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Topic learning outcomes

At the end of this lecture, students should be able to:

NAD559
Counseling for Nutrition and Dietetics 1. Describe the Cognitive Behavioral Therapy
2. Apply the CBT in the diet counseling

Developing a Nutrition Care

Mohd Ramadan bin Ab Hamid

(Bsc. Dietetics (Hons) (UIAM), MSc. Clincal Nutrition (UKM)
Lecturer & Dietitian
Centre of Nutrition and Dietetics
Faculty of Health Sciences
Universiti Teknologi MARA

“Endeavour, Religious, Dignified”

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Assessment of readiness to change:

Tazkirah Stage of changes

Stages Description Patient Stage Tx

Sentiasa berdoa dalam menuntut ilmu Pre- No intention to take •Not thinking about change MI/CBT
contemplation action within the next 6 •Feeling of no control
months •Denial : Does not believe it applies
Dalam menuntut ilmu hendaknya kita selalu berdoa agar diberi to self
•Believes consequences are not
kemudahan dalam menyerap ilmu dan mengamalkannya. serious
Contemplation Intends to take action Weighing benefits and cost of MI/CBT
‫ب ِز ْدنِي ع ِْل ًما‬ِِّ ‫َوقُلْ َر‬ within the next 6 months behaviour, proposed change.
dan katakanlah :”Ya Rabbku, tambahkanlah kepadaku ilmu pengetahuan”. Preparation Intends to take action Experimenting with small changes CBT
[Thâhâ /20:114] within the next 30 days
and has taken some
behavioural steps in this
direction

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Assessment of readiness to change:

Stage of changes Cognitive behavioural therapy (CBT)

• Incorporates behavioral approaches and goes beyond to identify

Stages Description Patient Stage Tx and treat the cognitive processes that maintain disordered eating
Action Changed overt Taking a definitive action to change CBT and lack of exercise.
behaviour for less than
• Targets include unrealistic weight goals; body image concerns; the
6 months
patient’s primary (non-weight) goals; weight loss; and the difference
Maintenance Changed overt Maintaining new behaviour over time CBT between weight loss and weight maintenance.
behaviour for more
than 6 months • Principles of CBT:
• Cognitive
Termination No temptation to •Experiencing normal part of process of MI/CBT
• Behavioral
relapse and 100% change
confidence •Usually feels demoralized • Characteristics of CBT
OR Solution-
Time-limited Skills building Homework
•No temptation to relapse focused
•100% confidence

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Cognitive behavioural therapy (CBT) Cognitive behavioural therapy (CBT)

• CBT is based on the concept that your thoughts, feelings, physical

sensations and actions are inter-connected and that negative thoughts Cognitive principle of CBT
and feelings can trap you in a vicious cycle. • It is interpretations of events, not events themselves, which are crucial
• CBT aims to help you deal with overwhelming problems in a more
positive way by breaking them down into smaller parts.
• You’re shown how to change these negative patterns to improve the way you
feel.
• Unlike some other talking treatments, CBT deals with your current
problems, rather than focusing on issues from your past.
• It looks for practical ways to improve your state of mind on a daily basis

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Cognitive behavioural therapy (CBT) Cognitive behavioural therapy (CBT)

Behavior principle of CBT Focus of CBT

• What we do has a powerful influence on out thoughts and emotions. • It is usually more fruitful to focus on current processes rather than the past

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Cognitive behavioural therapy (CBT) Cognitive behavioural therapy (CBT)

Interacting system principle

• It is helpful to look at problems as interactions between thoughts, emotions,
behaviour and physiology and the environment in which the person operates

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Cognitive behavioural therapy (CBT) Cognitive behavioural therapy (CBT)

• EXAMPLE: The cognitive model in weight loss management. • Weight loss requires dieting skill among patients.
• Pre-dieting skills include:
Situation 1. Motivating self-daily
A friend did not give a call (trigger) Notices the feeling of sadness • Response cards (Advantages & coping statements)
2. Develop discipline to use good eating habits
• Eat sitting down
• Eat slowly and mindfully
Automatic “I hate this feeling. 3. Solving problems
(sabotaging) • Time
She doesn’t care for me thoughts If I eat, I’ll feel better”
• Energy
• Arranging the environment
4. Dealing with hunger, craving & emotional eating
Reaction : 5. Minor food changes
I feel sad Behavioral Eats

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Cognitive behavioural therapy (CBT) vs

1. Motivating self-daily
Motivational Interviewing (MI)

COGNITIVE BEHAVIORAL THERAPY MOTIVATIONAL INTERVIEWING

• Write down a list of advantages of losing weight (1st session)
SIMILARITIES
• Identify thinking mistakes and help client to cope. (from time to time)
• Talk therapies
• Share common elements of a therapeutic relationship (empathy, collaboration)
• Emphasize client activity outside meetings.
• Empirical support for efficacy
• Require training for provider competence
1. Read the advantages of losing weight.
DIFFERENCES 2. In group, list down top 10 of the most important advantages of
losing weight
• Building skills • Building motivation
• Educative • Evocative
• Solutions pre-selected • Clients picks solutions
• Empirical support for group format • Briefer, strategies for client resistance

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1. Motivating self-daily 1. Motivating self-daily

Sabotaging and coping strategy

Thinking errors/mistakes in CBT
Guide Example
Identify sabotaging I don’t want to plan my diet. I want to spontaneously eat. I • Thinking Errors – also known as Cognitive Distortions – are irrational and
thoughts feel more happy that way. extreme ways of thinking that can maintain mental and emotional issues.
• Anxiety, low mood, worry, anger management issues are often fuelled by
Questioning Is it true that I will feel happy this way?
Am I looking about my wish to get thinner at the whole
this type of thinking.
picture? • Thinking errors are automatic, often unrealistic types of thinking that can
Am I being rational? rapidly affect our mood and keep us stuck in a cycle of anxiety, sadness or
Will this support me to achieve my aim? other difficult emotions.
• However, in CBT, learning how to identify and label them, can make the
Answer the questions I usually feel good when I eat BUT immediately after I
difference between escalating and containing our difficult emotions.
realize about my mistake to eat according to schedule, I
will feel bad.
Construct coping I choose to eat according to my plan and be thinner
statements because that will make me happy in the long run

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1. Motivating self-daily 1. Motivating self-daily

Sabotaging and coping strategy

It is difficult for my mum to prepare something else, healthier for me
• If I continue eating calorie-densed food prepared by my mom, it will be
difficult for me to lose weight. However, I can help my mom to prepare
low calorie meals which is beneficial not just for me but my whole family.
It is rude for me to say “No”. I seems like I’m anti-social
• If I eat high calorie snacks offered by my colleagues, I will exceed my
calorie requirement. I am sure my colleagues will understand that I’m
saying “No” for my health.
Healthy food is expensive
• Healthy food may be expensive. But there are always affordable food
available.
Thinking errors/mistakes in CBT
• Cognitive distortions tend to be consistent with the expectations we have
of a situation.
• For instance, if we have a generally negative outlook on how others see us,
it’s more likely that our thinking errors will confirm such negative
expectations.
• For example, after our boss expresses dissatisfaction with our department’s
performance, typical thinking errors that may arise could be: “She thinks I
am rubbish” (Mind Reading) and “I will lose my job” (Catastrophising).

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Cognitive Distortion/ Examples

1. Motivating self-daily Thinking Error
Emotional reasoning Assuming that because we feel a certain way, what we think must be
true.
“I feel embarrassed so I must be an idiot”
Thinking errors/mistakes in CBT Labelling Assigning labels to ourselves or other people
“I’m a loser, I’m completely useless. They’re such idiots”
• Thinking Errors – also known as Cognitive Distortions – are irrational and Using “Should” Using critical words like ‘should’ can make us feel guilty, or like we
extreme ways of thinking that can maintain mental and emotional issues. have already failed. If we apply ‘shoulds’ to other people the result is
• Anxiety, low mood, worry, anger management issues are often fuelled by often frustration
this type of thinking. “I should have thought about it!” “ They should have predicted it!”
• Thinking errors are automatic, often unrealistic types of thinking that can Catastrophising Blowing thing out of proportion
rapidly affect our mood and keep us stuck in a cycle of anxiety, sadness or “If I don’t pass the exam, my life will be a failure!!”
other difficult emotions. Mental Filter Only paying attention to certain types of evidence
• However, in CBT, learning how to identify and label them, can make the “I’m not drinking tonight, and my friend find me boring! I’m fun only
difference between escalating and containing our difficult emotions. when I’m drinking!”
Personalisation Blaming yourself or taking responsibility for something that wasn’t
completely your fault! Or Blaming other people for something that was
your fault!
“This is all my fault”; “This is all his fault”

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1. Motivating self-daily 2. Develop good discipline to use good eating habit.

Cognitive Distortion/ Examples

Thinking Error
Black and White Thinking
Mind Reading
Crystal ball gazing
Overgeneralising
Disqualifying the positive
It is all or nothing, without a grey area in between
“Everyone else gets it right; I never do anything worthy”.
Concluding that one knows what others are thinking or feeling.
“Everyone else must think I am boring”,
Making negative predictions about the future.
It will not work, there is no point in trying.
Seeing one negative event as an indication of everything being
negative.
I will never get another job; I will probably lose my house and end up in
the street.
Discounting the good things that have happened or that you have done
for one reason or another
“I wrote that report very well, but it was just luck: I am still not good
enough”
Practical and helpful techniques to control eating.
• Eat sitting down.
• Mindful eating.
• Place the selected food on a plate in front of you (e.g raisin). Take your
client through the script below, varying it as you feel appropriate.
• “Look at the (food’s name). What is its shape? What size is it? What
color is the (food)” What smell do you notice? What sensation do you
notice in your mouth as you look at the (food)? What’s the feeling in
your stomach? Pick up the food slowly. Hold the (food) in your fingers
and look at it in your grasp. What does the (food) feel like in your hand
Its texture, temperature?

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2. Develop good discipline to use good eating habit. 4. Dealings with hunger, craving and emotional eating.

• To develop the skill of not always eating when feeling “hungry”. I can wait
• Mindful eating. for my next meal.
• Bring the (food) slowly to your lips. Before putting the food to your • Practice hunger tolerance. Fill in the hunger discomfort chart.
mouth, pause and be aware of what you are experiencing in your
mouth. Slowly open and place the (food) on your tongue for a moment
without biting into it. Feel what you mouth wants to do with this (food).
Time Current level of discomfort (1-10)
Take a few moments before you bite into it. Feels its texture on your
tongue and in your mouth. What do you taste? 1pm
• Now bite into it noticing what you taste and what it feels like. As you 2pm
continue to taste, try not to swallow the (food) right away. Does the 3pm
taste and feeling change as you are chewing? Feel the food going
down as you swallow. Refocus on your mouth. Notice your stomach
and what it may be feeling. Notice what you are feeling. Now, you have
finished your exercise.

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3. Solving problems 4. Dealings with hunger, craving and emotional eating.

• Time and energy • “This is great… I’m feeling a craving, but I know I can tolerate it and it’ll go
• Make a priority list. away… It’s great that I’m tolerating it!”
• Jot down daily activities. Make a review. • Measure your craving
• Arranging the environments
• Changes at home Day, time Monday, 3pm Monday, 7 pm Monday, 9.30pm
• Remove your personal temptations How uncomfortable did 6 3 2
• Rearrange your dishes the craving get on my
• Consider others discomfort scale (1-
10)?
• Changes at work
• Arrange healthier options in the pantry How long did it last 10 min 4 min 2 min
• Ask coworkers to move their snacks to a less-visible location What anti-craving Did the mindset Did the mindset Did the mindset
• Talk to your boss to start on a healthy eating campaign techniques did I try? techniques; left the techniques; drank a techniques; put leftover
room; did relaxed glass of water; email food down garbage
breathing; got back to friends disposal
work

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4. Dealings with hunger, craving and emotional eating. Behavior conditioning therapy for obesity

Anti-craving strategies

Mindset techniques
• Label it. Tell yourself. “this feeling is just a craving. It’s uncomfortable an intense, but
its not an emergency.”
Hypnosis
• Stand firm. Tell yourself that you’re absolutely not going to eat the food that you’re
craving. Remind yourself that you truly don’t want to strengthen your giving-in muscle • An adjunct to cognitive-behavioral therapy with patients
and weaken your resistance muscle.
• Don’t give yourself a choice. The emotionally painful part about a craving is the
who are inclined to it, as a means to encourage them to
struggle you feel. Once you can tell yourself with total conviction, NO CHOICE. And do repeat self-statements to correct dysfunctional thoughts,
something else, the craving will diminish. attitudes, and beliefs
• Imagine the aftermath of giving in.

Behavioral techniques
• Distance yourself from the food you crave.
• Drink a no-or low-calorie beverage.
• Relax
• Distract yourself.

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4. Dealings with hunger, craving and emotional eating. Behavior conditioning therapy for obesity

TUTORIAL 1
Mindfulness
• Paying attention to the present moment in a nonjudgmental way.
1. Fill in my distraction activities chart.. • An application of mindfulness in the treatment of obesity might
2. List down top 10 of your group distraction activity enable individuals to become more aware of their food choices
and have a better perception of how much they have consumed
• Such approaches might include increasing chewing, isolating the
seven tastes of food,
• Focusing fully on the act of eating, visualizing and taking control of
hunger, and using meditation to control food cravings
• Studies have reported that mindfulness training has been effective
in reducing food cravings among obese and overweight adults

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Conclusion

• Psychological aspects of obesity include internal and external forces,

addictive, social, cultural, developmental, and psychopathological
processes.

• Many approaches to treatment have been tried with good short-term

success but poor long-term success.

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THE END

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