Behaviour Research and Therapy 39 (2001) 499511

www.elsevier.com/locate/brat

Invited essay

A new cognitive behavioural approach to the treatment of

obesity
Zafra Cooper *, Christopher G. Fairburn
Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK

Abstract
While behavioural approaches to the management of obesity are often successful in achieving clinically
significant weight loss, the weight lost is generally regained. The great majority of patients return to their
pre-treatment weight within 3 years. There have been attempts to improve the long-term effectiveness of
behavioural treatment but the results have been disappointing. In this paper we suggest that, among other
factors, this is because of the neglect of the contribution of cognitive factors to weight regain, and because
there is often ambiguity over the goals of treatment. We present a cognitive behavioural analysis of the
processes involved in weight regain, and we describe a new cognitive behavioural treatment derived from
it. This treatment is designed to minimise the problem of weight regain by addressing psychological
obstacles to the acquisition of, and long-term adherence to, effective weight-control behaviour. 2001
Elsevier Science Ltd. All rights reserved.
Keywords: Obesity; Treatment; Cognitive behaviour therapy; Relapse; Weight; Body image

1. The effectiveness of current treatments for obesity

Obesity is a major health problem. Childhood and adult obesity are common in Western
societies and their rates are rising (Prescott-Clarke & Primatesta, 1999; Flegal, Carroll, Kuczmarski & Johnson, 1998; Seidell & Rissanen, 1998). Obesity has been described by the World Health
Organisation as a global epidemic (World Health Organisation, 1997). As a result of this
increase, more people will suffer from the many weight-related medical complications, including
heart disease, hypertension, stroke, diabetes osteoarthritis and some cancers (Bray, Bouchard &

The seminal paper on the behavioural treatment of obesity was published in this journal in 1967. Stuart, R. B. (1967). Behavioural
control of overeating. Behaviour Research and Therapy, 5, 357365.
* Corresponding author. Tel.: +44-1865-226479; fax: +44-1865-226244.

0005-7967/01/$ - see front matter 2001 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 0 5 - 7 9 6 7 ( 0 0 ) 0 0 0 6 5 - 6

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Z. Cooper, C.G. Fairburn / Behaviour Research and Therapy 39 (2001) 499511

James, 1998). In addition, they will be at increased risk of the adverse psychological and social
consequences of obesity (Gortmaker, Mist, Perrin, Sobol & Dietz, 1993; Stunkard & Sobal, 1995).
The management of obesity is the subject of uncertainty and controversy. There is an extensive
body of treatment research but this has important methodological shortcomings (Glenny, OMeara,
Melville, Sheldon & Wilson, 1997). There are three main evidence-based approaches to treatment.
Surgical treatment Surgery for obesity is recommended for patients who are extremely
overweight, for example, those with a body mass index [BMI; weight (kg)/height2 (m)] of 40
or more (National Institutes of Health Consensus Development Conference, 1992). This applies
to a small proportion of cases. Such surgery usually results in substantial weight loss over
the first 612 months (2045% of preoperative weight) which is generally well maintained
(Kral, 1998).
Pharmacotherapy Drug treatment results in 510% weight loss amongst those who comply
with treatment (National Task Force on the Prevention and Treatment of Obesity, 1996; Bray,
1998). Thus the loss is modest with most patients remaining significantly overweight. The
weight loss usually occurs within the first 6 months of starting treatment with body weight
levelling out thereafter. If drug treatment is stopped, there is almost invariable weight regain.
Therefore for pharmacotherapy to have a lasting effect, it needs to be continued indefinitely
which is a cause for concern since there have been few long-term studies of these drugs safety
or effectiveness.1
Behavioural treatment This form of treatment was developed in the 1960s (Ferster,
Nurnberger & Levitt, 1962; Stuart, 1967) and has been refined over the years. A typical behavioural programme, incorporating a 1200 kcal/day diet, produces a weight loss of about 10% of
initial body weight among those patients who complete treatment (about 80%) (Wing, 1998).
There is almost always regain of the weight lost with about 40% being regained over the first
year following treatment and much of the rest over the following 3 years (e.g. Graham, Taylor,
Hovell & Siegel, 1983; Stalonas, Perri & Kerzner, 1984; Kramer, Jeffery, Forster & Snell,
1989; Wadden, Sternberg, Letizia, Stunkard & Foster, 1989).
Thus the two non-surgical evidence-based treatments for obesity produce, on average, about ten
percent weight loss among treatment completers, with the weight lost being regained once treatment is stopped.
2. The goals of obesity treatment
Over the past 5 years it has become increasingly clear that modest weight loss is associated with
significant health benefits. A 510% reduction in weight is accompanied by clinically important
improvements in cholesterol, blood pressure, blood glucose and other health indices (Goldstein,
1992; Kanders & Blackburn, 1992; Wing & Jeffery, 1995; Tremblay et al., 1999), and there is
1
These concerns have been magnified by the recent finding of an association between fenfluramine use and the presence of
valvular heart disease (Connolly et al., 1997; Centers for Disease Control, 1997), an association which only emerged after 30 years
of its availability. As a result of this association, fenfluramine was promptly withdrawn in 1997.

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501

evidence that these benefits are sustained if the lost weight is not regained (Wing & Jeffery,
1995). While the longer-term benefits of this degree of weight loss remain to be established
(Wadden, Anderson & Foster, 1999), 510% weight loss is now the recommended goal for obesity
treatment programmes. For example, the US Institute of Medicine (1995) publication Weighing
the Options: Criteria for Evaluating Weight-Management Programs defines treatment success as
five to ten percent weight loss maintained for at least 1 year. Similarly, a recent report from the
UK Royal College of Physicians (1998) states that the primary goal of treatment is a 10%
reduction from the initial weight, and it defines successful weight loss as a loss of more than
5% of initial weight.
Since 510% weight loss can be achieved by many patients and furthermore is worth achieving,
the challenge for those developing new treatments for obesity is how best to prevent, or minimise,
the weight regain that follows both pharmacotherapy and behaviour therapy. This is a very different objective from the more conventional one of achieving greater weight loss. One option is longterm, or even indefinite, treatment (Perri, 1998). This is supported by evidence which suggests that
extending treatment improves outcome (see below). However, these data come largely from efficacy studies in which the focus has been on those patients who complete treatment, yet it is well
recognised that patient attendance declines as treatment is extended in length. The utility of longterm treatment remains to be established. Another option is long-term drug treatment but, for a
number of reasons, this is never likely to be a complete answer. Firstly, as noted, there is the
possibility that long-term use will be associated with adverse effects. Secondly, many patients
would prefer not to be treated with drugs and as treatment is extended there are likely to be
more problems with compliance. Thirdly, there are situations in which drug treatment would be
inappropriate, for example, during pregnancy. Given these considerations, there is a clear need
for new approaches to the prevention of weight regain.
3. The research on weight regain and its prevention
There has been little research on the mechanisms responsible for weight regain as opposed to
weight loss. Among potential physiological mechanisms, the decrease in energy requirements
which accompanies weight loss (Prentice et al., 1991; Leibel, Rosenbaum & Hirsch, 1995; Pasman, Saris & Westerterp-Plantenga, 1999) is likely to contribute as may the increase in lipoprotein
lipase activity (Kern, Ong, Saffari & Carty, 1990). However, there is evidence that psychological
mechanisms are also of relevance.
There have been a number of studies of the behavioural characteristics of people who have
lost significant amounts of weight and experienced only minimal weight regain (Wadden, 1995).
Various research designs have been employed including detailed semi-qualitative studies of small
numbers of subjects (Colvin & Olson, 1983; Kayman, Bruvold & Stern, 1990; Tinker & Tucker,
1997), larger-scale community-based surveys (Klem, Wing, McGuire, Seagle & Hill 1997, 1998;
Shick et al., 1998; McGuire, Wing, Klem & Hill, 1999), and prospective studies of the characteristics of those who do best following treatment (Wadden, 1995; Wadden, Vogt, Foster & Anderson, 1998). Each of these designs has strengths and weaknesses, and to an extent they are complementary. It is therefore of note that their findings are generally consistent in identifying three
main behavioural characteristics shared by those who avoid significant weight regain. The first

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and most prominent of these is the maintenance of a high level of physical activity; the second
is the consumption of a low-fat diet; and the third is the active monitoring of body weight. It is
conceivable that these three forms of behaviour are simply markers of the mechanism actually
responsible for minimising weight regain, rather than directly making a contribution themselves.
On the other hand, the first two are likely to have a significant impact on energy balance while
the third will provide essential feedback on changes in weight. It is therefore plausible that these
three forms of behaviour directly contribute to successful weight control. What these studies have
not revealed is why some people engage in this behaviour while others do not.
Even a crude psychological analysis of the benefits and costs of weight loss and weight regain
suggests that the weight regain that follows weight loss is paradoxical. Weight loss, which is only
achieved as a result of a determined effort, is associated with a variety of beneficial effects for
the patient, including decreased anxiety and depression, enhanced self-esteem, reduced body dissatisfaction and improved interpersonal functioning (ONeil & Jarrell, 1992; Foster & Wadden,
1994); whereas weight regain, although less well studied (Foster & Wadden, 1994), is aversive
since it has negative effects on self-confidence, body image and mood. The fact that patients do
not actively engage in the behaviour needed to maintain their new lower weight, even though it
may not be as low as they would like it to be, requires explanation. Cognitive factors are likely
to contribute to our understanding of this phenomenon.
Largely independent of the research on the behavioural characteristics of those who have been
successful at achieving long-term weight control, there have been attempts by behaviour therapists
to minimise post-treatment weight regain. A variety of weight maintenance programmes have
been developed, most of which have been pragmatic in nature. These have achieved strikingly
modest results (Wilson, 1994; Perri, 1998). Particularly notable has been a programme of interrelated studies by Perri and his colleagues who have examined the effects of various forms of
extended treatment contact, social support, measures to promote exercising and training in relapse
prevention (Perri, McAdoo, Spevak & Newlin, 1984; Perri, Shapiro, Ludwig, Twentyman &
McAdoo, 1984; Perri, McAdoo, McAllister, Lauer & Yancey, 1986; Perri et al. 1987, 1988; Perri,
Nezu, Patti & McCann, 1989; Leermakers, Perri, Shigaki & Fuller, 1999). Other investigators
have evaluated extended therapist contact, monetary incentives, the provision of food, telephone
contact, social support and the use of personal trainers to encourage exercising (e.g. Baum,
Clark & Sandler, 1991; Jeffery et al., 1993; Jeffery & Wing, 1995; Wing, Jeffery, Hellerstedt &
Burton, 1996; Wing & Jeffery, 1999). None of these measures, which have concentrated largely
on external factors, has been successful in the longer-term. Rather, at best, they simply seem to
delay weight regain. Moreover, as treatment has been extended in duration, compliance has
become a progressively greater problem (Perri, 1998).
One reason for the lack of success of these programmes is an inherent ambiguity and inconsistency in their goals. More specifically, there tends not to be a clear distinction between the objective
of striving to achieve greater weight loss which requires sustaining an energy deficit, and the
objective of maintaining a stable weight (i.e. maintaining the weight lost) which requires patients
to establish a balance between energy intake and output.2 This is illustrated by the fact that some
2

Permeating much of the literature on the longer-term effects of treatments for obesity is the use of the term weight loss when
it is weight lost which is meant. Examples abound, one being this quote from a recent NIH report on the management of obesity:
The majority of persons who lose weight regain it, so the challenge to the patient and the practitioner is to maintain the weight
loss (National Heart, Lung and Blood Institute; National Institutes of Health, 1998, p. 119).

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weight maintenance programmes advocate an energy intake that is well below that required to
maintain a stable weight (e.g. Ditschuneit, Fletchtner-Mors, Johnson & Adler, 1999).
4. A cognitive behavioural analysis of weight regain
We propose that, among those with obesity, there are two interrelated reasons for patients
failure to engage in effective weight maintenance strategies. First, they do not achieve their weight
loss goals, nor the anticipated benefits of achieving them. As a result, they abandon their weight
loss efforts. Second, under these circumstances they neglect (or do not appreciate) the need to
acquire weight maintenance skills, and thus return to their previous eating habits and hence
gain weight.
4.1. Goals and expectations
4.1.1. Weight loss goals and expectations
Most patients present for treatment wanting to lose 2030% of initial body weight (Foster,
Wadden, Vogt & Brewer, 1997; Jeffery, Wing & Mayer, 1998). Given the modest weight loss
generally achieved, this is an unrealistic goal which is unlikely to be met. Nevertheless this tends
not to appreciated. Patients weight goals appear entirely reasonable in a society which promotes
the view that weight is largely amenable to personal control and that achieving a desired shape
is simply a matter of self-control. Unrealistically low weights are also encouraged by social pressures to be slim and the considerable prejudice against obesity. However, we suggest that the most
important factor in determining patients weight goals is their belief that other personally salient
objectives (termed here primary goals) cannot be achieved without the desired weight loss.
4.1.2. Primary goals and expectations
Weight loss is not undertaken simply to achieve a lower weight but because it is believed that
a range of other valued objectives cannot be achieved without it. Our experience interviewing
patients seeking to enter an obesity treatment study suggests that a desire to change appearance
(particularly to modify shape and be less fat) is the primary reason for most women wanting
to lose weight. They hope to improve their appearance, feel more attractive (or at least less
unattractive) and be able to wear clothes which they regard as more flattering and fashionable
than those currently available to them. A significant minority (about twenty per cent in our
experience) are intensely negative about their bodies and their functioning is impaired as a result.
For example, they avoid a range of social, interpersonal and professional situations which they
fear will elicit their own or others critical evaluation of their appearance. In such patients shape
change, and therefore weight loss, are seen as essential if they are to function normally.
A closely related reason for wanting to lose weight is a desire to improve self-confidence and
self-respect. For many patients these are intimately linked with the extent of their satisfaction
with their appearance. Indeed, for some, weight and shape change are not viewed as merely a
means of enhancing self-evaluation, but as virtually their only way of gaining self-confidence and
self-respect. Since weight and shape play a major and disproportionate role in their self-evaluation,
weight loss is viewed as an essential condition for positive self-evaluation.

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A less common motive for wanting to lose weight is a desire to improve health. While there
is widespread awareness that being overweight is associated with increased health risks, relatively
few female patients give this as their reason for seeking treatment. Some wish to be more active,
especially those with young children, and some want to lose weight because they already have a
disorder that is weight-related (such as diabetes mellitus or hypertension) or they have a family
history of such a condition.
4.1.3. The relationship between primary goals and weight loss
It is evident that the achievement of many of these primary goals is only loosely connected to
weight loss. While some of these goals require modest weight loss (e.g. certain health goals),
others are only achieved to a limited extent by losing weight (e.g. modifying shape) and some
do not necessarily require any weight loss (e.g. improving self-confidence or interpersonal
relationships). This tends not to be appreciated by patients and instead weight loss is undertaken
in the belief that only a loss of a certain magnitude will produce the desired outcome. Sometimes
important personal objectives are deferred until a specific weight has been achieved (e.g. a plan
to form new relationships or change employment).
4.2. The abandonment of weight control
In practice, most attempts to lose weight result in few, if any, of the patients goals being met.
Patients rarely achieve their weight goals because most experience a gradual cessation in weight
loss after 46 months at which time they have typically lost about 510% of their initial weight.
Also patients do not achieve their primary goals because the achievement of these is only loosely
dependent upon weight loss and because few are likely to have been addressed directly in treatment.
Not surprisingly, patients become demoralised by the decline in their rate of weight loss. This
is worsened by their tendency both to underestimate the significance of the weight loss they have
achieved and to ignore any other positive changes that have already occurred (e.g. greater fitness
and agility, and a reduction in clothes size). Instead, they focus on the weight still to be lost. At
this point some conclude that since their desired weight appears to be unattainable, the deprivation
and effort involved in trying to lose (further) weight are not worthwhile and accordingly they
abandon their attempts at weight control.
Other patients retain the belief that they are capable of losing more weight and thereby achieving their various goals. Indeed, for some achieving anything less is considered hardly worthwhile.
They tend to think that their efforts should involve an even greater level of dietary restriction
over an even longer period of time. This conclusion is particularly common among those whose
self-evaluation is intimately linked to their weight and shape. In the majority of such patients,
attempts to lose further weight do not result in the achievement of their desired weight, simply
because it is difficult to sustain high levels of restraint over prolonged periods of time. Many
view their inability to lose further weight as a personal failure arising from a lack of self-discipline,
rather than as a more general problem experienced by almost everyone in their position. Accordingly they persist in their efforts. A minority reach their goal weight by exercising high levels of
control over their eating. Irrespective of whether they reach their goals, the consequence of their
attempts to do so tends to be a form of dietary compliance which is subject to repeated lapses.

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These are often followed by the temporary abandonment of dietary control which may sometimes
result in overeating. Such lapses, and any accompanying weight gain, are interpreted as failures
of self-control and may lead to renewed attempts to diet. This in turn increases vulnerability to
further lapses. Over time, patients come to regard continuing attempts to lose weight as the only
form of weight control available to them, ignoring the possibility of weight maintenance. They
also develop growing doubts about their ability to achieve the benefits of weight loss. This leads
them to think that the considerable effort required to control their weight is futile and at this point
they are likely to abandon further attempts at weight loss.
4.3. The neglect of the need for active weight maintenance
The abandonment of attempts to lose further weight, whether or not these have been sustained,
tends not to be followed by efforts to maintain the new lower weight. Rather, most patients neglect
the need for active weight maintenance and return to their prior eating habits with weight regain
being the result. Patients in this situation are not in the right frame of mind to embark on weight
maintenance because they undervalue the weight loss that they have achieved and they do not
view their weight as controllable to any worthwhile extent. In addition, the widespread conflating
by patients (and their therapists) of weight loss and weight maintenance leads to a failure to
appreciate the importance of acquiring and practising effective weight control behaviour.
5. The new cognitive behavioural treatment
On the basis of this cognitive behavioural analysis of weight regain, we have developed a new
approach to the treatment of obesity (Cooper & Fairburn, in press). This is designed to minimise
the weight regain that generally follows weight loss by overcoming psychological obstacles to
the acquisition of, and long-term adherence to, effective weight-control behaviour. Three key
issues are addressed: first, the treatment helps patients accept and value the weight loss that they
have achieved; second, it encourages the adoption of weight stability and not weight loss as their
goal; and third, it helps patients acquire and then use the behavioural skills and cognitive responses
required for successful weight control.
The treatment, as currently being evaluated, takes eleven months and has two phases, a weight
loss phase and a weight maintenance phase. The objective of the first phase is both weight loss
and the addressing of potential obstacles to subsequent weight maintenance. By the end of this
phase patients should no longer be trying to lose further weight but instead should have accepted
weight stability as their objective. The second phase concentrates on helping patients acquire the
frame of mind and behaviours needed for successful long-term weight maintenance.
The treatment differs markedly from current behavioural treatments for obesity, as described
by Wing (1998). It is administered on a one-to-one basis, and in therapeutic style resembles
cognitive behavioural approaches to the treatment of eating disorders (Fairburn, Marcus & Wilson,
1993; Wilson, Fairburn & Agras, 1997). The treatment manual specifies the strategies and procedures to be used and these are organised in a series of treatment modules (see Fig. 1). The
modules are introduced sequentially and used in a flexible way according to the needs of the
particular patient.

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Fig. 1.

The treatment modules and their implementation.

Phase One lasts for the first 2430 weeks of treatment. In Module I (Starting Treatment)
patients are assessed and the treatment is described with the distinction between weight loss and
weight maintenance being introduced and stressed. The emphasis in Module II (Establishing and
Maintaining Weight Loss) is on helping patients to restrict their energy intake to about 1500
kcal daily. Patients are encouraged to devise their own dietary regime taking into account their
circumstances and food preferences. Module III (Addressing Barriers to Weight Loss) runs in
parallel with Module II. It focuses on identifying and addressing the various problems which may
interfere with adherence to the energy-restricted diet. These include motivational issues, inaccurate
monitoring of food intake, poor food choice, excessive alcohol intake, frequent snacking, eating
in response to adverse moods and frank binge eating. Module IV on nutrition (Eating Well) is
also introduced at this stage. At this point in treatment it is concerned with healthy eating while
losing weight. This module is re-introduced in Phase Two when its focus is on healthy eating as
part of long-term weight control.
The primary focus of Module V (Increasing Activity) is on establishing a more active lifestyle
in the context of weight maintenance. Thus it is of most relevance in Phase Two. However, this
notion is introduced earlier in treatment to encourage those patients who would like to include
activity and exercise in their weight loss efforts. The emphasis of the module is on increasing
activity level in general (which necessarily includes decreasing sedentariness) rather than on simply increasing formal exercising.
The other three modules that comprise Phase One are employed in a flexible manner both with
respect to their timing and the degree of emphasis placed on them. A distinctive feature of the
treatment is the identification and addressing of patients reasons for wanting to lose weight. In
Module VI (Body Image) patients concerns about their shape are systematically assessed. Cog-

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507

nitive behavioural strategies are used to help those patients who avoid body exposure, engage in
frequent body checking or have recurrent derogatory thoughts about their appearance, the goal
being to promote greater self-acceptance (as advocated by Wilson, 1996). In Module VII (Weight
Goals) the focus is on helping patients to consider the origins, significance and possible arbitrariness of their weight goals, distinguishing these from their primary goals, while also helping them
to value any changes in weight that are occurring. This dovetails with Module VIII (Primary
Goals) which is designed to help patients address their primary goals directly. As shown in Fig.
1, Modules VI, VII, and VIII are used not only in Phase One but often throughout the rest of
the treatment.
Phase Two lasts a minimum of 14 weeks. It is introduced at any point between weeks 24 and
30, according to the patients progress, the goal being to establish weight stability both for the
rest of treatment and for the future. By this stage, most patients will have experienced a slowing
down in their rate of weight loss or it may have stopped altogether, although the majority will
not have reached their initial weight goal. In the later stages of Phase One this discrepancy
between their desired and actual weight will have been addressed (in Module VII), and body
shape concerns and other primary goals will be in the process of being tackled (in Modules VI
and VIII respectively). As a result, by the time that they enter Phase Two, patients are generally
willing to accept weight stability rather than weight loss as their objective, although this issue
may need to be re-addressed.
The main emphasis in Phase Two is on helping patients acquire the strategies and skills needed
for long-term weight control (Module IX, Weight Maintenance). These are as follows:
The regular monitoring of weight This needs to be indefinite in duration. It should provide
patients with knowledge of their weight and how it is changing while not encouraging preoccupation with day-to-day fluctuations.
The use of appropriate cognitive responses Patients need to learn to evaluate the significance
of any changes in their weight and to take appropriate action when necessary. They also need
to acquire the belief that they are capable of taking effective action to control their weight.
One aspect of this involves adopting flexible guidelines regarding eating since they are more
likely to be followed than rigid dietary rules. This minimises the risk of patients breaking their
rules and as a result abandoning their weight-control efforts.
The practice of behavioural skills both to minimise significant weight fluctuations and to correct
any significant changes which occur The former requires an understanding, obtained through
experience, of how to maintain a stable weight by sustaining healthy eating habits and an active
lifestyle (addressed in Modules IV and V respectively). The latter requires temporarily decreasing energy intake and, possibly, increasing activity level.

6. Conclusion
This paper has presented a cognitive behavioural analysis of the problem of weight regain in
obesity, together with a treatment derived from it. Promising initial results have led to the treatment being evaluated in an ongoing randomised controlled trial. This trial is designed to test both

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the efficacy of the treatment and the ideas upon which it is based. If, on the basis of the results,
the treatment retains its promise, the next tasks will be to modify it to make it more suitable for
dissemination and to conduct effectiveness studies. Possible adaptations of the treatment include
its use in combination with other methods of weight control such as pharmacotherapy and longterm support.
Acknowledgements
The authors and this programme of research are supported by a grant from the Wellcome Trust
(046386). CGF is a Wellcome Principal Research Fellow. We are grateful to Kelly Brownell,
Thomas Wadden and Rena Wing for their help with our research and to our colleagues Lynda
Barnes, Gillie Bonner, Susan Byrne, Lucy Carsen, Helen Doll, Elizabeth Eeley, Paige Forbes,
Deborah Lovell and Marianne OConnor. We are also grateful to Susan Byrne, Deborah Lovell
and Roz Shafran for their comments on the manuscript.
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