Traditional behavioral therapy is one of the Four Pillars. Depending on your practice environment, you may have access to a multidisciplinary team to address the behavioral component of obesity treatment. If not, you must be prepared to refer for behavioral therapy or add that skill set to your toolkit. Traditional behavioral therapy for obesity starts with the following educational components: obesity as a disease, overall management of physical and mental health, nutrition, physical activity, sleep, and stress management. It also involves teaching the skills of stimulus control, cognitive restructuring, goal setting, self-monitoring, problem-solving, and building a social support network. Keep reading if you need a quick refresher on what these tools look like in action. If you are solid on these tools and want to dive into more advanced techniques, jump to the next section.
Stimulus control involves removing the stimulus to eat from the environment or controlling when the stimulus occurs. Examples of this would be recommending that your patient only shop when they are not hungry, shop with a list, do not bring hyper-palatable foods into the home, be willing to clean out the pantry rather than waiting to use up the tempting foods, only eating at meals or pre-defined snack times and eat only pre-planned foods.
Remind patients that thoughts influence mood and emotion, which then drives behaviors. Stopping or changing negative or false thought patterns is the first step to behavior change. Examples of cognitive restructuring might include pointing out when your patient speaks in ways that keep them locked into certain patterns of behavior, such as when they say, “I am just not a breakfast eater” or “I’m just not a gym person.” See Figure A. for a handout to use with patients to help them replace unhealthy emotional eating with healthy behaviors.
SMART goals are specific, measurable, achievable, relevant to overall life goals, and have a specific time frame attached to them. Encourage patients to work through the smart mnemonic each time you set goals together. If they have a goal around exercise, ask them to define specifically what type of exercise they plan to add, what day of the week they intend to do it, what amount of exercise they intend, and whether it is realistic based upon their current state of fitness and the available time in their schedule, what it will mean to their overall health goals and when they intend to have accomplished it. Instead of: I want to start exercising, a SMART goal might be: This week I plan to go for a 15min walk over my lunch break every day except Wednesday because I have a working lunch on Wednesdays. I don’t think I can fit in more than 15 minutes, and I may not have the endurance for that either. But, if I can get in 15 minutes of activity at noon, I will feel more alert and attentive during the afternoon and might sleep better that night.
Multiple studies now affirm that tracking food intake leads to more efficient weight loss. However, many patients are resistant to tracking with an app. Teaching them how to use some of the common, free tracking apps can help overcome these barriers. If you are unfamiliar with at least one free tracking app, pause now and download one to your smartphone. Learn how to navigate the app so that you can teach it to your patients. Other forms of self-monitoring might include wearing a smartwatch or activity tracker, monitoring sleep quantity and quality, keeping a photo diary of progress pictures, and daily or weekly weighing.
In the context of behavioral therapy for obesity, problem-solving might involve learning how to create a weekly menu that considers busy family schedules and having a backup plan in place for contingencies. Spend five minutes with a patient asking them to sketch out six dinner meals that they could prepare which would meet the dietary requirements you have recommended. Then ask them if they know what commitments the family has on each weeknight. If every Thursday means a late soccer practice, then planning for an easy Crock-Pot meal would be strategic. However, what happens if they forget to start the Crock-Pot on Thursday morning? A contingency or backup plan might be the container of leftover chili in the freezer from the week before.
Advanced tools to manage stress eating:
Stress is endemic in the modern environment. As practitioners, our messaging around stress must emphasize not eliminating stressors but modifying and improving the stress response. 35-40% of people report engaging in stress eating (Hill et al., 2021). Under laboratory conditions, 40% of stressed individuals will increase eating, 40% will decrease and 20% will not change their eating behavior (Yau & Potenza, 2013). In individuals with obesity, the tendency, when exposed to stressors, to turn to hyper-palatable foods, such as those high in fat or sugar, is exacerbated due to multiple neuroendocrine mechanisms. With the goal to treat individuals based on their obesity phenotype, most of you probably already screen for emotional or stress-eating behaviors. As obesity medicine specialists, we must also be prepared to teach our patients simple and effective tools to improve their stress-coping and mitigate the physiologic drive to medicate with foods
Based on the work of Elissa Epel, Ph.D., tools to address stress can be categorized into three groups, those that take a cognitive approach, a body-centered approach, or an environmental approach (Huberman, 2023). Cognitive tools that aim to change thinking to impact the physical response or behavior are best defined within the framework of cognitive behavioral therapy (CBT), one of the most effective behavioral therapies for obesity and binge eating disorder (Castelnuovo et al., 2017). A licensed mental health practitioner usually delivers it. There are brief, online courses available to teach the non-specialist. However, even those who do not plan to specialize in CBT may appreciate having a well-stocked toolkit, including some CBT techniques like mindfulness, radical acceptance, and reframing.
A study done by Hooker and colleagues, (2022) demonstrated that teaching mindfulness to patients undergoing behavioral therapy for obesity lowered their rates of depression and anxiety and increased psychological flexibility. Mindfulness can be defined as a state of being present in the moment without judgment (Rhindman, 2022). Demystify this and make it practical for your patients by asking them to be aware of each moment in the day that they are making a food or exercise-related decision. The classic cartoon depicting an angel on one shoulder and a devil on the other is familiar to most of us and accurately portrays at least the awareness aspect of mindfulness, if not the nonjudgmental aspect. Encourage your patient to acknowledge the progress they are making around mindfulness every time they are present and aware at the moment that they have a decision to make: to eat the healthy meal they had planned or to put a frozen pizza in the oven, to go for a walk after dinner or to head immediately to the couch.
A technique borrowed from dialectical behavior therapy, radical acceptance involves accepting the reality of one’s life, situation, or circumstances. When applied to the context of behavioral therapy for obesity, it is a technique that may be useful to help a patient frame those things they can control and separate them from things they cannot control. An example would be helping a patient to understand that:
- although they were not given a choice about the genetic blueprint they inherited and
- although they cannot change the fact that they may have been raised in an unhealthy food environment that set up patterns of food behaviors, and
- although they cannot change right now their physical condition or the fact that getting to a healthier place will involve time, hard work, and patience that
- they can agree to commit to a healthier future.
Radical acceptance is accepting that the work will be challenging but agreeing to undertake it anyway in order to get to a healthier place.
A very basic reframing skill that health coaches use daily involves helping a patient take a negative experience and find something positive within that experience. An example of this would be the patient who experiences weight gain after taking a vacation. One way to start is by asking them to reflect on the good things from the vacation, including the stress relief and rest that it afforded. You might then ask them if they held on to any of their healthier new food habits while on vacation; often, they will be able to reflect that they could eat the burger without the bun for example. Another way to reframe the same situation would be to have them reflect on how much walking they did on their vacation or how readily they resumed their healthy “at home” routine around food upon their return.
A body-centered approach to stress encourages patients to change behaviors to experience a change in their emotional response. These techniques can be taught to patients to help them, at the moment they are experiencing negative emotions and a drive to eat, de-escalate the emotional response. They include body scans combined with relaxation, breath work, cold therapy, and exercise. Several of these techniques can be done discreetly and may help the patient manage and modulate their stress response throughout the day so that it does not build up.
Starting with either the top of your head or your feet, do a quick mental scan of your body to identify tight or tense areas. Once you know where you typically hold on to your tension, you might be able to skip the identification step and move straight to the relaxation step. If the tension is in the shoulder girdle, dropping the chin to the chest or rolling the shoulder will help to relieve it. If the tension is in the chest, you may notice that your breath is shallow and rapid. Expanding your breath to fill your lungs and doing a couple of belly breaths followed by a deep sigh will often help.
There are many different techniques that can be effective to relieve stress at the moment. One that is easy to teach and remember is the 4-7-8 breath counting technique. Teach your patient to breathe in through the nose while counting to 4, hold the breath for a count of 7 and then breathe out through the mouth for a count of 8.
This one is gaining popularity, and your patients may ask about its efficacy for activating brown fat and stimulating fat loss. That is a topic for another article. However, cold therapy can be a great technique for teaching the body and the mind that it can endure hard things. The mild hormetic stress of cold-water immersion, whether through a cold shower or an ice bath, even dipping the face into a bowl of ice water, can be described as refreshing and rejuvenating. It could be used to rapidly move the brain out of a cycle of craving.
High-intensity interval training:
HIIT training is another hormetic stressor that has been postulated to improve stress coping and emotional responses. Many of your patients may not be at a point physically where they can engage in HIIT exercise, but it is something they can work up to. A brief burst of jumping jacks or burpees when feeling low energy or mood in the middle of the afternoon can wake you up and snap you out of the thought and emotion patterns that would otherwise lead you to the vending machine.
The environmental approach to stress management: taking oneself out of the stressful environment for even a brief interlude or evaluating and improving the social support structure is addressed in this approach. If stressors are too great, is the patient taking advantage of counseling or therapy? Does the patient have an untapped support network of family, friends, colleagues, or members of a faith group? Encourage them to reach out and even expand their network. In the context of obesity management, encourage them not to “fly under the radar” with their weight loss attempts but rather to share their goals, struggles, and successes with friends and family.
Encourage your patients to take advantage of the additive benefit of exposure to nature for their exercise. A brief walk outdoors at noon or after dinner can be looked at as restorative and may be more appealing than when it is framed as exercise. Time spent in nature has been linked to improved mood and lower stress (Weir, 2020).
Many of the patients we work with in obesity management would benefit from having a trained therapist for behavioral therapies; however, within the constraints of the typical practice environment, we are often called upon to expand our own skill set to provide the very best care to our patients who do not have access to mental health practitioners.