Psychology
2013. Vol.4, No.3A, 197-204
Published Online March 2013 in SciRes (http://www.scirp.org/journal/psych) http://dx.doi.org/10.4236/psych.2013.43A030
The Effects of a 12-Month, Small Changes Group Intervention on
Weight Loss and Menopausal Symptoms in Overweight Women
Suzanne R. Daiss, Heidi A. Wayment, Sabrina Blackledge
Department of Psychology, Northern Arizona University, Flagstaff, USA
Received December 21st, 2012; revised January 20th, 2013; accepted February 16th, 2013
To better understand how psychological principles related to goal-setting and motivation can be applied to
the problem of obesity and menopausal symptoms, we examined the effectiveness of a Small Changes In-
tervention (SCI) program on forty-five overweight (BMI = 33.67 ± 7.03) women (mean age = 50.14 ±
12.16). Grounded in task motivation theory (cf. Locke & Latham, 2002), our SCI group therapy approach
instituted small and maintainable steps in nutrition and physical activity to promote weight loss and a re-
duction in menopausal symptoms. Body weight, Body Mass Index (BMI), and scores on the Greene Cli-
macteric Scale were assessed at Baseline (pre-intervention), 3-month post-treatment, 6-month follow-up,
and 12-month follow-up. By the end of the 12-month study, 20 women were still participating and had
lost, on average, 6.4% of their body weight, and had experienced a significant reduction in BMI, (BMI =
30.9 ± 6.13), providing further support for the SCI approach as an effective weight loss intervention
method. Cross-sectional correlational analyses found expected associations between obesity and meno-
pausal symptoms at the follow-up assessments. These relationships were especially strong by the last as-
sessment period. Most importantly, menopausal symptoms decreased over the duration of the intervention.
Taken together, these results suggest that the longitudinal impact of SCI on weight and BMI can have a
positive impact on menopausal symptoms. These findings underscore the importance of applying well-
researched social psychological principles in goal setting to the problem of obesity and menopausal
symptoms. Furthermore, the results obtained from the SCI approach suggest that that while obese indi-
viduals may experience increased symptoms of menopause, the process of losing excess body weight
through achievement of small, achievable goals has the potential to improve menopausal symptoms.
Keywords: Goal Setting in Weight Loss; Task Motivation Theory; Menopausal Symptoms; Small
Changes Intervention
The Problem of Obesity
Obesity is medically defined by the World Health Organiza-
tion as abnormal or excessive fat accumulation that may impair
health, or more quantitatively, as the presence of a body mass
index (BMI) of greater than 30 (kilograms in body weight di-
vided by height in meters squared). Obesity is one of the lead-
ing causes of preventable death world-wide (Mokdad, Marks,
Stroup, & Gerberding, 2004). In 2008, 35% of adults world-
wide over age 20 were considered overweight (BMI > 25) and
11% were considered obese (BMI > 30)). Since 1980 world-
wide obesity has nearly doubled. Childhood obesity is also a
serious problem with more than 40 million children age 5 and
under being categorized as overweight in 2011 (World Health
Organization, 2013).
Unfortunately, obesity has had a negative impact on mental
health and well-being. Puhl and Brownell (2003) review the
stigma of obesity and summarize the research which shows that
overweight individuals are viewed as having negative charac-
teristics such as laziness and poor self-discipline and that they
are often viewed as unattractive, and less competent and moral.
It is no wonder that the psychological effects of obesity include
emotional suffering and increased risk of depression (Paxman,
Hall, Harden, O’Keeffee, & Simper, 2011). This effect is espe-
cially strong for women and the severely obese, who are often
subject to lower self esteem and poorer health-related quality of
life (Fabricatore & Wadden, 2006).
Behavioral modification of diet and exercise continue to re-
main the most used method of weight loss. Given the negative
impact of obesity on physical and psychological health as well
as research demonstrating that even small reductions in weight
can be beneficial (National Heart, Lung and Blood Institute,
1998), it is surprising how ineffective most weight loss reduc-
tion programs are in keeping weight off long term. Although
there is much controversy in the field, a recent study of several
different popular diets found no significant differences in their
effectiveness (Strychar, 2006).
We argue that the ability of cognitive-behavior programs to
deliver long-term weight loss success may be improved by con-
sideration of psychological principles related to goal-setting
and motivation. In fact, research from the National Weight
Control Registry (www.nwcr.ws) has recently argued that long-
term weight loss is not attainable by implementing a set of es-
sentially unrealistic and unsustainable goals to reduce obesity
including a temporary period of strict exercise and/or diet.
Rather, they conclude that long-term weight loss should be a
function of change in overall lifestyle. The psychological lit-
erature on goal setting and task motivation provides key in-
sights into factors that can help individuals make the kind of
overall lifestyle changes required for long-term weight loss.

S. R. DAISS ET AL.
Applied Goal Setting and Be havior Chan ge S trategies
Applying the literature on goal setting and task motivation to
the problem of obesity strongly suggests that diet and exercise
interventions that allow individuals to set effective goals will be
more successful in promoting healthy behavior (see Locke &
Latham, 2002, for review). Goal importance can be positively
influenced by public commitment, having professionally guided
rationale, enthusiasm, and support, and having individuals set
their own goals. Other important factors for successful goal
setting and attainment is a supportive group setting, receiving
goal-relevant feedback, having less complex goals (Wood,
Mento, & Locke, 1987), and a focus on “do-your-best” goals in
the context of long-term goals (Latham & Seijts, 1999).
Lutes and colleagues have applied these strategies for effec-
tive goal setting into a systematic intervention they call a
“Small Changes” approach to diet and exercise. A recent series
of studies has found that a focus on the implementation of small,
gradual changes in eating and physical activity, instead of life-
style “overhauls” used by most dietary plans, have been shown
to be successful in both initial weight loss, but more impor-
tantly, keeping weight off (approximately 5% to 6% body
weight over 6 to 9 months), even though the initial process of
weight loss may take longer (Damschroder, Lutes, Goodrich,
Gillon, & Lowery, 2010; Lutes, Daiss, Barger, Read, & Winett,
2012; Lutes, Daiss, Errickson, Barger, & Winett, 2012; Lutes et
al., 2008). Thus, the SCI approach is an example of the effec-
tiveness of applying psychological principles to the specific
health problem of obesity.
Obesity and Menopausal Symptoms
The majority of female participants who completed earlier
small change weight loss interventions led by the first author
were either perimenopausal or menopausal (mean age in this
study was 50.14 years). Common questions among past par-
ticipants related to the relationship between weight and the
physical and psychological impact of menopause. Based on the
newfound success of the SCI approach with obesity, we sought
to explore the efficacy of using the same program to reduce
menopausal symptoms in a similar overweight and obese fe-
male sample. Thus, the current study was designed as a natural
progression from evaluating the effectiveness of the SCI pro-
gram to evaluating how menopausal symptoms respond to this
same weight loss program.
Menopause is the permanent cessation of menstruation and
resulting infertility as the ovaries gradually decrease production
of estrogen and progesterone. Menopause may occur as early as
35 or as late as a woman’s sixties, but the average age in the US
is 51 years of age. Psychological and physiological symptoms
are well known in Western cultures and include symptoms such
as hot flushes or flashes, mood swings, depression, anxiety,
insomnia, fatigue, vaginal dryness, frequent urination, thinning
skin around the vaginal walls leading to discomfort during sex-
ual intercourse, and memory problems.
Although menopause is a natural event in women’s lives,
there are also known health threats associated with the reduc-
tion of estrogen and progesterone. The relationship among obe-
sity, metabolic syndrome, and depression/ anxiety is already
well established, especially among women (Carpenter, Hasin,
Allison, & Faith, 2000.) However, very little is known about
how obesity affects one of the most important aspects of
women’s health as they age: menopause.
Of the many menopausal symptoms reported by Western
women, hot flushes or flashes are the most frequently reported
symptom in U.S. women. Up to one third of women continue to
experience hot flushes up to five years past the actual cessation
of menstruation (Sterns et al., 2002). Accordingly, nearly all
research in the last decade examining the relationship between
obesity and the frequency and intensity of menopausal symp-
toms has been in the context of the severity and frequency of
hot flushes (e.g., Freeman et al., 2001; Gallicchino et al., 2005;
Gold et al., 2000; Gold et al., 2004; Huang et al., 2012; Schil-
ling et al., 2007; Whiteman et al., 2003). For example, in a
case-controlled study matching menopausal women who did
not report hot flushes to women who reported hot flushes (Gal-
licchino et al., 2005), BMI was positively associated with hot
flushes. It was hypothesized that decreased estrogen levels from
excess adipose stores is the mechanism by which this relation-
ship occurs. Gallicchino et al. (2005) found that very obese
women have significantly higher odds of having hot flushes and
experience them more often, although the estrogen level hy-
pothesis explaining this relationship was only partly supported.
Schilling et al. (2007) found that Estradiol, Estrone, Progester-
one, and Hormone Binding Globulin (SHGB) levels were sig-
nificantly lower in obese (as compared to normal weight) wo-
men, while testosterone levels were found to be higher in obese
women. They also found that the association between obesity
and hot flushes was no longer significant after controlling for
the effects of estrogens, progesterone, and SHGB.
Williams, Levine, Kalilani, Lewis, and Clark (2009) studied
a large sample of American postmenopausal women, and found
that the presence of menopausal symptoms had a significant
impact on daily activity and led to a decreased score in quality
of life. Factors such as BMI, weekly exercise, and tobacco use
were found to significantly impact the quality of life. It may be
that menopausal symptoms, especially hot flushes and fatigue,
tend to make physical activity and other health behaviors more
difficult, leading to a cyclic pattern of weight gain and in-
creased menopausal symptomatology. Indeed, severity of hot
flushes has also been linked to sedentariness (Chendraui et al.,
2010), a state of health closely connected to BMI and obesity.
A more recent study (Huang et al., 2010) examined the oc-
currence and improvement of hot flushes in a group of obese,
incontinent women who were participating in a clinical trial
evaluating a 6-month lifestyle weight loss intervention against a
health education program. Approximately half in each group
reported that they were at least slightly bothered by hot flushes
at baseline. For these women, the lifestyle weight loss interven-
tion was correlated with higher changes in weight and BMI
over 6 months as compared to the control education group.
Thus, hot flushes improved over the course of the study for
these participants. The authors also state that these participants’
self-reported physical activity was not associated with either
increase or decrease in hot flushes, indicating that exercise was
not likely the cause of the change in symptoms. In addition,
calorie intake, blood pressure, and general mental and physical
functioning were not associated with improved flushing. Huang
et al. (2010) concluded that overweight or obese women may
experience a reduction in hot flushes with behavioral weight
loss programs and may benefit from enrolling in such interven-
tions. They also suggest further research in both biological and
psychological factors in weight loss that might affect hot
flushes.
198

S. R. DAISS ET AL.
In terms of psychological factors, there seems to be an over-
lap between reduced health-related quality of life in obesity and
menopause. Laferrére et al. (2000) state that past studies show a
decrease in health-related quality of life after menopause. De-
pression and anxiety/irritability are also commonly reported as
symptoms of menopause. Little research, however, actually
addresses the psychological relationship between obesity and
menopause. Laferrére et al. (2000) examined psychological
well-being, health-related quality of life, race, and menopausal
status in obese women. Participants reported being primarily
middle class professional women. The investigators assessed
psychological distress, including anxiety and depression, as
well as satisfaction with life and self-esteem. No significant
differences were found between African American and white
women on these factors. However, there was a remarkable dif-
ference between premenopausal and postmenopausal women,
with premenopausal women reporting more life distress and
less vitality than the postmenopausal women, especially in the
African American group. These data are in conflict with the
findings that health-related quality of life often decreases after
menopause. In this sample, obese participants ranked slightly
higher on anxiety and depression scores than a non-obese con-
trol group, yet lower than published psychiatric norms. Life
satisfaction scores fell in the same range as a normative popula-
tion. It is clear that additional research is needed to clarify the
impact of psychological factors in menopausal, obese women.
Indeed, the physiological and psychological impact that
menopause can have on women’s well-being cannot be under-
estimated. It is important that we develop long-term, sustain-
able psychological interventions to ameliorate symptoms ex-
perienced by some during perimenopause and menopause.
Study Goal s a n d H ypotheses
Following evidence that the SCI approach is effective in re-
ducing body weight and BMI, we sought to explore whether
adult women enrolled in a small changes weight loss interven-
tion program would also show a reduction in menopausal
symptoms. Although it is well established that obesity can im-
pact the frequency and severity of hot flushes, little is known
about the impact of obesity on the full range of menopausal
symptoms, not only hot flushes. Furthermore, most studies are
cross-sectional in nature. Only one study to date (Huang et al.,
2010) has investigated the impact of obesity on hot flushes
longitudinally. Thus, for this current study, we examined the
longitudinal impact of SCI weight loss program on the variety
of known menopausal symptoms. We formulated three hy-
potheses for the study: a) overweight and obese women would
lose approximately 5% of their body weight, as this has been
shown in previous small changes studies; b) overweight and
obese women would show improvement in the full range of
menopausal symptoms as assessed by the Green Climacteric
Scale (Greene, 1998) at the end of the 12 months; and c) weight
loss among overweight and obese women who completed the
SCI program would be associated with lower menopausal sym-
ptoms at the 12 month follow-up assessment.
Method
Participants
The baseline sample consisted of forty-five women, age 30
and above, with a BMI of >25 (overweight or obese). They
responded to newspaper advertisements posted in the commu-
nity, and email advertisements posted on campus in a midsize
southwestern university. Participants called the telephone
number provided and were screened for the BMI requirements.
If participants were unsure of their BMI, they were invited to
the clinic to be weighed and measured so that BMI and eligibil-
ity could be determined. If participants met BMI criteria (>25),
they completed a brief screening questionnaire regarding medi-
cal and psychiatric conditions and medications. Participants
who reported severe depression or current anorexia or bulimia
were excluded from the study, as these conditions would inter-
fere with their ability to participate in the small changes weight
management program. In addition, those diagnosed with any
other serious medical conditions were asked to obtain a medical
release from their physician to show that their condition was
currently under control, otherwise they were excluded from the
study. BMI was calculated at the first assessment period to
validate that participants were still eligible to participate. At the
first assessment meeting, participants signed both a clinic and
Internal Review Board consent form. By the end of the 12-
month time period, 20 participants had completed the study.
Measures and Materials
Demographics
Demographics, including age, marital status, education, fam-
ily income, and race, were assessed online via Survey Mon-
key™.
Height and Weight
Height was measured without shoes with a height rod on a
spring scale to the nearest 0.05 cm. Body weight was also as-
sessed without shoes via Health-o-Meter Body Fat and Hydra-
tion Monitoring electronic scales (Sunbeam Products, Boca
Raton, FL, USA) to the nearest 0.1 pounds, and was then con-
verted to kilograms. Each weight loss group had its own body
weight scale. For height and weight, two measurements were
taken and the average was used as the final score. Body mass
index was calculated by dividing weight in kilograms by height
in meters squared. Weight loss and percent weight change
(baseline minus follow-up weight divided by baseline weight ×
100) were both calculated.
The Greene Climacte ri c Scale (GCS)
This brief menopausal questionnaire (GCS; Greene, 1998) is
a well-known, widely used, valid instrument that provides as-
sessment for a diverse range of symptoms including vasomotor
(i.e., hot flushes, sweating at night), somatic (e.g., headaches,
muscle and joint pains), and psychological (e.g., feeling tense
or nervous, feeling unhappy or depressed). On the GCS, par-
ticipants were instructed to “please indicate the extent to which
you were bothered at the moment by any of these symptoms by
placing a tick in the appropriate box” (Green, 1998: p. 84). All
items including those above were answered on a Likert scale,
from: Not at all = 0, A little = 1, Quite a bit = 2, and Extremely
= 3. Total scores ranged from 0 (no symptoms) to 63 (severe
symptoms). Confirmatory factor analysis has demonstrated the
construct validity of the GCS and items were found to have
good homogeneity in measuring the scale concepts (Cronbach’s
alpha > .70). Test-retest reliability for the GCS was also ade-

S. R. DAISS ET AL.
quate (Pearson’s r = .58, effect size = .59; N = 19; Chen, Davis,
Wong, & Lam, 2010). The GCS has also been standardized on
both clinical and normative population samples, and has been
shown to have both content and construct validity (Greene,
1998). The GCS was also highly reliable in our sample (α
= .92).
The Stop Light Diet and Daily Food Logs
The Stop Light Diet (Epstein & Squires, 1988) is an effective
system of food categorization for weight loss originally devel-
oped for children and their families (Epstein et al., 2007), but
has also been shown to be successful for adults in making die-
tary decisions (Borgmeier & Westenhoefer, 2009) across a con-
siderably diverse population (Gorton, Mhurchu, Chen, & Dixon,
2009). Based on calorie count and fat content, food is divided
up into three simple colors: green, yellow, and red. Green foods,
the majority of which are fruits and vegetables, are high in nu-
tritional value and low in calories and should be eaten often
with no limit on quantities. Yellow foods make up the staple of
a typical diet and are slightly higher calorie; they are to be eaten
in moderation. Red foods tend to be very high in calories, fat,
sugar, and commercial processing, and should be reduced
throughout the diet’s progression. However, no food is specifi-
cally forbidden, and although red foods should be minimized,
they are still allowed. Stop Light Diet manuals were given to
participants to code their food for their daily food logs. Food
logs included space for all foods and drinks consumed each day,
their stop light color, and calorie counts.
Weekly Goal Sheets
Weekly goal sheets detailed ideal average daily calorie intake
as well as average daily number of red and green foods, which
the participants tailored to their own needs and comfort level.
After a baseline for daily average calories and amount of red,
yellow and green foods was established during the first week,
participants chose to decrease daily calories by up to, but no
more than, 200 calories per day. Most participants stayed at
1500 calories or greater, and they were asked not to drop their
daily calories below 1200 at any point.
Design and Procedur e
Five groups of 8 to 10 women were semi-randomly assigned
by forming selection groups with approximately the same BMI
range and randomly distributed from each selection group. This
helped to ensure a diverse range of BMIs across each group. A
fee of $50 was charged for the year-long program and covered
the costs of basic materials. From the Baseline assessment to
the 3-month post-treatment assessment, the five groups met for
ten weeks over a three-month period. From post-treatment through
the end of the study, groups continued to meet bi-weekly, then
every three weeks, then monthly until the end of the 12 month
study. There were four assessments periods: Baseline (before
the start of the weight loss group), 3-month post-treatment (the
end of the initial 3 months of the program), 6-Month Follow-up
(six months after Baseline) and 12-month follow-up (12 months
after baseline). Dependent variables included Body Weight
(Kg), BMI, and the Greene Climacteric Scores.
One and one half hour group sessions were led by Health
Psychology graduate students and supervised by the first author,
a licensed clinical psychologist. The overriding theme of the
program included a “non-dieting” approach with participants
making their own choices about the small changes they would
make in eating and physical activity over time. Each session
covered a specific topic related to weight loss. The format al-
lowed for educational and group discussion. In addition, cogni-
tive-behavioral techniques were used by the lifestyle coaches to
promote weight loss and healthy lifestyles. Active problem
solving and implementing coping strategies was also discussed
during sessions. Examples of topics covered included: general
nutrition, physical activity, body image, mindful eating, social
support, stress reduction, and negative thought patterns. Spe-
cific interventions for menopausal symptoms were not part of
the intervention materials, though participants could have ap-
plied the general stress management strategies they learned to
reduce such symptoms. Weekly goals for daily calorie con-
sumption and red and green food counts were set at the end of
each session. Weigh-ins were conducted every two weeks to
track weight loss progression from the Baseline to post-treat-
ment times and at every session in the Follow-up period. After
the 3-month post-treatment assessment (at 3 months), partici-
pants were asked to continue monitoring three days a week.
Though monitoring was generally less stringent during the fol-
low-up period, participants continued to report their general
progress at the follow-up group sessions.
Statistical Analyses
Given the small sample size, two decisions were made with
respect to how to judge the statistical results. First, an a priori
decision was made to allow for a p < .10 cutoff (one-tailed) to
determine statistical significance for all hypothesized relation-
ships. For all preliminary analyses a p < .05 cutoff was utilized.
Second, Cohen’s (1988) conventions were used to interpret
effect size, irrespective of the associated p value (.10 = weak or
small association; .30 = moderate correlation; .50 or larger =
strong or large correlation). The overall strategy was to exam-
ine the data for replicated patterns with non-negligible effect
sizes. Statistical analyses were conducted using SPSS (version
19; SPSS Inc., Chicago, IL).
Results
Participant characteristics at baseline are presented in Table
1. The study sample at Baseline consisted of 45 women who
were primarily White and averaged 50.14 years of age. The
women in this sample fell into the category of “obese” (BMI ≥
30) with an average BMI of 33.25, (SD = 5.68), ranging from
25.6 to 52.6. The mean weight of participants was 89.9 kilo-
grams. Just under half of the original sample (N = 20) were still
participating in the study 12 months after the initial study began,
resulting in a 44% retention rate one year later.
Finally, a one-way MANOVA was conducted to ascertain if
there were differences at Baseline between completers and non-
completers on the study variables of body weight, BMI, and
GCS scores. The results were found to be nonsignificant, Pil-
lai’s Trace F (6, 39) = .44, p = .78. Finally, study variables at
all four time points were examined for departures from normal-
ity. BMI and the Green Climacteric Scale scores were fairly
normally distributed. One variable, body weight, showed some
positive skew but fell well within a normal range for skew by
six months follow-up. However, given the nature of the group
intervention (e.g., weight loss), some positive skew for body
weight was expected as the stated criteria for inclusion in the
group was that one had to qualify as “overweight”.
200

S. R. DAISS ET AL.
Table 1.
Participant’s baseline characteristics (N = 45).
Age (years, mean + SD) 50.14 (12.16)
BMI (KG/m2) 33.30 (5.70)
Weight (kg) 89.90 (17.90)
Ethnicity (%)
Caucasian 86.70
Hispanic 6.70
American Indian 2.20
Non-Responders 4.40
Education (%)
Post High School 24.40
College Degree 31.10
Post Baccalaureate 40.00
Non-Responders 4.40
Marital Status (%)
Single 24.40
Married 64.40
Living Together 2.20
Widowed 4.40
Non-Responders 4.40
Family Income per Year
<$50,000 22.20
$50 - 75,000 31.10
$75 - 100,000 22.20
>$100,000 22.20
Non-Responder 4.40
Weight Loss and BMI
It was hypothesized that the Small Change Intervention (SCI)
method of lifestyle modification program, administered weekly
over twelve weeks and bi- and tri-weekly, then monthly, for a
follow-up period lasting an additional 9 months, would result in
a significant reduction in initial body weight and BMI. Based
on the previous SCI studies, a body weight change in the range
of 5% was expected and found. Average BMI across the
twelve-month program decreased from 33.67 (std = 7.03) to
30.90 (std = 6.13). A one-way repeated measure ANOVA was
significant, Pillai’s Trace F (3,15) = 4.98, p = .014, ηp2 = .50,
revealing that BMI had significantly changed over time. Post-
hoc analyses revealed that BMI at the 3 month, 6 month and 12
month assessments were all significantly lower than baseline (ts
ranged from 3.67 to 3.87, ps ranged from. 001 to .002). How-
ever, there were no significant differences between the BMI
scores between the 3, 6, and 12-month assessments (ts ranged
from .35 to 1.74, ps ranged from .10 to .74). See Table 2.
Average body weight decreased from 90.83 kgs (std = 23.64)
to 85.05 kgs (std = 21.55); a total loss of 5.78 kgs, or a 6.4%
reduction in body weight. Average body weight was lowest at
the six month follow-up (84.55 (std = 21.22) with an average
loss of 6.28 Kg or 6.9% reduction in body weight. A one-way
repeated measure ANOVA was significant, Pillai’s Trace F
Table 2.
Means for body weight, BMI, and GCS over 12 months.
Time F (3, 15)
Baseline3 Months 6 Months 12 Months
Body Weight90.83a
(23.63)
86.83b
(21.90)
84.55c
(21.22)
85.05bc
(21.56) 13.20**
BMI 33.67a
(7.03)
31.71b
(6.23)
31.09b
(7.33)
30.90b
(6.13) 5.00**
GCS 10.83a
(7.38)
7.67b
(9.68)
8.22b
(10.13)
6.67b
(8.06) 5.40**
Note: Means (and standard deviations) for post hoc tests. Means with different
subscripts differ significantly at p < .10; **p < .01.
(3,15) = 13.20, p = .001, ηp2 = .73, revealing that weight had
significantly changed over time. Post-hoc analyses revealed that
body weight at the 3-month, 6-month, and 12-month assess-
ments were all significantly lower than baseline (ts ranged from
4.52 to 6.92, ps = .0001). Weight loss was also significant be-
tween the 3 and 6 month assessment, t (1) = 3.06, p = .006).
However, there were no significant differences between the
weight loss between 3 and 12 month and 6 and 12 months (ts
1.73 and –.66 respectively, ps = .10 and .52 respectively). See
Table 2.
Menopausal Symptoms
In order to assess if BMI and body weight (KG) were associ-
ated with greater menopausal symptoms at each assessment
point, four sets of correlational analyses were conducted. At
baseline, menopausal symptoms were not significantly corre-
lated with body weight, r(43) = .08 or BMI, r(43) = −.00. At
the three month follow-up, the correlations were small but posi-
tive (body weight: r(32) = .22; BMI: r(32) =.16). At the six
month follow-up, the correlations were moderate and signifi-
cant (body weight: r(25) = .48, p = .016; BMI: r(25) = .36, p
= .074). At the nine month follow-up, the correlations remained
moderate and significant (body weight: body weight: r(18)
= .42, p = .08; BMI: r(18) = .44, p = .07. Taken together, these
results indicate that body weight and BMI were weakly to
moderately associated with increased menopausal symptoms at
the end of the 12 week treatment in this small sample, but con-
sistently and significantly related by the six and nine month
marks following the treatment intervention. It was hypothesized
that the SCI method of lifestyle modification would result in a
statistically significant reduction in GCS scores over time. A
one-way within-subjects analyses of variance (ANOVA) was
conducted using GCS scores as the dependent variable. As
hypothesized, there was a significant decrease in average CGS
scores across the span of the weight loss program. F (3,15) =
5.40, p = .01, partial ηp2 = .52. Post-hoc tests indicated that
scores were significantly lower at the 3, 6, and 9 month follow
up as compared to baseline scores (ts ranged from 2.00 to 3.38,
ps ranged from .06 to .008). There were no statistical differ-
ences between the 3, 6, and 9 month assessments (ts ranged -.42
to 1.14, ps ranged .27 to .67). See Table 2.
Finally, it was hypothesized that weight loss among over-
weight and obese women who completed the SCI program
would be associated with lower menopausal symptoms at the
12-month follow-up assessment. To examine these hypotheses,
two change scores were computed by subtracting the Baseline
measures of body weight and BMI from their respective 12-
month, end of study scores. Higher scores on these change

S. R. DAISS ET AL.
variables represented greater weight loss and greater reductions
in BMI over time. Next, these two change scores were corre-
lated with the 12-month measure of menopausal symptoms.
Seen in Table 3, as expected, BMI change scores were found to
be significantly and negatively related to GCS scores, r(18) =
–.37, p = .07 (one-tailed). That is, participants whose BMI
scores had a greater decrease over time also reported fewer
menopausal symptoms at the final assessment. The result for
weight loss was also in the moderate range for correlations, but
due to the small sample size was not significant, r(18) = –.24, p
= .17 (one-tailed). See Table 3.
Discussion
This study examined how psychological principles related to
goal-setting and motivation can be applied to a cognitive-be-
havioral program designed to reduce the long-term physical and
psychological effects of obesity and menopausal symptoms in
women. To date, the impact of weight loss and reductions in
BMI on women’s experience of menopause has not been
widely examined. As hypothesized, results of this study provide
further support for the use of an intervention based on sound
and well researched literature on effective goal setting. The
Small Changes approach, which incorporated self-directed goal
setting, expertise, group support, and other program elements
designed to increase self-efficacy, coupled with a follow-up
period of support, was effective in moderate weight loss of
6.4% initial body weight over a 12-month period. Findings of
this study mirror that of previous research using similar meth-
odology (Damschroder et al., 2010; Lutes et al., 2012; Lutes,
Daiss, et al., 2012; Lutes et al., 2008). A 5% - 10% decrease in
body weight has been shown to be beneficial in a variety of
health outcomes, as well (Fabricatore & Wadden, 2006; Jeffrey
et al., 2000; National Heart, Lung, and Blood Institute, 1998).
Although the women in the sample also evidenced a significant
reduction in BMI, their mean BMI scores still placed them in
the obese category by their last assessment period (Mean BMI
= 30.9). However, it is important to note that a modest 5% de-
crease in body weight (which was accomplished in this study)
has been shown to provide numerous health benefits, even if
the reduction still leaves the individual well above a normal
weight range (Fabricatore & Wadden, 2006; Jeffrey et al. 2000,
Heart, Lung, and Blood Institute, 1998). Results of this study
also demonstrate both cross-sectional and longitudinal evidence
regarding the relationship between obesity and menopausal
symptoms. First, at each assessment period, women with higher
body weights and higher BMIs reported more menopausal sym-
ptoms. Conversely, and as predicted, women with lower body
weights and lower BMIs reported fewer menopausal symptoms.
Furthermore, the strength of these relationships increased over
time. These results are consistent with findings from earlier re-
search about the relationship between menopausal symptoms and
Table 3.
Correlations among weight and BMI Change variables and GCS at 12
months.
Weight Change BMI change GCS 12 month
Weight Change -
BMI Change .60*** -
GCS 12-month –.24 –.37* -
*p < .10; ***p < .01.
excess body weight (e.g., Freeman et al., 2001; Gold et al., 2000).
More importantly, because this study examined these relation-
ships longitudinally, the data revealed that women who experi-
ence a greater reduction in BMI over the course of the interven-
tion report fewer menopausal symptoms at the follow-up as-
sessment period. These finding are consistent with the only
other study to find reductions in hot flushes over the course of a
behavioral weight loss program (Huang et al., 2010).
Additionally, the biggest drop in overall menopausal symp-
tom scores co-occurred with the biggest decreases in BMI/body
weight, during the first three months of the program. This
three-month window of assessment may point to a critical pe-
riod in which positive physiological and psychological benefits
are most likely to occur. It is also the time period in weight loss
trials when researchers may expect the largest observations in
weight loss. These results underscore the importance of apply-
ing psychological principles to real-world problems, and that
behavior modification programs based on empirically tested
effective forms of goal-setting (and enhanced motivation) may
be more effective than programs based on short-term imple-
mentation of unrealistic goals.
We identify several limitations to this study. The first con-
cerns our small sample size. One of the most difficult aspects of
long-term weight-loss interventions is minimizing drop out
rates. Our retention rate of 44%, obtained over one year’s time,
resulted in a small sample size. In the weight loss literature, a
60% retention rate is usually standard, even when extensive
follow-up contact measures for no-show participants are used
(Ware, 2003). As with other past studies, our attrition was pri-
marily among non-white participants (Honas, Early, Frederick-
son, & O’Brien, 2003), suggesting an important area for future
investigations. Thus, given our attrition rate and small sample
size, our findings should be considered preliminary and en-
courage future work that examines not only the effectiveness of
small change behavioral modification, but also explores the
potential causes of attrition among non-white women.
Another limitation of our study is the lack of a control group.
Although a wait-list control group was planned as part of the
study, too few individuals were enrolled to properly complete
statistical analyses. Future studies would benefit from the in-
clusion of a matched control group. With only one other study
(Huang et al., 2010) finding that losing weight and/or attending
weight loss groups may be beneficial in the reduction of meno-
pausal symptoms, further research with larger sample sizes and
control groups is needed to validate these findings. Additionally,
symptoms may vary in response to menopausal status (e.g.,
Laferrére et al. (2000), from periomenopause to menopause to
postmenopause, so it would be beneficial to develop and com-
pare interventions within these time frames.
In spite of the limitations, our study’s strengths include the
application of important psychological principles to an inter-
vention that has long-term effectiveness for weight loss and
menopausal symptom reduction. Given the psychological and
physical distress associated with menopausal symptoms, and
the relative dearth of studies that specifically examine the link
between obesity and menopausal symptoms in women, our
study results have important implications for women’s health
and well-being.
Conclusion
Goal setting and task motivation theory argues that success-
202

S. R. DAISS ET AL.
ful formulation and implementation of specific, achievable and
relevant goals, in a setting that affirms and increases self-effi-
cacy through expert guidance, social support, and success (La-
tham, Winters, & Locke 1994; Wood & Bandura, 1989) are
central to designing effective diet and exercise protocols. Ac-
cordingly, health care professionals are urged to consider the
application of existing psychological research that provides
evidence that to fight obesity and associated menopausal symp-
toms a Small Changes approach is effective. In our SCI ap-
proach obese and overweight women were supported and en-
couraged to “do their best” for meeting their diet and exercise
goals instead of utilizing intervention strategies that encouraged
evaluative pressure and performance anxiety which would
likely have interfered with effective behavior modification
(Early, Connolly, & Ekegren, 1989). Our study results provide
further evidence of a significant reduction in menopausal symp-
toms for its participants over a 12-month period. Continued
attention towards women’s issues in weight loss and meno-
pause is needed.
REFERENCES
Borgmeier, I., & Westenhoefer, J. (2009). Impact of different food label
formats on healthiness evaluation and food choice of consumers: A
randomized-controlled study. BioMedCentral Pu bl i c H e al t h , 9, 184.
doi:10.1186/1471-2458-9-184
Carpenter, K. M., Hasin, D. S., Allison, D. B., & Faith, M. S. (2000).
Relationship between obesity and DSM-IV major depressive disorder,
suicide ideation, and suicide attempts: Results from a general popu-
lation. American Journal of Public Health, 90, 251-257.
Chedraui, P., Aguirre, W., Calle, A., Hidalgo, L., Leon-Leon, P., Mi-
randa, O., Martinez, N., Mendoza, M., Narvaez, J., Sanchez, H., Sch-
wager, G., Quintero, J. C., Zambrano, B., Aguilar, A., Martinez, M.
A., Rivera, R., & Ruilova, I. (2010). Risk factors related to the pres-
ence and severity of hot flushes in mid-aged Ecuadorian women.
Mauritas, 65, 378-382. doi:10.1016/j.maturitas.2009.11.024
Chen, R., Davis, S., Wong, C., & Lam, T. (2010). Validity and cultural
equivalence of the standard Greene Climacteric Scale in Hong Kong.
Menopause, 17, 630-635.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences
(2nd ed.). Mahwah, NJ: Lawrence Erlbaum Associates.
Damschroder, L. J., Lutes, L. D., Goodrich, D. E., Gillon, L., & Lowery,
J. C. (2009). A small-change approach delivered via telephone pro-
motes weight loss in veterans: Results from the ASPIRE-VA pilot
study. Patient Education and Counseling, 79, 262-266.
doi:10.1016/j.pec.2009.09.025
Earley, P. C., Connolly, T., & Ekegren, G. (1989). Goals, strategy de-
velopment and task performance: Some limits on the efficacy of goal
setting. Journal of Applied Psychology, 74, 24-33.
doi:10.1037/0021-9010.74.1.24
Epstein, L. H., Paluch, R. A., Roemmich, J. N., & Beecher, M. D.
(2007). Family-based obesity treatment, then and now: Twenty-five
years of pediatric obesity treatment. Health Psychology, 26, 381-391.
doi:10.1037/0278-6133.26.4.381
Epstine, L. H., & Squires, S. (1988). The stop-light diet for children.
Boston: Massachussets.
Fabricatore, A. N., & Wadden, T. A. (2006). Obesity. Annual Review of
Clinical Psychology, 2 , 357-377.
doi:10.1146/annurev.clinpsy.2.022305.095249
Freeman, E. W., Sammel, M. D., Grisso, J. A., Battistini, M., Garcia-
Espagna, B., & Hollander, L. (2001). Hot flashes in the late repro-
ductive years: Risk factors for African American and Caucasian wo-
men. Journal of Women’s Health & Gender-Based Medicine, 10, 67-
76. doi:10.1089/152460901750067133
Gallicchio, L., Visvanathan, K., Miller, S. R., Babus, J., Lewis., L. M.,
Zacur, H., & Flaws, J. A. (2005). Body mass, estrogen levels, and hot
flashes in midlife women. American Journal of Obstetrics and Gy-
necology, 193, 1353-1360. doi:10.1016/j.ajog.2005.04.001
Gold, E., Block, G., Crawford, S., Lachance, L., FitzGerald, G., Mira-
cle, H., & Sherman, S. (2004). Lifestyle and demographic factors in
realtion to vasomotor symptoms: Baseline results from the study of
women’s health across the nation. American Journal of Epidemiol-
ogy, 159, 1189-1199.
Gold, E., Sternfeld, B., Kelsey, J., Brown, C., Mouton, C., Reame, N.,
Salamone, L., & Stellato, R. (2000). Relation of demographic and
lifestyle factors to symptoms in a multi-racial/ethnic population of
women 40-55 years of age. American Journal of Epidemiology, 152,
463-473. doi:10.1093/aje/152.5.463
Gorton, D., Mhurchu, C. N., Chen, M. H., & Dixon, R. (2009). Nutri-
tion labels: A survey of use, understanding and preferences among
ethnically diverse shoppers in New Zealand. Public Health Nutrition,
12, 1359-1365. doi:10.1017/S1368980008004059
Greene, J. G. (1998). Constructing a standard climacteric scale. Mauri-
tas, 29, 25-31. ddoi:10.1016/S0378-5122(98)00025-5
Hollis, J. F., Gullion, C. M., Stevens, V. J., Brantley, P. J., Appel, L. J.,
Ard, J. D., Champagne, C. M., & Svetkey, L. P. (2008). Weight loss
during the intensive intervention phase of the weight-loss mainte-
nance trial. American Journal of Preventive Medicine, 35, 118-126.
doi:10.1016/j.amepre.2008.04.013
Honas, J., Early, J., Frederickson, D., & O’Brien, M. (2003). Predictors
of attrition in a large clinic-based weight-loss program. Obesity Re-
search, 7, 888-894. doi:10.1038/oby.2003.122
Huang, A. J., Subak, L. L., Wing, R, West, D., Hernandex, A. L.,
Macer, J., & Grady, D. (2010). An intensive behavioral weight loss
intervention and hot flushes in women. Archives of Internal Medicine,
170, 1161-1167. doi:10.1001/archinternmed.2010.162
Jeffery, R. W., Drewnowski, A., Epstein, L. H., Stunkard, A. J., Wilson,
G. T., & Wing, R. R. (2000). Long-term maintenance of weight loss:
Current status. Health Psychology, 10, 5-16.
doi:10.1037/0278-6133.19.Suppl1.5
Laferrére, B., Zhu, S., Clarkson, J. R., Yoshikoka, M. R. M., Kruaskopf,
K., Thornton, J. C., & Pi-Sunyer, F. X. (2000). Race, menopause,
health-related quality of life, and psychological well-being in obese
women. Obesity Research, 10, 1270-1272.
doi:10.1038/oby.2002.172
Latham, G. P., & Seijts, G. H. (1999). The effects of proximal and
distal goals on performance on a moderately complex task. Journal
of Organizational Behavior , 20, 421-429.
doi:10.1002/(SICI)1099-1379(199907)20:4<421::AID-JOB896>3.0.
CO;2-#
Latham, G. P., Winters, D., & Locke, E. (1994). Cognitive and motivi-
tional effects of participation: A mediator study. Journal of Organ-
izational Behavior, 15, 49-63. doi:10.1002/job.4030150106
Locke, E. A. (2000). Motivation, cognition, and action: An analysis of
studies of task goals and knowledge. Applied Psychology: An Inter-
national Review, 49, 408-429. doi:10.1111/1464-0597.00023
Locke, E. A., & Latham, G. P. (2002). Building a practically useful
theory or organizational management. Academy of Management Re-
view, 14, 361-384.
Lutes, L. D., Daiss, S. R., Barger, S. D., Read, M., & Winett, R. A.
(2012). A small change approach promotes initial and continued
weight loss with a phone-based follow-up: Nine-month outcomes
from ASPIRES American Journal of Health Promotion, 26, 235-238.
Lutes, L. D., Winett, R. A., Barger, S. D., Wojcik, J. R., Herbert, W. G.,
Nickols-Richardson, S. M., & Anderson, E. S. (2008). Small changes
in nutrition and physical activity promote weight loss and mainte-
nance: 3-month evidence from the ASPIRE randomized trial. Annals
of Behavioral Medicine, 25, 351-357.
doi:10.1007/s12160-008-9033-z
Lutes, L. D., Daiss, S. R., Errickson, M. A., Barger, S. D. & Winett, R.
A. (2012). Small changes can promote initial and continued weight
loss delivered in person or using the internet: Nine-month results
from the ASPIRE III pilot study. In Press.
Mokdad, A. H., Marks, J. S., Stroup, D. F., & Gerberding, J. L. (2004).
Actual causes of death in the United States, 2000. Journal of the
American Medical Association, 291, 1238-1245.
doi:10.1001/jama.291.10.1238
National Heart, Blood, and Lung Institute (NHLBI) (1998). Clinical

S. R. DAISS ET AL.
204
guidelines on the identification, evaluation, and treatment of over-
weight and obesity in adults: The evidence report. Obesity Research,
6, 51S-210S.
National Weight Control Registry (n.d.) URL (last checked 13 March
2013). http://www.nwcr.ws/
Paxman, J. R., Hall, A. C., Harden, C. J., O’Keeffe, J., & Simper, R. N.
(2011). Weight loss is coupled with improvements to affective state
in obese participants engaged in behavior change therapy based on
incremental, self-selected “Small Changes”. Nutrition Research, 31,
327-337. doi:10.1016/j.nutres.2011.03.015
Puhl, R. M.., & Brownell, K. D. (2003). Psychosocial origins of obe-
sity stigma: Toward changing a powerful and pervasive bias. Obesity
Reviews, 4, 213-227. doi:10.1046/j.1467-789X.2003.00122.x
Schilling, C., Gallicchio, L., Miller, S. R., Langenber, P., Zacur, H., &
Flaws, J. A. (2007). Relation of body mass and sex steroid hormone
levels to hot flushes in a sample of mid-life women. Climacteric, 10,
27-37. doi:10.1080/13697130601164755
Sterns, V., Ullmer, L., Lopez, J. F., Smith, Y., Isaacs, C., & Hayes, D.
(2002). Hot flushes. Lancet, 360, 1851-1861.
Strychar, I. (2006) Diet and weight loss-response. Canadian Medical
Association Journal, 175, 1407.
Ware, J. (2003) Interpreting incomplete data in studies of diet and
weight loss. New England Journal of Medicine, 348, 2136-2137.
doi:10.1056/NEJMe030054
Whiteman, M. K., Staropoli, C. A., Langenberg., P. W., McCarter, R. J.,
Kjerulff, K. H., & Flaws, J. A. (2003). Smoking, body mass, and hot
flashes in midlife women. Obstetrics & Gynecology, 101, 264-272.
doi:10.1016/S0029-7844(02)02593-0
Williams, R. E., Levine, K. B., Kalilani, L., Lewis, J., & Clark, R. V.
(2009). Menopause-specific questionnaire assessment in US popula-
tion-based study shows negative impact on health-related quality of
life. Maturitas, 62, 153-159. doi:10.1016/j.maturitas.2008.12.006
World Health Organization (2013). URL (last checked 13 March 2013).
http://www.who.int/mediacentre/factsheets/fs311/en/index.html
Wood, R., & Bandura, A. (1989). Social-cognitive theory of organiza-
tional management. Academy of Management Review, 14, 361-384.