Treating Obesity with Personalized Cognitive Behavioral Therapy

251 Pages·2018·3.405 MB·English

by  Riccardo Dalle Grave, Massimiliano Sartirana, Marwan El Ghoch, Simona Calugi

Treating Obesity with
Personalized Cognitive
Behavioral Therapy
Riccardo Dalle Grave
Massimiliano Sartirana
Marwan El Ghoch
Simona Calugi
123
Treating Obesity with Personalized
Cognitive Behavioral Therapy
Riccardo Dalle Grave • Massimiliano Sartirana
Marwan El Ghoch • Simona Calugi
Treating Obesity with
Personalized Cognitive
Behavioral Therapy
Riccardo Dalle Grave Massimiliano Sartirana
Department of Eating and Weight Disorders Department of Eating and Weight Disorders
Villa Garda Hospital Villa Garda Hospital
Garda (VR) Garda (VR)
Italy Italy
Marwan El Ghoch Simona Calugi
Department of Eating and Weight Disorders Department of Eating and Weight Disorders
Villa Garda Hospital Villa Garda Hospital
Garda (VR) Garda (VR)
Italy Italy
ISBN 978-3-319-91496-1 ISBN 978-3-319-91497-8 (eBook)
https://doi.org/10.1007/978-3-319-91497-8
Library of Congress Control Number: 2018945488
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Preface
This book provides a detailed description of a new personalised cognitive behav-
ioural therapy for obesity, termed “CBT-OB”. The treatment has been developed to
help patients reach and maintain a healthy weight loss by combining strategies and
procedures derived from traditional behavioural therapy for obesity (BT-OB) with
others targeting the cognitive processes that our research has found to influence
attrition, weight loss and weight-loss maintenance.
CBT-OB has been primarily designed for outpatient settings in which patients
with obesity are treated on a one-to-one basis, but it has subsequently also been
adapted for delivery in a group setting, as well as for patients with binge-eating
disorders (BED) associated with obesity. This versatile treatment can be delivered
within a multistep approach that can be applied, with appropriate adaptation, at
three levels of care—outpatient, day hospital and residential settings. What is more,
it can be effectively used to treat all classes of obesity, including patients with severe
comorbidities and obesity-associated disabilities—who are not generally recruited
for lifestyle modification trials, and therefore have limited non-surgical evidence-
based treatment options. Importantly, however, it can be used in conjunction with
other proven treatment strategies such as weight-loss drugs and bariatric surgery.
CBT-OB adopts some principles of the so-called enhanced cognitive behavioural
therapy (CBT-E)—an evidence-based treatment for all eating disorders. Indeed, our
consolidated clinical experience of treating many patients with eating disorders has
shown that many problems that CBT-E enables us to successfully address in patients
with bulimia nervosa and other eating disorders overlap with those seen in patients
with obesity. Specifically, these include the difficulties patients have in playing an
active role in their own treatment, their loss of control over eating, dissatisfaction
with shape and weight and unhealthy preoccupation with eating. As such, many
principles of CBT-E were exploited in the design of CBT-OB, in particular the col-
laborative style of treatment, the general structure of the sessions, the strategies
used to encourage patients’ active participation in their own treatment and lifestyle
change and to overturn their negative body image, as well as procedures to address
episodes of binge eating where appropriate (in patients with BED). Like CBT-E,
CBT-OB is also flexible, modular and personalised.
The book has been written in the form of a clinician’s manual. The major con-
tributors come from different clinical backgrounds—specifically two medical doc-
tors and two clinical psychologists—but all can be described as experts in delivering
v
vi Preface
CBT-OB in real-world clinical settings, from outpatient to residential. In order to
aid the practitioner, the treatment is described in detail, from the first assessment
session through to the post-treatment review. Clinical vignettes are included to illus-
trate important points, and strategies for personalising the intervention and adapting
it to an individual patient’s needs and particular settings are discussed.
We have endeavoured to make this book of interest to all professionals working
with patients with obesity, whether physicians, dieticians, nutritionists, psycholo-
gists, psychiatrists, nurses or physical educators and more. It is particularly suitable
for healthcare professionals working as part of a multidisciplinary team that wishes
to adopt an evidence-based, non-eclectic, stepped-care approach to the treatment of
obesity, grounded in cognitive behavioural theory.
Although no specific professional qualifications are required to practice CBT-OB,
potential therapists should ideally have had some training in cognitive behavioural
therapy, as well as clinical experience of treating patients with obesity. Most thera-
pists with these two prerequisites will be able to practice CBT-OB successfully
using the strategies and procedures described in this book.
That being said, and though extensive cross-referencing has been included to
help readers navigate the concepts with ease, it is advisable for readers to approach
the book as a whole, as each sequential chapter assumes knowledge of the content
of those which have come before. As such, the book is structured as follows:
• Chapter 1 describes the problems associated with the current treatments for obe-
sity, in particular the neglected role of cognitive processes. It then goes on to
summarise the data obtained from our extensive clinical research on the cogni-
tive factors associated with attrition, weight loss and weight maintenance.
• Chapter 2 provides a general overview of CBT-OB. It outlines its goals, general
strategies and specific procedures designed to promote weight loss and minimise
attrition. It also describes the different versions of CBT-OB, highlights certain
points regarding the respective roles of patient and therapist in the treatment and
explains how the environment in which treatment is provided can best be
organised.
• Chapter 3 explains how patients should be assessed and prepared for treatment.
It also provides some advice to non-medical therapists on the medical manage-
ment of patients.
• Chapters 4–9 describe the core protocols of CBT-OB and details of how to
implement the six programme modules.
• Chapter 10 illustrates the importance of the involvement of significant others in
the sessions and how to help patients receive support from family members and
others in their social circle.
• Chapters 11–14 describe, respectively, how to adapt CBT-OB for group treat-
ment, intensive levels of care, and patients with BED and how CBT-OB can be
combined with weight-loss drugs and bariatric surgery.
• Chapter 15 provides suggestions on how to exploit modern technology in deliv-
ering treatment and training CBT-OB therapists.
Preface vii
• Appendices A–E provide useful handouts for clinicians, including the CBT-OB
Monitoring Record and the Personal Formulation template, as well as CBT-OB
menus and food group information sheets, and the latest versions of the Weight-
Loss Obstacles Questionnaire and Weight and Primary Goals Questionnaire (see
Chaps. 6–10 for details).
Before moving on, we would like to take this opportunity to thank our brilliant
colleagues whose ideas inspired us to write this book. In particular, we thank Kelly
Brownell for his pioneering work incorporating the principle of behaviour modifica-
tion in the treatment of obesity in a comprehensive manual, Giulio Marchesini for
his fundamental role in the research we performed together on the cognitive factors
influencing the treatment of obesity and, especially Zafra Cooper and Christopher
Fairburn, who were the first not only to underscore the importance of cognitive
processes in hindering the treatment of obesity, but also to propose a treatment
based on the cognitive behavioural precepts from which we derived many of the
principles described in this book. We also wish to thank all of the colleagues—too
numerous to mention—who work with us in our outpatient and intensive CBT-OB
clinics for their enthusiasm, the passion and dedication with which they help patients
with obesity to address their individual problems and for their continuous precious
feedback, much of which has helped to improve the treatment. Particular thanks are
also due to Anna Forster for her assistance and competence in editing the English
text and to Elena Mischiatti for her help in producing the figures. Last but not least,
we would like to extend special thanks to the patients we have had the privilege to
treat; they also made invaluable suggestions that enabled us to become better thera-
pists and to perfect the treatment that we present in this book.
Garda (VR), Italy Riccardo Dalle Grave
Massimiliano Sartirana
Marwan El Ghoch
Simona Calugi
Contents
1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 Current Treatments for Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.1 Biomedical Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1.2 Behavioural Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.1.3 Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1.4 Summary of the Main Problems Associated
with Current Treatments for Obesity . . . . . . . . . . . . . . . . . . . 4
1.2 The Neglected Role of Cognitive Processes . . . . . . . . . . . . . . . . . . . 4
1.2.1 Cognitive Factors and Attrition . . . . . . . . . . . . . . . . . . . . . . . 5
1.2.2 Cognitive Factors and Weight Loss . . . . . . . . . . . . . . . . . . . . 7
1.2.3 Cognitive Factors and Weight-Loss Maintenance . . . . . . . . . 7
1.2.4 Summary of Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.3 From BT-OB to CBT-OB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 Treatment Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.1 Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2 Strategies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2.1 General Strategies and Procedures . . . . . . . . . . . . . . . . . . . . . 14
2.2.2 Strategies and Procedures for Minimising Attrition . . . . . . . 15
2.2.3 Strategies and Procedures for Enhancing Weight Loss . . . . . 17
2.2.4 Strategies and Procedures for Improving
Weight-Loss Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.3 The Versions of CBT-OB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.4 The Role of the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.5 The Role of the Therapist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.6 The Office Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.7 The Effectiveness of CBT-OB . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3 Preparatory Phase. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1 Developing a Collaborative and Trusting Relationship . . . . . . . . . . . 27
3.2 Assessing the Nature and Severity of Obesity . . . . . . . . . . . . . . . . . . 28
ix
x Contents
3.3 Assessing the Indications and Contraindications to Weight Loss . . . 31
3.4 Engaging the Patient in the Treatment . . . . . . . . . . . . . . . . . . . . . . . . 32
3.4.1 Adopting an Engaging Style . . . . . . . . . . . . . . . . . . . . . . . . . 32
3.4.2 Educating the Patient on Obesity and CBT-OB . . . . . . . . . . . 33
3.4.3 Involving the Patient Actively in the Decision to Change . . . 35
3.4.4 Assessing the Patient’s Readiness to Change . . . . . . . . . . . . 36
3.4.5 Assessing Whether a Patient Will Make
the Programme a Priority . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.4.6 “To Lose Weight or Not to Lose Weight” Questionnaire . . . . 37
3.4.7 Assessing the Involvement of Significant Others . . . . . . . . . 38
3.5 Addressing Concerns and Questions About the Treatment . . . . . . . . 39
3.6 Assessment Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.7 Medical Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.7.1 Points for Non-medical Therapists to Keep in Mind . . . . . . . 42
3.7.2 Recommended Medical Tests . . . . . . . . . . . . . . . . . . . . . . . . 42
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4 Module 1: Monitoring Food Intake, Physical Activity
and Body Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1 Explaining What the Treatment Will Involve. . . . . . . . . . . . . . . . . . . 45
4.2 Educating on Energy Balance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4.3 Initiating Real-Time Monitoring of Food Intake
and Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
4.3.1 Addressing Concerns and Questions About
Self-Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.4 Establishing Weekly Weighing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
4.5 Bringing the Session to a Close . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
5 Module 2: Changing Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.1 In-Session Weighing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
5.2 Reviewing Records and Other Homework . . . . . . . . . . . . . . . . . . . . . 59
5.3 Introducing the Change in Eating . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
5.3.1 Planning Ahead When, What and Where to Eat . . . . . . . . . . 61
5.3.2 Continuing Real-Time Monitoring of Food Intake . . . . . . . . 69
5.3.3 Eating Consciously . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5.3.4 Addressing Concerns and Questions About
Meal Planning, Real-Time Monitoring
and Eating Consciously . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5.4 Bringing the Session to a Close . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
6 Module 3: Developing an Active Lifestyle . . . . . . . . . . . . . . . . . . . . . . . 75
6.1 Preparing the Patient for an Active Lifestyle . . . . . . . . . . . . . . . . . . . 75
6.1.1 Assessing a Patient’s Eligibility for Exercise . . . . . . . . . . . . 76
6.1.2 Assessing the Patient’s Functional Exercise Capacity . . . . . . 76
6.1.3 Strategies for Motivating Patients to Exercise . . . . . . . . . . . . 77
Contents xi
6.2 Types of Exercise Recommended by CBT-OB to Increase
Levels of Physical Activity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
6.2.1 Strategies for Developing an Active Lifestyle . . . . . . . . . . . 80
6.2.2 Strategies for Improving Physical Fitness . . . . . . . . . . . . . . 82
6.2.3 Strategies for Continuing or Commencing
Formal Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
6.3 Strategies for Increasing a Patient’s Adherence to Exercise . . . . . . 84
6.3.1 The Problem of Adherence to Exercise . . . . . . . . . . . . . . . . 84
6.3.2 Tailoring Activity Goals to Individual Patients . . . . . . . . . . 85
6.3.3 Goal Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.3.4 Self-Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.3.5 Responding to Non-adherence . . . . . . . . . . . . . . . . . . . . . . . 86
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
7 Module 4: Addressing Obstacles to Weight Loss . . . . . . . . . . . . . . . . . 89
7.1 Educating Patients on Cognitive Behavioural
Weight-Loss Obstacles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
7.1.1 Antecedent Stimuli. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
7.1.2 Positive Consequences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
7.1.3 Problematic Thoughts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
7.2 Introducing the Weight-Loss Obstacles Questionnaire . . . . . . . . . . 92
7.3 Creating the Personal Formulation . . . . . . . . . . . . . . . . . . . . . . . . . 93
7.4 Addressing Weight-Loss Obstacles . . . . . . . . . . . . . . . . . . . . . . . . . 99
7.4.1 Reducing Environmental Stimuli . . . . . . . . . . . . . . . . . . . . . 99
7.4.2 Addressing Events Influencing Eating
and Physical Activity Habits . . . . . . . . . . . . . . . . . . . . . . . . 102
7.4.3 Addressing Impulses and Emotions Influencing
Eating and Physical Activity Habits. . . . . . . . . . . . . . . . . . . 105
7.4.4 Addressing Problematic Thoughts . . . . . . . . . . . . . . . . . . . . 106
7.4.5 Addressing the Use of Food as a Reward . . . . . . . . . . . . . . 107
7.4.6 Addressing the Patient’s Rational Excuses
for Not Adopting an Active Lifestyle . . . . . . . . . . . . . . . . . 113
7.5 Getting Back on Track . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8 Module 5: Addressing Weight-Loss Dissatisfaction . . . . . . . . . . . . . . . 117
8.1 Detecting Weight-Loss Dissatisfaction and General
Strategies to Address It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
8.2 Identifying Reasons for Weight-Loss Dissatisfaction . . . . . . . . . . . 118
8.3 Which Reasons for Weight-Loss Dissatisfaction
to Address First? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
8.4 Addressing Unrealistic Weight Goals . . . . . . . . . . . . . . . . . . . . . . . 120
8.4.1 Educating the Patients on Body Weight Regulation . . . . . . 120
8.4.2 Questioning the Desired Weight . . . . . . . . . . . . . . . . . . . . . 121
8.4.3 Reviewing the Causes of Poor Weight-Loss
Maintenance in Previous Attempts . . . . . . . . . . . . . . . . . . . 122