Why is it so difficult to lose weight and keep it off? By now, the "how" is no mystery: everybody knows the drill, whether you want to lose 2 pounds or 200. Just decrease your calories and get more exercise. And millions of people routinely set off with high hopes determined to do just that. Nevertheless, study after study indicates that while many succeed in losing some weight, the long-term results are overwhelmingly poor. The unfortunate reality is that if there's one thing as common in America as someone on a diet, it's someone who's fallen off a diet—who's gradually (or quickly) regained every ounce he or she struggled to lose, often adding pounds along the way. Why is it so hard to stick to a healthy eating plan and a reasonable exercise regimen?
From the viewpoint of Cognitive-Behavioral Therapy (CBT), the reason isn't hard to find: knowing what to do and knowing how to get yourself to do it are entirely separate skills. When it comes to changing behavior, especially long-term, habitual patterns, getting yourself to do something different, even when you know it's good for you, depends largely on what you tell yourself: that is, on your thinking.
For example, let's say you're at a dessert party and see five really delicious pastries. Will you end up eating too much? You probably will if you think, I don't care. I don't want to deprive myself. It isn't fair that everyone else gets to eat whatever they want, and I have to settle for one small piece. By contrast, if you say to yourself, "I'm going to pick my favorite dessert. I'll eat one small piece slowly and enjoy every bite. I know I'm going to feel so proud of myself," you stand a much better chance of not overeating.
To be sure, dieters aren't alone in having difficulty in getting themselves to take action to alter lifelong behavior patterns. When I began practicing CBT in the mid-'80s, I was struck by how hard it was to get many depressed clients to stop spending hours on the couch watching TV and begin to carry out the simplest tasks of daily life, even when it was apparent that taking such action was essential to improving their condition. But once we focused more closely on what these clients' unexpectedly active minds were telling them in the midst of their inactivity, it became clear that the roots of their apathy lay in their internal cascade of negative and pessimistic thoughts: This is too hard. I won't enjoy myself. It won't be worth it. What's the point? They got caught in a vicious cycle of dysfunctional cognitions: the more they believed their thoughts, the worse they felt and the less they did. The less they did, the more depressed they became and the less motivated to make changes.
Like depressed clients—or those with anxiety, substance abuse, or eating disorders—people who repeatedly find themselves unable to regulate their own weight typically can't get past their negative, dysfunctional thinking. After many years of practice, it's clear to me that to achieve their goals, unsuccessful dieters don't need to uncover hidden motivations or explore the hypothesized childhood origins of their problems. Instead, they need to learn how to address the dysfunctional thinking that leads to overeating.
I've developed a program for nonpsychiatric (and noneating-disordered) individuals that utilizes the basic principles of CBT to address overeating directly. For all their differences in personality, background, and psychological profile, I've found that unsuccessful dieters all have one characteristic in common: self-sabotaging thinking. A day, a week, three weeks into a diet, they're tempted to eat something that's not on the plan because of what they think: It's OK for me to eat this because . . . I'm really sad and need to cheer myself up. . . . I feel happy right now, and I want to keep this good mood going. . . . I'm working really hard and I need a reward. . . . I'm celebrating! . . . If I let myself get too hungry, something bad will happen: maybe I'll faint! . . . There's no point in continuing to diet, since I've lost only a couple of pounds after two weeks.
Thoughts like these are completely natural for dieters, but they aren't helpful. To deal with them, dieters need to learn how to anticipate them and prepare themselves in advance, while continuing to remind themselves why it's worth the effort to limit their eating. So a major component of a successful CBT dieting strategy is helping clients learn to practice responses to the thoughts that undermine motivation, increase disappointment, and exacerbate a sense of deprivation—all of which reinforce old, maladaptive eating patterns.
Perhaps the most basic tool that helps clients learn the cognitive skills they need to adhere to their diets is the use of index cards on which they write messages they'll need to read when they're tempted to overeat. They develop the practice of reading "response cards" containing these helpful messages every morning and at least one more time, at their most vulnerable part of the day. Here are a few examples of response-card messages:
- I can eat whatever I want, whenever I want, or I can be thinner. I can't have it both ways.
- Hunger and craving always pass. I can make them go away faster by focusing my attention on something else.
- My body doesn't know it's a holiday. It'll process food in exactly the same way as on other days.
Reading these cards daily, even when motivation is high, allows dieters to immerse themselves in crucially important ideas that prepare them for the inevitable difficult times, especially the thoughts that lead to negative, motivation-sapping emotions: This is just too hard leads to discouragement. It's not fair leads to anger and a sense of deprivation. I really want to eat this right now leads to disappointment. Dieters can't prevent these sabotaging thoughts from entering their minds, but if they've been practicing helpful responses, they'll be able to deal with them and modify their habitual eating behavior.
Research is increasingly demonstrating that lasting behavioral change—not only in eating, but also in the areas of substance use, overspending, procrastination, gambling, aggressive behavior, or self-harm—requires changes in dysfunctional thought patterns. To challenge old, entrenched patterns, people need to know what to tell themselves when they're feeling stressed, tired, unmotivated, discouraged, disappointed, or deprived; when they want to overindulge because of cravings or emotional distress; when they want to celebrate, keep a good mood going, or eat like everyone else.
Despite the fact that the dieting industry has largely failed to recognize the importance of changing thought patterns when attempting to change behavior, a growing body of recent research bears out the importance of having a dual emphasis on behavior and cognition. For example, in a study reported in 2005, psychiatrists Lisbeth Stahre and Tore Hallstrom found that participants in the CBT modality of their randomized controlled trial lost, on average, 17 pounds. Even more impressively, they continued to lose, on average, another 5 pounds during the 18-month follow-up period, while patients on the waiting list gained weight. Likewise, another randomized controlled trial of dieters who received CBT, conducted by psychologist Marieke Werrij of Maastricht University and colleagues, reported in 2009, found that they not only lost weight, but also were more successful in keeping it off than those in a program without CBT. The results of these studies and others like them contrast starkly with a metanalysis performed by weight-loss expert Michael Dansinger and reported in 2007. He found that dietary counseling focusing on nutritional and behavioral advice produces little weight loss—and dieters almost always gain weight back.
Yet, despite the growing evidence for its power as a dieting strategy, CBT is currently only a blip on the radar screen of the vast American weight-loss industry. Why do so few of the hundreds, if not thousands, of companies promoting diet plans, books, or weight-loss programs incorporate CBT in their approach? Despite becoming the treatment of choice for a multitude of behavioral and psychological problems, why hasn't CBT caught on more in the weight-loss world?
There are many factors accounting for this, few of which have anything to do with scientific findings. Perhaps the most consequential is that the weight-loss industry is dominated by pharmaceutical companies, which obviously have an interest in selling drugs. Unfortunately, however, research to date shows that most of these medications produce only a modest loss of weight, with high relapse rates and often highly unpleasant side effects. Another factor is that psychological approaches to weight control up to now have been dominated by behavior therapists, who tend to view dieters' thought patterns as relatively unimportant, focusing instead on teaching dieters what to do, how to arrange their environments, and how to set up reward systems. While these are important skills, most dieters tend to discontinue them after a while. And a key factor standing in the way of the wider adoption of CBT methods is one never to be underestimated in American culture—our love of a quick and easy fix. People just don't like the message that losing weight and keeping it off are ongoing, lifelong tasks. They prefer to think that they can make short-term changes, lose weight, and then return to what they used to do.
Successful Weight Loss and Maintenance
The single most important lesson I learned early in my work with dieters is that it's a mistake to ask them to develop the cognitive and behavioral skills they need to stick to a diet at the same time they actually start their diet plan. It's too difficult for most people to change their eating plan and simultaneously learn the skills that will enable them to stick to it. Instead, I've developed a 5-stage program, in which dieters don't change when they eat or what they eat until they've mastered basic skills. It follows this sequence:
Stage 1: Developing pre-dieting skills (learning how to stay motivated, getting oneself to use good eating habits, dealing with hunger and cravings, and recovering immediately from an eating mistake)
Stage 2: Regularizing eating (eating according to a schedule)
Stage 3: Changing food selections (making changes that one can continue to follow for a lifetime)
Stage 4: Planning for special occasions (making decisions in advance that allow one to eat more flexibly)
Stage 5: Staying motivated for life—especially when the scale stops going down, or there's a lapse or relapse
There's no special "maintenance phase." When dieters' weight reaches a plateau, they keep on eating in the same way they did when they were actively losing weight. Whatever changes dieters make in their eating, they make permanently.
So how does this approach work in practice? Let's consider Jean, who entered my office one day more than five years ago. She was 52 and carried 228 pounds on her 5-foot, 2-inch frame. She wore an old black sweat suit. (She said later that she hated shopping for clothes and hadn't wanted to buy anything new until she'd lost weight.) She sat hunched over in her chair, her head hanging down dejectedly.
Jean had more than her fair share of emotional, financial, and physiological stress. She was struggling to support herself and the three grandchildren who lived with her on her salary as a school cafeteria worker while dealing with her prediabetic medical condition: high blood pressure and knees that hurt badly when she walked. Because of her weight, her self-esteem was in the basement, and her confidence in her ability to lose weight was almost zero. "To be honest with you," she said, "I don't think you can help me. I've been dieting on and off since I was 12. I've tried every diet in the world. I've lost 10 pounds more times than I can count, but I've always gained them back—and more."
While empathizing with Jean, I also knew it was important to give her realistic hope. So I asked her whether anyone had ever taught her how to diet. She was puzzled. I gave her some examples: "Did anyone ever teach you how to motivate yourself every day? Or enjoy every bite you eat? Or give yourself credit every time you follow your plan? Or get right back on track when you make a mistake?"
When she replied that she hadn't ever learned, or even heard, of any of these skills, I said, "Good. That gives me hope for you. I think the problem has always been that you never learned how to diet. No wonder you've had trouble." I then gave her an analogy: "If you'd never tried to play the piano before, would you be surprised if you sat down one day, with a page of sheet music in front of you, and found you couldn't follow the notes at all, much less play a beautiful piece of music? Of course not. You'd know that to be a good pianist, you need someone to teach you how to read music and how to play, and then you'd have to practice your new piano skills, over and over. Pretty soon, playing the piano would become easier and eventually you would be able to play that piece of music. It's the same with dieting. You can't be successful until someone teaches you how."
She still wasn't convinced. "Well, I can see how that might help other people," she said hopelessly, "but I don't know if I can ever lose weight."
I repeated her idea aloud, "I can't ever lose weight," and jotted it down. "Well, it would be interesting to find out whether that thought is 100 percent true, 0 percent true, or someplace in between. Would you be willing to do an experiment?" I asked. "Would you like to work together for six weeks and see what happens? I have to warn you, though, that I don't expect you to lose much weight in six weeks. In fact, I don't want you to make major changes in your eating right away. It may take several weeks for you to learn the skills you need before you actually start a diet."
Jean looked startled. "I thought you'd tell me I have to eat, like, 1,000 calories a day, starting today."
"No," I said. "That's exactly what I don't want you to do. First, 1,000 calories is too low for almost anyone to keep up long term. You'd just be setting yourself up for failure—either now or in the future. I don't want you to make any changes in your eating that you can't keep up for life.
"Second, I don't want you to start a diet until you've learned the skills I mentioned before; until you know exactly what to do and what to say to yourself so you can get yourself to use good eating habits. I also want you to know exactly what to do to get right back on track when you eat something you're not supposed to."
Now she looked relieved. She let out a big sigh. "This does sound different," she acknowledged. "I've always just gone full steam ahead when I've started a diet." Jean agreed to work with me.
Stage 1: Developing Pre-Dieting Skills
In this first stage, dieters don't change what they eat, although they can gradually reduce portion sizes, if they like. Too much attention to food at this point means less attention to mastering essential skills. Instead, dieters learn the skills mentioned above and others in a step-by-step fashion, practicing each new skill over and over until they've mastered it. Then they learn and master the next one. For example, they learn how to motivate themselves by creating a list of all the reasons they want to lose weight, and then they read this list each morning and again later in the day.
Most dieters come up with at least 15 to 20 reasons initially. ("I want to feel better about myself. I want to look better. I want to have more energy. I want to cut back on my medication.") While it's easy for dieters to read the list, it's more difficult to respond to sabotaging thoughts that get in the way of reading it. (I don't have to read it: I know what the reasons are. I'm feeling motivated right now so I don't need it. I can rehearse the reasons in my head.) At this point, we usually discuss how effective their dieting efforts were in the past when they didn't have a list to read each day. I ask them about the last time they ate something they were sorry for, and whether all the reasons for losing weight were really clear in their minds at that moment. Eventually most clients get the point: if they want to be successful, they have to learn to do things differently.
Some Stage 1 skills were easy for Jean to learn: she had no trouble reading her list of reasons to lose weight and taking a short exercise walk every day. But initially, she had a great deal of difficulty eating everything slowly and mindfully while sitting down. "I like to eat standing up—and I like to eat fast," she said. "I don't see why I need to sit down. It's the same food, isn't it?"
I explained that she couldn't possibly enjoy every bite fully if she ate quickly, while standing up. As we spoke, she recognized that all of her minibinges occurred when she stood in front of her open refrigerator and food cabinets, quickly shoving food in her mouth so she wouldn't notice how much she was eating and feel guilty. She realized that good eating habits had to become a lifetime rule if she wanted to quit minibingeing and lose weight permanently.
By the end of Stage 1, which took Jean almost four weeks, she'd lost a few pounds even though she wasn't following a diet plan. Savoring every bite enabled her to get more satisfaction from food, and she naturally began to eat a little less. She also learned to get over her intense fear of hunger, a powerful negative emotion for many unsuccessful dieters. Previously she'd believed that she should avoid ever becoming hungry—she thought that if she did become hungry, it would get worse and worse until she could no longer stand it. With the approval of her doctor, she skipped lunch one day, eating nothing from breakfast until dinner time. This experiment proved to her that hunger was only mildly uncomfortable and that she didn't feel hungry throughout the whole day: she had short periods of hunger, which she tolerated fairly easily.
When she was experiencing craving or the desire to eat for emotional reasons, Jean learned to distract herself by calling a friend, taking a walk, doing a Sudoku puzzle, or painting her nails. More importantly, she learned to change her thinking. Twice a day, she read through her response cards. Some of the more helpful cards were, "If I eat this junk food, it'll feel good for a few moments, but then I'll be mad at myself." "Cravings always go away." "Extra food will always go to waste—either in the trash or on my body."
Stage 2: Regularizing Eating
In this stage, dieters learn to eat according to a schedule, which is particularly important because dieters often have difficulty recognizing true hunger and are susceptible to sabotaging thoughts that give them "permission" to eat whenever they want. They get the physiological boost that food gives them on a regular schedule, providing themselves with fuel at predetermined times throughout the day (starting with breakfast) to avoid excessive hunger and cravings that can lead to overeating.
In this stage, dieters experiment to find which schedule works best for them. Most eat three meals and three snacks a day. Some eat three (slightly larger) meals with no snacks. Some avoid snacks during the day, but have two snacks in the evening. They employ the skills they learned in Stage 1 when they want to eat off-schedule and learn how to respond to sabotaging thoughts such as, I should be able to eat whenever I want. At the end of Stage 2, most people have continued to lose weight because they aren't eating as frequently.
Since she was accustomed to eating at will, Stage 2 was difficult for Jean, who found it hard not to head for the refrigerator at every hunger pang. While she agreed in principle with the necessity of regularizing her eating, she was initially besieged with sabotaging thoughts, especially, It won't matter if I eat this one extra time. I reviewed a fundamental concept with her: that every act of eating was important, even if it was just a small amount. "Every time you eat when you're not supposed to," I explained, "you strengthen your 'giving-in' muscle, which makes it likelier that the next time, you'll give in to unscheduled eating, and the time after that, and the time after that. But every time you resist unscheduled eating, you build up your 'resistance' muscle, which makes it likelier that you'll be able to resist unscheduled eating the next time and the time after that. So every unscheduled eating decision is important." Jean wrote this idea on a response card and continued to create cards for new sabotaging thoughts. It took her nearly three weeks to master the skill of scheduled eating.
Stage 3: Changing Food Selections
At this point, dieters are finally ready to change what they eat, one step at a time. They avoid making changes they can't keep up for life. They learn how to respond to sabotaging thoughts, so they can get themselves to eat fruits and vegetables at the beginning of every meal, decrease caloric beverages, limit junk food to just once a day, and decrease portion sizes. If followed, these four steps naturally lead to weight loss.
In this stage, some dieters decide that these changes are enough; they don't want to commit to the considerable amount of effort required to make additional changes. But for those (like Jean) who do, they next learn the skill of planning what they're going to eat in advance (each evening or morning) and monitoring their intake as they go along. In the final part of Stage 3, dieters can start following a balanced eating plan that incorporates moderate portions of their favorite foods and contains enough calories to satisfy them over the long haul. There's no sense in cutting calories to a minimum because dieters will become too hungry, overeat, gain weight, become discouraged, and find themselves right back on the old treadmill. To minimize hunger, the diet plan needs to contain substantial amounts of protein and a moderate amount of fat at every meal.
For the most part, Jean did well in Stage 3. She loved the idea that no foods were ever out of bounds and that she could plan to have a favorite food every day. She usually planned to have a moderate portion of ice cream, but only at bedtime, so that if a craving for more hit her, she'd be in bed. Her greatest difficulty was getting herself back on track when she made a mistake, since she struggled with common sabotaging thoughts, such as: I can't believe I ate that. I'm so weak. Oh, well, I might as well eat whatever I want for the rest of the day, and start again tomorrow.
To help Jean see the irrationality of this line of thinking, I suggested an analogy:
"If you went through a red light by mistake, would you say to yourself, 'I can't believe I did that! Oh, well, I might as well keep going through red lights for the rest of the day, and start driving carefully tomorrow?'" She got the point: it makes no sense to compound one mistake with more. I also explained to her that if she ate an unplanned 300-calorie piece of cake, it probably wouldn't even show up on the scale at the end of the week, but if she used one mistake as a justification to eat whatever she wanted, she'd see the negative consequences on the scale the next morning. It took Jean almost two months to consistently get herself back on track whenever she ate something she wasn't supposed to. But the more she was able to limit her mistakes, the more her confidence grew, until she finally mastered this essential skill.
Stage 4: Planning for Special Occasions
At this stage, dieters learn how to handle special eating situations—restaurants, travel, holidays, social events, illness, and increased stress. Although problem-solving is usually beneficial, dieters most need to learn to respond to the sabotaging thoughts that give them permission to abandon their diet plan altogether. They develop "special occasion guidelines" that allow them to increase their calories temporarily, and in a controlled way.
Jean had typical sabotaging thoughts when faced with special occasions. When considering Thanksgiving, for example, she predicted that she'd probably think, I deserve to eat whatever I want. It's not fair that I have to limit myself. I want to be able to eat and drink like everyone else. So I asked Jean what her goal was: to eat whatever she wanted on special occasions or to lose weight permanently. After explaining that the two goals were incompatible, I helped her develop a reasonable rule for herself: as long as she had no more than two special occasions per week, she could eat about 300 calories more at those events. Expecting her to eat in exactly the same way as on an ordinary day just wasn't reasonable—it was more important to make sure that she didn't revert back to her old way of eating, gain weight, become demoralized, and perhaps quit the diet altogether.
Stage 5: Staying Motivated for Life
By the final stage of the dieting process, the focus is on helping clients learn to cope with declining motivation after they reach their ideal weight (which I define as the weight at which they plateau when they're eating a healthy diet they can keep up for the rest of their lives—plus about 5 to 10 pounds). Dieters need to start preparing themselves in Stage 1 for the probability that they won't lose as much weight as they'd like, and they need to work hard in Stage 5 to deal with the disappointment they feel when the number on the scale no longer goes down. The emphasis here is on practicing skills to continue to motivate themselves daily, arrest mistakes before they turn into setbacks, and recover from setbacks so they don't turn into full relapses.
From the beginning of treatment, Jean had struggled with the idea that, if she were to avoid the dieting roller coaster, she'd need to continue to eat in the same way as long as she lived. We'd spoken about this repeatedly, but it hadn't really sunk in. I explained it to her in this way: "You've lost 48 pounds and seem to have stopped losing weight. I think we should officially declare that you're in maintenance."
"Does that mean I can start to eat more?" she asked.
"It depends on your goal," I replied. "If you want to stay at 180 pounds, you'll have to keep eating exactly as you have been. If you're willing to gain a few pounds, you can eat a little extra. What's your preference?"
Like many dieters, Jean half-believed that she could somehow magically go "off" the diet and eat exactly the way she used to eat without regaining weight. Although disappointed, she understood the reality of the situation and decided to stay at the same caloric level. Six months later, she raised the level, deciding that being able to eat some more was worth the few extra pounds she'd gain.
The bottom line of the CBT approach is that maintenance is really no different from the losing-weight phase of the plan, and dieters continue to eat in the same way. When the approach succeeds, most skills, such as eating everything sitting down, slowly and mindfully, have become automatic habits by this point. Dieters can reinstitute other techniques, such as reading response cards, on an as-needed basis, whenever motivation starts to slip or they're going through a difficult stretch.
It took Jean just about a year to lose 48 pounds. Initially, we had weekly sessions, and then spaced them out to once every two or three weeks, with brief weekly phone calls. Toward the end of the first year, I was seeing her once a month. We continued to have occasional booster sessions or phone check-ins after that. Jean has now maintained a weight loss of 44 pounds for the past four years—a goal she never thought she'd achieve.
Hope for the Future
Perhaps the most important lesson I've learned from my clients and other clinicians is the necessity of preparing dieters for difficult times. Dieters get fooled when they start a diet. Initially, they find dieting easy. Why? Because they only begin a diet when they're feeling highly motivated, and losing a significant amount of weight the first week—most of which is actually only water weight—keeps them motivated.
But dieting gets harder for everyone after a few weeks or months. Fortunately, dieters don't need to plumb the depths of their psyches to find out why dieting has become more difficult. To lose weight, they don't need to radically change their relationships with other people. They don't need to look for unconscious reasons for abandoning their efforts. They just need to learn basic cognitive and behavioral skills, including motivational techniques to get themselves to use these skills, regardless of how they're feeling. In this way, they can successfully lose weight, much as they've been successful in other areas of life.
In the past 30 years, CBT has been shown to be effective for a host of psychiatric, psychological, and behavioral problems. It's good news that a clear, systematic, easily teachable clinical approach for weight loss and maintenance is beginning to emerge and a scientific foundation for this approach is being established. If the encouraging studies on CBT, like those published in the last few years, continue, we may be entering into a new era—one in which Americans turn away from trendy, often dangerous diet fads and stop wasting billions and billions of dollars. After decades of dismal results for this public-health crisis, a truly effective, empirically supported way of helping people safely and reliably lose weight is finally on the horizon.
Photo by Kampus Production
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