Cognitive Behavioural
Interventions in Weight
Management
Dr Mira Mojee
Clinical Psychologist
GCWMS
Aims for today
1.
2.
3.
4.
What is Cognitive Behavioural Therapy ?
Why CBT in weight management?
Specific CBT strategies for Preparation;
Action; Maintenance; Relapse
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 & selfefficacy (Bandura)
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Cognitive Model


Beck 1970’s/80’s
Early experiences
can influence our
thinking
Negative Automatic Thoughts
Assumptions
Core
Beliefs
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Cognitive Behavioural Model
THOUGHTS
BEHAVIOURS
I’m going to
fail again
FEELINGS
Sad
Low
Hopeless
Stop
attending
groups; stop
trying
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Why CBT in weight management?
SIGN
Guidelines (2010) Individual or group based psychological
interventions should be included in weight management programmes.
CBT techniques specifically mentioned
NICE
(2006) Interventions should be multi-component and include
behaviour change
European
Obesity Management Task Force (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 journey
BPS 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
Self
Monitoring
Problem
Solving
Contingency
Management / RP
& Maintenance
Cognitive
Restructuring
Social
Support
Stimulus
Control
Stress
Management
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Wadden and Foster. Med Clin North Am 2000:84:441.
Strategies to Prepare for Change
“What do I need to change?”
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Self Monitoring
Time
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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Self-Monitoring Consistency and Weight
Loss
Weight change (lb) at 18 wk of behavior therapy
10
5
0
-5
-10
-15
-20
-25
-30
-35
P = 0.01 for weight change among quartiles
1
2
3
Self-Monitoring Index Quartiles
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Baker and Kirschenbaum. Behav Ther 1993;24:377.
4
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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:
Self-monitor using a diary to
identify the context of eating
i.e. setting, situation,
thoughts, feelings
1.
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.
Get home
and go into
the kitchen.
Feel very hungry
and can’t be
bothered cooking.
Call takeaway
and eat crisps
while you wait.
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Miss breakfast
to compensate
for overeating.
Light lunch to
compensate for
overeating.
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 Urges
Psychological 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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Physical
Hunger
VS
In our stomach
 Eat anything
 Gnawing
 Shaky/Light headed
 Is it time to eat?
 Gets worse

Cravings
In our head
 Specific foods
 Agitated
 Trigger?
 Have you eaten?
 Go away

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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 RestructuringThinking 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 selfcontrol

A method of learning from mistakes as well as
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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 slip
Relapse = sequence of lapses
Collapse = 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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John…
“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.”
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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 Plan
Reasons 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;16:623
British Psychological Society (2011) Obesity in the UK: A Psychological
Perspective. BPS: Leicester
Cooper, Z., Fairburn, C.G & Hawker, D. (2003) Cognitive-Behavioural
Treatment of Obesity. The Guilford Press
Effective Health Care; The prevention and treatment of obesity (1997), NHS
Centre for Reviews and Dissemination, University of York
European 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/
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