Cognitive Behavioural Interventions in Weight Management

Dr Mira MojeeClinical Psychologist

GCWMS

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Aims for today

1. What is Cognitive Behavioural Therapy ?

2. Why CBT in weight management?

3. Specific CBT strategies for Preparation; Action; Maintenance; Relapse

4. Conclusions

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What is CBT?

A psychological approach that emphasises the role of thoughts in how we feel and what we do

Supports people to change

Collaborative effort

Has a framework to follow, is educational, and sets goals

Evidence base across range of emotional & behavioural problems

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Behavioural Model

Problem behaviours are the result of past and present learning processes

Alter environmental cues: Classical conditioning (Pavlov)

Alter reinforcers (positive/negative):

Operant conditioning (Thorndike)

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Behavioural → CBT Model

Social learning: observation of others’ behaviour & self-efficacy (Bandura)

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Cognitive Model

Beck 1970’s/80’s Early experiences

can influence our thinking

Core Beliefs

Negative Automatic Thoughts

Assumptions

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Cognitive Behavioural Model

BEHAVIOURS FEELINGS

THOUGHTSI’m going to

fail again

SadLow

HopelessStop

attending groups; stop

trying

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Why CBT in weight management?SIGN Guidelines (2010) SIGN Guidelines (2010) Individual or group based psychological Individual or group based psychological interventions should be included in weight management programmes. interventions should be included in weight management programmes. CBT techniques specifically mentionedCBT techniques specifically mentioned

NICE (2006) Interventions should be Interventions should be multi-componentmulti-component and and include include behaviour changebehaviour change

European Obesity Management Task ForceEuropean Obesity Management Task Force (2004)(2004) Multiple treatment approaches should be used. CBT approaches mentioned specifically. CBT approaches can and should be delivered by other professionals, with training

SEHD : Review of Bariatric Surgical Services in Scotland (2004)Psychological assessment & support required through patient’s journeyBPS Report (2011) Obesity in the UK- BT and CBT interventions need to be tailored to the complexity of the client

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CBT in GCWMS

1:1

DEG

Psychology talks

Weight loss groups

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Aim of CBT in WM groups

Combine with dietary therapy to achieve a negative energy balance for weight loss;

Alter eating habits to reduce calorie consumed

Use up more energy (activity) Support people to develop

self-help skills to help them control their weight

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Components of CBT Approaches for Obesity

Wadden and Foster. Med Clin North Am 2000:84:441.

SelfSelfMonitoringMonitoring

ProblemProblemSolvingSolving

ContingencyContingencyManagement / RP Management / RP

& Maintenance& MaintenanceCognitiveCognitive

RestructuringRestructuring

Social Social SupportSupport

StressStressManagementManagement

StimulusStimulusControlControl

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Strategies to Prepare for Change

“What do I need to change?”

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Self MonitoringTime Food Hunger

1-10

Situation Calories Portions

Mood

Feelings

8 am 2 slices wholemeal bread, margarine,

Orange juice

6 Before work, in front of TV

2 starch

1 fat

1 fruit

Feel pleased, positive start to the day

10.30 Tea

Banana

5 Break at work 1 fruit Normally crisps, trying to swap for healthy snack, pleased I managed the craving

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-35-30-25-20-15-10

-505

10

Self-Monitoring Consistency and Weight LossWeight change (lb) at 18 wk of behavior therapy

1

Baker and Kirschenbaum. Behav Ther 1993;24:377.

Self-Monitoring Index Quartiles2 3 4

P = 0.01 for weight change among quartiles

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Specific Change Strategies for Later Stages

“How will I change?”

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Useful CBT Strategies for Preparation and Action

Goal Setting Developing a Change

Plan for each goal

To initiate the plan and take control;

Stimulus Control- Changing Environmental Triggers- Controlling Internal Triggers

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“SMART” Exercise Goals

Specific

Measurable

Achievable

Relevant

Time-specific

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My CHANGE PLAN

My goal for the fortnight:___________________

The main reason I want to make these changes are:

The most important reasons I want to make these changes are:

The ways I will reward myself are:

Some things that could make my plan difficult:

Things I can do to help me cope with difficult situations:

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Stimulus Control Unplanned eating is

triggered by either INTERNAL or EXTERNAL events

Internal - emotions such as boredom, anger, sadness, tiredness or feelings of hunger/thirst

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Stimulus Control External –

situations we are in

such as shopping, at

home alone, seeing

adverts etc.

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Stimulus Control – Coping with INTERNAL/ EXTERNAL Triggers Make changes Internal &

External environment to reduce exposure to triggers.

Start with:1. Self-monitor using a diary to

identify the context of eating i.e. setting, situation, thoughts, feelings

2. Use this information for ‘Functional Analysis’ to increase self-awareness of problems e.g. ‘behaviour chains’

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Breaking the Habit Chain

Overeating in the evening.

Late getting up for work.

Miss breakfast to compensate for overeating.

Light lunch to compensate for

overeating.Get home and go into the kitchen.

Feel very hungry and can’t be

bothered cooking.

Call takeaway and eat crisps while you wait.

Overeating in the evening.

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Stimulus Control – Making changes to EXTERNAL Triggers■ Designed to limit exposure to problem situations and

foods. Advice is given on;- Storing food- Preparing food- Consuming food

■ Rewarding positive eating behaviours

■ Learned Self-control

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Stimulus Control – Coping with INTERNAL Triggers

■ Cravings and UrgesPsychological desire to eat

rather than physical hunger. Need to learn to distinguish the two.

Let them pass:

Distraction techniques- Activity based- Cognitive based

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In our head Specific foods Agitated Trigger? Have you eaten? Go away

In our stomach Eat anything Gnawing Shaky/Light headed Is it time to eat? Gets worse

Physical Hunger

CravingsVS

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Cognitive Restructuring

Challenging Negative thinking Clients with weight problems often express a number of negative

thoughts about their weight, their difficulties controlling it and chances of achieving change.

Negative thoughts have certain characteristics;- Automatic- Distorted- Unhelpful - Plausible- Involuntary

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Are our thoughts always true?

How would you think about the following situation?

“You come along to your first group meeting. You sit down and say hello to the person sitting next to you. They look at you and don’t say hello back.”

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Thoughts, Feelings, and Behaviour

You might think that this person is very rude because they ignored you.

You might think they ignored you because they don’t like you.

You might think they are very shy.

**Not all of these thoughts are TRUE. The way you think about this situation will affect the way you feel and behave.**

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Cognitive Restructuring- Thinking Errors Modifying negative

thinking & unhelpful beliefs

All or nothing Mind reading Fortune-telling Catastrophising Emotional reasoning

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Emily…

“I have always been unhappy with my weight and appearance. My dad used to call me “chubby” and I was larger than the other girls at school.

Looking back at pictures of myself I don’t think I was that big. I used to tell myself I was really fat and ugly. I especially hated my thighs, hips, and bottom. I would stare at them for hours at a time, pinching, folding, and pulling the fat and skin backwards.

I am now a lot bigger and I hate my body more than ever! I’m disgusting! My thighs are so fat and wobbly. The cellulite on my body is criminal! I deserve to be in jail because I am so fat and unattractive.

My body image has gotten so bad that I rarely go out. When I do go out, I often think people are staring at me and making comments about my weight. I spend hours deciding on what to wear and sometimes get so frustrated that I decide to stay at home and eat instead.”

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Challenge Unhelpful Thoughts The first step is to identify unhelpful thoughts and

write them down.

The second step is to challenge those thoughts: What would you say to a friend? What is the evidence that the thought is

true/ false?

Over time we should be able to retrain our thoughts and become more realistic in our thinking.

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What then?………..Useful CBT Methods for Maintenance and Relapse

Relapse Prevention

- Managing lapses and relapses

Weight Maintenance Skills

- Clients need to be taught how to stop weight cycling problems

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What is Relapse Prevention?

Psycho-educational approach to ‘habit change’

Is more relapse management rather that prevention as it is concerned with the PROCESS of change rather than absolute success

Teaches principles of self-management or self-control

A method of learning from mistakes as well as successes

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What is Relapse?

Most common outcome of interventions to change behaviour. Slips occur in High Risk Situations

Lapses and Relapses are not the same thing Lapse = a one-off slipRelapse = sequence of lapsesCollapse = complete return to old eating patterns

*it is the largely psychological factors (thinking processes and mood) following a lapse that decide whether relapsing is more likely

Thinking Traps = ‘Apparently Irrelevant Decisions’ & ‘Rule Violation Effect’

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High Risk Situations

A HRS is any situation or condition that poses a threat to the clients sense of control (self-efficacy). Broad general categories associated with high rates of relapse:

Internal causes -negative emotional states-positive emotional states Social Causes- interpersonal conflict- Social pressure

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“Every time I visit my mother she always buys in loads of cakes and biscuits for me coming. I keep telling her that I’m trying to lose weight and that I don’t want those foods anymore. She always says that I’m fine the way I am and don’t need to lose weight.

Most of the time I end up eating the cakes and biscuits because she always seems really offended and put out when I say no, but the other day I got really mad and shouted at her. She got very upset and started to cry. It doesn’t matter what I do, I cant get the message across that I don’t want to eat like that anymore.”

John…

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Relapse Prevention Strategies

Increasing self-awareness i.e. self-monitoring (identify habit pattern, possible triggers, high risks, consequences etc.)

Skills training and behavioural procedures (anxiety management / assertiveness training)

Cognitive strategies (cognitive restructuring)

Lifestyle interventions (lifestyle balance, substitute indulgences, stimulus control)

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Weight Maintenance PlanReasons for not wanting to regain weight:

The good habits I will continue:

Danger areas and risky situations:

Things I can do to help in risky situations:

Who will support me:

What I will do if my weight increases by 5Ibs:

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Conclusions

Useful to teach clients HOW to make the changes required to their diet not just tell them WHAT they should do

Client ‘readiness’ to change behaviour is crucial

Increasing clients awareness of the external and internal cues for problem-eating & teaching skills to manage these situations is helpful

There should be an emphasis on weight maintenance

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References

Baker and Kirschenbaum. Behav Ther 1993;24:377.Adapted from Wadden and Foster. Med Clin North Am 2000;84:441.Björvell and Rössner. Int J Obes Relat Metab Disord 1992;16:623British Psychological Society (2011) Obesity in the UK: A Psychological Perspective.

BPS: LeicesterCooper, Z., Fairburn, C.G & Hawker, D. (2003) Cognitive-Behavioural Treatment of

Obesity. The Guilford PressEffective Health Care; The prevention and treatment of obesity (1997), NHS Centre for

Reviews and Dissemination, University of YorkEuropean Obesity Management Task Force, (2004) Management of Obesity in Adults:

Project for European Primary Care, International Journal of Obesity, 28, S226-231.Health Development Agency (2003) The management of obesity and overweight: an

analysis of reviews of diet, physical activity and behavioural approaches. Website: www.hda.nhs.uk

Hunt, P. & Hillsdon, M. (1996) Changing Eating & Exercise Behaviour. Blackwell Science.

.

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Klem et al. Am J Clin Nutr 1997;66:239 Miller, W.R & Rollnick, S. (2002) Motivational Interviewing: preparing people for change. (2nd edition). The Guilford Press.

Miller, W.R. (1999) Enhancing motivation for change in substance abuse treatment. (Treatment Improvement Protocol [TIP] series no. 35). Rockville, MD: Center for Substance Abuse Treatment McGuire et al.Int J Obes Relat Metab Disorder 1998;22:572.

National Institute for Health and Clinical Excellence (NICE). (2006). Obesity: the prevention, identification, assessment, and management of overweight and obesity in adults and children. London: NICE.

Resnicow, K. & Blackburn, D. (2005). Motivational Interviewing in Medical Settings. Obesity Management, 1 (4), 155-159

Scottish Intercollegiate Guidelines Network (SIGN). (2010). Management of Obesity- a national clinical guideline. SIGN: UK

Wadden and Foster. Med Clin North Am 2000:84:441.Wanigaratne, S et al (1995) Relapse Prevention for Addictive Behaviours.

Blackwell Science.

* http://www.motivationalinterview.org/