Simultaneous nutritional cognitive–behavioural therapy in obese patients

Patient Education and Counseling 42 (2001) 47–52 www.elsevier.com / locate / pateducou

Simultaneous nutritional cognitive–behavioural therapy in obese patients ´ Dominique Painot a , Sebastien Jotterand a , Anne Kammer b , Michelle Fossati a , a, Alain Golay * a

Division of Therapeutic Education for Chronic Diseases, University Hospital Geneva, 1211 Geneva 14, Switzerland b Division of Nutrition, University Hospital Geneva, 1211 Geneva 14, Switzerland Received 10 May 1999; received in revised form 20 December 1999; accepted 4 January 2000

Abstract The most important problem in cognitive–behavioural therapies for obese patients is to initiate weight loss without reinforcing the eating–behavioural disorders. We propose to assess the cognitive–behavioural therapy in obese patients suffering from eating disorders with and without combining a nutritional approach based on fat information. The patients (n 5 60) have followed a group treatment of 12 weekly cognitive–behavioural therapy sessions with or without a combined nutritional approach mainly focused on fat restriction. The scores for depression (P , 0.01), anxiety (P , 0.01) and eating disorders (P , 0.001) are significantly and similarly improved with both types of treatments. The mean weight loss is significant (P , 0.001) only after a combined nutritional cognitive–behavioural approach. The Eating Disorders Inventory (EDI) subgroup ‘Drive for thinness’ remains only in a combined therapy (ANOVA P , 0.01), which could explain the weight loss that only occurs in this group. Finally, the association between a cognitive–behavioural therapy and a nutritional learning process improves the anxiety and depression related to eating disorders as well as the weight loss.  2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Obesity; Eating disorders; Cognitive–behavioural therapy

1. Introduction The long-term weight loss results for obese patients are disappointing not only in a cognitive– behavioural approach but also when they are the result of a diet [1,2]. *Corresponding author. Tel.: 141-22-372-9704; fax: 141-22372-9715. E-mail address: [email protected] (A. Golay).

0738-3991 / 01 / $ – see front matter PII: S0738-3991( 00 )00092-6

The cognitive–behavioural approach is nevertheless recognised as an effective treatment especially when it is compared to purely dietetic methods [3,4]. The comparison of various researches has shown that compared to a purely dietetic approach there is a better improvement in the results when behavioural therapies are associated with a nutritional education based on fat information [5]. Few long-term studies evaluate these results positively [6–8]. The major difficulties found in the cognitive–

 2001 Elsevier Science Ireland Ltd. All rights reserved.

D. Painot et al. / Patient Education and Counseling 42 (2001) 47 – 52

48

behavioural therapies with obese patients is their desire to lose weight [9]. Indeed, the wish to lose weight by going on overly rigid and restrictive dietary regimes can reinforce the eating disorders [10–12]. In our prior studies with obese patients, the establishment of regular and healthy eating patterns has resulted in improving eating disorders although it did not produce a significant weight loss [13]. This was also confirmed by Fairburn and Wilson [14] in their studies in which they even observed a weight gain associated with the improvement of the eating disorders in obese patients. Various types of psychotherapy have been elaborated for the treatment of eating disorders. In this respect, Laessle [15] compared two types of group psychotherapy for patients suffering from eating disorders. One group received nutritional counselling and another a stress management counselling. The eating behaviour of the patients in the nutritional counselling group improved faster. The patients that took the stress management course showed an improvement in their feelings of ineffectiveness and of anxiety. When the patients were successively offered both treatments, the authors show that the efficiency is global and is maintained during the year following the assessment. Agras and Telch [16] proposed to combine the cognitive–behavioural treatment with a nutritional approach. This approach is based on the patients’ recovering control on their eating patterns and especially on the fat content in the food. At the same time as a nutritional education based on fat information, it seems necessary to point out the dietetic ‘mistakes’ to allow the patients to change their dysfunctional behaviours regarding nutrition and weight management [17,18]. We propose to evaluate a cognitive–behavioural approach with or without a combined nutritional education in obese patients who have eating disorders in order to prove that this type of therapy allows a weight loss without reinforcing eating disorders. 2. Methods

2.1. Subjects Participants (n 5 62) were recruited within the

obesity outpatient clinic of the Internal Medicine Department at the Geneva University Hospital and agreed to participate in this study. All subjects were female, Caucasian with a mean age of 4262 years and a mean body mass index (BMI) of 3361 kg / m 2 at baseline and met criteria for binge eating disorder. Binge eating disorder diagnosis was determined on the DSM-IV criteria by two master-level psychologists with extensive experience in diagnostic assessment. Exclusion criteria included any type of compensatory behaviour in the past 6 months (i.e. purging, strict dieting, fasting, or excessive exercising) as well as current substance abuse or dependence and concurrent treatment. Out of 62 patients, only two dropped out the study. The main reason was a lack of motivation. Moreover, statistics were done on 60 patients only.

2.2. Procedure All participants were interviewed face-to-face twice by the psychologists before starting the treatment. The patients were randomly assigned to two groups: the first one (n 5 35) received a purely cognitive–behavioural approach (CB). The second group (n 5 25) received a nutritional cognitive–behavioural approach (NCB) in which a nutritional approach essentially based on the knowledge of quantitative and qualitative fat contents in food was integrated to the usual cognitive–behavioural approach. Both groups were similar in age (4262 years; 4462 years in CB and NCB, respectively). The groups were also similar in initial weight (CB: 9162 kg; NCB: 9163 kg). Individuals were asked to complete standardized assessment instruments within 1 week of admission and within the last week of treatment in order to characterize symptoms at admission and at their way out.

2.3. Materials 2.3.1. Psychological assessments 2.3.1.1. The Eating Disorder Inventory 2 ( EDI II) It is a new version of the EDI, a standardized self-report measure consisting of 11 subscales relating to specific behavioural and cognitive dimensions of eating disorders [19]. This instrument has already been used on obese patients [20]. The higher the scores, the more pathological are the patients.

D. Painot et al. / Patient Education and Counseling 42 (2001) 47 – 52

2.3.1.2. The Hospital Anxiety Depressions ( HAD) This self-report instrument yields separate scores for state of depression (HADD) and state of anxiety (HAAD). The psychometric properties are the same for depression and anxiety and consist of a score of 7 or less for non-cases, scores of 8–10 for doubtful cases and scores of 11 or more for definite cases [21].

49

them. Identification exercises were offered to make the learning process easier. A particular effort was made to teach the patients how to recognise fat in nutrients. At the beginning of each session, the patients announced the amount of binges they had had during the week.

2.5. Statistical analysis 2.3.1.3. The Beck Depression Inventory ( BDI) This is a widely used self-report inventory measuring the behavioural manifestations and the intensity of depression [22]. Psychometric properties consist of: • • • •

, 10: normal rate 10–18: mild depression 19–29: moderate depression 30: severe depression

All results are expressed as means6S.E.M. Eating disorders, depression, anxiety, weight and binges were measured before and after the cognitive–behavioural group treatment. A one-way analysis of variance (ANOVA) was used to examine these variables. An analysis of covariance (ANCOVA) was used to compare within groups and between groups changes. Significance was defined at the 0.05 level using the Fischer and Scheffe test [24].

All these assessments were translations of English originals and have been validated [23]. 3. Results

2.3.1.4. Body weight The patients were weighted every fortnight. 2.4. Treatment It consisted in a group treatment of 12 weekly sessions of 1 ]12 h, structured in two stages. The goal of the first behavioural stage (six sessions) was to reorganize the eating behaviour: reintroducing eating schedules, modifying contents of the meals, and fighting against forbidden and avoided foods. Filling out a daily food record made it easier to observe one’s own inadequate eating patterns and to identify specific problems contributing to the binge eating and chaotic eating patterns. In this food record, patients of the NCB group indicated precisely and quantitatively the fat content in the food they selected. The second part (six sessions) aimed at a cognitive restructuring, identifying the psychological patterns that caused cognitive distortions and dysfunctional thinking patterns and mainly those related to food. In the nutritional–cognitive–behavioural group, a nutritional education had been added and consisted, during all the sessions, of identifying and quantifying the amount of fat in their food in order to reduce

The mean weight loss was substantial and significant (P,0.001) after the NCB group (1.960.6 kg), while no weight loss was obtained in the CB group (20.560.6 kg). The depression scores measured by the BDI improved significantly in both groups (CB5P, 0.001; NCB5P,0.01) (Table 1). The HADD scale, also measuring depression, showed the same tendency (CB5P,0.001; NCB5P,0.01). On the HAAD, both groups improved significantly (P,0.05) (Table 1). On the EDI (Tables 1 and 2), scores improved significantly in both groups (P, 0.001). Especially Bulimia (P,0.001), Ineffectiveness (CB5P,0.001; NCB5P,0.01), Interoceptive Awareness (P,0.01), Impulse Regulation (CB5P, 0.05; NCB5P,0.01). Some subgroups improved only after the purely CB group: Drive for thinness (P,0.001) Maturity Fears (P,0.05) and Social Insecurity (P,0.05). On the other hand, the NCB group, showed significant improvements in Body Dissatisfaction (P,0.05) and Ascetism (P,0.01) subgroups. On Drive for thinness subgroup, results clearly show a significantly higher difference with the CB treatment (4.361.0 in CB group vs. 0.760.8 in the NCB group P,0.01).

D. Painot et al. / Patient Education and Counseling 42 (2001) 47 – 52

50

Table 1 Evolution of BDI, HAD and EDI scores before and after cognitive–behavioural treatment in CB and NCB groups Cognitive–behavioural approach (CB)

Weight (kg) BDI a HADD a HAAD a EDI (total score)a

Nutritional–cognitive–behavioural approach (NCB)

Before treatment

After treatment

Before treatment

After treatment

9162 1762 661 1061 8265

9163 1161*** 561** 961* 6265***

9163 1762 661 1161 7966

8963*** 1462** 561** 1061* 6667***

a

BDI, Beck Depression Inventory; HADD, Hospital Anxiety Depression (scores for state of Depression); HAAD, Hospital Anxiety Depression (scores for state of Anxiety); EDI, The Eating Disorder Inventory. * P,0.05, ** P,0.01, *** P,0.001 before vs. after treatment.

Table 2 Evolution of EDI scores before and after cognitive–behavioural treatment in CB and NCB groups EDI a

Total score Drive for thinness Bulimia Body dissatisfaction Ineffectiveness Perfectionism Interpersonal distress Interoceptive awareness Maturity fears Asceticism Impulse repletion Social insecurity

CB Group

NCB Group

Before

After

Before

After

8265 1165 665 2365 761 661 361 861 361 560.4 461 560.5

6265*** 761** 361*** 2161 461*** 561 361 561** 261* 560.4 361* 461*

7966 961 561 2061 761 761 461 861 261 661 461 561

6667*** 861 361*** 1861* 661** 661 461 661** 261 561** 361** 461

a

The Eating Disorder Inventory. * P,0.05, ** P,0.01, *** P,0.001 before vs. after treatment.

4. Discussion The usual dietetic treatments for obese patients without binge eating disorders, lead to a 3–6-kg weight loss in a 3-month period [25–27]. On the other hand, for obese patients with binge eating disorders, a purely cognitive–behavioural treatment does not allow a weight loss [13,16,28]. Our study shows that when a nutritional approach is associated with a cognitive–behavioural treatment, weight loss is relatively weak (1.960.6 kg) but significant (P,0.001). Olmsted [29], in a literature magazine, underlines the efficiency of a ‘psychoeducational’ support in the improvement of the

eating disorders. Despite this small weight loss, we observe that eating disorders decrease at the same time as depression symptoms, as shown in Marcus’ work [30]. The group that received a nutritional education lost significantly more weight, even though the improvement of the depression symptoms is similar in both groups. This result seems to confirm the Wadden et al. [31] studies in which depression decreases equally with or without a weight loss. The depression seems to be more linked to the eating disorders than to the obesity. For patients suffering from eating disorders, obesity would be just one more symptom of a depression. The depression

D. Painot et al. / Patient Education and Counseling 42 (2001) 47 – 52

decrease seems to be directly linked to the impact of the cognitive–behavioural treatment. The ‘Drive for thinness’ subscale does not change with the combined nutritional cognitive–behavioural approach (Table 2). This subgroup could lead to a constant motivation allowing a weight loss, whilst in purely cognitive–behavioural groups, this ‘drive for thinness’ is non-existent, which could seem to lead to the absence of a motivation to lose weight. The initial goal of the usual cognitive–behavioural treatment is to bring the patients to stop the restrictive diets and reduce their ‘Drive for thinness’. Due to the aims of these therapies that were conceived essentially for bulimic non-obese patients, the patients often give up the idea of losing weight. The absence of the nutritional approach underlines the difference between learning to control food intake and using an unsuitable diet. In the nutritional cognitive–behavioural approach, the patients obtain a dietetic knowledge that allow them to consider a regular and healthy diet and not one based on restrictive and rigid dieting practices. This behaviour seems to us to be more adapted to this type of group than in an usual cognitive–behavioural therapy. Ideally, the nutritional education should be progressively included in the psychotherapeutical treatment. In the same way, the ‘Body Dissatisfaction’ decreases significantly with the weight loss obtained in the combined approach. The same process occurs with the anxiety that improves with the combined approach. In conclusion, a nutritional approach, without the prescription of a restrictive diet, but based specifically on the control of fat intake, does not worsen the binge eating disorders. On the contrary, the combination of a cognitive–behavioural approach with a nutritional education allows a decrease in anxio-depressive disorders, an improvement in the eating behaviour as well as a weight loss. Our results should be confirmed by a long-term study.

Acknowledgements Research organisation which supported the work: ¨ Institut Benjamin Delessert, 30, rue de Lubeck, F75116 Paris.

51

References [1] Fairburn CG, Cooper Z. New Perspectives on dietary and behavioural treatments for obesity. Int J Obes 1996;20(Suppl 1):S9–S13. [2] Fairburn CG. Short term psychological treatments for bulimia nervosa. In: Eating disorders and obesity, New York: Guilford Press, 1995, pp. 344–8. [3] Wardle J. Obesity and behaviour change: matching problems to practice. Int J Obes 1996;20(1):S1–8. ´ [4] Apfeldorfer G. Les resultats du traitement des troubles du ´ ´ (Results of binge comportement alimentaire et de l’obesite eating disorders therapy and obesity treatment). In: Anorex´ ´ (Anorexia, bulimia, obesity), Paris: ie, boulimie, obesite Dominos Flammarion, 1995, pp. 70–3. ´ ´ et troubles du [5] Jacquemet S, Golay A, Assal JPh. Obesite comportement alimentaire. Une approche psycho´ pedagogique interdisciplinaire (Obesity and binge eating disorders. An interdisciplinary psychopedagogic approach). ´ ` 1996;1:1164–8. Medecine Hygiene [6] Pekkarinen T, Takala I, Mustajoki P. Two year maintenance of weight loss after a VLCD and behavioural therapy for obesity: correlation to the scores of questionnaires measuring eating behaviour. Int J Obes 1996;20:332–7. [7] Holden JH, Darga LL, Olsen SM, Stettner DC, Ardito EA, Lucas CP. Long-term follow-up of patients attending a combination very-low calorie diet and behaviour therapy weight loss programme. Int J Obes 1992;16:605–13. ¨ ¨ [8] Bjorvell H, Rossner S. A ten-year follow-up of weight change in severely obese subjects treated in combined behavioural modification programme. Int J Obes 1992;16:623–5. [9] Marcus MD, Wing RR, Hopkins J. Obese binge eaters: affect, cognitions and response to behavioral weight control. J Consult Clin Psychol 1988;56:433–9. [10] Wilson GT. Behavioral approaches to the treatment of obesity. In: Eating disorders and obesity, New York: Guilford Press, 1995, pp. 479–83. [11] Van Strien T. On the relationship between dieting and «obese» and bulimic eating patterns. Int J Eat Disor 1996;19:83–92. [12] Herman CP, Polivy J. Restrained eating. In: Stunkard AJ, editor, Obesity, Philadelphia: W.B. Saunders, 1980, pp. 208– 25. [13] Painot D, Golay A, Morel Y. Traitement cognitivo-com´ ´ (Cognitive–behavioral therapy and portemental et obesite ´ Comport. Cogn. 1997 (in press). obesity). J. Ther. [14] Fairburn CG, Wilson GT. Binge eating, New York: Guilford Press, 1993. [15] Laessle RG, Bermont PJV, Butow P, Lennerks N, O’Connor M, Pirke KM, Tovys SN, Waadt SA. Comparison of nutritional management with stress management in the treatment of bulimia nervosa. Br J Psychol 1991;159:250–61. [16] Agras SW, Telch CF, editors, Cognitive behavioral therapy for binge eating disorders. Therapist manual, Stanford, CT: Stanford University Press, 1992, Revision. [17] Divac SM, Mirabel-Sarron C, Vera L. Bases comportemen-

52

[18]

[19]

[20]

[21] [22]

[23]

[24]

D. Painot et al. / Patient Education and Counseling 42 (2001) 47 – 52 tales et cognitives du traitement des troubles des conduites alimentaires (Cognitive–behavioral basis of binge eating disorders therapy). In: Samuel-Lajeunesse B, Foulon C, editors, Les conduites alimentaires, Paris: Masson, 1994. ´´ ` ponderal ´ (Dietetic Morel Y. L’approche dietetique de l’exces approach in obesity). Schweiz Rund Med (PRAXIS) 1996;85(49):1584–8. Garner DM. EDI 2. Eating disorder inventory. professional manual, 2nd ed, New York: Psychological Assessment Resources, 1990. Golay A, Hagon I, Painot D, Rouget P, Allaz AF, Morel Y, Nicolet J, Archinard M. Personalities and alimentary behaviors in obese patients. Pat Educ Couns 1997;31:103–12. Zigmund AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–70. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561–71. ´ ´ Bouvard M, Cottraux J. Protocoles et echelles d’evaluation en psychiatrie et en psychologie (Protocols and evaluation scales in psychiatry and psychology), Paris: Masson, 1996. Morrison DF. Multivariate statistical methods, New York: McGraw-Hill, 1978.

[25] Golay A A, Allaz AF, Morel Y, de Tonnac N, Tankova S, Reaven GM. Similar weight loss with low-or high carbohydrate diets. Am J Clin Nutr 1996;63:174–8. [26] Golay A, Eigenheer C, Morel Y, Kujawski P, Lehmann T, de Tonnac N. Weight loss with low or high carbohydrate diet? Int J Obes 1996;20:1067–72. [27] Morel Y, Allaz AF, de Tonnac N, Kammer A, Golay A. Le ´´ ` ponderal ´ traitement dietetique de l’exces — phase de perte de poids et phase de maintien du poids (Dietetic treatment in obesity — weight loss and weight maintenance process). Schweiz Rund Med (PRAXIS) 1996;85(49):1574–7. [28] Marcus MD. Binge eating in obesity. In: Fairburn CG, Wilson CT, editors, Binge eating, nature, assessment and treatments, New York: Guilford Press, 1993, pp. 77–96. [29] Olmsted MP, Davis R, Rockert N, Irvine MJ, Eagle M, Garner DM. Efficacity of a brief psychoeducational intervention for bulimia nervosa. Behav Res Cher 1991;29:71–83. [30] Marcus MD. Binge eating and obesity. In: Eating disorders and obesity, New York: Guilford Press, 1995, pp. 441–4. [31] Wadden TA, Foster GD, Letizia KA. One behavioral treatment of obesity: comparison of moderate and severe caloric restriction and the effects of weight maintenance therapy. J Consul Clin Psychol 1994;62:165–71.