Obesity Preventionobr_729 430..439

The effect of theory-based interventions on physicalactivity participation among overweight/obeseindividuals: a systematic review

A. Bélanger-Gravel1, G. Godin2, L.-A. Vézina-Im3, S. Amireault1 and P. Poirier4

1Department of Social and Preventive

Medicine, Division of Kinesiology, Laval

University, Quebec City, QC, Canada;2Canada Research Chair on Behaviour and

Health, Faculty of Nursing, Laval University,

Quebec City, QC, Canada; 3Faculty of

Nursing, Laval University, Quebec City, QC,

Canada; 4Department of cardiology, Centre

de recherche de l’Institut universitaire de

cardiologie et de pneumologie de Québec,

Hôpital Laval, Quebec City, QC, Canada

Received 12 November 2009; revised 21

December 2009; accepted 7 January 2010

Address for correspondence: A

Bélanger-Gravel, Canada Research Chair

on Behaviour and Health, FSI-Vandry,

Laval University, Quebec City, QC, G1V

0A6, Canada. E-mail:

ariane.belanger-gravel@fsi.ulaval.ca

SummaryLittle attention has been paid to the evaluation of the long-term impact oftheory-based interventions on physical activity participation among overweight/obese individuals after the interventions have ended. The primary aim of thissystematic review was to investigate the long-term effectiveness of theory-basedinterventions increasing physical activity and identify the most effective tech-niques for behaviour change among overweight/obese individuals. The secondaryaim was to investigate the effect of these interventions on theoretical variables.Eighteen studies were reviewed. Among these studies, three reported significantshort-term and two long-term effects of interventions on physical activity partici-pation. Most of the studies observed a significant short- or long-term effect of timeon this behaviour. Theoretical frameworks most often applied included the Behav-ioural Model and the Social Learning/Cognitive Theory. However, few of thestudies reported any impact on theoretical variables. The most prevalent tech-niques consisted of providing opportunities for social comparison and instructionas well as self-monitoring. Leading techniques differentiating the experimentalgroup from the control group included prompting practice and intentions forma-tion and barriers identification. Although the combination of these three tech-niques appears successful, the long-term impact of theory-based interventionsremains ambiguous.

Keywords: Obesity, physical activity, systematic review, theory-basedintervention.

obesity reviews (2011) 12, 430–439

Introduction

Both obesity and physical inactivity contribute to the devel-opment of several chronic diseases and generate importanthealthcare costs (1). Consequently, lifestyle interventionsfor weight loss and maintenance are an important publichealth priority (2,3). In recent decades, significant effortshave been invested in the development of more effectivebehavioural approaches to the treatment of obesity. Assuch, some systematic reviews and meta-analyses have been

published about the efficacy of interventions on weightloss (4,5). However, scant attention has been paid to theevaluation of the long-term effect of such interventions onphysical activity after the interruption of contact withparticipants (6,7). This observation is quite surprising,given that exercise represents one of the major componentsof behavioural treatment of obesity (8). In a systematicreview of this topic, mixed results about changes inphysical activity have been reported (9). Moreover,although individually adapted programmes or behaviour

obesity reviews doi: 10.1111/j.1467-789X.2010.00729.x

430 © 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 430–439

modification is effective in increasing physical activity onthe short term (10,11), the long-term effect of such pro-grammes is less conclusive (12).

The development of more effective interventions wouldbenefit from health behaviour theory research and, moreimportantly, from the identification of the psychologicalprocesses whereby these interventions have an impact onbehaviour (i.e. the ‘active ingredients’) (7,12–16). In theliterature, little attention has been paid to the identificationof the ‘active ingredients’ of theory-based interventions onphysical activity among overweight/obese adults using vali-dated taxonomy (9). Thus, the primary aim of this system-atic review was to investigate the long-term effectiveness oftheory-based interventions to increase physical activity par-ticipation among overweight/obese adults and identifypotential intervention components that might prove mosteffective. A secondary aim involved investigating the effectof these interventions on modifying key theoretical vari-ables (i.e. mediators).

Methods

Literature search

A literature search and data extraction were performedbetween April and October 2008. We searched for studiespublished in English in psycINFO, MEDLINE, EMBASE,CIHNAL, Sport Discuss, Cochrane library (CochraneCentral Trials Register) and PROQUEST dissertations &theses. The search strategy in MEDLINE involved (type ofbehavior) AND (targeted population) AND (intervention)AND adult (Table A1). The reference lists of all relevantarticles were checked manually and additional searches wereperformed for articles published by important authors in thefield of obesity treatment (e.g. Wing, Perri, Jeffery, etc.).

Inclusion and exclusion criteria

The mean age and body mass index was established asbeing between 18 and 64 years of age and 25.0 and39.9 kg m-2, respectively. Because the definition of obesityhas changed over time, the last criterion was adjusted forstudies that classified body weight according to other cri-teria such as the criterion developed by the MetropolitanLife Insurance Company (17).

Studies that included participants with known mentaldisorders, physical diseases or targeted specific populationswere excluded. However, studies that targeted overweight/obese adults with diabetes, glucose intolerance, impairedglucose tolerance, insulin resistance, hyperinsulinaemia,hypercholesterolaemia and hypertension were included.

Interventions based on one or several psychosocial theo-ries were considered. Because most of these theories weredeveloped in the late 1970s and thereafter, only studies

published after 1980 were included. Interventions thatused weight loss pharmacotherapy, herbal/natural prod-ucts, very-low-calorie diets, meal replacement or foodprovision were excluded. Studies reporting the effect ofstructured physical activity programmes or diets were alsoexcluded. Finally, studies that were included had to reportresults based on an objective (e.g. accelerometers andpedometers) or subjective (self-reported questionnaires)measure of participation in physical activity or an indicatorof participation (i.e. physical fitness), at baseline, post-intervention and at follow-up.

Randomized control trials as well as quasi-experimentaldesigns were included in the review, with the exceptionof studies adopting a one-group pre–post design. Thefollow-up period was defined as no contact with partici-pants for at least 3 weeks. All studies that maintained someform of contact, even at low intensity (or frequency) duringa maintenance phase, were not considered concurrent withour follow-up definition and were excluded if no additionalfollow-up was reported.

Data abstraction

Data were independently abstracted by two reviewers anddisagreements were resolved by consensus with a thirdreviewer. Where necessary, attempts were made to contactauthors by email for information on key missing dataelements.

Before analysing the data set, a number of decisions weretaken. First, several studies reported both on physical activ-ity behaviour and physical fitness levels. Because this studyconcerns observable behaviours, results for physical activ-ity instead of fitness were reported when information forthese two outcomes was available. In an attempt to stan-dardize outcome measures to the recommended amount ofphysical activity (i.e. 150 min/week of moderate physicalactivity) (18), only results on frequency or duration wereabstracted when several physical activity outcomes werereported in the same study. Second, the attrition rate atfollow-up was calculated only when the exact number ofparticipants was clearly reported. Third, the analysis ofbehaviour change techniques was based on a taxonomydeveloped by Abraham and Michie (19) (Table A2). Thisanalysis, as well as the analysis of the theoretical constructstargeted and assessed, was limited to intervention compo-nents explicitly related to physical activity. For more infor-mation on technical terms and expressions used in thepresent systematic review, please refer to Table S1.

Results

Characteristics of the interventions

The flow diagram of the bibliographic screen is presented inFig. 1. For the analysis, 23 studies describing 18 interven-

obesity reviews Physical activity and overweight/obese adults A. Bélanger-Gravel et al. 431

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 430–439

tions were included (see Table 1 for the summary of resultsand Tables S2 and S3 for more information on abstracteddata).

All studies included were described as randomizedcontrol trials but, for 11 studies (20–30), it was impos-sible to determine the randomization procedure used. Noquasi-experimental design met the inclusion criteria.Increasing physical activity was the primary purpose ofthree of the studies (22,29,31), whereas all other studieswere interested primarily in weight management(i.e. weight loss and/or post-weight-reduction weightmaintenance).

The duration of the studies, as well as the intensity andfrequency of contacts with the participants, varied sub-stantially across the studies. For most studies, thetreatment phase lasted 3 months (20,32,33) or less(23,24,26,31,34). The longest treatment phases were 6months (21,22,27,35) or more (28). For studies includinga maintenance phase (20,25,27,36), the duration variedbetween 3 and 12 months. Finally, for most of thestudies, the duration of the no-contact follow-up periodwas 6 months or more (20–23,25–28,30,33–37). Unfor-tunately, it was not possible to extract a clear picture ofthe intensity and frequency of contacts, given the variabil-ity of the studies.

Characteristics of the participants

The mean age and body mass index of the participantsvaried between 37.7 and 55.1 years and 29.7 and37.9 kg m-2, respectively. Participants in the studies weremostly female and highly educated Caucasian adults.African Americans were targeted in one study (34). Twostudies were conducted among individuals with type 2 dia-betes (29,30) and one targeted hypertensive (36) obeseparticipants. The number of participants varied between 24and 389 individuals at baseline, with an attrition rate atfollow-up varying between 6% and 46.3%. Only threestudies reported an attrition rate lower than 20% at 6- or12-month follow-up (26,28,30).

Characteristics of physical activity behaviour

For the most part, physical activity behaviour was subjec-tively (20–22,24,27,28,30,31,35,36) rather than objec-tively assessed (23,25,26,29,32–34,37). Subjective physicalactivity was usually assessed by means of self-reportedquestionnaires (21,22,24,27,30,31,35,36). The exact valid-ity and reliability values of the instruments used for evalu-ating subjective physical activity were rarely reported(22,28,35), although analysis of the cited references

Number of hits (n = 8172)

Studies retrieved for more detailed evaluation (n = 203)

Studies with usable information (n = 23), describing 18 interventions

Excluded studies (n = 340) Non-intervention evaluation studies (n = 41) Mean age ≥ 65 years (n = 4) Mean BMI < 25 or ≥ 40 kg m–2 (n = 16) Insufficient / no information about BMI or % overweight (n = 43) Physical and mental disorders / bariatric surgery (n = 10) Use of pharmacotherapy / supplementation / meal replacement/VLCD (n = 42) Test of different prescription of diets or physical activity (n = 60) One-group pre–post design (n = 65) No theoretical background (n = 59)

Excluded studies (n = 180) No no-contact follow-up (n = 59) No information on physical activity (n = 121)

Potentially relevant studiesidentified and screened for retrieval (n = 543)

Figure 1 The flow diagram of includedstudies. BMI, body mass index; VLCD, verylow calorie diet.

432 Physical activity and overweight/obese adults A. Bélanger-Gravel et al. obesity reviews

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 430–439

Tab

le1

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obesity reviews Physical activity and overweight/obese adults A. Bélanger-Gravel et al. 433

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 430–439

Tab

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tinue

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9)(2

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434 Physical activity and overweight/obese adults A. Bélanger-Gravel et al. obesity reviews

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 430–439

revealed that almost all questionnaires used were adequate,except for three studies in which the instruments used werenot validated (20,24,27).

Measurements of objective physical activity wereobtained by means of pedometers (29,32), accelerometers(25) or physical fitness indicators (23,26,33,34,37). Threestudies specified that the tool was valid or reliable(25,29,34). For physical fitness, however, there was nomention of the reliability and validity of almost all of thetests used (23,26,33,37).

Results of interventions on physical activity

One study reported results for an intention-to-treat analysisat follow-up (36). Two additional authors mentioned thatthey used this statistical approach (27,35), but provided noinformation on the management of missing data; likewise,the number of participants included in the analysis waseither missing or inexact.

Overall, three studies reported significant between-groupeffects at post-intervention (including treatment and main-tenance phases) on physical activity behaviour (22,23,29);one of these studies reported a sustained and significantbetween-group effect at follow-up (22). Another studyreported a significant between-group effect at follow-upwithout significant results at post-intervention (32).Twelve of the 18 studies reported a significant effectof time at post-intervention and/or at follow-up (20–23,26,27,29,30,33,34,36,37). Given the observed variabil-ity between the studies for almost all methodologicalparameters, no meta-analysis of the results was performed.

Theoretical framework and psychosocial variables

The traditional Behavioural Model used in clinical psychol-ogy (i.e. behaviour therapy) and the Social Learning/Cognitive Theory were the two theories most often applied(83%). They were used alone (23,26,29,30,32–35,37) or incombination with other theories (20,22,24,28,31,36). Nolong-term between-group effect on physical activity wasobserved in any of the interventions based on the Behav-ioural Model (20,23,26,28,30,33,35), whereas a significanteffect of time was observed in five studies (71%). On theother hand, the two studies that had reported significantbetween-group effects at follow-up were partially (22) orexclusively (32) based on the Social Learning/CognitiveTheory.

Others theories used included the TranstheoreticalModel (22,27,31,36), Relapse Prevention Model(20,25,27), Self-Control Theory (21), Elaboration Likeli-hood Model (24), Decision Theory (28) and the HealthBelief Model, Decisional Balance and Theory of PlannedBehaviour (36). Some of these theories were used alone(21,25), but most were applied in combination with other

theories. Among the four studies based on the Transtheo-retical Model, only one reported a between-group differ-ence at follow-up (22). However, this latter study was alsobased on the Social Learning/Cognitive Theory. As it wasobserved for the Behavioural Model, the majority of thestudies based on the Transtheoretical Model (75%)reported a significant effect over time. None of the studiesbased on the Relapse Prevention Model reported significantbetween-group effects at follow-up, although they observedsignificant effects over time (66%).

Eight of the theory-based interventions clearly specifiedwhich theoretical variables were targeted to change physi-cal activity (21,22,24,27,29,31,34,36). Among these,self-efficacy was the predominant variable targeted(22,24,27,29,31,34,36), as most of the studies were basedon Social Learning/Cognitive Theory. Two studies based onthis model did not explicitly target self-efficacy (32,37). Inone study, self-control was targeted according to the Self-Control Theory (21). In the same way, both stages andprocesses of change were targeted in almost all interven-tions partially or exclusively based on the TranstheoreticalModel (22,27,31). Any of the studies based on the Behav-ioural Model specified the mechanisms of behaviouralchange. The psychometric qualities of the constructs werereported (or retrieved in cited reference) as adequate in fivestudies (22,27,31,34,35), but this information was notalways retrievable (21,24,31,36).

Two studies reported significant between-group effectson some theoretical variables at post-intervention (22,36).For instance, in the intervention by Burke et al. (36),between-group effects were reported for perceived barriers,self-efficacy (this effect was observed in post-treatment, butwas not sustained after the maintenance phase) and somecoping mechanisms. In the intervention by Dallow andAnderson (22), between-group effects were observed forsome processes of change, but not for self-efficacy. Thiseffect was not sustained at follow-up.

Two studies reported significant group effects on sometheoretical variables at follow-up, but there was no consis-tency in the results obtained. In the study by Ash et al. (35),general self-efficacy was higher in the experimental groupthan in the control group, whereas no significant groupeffect was observed for this variable in the study by Kreuteret al. (24). In this latter study, some between-group effectswere observed for several levels of thought, personal con-nection, self-assessment and intention.

Theoretical techniques used

Providing opportunities for social comparison was thetechnique most often used in the experimental groups (20–23,25–30,32–37). Significant effects of time were observedin 75% of the studies using this technique (20–23,26,27,29,30,33,34,36,37), and a between-group effect

obesity reviews Physical activity and overweight/obese adults A. Bélanger-Gravel et al. 435

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at follow-up was observed in the two studies that reportedsignificant effects of their treatment on physical activity(22,32). The other main techniques used in the experimen-tal groups were providing instructions (22,23,25–28,30–34,36,37) and self-monitoring (20,21,23,25–29,31–33,36,37). Significant time effects were observed in six ofthe studies (67%) using the combination of these threetechniques (23,26,27,33,36,37). Two studies reported sig-nificant short-term (23) and long-term (32) effects of thetreatment. Finally, among all techniques listed by Abrahamand Michie (19), providing information on others’approval, setting specific goals and identification as a rolemodel were not used in any of the included studies.

Notwithstanding the above observations, the techniquesthat distinguished or characterized the experimentalgroups from the control groups were promptingpractice (22,25,29,30,32,33,36), barrier identification(22,24,25,29,32,36) and prompting intention formation(22,24,29,32,36,37). All of the studies that reported sig-nificant between-group effects on physical activity atpost-intervention (22,29) and follow-up (22,32) used acombination of these three techniques, except for the studyby James and May Hampton (23).

The number of theoretical techniques used varied sub-stantially across studies, although the interventions referredto the same theoretical background. For instance, betweenfour and twelve techniques were used for interventionsbased exclusively on the Social Learning/Cognitive theory(32,34,37). Moreover, for these interventions based exclu-sively on the Social Learning/Cognitive Theory, there wasno consistency in the techniques used that could character-ize the differences between the experimental groups and thecontrol groups. This was also observed for studies exclu-sively based on the Behavioural Model in which betweenthree and nine techniques were used in the experimentalgroups (23,26,30,33,35).

Discussion

Findings of the present systematic review indicate that themost frequently observed pattern of results was a signifi-cant improvement in the level of physical activity overtime, suggesting that all participants increased their levelof physical activity regardless of the assignment group. Inaddition, it was observed that the long-term effectiveness oftheory-based interventions to increase the level of physicalactivity among overweight/obese is weakly supportedbecause very few studies observed a superior effect of theirexperimental conditions (22,32). Overall, the informationin the literature adds little to our understanding of howinterventions succeed or fail to change physical activityamong this population.

These findings are somewhat surprising, given that theuse of theoretical frameworks should increase the likeli-

hood of developing more effective interventions (13–15). Ina recent meta-analysis (38), strong support was providedfor several behaviour change theories in the context of HIVprevention. In the present context, however, it must beacknowledged that almost all interventions were driven byproblem-solving rather than theory-testing. Thus, the theo-retical processes underlying behaviour change were seldomexplicitly described and no mediation test was carried outin most of the studies.

This apparent lack of concern for theoretical issues limitsthe possibility of developing evidence-based interventionsfor overweight/obese individuals to increase physical activ-ity. According to our systematic review, appropriate media-tion analysis was performed only by Burke et al. (39). Theiranalysis revealed that the short-term effect of the Activity,Diet and Blood Pressure Trial (ADAPT) programme wasmediated by self-efficacy. Their results compared favourablywith a previous review in which self-efficacy was the mostsupported mediator of interventions aimed at increasingphysical activity among adults (40) and could provide someempirical support for Bandura’s Social Cognitive Theory.

A second finding of this systematic review was that mostof the interventions failed to modify the theoretical media-tors of change under experimental conditions when com-pared with the control group. This apparent lack ofsupport for theories could be attributed to the failure toexperimentally manipulate the theoretical constructs.Indeed, in many studies, several techniques related to thetheoretical framework were used in both experimental andcontrol conditions. For instance, self-monitoring, a tech-nique usually associated with behavioural treatmentprogrammes, and providing opportunities for socialcomparison, a fundamental technique of the SocialLearning/Cognitive Theory, were used in all groups. More-over, when looking at the techniques that can distinguishcharacteristics of experimental groups and control groups,no similarity was observed between studies based on thesame theoretical model. This lack of coherence suggeststhat there are some problems with the correct operational-ization of theoretical frameworks. Consequently, no clearconclusion could be drawn regarding the most effectivetheories or components, as well as the most effective com-bination of these to promote a long-term physical activitypattern among overweight/obese individuals. Notwith-standing the above conclusion, our results suggest that itcould be interesting, in future studies, to investigate theeffect of combining techniques such as prompting practice,barrier identification and prompting intention formation.According to Michie et al. (41), these latter three tech-niques could be used to enhance beliefs about capabilities,motivation and goals.

Interestingly, little attention has been paid to the litera-ture on the determinants of physical activity and the impor-tant contribution of theories such as the Theory of Planned

436 Physical activity and overweight/obese adults A. Bélanger-Gravel et al. obesity reviews

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Behaviour (42). Recently, this theory was suggested as oneof the most appropriate theories to guide the developmentof interventions aimed at weight management (43).According to this theory, intention is the proximal deter-minant of behaviour. Perceived behavioural control, or per-ceived ease or difficulty associated with the performance ofthe behaviour, is also viewed as a determinant of behaviouralong with intention. Meta-analyses of the predictive valueof this theory have reported that both intention and per-ceived control are significant determinants of physicalactivity among adults, with intention responsible for mostof the explained variance (21–27%) (44,45). Among obeseadults, intention has also been identified as the most impor-tant determinant of physical activity (46).

Finally, given that these interventions were quite inten-sive and involved multiple assessments of participants’physiological and/or behavioural characteristics, it cannotbe excluded that mere-measurement effects interfered withthe effect of interventions (47). Mere-measurement refersto the reactivity of measures on participants’ future behav-iour; some individuals change their behaviour followingexamination of information obtained from measurement.In previous investigations, it was observed that the mea-surement of physical fitness or the completion of a psycho-social questionnaire has a significant impact on futurebehaviour (48–50).

A number of limitations should be noted. First, only alimited number of studies met the inclusion criteria. It wouldappear that most of the effort deployed by such interven-tions concerned the evaluation of short-term effects onweight loss. Also, most of the studies included were con-ducted among well-educated and healthy participants,involved a greater proportion of women and reported highattrition rates. Second, this systematic review was onlydescriptive, as too much variability was observed in thestudies included. This limited the possibility of reportingaccurate pooled effect sizes. Likewise, the small number ofstudies included limited the possibility of resorting to moresophisticated meta-analysis techniques. Third, it is notewor-thy that the taxonomy used to identify techniques of behav-iour change was probably not exhaustive. Indeed, Michieet al. (41) recently published another taxonomy in whichmore techniques are listed. It may be possible that sometechniques used in the studies included were not listed in thepresent review. Also, given that the description of the inter-vention was frequently incomplete or unclear, other tech-niques could have been missed. However, this was a firstattempt to apply this new taxonomy to a systematic reviewamong overweight/obese individuals. Finally, most of thestudies relied on subjective physical activity assessments toevaluate the impact of their interventions. Consequently,between-group effects might have been overshadowedbecause of the lack of power of self-report instruments todetect small effect size.

Recommendations for future studies

Based on this systematic review, a few recommendationscould be made. First, more evaluation studies of long-termeffect of interventions (i.e. after all the intervention con-tacts ceased) are needed to gain better insight into thelong-term efficacy of modifying physical activity. Second, toincrease the likelihood of developing more effective inter-ventions, researchers should isolate targeted theoreticalconstructs and, more importantly, techniques in theirexperimental conditions to evaluate the specific contribu-tion of these variables. In the same way, they should payparticular attention to carefully selecting and describing thetheoretical techniques adopted to change key theoreticalconstructs. Presently, taxonomies developed by Abrahamand Michie (19) and Michie et al. (41) could help research-ers select the most appropriate techniques. Also, targetedtheoretical variables should be assessed in order to performmediation analysis (51). Finally, researchers should try totest the effectiveness of alternative social cognitive modelshaving good predictive validity such as the Theory ofPlanned Behaviour (42) and the Self-Determination Theory(52). Likewise, strategies such as implementation intentionsdeserve more attention, considering their estimated largeeffect size in changing health-related behaviours (53).

Conflict of Interest Statement

No conflict of interest was declared.

Acknowledgement

The first author is supported by a grant from the CanadianInstitute of Health Research

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Supporting Information

Additional Supporting Information may be found in theonline version of this article:

Table S1. Glossary of technical terms and expressions usedin the systematic review.Table S2. Characteristics of the studies included andprincipal results of the interventions on physical activityparticipation.Table S3. Theoretical characteristics of the studies includedand principal results of the intervention on theoreticalvariables.

Please note: Wiley-Blackwell is not responsible for thecontent or functionality of any supporting materials sup-plied by the authors. Any queries (other than missing mate-rial) should be directed to the corresponding author for thearticle.

Appendix

Table A1 The search strategy

Keywords, descriptors or operators

Type of behavior Physical activity ORExercise ORDiet ORNutrition ORBehavior or behavior ORLifestyle

Targeted population Obesity ORObese OROverweight

Intervention Intervention ORProgram

Table A2 Behaviour change techniques*

Techniques included in the interventions

1. Information about behaviour–health link2. Information on consequences3. Information on others’ approval4. Intention formation5. Barrier identification6. General encouragement7. Graded tasks8. Instruction9. Model/demonstration of the behaviour

10. Specific goal setting11. Review of behavioural goals12. Self-monitoring13. Feedback on performance14. Contingent rewards15. Use prompts/cues16. Behavioural contract17. Practice18. Follow-up prompts19. Opportunities for social comparison20. Social support/social change21. Identification as role model22. Self-talk23. Relapse prevention24. Stress management25. Motivational interviewing26. Time management27. Cognitive restructuring28. Stimulus control

Adapted from Abraham and Michie (19).*Note that we added cognitive restructuring and stimulus control to thelist, given the predominance of the Behavioural Model in the field ofobesity treatment.

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