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 okay 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 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.
Hope for the Future
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. 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.
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