The rate of obesity in America has increased dramatically in the last 20 years. According to the National Center for Health Statistics, more than half of U.S. adults are overweight and nearly 30 percent (over 60 million people) are obese. The number of children and adolescents who are overweight has more than tripled since 1980. Excessive weight has been linked to a wide variety of serious health problems. While bariatric surgery and medication can be effective, at least in the short-run, these treatments carry significant risks and side effects.
Two studies have demonstrated that Cognitive Therapy (CT) is effective not only in helping people lose weight but also in maintaining that weight loss (Stahre & Hallstrom, 2000; Fossati et al, 2004). Exercise and nutritional counseling are essential components of effective programs, as are the following CBT techniques.
- Education. Dieters who want to lose weight need dietary information to select a highly nutritious diet that is flexible enough for planned indulgences and which they can maintain for their lifetime with minor modifications. Therapists should urge them to set only short-term goals (e.g., to lose 5 pounds) and to plan to lose weight very slowly. Dieters should develop the expectation that they will not lose weight every week, even if they maintain a consistent caloric intake and exercise level. They also may need guidance to select an appropriate exercise plan. When therapists provide the above information, dieters often have a host of negative thoughts that, left unchecked, could result in non-adherence to their diet or exercise program. Therapists need to help them effectively respond to their thinking using standard cognitive restructuring techniques.
- Self-monitoring. Dieters need to learn to plan their eating ahead of time and engage in daily self-monitoring in writing of their weight, food intake and exercise. Reading a card, several times a day, which reminds them of all the reasons they want to lose weight can help continually motivate them to do this work. After several months, many dieters can discontinue daily written records but will need to reinstitute this strategy, either during their active weight loss phase or during lifetime maintenance, if their weight plateaus or rises for several weeks in a row. They often need cognitive restructuring if they are reluctant to do these tasks.
- Problem-solving. Therapists need to help dieters anticipate and solve problems they are bound to encounter, such as finding time and energy for dieting and exercising, dealing with “food pushers,” uncooperative family members, eating out and eating while traveling. Cognitive restructuring is often required when dieters reject reasonable solutions.
- Accountability and support. Dieters need a “diet coach.” This role can be fulfilled initially by the therapist and later by a supportive, problem-solving oriented friend or family member. They should weigh themselves daily if possible and report their change in weight once a week to their diet coach. Some dieters need more contact with their therapist or diet coach than weekly sessions. Daily e-mails, voice mails, faxes or phone calls can help keep dieters accountable and motivated. Cognitive restructuring can spur a reluctant dieter to find a coach and keep up regular contact.
- Change in eating habits. Therapists need to provide strong rationales for dieters to eat every single meal and snack slowly and mindfully while sitting down and to develop a system for self-monitoring. Cognitive restructuring can help dieters who resist making this behavioral change understand that they can keep using unhelpful eating habits or they can be thinner, but they can’t get or remain thinner with unhelpful habits.
- Responding to sabotaging thoughts. Dieters have a multitude of sabotaging thoughts and need to be taught how to effectively respond to these thoughts. Many thoughts represent self-deluding thinking: “It’s okay to eat this because … I’m happy/I’m sad/everyone else is eating it/it’s just a little piece/it’s a celebration/I’m hungry/I’ve already cheated.”
- Experiments to decrease fear and increase tolerance of hunger and craving. Even if they are not fully aware of it, dieters often fear hunger and overeat to avoid feeling uncomfortable. They need to deliberately postpone meals occasionally (health permitting) to prove to themselves that they can withstand hunger and craving.
- Maintenance: Dieters need to be taught skills to motivate themselves to adhere to a maintenance diet and exercise program for life, for example, by continually reminding themselves about the benefits of weight loss. They need to have a written plan containing the diet strategies they’ve already learned for days when the scale goes three pounds or more above their maintenance weight.
Therapists need to pace treatment according to the individual. Most dieters require significant preparation, including education, nutritional counseling, problem-solving and cognitive restructuring before they’re ready to start. They also vary in how quickly they learn and master skills. Some dieters do better learning good eating habits before they actually change what they eat, for example. Some dieters also do better if they change what they eat more gradually, e.g., getting in the habit of eating a lower-calorie, more nutritious night-time snacks before they tackle their daytime eating.
While currently most people either fail to lose as much weight as needed for good health or gain back the weight they lost, their future success can be significantly enhanced through the use of Cognitive Therapy techniques. More information about this approach can be found at www.beckdietsolution.org.
Judith S. Beck, Ph.D., is director of the Beck Institute for Cognitive Therapy, clinical associate professor of psychology in psychiatry at the University of Pennsylvania, and president of the Academy of Cognitive Therapy. Her latest book is The Beck Diet Solution. She can be reached at firstname.lastname@example.org.