Psychology
2011. Vol.2, No.7, 694-699
Copyright © 2011 SciRes. DOI:10.4236/psych.2011.27106
Moderation of Fatigue and Stress in the Carry-over of
Self-Regulation and Self-Efficacy for Exercise to Self-Regulation
and Self-Efficacy for Managed Eating
James J. Annesi
YMCA of Metropolitan Atlanta, Atlanta, Georgia, USA.
Received July 14th, 2011; revised August 28th, 2011; accepted October 1st, 2011.
Behavioral treatments for morbid obesity have not been effective, possibly because of a poor understanding of
the relations of psychosocial factors and exercise and eating behaviors. Recent research suggests that exercise
program-induced improvements in self-efficacy and self-regulatory skills use may carry-over to self-efficacy
and self-regulation for controlled eating. However, for individuals with morbid obesity, fatigue and anxiety may
moderate these relationships. The purpose of this research was to evaluate this moderation. Adults with Grade 3
obesity (MBMI = 46.0 kg/m2) participated in 26 weeks of cognitive-behaviorally supported exercise paired with
12 weeks of either nutrition education (n = 95) or a cognitive-behavioral nutrition component (n = 109). There
were significant improvements in self-regulation and self-efficacy for exercise, and self-regulation and
self-efficacy for controlled eating, which did not differ by treatment condition. Bivariate relationships between
changes in self-regulation for exercise and self-regulation for controlled eating (β = .63), and changes in exercise
self-efficacy and self-efficacy for controlled eating (β = .51), were strong. Moderation of these relationships by
fatigue and anxiety was either significant or marginally significant (ps < .01 and ps < .08, respectively). Both
changes in self-regulation for controlled eating and self-efficacy for controlled eating significantly contributed to
the explained variance in BMI change (R2 = .30). Implications of the findings for behavioral weight-loss treat-
ment for those with morbid obesity were discussed.
Keywords: Self-Regulation, Self-Efficacy, Exercise, Obesity, Nutrition
Introduction
Approximately 6% (13.5 million) of adults in the U.S. have
Grade 3, or morbid, obesity (body mass index [BMI] ≥ 40
kg/m2) compared to the 34% that reach the threshold for Grade
1 obesity (BMI ≥ 30 kg/m2) or the 68% who are overweight
(BMI of 25 to 29.9 kg/m2) or above (Flegal, Carroll, Ogden, &
Curtin, 2010). Health risks such as hypertension, hyperlipide-
mia, and Type 2 diabetes increase exponentially as degree of
excess weight increases (Mokdad et al., 2003). Psychosocial
factors such as anxiety, fatigue, self-efficacy, and coping are
predictably worse in individuals with obesity than those of a
healthy weight (Greenberg, Perna, Kaplan, & Sullivan, 2005).
Moreover, it is likely that the effect of these constructs on eat-
ing and exercise behaviors is distinct in persons with morbid
obesity (Davies, 2007), and thus may require specific study
(Annesi & Whitaker, 2010). The lack of understanding of po-
tentially modifiable psychological predictors of weight-man-
agement behaviors may contribute to the overwhelming failure
of behavioral weight-loss treatments (Mann et al., 2007) that
increasingly yield to invasive and expensive medical proce-
dures such as gastric bypass and gastric banding surgery (Bult,
Van Dalen, & Muller, 2008) (that possess health risks of their
own; Maggard et al., 2005).
Because of it being the strongest predictor of sustained
weight loss (Fogelholm & Kukkomen-Harjula, 2000; Svetkey
et al., 2008), exploration of the role of exercise, beyond simple
caloric expenditure (that is typically minimal in deconditioned
and obese individuals; American College of Sports Medicine,
2009), has been strongly encouraged (Mann et al., 2007). Fol-
lowing from a social cognitive and self-efficacy framework
(Bandura, 1986, 1997), it has been suggested that exercise may
have important linkages to individuals’ control over excess
eating through psychosocial pathways such as the effect of
physical activity on perceived control, feelings of competence,
and mood (Baker & Brownell, 2000). Examples of recently
identified relationships having treatment implications include
associations between self-regulation and self-efficacy improve-
ments and improvements in exercise and eating behaviors; and
carry-over effects of self-regulation for exercise to self-regula-
tion for eating, and exercise-related self-efficacy to self-effi-
cacy for controlling eating (Annesi & Marti, 2011; Hankonen,
Absetz, Haukkala, & Uutela, 2009; Oaten & Cheng, 2006;
Teixeira et al., 2010).
However, because completion of physical activity may be
exceedingly difficult, unpleasant, and, ultimately, a different
experience for individuals with morbid obesity, it is not known
if these relationships generalize to them. Self-efficacy and per-
sistence with self-regulatory skills may also be affected in indi-
viduals with morbid obesity, who are typically viewed critically
by society (Puhl & Brownell, 2002). Also, although exercise
program-induced improvements in mood (e.g., anxiety, fatigue,
depression) have been shown to improve emotional and other-
wise uncontrolled eating (Annesi & Marti, 2011), mood may
play a quite different role in persons with morbid obesity. For
example, the heightened stress and fatigue associated with this
disorder may adversely affect carry-over from exercise-related
self-regulation and self-efficacy to self-regulation and self-
efficacy related to managed eating. Previous research suggests
that fatigue and stress affects coping skills and feelings of abil-
ity to effectively deal with barriers (Hagger, Wood, Stiff, &
Chatzisarantis, 2009; Tice & Bratslavsky, 2000).

J. J. ANNESI 695
Thus, various research questions were tested here to aid in
the ultimate development of an original, theoretically driven
behavioral treatment for morbid obesity that may have better
sustained effects than those currently available. In the present
experimental design, cognitive-behaviorally supported exercise
was incorporated because it provided impetus for analyses of
the transfer of self-regulation and self-efficacy for exercise to
self-regulation and self-efficacy for controlled eating and wei-
ght loss. Based on recent suggestions (Glasgow, 2008; Glasgow
& Emmons, 2007), a naturalistic environment was chosen for
the investigation to maximize external validity and rapid gener-
alizability of findings to practice settings.
Several hypotheses were proposed:
1) It was expected that the addition of a cognitive-behavior-
ally based nutrition component to the exercise support would be
associated with greater improvements in self-regulatory skill
usage and self-efficacy for controlled eating when contrasted
with the addition of a more typical approach to nutrition that
emphasized education in healthy eating.
2) It was also expected that, consistent with findings of indi-
viduals with varied of degrees of overweight (Annesi & Marti,
2011), the relationships between self-regulation for exercise
and self-regulation for eating, and self-efficacy for exercise and
self-efficacy for controlled eating would be strong.
3) It was thought that both fatigue and stress (tension) would
significantly moderate the aforementioned relationships in the
present sample.
Hopefully, a better understanding of interrelations between
social cognitive theory variables related to exercise, eating, and
weight control in adults with Grade 3 obesity will prove useful
to both theory and the development of more successful behav-
ioral treatments.
Method
Participants
Men and women responded to advertisements soliciting vol-
unteers for research on exercise and nutrition instruction for
weight loss. Inclusion criteria were a minimum age of 21 years,
a BMI of 40 to 60 kg/m2 (Grade 3, or morbid, obesity), and no
regular exercise within the previous year. Present or soon-
planned pregnancy and use of medications for weight loss or a
psychological condition were reasons for exclusion. A written
statement of adequate health to participate was required from a
physician. Appropriate institutional review board approval and
written informed consent from all participants was obtained.
There was no significant difference in percentage of women
(overall 84%), age (overall M = 41.6 years, SD = 10.4), BMI
(overall M = 46.0 kg/m2, SD = 4.9), and racial make-up (overall
44% White, 53% Black, and 3% of other racial groups) be-
tween participants randomly assigned to cognitive-behavioral
exercise support plus nutrition education (Nutrition Education
group; n = 95) and cognitive-behavioral exercise support plus
cognitive-behavioral methods applied to nutritional change
(Behavioral Nutrition group; n = 109). Most participants were
middle-class. There was minimal attrition from initial accep-
tance into the study to actual treatment participation (4%) that
did not differ by group.
Measures
Self-efficacy for exercise (perceived ability to overcome bar-
riers to completing exercise) was measured by the 5-item Exer-
cise Self-Efficacy Scale (Marcus, Selby, Niaura, & Rossi,
1992). It requires responses that begin with the stem, “I am
confident I can participate in regular exercise when” e.g., “I
have more enjoyable things to do”, ranging from 1 (Not at all
confident) to 7 (Very confident). Internal consistencies ranged
from .76 to .82, and test-retest reliability over 2 weeks was .90
(McAuley & Mihalko, 1998).
Self-efficacy for controlled eating (perceived ability to over-
come barriers to managing eating) was measured by the
20-item Weight Efficacy Lifestyle Questionnaire (Clark, Ab-
rams, Niaura, Eaton, & Rossi, 1991). Responses to five sub-
scales of Negative Emotions, Social Pressure, Availability,
Physical Discomfort, and Positive Activities (e.g., “I can resist
eating when I am watching TV”) range from 0 (Not confident)
to 9 (Very confident), and are summed. Internal consistencies
ranged from .70 to .90 (Clark et al., 1991), and the predictive
validity was acceptable in multiple studies (Warziski, Sereika,
Styn, Music, & Burke, 2008).
Self-regulation for exercise and self-regulation for eating
were separately measured by modified versions of a scale by
Saelens and colleagues (2000), where 10 items each are based
on the content of the treatment (e.g., “I set physical activity
goals” and “I say positive things to myself about eating well”,
respectively). Responses ranged from 1 (Never) to 5 (Often).
The internal consistencies were .78 and .81, and test-retest reli-
abilities over 2 weeks were .78 and .74, respectively (Annesi &
Marti, 2011).
Tension and fatigue. The Profile of Mood States Short Form
(McNair & Heuchert, 2005) 5-item scales of Tension (e.g.,
anxious) and Fatigue (e.g., worn-out) required responses from 0
(Not at all) to 4 (Extremel y) to indicate “how you have been
feeling during the past week including today”. Internal consis-
tencies were .91 and .93, and test-retest reliabilities over 3
weeks were .70 and .66, respectively (McNair & Heuchert,
2005). Concurrent validity was demonstrated with a variety of
accepted instruments.
BMI was calculated as weight in kg/height in m2. A recently
calibrated digital scale was used to measure weight, and a sta-
diometer was used to measure height.
Procedure
Each participant was provided full access to a YMCA well-
ness facility and received an orientation to study processes
associated with his/her assigned group. The exercise support
component was identical in both the Nutrition Education and
Behavioral Nutrition groups. It consisted of a previously tested
protocol of cognitive-behavioral methods within six, 1-hour
meetings with a trained YMCA wellness leader, spaced across
26 weeks (Coach Approach; Annesi & Unruh, 2007). The
one-on-one sessions included an orientation to exercise appara-
tus and setting an exercise plan. Widely used recommendations
for volume of weekly exercise (150 minutes of moderate car-
diovascular physical activity, Garber et al., 2011) were de-
scribed, but it was clearly indicated that any volume of exercise
may be beneficial—especially initially. Most time, however,
was spent on an array of self-regulatory/self-management
methods intended to promote adherence. Long-term exercise
goals were identified, documented, and broken down into proc-
ess-oriented short-term goals where ongoing progress was
tracked graphically to increase feelings of competence. Instruc-
tion in additional self-regulatory skills such as cognitive re-
structuring, stimulus control, self-reward, and relapse preven-
tion were given during the sessions. According to the taxonomy
of behavior change techniques suggested by Abraham and Mi-

J. J. ANNESI 696
chie (2008), the following techniques were applied: barrier
identification, encouragement, behavioral goals, specific goal
setting, establishing graded tasks, instruction in desired behav-
iors, self-monitoring behaviors, performance feedback, use of
prompts or cues, behavioral contracting, social supports,
self-talk, relapse prevention, stress management, and time
management.
The nutrition component of the treatments varied by group.
In the Nutrition Education group, a standardized program of six,
1-hour group sessions of nutrition education (Kaiser Perma-
nente Health Education Services, 2008) was administered over
12 weeks. Sessions began 5 to 6 weeks after initiation of the
exercise support component and were led by trained YMCA
wellness leaders. Program components included understanding
macronutrients, using the U.S. Food Guide Pyramid, and menu
planning. An emphasis was placed on educating participants in
healthy eating.
The Behavioral Nutrition group had the identical format and
meeting times as the Nutrition Education group. Treatment
components differed, however, and instead of education on
healthy eating they primarily focused on cognitive-behavioral
techniques such as setting caloric goals and logging daily food
and calorie intake, regular self-weighing, cognitive restructur-
ing, relapse prevention training, cues to overeating, and relaxa-
tion strategies. The array of eating behavior change techniques
used was similar to that of the exercise support component.
Wellness leaders were trained in only one of the nutrition
protocols along with the exercise support protocol, and were
blind to the purposes of the investigation. Compliance with
treatment protocols was monitored by YMCA supervisors in
cooperation with study administrators. Psychological and phy-
siological assessments were administered at baseline, Week 13,
and Week 26.
Data Analyses
An intention-to-treat design was used. Consistent with re-
lated research (Nackers, Ross, & Perri, 2010; Teixeira et al.,
2010), the conservative last-observation-carried forward method
for imputation, recently used in related research was incorpo-
rated.1 Based on recent suggestions (Glymor, Weuve, Berkman,
Kawachi, & Robins), change scores were calculated as the
non-adjusted difference between scores at baseline (Time 1)
and scores at Week 13 (for self-regulation for exercise and
Exercise Self-Efficacy) or Week 26 (for self-regulation for eat-
ing, self-efficacy for controlled eating [Weight Efficacy Life-
style], and BMI) (each designated as Time 2). These differing
intervals were chosen because 1) treatments were designed to
affect self-regulation and self-efficacy for exercise prior to
self-regulation and self-efficacy for controlled eating, and 2)
previous research (Oaten & Cheng, 2006; Teixeira et al., 2010)
and theory (Hagger et al., 2009) suggests a carry-over effect in
the direction of self-regulation and self-efficacy for exercise to
self-regulation and self-efficacy for eating. Statistical signifi-
cance was set at p < .050, throughout. Because this research
was probative, findings of p = .051 to .100 were also reported.
Initially, a series of mixed-model repeated measures ANOVAs
was conducted to assess changes in the self-regulation and
self-efficacy measures, and BMI, over time, and whether these
changes differed by treatment condition. Regression analyses
were then conducted to assess the relationship between changes
in self-regulation for exercise and self-regulation for eating, and
exercise self-efficacy and self-efficacy for controlled eating;
and whether those relationships were affected by treatment
condition. In the primary analyses, Tension and Fatigue scores
(mean scores from baseline, Week 13, and Week 26) were
separately evaluated as moderators of the relationships of score
changes in self-regulation for exercise with self-regulation for
controlled eating, and exercise self-efficacy with self-efficacy
for controlled eating. As suggested by Baron and Kenny (1986)
and Frazier, Tix, and Barron (2004), in Step 1 of each of the
corresponding multiple regression equations, the predictor and
moderator were simultaneously entered. These variables were
subsequently centered and standardized via Z-score transforma-
tion (X—MX/SDX) prior to being multiplied with one another to
create an interaction term. This interaction term was then forced
into the multiple regression equation in Step 2 to determine if it
significantly added to the variance explained in Step 1. Thus, if
the associated change in R2 was significant, then significant
moderation was identified.
A multiple regression analysis was also conducted to deter-
mine the proportion of the variance in BMI change accounted
for by changes in self-regulation for eating and self-efficacy for
controlled eating.
Results
No significant group difference was found at baseline. There
were significant over-time improvements in self-regulation for
exercise, self-regulation for controlled eating, Exercise Self-
Efficacy, and Weight Efficacy Lifestyle (self-efficacy for con-
trolled eating) scores (all ps <.001), however none of the changes
differed by treatment condition (see Table 1 for descriptive
statistics). Using data aggregated across groups, there were strong
relationships found between scores of changes in self-regula-
tion for exercise and self-regulation for controlled eating (β
= .63, SE = .04, p < .001), and changes in Exercise Self-Efficacy
and Weight Efficacy Lifestyle (β = .51, SE = .19, p < .001). Group
membership did not significantly affect these relationships.
All linear bivariate relationships between scores on the inde-
pendent variables of Tension (M = 4.97, SD = 4.50) and Fatigue
(M = 12.32, SD = 7.25), and the dependent variables of changes
in Exercise Self-Efficacy and Weight Efficacy Lifestyle, were
inverse (rs = –.08 to –.14), indicating that as mood scores were
less favorable, improvements in self-regulation and self-ef-
ficacy for controlled eating were less. Both Tension and Fatigue
scores significantly moderated the relationship between ch-
anges in self-regulation for exercise and self-regulation for
controlled eating (Table 2). Tension and Fatigue each ap-
proached significant moderation of the relationship between
changes in Exercise Self-Efficacy and Weight Efficacy Life-
style scores (Table 2).
Reduction in BMI was significant, F(1, 202) = 89.50,
p < .001. The Behavioral Nutrition group had a greater reduc-
tion that was marginally significant, F(1, 202) = 3.01, p = .084.
For all participants aggregated, both change in self-regulation
for controlled eating (β = –.35, SE = .02, p < .001) and Weight
Efficacy Lifestyle (β = –.26, SE = .004, p < .001) significantly
contributed to the explained variance in BMI change (R2 = .30,
p < .001).
Discussion
1It should be noted that results did not differ when multiple imputation,
which has been considered preferable by some (Schafer & Graham, 2002),
was used for imputation of missing values. Consistent with previous resea ch with adults across degrees r

J. J. ANNESI 697
Table 1.
Changes in self-regulation and self-efficacy measures.
Possible score range Time 1 Time 2 Change score
M SD M SD Mchange SD
Nutrition Education group (n = 95)
Self-regulation for exercise 10 - 50 20.08 5.96 25.78 8.04 5.70 8.09
Self-regulation for eating 10 - 50 21.50 6.33 25.81 7.09 4.31 5.62
Exercise Self-Efficacy 5 - 35 28.12 11.38 31.54 11.49 3.42 10.17
Weight Efficacy Lifestyle 0 - 180 96.07 34.15 115.83 33.70 19.76 32.61
BMI (kg/m2) 45.81 4.78 44.74 4.96 –1.07 1.59
Behavioral Nutrition group (n = 109)
Self-regulation for exercise 10 - 50 21.51 4.89 26.55 7.41 5.04 7.16
Self-regulation for eating 10 - 50 21.46 6.15 26.69 7.83 5.23 6.09
Exercise Self-Efficacy 5 - 35 29.69 10.98 32.59 11.17 2.90 10.28
Weight Efficacy Lifestyle 0 - 180 97.72 34.41 117.38 38.00 19.66 31.78
BMI (kg/m2) 46.24 5.02 44.68 5.30 –1.56 2.27
Table 2.
Moderation analyses of Tension and Fatigue on relationships of changes in exercise-related and eating-related self-regulation and self-efficacy (N =
204).
B SE B β R
2 p ΔR2 p
Relationship of changes in self-regulation for exercise with self-regulation for controlled eating
Tension as moderator
Step 1 .39 <.001
ΔSelf-regulation for exercise 3.68 .33 .63 <.001
Tension –.02 .33 .00 .964
Step 2 .42 <.001 .03 .002
ΔSelf-regulation for exercise 3.83 .32 .65 <.001
Tension .23 .33 .04 .491
ΔSelf-regulation for exercise × Tension 1.10 .35 .17 .002
Fatigue as moderator
Step 1 .39 <.001
ΔSelf-regulation for exercise 3.64 .33 .62 <.001
Fatigue –.27 .33 –.05 .401
Step 2 .41 <.001 .02 .010
ΔSelf-regulation for exercise 3.78 .33 .64 <.001
Fatigue .10 .35 .02 .768
ΔSelf-regulation for exercise × Fatigue 1.09 .42 .16 .010
Relationship of changes in Exercise Self-Efficacy with Weight Efficacy Lifestyle scores
Tension as moderator
Step 1 .26 <.001
ΔExercise Self-Efficacy 16.13 1.97 .50 <.001
Tension –1.51 1.97 –.05 .442
Step 2 .28 <.001 .02 .053
ΔExercise Self-Efficacy 17.12 2.02 .53 <.001
Tension –.98 1.97 –.03 .621
ΔExercise Self-Efficacy × Tension 4.57 2.35 .12 .053
Fatigue as moderator
Step 1 .26 <.001
ΔExercise Self-Efficacy 16.42 1.98 .51 <.001
Fatigue .36 1.98 .01 .857
Step 2 .27 <.001 .01 .071
ΔExercise Self-Efficacy 17.24 2.02 .54 <.001
Fatigue .83 1.98 .03 .677
ΔExercise Self-Efficacy ×Fatigue 4.20 2.32 .11 .071

J. J. ANNESI 698
of overweight (Klem, Wing, McGuire, Seagle, & Hill, 1997),
the use of exercise for improving behavioral predictors of re-
duced weight in adults with morbid obesity was supported.
More specifically, findings indicated that cognitive-behavioral
exercise support was associated with significant improvements
in self-regulation for exercise, exercise self-efficacy, self-
regulation for eating, and self-efficacy for controlled eating.
One explanation for the lack of a significantly greater increase
in self-efficacy and self-regulation for controlled eating associ-
ated with the cognitive-behaviorally based nutritional methods
vs. simply nutrition education is a ceiling effect. Possibly the
supported exercise induced improvements in self-regulation and
self-efficacy for controlled eating to a point that is difficult to
further increase. This, however, requires direct investigation.
As expected, the relations between changes in self-regulation
for exercise and self-regulation for controlled eating, and
changes in exercise self-efficacy and self-efficacy for con-
trolled eating, were strong. Whether specific types of self-effi-
cacy (e.g., to resist social pressure to overeat) or self-regulatory
skills (e.g., productive self-talk) have especially strong carry-
over effects from exercise to eating may also be an important
topic for further research, and may help to refine the foci of the
treatment. When taxonomies of behavior change methods (e.g.,
Abraham & Michie, 2008) are better reflected in validated in-
ventories, effects emanating from corresponding treatment
components may be analyzed and used to evolve methods to
improve outcomes. For example, Annesi (2011) suggested that
goal setting methods defined as “review of behavioral goals”
and “feedback on [goal-related] performance” (Abraham &
Michie, 2008) are associated with increased self-efficacy. Pre-
sently, even “state-of-the-art” cognitive-behavioral treatments
for weight loss (e.g., Cooper, Fairburn, & Hawker, 2003) in-
corporate a quite generic array of techniques that, even over
decades of research, generally fail in their goal of sustained
weight loss (Cooper et al., 2010).
Because higher levels of tension and fatigue demonstrated
tendencies for diminishing the newly identified relationships
between exercise- and eating-related self-regulation and self-
efficacy in persons with Grade 3 obesity, assessment of these
mood factors prior to, and throughout, intervention may be
warranted for this subgroup. Hopefully, appropriate methods
(e.g., deep breathing for heightened tension; energizing imagery
for heightened fatigue) may judiciously be applied so that
carry-over effects from exercise to controlled eating may be
maximized. Continued research in these areas may also eventu-
ally uncover reasons why exercise is the strongest predictor of
sustained weight loss. It has been suggested that negotiating
maintained exercise may nurture self-efficacy and self-regula-
tory skills prior to their being required for overcoming adverse
eating behaviors related to a disappointing plateau in weight-
loss shortly after treatment initiation (Annesi & Marti, 2011).
The use of research to simultaneously advance theory and
treatment in this manner has been specifically suggested
(Baranowski, Lin, Wetter, Resnicow, & Hearn, 1997).
Limitations of the research were, however, present. Although
also interpreted as a strength (Glasgow, 2008), the use of a field
setting challenged internal validity. For example, social support
and expectation effects by both instructors and fellow partici-
pants were not controllable, thus their impact on findings is
unknown. Also, participants were volunteers, which may have
been associated with high motivation and/or other personal
characteristics that may have influenced results. Although dif-
ficult, the use of a true control condition may mitigate these
limitations in extensions of this research. It will also be impor-
tant to determine if findings generalize to individuals with dis-
orders such as diabetes and cardiorespiratory disease, in addi-
tion to Grade 3 obesity. Extensions of this research will also be
required to determine the minimum dosages of exercise and
professionally led intervention required for significant effects.
Because adherence to exercise is problematic (Annesi & Unruh,
2007), and may be particularly difficult for persons with morbid
obesity, minimum volumes of physical activity for acceptable
effects should be carefully considered (rather than standard
guidelines [i.e., Garber et al., 2011] be relied upon). This is
particularly important as only maintained exercise is a correlate
of sustained weight loss (Klem et al., 1997). Although ad-
dressed in samples of a lower weight (Annesi & Marti, 2011),
the directionality if psychosocial changes from exercise- to
eating-related should be addressed beyond the theoretically
based assumptions of temporality made within the measure-
ment of self-regulation and self-efficacy within this research.
Due to the clear failure of traditional behavioral methods
(Cooper et al., 2010; Mann et al., 2007), the invasive and ex-
pensive procedure of bariatric surgery is now often the “treat-
ment-of-choice” for adults with Grade 3 obesity (Maggard et al.,
2005). Thus, it is the responsibility of behavioral science to
better understand the mechanisms for success with behavioral
treatments, and translate these findings into more effective,
efficient, and reliable interventions for that population. The
present findings have the prospect of contributing to this
important task. As suggested by theory (Baker & Brownell,
2000), review of previous research (Mann et al., 2007), and the
present findings, it is possible that cognitively supported exer-
cise may be leveraged for weight loss in ways not previously
identified.
References
Abraham, C., & Michie, S. (2008). A taxonomy of behavior change
techniques used in interventions. Health Psychology, 27, 379-387.
doi:10.1037/0278-6133.27.3.379
American College of Sports Medicine (2009). Appropriate physical
activity intervention strategies for weight loss and prevention of
weight regain for adults. Medicine & Science in Sports & Exercise,
42, 459-471.
Annesi, J. J. (2011). Self-regulatory skills usage strengthens the rela-
tions of self-efficacy for improved eating, exercise, and weight in the
severely obese: Toward an explanatory model. Behavioral Medicine,
37, 71-76. doi:10.1080/08964289.2011.579643
Annesi, J. J., & Marti, C. N. (2011). Path analysis of exercise treat-
ment-induced changes in psychological factors leading to weight loss.
Psychology and Health, 26, 1081-1098.
doi:10.1080/08870446.2010.534167
Annesi, J. J., & Unruh, J. L. (2007). Effects of The Coach Approach
intervention on drop out rates among adults initiating exercise pro-
grams at nine YMCAs over three years. Perceptual and Motor Skills,
104, 459-466. doi:10.2466/pms.104.2.459-466
Annesi, J. J., & Whitaker, A. C. (2010). Psychological factors dis-
criminating between successful and unsuccessful weight loss in a
behavioral exercise and nutrition education treatment. International
Journal of Behavioral Medicine, 17, 168-175.
doi:10.1007/s12529-009-9056-2
Baker, C. W., & Brownell, K. D. (2000). Physical activity and mainte-
nance of weight loss: Physiological and psychological mechanisms.
In C. Bouchard (Ed.), Physical activity and obesity (pp. 311-328).
Champaign, IL: Human Kinetics.
Bandura, A. (1986). Social foundations of thought and action: A social
cognitive theory. Englewood Cliffs, NJ: Prentice Hall.
Bandura, A. (1997). Self-efficacy: The exercise of control. New York,
NY: Freeman.
Baranowski, T., Lin, L. S., Wetter, D. W., Resnicow, K., & Hearn, M.

J. J. ANNESI 699
D. (1997). Theory as mediating variables: Why aren’t community
interventions working as desired? Annals of Epidemiology, 7, S89-
S95. doi:10.1016/S1047-2797(97)80011-7
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable
distinction in social psychological research: Conceptual, strategic,
and statistical considerations. Journal of Personality and Social
Psychology, 51, 1173-1182. doi:10.1037/0022-3514.51.6.1173
Bult, M. J., van Dalen, T., & Muller, A. F. (2008). Surgical treatment of
obesity. European Journal of Endocrinology, 158, 135-145.
doi:10.1530/EJE-07-0145
Clark, M. M., Abrams, D. B., Niaura, R. S., Eaton, C. A., & Rossi, J. S.
(1991). Self-efficacy in weight management. Journal of Consulting
and Clinical Psychology, 59, 739-744.
doi:10.1037/0022-006X.59.5.739
Cooper, Z., Doll, H. A., Hawker, D. M., Byrne, S., Bonner, G., Eeley,
E., Fairburn, C. G. et al. (2010). Testing a new cognitive behavioural
treatment for obesity: A randomized controlled trial with three-year
follow-up. Behavior Research and Therapy, 48, 706-713.
doi:10.1016/j.brat.2010.03.008
Cooper Z., Fairburn C. G., & Hawker, D. M. (2003). Cognitive-beha-
vioral treatment of obesity: A clinician’s guide. New York: Guilford.
Davies, M. (2007). Psychological assessment of candidates for bariatric
surgery. Irish Journal of Psychological Medicine, 24, 99-102.
Flegal, K. M., Carroll, M. D., Ogden, C. L., & Curtin, L. R. (2010).
Prevalence and trends in obesity among US adults, 1999-2008.
Journal of the American Medical Association, 303, 235-241.
doi:10.1001/jama.2009.2014
Fogelholm, M., & Kukkomen-Harjula, K. (2000). Does physical activ-
ity prevent weight gain—A systematic review. Obesity Reviews, 1,
95-111. doi:10.1046/j.1467-789x.2000.00016.x
Frazier, P. A., Tix, A. P., & Barron, A. P. (2004). Testing moderator
and mediator effects in counseling psychological research. Journal of
Counseling Psychology, 51, 115-134.
doi:10.1037/0022-0167.51.1.115
Garber, C. E., Blissmer, B., Deschenes, M. R. Franklin, B. A., Lamonte,
Michael, J., David P. et al. (2011). Quantity and quality of exercise
for developing and maintaining cardiorespiratory, musculoskeletal,
and neuromotor fitness in apparently healthy adults: Guidance for
prescribing exercise. Medicine & Science in Sports & Exercise, 43,
1334-1359. doi:10.1249/MSS.0b013e318213fefb
Glasgow, R. E. (2008). What types of evidence are most needed to
advance behavioral medicine? Annals of Behavioral Medicine, 35,
19-25.
Glasgow, R. E., & Emmons, K. M. (2007). How can we increase trans-
lation of research into practice? Types of evidence needed. Annual
Review of Public Health, 28, 413-433.
doi:10.1146/annurev.publhealth.28.021406.144145
Glymor, M. M., Weuve, J., Berkman, L. F., Kawachi, I., & Robins, J.
M. (2005). When is baseline adjustment useful in analyses of change?
An example with education and cognitive change. American Journal
of Epidemiology, 162, 267-278. doi:10.1093/aje/kwi187
Greenberg, I., Perna, F., Kaplan, M., & Sullivan, M. A. (2005). Behav-
ioral and psychological factors in the assessment and treatment of
obesity surgery patients. Obesity Research, 13, 244-249.
doi:10.1038/oby.2005.33
Hagger, M. S., Wood, C., Stiff, C., & Chatzisarantis, N. L. D. (2010).
Ego depletion and the strength model of self-control: A meta-analy-
sis. Psychological Bulletin, 136, 495-525. doi:10.1037/a0019486
Hankonen, N., Absetz, P., Haukkala, A., & Uutela, A. (2009). Socio-
economic status and psychosocial mechanisms of lifestyle change in
a Type 2 diabetes prevention trial. Annals of Behavioral Medicine,
38, 160-165. doi:10.1007/s12160-009-9144-1
Kaiser Permanente Health Education Services (2008). Cultivating
Health weight management kit (8th ed.). Portland, OR: Kaiser Per-
manente.
Klem, M. L., Wing, R. R., McGuire, M. T., Seagle, H. M., & Hill, J. O.
(1997). A descriptive study of individuals successful at long-term
maintenance of substantial weight loss. American Journal of Clinical
Nutrition, 66, 239-246.
Maggard, M. A., Shurgarman, L. R., Suttorp, M., Maglione, A., Suger-
man, H. H., Livingston, E. J., Li, Z. et al. (2005). Meta-analysis:
Surgical treatment of obesity. Annals of Internal Medicine, 142, 547-
559.
Mann, T., Tomiyama, J., Westling, E., Lew, A. M., Samuels, B., &
Chatman, J. (2007). Medicare’s search for effective obesity treat-
ments: Diets are not the answer. American Psychologist, 62, 220-233.
doi:10.1037/0003-066X.62.3.220
Marcus, B. H., Selby, V. C., Niaura, R. S., & Rossi, J. S. (1992). Self-
efficacy and the stages of exercise behavior change. Research Quar-
terly for Exercise and Sport, 63, 60-66.
McAuley, E., & Mihalko, S. L. (1998). Measuring exercise-related
self-efficacy. In J. L. Duda (Ed.), Advances in sport and exercise
psychology measurement (pp. 371-390). Morgantown, WV: Fitness
Information Technology.
McNair, D. M., & Heuchert, J. W. P. (2005). Profile of Mood States
technical update. North Tonawanda, NY: Multi-Health Systems.
Mokdad, A. H., Ford, E. S., Bowman, B. A., Dietz, W. H., Vinicor, F.,
Bales, V. S., & Marks, J. S. (2003). Prevalence of obesity, diabetes,
and obesity-related health risk factors, 2001. Journal of the American
Medical Association, 289, 76-79. doi:10.1001/jama.289.1.76
Nackers, L. M., Ross, K. M., & Perri, M. G. (2010). The impact of rate
of initial weightloss on long-term success in obesity treatment: Does
slow and steady win the race? International Journal of Behavioral
Medicine, 17, 161-167. doi:10.1007/s12529-010-9092-y
Oaten, M., & Cheng, K. (2006). Longitudinal gains in self-regulation
from regular physical exercise. British Journal of Health Psychology,
11, 717-733. doi:10.1348/135910706X96481
Puhl, R., & Brownell, K. D. (2002). Stigma, discrimination, and obesity.
In C. G. Fairburn, & K. D. Brownell (Eds.). Eating disorders and
obesity (2nd ed., pp. 108-112). New York: Guilford.
Saelens, B. E., Gehrman, C. A., Sallis, J. F., Calfas, K. J., Sarkin, J. A.,
& Caparosa, S. (2000). Use of self-management strategies in a 2-year
cognitive-behavioral intervention to promote physical activity. Be-
havior Therapy, 31, 365-379. doi:10.1016/S0005-7894(00)80020-9
Schafer, J. L., & Graham, J. W. (2002). Missing data: Our view of the
state of the art. Psychological Methods, 7, 147-177.
doi:10.1037/1082-989X.7.2.147
Svetkey, L. P., Stevens, V. J., Brantley, P. J., Appel, L. J., Hollis, J. F.,
Loria, C. M., Aicher, K. et al. (2008). Comparison of strategies for
sustaining weight loss. Journal of the American Medical Association,
299, 1139-1148. doi:10.1001/jama.299.10.1139
Teixeira, P. J., Silva, M. N., Coutinho, S. R., Palmeira, A. L., Mata, J.,
Viera, P. N., Sardinha, L. B. et al. (2010). Mediators of weight loss
and weight loss maintenance in middle-aged women. Obesity, 18,
725-735. doi:10.1038/oby.2009.281
Tice, D. M., & Bratslavsky, E. (2000). Giving in to feel good: The
place of emotion regulation in the context of general self-control.
Psychological Inquiry, 11, 149-159.
doi:10.1207/S15327965PLI1103_03
Warziski, M. T., Sereika, S. M., Styn, M. A., Music, E., & Burke, L. E.
(2008). Changes in self-efficacy and dietary adherence: The impact
on weight loss in the PREFER study. Journal of Behavioral Medi-
cine, 31, 81-92. doi:10.1007/s10865-007-9135-2