Weight loss and maintenance-Cognitive Behavioral Therapy

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Obesity is a health problem affecting millions of people worldwide. Obesity can lead to several health issues. Namely, heart disease, diabetes, high blood pressure, obstructive sleep apnea and arthritis.

About, 34% of adults and 17% of children in the United States are obese, defined as a BMI of 30 or greater. These are respectively double and triple the rates of a quarter century ago, and these numbers continue to rise. Obesity is a long-term problem. It is caused by consuming more food than is being used through exercise and daily activities. Over a long period of time the excess energy stored as fat builds up and consequently begins to cause significant health problems.

Weight loss

There are numerous different programs available to help people lose weight. Obesity is in fact a long-term problem and therefore no single treatment will work for all overweight individuals. There are several categories of treatment for obesity. The most important is lifestyle modification, which requires a reduction of food intake and an increase in physical activity. This should be included as a part of all attempts to lose weight. Medications can also help with weight loss. However, they often have undesirable side effects. The third main option is surgical treatment. This treatment is usually only considered in severe cases and the risks and benefits must be carefully considered. For class II or III obese patients (BMI >35) in whom diet, exercise, and/or medication have failed, especially those with significant obesity-related comorbidities, weight loss surgery should be considered.  The NIH Consensus Development Conference Statement suggested the following criteria for considering a patient for bariatric surgery:

1. Patients should be well-informed, motivated, eager to participate in treatment and long-term follow-up, and have acceptable operative risks.

2. Patients should have a BMI that exceeds 40.

3. Patients with a BMI between 35 and 40 with obesity- related comorbidities, such  as severe sleep  apnea, diabetes, or severe joint disease, should be considered.

4. Patients should be evaluated by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise.

Surgical therapies involve restriction of stomach size and malabsorption of ingested calories as their mechanisms of action.

Obesity treatments by Cognitive behavioral therapy (CBT) is a type of psychological therapy that is used to treat many different problems, ranging from anxiety to weight loss. CBT should not be used by itself to lose weight, but rather it is used to support lifestyle changes.

CBT can assist a person to lose weight by:

    Helping a person control their diet.

    Helping to increase motivation to do exercise.

    Providing skills to handle any lapses in diet.

    Providing long term weight maintenance skills.

    Improving a person’s body image and their expectation of   body image.

    Improving a person’s self-esteem.

    Helping with stress management, reason for ‘comfort eating’.

    Helping set reasonable goals for both weight loss and maintenance.

Recently a large study that involved CBT for weight loss, revealed that CBT is a valuable addition to diet and exercise for weight loss. Those people who had both CBT and lifestyle changes lost more weight than those who only had lifestyle changes. CBT alone was also found to be slightly effective in some patients who had problems with binge eating. However, CBT alone will not work for everyone and in any case when CBT is combined with lifestyle changes the results are always better than with CBT alone.

Why do people want to lose weight?

CBT for weight loss hard and people do not try to lose weight for no reason. The most common reason is that people try to lose weight to change their shape, appearance and feel less ‘fat’. Women often hope to improve their appearance, feel more attractive and be able to wear ‘more fashionable’ clothes. These people will have extremely negative views of themselves and are often very self-conscious and even embarrassed when around others. Another reason people try to lose weight is that they lack self-confidence.

Hence, body form and shape is closely linked to self-worth and therefore self-confidence. These people believe that losing weight is the only way to increase their self-confidence. A desire to improve their health is another reason people try to lose weight, albeit this is a less common reason. There are other reasons like wanting to be more active to play with children or being diagnosed with diabetes, but these are rare reasons. As seen above most patients see weight loss as the only way of achieving some benefit that is especially important to the patient. These benefits are the patient’s ‘primary goals’ and while they are not always causally linked to weight loss fulfilling these primary goals are of the highest importance to the patient.

Most patients want to lose 20–30% of their body weight. This is often an unrealistic goal however people do not realize it. Our society suggests that weight loss is simply a matter of self-control. Compounding this is our society’s obsession with body image and the constant pressure from advertising, the media and other sources that to be slim, often to the point of being unhealthy, is the best way to be. Consequently, many people link body image with beauty, confidence and self-respect. The result is that people set goals to lose unrealistic amounts of weight in the hope that this will fulfil their primary goals.

It is easy to see that many of the primary goals are only loosely connected to weight loss. In some individuals it is important to lose weight to achieve better health, but other primary goals often have no connection to body weight. Goals about self-confidence, better social or work skills or even how attractive a person considers themselves are not dependent on their weight.

When someone starts to lose weight they are usually successful for a short time. The first problem is that after several months and a 5-10% weight loss the loss of weight stops due to normal body processes. At this point a person has not yet achieved their ‘set goals’. As a result, people become discouraged, often underestimate their achievement and ignore any benefits like greater fitness, a change in clothes size or having more energy.

    Therefore, most people think that their goals are unachievable and give up on weight loss (at least for some time).

    Some people continue to try and often do lose more weight. However, there comes a time when more weight loss becomes impossible, and these people also give up.

    A small minority do reach their goal weight but often this does not fulfil their primary goals and they give up on any form of weight control.

Regardless of whether the person reaches their weight loss goals, initial goals remain unachieved and therefore the person is at high risk of lapses. These lapses usually involve over-eating, which results in weight gain. This weight gain is then seen as a failure resulting in further dieting and then further lapses. Over time there develops a yo-yo-ing style of weight loss with large losses followed by weight being regained.

People work hard to try to reduce their weight but tend not to try to maintain the new lower weight. A person not fulfilling primary goals and the idea that with even more weight loss these will be fulfilled. A person neglecting the benefits they have already achieved. However, without weight maintenance people return to their prior lifestyle habits and soon begin to regain weight.

CBT for weight loss

As is seen above weight loss is an overly complex issue that usually involves issues of body image, self-image, confidence and self-respect. Because of this CBT can be useful in several stages of a weight loss program. Below is an example of a weight loss program that uses CBT. The program has 6 parts outlined below.

Part 1: Lifestyle changes This is the start and the most important part of losing weight. A diet should be started to encourage healthy eating that provides nutrients and vitamins but reduces calories. There must also be a focus on increasing activity. The aim is to increase a person’s activity level in general (e.g., take the stairs not the lift, walk more, etc) rather than simply increasing formal exercise. If the patient has a steady general increase in activity, they are more likely to continue this into the long term once the initial enthusiasm has worn off.

Part 2: Problems with the diet Once the above is in place it is important to address the problems that can cause a person to abandon their diet. Issues include motivation, frequent snacking, excessive alcohol consumption, binge eating and eating in response to mood (comfort eating). Here CBT can be used to try to solve some of these problems. CBT has been shown to be particularly good at improving mood and so it can be used to stop comfort eating.

Part 3: Body image as mentioned before the majority of people who try to lose weight have very negative views about their body image. This part applies the basics of CBT to try to change a person’s view of their body image and its importance to them. Body image is especially important in our society, but body image should not define a person. Therefore, CBT can be used to correct a person’s obsession with body image and to show them that there is more to a person than how they appear.

Part 4: Weight loss goals as mentioned before many people dismiss the weight loss they have achieved and any benefits they have had. This leads them to become discouraged with weight loss. CBT can help a person appreciate how far they have already come and show them why they should be happy with their achievements. This part also allows a person to start to separate weight goals and primary goals.

Part 5: Initial goals, ss discussed earlier these are the real reasons a person wants to lose weight but are often unrelated to a person’s weight. This is where CBT is especially important. CBT works by changing a person’s ‘false beliefs’ and this will result in a change in the persons thoughts, feelings and ultimately actions. Let us take the example of a patient who is trying to lose weight as they currently lack self-confidence. The person believes that external appearance is the most important aspect of their lives and because they view their appearance in a negative way they view themselves as a person in a negative way. In social settings they may become extremely self-conscious, leading to feelings of anxiety that in turn lead to the person being quiet and withdrawn, so the person lacks self-confidence. If the person receives therapy and they begin to understand that there is more to them than merely their external appearance, then the situation can change. The person becomes less self-conscious of their image, thus they are no longer anxious and thus their self-confidence increases. Helping a person achieve their primary goals is an extremely important step in allowing them to lose an appropriate amount of weight and then maintain this weight.

Part 6: Maintenance, long term maintenance is extremely important to ensure a person has a steady weight. CBT can be used to reinforce the significance of the weight already lost and encourage ongoing weight control. There must also be an emphasis that dieting is a set of flexible guidelines and not a set of rigid rules. A person may break their diet on occasion, and this is not the end of the world and the patient still has control over their weight.

Summary

Weight loss is difficult and requires a lot of effort. However, the reasons why people try to lose weight are often related to negative views of body image and a lack of social skills and confidence. Weight loss therefore becomes a method by which people hope to improve social skills, etc. CBT is vital in helping people separate these goals from their weight loss goals. After the patient understands that the two are different CBT helps the patient fulfil their primary goals separately form their weight loss goals. The result is that people become far happier with themselves and with the weight they lose resulting in long term weight control.

References

    Braunwald E, Fauci A, Kasper D, Hauser S, Longo D, Jameson J (Eds). Harrison’s Manual of Medicine. 16th Ed. McGraw-Hill; 2005. [Book]

    Clinical practice guidelines for the management of overweight and obesity in adults [online]. Canberra, ACT: Australian Government Department of Health and Ageing; 18 September 2003 [cited 9 August 2007]. Available from: URL link

    Cognitive therapy, cognitive behavioral therapy [online]. The American Institute of Cognitive Therapy. [cited 22 September 2007].

    Forest J, Poston W. The role of the behavioral counselor in obesity treatment. J Am Diet Assoc. 1998;98: S27-30. [Abstract]

    Shaw K, O’Rourke P, Del Mar C, Kenardy J. Psychological interventions for overweight or obesity. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD003818.

    Cooper Z, Fairburn CG. A new cognitive behavioral approach to the treatment of obesity.

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