Behavioral Treatment of Obesity.pdf

7/28/2019 Behavioral Treatment of Obesity.pdf

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Behavioral Treatment of Obesity inChildren and Adults:

v ence- ase n erven ons

Hollie Raynor, Ph.D., R.D., L.D.N.Hollie Raynor, Ph.D., R.D., L.D.N.

Associate ProfessorAssociate ProfessorDepartment of NutritionDepartment of Nutrition

Obesity Research CenterObesity Research Center

Objectives

Define evidenceDefine evidence--based treatmentbased treatment

--based childhood obesity interventionsbased childhood obesity interventions

Describe the components of evidenceDescribe the components of evidence--based adult obesity interventionsbased adult obesity interventions

en y e ec ve e ary nerven onsen y e ec ve e ary n erven onsused in adult behavioral weight controlused in adult behavioral weight controlinterventionsinterventions


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What is Evidence-based? The focus on using evidenceThe focus on using evidence--basedbased

n erven ons comes rom concerns an erven ons comes rom concerns apatients/clients receive treatment that ispatients/clients receive treatment that isgrounded in tradition and/or outdated training,grounded in tradition and/or outdated training,rather than scientific evidencerather than scientific evidence

esearc commun y encourage oesearc commun y encourage oscrutinize and evaluate interventions in orderscrutinize and evaluate interventions in orderto ascertain their efficacyto ascertain their efficacy

What is Evidence-based?

Accumulation of researchAccumulation of research

Quality of researchQuality of research Experimental vs. Observational designsExperimental vs. Observational designs

MethodsMethods

Measures (selfMeasures (self--report vs. objective)report vs. objective)

Randomized Controlled TrialsRandomized Controlled Trials

MetaMeta--analysesanalyses


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What is Evidence-based? --

Current best evidence for making clinicalCurrent best evidence for making clinicaldecisions about the care of patients/clientsdecisions about the care of patients/clients

Incorporates best research evidence,Incorporates best research evidence,clinical expertise, and patient valuesclinical expertise, and patient values

Currentl used to im rove the ualit ofCurrentl used to im rove the ualit ofcare, and can provide objective criteria forcare, and can provide objective criteria for

decisions regarding the allocation of healthdecisions regarding the allocation of healthcare resourcescare resources

What is Evidence-based?

LimitationsLimitations

Understanding efficacy (emphasis onUnderstanding efficacy (emphasis oninternal validity) vs. effectivenessinternal validity) vs. effectiveness(emphasis on external validity)(emphasis on external validity)

Type of population studiedType of population studied

Geographic settingsGeographic settings

Health care settingHealth care setting

Will change over timeWill change over time


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Overweight/Obese - definition

Definitions of overweight and obese are based uponDefinitions of overweight and obese are based upon bodybodymass index (BMI):mass index (BMI): weight (kg)/height (mweight (kg)/height (m22))

In children,In children, BMI percentileBMI percentile for age and gender is thefor age and gender is thepreferred measure for detecting overweight in childrenpreferred measure for detecting overweight in childrenand adolescentsand adolescents

Overweight (at risk for overweight):Overweight (at risk for overweight): 8585thth to 94to 94thth ercentile BMIercentile BMI

Obese (overweight):Obese (overweight): >>9595thth percentile BMIpercentile BMI


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Overweight/Obese - definition

,,classified by BMIclassified by BMI

BMIBMI >>25 = overweight25 = overweight

BMIBMI >>30 = obese30 = obese

BMIBMI >>40 = extreme obesity40 = extreme obesity

Body Mass Index Table

BMI =25BMI =25 BMI =30BMI =30

InchesInches Body weight (lbs)Body weight (lbs)

6060 129129 153153

6161 133133 158158

6262 137137 164164

6363 142142 169169

6464 146146 174174

6565 151151 180180

6666 155155 186186

6767 160160 191191

6868 165165 197197

6969 170170 203203

7070 175175 209209

7171 180180 215215


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Goals of Behavioral Lifestyle

Interventions

Behavioral lifestyle interventions focus onBehavioral lifestyle interventions focus onc angngc angng ea ngea ng anan e suree sure-- me ac v yme ac v ybehaviorsbehaviors

Goal is to:Goal is to:

Improve weight statusImprove weight status Weight loss in adultsWeight loss in adults

Maintain weight statusMaintain weight status

Long term weight loss maintenanceLong term weight loss maintenance Weight gain preventionWeight gain prevention

Behavioral Lifestyle Interventions

LeisureLeisure--time activity goalstime activity goals

Behavioral modification techniquesBehavioral modification techniques


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Behavioral Theory

EvidenceEvidence--based childhood and adult obesitybased childhood and adult obesity

Antecedents Behaviors ConsequencesAntecedents Behaviors Consequences

The interventions use behavior modificationThe interventions use behavior modification

-2

0

2

-8

-6

-4

Weightloss(kg) vce uca on

Diet (behavioral intervention)

Diet +exercise (behavioral

intervention)

-10

0 6-mo 12-mo 24-mo

Months

Franz MJ et al. Weight-loss outcomes: a systematic review and meta-analysis of weight loss clinical

trials with a minimum 1-year follow-up. JADA 2007;107:1755-67.


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ADA-Evidence Analysis Library Pediatric weight managementPediatric weight management

Using behavioral counseling as part of aUsing behavioral counseling as part of amultimulti--component pediatric weightcomponent pediatric weightmanagement (PWM) program to treatmanagement (PWM) program to treatoverweight results in significant reductionsoverweight results in significant reductionsin weight status and adiposity in childrenin weight status and adiposity in childrenan a o escen s.an a oescen s.

Rating: Grade I (good)Rating: Grade I (good)

ADA-Evidence Analysis Library

pediatric obesity in children andpediatric obesity in children andadolescent obesity treatmentadolescent obesity treatment

Family participationFamily participation Children (6Children (6--12 yrs)12 yrs) Rating: Strong (Imperative)Rating: Strong (Imperative)

Rating: Fair (conditional)Rating: Fair (conditional)


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What about younger children?What about younger children?

No ratin s as ver little research has beenNo ratin s as ver little researchhas beenconducted in this age groupconducted in this age group

Given the evidence for children aged 6 to 12 yrs,Given the evidence for children aged 6 to 12 yrs,most likely intervention should be familymost likely intervention should be family--basedbased

Effectiveness aside, weight loss (in contrast toEffectiveness aside, weight loss (in contrast toweight management) in this population may beweight management) in this population may beappropra e ony un er cer an crcums ances.appropra e ony un er cer an crcums ances.However, these circumstances have not beenHowever, these circumstances have not been

identified in the research.identified in the research.


-- ,,kcal per day) as part of a clinicallykcal per day) as part of a clinicallysupervised, multisupervised, multi--component weightcomponent weight--loss program is associated with bothloss program is associated with bothshortshort--term and longerterm and longer--term reduction interm reduction inadi osit amon sixadi osit amon six-- to 12to 12-- eaea --oldoldchildren.children. Rating: Grade I (good)Rating: Grade I (good)


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component of a clinically supervised,component of a clinically supervised,multimulti--component childhood weightcomponent childhood weight--management intervention program.management intervention program.

Rating: Grade I (good)Rating: Grade I (good)

Childhood Obesity Interventions

> 85> 85thth percentile BMI, but not greaterpercentile BMI, but not greaterthan 100% overweightthan 100% overweight

Conducted in research settingsConducted in research settings


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Behavioral Targets

EvidenceEvidence--based interventions targetbased interventions targetbehaviors that reduce energy intake andbehaviors that reduce energy intake andincrease energy expenditureincrease energy expenditure

LowLow--calorie diet (900calorie diet (900--1200 kcals/day)1200 kcals/day) Most widely studied is the Traffic Light Diet (Epstein andMost widely studied is the Traffic Light Diet (Epstein and

colleagues)colleagues)

Categorizes food into Green, Yellow, Red (based uponCategorizes food into Green, Yellow, Red (based uponenergyenergy--density and nutrient quality)density and nutrient quality)

e uce n a e o ase uce na e o as -- oo , so a, swee an sa y snacoo , so a, swee an sa y snacfoodsfoods

Generally does not cause an increase in F&V and dairyGenerally does not cause an increase in F&V and dairyproducts unless specifically targeted in treatmentproducts unless specifically targeted in treatment

Behavioral Targets

--

Increase in physical activity (60 minutes/day),Increase in physical activity (60 minutes/day),with focus on play and family activitieswith focus on play and family activities

Reduction in TV watching (Reduction in TV watching (


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Riley et al., 2008

FamilyFamily--based is not just includingbased is not just includingparents/caregivers in the treatment ofparents/caregivers in the treatment of

''

Changing the context of the family (home)Changing the context of the family (home)environment to help support the change aenvironment to help support the change achild is making:child is making:

ParentingParenting

CommunicationCommunication

SupportSupport

EnvironmentEnvironment


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Behavioral Parenting Program Strategies for Antecedents:Strategies for Antecedents:

-- aren a mo e ngaren a mo e ng Parent makes all of the same changes in behaviors asParent makes all of the same changes in behaviors as

childchild

-- Change the home environment (stimulus control)Change the home environment (stimulus control) EatingEating

-- Overt and covert restrictionOvert and covert restriction

--

-- ProblemProblem--solving and presolving and pre--planningplanning

Behavioral Parenting Program

Strategies for behaviors:Strategies for behaviors: --

Goals of programGoals of program Kcals, Red Foods, F&VKcals, Red Foods, F&V Physical ActivityPhysical Activity TV WatchingTV Watching WeightWeight

ParentParent--child meetingschild meetings

Tie weight change to behavior change toTie weight change to behavior change to

weightweight Feedback on selfFeedback on self--monitoring is importantmonitoring is important


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Behavioral Parenting Program Strategies for consequences:Strategies for consequences:

Positive reinforcementPositive reinforcement

PraisePraise

Contingency contractingContingency contracting

Point systemPoint system

Reduction of negative reinforcementReduction of negative reinforcement

Increase use of extinction for problematicIncrease use of extinction for problematic

behaviorsbehaviors

FamilyFamily--based:based:

Group processGroup process

Treatment Structure

CogntveCogntve-- e avorae avora

Social learning (Interventionist serves as model ofSocial learning (Interventionist serves as model ofparenting behaviors)parenting behaviors)

Sessions:Sessions:

Review of assigned homework (group process andReview of assigned homework (group process and

Presentation and discussion of new topic (cognitivePresentation and discussion of new topic (cognitivebehavioralbehavioral parenting behaviors/practices)parenting behaviors/practices)

Assignment of new homeworkAssignment of new homework


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Treatment Structure 66--months of treatment (Parent + child)months of treatment (Parent + child)

Weekly sessions for 12 to 16 weeksWeekly sessions for 12 to 16 weeks Group session for parentsGroup session for parents

Group session for childrenGroup session for children

15 minute individual parent15 minute individual parent--child meeting with anchild meeting with aninterventionistinterventionist

For remaining 2 to 3 months of treatment,For remaining 2 to 3 months of treatment,frequency of sessions drops to either one or twofrequency of sessions drops to either one or twomeetings/monthmeetings/month

Assessments at 0, 6, 12 months (DV =Assessments at 0, 6, 12 months (DV =

percent overweight or zBMI)percent overweight or zBMI)

Childhood Obesity Treatment

These evidenceThese evidence--based interventions targetingbased interventions targetingc ren age o years pro ucesc ren age o years pro ucessignificant reductions in percent overweightsignificant reductions in percent overweight((--15 to15 to --20%), with 1020%), with 10--year followyear follow--up showingup showingalmost 1/3 of treated children no longeralmost 1/3 of treated children no longeroverweight and a mean reduction in percentoverweight and a mean reduction in percent

-- ,,Paluch, & Raynor, 2002; Epstein, Paluch, Kilanowski, Raynor,Paluch, & Raynor, 2002; Epstein, Paluch, Kilanowski, Raynor,2004; Raynor,2004; Raynor, Kilanowski, Esterlis, & Epstein, 2002 )Kilanowski, Esterlis, & Epstein, 2002 )


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Maternal and Child Health Bureau

Recommendations for Treatment in a

Primary Care Setting

..

years of ageyears of age

2. Apply a family2. Apply a family--based model in treatmentbased model in treatment

3. Use behavior modification techniques3. Use behavior modification techniques

4. Help families make small changes4. Help families make small changes

5. Target changing 2 or 3 eating and activity5. Target changing 2 or 3 eating and activity

behaviors at a timebehaviors at a time

Childhood Interventions Behaviors recommended to target in primary careBehaviors recommended to target in primary care

settingssettings

FastFast--food intake (limit)food intake (limit)

Sweetened drink intake (limit)Sweetened drink intake (limit)

Sweet and salty snack foods (limit)Sweet and salty snack foods (limit)

LowLow--fat dairy (2 servings per day)fat dairy (2 servings per day)

Fruits & vegetables (1.5 c fruits & 2.5 c vegetables/day)Fruits & vegetables (1.5 c fruits & 2.5 c vegetables/day)

Physical activity (60 minutes per day)Physical activity (60 minutes per day) TV watching (< 2 hrs/day)TV watching (< 2 hrs/day)


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Childhood Interventions

Will these recommendations beWill these recommendations beeffective at treating young children whoeffective at treating young children whoare overweight?are overweight?

ANDAND

What are the best behaviors to target?What are the best behaviors to target?

Pediatric Obesity Treatment Child HELP and Kids CANChild HELP and Kids CAN

Two research programs funded by theTwo research programs funded by theAmercan D a etes Assoc aton an t eAmercan D a etes Assoc aton an t eNational Institutes of HealthNational Institutes of Health

For children between the ages of 4 to 9For children between the ages of 4 to 9years,years, >>8585thth percentile BMI, with at leastpercentile BMI, with at least

one problematic eating or activity behaviorone problematic eating or activity behavior


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Pediatric Obesity Treatment Both programs randomly assign families toBoth programs randomly assign families to

one o ree, mon n erven onsone o ree, mon n erven ons

Behavioral parenting program (2 differentBehavioral parenting program (2 differentparenting programs in each study)parenting programs in each study)

NewsletterNewsletter

Anthropometric assessments conductedAnthropometric assessments conducted--

feedback to families and pediatricianfeedback to families and pediatrician

Child HELP

IncreaseIncrease

Fruits and VegetablesFruits and Vegetables

(2 servings fruit and 3(2 servings fruit and 3servings vegetables/day)servings vegetables/day)

LowLow--fat dairyfat dairy

(2 servings/day)(2 servings/day)

LowLow--energyenergy--dense foodsdense foods

Sweet/salty snack foodsSweet/salty snack foods

((


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2

2.2

2.4

2.6

2.8

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

zBMI Newsletter

Increase

Decrease

0

0.2

0 6 12

Months

Kids CAN

Physical ActivityPhysical Activity

(60 min/day)(60 min/day)

Sweetened drinksSweetened drinks

((


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1.8

2

2.2

2.4

2.6

0.4

0.6

0.8

1

1.2

1.4

1.6

zBMI Newsletter

Traditional

Substitute

0

0.2

0 6 12

Months

Important Components of Treatment Measures of weight statusMeasures of weight status

Provides regulatory feedbackProvides regulatory feedback

Children that do better have parents that are doingChildren that do better have parents that are doing

betterbetter SelfSelf--monitoringmonitoring ModelingModeling Stimulus controlStimulus control PrePre--planning, problemplanning, problem--solvingsolving

Pro rams that tar et arents onl also show oodPro rams that tar et arents onl also show oodoutcomesoutcomes

Caloric prescription appears to be needed toCaloric prescription appears to be needed toproduce clinically relevant weight statusproduce clinically relevant weight statusimprovementsimprovements


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Weight loss and weight maintenanceWeight loss and weight maintenance

therapy should be based on atherapy should be based on acomprehensive weight managementcomprehensive weight managementprogram including diet, physical activity,program including diet, physical activity,and behavior therapy. The combinationand behavior therapy. The combination

erapy s more success u an usng anyerapy s more success u an usng anyone intervention alone.one intervention alone. Rating: StrongRating: Strong


A com rehensive adult wei ht mana ement ro ramA com rehensive adult wei ht mana ement ro ramshould make maximum use of multiple strategies forshould make maximum use of multiple strategies forbehavior therapy (e.g. self monitoring, stressbehavior therapy (e.g. self monitoring, stressmanagement, stimulus control, problem solving,management, stimulus control, problem solving,contingency management, cognitive restructuring,contingency management, cognitive restructuring,and social support). Behavior therapy in addition toand social support). Behavior therapy in addition todiet and physical activity leads to additional weightdiet and physical activity leads to additional weightloss. Continued behavioral interventions ma beloss. Continued behavioral interventions ma benecessary to prevent a return to baseline weight.necessary to prevent a return to baseline weight. Rating: StrongRating: Strong


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Adult Obesity Treatment ,,

treatments achieve a mean weight loss of 10treatments achieve a mean weight loss of 10kg over 6 months of treatment, but have akg over 6 months of treatment, but have aweightweight--loss regain of 38% over a mean f/u ofloss regain of 38% over a mean f/u of18 months (Wing, 2002)18 months (Wing, 2002)

How can weight loss maintenance beHow can weight loss maintenance be

improved?improved?

Adult Obesity Interventions

LowLow--calorie diet (1200calorie diet (1200--1500 kcals/day)1500 kcals/day)

LowLow--fat diet (20% to 30% kcals/fat)fat diet (20% to 30% kcals/fat)

Strong focus on increasing structure of the dietStrong focus on increasing structure of the diet

Physical activityPhysical activity

--10,000 steps/day10,000 steps/day


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Behavior Modification Strategies for Antecedents:Strategies for Antecedents:

-- ange e ome envronmen s muusange e ome envronmen s muuscontrol)control)EatingEating

LeisureLeisure--time behaviorstime behaviors

-- ProblemProblem--solving and presolving and pre--planningplanning

--

-- Cognitive restructuringCognitive restructuring

-- RelaxationRelaxation


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Behavior Modification Strategies for behaviors:Strategies for behaviors:

SelfSelf--monitoringmonitoringGoals of programGoals of program

Kcals, fatKcals, fat

Physical ActivityPhysical Activity

WeightWeight

Tie weight change to behavior change toTie weight change to behavior change toemonstrate reatons p etweenemonstrate reatons p etween

behaviors and weightbehaviors and weight

Feedback on selfFeedback on self--monitoring is importantmonitoring is important


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Behavior Modification Strategies for consequences:Strategies for consequences:

Positive reinforcementPositive reinforcement

Weight loss vs. maintenanceWeight loss vs. maintenance

Reinforcing value of foodReinforcing value of food

Structure of Treatment

outcomes, standard length of intervention isoutcomes, standard length of intervention is18 months18 months

Weight loss interventionsWeight loss interventions Weekly for 6 monthsWeekly for 6 months 60 minute group sessions60 minute group sessions

2 times/month for months 72 times/month for months 7--1818 -- 60 minute group60 minute group

sessonssessons Assessments at 0, 6, 12, 18 months (DV =Assessments at 0, 6, 12, 18 months (DV =

wt)wt)


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Important Components of

Treatment Measures of wei ht statusMeasures of wei ht status

Provides regulatory feedbackProvides regulatory feedback

Regular and longRegular and long--term followterm follow--upup AccountabilityAccountability

Habit changeHabit change

SelfSelf--monitoringmonitoring

Dietary structureDietary structure Meal plans, meal replacements, portion controlled foodsMeal plans, meal replacements, portion controlled foods

Variety?Variety?

Lots of physical activity!Lots of physical activity!

Materials from DPP

. . .. . .p_part.htmlp_part.html


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Macronutrient Content

of the Diet


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Macronutrient Composition

and Weight Loss Maintenance 800 artici ants800 artici ants Randomly assigned to 1 of 4 diets:Randomly assigned to 1 of 4 diets: the targeted

percentages of energy derived from fat, protein,and carbohydrates in the four diets were 20, 15,and 65%; 20, 25, and 55%; 40, 15, and 45%; and40, 25, and 35% - diets consisted of similar foodsand met guidelines for cardiovascular health

Received behavior modification, and had a

physical activity goal of 90 min/week


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Dietary Structure


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Do meal replacements help with

weight loss?

Foods of fixed calorie and nutrient contentFoods of fixed calorie and nutrient contentthat are designed to take the place of a mealthat are designed to take the place of a mealor snackor snack

PortionPortion--controlled and nutritionally balancedcontrolled and nutritionally balanced

, , ,, , ,prepared mealsprepared meals

Typical recommendation is to replace 2Typical recommendation is to replace 2meals with a meal replacementmeals with a meal replacement

Do meal replacements help withweight loss?

Purpose: To examine whether using mealPurpose: To examine whether using mealreplacements improves weight loss in adultsreplacements improves weight loss in adultsenrolled in a weight loss program.enrolled in a weight loss program.

Participants: 100 overweight and obese menParticipants: 100 overweight and obese men

diet groups.diet groups.

Length of weight loss program: 27 monthsLength of weight loss program: 27 months


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Do meal replacements help

with weight loss?

Diet A: 1200Diet A: 1200--1500 calories/day, with1500 calories/day, withparticipants eating regular foodsparticipants eating regular foods

Diet B: 1200Diet B: 1200--1500 calories/day, with1500 calories/day, withparticipants using meal replacements for 2participants using meal replacements for 2meals and 2 snacks each daymeals and 2 snacks each day

as mon s:as mon s:

Both groups followed the same 1200Both groups followed the same 1200--15001500kcals/day diet and used meal replacementskcals/day diet and used meal replacementsfor 1 meal and 1 snack per dayfor 1 meal and 1 snack per day

Weight Loss Maintenance Using

Meal Replacements0

ight

4

6

8

ereductionininitialw Standard then

Meal

Replacement

10

12Percentag

TimeDitschuneit et al., AJ CN; 1999; 69: 198-204

Meal

Replacement

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28


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Why are meal replacements

effective for weight loss?

ConvenientConvenient

PortionPortion--controlledcontrolled

Removes work of estimating portion size andRemoves work of estimating portion size andcaloriescalories

Widely availableWidely available

Easy to selfEasy to self--monitormonitor

Dietary Variety

with increased intake, weight, and bodywith increased intake, weight, and bodyfat in animals (for a review Raynor &fat in animals (for a review Raynor &Epstein, 2001, Psychological Bulletin)Epstein, 2001, Psychological Bulletin)

Increased variet within a meal isIncreased variet within a meal isassociated with increased consumptionassociated with increased consumptionin humansin humans


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HFF

20

30

40

50

60

70

Percentvariety

Before intervention

After intervention

Registry

FOS

20

30

40

50

60

70

Percentvariety

LFM

20

30

40

50

60

70

Percentvariety

0 0

10

0

10

LFB

10

20

30

40

50

60

70

Percentvariety

LFV

10

20

30

40

50

60

70

Percentvariety

0 0

Mean percent variety in 5 food groups for recent successful weight losers before and after a standard

weight loss intervention (n=96), and registry participants (n =2237) (M +SEM).

Raynor, H. A., J effery, R. W., Phelan, S., Hill, J . O., & Wing, R.R. (2005). Amount of foodgroup variety consumed in the diet and long-term weight loss maintenance. Obesity Research, 13, 883-890.

Food Group Variety andObesity Treatment

different foods, particularly energydifferent foods, particularly energy--densedensefoods, in the diet may help with successfulfoods, in the diet may help with successfulweight loss and longweight loss and long--term weight lossterm weight lossmaintenancemaintenance

Limiting variety may be especially helpfulLimiting variety may be especially helpfulduring maintenance, when selfduring maintenance, when self--monitoring ofmonitoring ofintake is less consistentintake is less consistent


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Dietary Variety Prescription 18 month trial testin the effectof limitin snack food18 month trial testin the effectof limitin snackfood

variety (R01variety (R01 -- NIDDK)NIDDK)

2 groups: Standard vs. Standard + variety2 groups: Standard vs. Standard + varietyprescriptionprescription Can this prescription be adhered to over the longCan this prescription be adhered to over the long--term?term?

Will a greater length of time of limiting variety effect weightWill a greater length of time of limiting variety effect weightloss?loss?

control)?control)?

200 participants200 participants

Research TeamProvidence, RIProvidence, RI Knoxville, TNKnoxvi lle, TN

Rena Wing, Ph.D.Rena Wing, Ph.D. Betsy Anderson, M.S., R.D. L.D.N.Betsy Anderson, M.S., R.D. L.D.N.

Chantelle Hart, Ph.D.Chantelle Hart, Ph.D. Ashlee SchochAshlee Schoch

Elissa Jelalian, Ph.D.Elissa Jelalian, Ph.D. Lusi MartinLusi Martin

Patrick Vivier, M.D.Patrick Vivier, M.D. Shannon Looney, M.P.H.Shannon Looney, M.P.H.

Kathrin Osterholt, M.S.Kathrin Osterholt, M.S. Christen Mullane, M.A.Christen Mullane, M.A.

Amanda FineAmanda Fine J ess Bachman, M.S., R.D., L.D.N.J ess Bachman, M.S., R.D., L.D.N.

Allison MartirAllison Martir Emily Van Walleghen, Ph.D.Emily Van Walleghen, Ph.D.

Patty TellierPatty Tellier Andrew CarberryAndrew Carberry

Holly ManiganHolly Manigan Adriana ColettaAdriana Coletta

Documents

Behavioral Treatment of Obesity.pdf