Health Psychology Ch.5: Heath Comprising Behaviors

Treating Bulimia

A barrier to treating bulimia is that many women either do not believe that their problem is a serious one, or they do not believe that a medical intervention will overcome it. Accordingly, one of the first steps in treatment is to convince bulimics that the disorder threatens their health A combination of medication and cognitivebehavioral therapy appears to be the most effective therapy. Typically, this treatment begins with self monitoring, keeping a diary of eating habits, including time, place, type of food consumed, and emotions experienced. Simple self-monitoring can produce decreases in binge-purge behavior. Most therapies combine monitoring with an individualized or group CBT program to bring eating under control. Specific techniques include inducing the client to increase the regularity of meals, eat a greater variety of foods, delay the impulse to purge as long as possible, and eat favorite foods in new settings not previously associated with binges. Perceptions of self-efficacy facilitate the success of cognitive-behavioral interventions. Relapse prevention techniques are often added to therapeutic programs. These include learning to identify situations that trigger binge eating and developing coping skills to avoid them. Relaxation and stress management skills are often added to these programs as well.

Relapse Prevention

A meta-analysis of alcohol treatment outcome studies estimates that more than 50 percent of treated patients relapse within the first 3 months after treatment Practicing coping skills or social skills for highrisk-for-relapse situations is a mainstay of relapse prevention interventions. In addition, the recognition that people often stop and restart an addictive behavior several times before they are successful has led to the development of techniques for managing relapses. Understanding that an occasional relapse is normal helps the problem drinker realize that any given lapse does not signify failure. Overall, the evidence shows that cognitive behavioral treatments (CBT) to treat alcohol disorders are successful across a broad range of people and situations (Magill & Ray, 2009). Interventions with heavydrinking college students have made use of these approaches

What Is Substance Dependence?

A person is said to be dependent on a substance when he or she has repeatedly self-administered it, resulting in tolerance, withdrawal, and compulsive behavior (American Psychiatric Association, 2000). Substance dependence can include physical dependence, when the body has adjusted to the substance and incorporates the use of that substance into the normal functioning of the body's tissues. Physical dependence often involves tolerance, the process by which the body increasingly adapts to the use of a substance, requiring larger and larger doses of it to obtain the same effects, and eventually reaching a plateau. Craving is a strong desire to engage in a behavior or consume a substance. It results from physical dependence and from a conditioning process: As the substance is paired with environmental cues, the presence of those cues triggers an intense desire for the substance. Addiction occurs when a person has become physically or psychologically dependent on a substance following repeated use over time. Withdrawal refers to the unpleasant symptoms, both physical and psychological, that people experience when they stop using a substance on which they have become dependent. Although the symptoms vary, they include anxiety, irritability, intense cravings for the substance, nausea, headaches, tremors, and hallucinations.

Commercial Programs and Self-Help

A variety of self-help aids and programs have been developed for smokers to quit on their own. These include nicotine patches, as well as more intensive self-help programs. Cable television programs designed to help people stop initially and to maintain their resolution have been broadcast in some cities. Although it is difficult to evaluate self-help programs formally, studies suggest that initial quit rates are lower but that long-term maintenance rates are just as high as with more intensive behavioral interventions. Because self-help programs are inexpensive, they represent an important attack on the smoking problem for both adults and adolescents. Quit lines provide telephone counseling to help people stop smoking and are quite successful. People can call in when they want to get help for quitting or if they are worried about relapse. Most such programs are based on principles derived from CBT. Both adults and younger smokers can benefit from this kind of telephone counseling . Internet interventions are a recent approach to the smoking problem that has several advantages: People can seek them out when they are ready to and without regard to location. They can deal with urges to smoke by getting instant feedback from an Internet service. In a randomized control trial sponsored by the American Cancer Society, an Internet program for smoking cessation was significantly more helpful to smokers trying to quit than a control condition. Moreover, the effects lasted longer than a year, suggesting the longterm efficacy of Internet interventions for smoking cessation. Public health approaches to reducing smoking begin with warning labels on cigarette packs, billboards, and other places where they are likely to be noticed. These warnings help raise concerns, which can lead to quit attempts (Yong et al., 2014). More broad-based approaches initially focused on community interventions combining media blitzes with behavioral interventions directed especially at high-risk people, such as people with other risk factors for CHD. However, such interventions are often expensive, and long-term followups suggest limited long-term effects (Facts of Life, July 2005). Ultimately, banning cigarette smoking from workplaces and public settings and raising cigarette taxes have been most successful in reducing smoking

Stress & Eating

About half of people eat more when they are under stress, and half eat less For nondieting and nonobese normal eaters, stress or anxiety may suppress physiological cues of hunger, leading to lower consumption of food. For overweight and obese people, however, stress and anxiety can disinhibit food consumption, removing the selfcontrol that usually guards against eating. Whereas men tend to eat less in stressful circumstances, many women eat more. Stress also influences what food is consumed. People who eat in response to stress usually consume more low-calorie and salty foods, although when not under stress, stress eaters show a preference for high-calorie foods . Anxiety and depression figure into stress eating as well. People who eat in response to negative emotions show a preference for sweet and high-fat foods.

SES, Culture, and Obesity

Additional risk factors for obesity women of low SES Depression and weight gain are linked. People who are high in neuroticism, extraversion, and impulsivity and low in conscientiousness are more likely to be obese A person's chances of becoming obese increase substantially when he or she has a friend, sibling, or partner who has become obese.

Evaluation of Interventions

Adult smokers are well served by cognitive behavioral interventions that include self-monitoring, modification of the stimuli that elicit and maintain smoking, reinforcing successful smoking cessation, and relapse prevention techniques such as rehearsing alternative coping techniques in high-risk situations. However, these approaches may be less successful with adolescents. What may be needed instead are inexpensive, efficient, short-term interventions. Programs that include a motivation enhancement component, a focus on self-efficacy, stress management, and social skills training can be successful and can be delivered in school clinics and classrooms . Virtually every imaginable combination of therapies for getting people to stop has been tested. Typically, these programs show high initial success rates for quitting, followed by high rates of return to smoking, sometimes as high as 90 percent. Those who relapse are more likely to be young and dependent on nicotine. Those who relapse often have a low sense of self-efficacy, concerns about gaining weight after stopping smoking, more previous quit attempts, and more slips (occasions when they used one or more cigarettes) Although the rates of relapse suggest some pessimism, it is important to consider the cumulative effects of smoking cessation programs. Any single effort to stop smoking yields only a 20 percent success rate, but with multiple efforts to quit, eventually the smoker may become an ex-smoker. In fact, hundreds of thousands of smokers have quit, albeit not necessarily the first time they tried. Over time, people may amass enough techniques and the motivation to persist. People who quit on their own are typically welleducated and have good self-control skills, selfconfidence in their ability to stop, and a perception that the health benefits of stopping are substantial. Stopping on one's own is easier if one has a supportive social network that does not smoke and if one is able to distance oneself from the typical smoker and identify with nonsmokers instead. Stopping is also more successful following an acute or chronic health threat, such as a diagnosis of heart disease, especially among middle-aged smokers .

ALCOHOLISM AND PROBLEM DRINKING

Alcohol is responsible for approximately 79,000 deaths each year, making it the third-leading cause of preventable death after tobacco and improper diet and exercise. More than 20 percent of Americans drink at levels that exceed government recommendations (Centers for Disease Control and Prevention, September 2008). About 15 million American adults meet criteria for alcohol abuse and dependence As a health issue, alcohol consumption has been linked to high blood pressure, stroke, cirrhosis of the liver, and some forms of cancer. Excessive alcohol consumption has also been tied to brain atrophy and consequent deteriorating cognitive function (Anstey et al., 2006). Alcoholics can have sleep disorders, which, in turn, may contribute to immune alterations that elevate risk for infection (Redwine, Dang, Hall, & Irwin, 2003). Approximately 31 percent of trafficrelated deaths are related to alcohol, and it is estimated that 50 percent of Americans will be involved in an alcohol-related accident during his or her lifetime direct costs of alcoholism through illness, accidents, and economic costs, alcohol abuse contributes to social problems. Alcohol disinhibits aggression, so homicides, suicides, and assaults occur under the influence of alcohol. Alcohol can also facilitate other risky behaviors. For example, among sexually active adults, alcohol leads to more impulsive sexuality and poorer skills for negotiating condom use . Overall, though, it has been difficult to define the scope of alcoholism. Many problem drinkers keep their problem successfully hidden, at least for a time. By drinking at particular times of day or at particular places, and by restricting contacts with other people during these times, the alcoholic may be able to drink without noticeable disruption in his or her daily activities.

Obesity depends on both the number and the size of an individual's fat cells

Among moderately obese people, fat cells are typically large, but there is not an unusual number of them. Among the severely obese, there is a large number of fat cells, and the fat cells themselves are exceptionally large (Brownell, 1982). Childhood constitutes a window of vulnerability for obesity because the number of fat cells a person has is typically determined in the first few years of life, by genetic factors and by early eating habits.

Social Support and Stress Management

As is true for other health habit interventions, would-be ex-smokers are more likely to be successful over the short term if they have a supportive partner and nonsmoking supportive friends. The presence of smokers in one's social network is a hindrance to maintenance and predicts relapse. Consequently, couple-based interventions have been developed that seem to be especially effective. Stress management training is helpful for successful quitting . Because smoking is relaxing for so many people, teaching smokers how to relax in situations in which they might be tempted to smoke provides an alternative method for coping with stress or anxiety. Lifestyle rebalancing through changes in diet and exercise also helps people cut down on smoking or maintain abstinence after quitting. Image is also important in helping people stop. Specifically, people who have a strong sense of themselves as nonsmokers do better in treatment than those who have a strong sense of themselves as smokers. Interventions with young women who smoke must take into account appearance-related issues, as young women often fear that if they stop smoking, they will put on weight.

Treatment of Alcohol Abuse

As many as half of all alcoholics stop or reduce their drinking on their own. This "maturing out" of alcoholism is especially likely in the later years of life alcoholism can be successfully treated. Nonetheless, as many as 60 percent of the people treated through such programs may return to alcohol abuse Alcoholics who are high in socioeconomic status (SES) and who are in highly socially stable environments (that is, who have regular jobs, intact families, and a circle of friends) do very well in treatment programs, achieving success rates as high as 68 percent. In contrast, alcoholics of low SES often have success rates of 18 percent or less.

Factors Associated with Smoking in Adolescents

At least 46 percent of high school students have tried cigarette smoking. But smoking does not start all at once. There is a period of initial experimentation, during which the adolescent tries out cigarettes, experiences peer pressure to smoke, and develops attitudes about what a smoker is like. Following experimentation, only some adolescents go on to become heavy smokers. Starting to smoke results from a social contagion process through contact with others who smoke. More than 70 percent of all cigarettes smoked by adolescents are smoked in the presence of a peer. Once they begin smoking, adolescents are more likely to prefer the company of peers who smoke. Schools that look the other way or that have poor levels of discipline may inadvertently contribute to regular cigarette use. As the prevalence of smoking goes up at a particular school, so does the likelihood that additional students will start smoking. Smoking runs in families. Adolescents are more likely to start smoking if their parents smoke, and if their parents smoked early and often. If their parents stopped smoking before the child turned approximately 8, smoking cessation actually reduces the risk of smoking, presumably because of the family's anti-smoking attitudes . Adolescents are more likely to start smoking if they are from a lower social class, if they feel social pressure to smoke, and if there has been a major stressor in the family, such as parental separation or job loss . These effects are partly due to the increase in stress and depression that may result. Even watching people smoke in movies and on television contributes to high rates of adolescent smoking. Once adolescents begin to smoke, the risks they perceive from smoking decline, and so smoking itself reduces perceptions of risk . Smoking clusters in social networks, almost as an infectious disease migh.. Although smoking has declined overall, clusters of smokers who know each other increase the likelihood that a friend or relative will continue to smoke. The good news is that these geographic clusters also appear to spread quitting: The likelihood that someone will stop smoking increases by two-thirds if their spouse has stopped smoking, by 25 percent if a sibling has quit, and by 36 percent if a friend has quit. Even smoking cessation by a coworker decreases the likelihood that one will continue to smoke by 34 percent. Smoking, like so many other risky behaviors, spreads through social ties

The Therapeutic Approach to the Smoking Problem

Attentional retaining involves helping smokers reorient their attention away from smoking-related cues, both internal and in the environment. It can be a first step in a stopping smoking intervention to help reduce craving and orienting toward smoking-related cues. Exercise is also a method of reducing attentional bias toward smoking-related cues). Many smoking intervention programs have used the stages of change model as a basis for intervening. Interventions to move people from the precontemplation to the contemplation stage center on changing attitudes, emphasizing the adverse health consequences of smoking and the negative social attitudes that most people hold about smoking. Motivating a readiness to quit may, in turn, increase a sense of self-efficacy that one will be able to do so, contributing further to readiness to quit . Moving people from contemplation to action requires that the smoker develop implementation intentions to quit, including a timetable for quitting, a program for how to quit, and an awareness of the difficulties associated with quitting. Moving people to the action phase employs many of the cognitive-behavioral techniques that have been used to modify other health habits. As this account suggests, smoking would seem to be a good example of how the stage model might be applied. However, interventions matched to the stage of smoking are inconsistent in their effects

Origins of Alcoholism and Problem Drinking

Based on twin studies and on the frequency of alcoholism in sons of alcoholic fathers, genetic factors appear to be implicated. Modeling a parent's drinking is also implicated Men have traditionally been at greater risk younger women and women employed outside the home are catching up to men Sociodemographic factors, such as low income, also predict alcoholism.

Brief Interventions

Brief interventions by physicians and other health care practitioners can bring about smoking cessation and control relapse (Vogt, Hall, Hankins, & Marteau, 2009). Providing smoking cessation guidelines during medical visits may improve the quit rate (Williams, Gagne, Ryan, & Deci, 2002). One health maintenance organization targeted the adult smokers in their program with telephone counseling and newsletters that offered quitting guidelines; the program achieved its goal of reducing the smoking, and, most notably, it reached smokers who otherwise would not have participated in cessation programs began offering free stop smoking treatment to poor residents in 2006 and achieved a remarkable decline in smoking from 38 to 28 percent, suggesting that incorporating brief interventions into Medicaid programs can be successful

Evaluation of Cognitive-Behavioral Weight-Loss Techniques

Cognitive-behavioral programs typically produce modest success, with weight loss of nearly 2 pounds a week for up to 20 weeks and long-term maintenance over at least 2 years (Brownell & Kramer, 1989). Programs that emphasize diet modification self-direction and exercise and include relapse prevention techniques are particularly successful (Jeffery, Hennrikus, Lando, Murray, & Liu, 2000). Interventions with children and adolescents show particularly good results when parents are involved (Kitzmann et al., 2010). Table 5.2 describes some of the promising leads that current research suggests for enhancing longterm weight loss in cognitive-behavioral programs.

Evaluation of Social Influence Programs

Do these programs work? Overall, social influence programs can reduce smoking rates for as long as 4 years. However, experimental smoking may be affected more than regular smoking, and experimental smokers may stop on their own anyway. What is needed are programs that will reach the child destined to become a regular smoker, and as yet, we know less about what helps to keep these youngsters from starting to smoke.

Interventions with Adolescents

Earlier, we noted how important the image of the cool, sophisticated smoker is in getting teenagers to start smoking. Several interventions to induce adolescents to stop smoking have made use of self-determination theory. Because adolescents often begin smoking to shore up their self-image with a sense of autonomy and control, selfdetermination theory targets those same cognitions— namely, autonomy and self-control—but from the opposite vantage point; that is, they target the behavior of stopping smoking instead

A Brief History of the Smoking Problem .

For years, smoking was considered to be a sophisticated and manly habit. Characterizations of 19th- and 20th-century gentry, for example, often depicted men retiring to the drawing room after dinner for cigars and brandy. Cigarette advertisements of the early 20th century built on this image, and by 1955, 53 percent of the adult male population in the United States smoked. Women did not begin to smoke in large numbers until the 1940s, but once they did, advertisers began to tie cigarette smoking to feminine sophistication as well Critics argue that the tobacco industry has disproportionately targeted minority group members and teens for smoking, and indeed, the rates among certain low-SES minority groups, such as Hispanic men, are especially high. These differences may be due in part to differences in cultural attitudes regarding smoking. At present, 22 percent of high school students smoke. As pressures to reduce smoking among children and adolescents have mounted, tobacco companies have turned their marketing efforts overseas. In developing countries, smoking represents a growing health problem. For example, smoking is reaching epidemic proportions in China. It is estimated that a third of all young Chinese men will die from the effects of tobacco, more than 3 million deaths each year by 2050

Developing Anorexia Nervosa

Genetic factors are clearly implicated, especially genes involving the serotonin, dopamine, and estrogen systems. These systems have been implicated in both anxiety and food intake. Interactions between genetic factors and risks in the environment, such as early exposure to stress, may also play a role (Striegel-Moore & Bulik, 2007), and dysregulated biological stress systems may be involved. Personality characteristics and family interaction patterns may be causal factors in anorexia. Anorexics may experience a lack of control coupled with a need for approval and exhibit conscientious, perfectionistic behavior. Body image distortions are also common among anorexic girls, although it is not clear whether this distortion is a consequence or a cause of the disorder. Anorexic girls can come from families with psychopathology or alcoholism or from families that are extremely close but have poor skills for communicating emotion or dealing with conflict. Mothers of daughters with eating disorders appear to be more dissatisfied with their families, more dissatisfied with their daughters' appearance, and more vulnerable to eating disorders themselves. Mothers who are preoccupied with their own weight and eating behaviors place their daughters at risk for developing eating problems. More generally, eating disorders have been tied to insecure attachment in relationships, that is, to the expectation of criticism or rejection from others. By the time a young woman or man goes into treatment for anorexia, the behavior may have become a habit that is, consequently, much harder to treat

Risks of Obesity

It contributes to death rates for all cancers and for the specific cancers of the colon, rectum, liver, gallbladder, pancreas, kidney, and esophagus, as well as non-Hodgkin's lymphoma and multiple myeloma. Estimates are that excess weight may account for 14 percent of all deaths from cancer in men and 20 percent of all deaths from cancer in women Obesity also contributes substantially to deaths from cardiovascular disease, and it is tied to atherosclerosis, hypertension, Type II diabetes, and heart failure. Obesity increases risks in surgery, anesthesia administration, and childbearing. It has been tied to poorer cognitive skills as early as adolescence, well in advance of any diagnosable chronic health condition

Self-Identity and Smoking

Low self-esteem, dependency, feelings of powerlessness, and social isolation all increase the tendency to imitate others' behavior, and smoking is no exception. Feelings of being hassled, angry, or sad increase the likelihood of smoking . Feelings of self-efficacy and good self-control skills help adolescents resist temptations to smoke. Self-identity is also important for stopping smoking. Identifying oneself as a smoker impedes the ability to quit smoking, whereas identifying oneself as a quitter can promote it

Nicotine Replacement Therapy

Many therapies begin with some form of nicotine replacement, such as nicotine patches, which release nicotine in steady doses into the bloodstream. Nicotine replacement therapy significantly increases initial smoking cessation . E-cigarettes, which work by turning a nicotine-infused liquid into a vapor, are based on this principle. Whether e-cigarettes are safe, however, is unclear . Finding the answer to this question is important, because more youngsters now smoke e-cigarettes than traditional ones

Obesity is associated with early mortality

People who are overweight at age 40 die, on average, 3 years earlier than people who are thin . Abdominally localized fat, as opposed to excessive fat in the hips, buttocks, or thighs, is an especially potent risk factor for cardiovascular disease, diabetes, hypertension, cancer, and decline in cognitive function . People with excessive abdominal weight (sometimes called "apples," in contrast to "pears," who carry their weight on their hips) are more psychologically and physiologically reactive to stress. Fat tissue produces proinflammatory cytokines, which may exacerbate diseases related to inflammatory processes . Often ignored among the risks of obesity is the psychological distress that can result. Although there is a robust stereotype of overweight people as "jolly," studies suggest that the obese are prone to neuroticism and psychiatric conditions, especially depression. There are social and economic consequences of obesity as well. An obese person may have to pay for two seats on an airplane, have difficulty finding clothes, endure derision and rude comments, and experience other reminders that the obese, quite literally -- The resulting effect of repeated exposure to others' judgments about their weight can be heightened biological responses to stress (Tomiyama et al., 2014), social alienation, and low self-esteem. As a result, obese people sometimes become reclusive, and one consequence is that diabetes, heart disease, and other complications of obesity may be far advanced by the time they seek a physician. Positive media portrayals of overweight and obese people can go some distance to mitigate the stigma

Drinking and Stress

People who have a lot of negative life events, experience chronic stressors, and have little social support are more likely to become problem drinkers than people without these people who have been laid off from their jobs Alienation from work, low job autonomy, the sense that one's abilities are not being used, and lack of participation in decision making at work are associated with heavy drinking . Financial strain, especially if it produces depression, leads to drinking, and a sense of powerlessness in one's life has also been related to alcohol use and abuse Many people begin drinking to enhance positive emotions and reduce negative ones, and alcohol does reliably lower anxiety and depression and improve self-esteem, at least temporarily

Alcoholism and Problem Drinking

Problem drinking and alcoholism substance dependence disorders that are defined by several specific behaviors. These patterns include the need for daily use of alcohol, the inability to cut down on drinking, repeated efforts to control drinking through temporary abstinence or restriction of alcohol to certain times of the day, binge drinking, occasional consumption of large quantities of alcohol, loss of memory while intoxicated, continued drinking despite known health problems, and drinking of nonbeverage alcohol, such as cough syrup.

Relapse Prevention

Relapse prevention techniques are incorporated into treatment programs, including matching treatments to the eating problems of particular clients, restructuring the environment to remove temptation, rehearsing high-risk situations for relapse (such as parties and holidays), and developing coping strategies to deal with high-risk situations. Moreover, weight loss efforts can fail and lapses are likely, and so people need to be protected against their self-recrimination and tendency to let a lapse turn into a full-blown loss of control. Weight loss programs such as these can be implemented successfully, over the Internet (Krukowski, Harvey-Berino, Bursac, Ashikaga, & West, 2013), through workplace weight loss interventions, and through commercial weight loss programs. Indeed, more than 500,000 people each week are exposed to behavioral methods to control obesity through commercial programs such as Weight Watchers and Jenny Craig. .

Evaluation of Alcohol Treatment Programs

Several factors are associated with successful alcohol treatment programs: a focus on factors in the environment that elicit drinking and modifying those factors or instilling coping skills to manage them; a moderate length of participation (about 6-8 weeks); and involving relatives and employers in the treatment process. Interventions that include these components can produce up to a 40 percent treatment success rate (Center for the Advancement of Health, 2000d). Even minimal interventions can make a dent in drinking-related problems. For example, a few sessions devoted to a discussion of problem drinking and telephone interventions have shown some success in reducing drinking (Oslin et al., 2003). Most alcoholics, though, approximately 85 percent, do not receive formal treatment. As a result, social engineering approaches such as banning alcohol advertising, raising the drinking age, and enforcing penalties for drunk driving can complement formal intervention efforts.

Synergistic Effects of Smoking

Smoking enhances the detrimental effects of other risk factors. For example, smoking and cholesterol interact to produce higher rates of heart disease than would be expected from simply adding together their individual risks. Stress and smoking can also interact in dangerous ways. For men, nicotine can increase heart rate reactivity to stress. For women, smoking can reduce heart rate but increase blood pressure responses to stress. Trauma exposure and posttraumatic stress disorder increase the health risks of smoking. Smoking acts synergistically with low SES as well: Smoking inflicts greater harm among disadvantaged groups than among more advantaged groups. Weight and smoking can interact to increase mortality. Cigarette smokers who are thin are at increased risk of mortality, compared with average-weight smokers. Thinness is not associated with increased mortality in people who have never smoked or among former smokers. Smokers engage in less physical activity than nonsmokers, which represents an indirect contribution of smoking to ill health. Smoking is more likely among people who are depressed, and smoking interacts synergistically with depression to increase risk for cancer. may also be a cause of depression, especially in young people, which makes the concern about the synergistic effects of smoking and depression on health more alarming. Smoking is related to anxiety in adolescence; whether smoking and anxiety have a synergistic effect on health disorders is not yet known, but the chances of panic attacks and other anxiety disorders are increased. The synergistic health risks of smoking are very important and may be responsible for a substantial percentage of smoking-related deaths; however, research suggests that the public is largely unaware of the synergistic adverse effects of smoking

Nicotine Addiction and Smoking

Smoking is an addiction, reported to be harder to stop than heroin addiction or alcoholism. Only so-called chippers are able to smoke casually without showing signs of addiction. However, the exact mechanisms underlying nicotine addiction are unknown. People smoke to maintain blood levels of nicotine and to prevent withdrawal symptoms. In essence, smoking regulates the level of nicotine in the body, and when plasma levels of nicotine depart from the ideal levels, smoking occurs. Nicotine alters levels of neuroregulators, including acetylcholine, norepinephrine, dopamine, endogenous opioids, and vasopressin. Nicotine may be used by smokers to engage these neuroregulators because they produce temporary improvements in performance or affect. Acetylcholine, norepinephrine, and vasopressin appear to enhance memory, and acetylcholine and beta endorphins can reduce anxiety and tension. Alterations in dopamine, norepinephrine, and opioids improve mood. Smoking among habitual smokers improves concentration, recall, alertness, arousal, psychomotor performance, and the ability to screen out irrelevant stimuli, and consequently smoking can improve performance. Habitual smokers who stop smoking report that their concentration is reduced; their attention becomes unfocused; their memory suffers; and they experience increases in anxiety, tension, irritability, craving, and moodiness. However, this is not a complete picture. In studies that alter nicotine level in the bloodstream, smokers do not alter their smoking behavior enough to compensate for these manipulations. Moreover, smoking is responsive to rapidly changing forces in the environment long before such forces can affect blood plasma levels of nicotine. High rates of relapse are found among smokers long after plasma nicotine levels are at zero. Thus, the role of nicotine in addiction may be more complex.

SMOKING

Smoking is one of the greatest causes of preventable death. By itself and in interaction with other risk factors, it remains a chief cause of death in developed countries. In the United States, smoking accounts for at least 480,000 deaths each year—smoking is known to be the cause of 9 out of 10 lung cancer deaths in men and women. Nearly 17% of people in the United States still smoke, about 42 million people overall. Smoking is related to a fourfold increase in women's risk of developing breast cancer after menopause. Smoking also increases the risk for chronic bronchitis, emphysema, respiratory disorders, damage and injuries due to fires and accidents, lower birth weight in offspring, and retarded fetal development. Smoking also increases risk of erectile dysfunction by 50 percent Parental cigarette smoking can lower cognitive performance in adolescents by reducing blood oxygen capacity and increasing carbon monoxide levels

Preventive Approaches to Alcohol Abuse

Social influence programs in middle schools are typically designed to teach young adolescents drinkrefusal techniques and coping methods for dealing with high-risk situations. Research suggests some success with these programs. First, such programs enhance adolescents' self-efficacy, which, in turn, may enable them to resist the passive social pressure that comes from seeing peers drink. Second, these programs can change social norms that typically foster adolescents' motivation to begin using alcohol, replacing them with norms stressing abstinence or controlled alcohol consumption. Third, these programs can be low-cost options for low income areas, which have traditionally been the most difficult to reach.

There are two windows of vulnerability for alcohol use and abuse.

The first, when chemical dependence generally starts, is between the ages of 12 and 21 . The other is in late middle age, in which problem drinking may act as a coping method for managing stress . Late onset problem drinkers are more likely to control their drinking on their own or be successfully treated, compared with people who have more long-term drinking problems Depression and alcoholism are linked. Alcoholism may represent untreated symptoms of depression, or depression may act as an impetus for drinking in an effort to improve mood. Accordingly, in some cases, symptoms of both disorders must be treated simultaneously

Taking a Public Health Approach

The increasing prevalence of obesity makes it evident that prevention is essential for combating this problem (Institute of Medicine, 2011d). Prevention with families at risk for having obese children is an important strategy. Parents should be trained early to adopt sensible meal-planning and eating habits that they can convey to their children. Although obesity has proven to be very difficult to modify with adults, it is easier to teach children healthy eating and activity habits. Obese children can benefit from lifestyle interventions involving reinforcements for giving up sedentary activities like television watching, inducements to engage in sports and other physical activities, and steps to encourage healthier eating practices including avoiding or eliminating snacking (Wilfley et al., 2007). School-based interventions directed to making healthy foods available and modifying sedentary behavior will help (Dietz & Gortmaker, 2001). The World Health Organization has argued for several changes, including food labels that contain more nutrition and serving size information, a special tax on foods that are high in sugar and fat (the so-called junk food tax), and restriction of advertising to children or required health warnings (Arnst, 2004). Some states now control the availability of junk food and sugary drinks in schools, products that have been linked directly to weight in children

Interventions to Reduce Smoking : Changing Attitudes Toward Smoking Taylor, Shelley; Taylor, Shelley. Health Psychology

The mass media have been effective in providing the educational base for anti-smoking attitudes. Most people now view smoking as an addiction with negative social consequences. Antismoking media messages have also been effective in discouraging adults and adolescents from beginning to smoke. However, education provides only a base and by itself may nudge people closer to the desire to quit but not to quitting itself.

Obesity is a chief cause of disability

The number of people age 30-49 who are too heavy to care for themselves or perform routine household tasks has jumped by 50 percent. This increase bodes poorly for the future. People who are disabled in their 30s and 40s are more likely to have health care expenses and to need nursing home care in older age, if they live that long (Richardson, 2004, January 9). Being obese also reduces the likelihood that a person will exercise, and lack of exercise increases obesity; yet obesity and lack of exercise appear to exert independent adverse effects on health, leading to greater risks than either risk factor alone. One in four people over 50 is obese, and as the population ages, the numbers of people who will have difficulty performing the basic tasks of daily living, such as bathing, dressing, or even walking, will be substantial. Obesity is tied to poor cognitive functioning as well .

Smoking Prevention Programs

The war on smoking also focuses on keeping potential smokers from starting. These smoking prevention programs aim to catch potential smokers early and attack the underlying motivations that lead people to smoke. Typically, these programs are implemented through the school system. They are inexpensive and efficient because little class time is needed and no training of school personnel is required. The central components of social influence interventions are: ∙ Information about the negative effects of smoking is carefully constructed to appeal to adolescents. ∙ Materials are developed to convey a positive image of the nonsmoker (rather than the smoker) as an independent, self-reliant individual. ∙ The peer group is used to foster not smoking rather than smoking.

Why Do People Smoke?

There appear to be genetic influences on smoking Genes that regulate dopamine functioning are likely candidates for these heritable influences. Cigarette smokers are generally less health conscious, less educated, and less intelligent than nonsmokers. Smoking and drinking often go together, and drinking seems to cue smoking. Smokers are more impulsive, have more accidents and injuries at work, take off more sick time, and use more health benefits than nonsmokers, thereby representing substantial costs to the economy. Smoking is an entry-level drug in childhood and adolescence for subsequent substance abuse: Trying cigarettes makes one significantly more likely to use other drugs in the future

What causes the high rates of obesity in childhood?

There are genetic contributors to obesity, which combine with risks conferred by low SES, increasing overall risk to be obese (Dinescu, Horn, Duncan, & Turkheimer, 2016). The impact of genetics on weight may be exerted in part by a vigorous feeding style that is evident early in life. There are also genetically based tendencies to store energy as fat rather than lean tissue. Another important factor is sedentary lifestyles, involving television, video games, and the Internet. Consumption of snacks and sugary drinks during the sedentary activities greatly increase the risks associated with obesity Children are less likely to be obese if they participate in organized sports or physical activity, but obese children may come from families that do not value or do not have access to exercise facilities (Kozo et al., 2012; Veitch et al., 2011). Children who take in too many calories in infancy and childhood are more likely to become obese adults (Kuhl et al., 2014). Even the family dog is more likely to be overweight in families with large portion sizes and low activity levels. By contrast, positive parenting can mitigate poorly controlled eating in children (Connell & Francis, 2014). Figure 5.2 illustrates the high rates of obesity among children.

Drinking and Driving

Thousands of vehicular fatalities result from drunk driving each year. Programs such as MADD (Mothers Against Drunk Driving), founded and staffed by the families and friends of those killed by drunk drivers, put pressure on state and local governments for tougher alcohol control measures and stiffer penalties for convicted drunk driver. Moreover, hosts and hostesses are now pressured to assume responsibility for the alcohol consumption of their guests. With increased media attention to the problem of drunk driving, drinkers seem to be developing self-regulatory techniques to avoid driving while drunk. These include limiting drinks to a prescribed number, arranging for a designated driver, getting a taxi, or delaying or avoiding driving after consuming alcohol. Although eliminating drinking altogether is unlikely to occur, the rising popularity of self-regulation to avoid drunk driving may help reduce this serious problem.

Cognitive-Behavioral Treatments

Treatment programs for alcoholism and problem drinking typically use cognitive-behavioral therapy (CBT) to treat the biological and environmental factors involved in alcoholism simultaneously (NIAAA, 2000b). The goals of CBT are to decrease the reinforcing properties of alcohol, to teach people new behaviors inconsistent with alcohol abuse, and to modify the environment to include reinforcements for activities that do not involve alcohol. Learning coping techniques for dealing with stress and relapse prevention skills enhance the prospects for long-term maintenance. Many CBT programs begin with a self-monitoring phase, in which the alcoholic or problem drinker charts situations that give rise to drinking. Motivational enhancement procedures are often included because the responsibility and the capacity to change rely entirely on the client (NIAAA, 2000a). Some programs also include medications for blocking the alcohol brain interactions that may contribute to alcoholism.

Treating Anorexia

bring the patient's weight back up to a safe level, a goal that often must be undertaken in a residential treatment setting, such as a hospital. To achieve weight gain, most therapies use cognitive behavioral approaches. cognitive behavioral therapy do not always work well with anorexics. Motivational issues are especially important, as inducing the anorexic to want to change her behavior is essential Family therapy may help families learn positive methods of communicating emotion and conflict. During the early phases of treatment, parents are urged to assume control over the anorexic family member's eating, but as the anorexic family member begins to gain weight and comply with parental authority, he or she (usually she) begins to assume more control over eating. Because of the health risks and difficulties in treating anorexia nervosa, research has increasingly moved toward prevention. Some interventions address social norms regarding thinness directly. For example, one study gave women information about other women's weight and body type, on the grounds that women who develop eating disorders often wrongly believe that other women are smaller and thinner than they actually are . The intervention succeeded in changing women's estimates of their actual and ideal weight

Bulimia

characterized by alternating cycles of binge eating and purging through such techniques as vomiting, laxative abuse, extreme dieting or fasting, and drug or alcohol abuse. Bingeing appears to be caused at least in part by dieting. About half the people diagnosed with anorexia are also bulimic. Bulimia affects 1-3 percent of women and an increasing number of men, and up to 10 percent of bulimics may have bingeing episodes.

Developing Bulimia

especially anWomen prone to bulimia, especially binge eating, appear to have altered stress responses, especially an atypical hypothalamic-pituitary adrenal diurnal pattern. Cortisol levels, especially in response to stress, may be elevated, promoting eating. Food can become a constant thought. Restrained eating, then, sets the stage for a binge. Bulimia may have a genetic basis, inasmuch as eating disorders cluster in families, and twin studies show a high concordance rate for binge eating. Families that place a high value on thinness and appearance are also likely to have bulimic daughters Physiological theories of bulimia focus on hormonal dysfunctions , low leptin functioning, hypothalamic dysfunction, food allergies, or disordered taste responsivity, disorder of the endogenous opioid system , neurological disorder, and a combination of these.

Obesity

fat should constitute about 20-27 percent of body tissue in women and about 15-22 percent in men. The average American's food intake rose from 1,826 calories a day in the 1970s to more than 2,000 by the mid-1990s. Soda consumption has skyrocketed from 22.2 gallons to 56 gallons per person per year. Portion sizes at meals have increased substantially over the past 20 years. Muffins that weighed 1.5 ounces in 1957 now average half a pound each. Snacking has increased more than 60 percent over the last three decades, and easy access to food through microwave ovens and fast food restaurants contributes to the increase. The average American weight gain over the past 20 years is the caloric equivalent of only three Oreo cookies or one can of soda a day (Critser, 2003), so it does not take vast quantities of food or sugary drinks to gain weight.

Physiological dependence

manifested in stereotypic drinking patterns (particular types of alcohol in particular quantities at particular times of day), drinking that maintains blood alcohol at a particular level, the ability to function at a level that would incapacitate less tolerant drinkers, increased frequency and severity of withdrawal, early-in-the-day and middle-of-the-night drinking, a sense of loss of control over drinking, and a subjective craving for alcohol

Is Modest Alcohol Consumption a Health Behavior?

modest alcohol intake may contribute to a longer life. Approximately one to two drinks a day (less for women) reduces risk of a heart attack, lowers risk factors associated with coronary heart disease, and reduces risk of stroke be especially true for older adults and senior citizens. Although many health care practitioners fall short of recommending that people have a drink or two each day, the evidence is mounting that modest drinking may actually reduce the risk for some major causes of death. Nonetheless, this remains an area of controversy.

Obesity and Dieting as Risk Factors for Obesity

obese have large fat cells, which have a greater capacity for producing and storing fat than do small fat cells. obese people have a high basal insulin level, which promotes overeating due to increased hunger. Dieting contributes to the propensity for obesity. Successive cycles of dieting and weight gain, so-called yo-yo dieting, enhance the efficiency of food use and lower the metabolic rate

Anorexia Nervosa

obsessive disorder amounting to self-starvation, in which an individual diets and exercises to the point that body weight is grossly below optimum level, threatening health and potentially leading to death. Most sufferers are young women, but gay & bisexual men are also at risk

alcoholic

reserved for someone who is physically addicted to alcohol. Alcoholics show withdrawal symptoms when they stop drinking, they have a high tolerance for alcohol, and they have little ability to control their drinking. Problem drinkers may not have these symptoms, but they may have social, psychological, and medical problems resulting from alcohol.

RELAPSE PREVENTION

the ability to remain abstinent shows a steady month-by-month decline, such that, within 2 years after smoking cessation, even the best programs do not exceed a 50 percent abstinence rate (Piasecki, 2006). Relapse prevention techniques begin by preparing people for withdrawal, including cardiovascular changes, increases in appetite, variations in the urge to smoke, increases in coughing and discharge of phlegm, and increases in irritability. These problems occur intermittently during the first 7-11 days. Relapse prevention also focuses on the ability to manage high-risk situations that lead to a craving for cigarettes, such as drinking coffee or alcohol and on coping techniques for dealing with stressful interpersonal situations. Some relapse prevention approaches include contingency contracting, in which the smoker pays a sum of money that is returned only on the condition of cutting down or abstaining. Like most addictive health habits, smoking shows an abstinence violation effect, whereby a single lapse reduces perceptions of self-efficacy, increases negative mood, and reduces beliefs that one will be successful in stopping smoking. Stress-triggered lapses lead to relapse more quickly than do other kinds . Consequently, smokers need to remind themselves that a single lapse is not necessarily worrisome, because many people lapse on the road to quitting. Sometimes, buddy systems or telephone counseling procedures can help quitters avoid turning a single lapse or a full blown relapse

Treatment Programs

the first phase of treatment is detoxification. Because this process can produce severe symptoms and health problems, detoxification is typically conducted in a carefully supervised and monitored medical setting. Once the alcoholic has at least partly dried out, therapy is initiated. The typical program begins with a short-term, intensive inpatient treatment followed by a period of continuing treatment on an outpatient basis A self-help group, especially Alcoholics Anonymous (AA), is the most commonly sought source of help for alcohol related problems

Set Point Theory of Weight

the idea that each individual has an ideal biological weight, which cannot be greatly modified. According to the theory, the set point acts like a thermostat regulating heat in a home. A person eats if his or her weight gets too low and stops eating as the weight reaches its ideal point. Some people have a higher set point than others, leading to a risk for obesity. The theory argues that efforts to lose weight may be compensated for by adjustments in energy expenditure, as the body actively attempts to return to its original weight. This theory applies to obese people too. Once obesity is established, it is often stamped in, and the body will defend against efforts to lose weight

EATING DISORDERS

the pursuit of thinness is a major public health threat. Women ages 15-24 are most likely to practice these behaviors, but cases of eating disorders have been documented in people as young as 7 and as old as their mid-80s. Eating disorders result in death for about 6 percent of those who have them. Suicide attempts are not uncommon. Women with eating disorders or tendencies toward them are also more likely to be depressed, anxious, and low in selfesteem and to have a poor sense of mastery.

Binge Eating Disorder

usually occurs when the individual is alone; it may be triggered by negative emotions produced by stressful experiences. The dieter begins to eat and then cannot stop, and although the bingeing is unpleasant, the binger feels out of control, unable to stop eating. Low self esteem is implicated in binge eating and may be a good target for prevention and treatment. Many people with binge eating disorder also have a mental health disorder, such as anxiety or depression Binge eating disorder is a health problem at least on a scale with bulimia. However, many people with the disorder do not seek or obtain treatment. Binge eating increases in response to stress, and a rise in ghrelin, which controls the urge to eat, may be responsible. People with binge eating disorders are characterized by an excessive concern with body and weight; a preoccupation with dieting; a history of depression, psychopathology, and alcohol or drug abuse; and difficulties with managing work and social settings . Overvaluing body appearance, a larger body mass than is desired, dieting, and symptoms of depression are implicated in triggering binge episodes.

CHARACTERISTICS OF HEALTH-COMPROMISING BEHAVIORS

window of vulnerability in adolescence. Behaviors such as drinking to excess, smoking, using illicit drugs, practicing unsafe sex, and taking risks that can lead to accidents or early death all begin in early adolescence and sometimes cluster together as part of a problem behavior syndrome obesity, for example, can begin early in childhood. Many of these behaviors are tied to the peer culture, as children learn from and imitate their peers, especially the male peers they like and admire. Wanting to be attractive to others becomes very important in adolescence, and this factor is significant in the development of eating disorders, alcohol consumption, tobacco and drug use, tanning, unsafe sexual encounters, and vulnerability to injury. Exposure to peers' risky behavior, such as unsafe driving, increases risk-taking. Many of these behaviors are pleasurable, enhancing the adolescent's ability to cope with stressful situations, and some represent thrill seeking, which can be rewarding in its own right. However, each of these behaviors is also dangerous. Each has been tied to at least one major cause of death, and several, especially smoking and obesity, are risk factors for more than one major chronic disease. Adolescents who slip into these patterns are less likely to practice good health habits and use leisure time for exercise in midlife, setting the stage for an unhealthy middle and older age Third, these behaviors develop gradually, as the person is exposed to the behavior, experiments with it, and later engages in it regularly. As such, many health compromising behaviors are acquired through a process that makes different interventions important at the different stages of vulnerability, experimentation, and regular use. Fourth, substance abuse of all kinds, whether cigarettes, food, alcohol, drugs, or health-compromising sexual behavior, are predicted by some of the same factors. Adolescents who get involved in risky behaviors often have conflict with their parents. Adolescents with a penchant for deviant behavior and with low selfesteem also show these behaviors. Adolescents who try to combine long hours of employment with school have an increased risk of alcohol, cigarette, and marijuana abuse (Johnson, 2004). Adolescents who abuse substances typically do poorly in school; family problems, deviance, and low self-esteem appear to explain this relationship. Reaching puberty early, and having a low IQ, a difficult temperament, and deviance-tolerant attitudes predict poor health behaviors. Good self control diminishes and poor self-regulation facilitates vulnerability to substance use. But co-occurring mental health disorders, such as depression or anxiety, may fuel these problem behaviors and make them harder to treat more common in the lower social classes the circuitry that controls reward and pleasure/pain

Why Is Smoking So Hard to Change?

• Tobacco addiction typically begins in adolescence, when smoking is associated with pleasurable activities. • Smoking patterns are highly individualized, and group interventions may not address all the motives underlying any particular smoker's smoking. • Stopping smoking leads to short-term unpleasant withdrawal symptoms such as distractibility, nausea, headaches, constipation, drowsiness, fatigue, insomnia, anxiety, irritability, and hostility. • Smoking is mood elevating and helps to keep anxiety, irritability, and hostility at bay. • Smoking keeps weight down, a particularly significant factor for adolescent girls and adult women. • Smokers are unaware of the benefits of remaining abstinent over the long term, such as improved psychological well-being, higher energy, better sleep, higher self-esteem, and a sense of mastery.

Workplace

Initially, workplace interventions were thought to hold promise in smoking cessation efforts. To date, however, workplace interventions are not more effective than other intervention programs (Facts of Life, July 2005). However, when workplace environments are entirely smoke free, employees smoke much less

Interventions

More people are treated for obesity in the United States than for all other health habits or conditions combined. More than half a million people attend weight-loss clinics, and Amazon.com lists more than 169,000 book titles that refer to diet or dieting. However, obesity is a very difficult condition to treat. Even initially successful weight-loss programs show a high rate of relapse. Exercise Exercise is critical to reducing weight. It can even change the underlying propensity to gain weight; that is, exercise can help reprogram genes that influence how fat is stored, making obesity less likely (The Economist, July 13, 2013). Sleep Some obese people have an altered sleep pattern, whereby they work when others are sleeping. By working when they are supposed to be asleep, their bodies become used to not expending much energy either during the day or at night, and overall fewer calories are burned (Healy, 2014). Dieting Most weight-loss programs begin with dietary treatment. People are trained to restrict their caloric and/or carbohydrate intake. In some cases, food may be provided to the dieters to ensure that the appropriate foods are being consumed. Generally, weight loss produced through dietary methods is small and rarely maintained for long (Agras et al., 1996). In fact, as Box 5.2 shows, dieting has risks. Very low-carbohydrate or low-fat diets do the best job in helping people lose weight initially, but these diets are the hardest to maintain, and people commonly revert to their old habits. Reducing caloric intake, increasing exercise, and sticking with an eating plan over the long term are the only factors reliably related to staying slim. Beginning as early as preschool, these are the best ways to tackle obesity (Kuhl et al., 2014). Surgery Surgical procedures represent a radical way of controlling extreme obesity. In one common surgical procedure, the stomach is literally stapled up to reduce its capacity to hold food, so that the overweight individual must restrict his or her intake. In another approach known as lap band surgery, an adjustable gastric band is inserted surgically around the top of the stomach to create a small pouch in the upper stomach to reduce the stomach's capacity to take in food. As with all surgeries, there are potential side effects such as gastric and intestinal distress. Consequently, this procedure is usually reserved for people who are at least 100 percent overweight, who have failed repeatedly to lose weight through other methods, and who have complicating health problems that make weight loss urgent. Cognitive Behavioral Therapy (CBT) Researchers now believe that the compulsive overeating that leads to obesity shares the same brain circuitry as other addictive disorders, making it a difficult problem to treat, like smoking or drug addiction Screening Some programs begin by screening applicants for their readiness to lose weight and their motivation to do so. Unsuccessful prior dieting attempts, weight lost and regained, high body dissatisfaction, and low self-esteem can all undermine weight loss efforts . Self-Monitoring Obese clients are trained in self-monitoring, to keep careful records of what they eat, when they eat it, how much they eat, and where they eat it. This record keeping simultaneously defines the behavior, makes clients more aware of their eating patterns, and can lead to beginning efforts to lose weight. Even online self-monitoring has been tied to weight loss Attentional Retaining People who are battling a health issue such as obesity or smoking will often show an attentional bias in favor of cues related to the issue. For example, an obese person may orient to food cues, such as appealing high-calorie foods, or a store window with rich foods (Kemps, Tiggemann, & Hollitt, 2014). Obese children whose attention goes to food may also gain weight (Werthmann et al., 2015). Attentional retaining involves breaking or at least moderating this automatic attentional bias by distracting one's self, focusing on other aspects of the environment, or even physical activity. Stimulus Control Clients are trained to modify the stimuli in their environment that have previously elicited and maintained their overeating and to take steps to modify their food consumption. Such steps include purchasing low-calorie foods (such as raw vegetables) and limiting the high-calorie foods kept in the house. Clients are taught to confine eating to one place at particular times of day, and to develop new discriminative stimuli that will be associated with eating, for example, using a particular place setting, such as a special placemat or napkin, and to eat only when those stimuli are present. Keeping portion size modest is also important Controlling Eating The next step is to gain control over the eating process itself. For example, clients may be urged to count each mouthful of food. They may be told to put down eating utensils after every few mouthfuls until the food in their mouths is chewed and swallowed. Longer and longer delays are introduced between mouthfuls so as to encourage slow eating (which tends to reduce intake). Finally, clients are urged to savor their food—to make a conscious effort to appreciate it while they are eating. The goal is to teach the obese person to eat less and enjoy it more. Self Reinforcement Success can be supported by a positive reinforcement, such as going to a movie or making a facebook message to a friend. Developing a sense of self-control over eating is an important part of behavioral treatment of obesity and can help people overcome temptations. Succeeding in losing weight is tied to greater vitality and psychological well-being (Swencionis et al., 2013), and this can act as another source of selfreinforcement. Controlling Self-Talk Cognitive restructuring is an important part of weight-reduction programs. As noted in Chapter 3, poor health habits can be maintained through dysfunctional monologues ("I'll never lose weight—I've tried before and failed so many times"). Participants in weight-loss programs are urged to identify the maladaptive thoughts they have regarding weight loss and to substitute positive selfinstruction. The formation of explicit implementation intentions (Luszczynska, Sobczyk, & Abraham, 2007) and a strong sense of self-efficacy—that is, the belief that one will be able to lose weight—also predicts weight loss (Warziski, Sereika, Styn, Music, & Burke, 2008). The goal of these aspects of interventions is to increase a sense of selfdetermination, which can enhance intrinsic motivation to continue diet modification and weight loss Adding Exercise Exercise is a critical component of any weight-loss program. As people age, increasing physical activity is essential just to maintain weight, let alone avoid gaining it (Jameson, 2004). Stress Management Efforts to lose weight can be stressful (Tomiyama et al., 2010), and so reducing life stress can be helpful. Among the techniques that have been used are mindfulness training and acceptance and commitment theory (ACT). Social Support Because people with strong social support are more successful at losing weight than those with little social support, most CBT programs include training in eliciting effective support from families, friends, and coworkers. Even supportive messages from a behavioral therapist over the Internet seem to help people lose weight (Oleck, 2001). Autonomy support, that is, social support that conveys the belief that the person is an autonomous, responsible agent of his/her own behavior appears to foster self regulation that can lead to more weight loss better than more directive support