Leslie Heinberg, PhD, on CBT’s Role in Treating Obesity

Obesity affects nearly 40% of adults in the United States and is often tied to comorbid conditions like cardiovascular disease, diabetes, and cancer.¹ Patients with obesity also commonly present with psychiatric comorbidities, such as depression, anxiety, and eating disorders, which can complicate the management and treatment of their condition.²

Due to the complexity of obesity, treatment often requires a multidisciplinary approach involving cognitive behavioral therapy (CBT). Leslie Heinberg, PhD, from Cleveland Clinic and the American Society for Metabolic and Bariatric Surgery, discussed the importance of CBT and addressing psychiatric comorbidities in treating patients with obesity.

Consultant360: What role does CBT play in treating obesity?

Dr Heinberg: There is a long history of utilizing behavioral treatment for obesity, and CBT has become an essential component of psychological and behavioral treatment of obesity and weight management.³ When we think of lifestyle change, the foundation of that is often the changing of behaviors related to diet and physical activity. Within the last 30 years or so, obesity treatment has focused on the addition of the “cognitive behavioral” component rather than just “behavioral,” or simply focusing on getting people to change their behavior. In CBT, individuals are enabled to focus on how their thoughts, beliefs, and attitudes impact their behaviors, and whether these factors make it easier or more difficult to make lifestyle changes.

C360: At what point during obesity treatment is CBT typically encouraged?

Dr Heinberg: This depends on where patients receive treatment for weight management. If a patient is involved in any type of interdisciplinary, comprehensive weight management program, they are often seen by professionals with expertise in behavioral health, exercise, nutrition, and medicine. When it comes to lifestyle changes or even bariatric surgery, this type of multidisciplinary approach is considered the gold standard of obesity treatment.³

However, if a patient only sees a primary care provider for weight loss medication, CBT is unfortunately not often a part of that type of treatment regimen.

C360: How can binge eating disorder (BED) complicate obesity treatment, and what special considerations are needed for patients with BED?

Dr Heinberg: BED is recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, as an eating disorder. BED is not simply overeating, but rather is a pattern of behavior in which patients consume a very large amount of food in a short period of time, which occurs with a concomitant loss-of-control feeling. Patients with BED are often triggered by emotions, such as boredom, stress, or depression. BED also involves other components, including eating until uncomfortably full or sick, eating alone or in secrecy, eating very rapidly without breaks, and feeling shame, embarrassment, and/or distress. A number of factors such as these have to be present for a patient to be diagnosed with BED. This condition affects a subset of people and is not seen in everybody who struggles to manage their weight or eating habits.

BED is more common among treatment-seeking populations with obesity compared to people with obesity who do not seek treatment. In comprehensive weight management centers or bariatric surgery programs in particular, we often see a higher percentage of people who have BED. Depending on the studies, this percentage tends to be around 15%.⁴

The loss-of-control component, as well as feelings of distress, can complicate treatment and make it harder for patients to make some of the changes that their doctor or dietitian may recommend. This can really impact a patient’s sense of accomplishment during weight loss interventions. Oftentimes, there is a need to treat comorbid BED in order to have good outcomes and to protect patients from weight regain after successfully completing a program.

C360: What other strategies do you employ for patients with comorbid mental health conditions?

Dr Heinberg: For BED in particular, interventions involving CBT are the gold standard, and even a brief intervention can be very helpful for patients with this eating disorder.³ Here at Cleveland Clinic, we offer a 4-session CBT group for patients with BED who are preparing for bariatric surgery. Within 4 sessions, the average patient can reduce their binge episodes by 50%.⁵ On a measure of binge eating,⁵ patients can go from being in the clinical range to within normal limits.

For other comorbid mental health conditions, interventions may be very different and, depending on the condition, may involve psychotherapy and/or referring patients to psychiatry for medication. Some patients may already be on psychiatric medications, and weight gain can be an adverse effect of many of these therapies. Often, a multidisciplinary approach may be needed to identify medications that may be less obesogenic for patients with comorbid mental health conditions, such as depression, which may impact their ability to fully engage in a weight management program.

Leslie Heinberg, PhD, is Chair of the American Society for Metabolic and Bariatric Surgery’s Integrated Health Program and Professional Education Committee; Director for Enterprise Weight Management at Cleveland Clinic; and Vice Chair for Psychology in the Center for Behavioral Health's Department of Psychiatry and Psychology and Professor of Medicine in the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University.

—Christina Vogt

Published in partnership with the American Society for Metabolic & Bariatric Surgery.

References:

1. Adult obesity facts. Overweight & obesity. Centers for Disease Control and Prevention. https://www.cdc.gov/obesity/data/adult.html. Page last reviewed August 13, 2018. Accessed May 9, 2019.

2. Rajan TM, Menon V. Psychiatric disorders and obesity: A review of association studies. J Postgrad Med. 2017;63(3):182-190. doi:10.4103/jpgm.JPGM_712_16.

3. Castelnuovo G, Pietrabissa G, Manzoni GM, et al. Cognitive behavioral therapy to aid weight loss in obese patients: current perspectives. Psychol Res Behav Manag. 2017;10:165-173. doi:10.2147/PRBM.S113278.

4. Mitchell JE, King WC, Courcoulas A, et al. Eating behavior and eating disorders in adults before bariatric surgery. Int J Eat Disord. 2015;48(2):215-22. doi:10.1002/eat.22275.

5. Ashton K, Drerup M, Windover A, Heinberg, LJ. Efficacy of a four-session cognitive behavioral group intervention for binge eating among bariatric surgery candidates. Surg Obes Rel Dis. 2009;5:276-262. doi:10.1016/j.soard.2009.01.005.