self-help were stepped-up to a weight loss program that emphasized reducing “obesogenic” cues and increasing “healthy” cues. This investigation examined whether (1) individuals could successfully lose weight with self-help, (2) individuals unsuccessful at losing 2.5% of their body weight during an initial self-help phase could successfully lose weight when stepped-up to more intensive treatment, (3) weight change differences would emerge between self-help and stepped-care participants during and following treatment, and (4) self-monitoring frequency and level of energy intake and expenditure would differentiate individuals who were successful at losing weight.

Methods

Participants

Fifty-eight individuals chose to participate in a locally advertised weight loss intervention. Participants were recruited through advertisements in local newspapers and campus email at a Midwestern university. Participants were included if they were: (a) overweight/obese (BMI ≥ 27 kg/ m2); (b) nonsmokers, and excluded if they had: (a) cardiovascular disease; (b) severe musculoskeletal problems; (c) Type I diabetes; or (d) uncontrolled hypertension. The investigation was completed between August 2007 and October 2008. Participants received no incentives for participating. This investigation received full human subjects review board approval, and all participants received their physician’s medical clearance. All assessments including baseline and follow-up were conducted by a licensed clinical health psychologist and 1–2 clinical psychology doctoral students. Weight assessments were conducted at baseline, week 6, post-treatment (week 18), and 6 months post-treatment (follow-up).

Participants’ mean age was 47.6 (SD = 10.3). Annual income exceeded $45,000 for 50.4% of the participants, and 46.5% had at least a baccalaureate degree. Most participants were Caucasian (93.1%) and female (89.7%). Mean baseline BMI was 36.6 (SD = 7.1) and weight was 214.7 lbs. (SD = 41.3; stepped-care: M = 214.6, SD = 42.6; self-help: M = 214.8, SD = 41.4).

Study design

Phase I

Participants received a 2.5% weight loss goal for the first 6 weeks. All participants began an 18 week self-help weight loss program. Participants attended an orientation session 1 week prior to the beginning of the program. At the orientation session, participants provided informed consent, received an accelerometer to track energy expenditure, a LEARN weight loss program manual (Brownell 2004), and instructions on how to self-monitor and electronically report diet and physical activity. Participants were instructed to read one chapter of the weight loss manual each week, self-monitor and record diet and physical activity, and create a 500 calorie/day deficit through diet and physical activity.

Body weight was measured using a digital scale. Height was measured in inches to the closest 0.5 inch using a height rod on a standard spring scale. With the exception of a monthly email reminder to submit self-monitoring forms and the weight assessment at week 6 to determine stepped-care eligibility, the self-help program was done completely independently.

Phase II

If participants were unable to achieve a 2.5% weight loss during Phase I, they were stepped-up to a weekly group for 12 weeks. Participants who lost greater than 2.5% total body weight continued with self-help for 12 additional weeks. Self-help participants completed the 12 week LEARN weight loss program manual (Brownell 2004), as well as a 6 week maintenance intervention manual emphasizing taking control of their personal food and physical activity environments (Carels et al. 2008a).

Weight loss program manual

The self-help weight loss manual used in this investigation was the LEARN weight loss program manual (Brownell 2004). The LEARN self-help weight loss approach is a comprehensive, empirically-supported approach to weight management (Andersen et al. 1999;Wadden et al. 1994). The widely used LEARN program emphasizes gradual weight loss, progressively increasing physical activity, and decreasing energy and fat intake through permanent lifestyle changes.

Stepped-care intervention

Participants who lost less than 2.5% of their total body weight during Phase I discontinued the self-help and were stepped-up to a weekly group intervention. The intervention emphasized having individuals “take control of” (i.e., modify in a healthy manner) their personal food and physical activity environments (Lowe 2003; Carels et al. 2008a). Following an introductory session and two sessions devoted to nutrition basics, the program encouraged participants to take responsibility for their eating and physical activity behaviors and to modify their personal eating and physical activity environments in order to reduce exposure to “obesogenic” cues (e.g., cues that encourage unhealthy eating and sedentary behaviors) and increase exposure to “healthy” cues (e.g., cues that encourage healthy eating and physical activity; Lowe 2003; Carels et al. 2008a). For example, environmental factors empirically recognized to influence eating were targeted for modification, such as portion sizes and food cues (Bell et al. 2003; Della Valle et al. 2005; French et al. 2001; Geier et al. 2006; Kral and Rolls 2004; Rolls et al. 2004a, b; Sobal and Wansink 2007; Stroebele and De Castro 2004; Wansink and Sobal 2007; Wansink 2004; Wansink et al. 2005, 2006; Wansink and Van Itternum 2003). In addition, participants were encouraged to take responsibility for aspects of their eating, such as planning meals and shopping, including findings ways to control their eating experiences when maintaining moderate food consumption was likely difficult (e.g., parties, vacation).

Four sessions were devoted to enhancing motivation for weight loss through the application of principles from self-regulatory theory (Higgins 2000). Trait-like self-regulatory orientation (prevention; promotion) was assessed using the 18-item Regulatory Focus Questionnaire (Lockwood et al. 2002). Participants engaged in activities where their trait regulatory fit (promotion vs. prevention) was matched to positive or negative role models, respectively. For example, depending on the participant’s self-regulatory orientation, participants were asked to imagine how they might gain the benefits of a healthy lifestyle or avoid the consequences of an unhealthy lifestyle.

The weight loss groups (i.e., stepped-care) were a combination of didactic instruction, individual activities, and out-of-class assignments. The 12 week program was administered in weekly, 90 min sessions. All classes were conducted by a licensed clinical health psychologist and 1–2 clinical psychology doctoral students.

Self-monitoring

Participants were instructed how to self-monitor dietary intake and were provided with demonstrations of common food measurement procedures, as well as instructions for estimating food portion sizes. Written instructions for measurement estimation were provided to participants as a reference. Participants used the food and beverage calorie guide provided with the weight loss program manual (Brownell 2004) or Internet dietary analysis programs, such as Calorie King (http://www.calorieking.com) or Nutrition Data (http://www.nutritiondata.com), to estimate energy intake from meals, snacks, and beverages. Participants were further instructed on how to electronically submit (or submit by paper and pencil) daily records of energy intake. Daily self-reported physical activity (type and duration of physical activity not including activity associated with daily living, such as occupational exertion or taking the stairs) and energy expenditure (accelerometer readings for total energy expended (kcal) during consecutive 24 h periods) were also submitted. No objective assessments of physical exertion (i.e., sweating, heart rate) were performed, and participants were instructed to record all purposeful physical activity, regardless of intensity.

Energy expenditure

Caltrac accelerometers were provided to participants to assess total daily energy expenditure. The Caltrac accelerometer measures vertical acceleration and converts the measurement into an energy expenditure value. Although Caltrac accelerometers have been shown to mildly overestimate the absolute energy cost (i.e., measured VO2) of selected activities, they provide a reliable assessment of total energy expenditure (Balogun et al. 1989; Fehling et al. 1999).

Results

Weight loss

During Phase I of the program, 24 participants (41.4%) lost at least 2.5% of their baseline weight (M = 4.5%, SD = 0.1), 21 (36.2%) lost less than 2.5% of their weight (M = 0.7%, SD = 0.1), and 13 (22.4%) dropped out of treatment. Baseline factors (age, race, gender, income, education), including weight, were unrelated to stepped-care status. Twenty-one (87.5%) participants who remained in self-help and 16 (76.2%) participants who were stepped-up completed the intervention. Thirty-six (97.2%) participants attended the 6 month post-treatment follow-up. See Fig. 1 for the participant flow diagram.

Fig. 1.

Fig. 1

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Participant treatment flow diagram

Differences in weight change between self-help and stepped-care groups during treatment and follow-up

A 2 (stepped-care; self-help) × 4 (baseline, Phase I, Phase II, follow-up) repeated-measures ANOVA indicated a significant overall treatment effect for body weight (lb), F (3,32) = 28.7, p < 0.001, Cohen’s d = 1.78. The time by treatment interaction was also significant, F (3,32) = 9.8, p < 0.001, Cohen’s d = 1.04 (See Fig. 2). Post hoc contrasts indicated significant differences in weight loss (lbs.; %) between participants who remained in self-help and those stepped-up to a weight loss group during Phase I, F (1,43) = 104.6, p < 0.01, Cohen’s d = 3.04, (self-help: M = −9.8; SD = 2.8; 4.6%; stepped-care: M = −1.1; SD = 2.8; 0.6%). Group differences did not emerge during Phase II, F (1,35) = 3.66, p = 0.06, Cohen’s d = 0.64, (self-help: M = −9.4; SD = 8.5; 4.4%; stepped-care: M = −5.2; SD = 4.6; 2.3%). Also, group differences did not emerge during the follow-up period, F (1,34) = 0.6, p = 0.56, Cohen’s d = 0.26, (self-help: M = +1.9; SD = 8.1; +0.8%; stepped-care: M = +3.5; SD = 3.2; +1.6%). However, significant differences in weight loss (lbs.; %) between participants who remained in self-help and those stepped-up to a weight loss group were observed from baseline through follow-up, F (1,35) = 12.4, p < 0.01, Cohen’s d = 1.17, (self-help: M = −17.4; SD = 15.2; 8.1%; stepped-care: M = −2.8; SD = 6.4; 1.2%).

Fig. 2.

Fig. 2

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Percent weight change during Phase I, Phase II, and follow-up in self-help and stepped-care participants

Weight change during treatment and follow-up

Post hoc paired sample contrasts indicated significant weight loss (lbs.; %) during Phase I, t(44) = 7.8, p < 0.001, Cohen’s d = 0.69, (M = −6.2 SD = 5.2, 2.9%), and Phase II, t(36) = 6.2, p < 0.001, Cohen’s d = 0.70, (M = −7.7; SD = 7.3, 3.4%), and significant weight gain during follow-up, t(35) = 2.3, p < 0.03, Cohen’s d = 0.77, (M = +2.6; SD = 6.5, 1.2%), regardless of group.

Self-monitoring and energy intake and expenditure

Chi-square and ANOVA were used to examine the impact of self-monitoring and energy intake and expenditure on stepped-care phase eligibility during Phases I and II (see Table 1). During Phase I, individuals stepped-up to more intensive treatment were less likely to self-monitor energy intake and expenditure, χ2(1, N = 45) = 12.85, p = 0.001, Cohen’s d = 1.14, (Self-help = 100.0% of participants; Stepped-care = 57.1% of participants), self-monitored fewer days, F (1,35) = 10.26, p = 0.003, Cohen’s d = 1.06, and reported higher daily caloric intake, F (1,35) = 7.86, p = 0.008, Cohen’s d = 0.93, compared to individuals who remained in the self-help group.

Table 1.

Comparison of self-monitoring and energy intake and expenditure between self-help and stepped-care participants

Phase I
 Phase II
 Total
Self-help Stepped-care Self-help Stepped-care Self-help Stepped-care
Factors M (SD) M (SD) M (SD) M (SD) M (SD) M (SD)
Self-monitoring frequency (days/week) 6.5 (1.6)* 4.1 (3.1) 6.2 (2.6) 2.2 (2.7) 6.3 (2.5)* 2.8 (2.8)
Caloric intake (daily) 1,547 (426)* 1,947 (310) 1,605 (375) 1,803 (464) 1,568 (429)* 1,883 (339)
Caloric expenditure (kcal/daily) 2,439 (1,166) 2,369 (550) 2,323 (373) 2,321 (488) 2,271 2,369 (488)
Activity expenditure (kcal/daily) 614 (355) 567 (235) 622 (489) 557 (255) 619.8 (380) 559 (255)
Exercise minutes 26.9 (20.9) 19.7 (22.1) 33.0 (26.2) 33.9 (31.3) 27.2 (22.5) 21.4 (24.8)
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Note Phase I: First 6 weeks; Phase II: Second 12 weeks; Total: Baseline to end of treatment

*

p < 0.05 (Self-help group vs. Stepped-care group)

During Phase II, compared to individuals who remained in self-help, individuals stepped-up to more intensive treatment were less likely to self-monitor energy intake and expenditure, χ2(1, N = 45) = 7.87, p = 0.006, Cohen’s d = 2.34, (Self-help = 79.2% of participants; Stepped-care = 38.1% of participants), and self-monitored fewer days, F (1,35) = 13.27, p = 0.003, Cohen’s d = 1.21. There were no differences between self-help and stepped-care participants in energy intake and expenditure.

Throughout the entire intervention, compared to individuals who remained in the self-help group, individuals stepped-up to more intensive treatment self-monitored fewer days, F (1,35) = 12.27, p = 0.003, Cohen’s d = 1.17, and reported higher daily caloric intake, F(1,35) = 4.98, p = 0.03, Cohen’s d = 0.74.

Discussion

Consistent with previous research (Latner 2001; Carels et al. 2008c), many individuals were quite successful at losing weight with self-help (of those completing the program, 57% of participants [N = 21] who remained in self-help maintained an 8% weight loss at follow-up). However, 43% of the participants were unsuccessful at losing weight with self-help and were stepped-up to more intensive treatment. Weight loss outcomes were equivalent for self-help and stepped-care participants during Phase II and follow-up.

Consistent self-monitoring appeared to contribute to the success of participants who remained in self-help. Compared to participants who remained in the self-help group, participants eligible for stepped-care were less likely to self monitor energy intake and expenditure and self-monitored less frequently during both Phase I and II of treatment. Additionally, during the self-help phase, participants eligible for stepped-care reported a significantly higher daily caloric intake (400 kcal) than participants who remained in the self-help group.

It is conceivable that while they were far less inclined to self-monitor their weight, the stepped-care participants utilized some of the information presented in the weekly stepped-care intervention to modify their eating and physical activity environments. The reduction in caloric intake (−144 kcal; p = 0.03) by the end of Phase II for the stepped-care group suggests some support for this claim. However, additional findings from the study to support this claim are not available. Nevertheless, it appears that stepping-up individuals to a more intensive treatment had a positive impact on energy intake through a means other than self-monitoring. Of course, the greater social support or perceived accountability of a weekly face-to-face group that included weigh-ins, may have contributed to the positive weight loss outcomes.

These findings provide tentative support for a stepped-care approach to weight loss, in which self-help intervention participants are rapidly stepped-up to a weight loss group if initial weight loss is not observed. While self-help participants lost significantly more weight during Phase I, weight loss outcomes were equivalent for self-help and stepped-care participants during Phase II and follow-up. However, participants stepped-up to the weight loss group may have further benefited from a longer weight loss group to enhance therapeutic gains. Similarly, in the present investigation, Phase I, which occurred over the December holiday season, evidenced high attrition (N = 13). Thus, optimal program initiation time and retention of potential drop-outs are critical issues to consider when implementing behavioral change programs.

Although the findings in this investigation suggest that a stepped-care approach to weight loss had a favorable effect on treatment outcomes, these conclusions should be viewed tentatively. The modest sample size, the small number of individuals who participated in stepped-care, and the predominately Caucasian and female sample suggest that replication with a larger, more diverse sample is warranted. Because we are not aware of any validated measures designed to assess modification of the individual’s personal eating and physical activity environment, our assessment of the aspects of the stepped-care program that contributed to its success is difficult to ascertain. It is unclear whether the observed benefits in those who received stepped-care were due to additional therapeutic contact or other factors, such as environmental modification and motivation. In addition, this investigation did not assess psychological factors, such as depression, known to be associated with poor weight loss outcomes (McGuire et al. 1999). The association between psychological factors and the likelihood of being stepped-up to more intensive treatment, as well as treatment outcomes, are not known. Finally, this investigation did not examine correlates of successful self-monitoring. Identifying individual differences that predict successful self-monitoring might allow for the modification of weight loss programs in a manner that draw on participants’ strengths to help them achieve weight loss goals.

Individuals benefited from early intensive intervention when they were unsuccessful at utilizing a self-help approach. Their weight loss during the more intensive treatment phase mirrored those who were successful with self-help although the self-help and stepped-care weight loss groups differed greatly in delivery and content. The self-help program simply provided participants with tools to enable their success, such as the LEARN weight loss manual, an accelerometer, and instructions on how to self-monitor. In addition to general information on exercise and nutrition, the LEARN program teaches individuals when, how, and why their eating and physical activity habits occur and, more importantly, how to incorporate healthier habits into their daily lifestyle. While consistent self-monitoring appeared to contribute to the success of participants who remained in self-help, stepped-care participants evidenced low levels of self-monitoring. However, the weekly face-to-face stepped-care group likely provided greater social support and accountability, including weekly weigh-ins. Similarly, while the self-help participants no doubt learned about the impact of the environment on their eating and physical activity patterns, the stepped-care intervention had a much greater emphasis on the actual modification of the participants’ eating and physical activity environments, as well as a much greater focus on enhancing and maintaining motivation. The stepped-care intervention was designed to empower participants to “Take Control” of their personal eating and physical activity environments. Thus, this investigation suggests that alternative approaches to weight loss, such as environmental modification, might produce improved outcomes among individuals who are initially unsuccessful at weight loss. A continued focus on developing effective treatments with varying emphases and therapeutic intensities will be essential for improving weight loss outcomes and combating the obesity epidemic.

Despite the importance of consistent self-monitoring, individuals who are struggling to lose weight with self-help might benefit from an alternative means to achieve weight loss success, such as environmental modification. It may be beneficial for future stepped-care interventions to target behaviors such as environmental modification, rather than self-monitoring, which many participants struggle to do consistently over the course of treatment.

Contributor Information

Robert A. Carels, Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, USA, rcarels@bgsu.edu; rcarels@bgnet.bgsu.edu

Carissa B. Wott, Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, USA

Kathleen M. Young, Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, USA

Amanda Gumble, Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, USA.

Lynn A. Darby, Kinesiology, Bowling Green State University, Bowling Green, OH 43403, USA

Marissa Wagner Oehlhof, Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, USA.

Jessica Harper, Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, USA.

Afton Koball, Department of Psychology, Bowling Green State University, Bowling Green, OH 43403, USA.

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