AlignMap

A Cognitive Therapy Approach to Weight Loss and Maintenance: An Expert Interview With Judith S. Beck, PhD Judith S. Beck, PhD, Medscape Psychiatry & Mental Health. Posted 04/23/2007

Do Cognitive Therapy Concepts For Losing Weight Apply To Improving Compliance?

I’m convinced this Medscape interview with Judy Beck on a cognitive therapy approach to weight loss has straightforward implications for optimizing patient compliance. Rather than argue the case, however, I encourage you to check it out for yourselves. To facilitate this process, I’ve excerpted some of the portions of the interview that are pertinent to treatment adherence. I suggest reading through the selections once for a sense of Dr. Beck’s notions regarding cognitive therapy and weight reduction and then re-reading the same material, mentally transforming the goal from weight loss to patient compliance. I think you’ll find the exercise simple and enlightening.

Medscape: Do people become demoralized when they find out that dieting isn’t as easy as they had thought?
Dr. Beck: Yes. That’s why it’s important to lay the groundwork with dieters first. In fact, I suggest that people spend a couple weeks learning certain skills before they even start. One skill is to compose and read every day a list of every advantage they can think of for losing weight. They’ll need to read this list for a very long time, so when they face temptation, these advantages will be firmly in mind. And they need to prepare in advance what to say to themselves when dieting gets harder, when they feel discouraged, when the scale hasn’t gone down, when they stray from their diet, and when they start to feel the injustice of food restriction.

Medscape: What role does distorted thinking play in unsuccessful efforts to lose weight?
Dr. Beck: Dieters who fail to lose weight or fail to maintain their weight loss think differently from those who are able to lose weight and keep it off long term. They have a lot of all-or-nothing thinking:

* Being full (often overly full) is good; hunger is bad;

* They’re good if they follow their diets, but bad if they make 1 mistake;

* Their eating week was either good (relatively easy) or bad (even if they only struggled for several minutes on several days);

* Food is either good or bad even though we recommend that dieters plan in advance to modify their diets so they can eat small portions of whatever food they want as often as once a day; and

* Dieters who fail to lose weight also view themselves as either in control (100% perfect) or out of control. They often think that 1 mistake should give them license to eat whatever they want for the rest of the day and delay starting fresh until the next day. They also believe that people of ‘normal’ weight rarely restrict their eating and rarely get hungry. They think that once they lose weight, they should be able to return to their old way of eating.

Medscape: How do you get people to recognize these kinds of ideas and what do you suggest they do about them?
Dr. Beck: We use standard cognitive therapy techniques, teaching them to ask themselves what’s going through their minds when they feel hunger and craving, when they are disgruntled about not eating, when they are tempted to eat something they haven’t planned. Then they read ‘response cards’; index cards that contain compelling answers to their thoughts. They read these cards at least once a day, usually in the morning; then pull them out again on an as-needed basis, sometimes several times a day toward the beginning of their diet.

Medscape: Can you give an example of a response card?
Dr. Beck: We make them up idiosyncratically with dieters. Some common ideas are: Even though I really want to eat now, I haven’t planned to. If I eat, I’ll strengthen my ‘giving-in’ habit, which means in the future I’m more likely to give in. If I don’t eat, I’ll strengthen my ‘resistance’ habit, which makes it more likely that in the future I’ll be able to resist. I can tolerate not eating now. I’ll be very glad in a few minutes when the desire goes away. I shouldn’t give myself a choice about this. After all, I’d rather be thinner. I can’t eat whatever I want AND also be thinner. I have to make a choice. Every time matters.

Medscape: What about emotional eating?
Dr. Beck: Dieters give themselves permission to stray from their diet for any number of reasons. They’re upset, happy, tired, stressed, celebrating, traveling, busy, at a party…the list is endless. They think, ‘It’s okay to eat because…. everyone else is; it’s only a small piece; no one is watching; the food is free; I rarely get a chance to eat this kind of food.’ They need to learn the same skills to avoid straying from their plan, no matter what the reason. They have to grasp the fact that they can either eat what they want, when they want, for whatever reason they want (including being upset) — or they can be thinner. But it’s impossible to have it both ways.

Medscape: What do you suggest people do when they’re tempted by food that they’re not supposed to eat?
Dr. Beck: As I keep saying, they have to prepare in advance for these times. They need to continually remind themselves (often by reading response cards) of the reasons to lose weight, that they can tolerate the discomfort of not eating (after all, they’ve tolerated much worse discomfort in their lives), that they’ll be happy in a few minutes when the desire to eat passes that they didn’t eat and they’ll be very unhappy in a few minutes if they give in to temptation. They also need a list of things they can do when they feel tempted — such as reading a diet book, surfing the Web for diet-related sites, taking a walk, calling a friend, brushing their teeth, writing emails, and so forth. We help dieters create a list of about 20 activities or so and urge them to try 5 of them each time they’re tempted.

Medscape: You mentioned that dieters need someone to be accountable to.
Dr. Beck: Yes, we encourage everyone to find a ‘diet coach’: a friend, family member, coworker, neighbor, or maybe someone else who is trying to lose weight. Diet coaches don’t necessarily need to know much about dieting. But they do need to be highly supportive and encouraging. They also need to be willing to hunt down the dieter who has failed to keep his or her regularly scheduled weekly appointment (by telephone or email, or in person), reporting on how his/her weight has changed that week. Dieters don’t need to reveal their weight; only their change in weight. In addition, diet coaches need to be good problem solvers.

Medscape: What kinds of problems arise that dieters need help with?
Dr. Beck: Common problems include practical ones, such as not enough time to schedule in dieting and exercise activities, and psychological ones, such as demoralization and discouragement. Some dieters need encouragement (and sometimes a little assertiveness coaching) to state their needs to family and coworkers. It’s surprising how many dieters are reluctant to turn down food that others offer or to ask that others bring only a single serving of overly tempting foods into the home, at least at the beginning. Ultimately, we want to build up dieters’ control so that they can keep any kind of food in the house and eat only small, planned-in-advance amounts.

Using Cash Bonuses and Penalties To Enhance Weight Loss In Obese Employees

Employers penalize obesity
By Daniel Costello
Baltimore Sun. July 29, 2007

This article reports on an increasing number of employers using monetary incentives or disincentives to promote dieting and exercise among overweight employees with the goal of improving the employees’ health and, consequently, lowering medical costs secondary to obesity-related health problems.

Some employers penalize overweight employees if they don’t slim down while others offer fit workers lucrative incentives that may decrease their healthcare premiums by thousands of dollars a year. Examples include

• Clarian Health Partners, an Indiana-based hospital chain, will, beginning in 2009, charge employees up to $30 every two weeks unless they meet weight, cholesterol and blood pressure guidelines the company deems healthy, i.e., employees’ pay will be docked if they fail to meet certain weight ratios, cholesterol, blood pressure or if they smoke.
• UnitedHealthcare, a national insurer, introduced a plan this month that, for a typical family, includes a $5,000 yearly deductible that can be reduced to $1,000 if an employee isn’t obese and doesn’t smoke.
• County workers in Benton County, Ark., were offered, beginning last summer, a similar plan. The $2,500-a-year deductible can be reduced to $500 if a worker meets low height/weight ratios during yearly on-site physicals. Thomas Dunlap, Benton County’s benefits administrator, said the plan had witnessed a nearly 30 percent drop in claims – and led to changes in the workplace. Workers can attend free weight-reduction classes, and there are now regular competitions between departments to see who can lose the most weight. Acknowledging that it could be partially the result of the new deductible, he noted that the county didn’t have to raise its insurance premiums this year and likely won’t next year.

Some criticize this tactic, claiming that the lose-weight-or-pay plans “turn the health care system into a police state.” In addition, implicit in the strategy is the notion that people who are obese and have other health issues and change their situations with reasonable effort.

Lewis Maltby, president of the National Workrights Institute, a Princeton, N.J.-based employees rights group, called the trend

Employers reply that they are only responding to the rise in both health care premiums and the proportion of obese Americans.

In a telling statistical change, sixty-two percent of 135 executives responding to a PricewaterhouseCoopers survey this spring said unhealthy workers such as those who smoke or are obese should pay higher benefit costs, compared with 48 percent who said so in 2005.

Further, in January 2007, the U.S. Department of Labor released final clarifications on the Health Insurance Portability and Accountability Act (HIPAA) of 1996, which ruled that employers can use financial incentives in wellness programs to motivate workers to get healthy. Nonetheless, some lawyers say weight-based compensation plans might run afoul of other employment laws such as the Americans with Disabilities Act.

In recent years, companies have offered cash, merchandise and gift cards to those who lose weight or lower their blood pressure. A few have begun refusing to hire workers who smoke. The new plans are different because employers are demanding that workers participate in health exams and have their weight checked and blood taken to screen for high cholesterol or blood sugar.

Commentary

The use of mandatory monetary penalties and/or bonuses to direct lifestyle changes in the name of better health, especially when “better health” is a proxy for “lower costs,” is intriguing on several levels.

First, of course, is the question of the efficacy and efficiency of such tactics.

The ethical questions already suggested extend beyond the employers-employees contracts. Governmental agencies currently pass laws regulating the use of tobacco, alcohol, and, most recently, high-fat foods. It is hardly inconceivable that medical care provided by the state might someday come at a higher price to those citizens whose habits are deemed unhealthy.

Other, more specific issues are present in abundance. Which healthcare habits are fair game for bonuses and penalties? Should those with hereditary disorders be expected to pay more? How about those with a genetic predisposition to obesity? Are those who fall below the weight norms to be penalized? Or those who do not make it to follow-up clinical appointments? Or those who choose to see a priest for healing rather than a physician? Who sets the standards for healthy behavior? If a pregnant worker doesn’t seek adequate pre-natal care but is healthy and bears healthy children, is that family assessed extra costs? If a 32 year old former college athlete turned company VP plays in a semipro football league with its attendant risk of injury, should his behavior be considered unhealthy and efforts made to change it? What if he sky-dives on weekends? How about if his moonlighting job is serving as guinea pig for testing medication?

It’s a tricky new world.