Background
Cognitive processes associated with attrition, weight loss and weight maintenance
Cognitive factors associated with treatment discontinuation: | |
• Primary goal for weight loss based on appearance at baseline [8] | |
• Acceptable or disappointing weight with respect to personal expectations [9] | |
• Dissatisfaction with weight loss obtained through treatment [10] | |
Cognitive factors associated with amount of weight lost: | |
• Increase in dietary restraint and reduction in disinhibition [11] | |
• Higher expected weight loss at baseline [12] | |
Cognitive factors associated with weight-loss maintenance: | |
• Satisfaction with the results achieved [7] | |
• Weight-loss satisfaction [12] | |
• Confidence in the ability to lose additional weight without professional help [7] | |
• Greater weight-loss satisfaction from week 15 or 19 of the weight-loss phase (a decline is associated with weight regain) [13] |
From BT-OB to CBT-OB
Goals, general strategies and procedures of CBT-OB
Strategies and procedures for minimising attrition: | |
• Addressing patient’s difficulties attending the sessions | |
- Scheduling the sessions at times compatible with a patient’s work commitments | |
- Routinely asking the patients whether they are experiencing any difficulties as regards attending the sessions, and devoting time to understanding and/or overcoming them. | |
• Showing interest in each patient as a person, irrespective of their weight and/or other issues | |
- Adopting a “people first” policy—putting individuals before the disability or disease when describing persons affected by obesity (e.g., “person with obesity” instead of “obese person” | |
- Avoiding any use of potentially pejorative adjectives or adverbs, or any language that implies moral judgements or highlights patients’ “character flaws” regarding their weight | |
• Addressing unrealistic weight loss expectations | |
- Encouraging patients to pursue and be satisfied with achievable short-term weight-loss goals (i.e., a weight loss of between 0.5 kg and 1.0 kg/week) and not disputing unrealistic goals at the beginning of treatment | |
- Addressing unrealistic goals only when patients have achieved some success in reaching a healthy weight, but manifest dissatisfaction with the weight loss achieved | |
• Maintaining therapeutic momentum | |
- Identifying with the patients the best time to start the treatment | |
- Stressing the importance of avoiding any interruptions in treatment, especially during the first 8 weeks | |
- Explaining to the patients in advance that another therapist will take the place of the primary therapist in the event of their absence | |
• Developing a protocol for dealing with late attendance or non-attendance | |
- Encouraging patients to arrive a little early for session (e.g., 10–15 min) in order to relax and mentally prepare themselves | |
- If patients are running late for an appointment, calling them after 15 min to express concern about their absence, and to try to reschedule the appointment as soon as possible | |
Strategies and procedures for enhancing weight loss | |
• Increasing dietary restraint and decreasing dietary disinhibition | |
- Eating regularly (i.e., three planned meals and two snacks, and refraining from eating in the intervals between) | |
- Planning meals in advance (when, what and where to eat) on a specific monitoring record, making reference to a structured meal plan | |
- Supplying patients with grocery lists, menus and recipes | |
- Monitoring food intake in real time | |
- Training patients to eat consciously (i.e., “think while you are eating”) | |
- Training patients to “ride out” the desire for food, educating them that any impulses will be transitory and can be tolerated | |
- Encouraging patients to consider their efforts to control eating as a necessary condition for achieving healthy weight loss and benefiting from its associated physical and psychological advantages | |
- Involving patients actively in identifying processes hindering weight loss using the “Weight-Loss Obstacles Questionnaire” | |
- Developing collaboratively with the patients their personal formulation of the processes that are hindering weight loss | |
- Designing personalized procedures aimed at addressing the specific obstacles encountered by each patient | |
- Involving, with the consent of patients, their significant others in treatment to create the optimal environment for facilitating patients attempts efforts to change their eating habits | |
• Strategies and procedures for improving weight-loss maintenance | |
- Addressing weight-loss satisfaction before starting weight-loss maintenance | |
- Dedicating one or two sessions to preparing patients for weight maintenance, and collaboratively developing a weight maintenance plan | |
- Encouraging patients to suspend any attempts to lose weight while learning weight-maintenance skills (i.e., at least 12 months) | |
- Creating a list of personal reasons to maintain weight | |
- Adopting a mindset with a constant focus on weight control, and keeping a constant but flexible focus on weight control and self-awareness regarding diet and physical activity | |
- Identifying and addressing high-risk weight- regain situations, preventing lapses from becoming relapses, and addressing any weight regain | |
- Implementing weekly self-weighing and ensuring patients maintain weight within a specific range of 4 kg | |
- Encouraging patients to follow a high-protein, low-glycaemic-index diet with moderate fat content, and to practice at least 30 min of moderate-intensity activity daily |
The versions of CBT-OB
- Preparatory Phase. This is delivered in one or two sessions, and has the aims of assessing the nature and severity of a patient’s obesity, as well as any associated medical and psychosocial comorbidities, as well as engaging the patient(s) in the treatment.
- Phase 1. This has been designed to help patients achieve a healthy rate of weight loss and be satisfied with the resulting weight. It lasts about 24 weeks and is delivered across 16 sessions, the first eight of which are held once a week, and the remaining eight on a two-weekly basis.
- Phase 2. This has the aim of helping patients to develop a lifestyle and mindset conducive to long-term weight maintenance. It usually lasts 48 weeks and is delivered across 12 sessions that are held at four-weekly intervals.
Module 1 - Monitoring food Intake, physical activity and body weight | |
• Initiating weekly weighing | |
• Explaining what the treatment will involve | |
• Educating on energy balance | |
• Establishing real-time monitoring of food intake and physical activity | |
• Initiating weekly weighing | |
Module 2 - Changing eating | |
• Creating an energy deficit of 500–1000 kcal per day produce a variable weight loss of about 0.5–1 kg a week. | |
• Planning ahead when, what and where to eat | |
• Eating consciously | |
Module 3 - Developing an active lifestyle | |
• Assessing the patient’s eligibility for exercise | |
• Assessing the patient’s functional exercise capacity | |
• Motivating the patient to exercise | |
• Developing an active lifestyle, reducing sedentary activities and increasing the daily step count | |
• Improving physical fitness | |
• Continuing or commencing formal exercise (in selected cases) | |
Module 4 - Addressing obstacles to weight loss | |
• Educating the patients on cognitive-behavioural weight-loss obstacles (antecedent stimuli, positive consequences, problematic thoughts) | |
• Introducing the Weight-Loss Obstacles Questionnaire | |
• Creating the Personal Formulation | |
• Addressing weight-loss obstacles | |
- Reducing environmental stimuli | |
- Addressing events influencing eating and exercise habits | |
- Addressing impulses and emotions influencing eating and exercise habits | |
- Addressing problematic thoughts | |
- Addressing the use of food as a reward, and the patient’s rational excuses for not adopting an active lifestyle | |
Module 5 - Addressing weight-loss dissatisfaction | |
• Detecting weight-loss dissatisfaction and its reasons | |
• Addressing unrealistic weight goals | |
• Addressing dysfunctional primary goals for losing weight | |
• Addressing negative body image | |
Module 6: Addressing the obstacles to weight maintenance | |
• Reviewing the changes achieved through weight loss | |
• Educating the patient on weight maintenance | |
• Involving the patient actively in the decision to start weight maintenance | |
• Introducing the procedures for weight maintenance | |
- Establishing weekly self-weighing and a weight-maintenance range | |
- Adopting eating habits and physical activity habits conducive to weight maintenance | |
- Constructing a weight-maintenance mindset | |
- Identifying and addressing high-risk situations and | |
- Addressing weight regain | |
• Discontinuing real-time monitoring of food intake | |
• Evaluating possible future weight-loss attempts | |
• Preparing a weight-maintenance plan | |
• Bringing the treatment to a close |