Cognitive behavioural therapy for obesity: one-year follow-up in a clinical setting

Cognitive remediation-enabled cognitive behaviour therapy for obesity: a case series

PURPOSE

Despite varied treatment effects, weight recidivism is common and typically associated with the abandonment of prescribed weight management strategies. Literature suggests that difficulty with weight management is associated with deficits in executive functioning, in particular cognitive flexibility and response inhibition, the neurocognitive processes that are involved in goal-directed behaviours, such as dietary adherence. These processes are overlooked by mainstream weight loss programmes. The aim of the study was to assess the effectiveness of a cognitive remediation-enabled cognitive behaviour therapy (CR-CBT) in addressing the neurocognitive, psychological and behavioural correlates of weight loss. It was hypothesised that CR-CBT would improve cognitive flexibility and response inhibition, reduce binge eating, aid weight loss and improve metabolic health.

METHODS

Four adults with obesity (body mass index > 30 kg/m²) received 7 weeks of manualised CR-CBT and were assessed via a case series analysis at baseline, end of treatment and 3-month follow-up. Treatment included 3 weekly 90-min group-based behaviour weight loss sessions for 3 weeks, followed by twice-weekly 50-min individualised CR-CBT sessions for 4 weeks.

RESULTS

Cognitive remediation-enabled cognitive behaviour therapy produced improvements in response inhibition and cognitive flexibility, and reductions in binge eating frequency, weight, and metabolic health readings between baseline and 3-month follow-up.

CONCLUSIONS

This is the first study to assess the effectiveness of CR-CBT in the treatment of obesity. Preliminary indications of treatment success are discussed with respect to study limitations. In light of these results, we recommend further investigation via a randomised control trial (RCT).

LEVEL OF EVIDENCE

Level IV, case series.

Personalized group cognitive behavioural therapy for obesity: a longitudinal study in a real-world clinical setting

PURPOSE

Severe obesity is difficult to treat, and non-surgical treatment is not supported by robust evidence. The aim of the present study was to establish the immediate and longer-term outcomes following "personalized" form of group cognitive behavioural therapy for obesity (CBT-OB)-a new treatment designed to address specific cognitive processes that have been associated with attrition, weight loss, and weight maintenance in previous studies.

METHODS

Sixty-seven adult patients with obesity (body mass index (BMI) ≥ 30 kg/m²) were recruited from consecutive referrals to an Italian National Health Service obesity clinic. Each patient was offered 22 group sessions of CBT-OB (14 in the 6-month weight-loss phase and 8 in the subsequent 12-month weight-maintenance phase).

RESULTS

76.2% patients completed the treatment, with an average weight loss of 11.5% after 6 months (10% in the intention-to-treat analysis) and 9.9% (7.5% in the intention-to-treat analysis) after 18 months. Weight loss was associated with a significant reduction in cardiovascular risk factors, anxiety, depression, and eating disorder psychopathology, and an improvement in obesity-related quality of life.

CONCLUSIONS

These findings provide strong preliminary support for the use of CBT-OB for obesity in standard clinical settings, and justify its further evaluation in randomized controlled trials.

LEVEL OF EVIDENCE

Level III, longitudinal cohort study.

Combination of GLP-1 receptor agonists and behavioural treatment in type 2 diabetes elicits synergistic effects on body weight: A retrospective cohort study

AIMS

Intensification of type 2 diabetes (T2DM) treatment with GLP-1 receptor agonists (GLP-1RAs) promotes weight loss. We aimed to determine the synergistic effect of behavioural programmes on body weight on top of GLP-1RA treatment.

MATERIALS AND METHODS

We retrospectively analysed the time course of 328 individuals with T2DM starting GLP-1RA treatment because of insufficient metabolic control. In 29, a structured programme of elementary nutritional counselling was also implemented (elementary nutritional education [ENE]-5 group sessions), whereas 53 entered a programme of cognitive-behavioural treatment (CBT-12 group sessions). Both programmes were completed within 6 months of switching to GLP-1RAs. Data of body weight and metabolic control were followed up to 2 years as part of regular follow-up. Weight loss targets (≥10% and ≥5%) and metabolic target (HbA1c < 7%) were analysed by Cox regression model in comparison with standard care (SC, N = 244).

RESULTS

Body weight remarkably decreased following both behavioural programmes, with significant differences compared with SC at 2 years (CBT, 8.5 ± 5.9% vs 6.3 ± 6.9 in ENE and only 3.1 ± 5.7 in SC; P < 0.001 and P = 0.045 vs CBT and ENE, respectively). The 10% weight loss was achieved and maintained in approximately 30% of cases during follow-up, and an additional 35% of cases lost between 5% and 10%. Data were consistent between behavioural programmes, after adjustment for confounders, including initial body weight (logreg Mantel-Cox: ENE vs SC, P < 0.01; CBT vs SC, P < 0.001). No differences in metabolic control were detected between groups.

CONCLUSIONS

Initiation of GLP-1RA treatment provides an opportunity for addressing patients' needs of weight control. By producing initial weight loss, patients' motivation and self-efficacy are expected to increase and adherence to long-term lifestyle changes might be more easily attained.

Expected benefits and motivation to weight loss in relation to treatment outcomes in group-based cognitive-behavior therapy of obesity

PURPOSE

We aimed to determine cognitive drivers, expected to play a role in target reach and/or attrition in obesity programs.

METHODS

We recorded the expected benefits of weight loss, weight targets, primary motivation for weight loss, perceived treatment needs, readiness and self-confidence to be successful and a battery of psychopathology questionnaires in 793 subjects with obesity (68% women; mean age 48.7; 46% obesity class III) enrolled into a group-based cognitive-behavioral treatment program. Their relevance on attrition and successful weight loss outcome were tested by logistic regression analysis.

RESULTS

The expected benefits of weight loss scored very high in all physical, psychological and social areas, with differences between genders. Attrition rate was 24, 41 and 65% at 6-, 12-, and 24-month follow-up. Average weight loss was 5.8 ± 7.1 kg (- 4.8%) at 6 months, with 17% of cases (32% of continuers) maintaining weight loss > 10% at 24 months. After adjustment for confounders, attrition was reduced by concern for present health, motivation/consciousness of the importance of physical activity and need for support; treatment discontinuation was favored by concern for body image, by expectations for drug treatment or bariatric surgery, and by high-challenging weight loss targets. Male gender, higher BMI and concern for present health predicted weight loss > 10%, whereas concern for body appearance was associated with lower probability of attaining the desired weight loss targets.

CONCLUSION

A more precise definition of needs and expectations might help tailor treatment to individual patients, but attrition rates and target reach remain difficult to predict.

LEVEL OF EVIDENCE

Level V, descriptive studies.

State of the Art Reviews: Relationship Between Diet/ Physical Activity and Health

Obesity and 4 of the leading causes of death—heart disease, cancer, stroke, and type 2 diabetes mellitus—are related to lifestyle. The combination of a healthy weight, prudent diet, and daily physical activity clearly plays a role in primary, secondary, and tertiary prevention of these and other chronic diseases. Because nearly 65% of the adult population is overweight or obese, weight loss and maintenance are central to this review article. Improved lipid profiles, blood pressure, insulin sensitivity, and euglycemia are associated with weight loss or a normal body weight; thus, maintaining a healthy weight is a universal recommendation for health. The methods for improving lifestyle described in the section on obesity include assessing nutritional status and stages of change of the client, setting realistic goals, eating a diet high in fruits and vegetables with low-fat sources of dairy and protein, and achieving appropriate physical activity levels. The importance of physicians discussing weight with clients and vice versa is stressed. The common features of lifestyle-related diseases make them amenable to similar lifestyle interventions.

Obesity treatment: results after 4 years of a Nutritional and Psycho-Physical Rehabilitation Program in an outpatient setting

INTRODUCTION

Obesity is a chronic disease as well as a risk factor for cardiovascular, metabolic and osteoarticular diseases, affecting the psychosocial health and the quality of life. Recent evidence suggests that the adequate treatment of obesity should provide a multidimensional multidisciplinary approach including nutritional therapy, psycho-educational classes and physical reconditioning/motor rehabilitation. The aim of this approach should be to maintain the results over time with a positive impact on the obesity-related cardiovascular and metabolic risk.

AIM OF THE STUDY

To evaluate the effectiveness of a multidisciplinary Nutritional and Psycho-Physical Reconditioning Program (NPPRP) in an outpatient setting.

MATERIALS AND METHODS

The observational prospective cohort study involved subjects, aged from 18 to 65 years, with a BMI >30 kg/m(2), who were followed up over 48 months. After the first nutritional and psychological examination, patients who refused NPPRP were treated according to standard nutrition procedures (SNT). Patients were followed through monthly medical examinations and then by annual telephonic structured interviews for 4 years. Changes in body weight, eating behavior, physical activity performance, and the occurrence of clinical obesity-related complications were considered as outcome measures.

RESULTS

Of 464 enrolled patients, 161 (34.7%) took part in the follow-up. From the enrollment to the end of follow-up, weight loss was greater in the NPPRP group than in the SNP group (-8.08 ± 10 kg versus -3.0 ± 6 kg). After 4 years eating behavior improved in both groups. The percentage of patients who continued to perform physical activity was higher in the NPPRP group than in the SNT group (61.0 versus 34.1%). The SNT group reported complications more frequently than the NPPRP group: hypertension (19 versus 5.8%), dyslipidemia (19.4 versus 12.7%), and skeletal problems (26.9 versus 17.5%). The main reasons for drop-out from the rehabilitation program were logistic problems (distance or time) in both groups; disappointment was higher in the SNT group than in the NPPRP group (37.8 versus 15.6%).

CONCLUSION

A multidimensional multidisciplinary approach including nutritional intervention and psycho-physical rehabilitation, set against a conventional diet therapy, was more effective in the long-term outcome of obesity with regard to weight loss, physical activity, possible eating disorders, and obesity-related complications.

Optimizing patient education for people with obesity: possible use of the autobiographical approach

OBJECTIVE

To review recent results of the current approaches to the education of obese people, focusing on the motivation for healthy behaviors, and to present the narrative-autobiographical approach as a possible tool in the education of obese people.

METHODS

Our overview will necessarily be partial, and limited to some studies that succeeded in improving the motivation for healthy lifestyles in people with overweight or obesity. We will also describe the use of the autobiographical approach in the "Io-muovo-la-mia-vita" project.

RESULTS

Many studies have induced relevant behavioral changes, mainly by using intensive interventions. Weight loss maintenance has been difficult and usually has required pro-active follow-up interventions. The use of self-writing may allow overweight and obese people to reveal their inner feelings to themselves and to peers, and may reinforce their motivation for self-care.

CONCLUSIONS

The association of weight loss with intensive interventions, and the need for follow-up pro-active interventions to maintain results make one wonder whether the inner motivation of participants is usually fostered as recommended.

PRACTICE IMPLICATIONS

The narrative-autobiographical approach appears to be a proper way to patient centered care, but for an effective practice, the human and relational attitudes of healthcare professionals should be integrated with specific educational skills.

Are behavioural approaches feasible and effective in the treatment of type 2 diabetes? A propensity score analysis vs. prescriptive diet

BACKGROUND AND AIMS

Lifestyle changes are considered first line treatment in type 2 diabetes, but very few data are available in the "real world" of diabetes units. We aimed to measure the effectiveness of moderate and high intensity interventions on weight loss, metabolic control and insulin use. We report a prospective cohort study, carried out in 822 consecutive subjects with type 2 diabetes, first seen in a 4-year period in a diabetes unit of an academy hospital.

METHODS AND RESULTS

Subjects were treated with either a sole prescriptive diet (Diet), or received an additional short-course Elementary Nutritional Education (4 group sessions-ENE) or an intensive Cognitive Behavioural Therapy (12-15 group sessions-CBT). The results were adjusted for the propensity score to be assigned different treatments, derived from logistic regression on the basis of age, gender, BMI, HbA1c, diabetes duration and insulin use at baseline. Main outcome measures were weight loss and weight loss maintenance, metabolic control, and secondary failure to insulin use. Both structured programmes produced a larger weight loss, and the adjusted probability of achieving the 7% weight loss target was increased. Similarly, both programmes favoured metabolic control, irrespective of insulin use. After adjustment for propensity score, both ENE (hazard ratio, 0.48; 95% CI, 0.27-0.84) and CBT (hazard ratio, 0.36; 95% CI, 0.16-0.83) were associated with a reduced risk of de novo insulin treatment.

CONCLUSION

Structured behavioural programmes aimed at lifestyle changes are feasible and effective in the "real world" setting of a diabetes unit for the treatment of type 2 diabetes.

State of the Art Reviews: Relationship Between Diet/ Physical Activity and Health

Obesity and 4 of the leading causes of death—heart disease, cancer, stroke, and type 2 diabetes mellitus—are related to lifestyle. The combination of a healthy weight, prudent diet, and daily physical activity clearly plays a role in primary, secondary, and tertiary prevention of these and other chronic diseases. Because nearly 65% of the adult population is overweight or obese, weight loss and maintenance are central to this review article. Improved lipid profiles, blood pressure, insulin sensitivity, and euglycemia are associated with weight loss or a normal body weight; thus, maintaining a healthy weight is a universal recommendation for health. The methods for improving lifestyle described in the section on obesity include assessing nutritional status and stages of change of the client, setting realistic goals, eating a diet high in fruits and vegetables with low-fat sources of dairy and protein, and achieving appropriate physical activity levels. The importance of physicians discussing weight with clients and vice versa is stressed. The common features of lifestyle-related diseases make them amenable to similar lifestyle interventions.

Weight loss expectations in obese patients and treatment attrition: an observational multicenter study

OBJECTIVE

To investigate the influence of weight loss expectations (expected 1-year BMI loss, dream and maximum acceptable BMI) on attrition in obese patients seeking treatment.

RESEARCH METHODS AND PROCEDURES

Obese subjects (1,785; 1,393 women; median age, 46 years; median BMI, 36.7 kg/m(2)) seeking treatment in 23 medical Italian centers were evaluated. Baseline diet and weight history, weight loss expectations, and primary motivation for seeking treatment (health or improving appearance) were systematically recorded. Psychiatric distress, binge eating, and body image dissatisfaction were tested at baseline by self-administered questionnaires (Symptom Check List-90, Binge Eating Scale, and Body Uneasiness Test). Attrition and BMI change at 12 months were prospectively recorded.

RESULTS

At 12 months, 923 of 1,785 patients (51.7%) had discontinued treatment. Compared with continuers, drop-outs had a significantly lower age, a lower age at first dieting, lower dream BMI, a higher expected 1-year BMI loss, and a higher weight phobia. At logistic regression analysis, the strongest predictors of attrition at 12 months were lower age and higher expected 1-year BMI loss. The risk of drop-out increased systematically for unit increase in expected BMI loss at 12 months (hazard ratio, 1.12; 95% confidence interval, 1.04 to 1.20; p = 0.0018). The risk was particularly elevated in the first 6 months.

DISCUSSION

Baseline weight loss expectations are independent cognitive predictors of attrition in obese patients entering a weight-losing program; the higher the expectations, the higher attrition at 12 months. Unrealistic weight goals should be tackled at the very beginning of treatment.

A physical activity program to reinforce weight maintenance following a behavior program in overweight/obese subjects

OBJECTIVE

To investigate the effects of a specific program to implement physical activity (fitness program) on weight loss maintenance, activity level and resting energy expenditure (REE).

DESIGN

Observational study of subjects completing a behavioral program.

SUBJECTS

In total, 200 overweight/obese subjects (36 males, aged 20-66 years; average BMI, 35.2 kg/m2). Program and measurements:The fitness program consisted of 12 bimonthly sessions, chaired by doctors and dietitians, involving groups of 8-12 subjects. Patients entered the program approximately 9 months after the end of behavioral treatment, during a weight loss maintenance period. The goal was set at a light-to-moderate daily physical activity (brisk walking), quantitatively measured by a pedometer; REE was measured before and after the fitness program by indirect calorimetry in a subset of patients.

RESULTS

The fitness program restarted the process of weight loss in over 60% of subjects. At the end of the study, 84% of patients walked at least 5000 steps per day, compared with 24% at the beginning of the study. The probability of losing from 5 to 10% of initial body weight increased by 20% for any 1000 steps/day (OR, 1.20; 95% CI (confidence interval), 1.07-1.35), and that of losing more than 10% by over 30% (OR, 1.33; 95% CI, 1.19-1.49). REE increased significantly by 100 kcal/day (+7.5%), in spite of further weight loss (-1.8%).

CONCLUSION

A specific fitness program in the weight maintenance phase after a behavioral program may significantly improve the long-term control of obesity.

A short-term cognitive group treatment program gives substantial weight reduction up to 18 months from the end of treatment. A randomized controlled trial

OBJECTIVE

To describe and evaluate long-term efficacy (18 months from the end of treatment) of a new cognitive short-term weight reducing treatment program for obese patients.

SUBJECTS

One hundred and five obese [Body Mass Index (BMI) > or = 30] patients participated in the study. Of these, 62 took part in the treatment program and 43 served as controls.

METHOD

From an obesity unit's waiting list, the patients were randomly assigned to either a treatment group or remained in the waiting list to serve as a control group. The treatment group participated in a 10-week (30 hours) cognitive group treatment program. All participants were weighed at the outset of the study, directly after treatment and at a 6-, 12- and 18-month post-treatment follow-up without any booster treatment after the 10-week program.

RESULTS

Fifty-seven (92%) patients completed treatment. For the 34 (60%) patients who participated in the study 18 months after treatment was terminated, the mean weight loss at treatment's end was 8.5 kg (SD=16.1). Eighteen months later their mean weight loss was 10.4 kg (SD=10.8). The control patients (n=31.72%) that participated in the study during the same period increased in weight by 2.3 kg (SD=7.0). The weight difference between the treatment and control group at the 18-month follow-up was highly significant (p<0.001).

CONCLUSION

The cognitive group treatment program was highly acceptable among the participants and was completed by nearly all the patients. The 10-week treatment program resulted in satisfactory weight loss. The weight difference between the treatment group and controls was nearly the same at 18 months after end of treatment as at six months. The study, therefore, does not provide support for the contention that a lengthy therapy for obesity is necessary if treatment results are lasting.