Cognitive-Behavioral Interventions for Obesity
Marghani M. Reever, PhD, LCSW
Abstract: This article reviews the use of cognitive-behavioral inter-
ventions as a part of the overall treatment for obesity. Obesity has been
declared a world-wide epidemic and the United States is a part of that
epidemic. There are an estimated 300,000 preventable deaths that oc-
cur each year in the United States as a result of an unhealthy diet and
physical activity. There has been a great deal of research conducted on
various treatment options for obesity including nutrition counseling,
exercise, cognitive-behavior management, pharmacological therapy and
even surgery for those considered to be morbidly obese. Additionally,
there has been much research conducted on why people become obese. It
is not at all clear whether obesity is a function of genetic predisposition
or a response to environmental influences or a combination of both.
Unfortunately, all treatments do not fit all people. More and more it
is being recognized that obesity is becoming a chronic disease and the
treatment must be tailored to the individual patient.
Introduction
Obesity has been declared a world-wide epidemic and the
United States is a part of that epidemic. There are an esti-
mated 300,000 preventable deaths that occur each year in
the United States as a result of an unhealthy diet and physical
activity. Not only does obesity have the potential for serious
physical impairment, it also has great potential for negative
psychological ramifications. All of this is in addition to the
real and potential economic consequences experienced due to
weight related health complications: 40 to 70 billion dollars
a year in the U.S. alone.1
There has been a great deal of research conducted on various
options for obesity treatment including nutrition counseling,
exercise, cognitive-behavior management, pharmacological
therapy and surgery. It is not at all clear whether obesity is a
function of genetic predisposition, a response to environmental
influences or a combination of both. Often the philosophy
of why people are obese dictates the type of treatment that
is recommended.
Unfortunately, all treatments do not fit all people. More
and more it is being recognized that obesity is a chronic
disease with multifactorial etiology, and the treatment must
be tailored to the individual patient. This is evident in the
popularity of numerous weight loss programs that are very
distinct from each other, focus on very different issues and
are successful with various types of people. An example of
this would be the difference between an Atkins type diet
(low carbohydrate, don’t worry about the fat) and a Weight
Watchers type diet (based on number of calories without
restricting any particular food group). Both have had some
successes and many failures. They work in different ways
using varying philosophies.
Address Correspondence to: Marghani M. Reever, PhD., a licensed
clinical social worker and courtesy lecturer for the University of
Florida Shands-Jacksonville, OB/GYN Department, Jacksonville,
FL. Email: reeverm@bellsouth.net.
www . DCMS online . org
Knowing what the patient thinks and believes regarding
weight issues becomes an important tool in being able to
tailor a program that will increase the possibility of successful
weight loss and maintenance. Using behavioral interventions
individually or as an adjunct to other types of weight loss/
maintenance treatment may help increase compliance, endur-
ance and long-term success. This paper provides a snapshot of
several different types of behavioral interventions and some
of the research support for the interventions.
Barriers
Multitudes of studies are unanimous in identifying the
key to weight loss. Energy input must be less than energy
output. No matter what miracles are offered through the
media, in order to lose weight, some combination of eating
less and exercising more must be implemented. Additionally,
most people would agree that weight loss is easier relative to
weight loss maintenance. Taking off pounds is not nearly as
difficult as keeping those same pounds off over a sustained
period of time.
There are many barriers to dealing with obesity as a chronic
medical condition including lack of payment by most insur-
ance plans for obesity-related treatment; not enough time for
patient education and counseling on weight loss and weight
loss maintenance; failure to recognize that obesity may be a
chronic illness that will require long-term management; poor
motivation on part of the patient and/or provider; denial on
the part of the patient; and negative perceptions on the part
of the provider that obesity is simply a lack of self-control
and discipline.
One significant but under-researched barrier to effective
weight loss and weight loss management is ‘goodness of fit’
between an individual and a particular weight loss program.
Many studies demonstrate the effectiveness of various pro-
grams. However, what is not often discussed is that people
with certain personality traits, eating patterns, temperaments,
or lifestyles will be more successful with some weight loss
programs than others. Many people have had great success
with the Atkins diet, while many more have not. The same
is true for Weight Watchers, South Beach, Jenny Craig and
all other structured weight loss programs. The distinction
between those who succeed on one plan versus those who
fail, or perhaps more significantly, those who succeed on one
plan after failing many others, lies in the concept of ‘goodness
of fit. There must be a ‘goodness of fit’ between the person
and the plan for success to be achieved and sustained over a
period of time.
Another major barrier to successful weight loss and weight
loss maintenance is the social environment. This not only
includes the easy access to foods that will sabotage any weight
Northeast Florida Medicine Vol. 59, No. 3 2008 37
loss program, but also includes the value that society places
on food. It is used to celebrate, to mourn, to deal with stress,
to reward ourselves, and to comfort. Whatever the emotional
need, in our culture and many others, food is the answer. This
social norm can provide a hostile environment to anyone who
is serious about weight loss. Another environmental barrier
is the reduced necessity of physical activity in our society.2 In
order to get exercise in our world today, we must schedule a
time and a place and dedicate ourselves to this “task.” As it
is unlikely that our society is going to spontaneously undergo
major changes in these areas, these barriers have to be dealt
with on both a cognitive and behavioral level.
The cognitive component of weight loss and weight loss
maintenance should not be underestimated. The brain is a
powerful tool that can be utilized either for the positive or
for the negative. Consider the issue of weight loss expecta-
tions and their influence on the definition of success. If a
patient has been told that it is in his/her best health interest
to lose weight and she/he believes that the expectation is 100
pounds, the perception is of guaranteed failure. A realistic goal
is 5-10% of body weight, or 15-30 pounds for a 300-pound
individual. Does it sound better to the patient’s mind to hear
“you need to lose about five percent of your body weight” or
“start with 15 pounds”? A person’s expectations regarding
ability to succeed will influence the motivation to continue
or discontinue a weight loss program.
Cognitive Behavioral Treatment
In essence, any effective treatment for obesity will involve
a cognitive behavioral approach. In order to not just lose
weight but to maintain weight loss, there must be a combina-
tion of thinking and behavioral changes. Regardless of the
specific weight loss plan (type of food plan, pharmacologic
intervention, surgery, etc), the need for cognitive and behav-
ioral changes remains paramount as part of an overall weight
loss/maintenance strategy. Even patients who undergo more
radical weight loss interventions must go on eating, and if
there is not cognitive-behavioral change, there will be weight
problems in the future. It is often said in Weight Watchers
meetings, “If you always do what you always did, you will
always get what you always got.” Cognitive change without
behavioral change is nothing more than a thinking exercise
and behavioral change without cognitive change is doomed
to failure. Cognitive behavior therapy (CBT) is not a specific
intervention but the use of systematic principles of social
cognitive theories to modify behaviors.3 While used for many
different psychological issues, in this case, CBTis utilized in
specific strategies with the goal of modifying the thinking and
the behaviors that contribute to obesity. The CBT strategies
most often utilized are described below.
Cognitive Behavioral Treatment Strategies
Motivational Interviewing
Greenwald4 makes this profound statement, “Individuals
must be self-motivated and amenable to change in order to
achieve success with their weight loss goals.” This may not
seem like ‘rocket science’, however one of the biggest issues
38 Vol. 59, No. 3 2008 Northeast Florida Medicine
in weight loss failure is the lack of motivation. For many
people, it does not matter how many statistics have proven
that obesity contributes to poor health, decreased productiv-
ity and quality of life, that money is lost as a consequence of
obesity, or even what the World Health Organization has to
say. Food tastes good, and they are not motivated to change
their eating habits. Many health care providers decide that
their patient is not motivated to change, so they don’t even
broach the subject.
Motivational interviewing is a patient-centered approach
to promoting behavioral change by exploring ambivalence
in a non-judgmental, supportive and directive style.5 In a
nutshell, it is earnestly trying to understand the patient’s
degree of willingness to make changes, including discussing
what they are not willing to change. The goal of motivational
interviewing is to move the patient a little further along the
continuum of change from 1) absolutely refusing to admit there
is a problem, to 2) admitting a problem but being unwilling
to do anything, to 3) being willing to think about changing,
and finally to 4) actively pursuing change. The recognition
that a patient is not going to jump immediately to actively
pursuing change frees the health care provider from feeling
like a failure. The recognition that successful intervention
would simply move the patient closer to meaningful change
allows for both the provider and the patient to experience a
sense of success and may increase motivation for the patient
to keep moving along the continuum.
In a study conducted by West, et al it was determined
that motivational interviewing significantly enhanced both
weight loss and glycemic control among overweight women
with type 2 diabetes. They state, “the beneficial impact of
motivational interviewing was apparent after only two ses-
sions with significantly greater weight loss and improvement
in metabolic control at 6 months.” 5
Self Monitoring
Self monitoring is exactly what it says. One self-monitoring
tool is to simply record calorie intake. The increased aware-
ness of calorie intake is the most obvious way of determining
when calorie intake is decreasing. Many people assume that
they generally know how many calories they consume or if
they are consuming large amounts or moderate amounts of
calories. This tends not to be true. A study conducted at
Cornell University determined that for some people portion
size determines calorie intake. When subjects were served
increasingly larger portions, they ate more food.6 These results
also reinforce results of several other studies that have shown
that the consumption of foods is directly related to the size
of the container in which they are served. Everyone knows
that a serving is one; one bag, one container, one tube of Girl
Scout cookies. Another study compared two groups of eat-
ers: one group eating regular-sized bowls of tomato soup and
the other group having bowls that were continuously refilled
(unknown to the eaters). The second group ate 73% more
than the first group. Bowl groups were instructed to eat until
they were full. One of the eaters, when asked if he was full,
replied, “Why would you think I’m full? I still have half a
bowl to go.” He had consumed almost a gallon of soup.7
www . DCMS online . org
 Writing down what is eaten is a well-utilized self monitor-
ing weight loss tool. A study by Carels, et al found that when
subjects were given the goal of losing 5% of their body weight,
those who lost the weight self-monitored more than twice as
many days than those who failed to lose the weight.8
Another self-monitoring tool is tracking one’s weight. This
exercise provides immediate feedback to a person. This can
be positive or negative. Some health care providers recom-
mend that patients weigh themselves no more than once a
week. Others suggest once a day. It depends on the patient’s
motivation as it relates to positive and negative feedback.
A study conducted by Butryn, et al9 found that “consistent
self-weighing may help individuals maintain their successful
weight loss by allowing them to catch weight gains before
they escalate and make behavior changes to prevent additional
weight gain.”
Stress Management
The correlation between stress and unhealthy coping
mechanisms is well known. Many people say that they eat,
drink, smoke, etc. when they are stressed. A structured and
utilized stress management program may reduce the level of
stress and promote healthy behaviors. This requires both
cognitive and behavior changes. While the steps to stress
management may be quite simple, it remains an over-dis-
cussed and under-utilized form of behavior change. There
are numerous programs and strategies that teach people how
to manage stress. One simple stress management model
involves identifying symptoms of stress (physical, psychologi-
cal and behavioral), identifying stressors (concrete or fluid,
i.e., can they be changed or not), developing a plan to deal
with stress (may include any healthy behavior that reduces
the level of stress such as exercise, reading, or taking a bath),
and evaluating and modifying the plan. A concrete formula
given to a patient may be the motivating factor to develop a
personal stress management plan. Done correctly, this may
be very helpful for those people who tend to deal with all
stress by eating.
Hypnosis
Hypnosis is defined as a “relaxed state of focused atten-
tion.”10 The American Medical Association approved hypnosis
as an appropriate tool for qualified professionals in 1958. In
a study completed by Bolocofsky, et al,11 [1985] they dem-
onstrated that more of the subjects achieved and maintained
their weight loss goals with hypnosis than without. In a 1996
meta-analysis of the effect of adding hypnosis as a cognitive
behavioral treatment for weight loss reduction, it was found
that the mean weight loss was greater for those with hypnosis
than those without and that after a period of time, weight loss
maintenance was better for those with hypnosis than those
without.The author determined that the benefits of hypnosis
increased substantially over time.12
Cognitive Restructuring
Cognitive restructuring means to deliberately change the
way that we think. It teaches patients to identify, challenge
and correct irrational thoughts that impact eating behaviors.1
www . DCMS online . org
Instead of thinking, “It’s been a hard day at work and I de-
serve a good meal and a great dessert,” we need to learn how
to restructure our thought process (and possibly our value
system) to make ourselves believe that there are rewards other
than food that can meet emotional needs. Like all Cognitive
Behavioral Treatment (CBT) tools, this is easier said than
done. In many ways another CBT technique, problem solv-
ing, is also cognitive restructuring. It is learning to develop
a system of dealing with whatever problem presents itself in
ways that do not involve consuming food.
Social Support
Social support is in itself not a CBT strategy. However,
the concept of utilizing social support is an important aspect
of both the cognitive and behavioral aspects of weight loss.
Many weight loss programs rely on the concept of social
support as part of their success. Social support may come in
the form of peer groups that meet on a weekly or monthly
basis to support weight loss efforts, friends or co-workers
getting together to support each other in weight loss efforts,
family members providing encouragement and support for
the patient or any number of other gatherings that provide
the patient with increased motivation to continue weight
loss efforts. Hopefully, the social support helps the patient
to obtain and maintain cognitive and behavioral changes in
relation to unhealthy eating habits. Social support draws on
both positive and negative reinforcement concepts, and on
such vastly different personal motivators as teamwork (“Let’s
see how much the group lost today”) and competition (“Who
lost the most weight today?”).
Relapse Prevention
Whether or not obesity constitutes a true addiction to
food is currently being debated. However, there do appear
to be a number of similarities between substance abuse and
unhealthy eating patterns. One of the similarities is the role
of relapse prevention in increasing the ability to maintain
desired behaviors. Relapse prevention refers to the identifica-
tion of triggers and high- risk situations and the development
of a plan to deal with them. Like the alcoholic, many people
with ongoing weight issues can identify situations where
their resolve to work their plan is tested and their ability to
remain strong is severely challenged. In relapse prevention,
these situations are identified ahead of time and a plan is de-
veloped to determine how the person will cope. Many times
these situations may be acted out so the person can practice
implementing their plan.
Summary
Although the degree to which cognitions and behaviors (as
opposed to genetics or metabolic factors) cause obesity is a
subject of great controversy, behavioral management clearly
plays a strong role in weight loss. Behavioral management may
be as simple as identifying and mitigating barriers to weight
loss. Other common techniques integrated into many weight
loss programs include self-monitoring and social support net-
works. More sophisticated cognitive-behavioral approaches
include motivational interviewing and hypnosis. Any or all
Northeast Florida Medicine Vol. 59, No. 3 2008 39
of these techniques may be used alone or in combination
with other strategies such as diet, pharmacology, or surgery, to
help produce the desired effect of durable weight loss. Most
importantly there is very little risk and a potential for high
return in adding a cognitive-behavioral aspect to any weight
loss/maintenance program.
References
1. Wadden TA, Foster GD. Behavioral treatment of obesity.
Medical Clinics of North America. 2000:March;84(2).
2. Westenhoefer J. The therapeutic challenge: behavioral changes
for long-term weight maintenance. International Journal of
Obesity. 2001:25, Suppl 1; 585-588.
3. Foreyt JP, Poston WS 2nd. What is the role of cognitive-behavior
therapy in patient management? Obesity Research. 1998 Apr;6
Suppl 1:18S-22S.
4. Greenwald A. Current nutritional treatments of obesity. Adv
Psychosom Med. 2006; 27:24-41.
5. West DM, DiLillo V, Bursac Z, Gore SA, Greene PG.
Motivational interviewing improves weight loss in women
with type 2 diabetes. Diabetes Care. 2007;30(5):1081-1087.
6. Levitsky DA, Youn T. The more food young adults are served,
the more they overeat. Journal of Nutrition. 2004; 134:2546-
2549.
7. Wansink R, Painter JE, North J. Bottomless bowls: why visual
cues of portion size may influence intake. Obesity Research.
2005 Jan;13(1):93-100.
8. Carels RA, Young KM, Coit C, Clayton AM, Spencer A, Hobbs
M. Can following the caloric restriction recommendations
from the Dietary Guidelines for Americans help individuals
lost weight? Eating Behavior. 2008 Aug;9(3):328-335.
9. Butryn ML, Phelan S, Hill JO, Wing RR. Consistent self-
monitoring or weight: a key component of successful weight
loss maintenance. Obesity. 2007 Dec;15(12):3091-3096.
10. Temes, R. Scientific Weight Loss Secrets: Tips from the
Psychological Research.Ebook. www.hypnosisnetwork.com.
11. Bolocofsky DN, Spinler D, Coulthard-Morris L. Effectiveness
of hypnosis as an adjunct to behavioral weight management.
Journal of Clinical Psychology. 1985 Jan;41(1):35-41.
12. Kirsch I. Hypnotic enhancement of cognitive-behavioral
weight loss treatments—another meta-reanalysis. Journal of
Consulting Clinical Psychology. 1996 Jun;64(3):517-519.

DCMS/Navy Dinner Meeting

Tuesday, September 23, 2008
NAS Jacksonville Officers’ Club
Reception 6:00 p.m./Dinner Buffet w/cash bar/Program 7:00 p.m.

Guest Speaker: RADM Michael C. Vitale,

USN, Commander, Navy Region Southeast

$25.00 per person

RSVP by September 12 to Patti Ruscito,
DCMS (904-355-6561 x104 or
pruscito@dcmsonline.org)

40 Vol. 59, No. 3 2008 Northeast Florida Medicine www . DCMS online . org