Sept 25, 2013 Integrated Care Conference

1. Sept 25, 2013 Integrated Care Conference Cognitive Behavioral Therapy for Weight Loss Janelle W. Coughlin, Ph.D.Department of Psychiatry and Behavioral SciencesDirector, Obesity Behavioral MedicineAssociate Director, Center for Behavior and Health

2. Objectives • To review briefly the obesity epidemic, its consequences, and the relationship between obesity and mental illness • To summarize obesity treatment, with an emphasis on traditional behavioral treatment • To provide an overview of cognitive-behavioral therapy (CBT) for obesity (and weight-related behaviors)

3. What is Obesity?

4. Causes of Obesity

5. Obesity: Medical and Financial Consequences • Medical Comorbidities • Coronary heart disease • Type 2 diabetes • Cancers (endometrial, breast, and colon) • Hypertension • Dyslipidemia • Stroke • Liver and Gallbladder disease • Sleep apnea and respiratory problems • Gynecological problems (abnormal menses, infertility) • Pain conditions • Medical Expenditures • $147 billion in 2008 (Finkelstein et al., 2009)

6. Prevalence of obesity among adults aged 20 and over by sex and age: United States, 2009–2010 Prevalence of obesity among adults aged 20 and over, by sex and age: United States, 2009–2010 Ogden et al., 2012

7. What about obesity and mental health? • Individuals with serious mental illness (SMI) have an extremely high prevalence of obesity • Nearly twice that of the overall population Allison et al., 2009; Dickerson et al., 2006

8. Obesity and Mental Health • Those with SMI have increased weight-related conditions • Mortality rates are 2-3 times higher in SMI as compared to the overall population Bresee et al., 2010; Carney et al., 2006; Himelhoch et al., 2004

9. Causes of Obesity in SMI? • Less active than the general population • Dietary behaviors in comparison to general population: • Higher fat intake • Less fruits and vegetables • Higher overall caloric intake • Medication side effects • Psychological factors/comorbidities Amani, 2007; Compton et al., 2006; Daumit et al. 2004; Jerome et al., 2009; McCreadie, 2003; Strassnig et al., 2003

10. Psychiatric Disorders Associated with Obesity • Binge Eating Disorder (BED) • recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances, with episodes marked by feelings of lack of control. • eating quickly, often in absence of hunger; feelings of guilt, embarrassment, or disgust, binge eating alone to hide the behavior; marked distress • occurs, on average, at least once a week over three months. APA, DSM-5

11. Psychiatric Conditions Associated with Obesity • Night Eating Syndrome (NES) • evening hyperphagia (ingestion of at least 25% of daily calories after supper) • awakenings with ingestions at least three times a week • awareness and recall of the eating • associated with significant distress and/or impairment in functioning Stunkard, 2008

12. CBT for BED and NES

13. Surgery BMI Pharmacotherapy Lifestyle Modification Diet Physical Activity Obesity Treatment Pyramid

14. Dietary Approaches to Lifestyle Modification • Calorie Deficit • ~1200-2000 kcal/d • Dietary Approaches: • Low-fat • Low-carbohydrate • Mediterranean • Low-glycemic load • Portion-controlled diets

15. Increasing Physical Activity • > 180 m/wk MVPA for weight loss • Must also include caloric restriction • Associated with a number of health improvements, independent of weight loss • Can be performed in short bouts • Increasing other lifestyle activities is also effective • > 2000 steps for weight loss; > 6000 to avoid regain • Critical for long-term weight loss maintenance • ~ 60 m/d MVPA

16. Lifestyle Modification Interventions for Obesity Self-monitoring Goal Setting Stimulus control Problem solving Increase self-efficacy and social support Relapse Prevention

17. Short-Term Outcomes • Lifestyle modification programs typically produce 7 to 10% reduction in initial weight in 6 months • Generally sustained at one year with ongoing, regular maintenance therapy

18. Weight Loss Maintenance • Patients gain ~ 1/3 of their lost weight in the year following treatment • Nearly half return to their original weight within 5 yrs • 1:6 adults accomplish > 1 yr of maintaining > 10% of IBW • Weight loss maintenance interventions can decrease the chance of weight regain

19. Appel et al, NEJM 2011;365:1959-68 *P <0.001 (vs control)

20. The ACHIEVE Trial Daumit et al., 2013

21. The ACHIEVE Trial Daumit et al., 2013

22. Adding cognitive therapy to standard treatment is associated with less relapse in obesity Werrij et al., 2009

23. What is Cognitive-BehavioralTreatment of Obesity • Assigns central importance to cognitive processes that maintain a problem • For lasting change to occur, maintaining mechanisms need to be modified • Utilize cognitive and behavioral procedures to change the maintaining mechanisms • Primary aim is to produce cognitive change • Behavioral experiments and cognitive restructuring are central Cooper, Fairburn & Hawker, 2003

24. Assess • Motivation: • How are weight, dietary behaviors, and inactivity interfering with: • What patient wants to do? How patient feels? Health? • History • Current Behavior: • Dietary and PA Assessment • Logs • Pros and cons of treatment; potential barriers; strengths; support; expectations

25. Self-Monitoring *Excessive, LOC, hunger, etc.

26. Self-Monitoring * Excessive, LOC, hunger, fullness, etc.

27. Circumstances • Who am I with? • What am I thinking? • What is going on? • What do I really want right now? • Where am I and how do I feel about this place? • When am I eating? You should be recording the date and time in the appropriate section, but here you can record more detail about what is going on. (I am eating when everyone else goes to bed) • Why am I eating? • How am I feeling physically? (I am in pain, I am tired) emotionally? (Do any of these words apply at the time of or right before this meal: bored, depressed, lonely, anxious, angry, guilty?)

28. Self-monitoring • To weigh or not to weigh? • Calories vs. no calories • Behaviors vs. calories • Provide an instruction sheet • Portions, etc. • When to introduce “circumstances” • Meals in brackets. • Include start and stop time of meal. • State simply the foods or beverages you consumed. • As much as possible, include portions. For example, if you have pizza include number of slices or state if something was a pre-portioned meal (e.g., Lean Cuisine). Often labeling of a product will give information about what the manufacturer considers a serving size for that particular food. • It is fine to use terms like “1 handful”, “2 serving spoons”, or “the size of a deck of cards” to estimate portions. • Include both caloric and non-caloric beverages. • Include whether you are using a low-fat version of a particular fool (e.g., skim milk) • Try to also record condiments like mayo or sugar packets.

29. Self-Monitoring

30. Regulate Eating Schedule • No skipping meals • 3 meals vs. 3 meals/2 snacks vs. 6 smaller meals • Eat breakfast • Eat around same time every day

31. Comprehensive Diary

32. Comprehensive Diary

33. Weight Maintenance • Reasons I do not want to regain • Good habits to keep up (eating) • Good habits to keep up (activity) • Danger areas to be aware of • Plan for monitoring • When to act Cooper, Fairburn & Hawker, 2003

34. Conclusions • Obesity is a serious pubic health problem, particularly among those with SMI • Lifestyle Modification is the cornerstone of all obesity treatments • Cognitive-behavioral therapy can help with more sustained change

35. Thank you jwilder3@jhmi.edu