Cognitive-Behavioral Therapy

The cognitive-behavioral theory (CBT) has its roots in the idea that thoughts and feelings precede actions, and that inaccurate thoughts drive unhealthy behaviors. The intention of CBT is to use cognitive techniques to challenge unhelpful or distorted thoughts while using behavioral techniques to reduce problematic behaviors. CBT focuses on current thinking, problematic behavior, precipitating factors, and developmental events. In addition, the approach requires active participation of the patient; it is goal oriented, problem focused, and structured while using many techniques to change distorted thinking, mood, and thus problematic behavior.

Specifically, in terms of disordered eating, patients are asked to maintain daily monitoring logs of foods eaten, eating disordered behaviors, thoughts, feelings, and details about the situation in which these behaviors occurred. Self-monitoring yields objective information [Page 149]that can be used with behavioral interventions such as cue recognition, desensitization, or reinforcement. It also reveals patterns of automatic thoughts (e.g., “I am fat,” “I can't eat this or I am weak,” “I blew it, now I might as well eat more”) that reflect broader core beliefs. Cognitive restructuring challenges these thoughts with rational alternatives. CBT is effective when beliefs change, automatic thoughts decrease, and problem behaviors are reduced.

CBT for weight control or obesity consists of core techniques including dietary recommendations, exercise, cognitive techniques, stimulus control, relapse prevention, and social support. Although weight loss is certainly the goal of treatment, weight is deemphasized as it is not a behavior per se, but a result of the behavior changes. Several important techniques are incorporated into this treatment.

Nutrition Education

It is important for patients to understand healthy versus unhealthy eating. Unhealthy eating consists of emotional eating (i.e., eating for any other reason than hunger including boredom, anger, frustration, excitement, etc.), eating in response to cravings or urges (which is also often linked to emotional reasons), and unhealthy dieting (either behaviorally via purging or restricting or psychologically in which dieting is conceptualized as a transitional time rather than a healthy permanent lifestyle change). Unhealthy dieting can result in physical problems (e.g., intense hunger, low energy, fatigue, headaches, visual problems, weight gain, electrolyte disturbance, dental problems, gastrointestinal problems), cognitive problems (e.g., focus on food, loss of interest, poor concentration, memory problems, difficulty with comprehension and decision making), and emotional problems (e.g., stress, irritability, and anxiety, depression). Individuals learn about healthy, balanced nutrition, to remain within a certain calorie range necessary for weight control/maintenance, and to consume three meals and approximately two or three planned snacks. Many individuals who overeat may resist eating during the day, which sets them up for overeating as they find their eating behavior out of control later in the day. Establishing a regular eating pattern includes setting meal times, not allowing greater than 3–4 hours between eating times, not skipping meals, and avoiding eating in between planned meal/snack times.

Self-Monitoring

Self-monitoring of energy intake is the hallmark of weight control interventions as it helps individuals understand their current eating patterns, so that they identify patterns that need to be changed. It also helps them learn about the nutritional value of individual foods, assists in planning meals, supports healthy food choices, and aids in helping individuals to avoid overeating or unhealthy eating given that they are being accountable. It also helps individuals notice their behavior changes and successes and observe the formation of new patterns.

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