Cognitive behavioural therapy for weight loss (CBT)

• Cognitive behavioural therapy for weight loss
• Treatments for losing weight
• What is cognitive behavioural therapy?
• The process of losing weight
  • Why do people want to lose weight?
  • How much weight to people expect to lose?
  • Primary goals & weight loss
  • When people actually start to lose weight
    • Active weight maintenance
• CBT for weight loss
  • Part 1: Lifestyle changes
  • Part 2: Problems with the diet
  • Part 3: Body image
  • Part 4: Weight loss goals
  • Part 5: Primary goals
  • Part 6: Maintenance
• Summary

Cognitive behavioural therapy for weight loss

Obesity is a serious health problem that affects millions of people worldwide. Being overweight or obese can lead to many health problems. These include heart disease, diabetes, high blood pressure, obstructive sleep apnoea and arthritis. It is estimated that 70% of Australian men and 50% of Australian women are overweight or obese and rates continue to climb. Obesity is a long term problem. It is caused by consuming more energy (eating too much 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 begins to cause serious problems.

Treatments for losing weight

There are many different programs available to help people lose weight. Obesity may seem simple but is in fact a complex 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 energy intake and an increase in physical activity. This should be included as a part of any attempt to lose weight. Then there is medication that can help with weight loss. While there are some drug treatments available they often have nasty side effects. The third main category is surgical treatment. This treatment is usually only considered in severe cases and the risks and benefits must be carefully considered. For more information click here.

What is cognitive behavioural therapy?

Cognitive behavioural 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 help a person to lose weight by:

• Helping a person control their diet
• Helping to increase motivation to do exercise
• Provide coping skills to handle any lapses in diet that the person will experience
• Provide long term weight maintenance skills
• Changing a person’s body image and their expectation of body image
• Improving a person’s self esteem
• Helping with stress management (a major reason for ‘comfort eating’)
• Helping set reasonable goals for both weight loss and maintenance.

Recently a large study was released that brought together many of the smaller studies that involved CBT for weight loss. It was found 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 (ie with no set diet or exercise changes) 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.

The process of losing weight

Why do people want to lose weight?

Losing weight is hard and people do not try to lose weight for no reason. There are many reasons why people try to lose weight. The most common reason is that people try to lose weight to change their shape and feel less ‘fat’. Women in particular often hope to improve their appearance, feel more attractive and be able to wear ‘more fashionable’ clothes. These people will have very 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.

To these people body 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 more rare reasons. As seen above the majority of patients see weight loss as the only way of achieving some benefit that is very important to the patient. These benefits are the patient’s ‘primary goals’ and while they are not always directly linked to weight loss fulfilling these primary goals are of the highest importance to the patient.

How much weight do people expect to lose?

Most patients want to lose 20–30% of their body weight. This is often an unrealistic goal which is unlikely to be met. However people do not realise this. Society suggests to us that weight loss is simply a matter of self control. Worsening this is our society’s obsession with body image and the constant pressure form advertising, the media and other sources that to be slim (often to the point of being unhealthy) is the best way to be. This results in many people linking 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.

Primary goals and weight loss

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 really dependant on their weight.

When people actually start to lose 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 ‘primary goals’ (as these are not really weight based). 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.

At this point one of three things can happen:

1. Most people think that their goals are unachievable and give up on weight loss (at least for some time).
2. 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.
3. 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 if the person reaches their weight loss goals, primary 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.

Active weight maintenance

People work hard to try to reduce their weight but tend not to make an effort to maintain the new lower weight. This arises from 2 reasons:

1. A person not fulfilling primary goals and the idea that with even more weight loss these will be fulfilled.
2. 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 a very 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 (eg take the stairs not the lift, walk more, etc) rather than simply increasing formal exercise (such as in the gym). 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. For example CBT has been shown to be very 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 very 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

Why is someone trying to lose weight? How much weight are they trying to lose? 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: Primary goals

As 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 very important. CBT works by changing a persons ‘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 then 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

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