Cognitive Behavioral Therapy for Weight Loss

Janelle W. Coughlin, Ph.D.Department of Psychiatry and Behavioral Sciences

Director, Obesity Behavioral MedicineAssociate Director, Center for Behavior and Health

Sept 25, 2013

Integrated Care Conference

Objectives

• To review briefly the obesity epidemic, its consequences, and the relationship between obesity and mental illness

• To summarize obesity treatment, with an emphasis on traditional behavioral treatment

• To provide an overview of cognitive-behavioral therapy (CBT) for obesity (and weight-related behaviors)

What is Obesity?

Weight Classification by BMI

BMI (kg/m2) Classification

<18.5 Underweight

18.5-24.9 Normal Range

25-29.9 Overweight

30-34.9 Mild obesity

35-39.9 Moderate obesity

≥40 Morbid/severe/extreme obesity

Causes of Obesity

Obesity: Medical and Financial Consequences

• Medical Comorbidities– Coronary heart disease – Type 2 diabetes – Cancers (endometrial, breast, and colon) – Hypertension – Dyslipidemia– Stroke – Liver and Gallbladder disease – Sleep apnea and respiratory problems – Gynecological problems (abnormal menses, infertility)– Pain conditions

• Medical Expenditures– $147 billion in 2008 (Finkelstein et al., 2009)

Prevalence of obesity among adults aged 20 and over by sex and age: United States, 2009–2010

Prevalence of obesity among adults aged 20 and over, b y sex and age: U nited States, 2009–2010

Ogden et al., 2012

What about obesity and mental health?

Allison et al., 2009; Dickerson et al., 2006

• Individuals with serious mental illness (SMI) have an extremely high prevalence of obesity• Nearly twice that

of the overall population

Obesity and Mental Health

• Those with SMI have increased weight-related conditions

• Mortality rates are 2-3 times higher in SMI as compared to the overall population

Bresee et al., 2010; Carney et al., 2006; Himelhoch et al., 2004

Causes of Obesity in SMI?

• Less active than the general population• Dietary behaviors in comparison to general

population:– Higher fat intake– Less fruits and vegetables– Higher overall caloric intake

• Medication side effects• Psychological factors/comorbidities

Amani, 2007; Compton et al., 2006; Daumit et al. 2004; Jerome et al., 2009; McCreadie, 2003; Strassnig et al., 2003

Psychiatric Disorders Associated with Obesity

• Binge Eating Disorder (BED)– recurring episodes of eating significantly

more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. • eating quickly, often in absence of hunger;

feelings of guilt, embarrassment, or disgust, binge eating alone to hide the behavior; marked distress

– occurs, on average, at least once a week over three months. APA, DSM-5

Psychiatric Conditions Associated with Obesity

• Night Eating Syndrome (NES)–evening hyperphagia (ingestion of at

least 25% of daily calories after supper)

–awakenings with ingestions at least three times a week • awareness and recall of the eating • associated with significant distress

and/or impairment in functioning Stunkard, 2008

CBT for BED and NES

Surgery

Pharmacotherapy

Lifestyle Modification

Diet Physical Activity

BMI

Obesity Treatment Pyramid

Dietary Approaches to Lifestyle Modification

Calorie Deficit ~1200-2000 kcal/d

Dietary Approaches:Low-fatLow-carbohydrateMediterranean Low-glycemic loadPortion-controlled diets

Increasing Physical Activity

> 180 m/wk MVPA for weight loss Must also include caloric restrictionAssociated with a number of health improvements,

independent of weight lossCan be performed in short boutsIncreasing other lifestyle activities is also effective

> 2000 steps for weight loss; > 6000 to avoid regainCritical for long-term weight loss maintenance

~ 60 m/d MVPA

Lifestyle Modification Interventions for Obesity

•Self-monitoring•Goal Setting•Stimulus control•Problem solving

• Increase self-efficacy and social support

• Relapse Prevention

Short-Term Outcomes

• Lifestyle modification programs typically produce 7 to 10% reduction in initial weight in 6 months

• Generally sustained at one year with ongoing, regular maintenance therapy

Weight Loss Maintenance

• Patients gain ~ 1/3 of their lost weight in the year following treatment

• Nearly half return to their original weight within 5 yrs

• 1:6 adults accomplish > 1 yr of maintaining > 10% of IBW

• Weight loss maintenance interventions can decrease the chance of weight regain

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The ACHIEVE TrialDaumit et al., 2013

Daumit et al., 2013

The ACHIEVE Trial

Adding cognitive therapy to standard treatment is associated with less relapse in obesity

Werrij et al., 2009

What is Cognitive-BehavioralTreatment of Obesity

– Assigns central importance to cognitive processes that maintain a problem

– For lasting change to occur, maintaining mechanisms need to be modified

– Utilize cognitive and behavioral procedures to change the maintaining mechanisms• Primary aim is to produce cognitive change• Behavioral experiments and cognitive restructuring

are central

Cooper, Fairburn & Hawker, 2003

Assess

• Motivation:– How are weight, dietary behaviors, and inactivity

interfering with:• What patient wants to do? How patient feels?

Health?

• History• Current Behavior:

– Dietary and PA Assessment– Logs

• Pros and cons of treatment; potential barriers; strengths; support; expectations

Self-Monitoring

Date/Time Food and Beverage Consumed{meals in brackets}

* Exercise(activity/minutes)

* Excessive, LOC, hunger, etc.

Self-Monitoring

Date/Time Food and Beverage Consumed{meals in brackets}

* Circumstances Exercise(activity/min)

* Excessive, LOC, hunger, fullness, etc.

Circumstances

• Who am I with?• What am I thinking?• What is going on?• What do I really want right now? • Where am I and how do I feel about this place? • When am I eating? You should be recording the date and time in the

appropriate section, but here you can record more detail about what is going on. (I am eating when everyone else goes to bed)

• Why am I eating? • How am I feeling physically? (I am in pain, I am tired) emotionally?

(Do any of these words apply at the time of or right before this meal: bored, depressed, lonely, anxious, angry, guilty?)

Self-monitoring

• To weigh or not to weigh?

• Calories vs. no calories• Behaviors vs. calories• Provide an instruction

sheet– Portions, etc.

• When to introduce “circumstances”

• Meals in brackets.• Include start and stop time of meal.• State simply the foods or beverages you

consumed. • As much as possible, include portions. For

example, if you have pizza include number of slices or state if something was a pre-portioned meal (e.g., Lean Cuisine). Often labeling of a product will give information about what the manufacturer considers a serving size for that particular food.

• It is fine to use terms like “1 handful”, “2 serving spoons”, or “the size of a deck of cards” to estimate portions.

• Include both caloric and non-caloric beverages. • Include whether you are using a low-fat version

of a particular fool (e.g., skim milk)• Try to also record condiments like mayo or

sugar packets.

Self-Monitoring

Behavior Sun Mon Tues Wed Thurs Fri Sat

Fruits 1 2 3 45 6 7 8

Vegetables 1 2 3 45 6 7 8

Sugar-sweetened beverages

1 2 3 45 6 7 8

Breakfast Y/N

Lunch Y/N

Dinner Y/N

Snacks 1 2 3 4

Regulate Eating Schedule

• No skipping meals– 3 meals vs. 3 meals/2 snacks vs. 6 smaller

meals• Eat breakfast• Eat around same time every day

Comprehensive Diary

Situation Feelings Thoughts Behavior Consequences

Comprehensive Diary

Situation Feelings Thoughts Behavior Consequences AlternativeThoughts

Weight Maintenance

• Reasons I do not want to regain• Good habits to keep up (eating)• Good habits to keep up (activity)• Danger areas to be aware of • Plan for monitoring• When to act

Cooper, Fairburn & Hawker, 2003

Conclusions

• Obesity is a serious pubic health problem, particularly among those with SMI

• Lifestyle Modification is the cornerstone of all obesity treatments

• Cognitive-behavioral therapy can help with more sustained change

Thank you

jwilder3@jhmi.edu