The MOVE Obesity Intervention for Veterans Keeps Obesity Prevalence Stagnant – Sarah Abramovitz
Given the current political climate and the ongoing war abroad, more attention than usual is being paid to our nation’s soldiers. Soldiers do a dangerous and taxing service for the country and they suffer as a result. The effects of their service last long after they return home from deployment. The Veterans Health Administration (VA) was instated in order to treat the mental and physical health needs of veterans. More recently, given rising global awareness of the obesity epidemic as a major public health problem, studies have documented that veterans have not been spared from the obesity trend. In fact, veterans are particularly at-risk for obesity compared to the general population due to acute and chronic morbidity. A study of VA patients found that 75% of the participants were overweight or obese (1) which is greater than the prevalence of overweight and obesity in the general population (65% as reported by 2, 3).
There are multiple synergistic factors that lead to obesity in the veteran community. Veterans who get healthcare at VA hospitals tend to be an older population with more chronic physical and mental health problems than the general population (4). The veteran population is sicker, older, more disabled, less educated, more likely to be African American and poorer (5, 6). They are also more likely to have posttraumatic stress disorder and abuse substances. Many detrimental health outcomes are highly correlated with obesity (e.g., diabetes, hypertension and cardiovascular disease; 7, 8) and multiple studies have found that there is a high disease burden associated with excess weight in VA patients (1, 9).
The obesity epidemic has been associated with a dramatic increase in related healthcare costs (10, 11). Consequently, the VA is invested in reducing obesity among the population it treats (1, 6). The MOVE program (Managing Overweight and Obesity in Veterans Everywhere) is a nationally mandated VA weight management program created in 2006 and designed by the VA National Center for Health Promotion and Disease Prevention (NCP). The program has 5 levels of treatment: Level 1 = Individual treatment: individuals identified as overweight or obese by their primary care provider take an online questionnaire and are given handouts to educate and aid in weight reduction. Level 2 = Group treatment: group health education classes. Level 3: Medication management. Level 4: Residential treatment for weight loss, Level 5: Bariatric surgery. The majority of veterans involved with MOVE are in levels 1 or 2 and currently only these two levels are mandated nationwide. Therefore, the rest of this critique will focus solely on MOVE’s individual and group level treatments. The MOVE program was established in order to counteract the declining health of veterans which is exacerbated by poor weight management. However, the MOVE obesity intervention relies on an ineffective public health model and strategy toward behavior change, does not invoke autonomous motivation, and limits self-efficacy to carry out health behaviors within the VA, thus fails to transform the obesogenic veteran community.
The MOVE program is based on an ineffective model of behavior change
The MOVE program will be unsuccessful in veteran weight reduction because the dominant conceptual model guiding this intervention is the Health Belief Model, a traditional public health model which focuses on individual behavior change rather than community level factors (12). While this model has been the basis for the majority of public health interventions in the last 30 years (13), it is an ineffective behavior change model for two reasons: 1) it assumes that intention leads to behavior and 2) it assumes behavior change is a rational, cognitive decision making process (13). Historically, these two facets of the health belief model have failed in weight management interventions (13), so there is no reason to believe this behavior change model will be effective for the veteran population.
Empirical studies have not been successful in finding support for cognitive mediators of behavior change in weight loss (13). As such, increasing evidence suggests that obesity is not simply a problem of will power or self-control (14). In 2005, Wang studied weight-related beliefs and behaviors in the veteran population. He found that the majority (75%) of obese VA users reported trying to lose weight, 93% tried to lose or maintain weight, and another 17% reported trying to maintain their weight (5). Additional data from Wang’s study suggests that veterans are aware that weight loss is good for their health and that in order to lose weight they need to eat less and exercise more. 85% of VA users participating in the study reported they were reducing intake of calories, fat, or both and 53% reported increasing physical activity. Despite these encouraging results, the prevalence of obese and overweight veterans continues to climb. These unintuitive findings suggest that weight gain in veterans is irrational and independent of intention.
Based on these data, the MOVE intervention uses an ineffective and inappropriate basic strategy to address obesity. As described by Chin and Benne (15), the MOVE intervention uses the empirical-rational strategy which relies on education to influence behavior change. Education based programs increase awareness of the poor outcomes related to unhealthy behavior, however may fail to change actual health outcomes. Author Paul Campos summarizes the phenomenon of failing education programs explicitly, “In a nation in which food is cheap and plentiful, and in which it is easy to become sedentary, telling people they should lose weight by eating less and exercising more does not work”(16).
The MOVE program does not emphasize ‘autonomy support’ as a source of motivation for behavior change and maintenance
Not only does the MOVE program use inappropriate content for successful health behavior change, it also fails to implement a key approach in delivering the program: enhancing motivation through increasing autonomy. The MOVE program fails to elicit autonomy in two ways: 1) The recruitment process: veterans who are identified by their VA primary care physician as overweight or obese are strongly encouraged to participate in the MOVE program. 2) Identified veterans are then assigned to individual and group education classes. Both of these mechanisms in MOVE can be regarded as “controlled behaviors: ones for which the regulation is experienced as pressured or coerced by some outside force” (17).
Self-determination theory (SDT; 18) proposes that behavior change will occur and persist if the new behavior is motivated by autonomy. SDT suggests that lasting behavior change depends “not on complying with demands for change”, likened to the tactics used in MOVE, but rather “on accepting the behavior change as stemming from one’s own volition”(17). SDT posits that successful, maintained weight reduction results because an individual personally values weight loss and its health benefits. One’s behavior change will be maintained, the theory asserts, when the “reasons for action are truly their own” (17).
According to self-determination theory, autonomy in behavior change can be manipulated by social-contextual conditions (19). In other words, in order to promote effective, long-term behavior change, “a successful intervention must offer choice, provide a meaningful rationale, minimize pressure, and acknowledge the individual's feelings and perspective”, a term deemed by Williams et al. as “autonomy support”(17). For example, past research has revealed that autonomy support led to “greater persistence at the target behavior and to more positive affect” (20). More recently, SDT has been applied to health related domains such as weight management programs and received similar support. Williams et al. (17) tested the SDT with a sample of participants in an obesity intervention and confirmed the theoretical foundation for SDT. Participants whose motivation for weight loss was more autonomous attended the program more regularly, lost more weight during the program, and maintained greater weight loss (17). Additionally, participants' autonomous motivation for weight loss depended on the perceived autonomy supportiveness of the weight loss program created by the health-care staff (17).
The current method of recruitment and assignment that the MOVE program subsists on does not elicit the type of motivation essential to effective behavior change. Therefore, in order for the MOVE program to succeed in promoting acute and long term weight loss, it needs to enhance and emphasize the importance of autonomy support.
Without promoting healthy behaviors in its environment, the VA fails to instill self-efficacy
Although the official position of the VA is that it supports healthy weight reduction behaviors, in practice the VA building itself does not address the environmental barriers to a healthy lifestyle that influence over-eating and under-exercising. While a participant in the MOVE program might learn what a healthy low calorie meal consists of, they are literally unable to make healthy meal choices at the VA. Currently, there is sparse availability of healthy foods at VA hospitals. Calorie-dense foods dominate the cafeteria, gift shop and vending machines. Making the food at the VA healthier would decrease geographic and economic disparities in access to healthy food between veterans getting care at VA hospitals. Currently, there is no initiative to change the built environment of the VA to promote physical activity such as walking or taking the stairs. A healthier environment at the VA would promote health behaviors at home through changing social norms of ‘battle buddies’, a powerful military ideology (21).
Albert Bandura’s social cognitive theory (SCT) and concept of self-efficacy is useful in understanding this important deficit of the MOVE program. SCT posits that an individual’s decision to engage in a behavior is influenced by the individual’s perception of self-efficacy: the belief that he or she can successfully complete the behavior. People with high levels of self-efficacy are more likely to try to engage in a new behavior, and it has been proven that self-efficacy is particularly important in weight reduction. Data from several studies have demonstrated that higher self-efficacy was predictive of weight loss (22-24). Bandura postulated that self-efficacy can be influenced by vicarious experiences (modeling from others) and social persuasions (encouragement or discouragement from others). However, the influences of vicarious experiences and social persuasions do not have room to take effect in the VA, given the unhealthy atmosphere. Educating individuals and providing examples of healthful behaviors (the main tactic of the MOVE program) is not enough to promote self-efficacy. MOVE will not succeed unless the environment at the VA supports the desired behaviors, thus promoting self-efficacy.
Conclusion
While the MOVE program may succeed in initiating dialogue among veterans about healthy eating and exercise behaviors, the program does little to actually change entrenched poor health behaviors in veterans. MOVE is based on a traditional public health model that has historically failed in obesity interventions due to its assumption that rational thought is implicated in altering behavior and its emphasis on individual behavior change. MOVE relies almost entirely on the dissemination of health education which is moot when the population is aware of healthy practices to begin with. What is more, MOVE’s implementation style does not encourage autonomy support, a tactic proven to generate lasting motivation for behavior change in individuals. Additionally, the environment of the VA exists in opposition the teachings of MOVE, a reality that limits self-efficacy, an important predictor of weight loss. As described by Edberg (25, pg. 37), the MOVE program succumbs to the “EZ program structure illusion”; such that the program fails to consider the complexity of human behavior and continues to use the same, tired, ineffective model for a weight management intervention that has been proven not to work.
Obesity is a complex problem with no easy solution. There are cultural, medical and community level factors that encourage obesity in veterans. We need to challenge the dogma of traditional public health approaches to combat obesity and think about new approaches to alleviate the overweight and obesity epidemic. Future public health obesity interventions with the veteran population must use alternative health behavior change models which focus on the group level interventions.
REFERENCES
1. Nowicki EM, Billington CJ, Levine AS, Hoover H, Must A & Naumova E. Overweight, obesity, and associated disease burden in the Veterans Affairs ambulatory care population. Military Medicine 2003, 168: 252-6.
2. Flegal KM, Carroll MD, Kuczmarski RJ & Johnson CL. Overweight and obesity in the United States: Prevalence and trends. 1960– 1994. International Journal of Obesity and Related Metabolic Disorders 1998, 22: 39–47.
3. Flegal KM, Carroll MD, Ogden CL & Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. Journal of the American Medical Association 2002, 288: 1723–1727.
4. Agha Z, Lofgren RP, VanRuiswyk JV & Layde PM. Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Archives of Internal Medicine 2000, 160: 3252-3257.
5. Wang A, Kinsinger LS, Kahwati LC, Das SR, Gizlice Z, Harvey RT, et al. Obesity and weight control practices in 2000 among veterans using VA facilities. Obesity Research 2005, 13: 1405-1411.
6. Das SR, Kinsinger LS, Yancy WS, Jr., Wang A, Ciesco E, Burdick M, et al. Obesity prevalence among veterans at Veterans Affairs medical facilities. American Journal of Preventitive Medicine 2005, 28: 291-294.
7. Lee IM, Rexrode KM, Cook NR, Manson JE & Buring JE. Physical activity and coronary heart disease in women: Is ‘no pain, no gain’ passe? Journal of the American Medical Association 2001, 285: 1447–1454.
8. Kenchaiah S, Evans JC, Levy D, Wilson PW, Benjamin EJ, Larson MG, et al. Obesity and the risk of heart failure. New England Journal of Medicine 2002, 347: 305–313.
9. Kress AM, Hartzel MC & Peterson MR. Burden of disease associated with overweight and obesity among U.S. military retirees and their dependents, aged 38-64. Preventative Medicine 2005, 41.
10. Cortes LM. Formative research to inform intervention development for diabetes prevention in the Republic of the Marshall Islands. Health Education and Behavior 2001, 28: 696–715.
11. Finkelstein EA, Fiebelkorn IC & Wang G. National medical spending attributable to overweight and obesity: how much, and who's paying? Health Aff (Millwood) 2003, Suppl Web Exclusives: W3-219-26.
12. Becker MH. The health belief model and personal health behavior. Health Education Monograph 1974, 2.
13. Jeffery RW. How can Health Behavior Theory be made more useful for intervention research? International Journal of Behavioral Nutrition and Physical Activity 2004, 1.
14. Lang A. Management of overweight and obesity in adults: behavioral intervention for long-term weight loss and maintenance. European Journal of Cardiovascular Nursing 2006, 5: 102-114.
15. Chin R & Benne KD. General Strategies for Effective Change in Human Systems. In Bennis WG ed, The Planning Change, (pp. 22-45). New York: Holt, Rinehart, Wilson, 1976.
16. Campos P. The Obesity Myth: Why America's Obsession with Weight is Hazardous to your Health (pp. 247-251). New York: Gotham Books, 2004.
17. Williams GC, Grow VM, Freedman ZR, Ryan RM & Deci EL. Motivational predictors of weight loss and weight-loss maintenance. Journal of Personality and Social Psychology 1996, 70: 115-126.
18. Deci EL & Ryan RM. Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum, 1985.
19. Deci EL & Ryan RM. The General Causality Orientations Scale: Self-determination in personality. Journal of Research in Personality 1985, 19: 109-134.
20. Deci EL, Eghrari H, Patrick BC & Leone DR. Facilitating internalzation: The self-determination theory perspective. Journal of Personality 1994, 62: 119-142.
21. Adler AB, Castro CA, Bliese PD, McGurk D & Milliken C. The efficacy of Battlemind training at 3-6 months post-deployment. In CA Castro (Chair), The Battlemind training system: Supporting soldiers throughout the deployment cycle, Symposium conducted at the meeting of the American Psychological Association. San Francisco, CA, 2007.
22. Jeffery RW, Bjornson-Benson WM, Rosenthal BS, Lindquist RA, Kurth CL & Johnson SL. Correlates of weight loss and its maintenance over two years of follow-up among middle-aged men. Preventative Medicine 1984, 13: 155–168.
23. Forster JL & Jeffery RW. Gender differences related to weight history, eating patterns, efficacy expectations, self-esteem, and weight loss among participants in a weight reduction program. Addictive Behaviors 1986, 11: 141–147.
24. Linde JA, Jeffery RW, Levy RL, Sherwood NE, Utter J, Pronk NP, et al. Binge eating disorder, weight control self-efficacy, and depression in overweight men and women. International Journal of Obesity and Metabolic Disorders 2004, 28: 418–425.
25. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury: Jones and Bartlett, 2007.
There are multiple synergistic factors that lead to obesity in the veteran community. Veterans who get healthcare at VA hospitals tend to be an older population with more chronic physical and mental health problems than the general population (4). The veteran population is sicker, older, more disabled, less educated, more likely to be African American and poorer (5, 6). They are also more likely to have posttraumatic stress disorder and abuse substances. Many detrimental health outcomes are highly correlated with obesity (e.g., diabetes, hypertension and cardiovascular disease; 7, 8) and multiple studies have found that there is a high disease burden associated with excess weight in VA patients (1, 9).
The obesity epidemic has been associated with a dramatic increase in related healthcare costs (10, 11). Consequently, the VA is invested in reducing obesity among the population it treats (1, 6). The MOVE program (Managing Overweight and Obesity in Veterans Everywhere) is a nationally mandated VA weight management program created in 2006 and designed by the VA National Center for Health Promotion and Disease Prevention (NCP). The program has 5 levels of treatment: Level 1 = Individual treatment: individuals identified as overweight or obese by their primary care provider take an online questionnaire and are given handouts to educate and aid in weight reduction. Level 2 = Group treatment: group health education classes. Level 3: Medication management. Level 4: Residential treatment for weight loss, Level 5: Bariatric surgery. The majority of veterans involved with MOVE are in levels 1 or 2 and currently only these two levels are mandated nationwide. Therefore, the rest of this critique will focus solely on MOVE’s individual and group level treatments. The MOVE program was established in order to counteract the declining health of veterans which is exacerbated by poor weight management. However, the MOVE obesity intervention relies on an ineffective public health model and strategy toward behavior change, does not invoke autonomous motivation, and limits self-efficacy to carry out health behaviors within the VA, thus fails to transform the obesogenic veteran community.
The MOVE program is based on an ineffective model of behavior change
The MOVE program will be unsuccessful in veteran weight reduction because the dominant conceptual model guiding this intervention is the Health Belief Model, a traditional public health model which focuses on individual behavior change rather than community level factors (12). While this model has been the basis for the majority of public health interventions in the last 30 years (13), it is an ineffective behavior change model for two reasons: 1) it assumes that intention leads to behavior and 2) it assumes behavior change is a rational, cognitive decision making process (13). Historically, these two facets of the health belief model have failed in weight management interventions (13), so there is no reason to believe this behavior change model will be effective for the veteran population.
Empirical studies have not been successful in finding support for cognitive mediators of behavior change in weight loss (13). As such, increasing evidence suggests that obesity is not simply a problem of will power or self-control (14). In 2005, Wang studied weight-related beliefs and behaviors in the veteran population. He found that the majority (75%) of obese VA users reported trying to lose weight, 93% tried to lose or maintain weight, and another 17% reported trying to maintain their weight (5). Additional data from Wang’s study suggests that veterans are aware that weight loss is good for their health and that in order to lose weight they need to eat less and exercise more. 85% of VA users participating in the study reported they were reducing intake of calories, fat, or both and 53% reported increasing physical activity. Despite these encouraging results, the prevalence of obese and overweight veterans continues to climb. These unintuitive findings suggest that weight gain in veterans is irrational and independent of intention.
Based on these data, the MOVE intervention uses an ineffective and inappropriate basic strategy to address obesity. As described by Chin and Benne (15), the MOVE intervention uses the empirical-rational strategy which relies on education to influence behavior change. Education based programs increase awareness of the poor outcomes related to unhealthy behavior, however may fail to change actual health outcomes. Author Paul Campos summarizes the phenomenon of failing education programs explicitly, “In a nation in which food is cheap and plentiful, and in which it is easy to become sedentary, telling people they should lose weight by eating less and exercising more does not work”(16).
The MOVE program does not emphasize ‘autonomy support’ as a source of motivation for behavior change and maintenance
Not only does the MOVE program use inappropriate content for successful health behavior change, it also fails to implement a key approach in delivering the program: enhancing motivation through increasing autonomy. The MOVE program fails to elicit autonomy in two ways: 1) The recruitment process: veterans who are identified by their VA primary care physician as overweight or obese are strongly encouraged to participate in the MOVE program. 2) Identified veterans are then assigned to individual and group education classes. Both of these mechanisms in MOVE can be regarded as “controlled behaviors: ones for which the regulation is experienced as pressured or coerced by some outside force” (17).
Self-determination theory (SDT; 18) proposes that behavior change will occur and persist if the new behavior is motivated by autonomy. SDT suggests that lasting behavior change depends “not on complying with demands for change”, likened to the tactics used in MOVE, but rather “on accepting the behavior change as stemming from one’s own volition”(17). SDT posits that successful, maintained weight reduction results because an individual personally values weight loss and its health benefits. One’s behavior change will be maintained, the theory asserts, when the “reasons for action are truly their own” (17).
According to self-determination theory, autonomy in behavior change can be manipulated by social-contextual conditions (19). In other words, in order to promote effective, long-term behavior change, “a successful intervention must offer choice, provide a meaningful rationale, minimize pressure, and acknowledge the individual's feelings and perspective”, a term deemed by Williams et al. as “autonomy support”(17). For example, past research has revealed that autonomy support led to “greater persistence at the target behavior and to more positive affect” (20). More recently, SDT has been applied to health related domains such as weight management programs and received similar support. Williams et al. (17) tested the SDT with a sample of participants in an obesity intervention and confirmed the theoretical foundation for SDT. Participants whose motivation for weight loss was more autonomous attended the program more regularly, lost more weight during the program, and maintained greater weight loss (17). Additionally, participants' autonomous motivation for weight loss depended on the perceived autonomy supportiveness of the weight loss program created by the health-care staff (17).
The current method of recruitment and assignment that the MOVE program subsists on does not elicit the type of motivation essential to effective behavior change. Therefore, in order for the MOVE program to succeed in promoting acute and long term weight loss, it needs to enhance and emphasize the importance of autonomy support.
Without promoting healthy behaviors in its environment, the VA fails to instill self-efficacy
Although the official position of the VA is that it supports healthy weight reduction behaviors, in practice the VA building itself does not address the environmental barriers to a healthy lifestyle that influence over-eating and under-exercising. While a participant in the MOVE program might learn what a healthy low calorie meal consists of, they are literally unable to make healthy meal choices at the VA. Currently, there is sparse availability of healthy foods at VA hospitals. Calorie-dense foods dominate the cafeteria, gift shop and vending machines. Making the food at the VA healthier would decrease geographic and economic disparities in access to healthy food between veterans getting care at VA hospitals. Currently, there is no initiative to change the built environment of the VA to promote physical activity such as walking or taking the stairs. A healthier environment at the VA would promote health behaviors at home through changing social norms of ‘battle buddies’, a powerful military ideology (21).
Albert Bandura’s social cognitive theory (SCT) and concept of self-efficacy is useful in understanding this important deficit of the MOVE program. SCT posits that an individual’s decision to engage in a behavior is influenced by the individual’s perception of self-efficacy: the belief that he or she can successfully complete the behavior. People with high levels of self-efficacy are more likely to try to engage in a new behavior, and it has been proven that self-efficacy is particularly important in weight reduction. Data from several studies have demonstrated that higher self-efficacy was predictive of weight loss (22-24). Bandura postulated that self-efficacy can be influenced by vicarious experiences (modeling from others) and social persuasions (encouragement or discouragement from others). However, the influences of vicarious experiences and social persuasions do not have room to take effect in the VA, given the unhealthy atmosphere. Educating individuals and providing examples of healthful behaviors (the main tactic of the MOVE program) is not enough to promote self-efficacy. MOVE will not succeed unless the environment at the VA supports the desired behaviors, thus promoting self-efficacy.
Conclusion
While the MOVE program may succeed in initiating dialogue among veterans about healthy eating and exercise behaviors, the program does little to actually change entrenched poor health behaviors in veterans. MOVE is based on a traditional public health model that has historically failed in obesity interventions due to its assumption that rational thought is implicated in altering behavior and its emphasis on individual behavior change. MOVE relies almost entirely on the dissemination of health education which is moot when the population is aware of healthy practices to begin with. What is more, MOVE’s implementation style does not encourage autonomy support, a tactic proven to generate lasting motivation for behavior change in individuals. Additionally, the environment of the VA exists in opposition the teachings of MOVE, a reality that limits self-efficacy, an important predictor of weight loss. As described by Edberg (25, pg. 37), the MOVE program succumbs to the “EZ program structure illusion”; such that the program fails to consider the complexity of human behavior and continues to use the same, tired, ineffective model for a weight management intervention that has been proven not to work.
Obesity is a complex problem with no easy solution. There are cultural, medical and community level factors that encourage obesity in veterans. We need to challenge the dogma of traditional public health approaches to combat obesity and think about new approaches to alleviate the overweight and obesity epidemic. Future public health obesity interventions with the veteran population must use alternative health behavior change models which focus on the group level interventions.
REFERENCES
1. Nowicki EM, Billington CJ, Levine AS, Hoover H, Must A & Naumova E. Overweight, obesity, and associated disease burden in the Veterans Affairs ambulatory care population. Military Medicine 2003, 168: 252-6.
2. Flegal KM, Carroll MD, Kuczmarski RJ & Johnson CL. Overweight and obesity in the United States: Prevalence and trends. 1960– 1994. International Journal of Obesity and Related Metabolic Disorders 1998, 22: 39–47.
3. Flegal KM, Carroll MD, Ogden CL & Johnson CL. Prevalence and trends in obesity among US adults, 1999-2000. Journal of the American Medical Association 2002, 288: 1723–1727.
4. Agha Z, Lofgren RP, VanRuiswyk JV & Layde PM. Are patients at Veterans Affairs medical centers sicker? A comparative analysis of health status and medical resource use. Archives of Internal Medicine 2000, 160: 3252-3257.
5. Wang A, Kinsinger LS, Kahwati LC, Das SR, Gizlice Z, Harvey RT, et al. Obesity and weight control practices in 2000 among veterans using VA facilities. Obesity Research 2005, 13: 1405-1411.
6. Das SR, Kinsinger LS, Yancy WS, Jr., Wang A, Ciesco E, Burdick M, et al. Obesity prevalence among veterans at Veterans Affairs medical facilities. American Journal of Preventitive Medicine 2005, 28: 291-294.
7. Lee IM, Rexrode KM, Cook NR, Manson JE & Buring JE. Physical activity and coronary heart disease in women: Is ‘no pain, no gain’ passe? Journal of the American Medical Association 2001, 285: 1447–1454.
8. Kenchaiah S, Evans JC, Levy D, Wilson PW, Benjamin EJ, Larson MG, et al. Obesity and the risk of heart failure. New England Journal of Medicine 2002, 347: 305–313.
9. Kress AM, Hartzel MC & Peterson MR. Burden of disease associated with overweight and obesity among U.S. military retirees and their dependents, aged 38-64. Preventative Medicine 2005, 41.
10. Cortes LM. Formative research to inform intervention development for diabetes prevention in the Republic of the Marshall Islands. Health Education and Behavior 2001, 28: 696–715.
11. Finkelstein EA, Fiebelkorn IC & Wang G. National medical spending attributable to overweight and obesity: how much, and who's paying? Health Aff (Millwood) 2003, Suppl Web Exclusives: W3-219-26.
12. Becker MH. The health belief model and personal health behavior. Health Education Monograph 1974, 2.
13. Jeffery RW. How can Health Behavior Theory be made more useful for intervention research? International Journal of Behavioral Nutrition and Physical Activity 2004, 1.
14. Lang A. Management of overweight and obesity in adults: behavioral intervention for long-term weight loss and maintenance. European Journal of Cardiovascular Nursing 2006, 5: 102-114.
15. Chin R & Benne KD. General Strategies for Effective Change in Human Systems. In Bennis WG ed, The Planning Change, (pp. 22-45). New York: Holt, Rinehart, Wilson, 1976.
16. Campos P. The Obesity Myth: Why America's Obsession with Weight is Hazardous to your Health (pp. 247-251). New York: Gotham Books, 2004.
17. Williams GC, Grow VM, Freedman ZR, Ryan RM & Deci EL. Motivational predictors of weight loss and weight-loss maintenance. Journal of Personality and Social Psychology 1996, 70: 115-126.
18. Deci EL & Ryan RM. Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum, 1985.
19. Deci EL & Ryan RM. The General Causality Orientations Scale: Self-determination in personality. Journal of Research in Personality 1985, 19: 109-134.
20. Deci EL, Eghrari H, Patrick BC & Leone DR. Facilitating internalzation: The self-determination theory perspective. Journal of Personality 1994, 62: 119-142.
21. Adler AB, Castro CA, Bliese PD, McGurk D & Milliken C. The efficacy of Battlemind training at 3-6 months post-deployment. In CA Castro (Chair), The Battlemind training system: Supporting soldiers throughout the deployment cycle, Symposium conducted at the meeting of the American Psychological Association. San Francisco, CA, 2007.
22. Jeffery RW, Bjornson-Benson WM, Rosenthal BS, Lindquist RA, Kurth CL & Johnson SL. Correlates of weight loss and its maintenance over two years of follow-up among middle-aged men. Preventative Medicine 1984, 13: 155–168.
23. Forster JL & Jeffery RW. Gender differences related to weight history, eating patterns, efficacy expectations, self-esteem, and weight loss among participants in a weight reduction program. Addictive Behaviors 1986, 11: 141–147.
24. Linde JA, Jeffery RW, Levy RL, Sherwood NE, Utter J, Pronk NP, et al. Binge eating disorder, weight control self-efficacy, and depression in overweight men and women. International Journal of Obesity and Metabolic Disorders 2004, 28: 418–425.
25. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury: Jones and Bartlett, 2007.
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