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.