Cognitive Behavioural Interventions in Weight Management

1. Cognitive Behavioural Interventions in Weight Management Dr Mira Mojee Clinical Psychologist GCWMS

2. Aims for today • What is Cognitive Behavioural Therapy ? • Why CBT in weight management? • Specific CBT strategies for Preparation; Action; Maintenance; Relapse • Conclusions GCWMS- Training

3. 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 GCWMS- Training

4. 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) GCWMS- Training

5. Behavioural → CBT Model • Social learning: observation of others’ behaviour & self-efficacy (Bandura) GCWMS- Training

6. Negative Automatic Thoughts Assumptions Core Beliefs Cognitive Model • Beck 1970’s/80’s • Early experiences can influence our thinking GCWMS- Training

7. Cognitive Behavioural Model I’m going to fail again Sad Low Hopeless Stop attending groups; stop trying GCWMS- Training

8. 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 andinclude 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 GCWMS- Training

9. CBT in GCWMS GCWMS- Training

10. 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 GCWMS- Training

11. OBESITY Components of CBT Approaches for Obesity SelfMonitoring ProblemSolving ContingencyManagement / RP & Maintenance CognitiveRestructuring Social Support StimulusControl StressManagement GCWMS- Training Wadden and Foster. Med Clin North Am 2000:84:441.

12. Strategies to Prepare for Change “What do I need to change?” GCWMS- Training

13. Self Monitoring GCWMS- Training

14. Self-Monitoring Consistency and Weight LossWeight change (lb) at 18 wk of behavior therapy P = 0.01 for weight change among quartiles 1 2 3 4 Self-Monitoring Index Quartiles GCWMS- Training Baker and Kirschenbaum. Behav Ther 1993;24:377.

15. Specific Change Strategies for Later Stages “How will I change?” GCWMS- Training

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17. 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 GCWMS- Training

18. “SMART” Exercise Goals • Specific • Measurable • Achievable • Relevant • Time-specific GCWMS- Training

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20. 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 GCWMS- Training

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22. Stimulus Control • External – situations we are in such as shopping, at home alone, seeing adverts etc. GCWMS- Training

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

25. Breaking the Habit Chain Miss breakfast to compensate for overeating. Late getting up for work. Overeating in the evening. 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. GCWMS- Training

26. Stimulus Control – Making changes toEXTERNAL 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 GCWMS- Training

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28. 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 GCWMS- Training

29. Physical Hunger VS Cravings • 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 GCWMS- Training

30. 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 GCWMS- Training

31. 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.” GCWMS- Training

32. 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.** GCWMS- Training

33. Cognitive Restructuring- Thinking Errors • Modifying negative thinking & unhelpful beliefs • All or nothing • Mind reading • Fortune-telling • Catastrophising • Emotional reasoning GCWMS- Training

34. 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.” GCWMS- Training

35. 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. GCWMS- Training

36. 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 GCWMS- Training

37. 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 GCWMS- Training

38. 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’ GCWMS- Training

39. 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 GCWMS- Training

40. 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.” GCWMS- Training

41. 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) GCWMS- Training

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43. 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 GCWMS- Training

44. 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. . GCWMS- Training

45. 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/ GCWMS- Training