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Sunday, October 31, 2010

To Lose Weight and Keep it Off, Try a Psychological Intervention

The epidemic of obesity in the US has recently been publicized in shows like “The Biggest Loser”  and “One Nation, Overweight.” In 2007-8, 34% of the US adult population was overweight and 34% was obese, according to figures from the Centers for Disease Control.  Among children and adolescents age 5 and older, the figures were 18 -20%. Being overweight, especially having excess abdominal fat and insulin resistance, the so called “metabolic syndrome,” conveys increased risk for Type II diabetes, high blood pressure, and heart attack or stroke.  There is also evidence from research studies that for many people, dieting alone doesn’t work for long-term weight loss. In one study, less than 20% of obese participants were able to lose 5% body weight and keep it off for 5 years. One reason for this regain seems to be our bodies’ natural tendencies to maintain body weight when food is scarce to prevent starvation.  Thus, dieting can slow metabolism, requiring further calorie restriction to lose weight.  Severe calorie restriction causes negative psychological effects, including depression, anxiety, irritability, obsessive thoughts about food,  binge-eating, and not feeling full even after a binge. 
As psychologists and counselors, we have much to contribute in the weight loss arena.  It is becoming increasingly clear from recent research that weight and eating are complex, incorporating biological vulnerability, activity level, diet, and behavioral and emotional factors. The most effective weight loss programs are those that combine diet, exercise, and psychological intervention. According to the Cochrane review, which synthesizes results of the most recent methodologically sound research, increasing the length or intensity of the psychological intervention significantly improves patient outcomes. In the future, we will see psychological interventions increasingly becoming the state of the art in weight loss treatment.


Cognitive Therapy for Weight Loss
Two innovative psychological interventions that have preliminary research support are Dr Judith Beck’s Cognitive Therapy for Weight Loss and Dr Jean Kristeller’s MB-EAT or Mindfulness-Based Eating Awareness Therapy. Cognitive Therapy is based on traditional Cognitive-Behavioral principles of planning what to eat, scheduling one’s day to include food shopping and mealtimes, arranging the environment to support weight loss and planning for “high-risk’ situations, such as a friend’s birthday party. The program also includes daily reading of written weight loss goal cards and countering counterproductive thoughts about food, such as “I deserve this piece of cake” or “I’ll never lose the weight.” In a Swedish study, the group randomized to receive Cognitive Therapy lost more weight and kept it off over the next 18 months, while those assigned to a waiting list gained weight over the same period.  

Mindfulness-Based Approach
MB-EAT  is based on the Mindfulness approach developed by Dr John Kabat-Zinn at Harvard and focuses on developing “innate wisdom” about food and appetite. Mindfulness exercises teach participants to tune into their own bodily cues of hunger and satiety as well as what specific taste or texture they are hungry for. There is also a behavioral exposure component in which participants expose themselves to increasingly tempting situations, including going to a buffet. The focus is on satisfying and pleasurable eating, rather than restriction.   A study of obese people and binge-eaters given MB-EAT showed that this intervention was more successful than a control condition at reducing emotional eating, and depression.  Dr Kristeller is currently conducting a study adding nutritional advice to MB-EAT to enhance the weight loss component.  
Biological Factors
It is also important to keep in mind that the factors maintaining excess weight are different for different people, which is why there can never be a “magic bullet” weight loss cure that works for everybody, despite advertiser’s claims.  A study conducted in Spain and published in the Journal of Clinical Endocrinology and Metabolism suggests that the hormonal biomarkers leptin and ghrelin were able to identify obese people more likely to regain weight after dieting. It is as if their brains were more resistant to hormonal signals of fullness.  Other studies have shown that people prone to emotional eating, that is eating in response to depression or anxiety, are also more likely to regain weight. There is a research base suggesting a link between abuse and attachment problems and obesity. Environmental factors such as poverty, lack of access to healthy food and exercise facilities, lack of time, and cultural practices also play a part in the weight loss and fitness picture.
Final Thoughts
As clinical psychologists and counselors working with overweight or obese patients, it is important to know about the research regarding weight loss and maintenance so we can individualize treatment to our clients’ lifestyles, biological makeup, and emotional and environmental factors, use approaches that have research support. We should also keep in mind the importance of working collaboratively with other professionals, such as exercise trainers, dieticians, and doctors, to most effectively help the patient. The rewards of this work are that you can teach people new healthy lifestyles that should help to prolong their lives.
Melanie Greenberg, Ph.D. is a Clinical and Health Psychologist in private practice in Mill Valley, CA. For more information about me, visit my goodtherapy.org profile, my website at www.melanieagreenbergphd.com or my blog at http://marinpsychologist.blogspot.com/.
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