WHEN TRYING TO LOSE weight, most people focus on two things: their nutrition and their activity levels. However, obesity medicine specialists and other health care providers are increasingly encouraging patients to also focus on shifting their perspective.
Weight-loss facilities have added licensed clinical psychologists to their staffs to help men and women develop healthier thought patterns. Dedicated binge eating and emotional eating therapy practices have opened throughout the country. And the American Diabetes Association and the American Psychological Association recently partnered to build the ADA-APA Mental Health Provider Diabetes Education Program to teach mental health professionals how to best care for patients with diabetes.
The link between weight and mental health is a "chicken and egg" scenario, says Jennifer Shapiro, a licensed clinical psychologist and director of everyBody Behavioral Health, a San Diego-based psychology practice focused on helping people establish a healthy relationship with food and their bodies. "Many people who are overweight or obese also experience depression, low self-esteem, binge eating disorder and other psychological disorders," Shapiro says. Meanwhile, a 2012 report published in the International Journal of Obesity suggests that high-fat diets and their associated weight gain result in neurological changes that increase the risk of depressionand, like drugs, can cause addictive behavior. Another threat to mental health in those who are overweight or obese is weight stigma, adds Dr. Jennifer C. Seger, an obesity medicine specialist at the Bariatric Medical Institute of Texas.
Many people who struggle with their weight also struggle with the mental implications of obesity-related conditions such as high blood pressure, cardiovascular disease, poor mobility and Type 2 diabetes. For example, in the case of those with Type 2 diabetes, which affects more than 9 percent of Americans according to the American Diabetes Association, around-the-clock health needs can increase the risk of depression and anxiety, says Dr. William T. Cefalu, chief scientific, medical and mission officer for the American Diabetes Association.
These are issues that people cannot just white-knuckle, and it's important to treat mental disorders as seriously as physical ones, Shapiro says. She recently presented on the impact of cognitive behavioral therapy, which is currently the most popular form of therapy for weight management, at the spring 2018 Obesity Medicine Association conference.
In a 2012 study published in the scientific journal Nutrition, 29 percent of patients who underwent Roux-en-Y gastric bypass surgery regained more than 10 percent of their lowest weight recorded. So, say a person reached a weight of 200 pounds after surgery. In that scenario, the individual would regain at least 20 pounds, according to the study's findings. For this reason, at BMI of Texas all patients must undergo psychological testing to be approved for weight-loss surgery, Seger explains.
A 2017 review published in Psychology Research and Behavior Management shows that cognitive behavioral therapy is particularly helpful at treating binge eating disorder, characterized by repeated episodes of eating large quantities of food, typically followed by physical discomfort as well as shame and guilt. According to a 2014 scientific review published in the journal Biological Psychiatry, about 1.4 percent of people will experience binge eating disorder in their lifetime, but fewer than half will receive treatment. Shapiro also notes that between 15 and 25 percent of patients receiving bariatric surgery suffer from binge eating disorder.
Meanwhile, in a 2012 study published in the International Journal of Women's Health, female dieters who underwent eight cognitive behavioral therapy sessions lost more weight over the course of four months than did those who tried to lose weight without therapy. The women who underwent therapy also reported improved quality of life and, following treatment, none of the women met the criteria for binge eating disorder.
What Exactly Is Cognitive Behavioral Therapy – And What Does It Involve?
Cognitive behavioral therapy, or CBT, is a form of talk therapy that emphasizes how thoughts drive behavior.
"It's not what happens to us that determines how we react," says Jennifer Carter, a psychologist who specializes in eating disorders and body image at Ohio State University's Wexner Medical Center. "Rather, it's how we think about or interpret the events around us that determine how we react. The therapy treatment involves identifying maladaptive thoughts and challenging them with more effective beliefs."
During structured sessions, a trained CBT therapist works with patients to discover why they are performing behaviors that hinder their weight loss and health. By determining the thoughts that drive these behaviors, such as skipping workouts or stress eating, and then working to replace them with more accurate thoughts, the therapy helps patients form healthier relationships with food, exercise and their bodies.
"The therapist would help the client identify core beliefs and the validity of those beliefs, then help the client challenge maladaptive beliefs to work toward more effective self-talk and behavior," Carter says. "Individuals who have dieted a lot tend to have all-or-nothing beliefs like: 'Either I eat perfectly or the whole day's shot,' 'I shouldn't eat any cookies, but I caved and ate one, so I might as well eat the whole bag now' or 'I have zero self-discipline.' The therapist helps the client find the middle ground by practicing beliefs such as, "Every meal or snack is an opportunity to follow my meal plan – nobody eats perfectly.' The therapist might team with a dietitian to help the client follow a meal plan that includes one serving of cookies – instead of zero or the whole bag," Carter says.
Cognitive behavioral therapy also prioritizes developing a healthy body image, sense of worth and self-efficacy. "CBT helps patients adhere to self-monitoring tools like food diaries to modify diet and increase activity, the two hallmarks of weight loss," Shapiro says. "It helps to increase motivation, identify barriers to change, set realistic expectations about weight loss, learn triggers to unhealthy eating, improve stimulus control, regulate mindfulness skills, challenge distorted beliefs about food, weight and oneself that leads to eating, and practice self-soothing and self-regulation skills to cope with unpleasant feelings and prevent relapse."
Cognitive behavioral therapists typically offer treatment in both individual or group settings, with frequency and structure varying based on a patient's exact needs. An example of a traditional CBT protocol would involve weekly one-hour sessions over the course of two to three months, then biweekly sessions for six to 12 months, Carter says. Thereafter, periodic sessions can help to maintain progress.