David Baxter PhD
Late Founder
A Cognitive Therapy Approach to Weight Loss and Maintenance
04/23/2007
Interview with Judith S. Beck, PhD
Editor's Note:
The rate of obesity has soared in the past 20 years. While many people are able to make behavioral changes and lose weight, very few are able to maintain their weight loss. A cognitive approach may make it much more likely that people will be able to sustain lifetime changes in their eating. To learn about this kind of dieting, Elizabeth Saenger, PhD, Editorial Director of Medscape's Psychiatry & Mental Health site, interviewed Judith S. Beck, PhD, Director of the Beck Institute for Cognitive Therapy and Research and Clinical Professor of Psychology in Psychiatry at the University of Pennsylvania.
Medscape: What are the key components of a cognitive therapy program for weight loss and maintenance?
Dr. Beck: Dieters need a great deal of education about dieting, food, eating, and maintenance. They have to choose a highly nutritious diet program and learn to plan and self-monitor their intake. They need help in solving problems that would otherwise derail them. They need to find someone to keep them accountable and to support them. Behavioral experiments are important to decrease their fear of hunger and cravings and increase their tolerance for these uncomfortable states. Finally, they need to learn how to identify and respond to dysfunctional thoughts that get in the way of their consistently implementing their diet and exercise programs.
Medscape: Are there certain parts to the educational component that might not be obvious to the average dieter -- or clinician?
Dr. Beck: Dieters need help in coming to grips with the fact that they need to lose slowly and sensibly -- and that they will need to be on a variation of this diet for their whole life. They need to know that they won't lose weight every single week, even if they're keeping their caloric intake and amount of exercise constant. Hormonal changes, water retention, and other biologic processes can cause weight to vary. Also, once they lose a certain amount of weight, they will plateau, unless they cut calories further or exercise more. And they also should know beforehand that dieting often starts off easy when people are motivated, then it's normal for it to get harder, but that it will become easier again when they have the right tools.
Medscape: Do people become demoralized when they find out that dieting isn't as easy as they had thought?
Dr. Beck: Yes. That's why it's important to lay the groundwork with dieters first. In fact, I suggest that people spend a couple weeks learning certain skills before they even start. One skill is to compose and read every day a list of every advantage they can think of for losing weight. They'll need to read this list for a very long time, so when they face temptation, these advantages will be firmly in mind. And they need to prepare in advance what to say to themselves when dieting gets harder, when they feel discouraged, when the scale hasn't gone down, when they stray from their diet, and when they start to feel the injustice of food restriction.
Medscape: Do you recommend that people try to learn the skill of eating only when they're hungry?
Dr. Beck: No, at least not for people who have struggled with dieting in the past. They need to learn to plan their food intake in advance and how to talk to themselves so they'll be able to stick to their plan without variation. Once they get really good at this skill, they can experiment with becoming slightly looser with their eating. I've found that chronic dieters just have too hard a time either distinguishing among hunger, a desire to eat, and craving -- or they don't really care at the moment which one they're experiencing; they just want to eat. That's why it's essential to just follow a sensible eating plan.
Medscape: Do dieters rebel against the idea of not necessarily eating when they're hungry?
Dr. Beck: First, we encourage people to select foods that minimize hunger. Second, we educate them about hunger. Most normal weight people experience hunger daily, before meals. They just wait to eat, though. Chronic dieters often fear hunger. That's why we have them do experiments where they skip a meal -- to prove to themselves that hunger is not an emergency, that it's only mildly uncomfortable compared to other discomfort they've experienced in their lives, that it actually comes and goes, and that they can tolerate it, no matter what.
Medscape: How do you determine how much weight dieters should lose?
Dr. Beck: We never know initially what is going to be reasonable. That's why we encourage dieters to set a goal to lose 5 pounds. Then they can set a goal to lose another 5 pounds, and so on. Ultimately, they either get down to a weight that they want to stay at or they plateau and can't sustain a further change in calories or exercise. Either way, this is what we term their 'lowest achievable weight.' It's unrealistic for many people, however, to continue to eat the same number of calories and/or exercise to the same degree for the long run. So we help them figure out reasonable levels of calories and exercise. They plan in advance to eat a little more or exercise a little less, knowing that their weight will rise to and then plateau at their 'lowest maintainable level.'
Medscape: What role does distorted thinking play in unsuccessful efforts to lose weight?
Dr. Beck: Dieters who fail to lose weight or fail to maintain their weight loss think differently from those who are able to lose weight and keep it off long term. They have a lot of all-or-nothing thinking:
Dr. Beck: We use standard cognitive therapy techniques, teaching them to ask themselves what's going through their minds when they feel hunger and craving, when they are disgruntled about not eating, when they are tempted to eat something they haven't planned. Then they read 'response cards'; index cards that contain compelling answers to their thoughts. They read these cards at least once a day, usually in the morning; then pull them out again on an as-needed basis, sometimes several times a day toward the beginning of their diet.
Medscape: Can you give an example of a response card?
Dr. Beck: We make them up idiosyncratically with dieters. Some common ideas are: Even though I really want to eat now, I haven't planned to. If I eat, I'll strengthen my 'giving-in' habit, which means in the future I'm more likely to give in. If I don't eat, I'll strengthen my 'resistance' habit, which makes it more likely that in the future I'll be able to resist. I can tolerate not eating now. I'll be very glad in a few minutes when the desire goes away. I shouldn't give myself a choice about this. After all, I'd rather be thinner. I can't eat whatever I want AND also be thinner. I have to make a choice. Every time matters.
Medscape: What about emotional eating?
Dr. Beck: Dieters give themselves permission to stray from their diet for any number of reasons. They're upset, happy, tired, stressed, celebrating, traveling, busy, at a party...the list is endless. They think, 'It's okay to eat because.... everyone else is; it's only a small piece; no one is watching; the food is free; I rarely get a chance to eat this kind of food.' They need to learn the same skills to avoid straying from their plan, no matter what the reason. They have to grasp the fact that they can either eat what they want, when they want, for whatever reason they want (including being upset) -- or they can be thinner. But it's impossible to have it both ways.
Medscape: What do you suggest people do when they're tempted by food that they're not supposed to eat?
Dr. Beck: As I keep saying, they have to prepare in advance for these times. They need to continually remind themselves (often by reading response cards) of the reasons to lose weight, that they can tolerate the discomfort of not eating (after all, they've tolerated much worse discomfort in their lives), that they'll be happy in a few minutes when the desire to eat passes that they didn't eat and they'll be very unhappy in a few minutes if they give in to temptation. They also need a list of things they can do when they feel tempted -- such as reading a diet book, surfing the Web for diet-related sites, taking a walk, calling a friend, brushing their teeth, writing emails, and so forth. We help dieters create a list of about 20 activities or so and urge them to try 5 of them each time they're tempted.
Medscape: You mentioned that dieters need someone to be accountable to.
Dr. Beck: Yes, we encourage everyone to find a 'diet coach': a friend, family member, coworker, neighbor, or maybe someone else who is trying to lose weight. Diet coaches don't necessarily need to know much about dieting. But they do need to be highly supportive and encouraging. They also need to be willing to hunt down the dieter who has failed to keep his or her regularly scheduled weekly appointment (by telephone or email, or in person), reporting on how his/her weight has changed that week. Dieters don't need to reveal their weight; only their change in weight. In addition, diet coaches need to be good problem solvers.
Medscape: What kinds of problems arise that dieters need help with?
Dr. Beck: Common problems include practical ones, such as not enough time to schedule in dieting and exercise activities, and psychological ones, such as demoralization and discouragement. Some dieters need encouragement (and sometimes a little assertiveness coaching) to state their needs to family and coworkers. It's surprising how many dieters are reluctant to turn down food that others offer or to ask that others bring only a single serving of overly tempting foods into the home, at least at the beginning. Ultimately, we want to build up dieters' control so that they can keep any kind of food in the house and eat only small, planned-in-advance amounts.
Medscape: To what degree do dieters have to change their eating habits?
Dr. Beck: Dieters need to figure out the optimal number of times to eat a day. For some people, that's 3 meals. Others do better if they plan to have up to 3 additional snacks. We teach dieters to eat everything sitting down, slowly and mindfully. Because they'll be restricting their intake permanently, they need to learn how to enjoy every bite of food they eat, so they'll feel psychologically satisfied at the end of meals. They need to eat slowly, too, so they'll feel physiologically full.
Medscape: Finally, what does research say about a cognitive therapy approach?
Dr. Beck: A randomized controlled trial in Sweden1 showed that obese subjects not only lost weight during a 10-week cognitive therapy program, but also most continued to lose weight during an 18-month follow-up. Obese controls gained weight during this period.
References
Stahre L, Hallstrom T. A short-term cognitive group treatment gives substantial weight reduction up to 18 months from the end of treatment: A randomized controlled trial. Eat Weight Disord. 2005;10;51-58. Abstract
Suggested Reading
Beck JS. The Beck Diet Solution. Birmingham, Ala: Oxmoor House; 2007.
04/23/2007
Interview with Judith S. Beck, PhD
Editor's Note:
The rate of obesity has soared in the past 20 years. While many people are able to make behavioral changes and lose weight, very few are able to maintain their weight loss. A cognitive approach may make it much more likely that people will be able to sustain lifetime changes in their eating. To learn about this kind of dieting, Elizabeth Saenger, PhD, Editorial Director of Medscape's Psychiatry & Mental Health site, interviewed Judith S. Beck, PhD, Director of the Beck Institute for Cognitive Therapy and Research and Clinical Professor of Psychology in Psychiatry at the University of Pennsylvania.
Medscape: What are the key components of a cognitive therapy program for weight loss and maintenance?
Dr. Beck: Dieters need a great deal of education about dieting, food, eating, and maintenance. They have to choose a highly nutritious diet program and learn to plan and self-monitor their intake. They need help in solving problems that would otherwise derail them. They need to find someone to keep them accountable and to support them. Behavioral experiments are important to decrease their fear of hunger and cravings and increase their tolerance for these uncomfortable states. Finally, they need to learn how to identify and respond to dysfunctional thoughts that get in the way of their consistently implementing their diet and exercise programs.
Medscape: Are there certain parts to the educational component that might not be obvious to the average dieter -- or clinician?
Dr. Beck: Dieters need help in coming to grips with the fact that they need to lose slowly and sensibly -- and that they will need to be on a variation of this diet for their whole life. They need to know that they won't lose weight every single week, even if they're keeping their caloric intake and amount of exercise constant. Hormonal changes, water retention, and other biologic processes can cause weight to vary. Also, once they lose a certain amount of weight, they will plateau, unless they cut calories further or exercise more. And they also should know beforehand that dieting often starts off easy when people are motivated, then it's normal for it to get harder, but that it will become easier again when they have the right tools.
Medscape: Do people become demoralized when they find out that dieting isn't as easy as they had thought?
Dr. Beck: Yes. That's why it's important to lay the groundwork with dieters first. In fact, I suggest that people spend a couple weeks learning certain skills before they even start. One skill is to compose and read every day a list of every advantage they can think of for losing weight. They'll need to read this list for a very long time, so when they face temptation, these advantages will be firmly in mind. And they need to prepare in advance what to say to themselves when dieting gets harder, when they feel discouraged, when the scale hasn't gone down, when they stray from their diet, and when they start to feel the injustice of food restriction.
Medscape: Do you recommend that people try to learn the skill of eating only when they're hungry?
Dr. Beck: No, at least not for people who have struggled with dieting in the past. They need to learn to plan their food intake in advance and how to talk to themselves so they'll be able to stick to their plan without variation. Once they get really good at this skill, they can experiment with becoming slightly looser with their eating. I've found that chronic dieters just have too hard a time either distinguishing among hunger, a desire to eat, and craving -- or they don't really care at the moment which one they're experiencing; they just want to eat. That's why it's essential to just follow a sensible eating plan.
Medscape: Do dieters rebel against the idea of not necessarily eating when they're hungry?
Dr. Beck: First, we encourage people to select foods that minimize hunger. Second, we educate them about hunger. Most normal weight people experience hunger daily, before meals. They just wait to eat, though. Chronic dieters often fear hunger. That's why we have them do experiments where they skip a meal -- to prove to themselves that hunger is not an emergency, that it's only mildly uncomfortable compared to other discomfort they've experienced in their lives, that it actually comes and goes, and that they can tolerate it, no matter what.
Medscape: How do you determine how much weight dieters should lose?
Dr. Beck: We never know initially what is going to be reasonable. That's why we encourage dieters to set a goal to lose 5 pounds. Then they can set a goal to lose another 5 pounds, and so on. Ultimately, they either get down to a weight that they want to stay at or they plateau and can't sustain a further change in calories or exercise. Either way, this is what we term their 'lowest achievable weight.' It's unrealistic for many people, however, to continue to eat the same number of calories and/or exercise to the same degree for the long run. So we help them figure out reasonable levels of calories and exercise. They plan in advance to eat a little more or exercise a little less, knowing that their weight will rise to and then plateau at their 'lowest maintainable level.'
Medscape: What role does distorted thinking play in unsuccessful efforts to lose weight?
Dr. Beck: Dieters who fail to lose weight or fail to maintain their weight loss think differently from those who are able to lose weight and keep it off long term. They have a lot of all-or-nothing thinking:
- Being full (often overly full) is good; hunger is bad;
- They're good if they follow their diets, but bad if they make 1 mistake;
- Their eating week was either good (relatively easy) or bad (even if they only struggled for several minutes on several days);
- Food is either good or bad even though we recommend that dieters plan in advance to modify their diets so they can eat small portions of whatever food they want as often as once a day; and
- Dieters who fail to lose weight also view themselves as either in control (100% perfect) or out of control. They often think that 1 mistake should give them license to eat whatever they want for the rest of the day and delay starting fresh until the next day. They also believe that people of 'normal' weight rarely restrict their eating and rarely get hungry. They think that once they lose weight, they should be able to return to their old way of eating.
Dr. Beck: We use standard cognitive therapy techniques, teaching them to ask themselves what's going through their minds when they feel hunger and craving, when they are disgruntled about not eating, when they are tempted to eat something they haven't planned. Then they read 'response cards'; index cards that contain compelling answers to their thoughts. They read these cards at least once a day, usually in the morning; then pull them out again on an as-needed basis, sometimes several times a day toward the beginning of their diet.
Medscape: Can you give an example of a response card?
Dr. Beck: We make them up idiosyncratically with dieters. Some common ideas are: Even though I really want to eat now, I haven't planned to. If I eat, I'll strengthen my 'giving-in' habit, which means in the future I'm more likely to give in. If I don't eat, I'll strengthen my 'resistance' habit, which makes it more likely that in the future I'll be able to resist. I can tolerate not eating now. I'll be very glad in a few minutes when the desire goes away. I shouldn't give myself a choice about this. After all, I'd rather be thinner. I can't eat whatever I want AND also be thinner. I have to make a choice. Every time matters.
Medscape: What about emotional eating?
Dr. Beck: Dieters give themselves permission to stray from their diet for any number of reasons. They're upset, happy, tired, stressed, celebrating, traveling, busy, at a party...the list is endless. They think, 'It's okay to eat because.... everyone else is; it's only a small piece; no one is watching; the food is free; I rarely get a chance to eat this kind of food.' They need to learn the same skills to avoid straying from their plan, no matter what the reason. They have to grasp the fact that they can either eat what they want, when they want, for whatever reason they want (including being upset) -- or they can be thinner. But it's impossible to have it both ways.
Medscape: What do you suggest people do when they're tempted by food that they're not supposed to eat?
Dr. Beck: As I keep saying, they have to prepare in advance for these times. They need to continually remind themselves (often by reading response cards) of the reasons to lose weight, that they can tolerate the discomfort of not eating (after all, they've tolerated much worse discomfort in their lives), that they'll be happy in a few minutes when the desire to eat passes that they didn't eat and they'll be very unhappy in a few minutes if they give in to temptation. They also need a list of things they can do when they feel tempted -- such as reading a diet book, surfing the Web for diet-related sites, taking a walk, calling a friend, brushing their teeth, writing emails, and so forth. We help dieters create a list of about 20 activities or so and urge them to try 5 of them each time they're tempted.
Medscape: You mentioned that dieters need someone to be accountable to.
Dr. Beck: Yes, we encourage everyone to find a 'diet coach': a friend, family member, coworker, neighbor, or maybe someone else who is trying to lose weight. Diet coaches don't necessarily need to know much about dieting. But they do need to be highly supportive and encouraging. They also need to be willing to hunt down the dieter who has failed to keep his or her regularly scheduled weekly appointment (by telephone or email, or in person), reporting on how his/her weight has changed that week. Dieters don't need to reveal their weight; only their change in weight. In addition, diet coaches need to be good problem solvers.
Medscape: What kinds of problems arise that dieters need help with?
Dr. Beck: Common problems include practical ones, such as not enough time to schedule in dieting and exercise activities, and psychological ones, such as demoralization and discouragement. Some dieters need encouragement (and sometimes a little assertiveness coaching) to state their needs to family and coworkers. It's surprising how many dieters are reluctant to turn down food that others offer or to ask that others bring only a single serving of overly tempting foods into the home, at least at the beginning. Ultimately, we want to build up dieters' control so that they can keep any kind of food in the house and eat only small, planned-in-advance amounts.
Medscape: To what degree do dieters have to change their eating habits?
Dr. Beck: Dieters need to figure out the optimal number of times to eat a day. For some people, that's 3 meals. Others do better if they plan to have up to 3 additional snacks. We teach dieters to eat everything sitting down, slowly and mindfully. Because they'll be restricting their intake permanently, they need to learn how to enjoy every bite of food they eat, so they'll feel psychologically satisfied at the end of meals. They need to eat slowly, too, so they'll feel physiologically full.
Medscape: Finally, what does research say about a cognitive therapy approach?
Dr. Beck: A randomized controlled trial in Sweden1 showed that obese subjects not only lost weight during a 10-week cognitive therapy program, but also most continued to lose weight during an 18-month follow-up. Obese controls gained weight during this period.
References
Stahre L, Hallstrom T. A short-term cognitive group treatment gives substantial weight reduction up to 18 months from the end of treatment: A randomized controlled trial. Eat Weight Disord. 2005;10;51-58. Abstract
Suggested Reading
Beck JS. The Beck Diet Solution. Birmingham, Ala: Oxmoor House; 2007.
