Psychological treatment for obesity: Determining what eating behaviours are involved

13 June 2012

Currently, there is no consensus on what main problematic eating behaviours are involved in obesity. Researchers from the University of Otago, New Zealand, the Canterbury District Health Board, UK, and Maastricht University, the Netherlands, developed a self-report questionnaire aimed to help researchers and clinicians identify such eating behaviours. Once these are defined, effective interventions can be established to help people lose weight without surgery.

Non-surgical treatments for obesity are not usually effective long-term. Bariatric surgery is an option for some people but not for everyone and can be expensive and risky. The authors of this opinion paper looked at obesity treatment from a behavioural perspective and discussed which eating behaviours might be most important to consider when treating obesity. They recognise the importance of other factors related to obesity, such as sedentary behaviour, but focused on behaviours that involve eating.

In contrast to obesity, the target behaviours involved in most common eating disorders are known. However, practitioners cannot assume these behaviours are the same as those involved in obesity. Hence, eating disorder treatment cannot be directly translated to obesity treatment.

The authors provide two approaches to identifying the target eating behaviours involved in obesity. One approach is to ask “where do the excess calories come from?” Obesity has been associated with an overall increase in energy intake. However, this manifests differently for different people. Whereas some frequently choose high calorie foods, others may have a very balanced diet but simply consume too much.

Another approach is to observe the eating behaviours of people who lose weight and keep it off. These behaviours could include regularly eating breakfast, eating a low-calorie low-fat diet, and/or eating consistently on weekdays and weekends. Emotions also affect eating behaviours. Reducing emotional eating and incorporating a flexible pattern of dietary restraint have proven critical to sustained weight loss. Exercising and self-monitoring also help sustain weight loss.

The “Target Eating Behaviours Questionnaire” was developed by these authors based on scientific literature and clinical experience. It analyses eating behaviours of individuals over the past 3 months, a time period that can be adapted to encompass past eating behaviours in general. The questionnaire is a new tool for health professionals to determine the frequency of different eating behaviours seemingly related to obesity in order to provide better treatment. It lists different behaviours and asks participants to rate the extent to which the behaviours were a problem for them in the past 3 months: not at all, a little bit, moderately, quite a bit, or extremely. Some behaviours listed include “eating large portion sizes”, “eating when feeling bored”, and “secret eating”.

It is important that researchers observe obese people in their natural environment so that findings are relevant. For example, many clinical trials have analysed binge eating in relation to obesity, but most people who are obese do not report binge eating. In contrast, grazing has been associated with weight gain but has not received much attention. There is no consensus on the definition of grazing, but the authors say, “Grazing involves the repeated consumption of smaller amounts of food over an extended period of time.” Though grazing can occur at any time, late afternoon and early evening seem to be high risk times, and the foods consumed are usually high in calories. It is unknown how common grazing is in the general population. However, due to its correlation with weight gain, it should be further researched.

People’s thoughts and feelings also affect their eating behaviours, but no consensus has been made on how to best describe feelings such as “comfort eating” when talking to patients. Similarly, since people eat for pleasure, it could be beneficial to offer alternative sources of pleasure in place of eating, but these will take time to be developed.

Currently, treatment approaches for these eating behaviours stem from those used for eating disorders and include cognitive behaviour therapy (CBT), dissonance-inducing activities, and cue exposure. CBT is based on the principal that thoughts control feelings and behaviours. The therapy involves becoming aware of negative thoughts and responding to them in a positive way. It has yielded mixed results for weight loss in those who are obese, yet adding CBT to dietary treatment was shown more effective than adding physical activity. Appetite-focused CBT helps people pay attention to their hunger and satiety cues and could help them respond better. Many studies have also shown that CBT can positively treat grazing. More trials are needed in these research domains.

Dissonance-inducing activities seem to be especially effective for changing eating symptoms. Dissonance refers to holding two conflicting beliefs (e.g. I want to eat this, but I know it is unhealthy). This mental state is unpleasant and motivates people to change their thoughts to be more consistent. Consequently, they change their behaviours.

Cue exposure treatment helps people prevent relapse. In cue exposure, patients are repeatedly exposed to situations (cues) that have previously led to overeating, but they respond by not eating.

In conclusion, researchers and clinicians need to understand the context in which eating behaviours occur and how people respond to them in order to develop effective treatment strategies. Practitioners should not necessarily use treatments developed for eating disorders as treatments for obesity. The problematic eating behaviours specifically involved in obesity need to be identified, and treatment strategies need to be centred on these identified behaviours. The “Target Eating Behaviours Questionnaire” aims to help researchers and clinicians identify these key eating behaviours.

For further information, see

Carter FA, et al. (2012). Improving psychological treatment for obesity: Which eating behaviours should we target? Appetite. 58:1063-1069.

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