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Cognitive Behavioural Interventions in Weight Management

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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 Cognitive Model Beck 1970’s/80’s
Core Beliefs Negative Automatic Thoughts Assumptions 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 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 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 Components of CBT Approaches for Obesity
Self Monitoring Problem Solving Contingency Management / RP & Maintenance Cognitive Restructuring Social Support Stimulus Control Self-monitoring very important in behaviour therapy. Systematic recording of food intake, activity, situational context, emotional context- useful for awareness raising, goal setting, and behavioural chains Problem-solving- skills needed for self-regulation of emotions. Learning to analyse problems and identify solutions Contingency management and relapse prevention- skills in recovering from episodes of overeating and weight regain- involves planning for the future/ goal setting Stimulus control- managing triggers for overeating Stress management- developing skills to reduce negative impact of stress –e.g. assertiveness training Social support- important to identify this and enhance, as impacts on behavioural change Cognitive restructuring- skills/ strategies to deal with unhelpful thoughts- applied to weight loss failure, and body image Stress Management 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 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 Normally crisps, trying to swap for healthy snack, pleased I managed the craving GCWMS- Training

14 Self-Monitoring Index Quartiles
Self-Monitoring Consistency and Weight Loss Weight 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

16 GCWMS- Training

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

19 My goal for the fortnight:___________________
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: Specific tool used following discussion about setting goals Brings client to point of commitment The more plan is verbalised the more the commitment Can be useful to summarise, plan have together Finish by checking is this what you plan to do? Think about how you can incorporate into the group programme? GCWMS- Training

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

21 GCWMS- Training

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

23 GCWMS- Training

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 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 GCWMS- Training

27 GCWMS- Training

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 VS Physical Hunger Cravings In our head Specific foods In our stomach
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 Internal causes Social Causes
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

42 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: GCWMS- Training

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, S Health Development Agency (2003) The management of obesity and overweight: an analysis of reviews of diet, physical activity and behavioural approaches. Website: Hunt, P. & Hillsdon, M. (1996) Changing Eating & Exercise Behaviour. Blackwell Science. . GCWMS- Training

45 Wadden and Foster. Med Clin North Am 2000:84:441.
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), 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. * GCWMS- Training

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