Adapting Interpersonal Psychotherapy for the Prevention of Excessive Weight Gain
A recent and novel adaptation of IPT, IPT for excess weight gain (IPT-WG), has been developed, and is currently being tested, for the prevention of excess weight gain in adolescents who report loss of control (LOC) patterns (Tanofsky-Kraff et al., 2007). LOC refers to the sense that one cannot control what or how much one is eating, regardless of the reported amount of food consumed (Tanofsky-Kraff, 2008). LOC eating is common among youths, is associated with distress and overweight (Tanofsky-Kraff, 2008), and predicts excess weight gain over time (Tanofsky-Kraff et al., 2009) and the development of partial- or full-syndrome BED (Tanofsky-Kraff et al., 2011). IPT-WG makes use of IPT for the prevention of depression in adolescents (IPT – adolescent skills training, or IPT-AST; Young, Mufson, & Davies, 2006) and group IPT for BED (Wilfley et al., 2000) and evolved from the unexpected finding that individuals with BED who cease to binge eat tend to maintain their body weight during or after treatment (Agras et al., 1995; Agras, Telch, Arnow, Eldredge, & Marnell, 1997; Devlin et al., 2005; Wilfley et al., 1993, 2002). Therefore, treatment of binge eating among youths has been hypothesized to reduce excess weight gain and prevent full-syndrome EDs during development (Tanofsky-Kraff et al., 2007).
Several factors have suggested that IPT is particularly appropriate for the prevention of obesity in high-risk adolescents with binge or LOC eating patterns. Specifically, youths frequently use peer relationships as a crucial measure of self-evaluation (Mufson, Dorta, Moreau, & Weissman, 2004; Tanofsky-Kraff, 2012). A study by Lemeshow et al. (2008) revealed the importance of perceived social interactions and social standing on body weight gain over time. In this prospective cohort study, adolescent girls who rated themselves lower on a subjective social standing scale were 69% more likely to gain more weight over time than girls who rated themselves on the higher end of the scale (Lemeshow et al., 2008). Furthermore, overweight teens are more likely to experience negative feelings about themselves, particularly regarding their body shape and weight, than normal-weight adolescents (Fallon et al., 2005; Schwimmer, Burwinkle, & Varni, 2003; Striegel-Moore, Silberstein, & Rodin, 1986), perhaps because of their elevated rates of appearance-related teasing, rejection, and social isolation (Strauss & Pollack, 2003). The social isolation that overweight teens report may be directly targeted by IPT.
Several longitudinal studies have found depressive symptoms to predict weight gain and obesity onset in children and adolescents (Anderson, Cohen, Naumova, & Must, 2006; Goodman & Whitaker, 2002; Pine, Goldstein, Wolk, & Weissman, 2001; Puder & Munsch, 2010; Stice, Presnell, Shaw, & Rohde, 2005). Thus, IPT s proven efficacy in decreasing depressive symptoms in adolescents (Mufson, Dorta, Wickramaratne, et al., 2004) may serve to decrease an additional risk factor for excessive weight gain. In addition to reducing depressive symptomatology, IPT is posited to increase social support, which has been demonstrated to improve weight loss and weight maintenance in overweight adults (Wing & Jeffery, 1999) and children (Wilfley et al., 2007). Indeed, data have suggested that low social problems predict better response to weight loss treatment in children (Wilfley et al., 2007).
IPT-WG for adolescents at high risk for adult obesity, delivered in a group format, maintains the key components of traditional IPT: (a) a focus on interpersonal problem areas that are related to the target behavior (in this case, LOC eating); (b) the use of the interpersonal inventory at the outset of treatment to identify interpersonal problems that are contributing to the targeted behavior; and (c) the triphasic structure of the intervention (initial, intermediate, and termination). The primary activities of IPT WG are to provide psychoeducation about risk factors for excessive weight gain and to teach general skill building to improve interpersonal problems. IPT-WG was founded on Young and Mufsons (2003) IPT-AST and group IPT for the treatment of BED in adulthood (Wilfley et al., 2000). IPT-WG differs from other adaptations in that it was developed specifically to address the particular needs of adolescent girls at high risk for adult obesity because of their current body mass index percentile and report of LOC eating behaviors (Tanofsky-Kraff et al., 2007).
Based on IPT-AST, IPT-WG is presented to teenagers as “Teen Talk” to be nonstigmatizing. Similar to IPT-AST, this preventive adaptation of IPT focuses on psychoeducation, communication analysis, and role playing (Young & Mufson, 2003). Specific interpersonal communications skills are taught, including “Strike while the iron is cold,” “Use T statements,” “Be specific” (when talking about a problem), and “Put yourself in their shoes” (Young & Mufson, 2003). For IPT-WG, an additional skill, “What you don't say speaks volumes,” has been added to teach adolescents how their body language has the ability to affect communication regardless of their words. During the interpersonal inventory, a “closeness circle” (Mufson, Dorta, Moreau, & Weissman, 2004) is used to identify the participants close relationships. To address developmental differences among participants, girls are assigned to groups on the basis of younger (12-14 years) and older (15 – 17 years) age. Thus, sessions may be appropriately geared toward the adolescents' developmental level. For instance, younger adolescents, who may be uncomfortable talking about themselves, may respond better to hypothetical situations and games, whereas older teenagers may more readily discuss their own interpersonal issues from the outset.
Based on IPT for BED, IPT-WG focuses on linking negative affect to LOC eating, overeating, times when individuals eat in response to cues other than hunger, and overconcern about shape and weight. Moreover, a timeline of personal eating, weight-related problems, and life events is discussed individually with participants before the group program. Unlike IPT for BED, the problem area of grief is rarely relevant because of the participants' young age but may be included on a case-by-case basis. Similar to both IPT-AST and IPT for BED, IPT-WG is delivered in a group format. IPT-WG consists of 12 weekly sessions, more than IPT-AST (8 sessions), but less than group IPT for BED (typically 20 sessions). Similar to IPT-AST, group size is smaller than in IPT for BED (5 vs. 9 members), enabling counselors to keep adolescents engaged (Tanofsky-Kraff, 2012). Although an effectiveness trial is still underway, preliminary data have suggested that IPT-WG may be a promising intervention for prevention of excess weight gain and BED (Tanofsky-Kraff et al., 2010).
In addition to future research to examine IPT-WG's effectiveness, several other important areas require further study. An important next step is to determine whether IPT for EDs can be translated from specialty care centers to the primary care setting and other typically nonresearch clinical practice milieus in which counselors may be trained to deliver IPT. In an effort to continually improve IPT and broaden its utility, we propose other research directions in the following sections.