One newer approach that has received considerable attention is acceptance-based interventions. Acceptance-based interventions build upon the behavioral skills used in traditional lifestyle programs by adding components derived from acceptance and commitment therapy (ACT). ACT has been described as a “third wave†behavioral therapy, following the “first wave†of initial behaviorism and the “second wave†of CBT20. As a larger therapeutic approach, ACT attempts to increase individuals’ “psychological flexibility,†or their ability to engage in behaviors consistent with their values despite uncomfortable thoughts, feelings, or cravings26. Core processes in ACT include the clarification of life “values†(e.g., why an individual would choose to engage in a target behavior) and building willingness to experience negative thoughts, emotions, and sensations in order to engage in behaviors consistent with those values.
In contrast to CBT approaches, ACT does not teach individuals to identify and change irrational or maladaptive thoughts; rather, the focus of ACT is on changing how an individual relates to these thoughts and feelings26. For example, someone who is trying to increase his or her physical activity may avoid exercising at a gym because this person worries about being judged by other patrons. In a CBT approach, this person would be encouraged to challenge or change that thought in order to go to the gym (e.g., considering “What is the worst that could happen?†“What are the odds that would actually happen?â€). In contrast, in an ACT-based approach, this person would be taught acceptance skills that would encourage them to go to the gym to exercise even if they feel uncomfortable. The novelty and success of ACT-based interventions lie in its focus on self-regulation skills and its potential broad effectiveness across diverse populations27. Further, ACT has proven suc cessful for treating individuals for diverse medical and behavioral issues including chronic pain, substance abuse, high-risk sexual behavior, anorexia among adolescent females, and depression28,29,30,31,32,33,34.
In adults with type 2 diabetes, only two studies have examined the efficacy of ACT relative to a control group for improving diabetes self-management behaviors and glycemic control. In one study, Gregg and colleagues randomized 81 adults with type 2 diabetes to one of two 7-h intervention workshops:1 diabetes education alone or2 combined diabetes education plus ACT35. Adults in the combined diabetes education plus ACT intervention were more likely to use ACT-based coping strategies, reported better diabetes self-care (including exercise, diet, and glucose monitoring), and showed a greater mean decrease in A1c. The ACT plus diabetes education condition also had a higher percentage of individuals with an A1c < 7.0 compared to adults in the diabetes education only group. Improvements in A1c from baseline to follow-up were mediated by participants’ use of acceptance-based coping and engagement in diabetes self-management behaviors. In the second study, Shayeghian and colleagues randomized 106 adults with type 2 diabetes to a diabetes education only condition or a diabetes education plus ACT intervention36. The diabetes education plus ACT intervention consisted of ten sessions over a three-month period, while adults in the diabetes education only group participated in a 2-h workshop on diabetes control36. At three months post-baseline, adults in the ACT intervention showed greater improvements in A1c and diabetes self-care activities (including exercise, diet, glucose monitoring, medication adherence, cigarette smoking, and foot care) relative to those in the control condition.
One promising direction for lifestyle modification is to take key elements of ACT and integrate them into evidence-based SBT weight management treatments (SBT + ACT). Researchers and practitioners are typically intentional in referring to this approach as “acceptance-based behavioral treatment†(ABT) rather than “acceptance and commitment therapy†(ACT) for two reasons: this language acknowledges the importance of retaining traditional behavioral components such as goal setting and self-regulation found in SBT, and also reflects that ABT interventions may not utilize all elements typically delivered in ACT. Traditional behavioral interventions (e.g., the DPP lifestyle intervention) have elements that are likely critical for maximizing changes in weight, eating behaviors, and physical activity, which can all significantly benefit weight loss and blood glucose control. Teaching ACT skills without these elements would likely compromise efficacy (and woul d be impractical, as ACT is at its core a behavioral treatment that incorporates behavioral targets). Thus, ABT often retains core behavioral components of traditional SBTs, including: use of structured goals for reducing caloric intake and increasing physical activity; regular self-monitoring of weight, eating, and physical activity; monitoring of weight and these self-monitoring records by a treatment provider to provide feedback, support, and to enhance supportive accountability37; and additional behavioral skills training such as goal setting, problem solving, and stimulus control. Cognitive restructuring and other CBT-based techniques designed to help individuals manage negative internal experiences are not retained, however, as ABT focuses on changing relationships with internal experiences rather than changing the experience itself. In the version of ABT that has been most extensively researched to date38, the ACT strategies that are integrated into the intervention are accep tance of uncomfortable states and emotions, increasing commitment to valued goals, and aligning your values with your actions. In addition, cognitive defusion is included but in a modified format, as other forms of internal experience, especially hedonic drive are thought to be as important as cognitive activity. For those familiar with ACT, it is important to note that other ACT strategies, such as self as process and self as context, receive less attention.
Two randomized controlled trials (RCTs) have demonstrated significantly greater weight losses for ABT compared to SBT39,40. The Mind Your Health Project, a 40-week RCT comparing ABT to SBT, demonstrated that ABT resulted in significantly higher weight loss than SBT at post-treatment (13.2 vs. 7.5%) and at 6-month follow-up (11.0 vs. 5.0%) in a post-hoc analysis when the intervention was administered by weight-control experts41. Similarly, the Mind Your Health II Project (MYH II), a larger and longer (1 year) RCT, demonstrated that ABT produced greater 12-month weight loss than did the SBT treatment (13.3 vs. 9.8%), again when conducted by experienced clinicians39. In the long-term post-treatment follow-up data from MYH II40, weight loss at 24-months (7.5 vs. 5.6%; P = 0.15) or at 36 months (4.7 vs. 3.3%; P = 0.31) did not significantly differ between ABT and SBT groups. However, among treatment completers who attained at least 10% body weight loss during the in tervention, those receiving ABT were almost twice as likely to retain at least 10% body weight loss at two-year follow-up (31.6 vs. 17.1%; P = 0.04). Importantly, another study showed that ABT’s effectiveness for weight loss did not differ by race, sex, or education27.
Lillis and colleagues compared an ABT intervention to SBT in adults with both overweight/obesity and high internal disinhibition (the tendency to overeat in negative emotional states), given that these individuals have poorer outcomes in typical weight management trials42. While there was no difference in initial weight loss between the ABT and SBT groups43, ABT appeared superior on other dimensions: participants in the ABT group regained less weight at 24-month follow-up than those in the SBT condition (4.6 vs. 7.1 kg) and were significantly more likely to achieve at least 5% total body weight loss at 24-months (38 vs. 25%).
Other interesting variants of ABT are currently being explored. For example, a recent pilot study examined remote delivery of ABT to bariatric surgery patients that experienced postoperative weight regain, finding initial support for the feasibility, acceptability, and preliminary efficacy of this intervention44.
