Can CBT help form healthy habits?

Dr Zoe Williams (TV Medical Presenter and NHS GP): As a society, it feels like we're all a little bit obsessed with weight.  And whilst we can't deny that obesity is a problem and can be linked to some medical conditions and ailments, I do just wonder whether this over-emphasis on body weight and body size is possibly causing more harm than good.

So today I'm joined by two wonderful experts to discuss this in a little bit more detail. So I'm joined by Petra Simic, who is Bupa's Medical Director of Health Clinics, and Bianca Clarke who's Bupa's Cognitive Behavioural Therapist.

Thank you both for joining me. We're gonna sort of cover a range of topics varying from how we can learn to be happy with who we are. How can we stop letting that number on the scales drive our emotional wellbeing, keeping a healthy perspective on weight and what are some of the healthy approaches when we are looking to make some changes and to manage our weight.

So I think it's important, first of all, Petra, when it comes to the causes of obesity, we know that there are over a 100 different causes of obesity. It's not simple, it's not straightforward, it's not just move more and eat less. We know that that doesn't work. So what are some of the major causes?

Dr Petra Simic: Well, I think there's been quite a lot of improvement in understanding why we have people that have obesity. But we're still on a journey as a medical profession to get our understanding clearer on what's become really clear in the last 10 years is how much genes influence people's body weight.

And I think when I qualified back in '99, I don't think there was any real recognition that genetics might play such a strong role in people's body weight.

Certainly, we might look at a family and see their overweight, but I think there's always been that almost judgment that was entirely by choice and environmental.

So really interesting research to suggest that over 140 genes are associated with higher BMI. So it's not just a single gene and the more genes that you have, the more likely you are to be overweight and the more overweight that you are.

So there's kind of a dose effect as it were. So the more of these genetic changes you have, the more likely you are to have weight problems. And these genetic changes appear to be related to your ability to self regulate, to your appetite, to your responses to certain foods. And also there'll be issues around your genetic build, your muscle profile, how easily you build muscle.

So there's kind of the intake issue and then how much energy you use up.

I think it's really interesting that genes play a stronger role than perhaps we as a society believe. Twin studies are really good example. So when we take identical twins and there've been studied, huge twin studies, one of the things that they do is they look at twins who have had to be separated at birth. So adopted twins, and they look at their BMIs when they've been brought up in different environments and they are approximately similar.

So genes. - So interesting. Genes are really much stronger than probably people realize.

Zoe Williams: And what if you were to put a percentage on it in that research, have you discovered what percentage risk is associated with our genes? Which of course we have absolutely no control over, it's a lottery of what we receive when our parents conceive us.

Petra Simic: So current research suggests it is between 40 and 70%, 3:57 your genetic profile, which determines your adult BMI. 

So that's quite a broad range, but I think we could all see that 50% sits in there quite comfortably. So it's at least half of the challenge. And it means that some people will find it much more difficult to maintain a healthy weight. And if they find themselves overweight or living with obesity, it's going to be much more of a challenge for them to lose the weight. And it may even be impossible to get into a normal weight category. So it's important that people understand that they are dealing with quite a challenge ahead.

Zoe Williams: And it's so important that everyone is aware of that. Because I'm sure there'll be many viewers watching this right now who were hearing that for the first time, who will feel, I guess, a sense of relief. A weight being lifted that, it's not my fault, I didn't choose to have these genetics, actually, when I think about it, my parents really struggle with their weight as well and my siblings do.

Petra Simic: And you know, it is largely down to genetics. GPs typically kind of fall into two camps, GPs that really happy to talk about weight management and many GPs who feel under-skilled in this area. It wasn't a big part of my medical school training. I don't know whether it was yours, but what we know is that, well, the first thing I say when people come in is, it's not your fault. And you can almost see the relief. - often tears.

Because all they've heard often for decades is, you need to have better willpower, you need to try harder.

There's lots of stereotypes for people that are living with obesity that are not charming or nice. And so when you point out to them that they are really trying to fight against their genetics. Then there's often a great sense of relief.

Now it's important to then say, just because you have the genetic tendency, it's not that you have no options.

Zoe Williams: Yes, it's not inevitable.

Petra Simic: You're not without power. But you are going to have to be empowered for much of your life if you have that genetic kind of profile. So environment probably is quite important to talk about Zoe as well.

Zoe Williams: Well, I think also a lot of people watching this will be thinking, well, then, if it's about genetics, genetics are so important, why is it that a 100 years ago there was no such thing as obesity? And now we know that over 50% of the adult population in the UK are what would be deemed above a healthy weight.

Petra Simic: Brilliant question. Our environment is entirely different now than it was a 100 years ago. It's been described as an obesogenic environment, and that means creating obesity, obesogenic. So all of our modern mod cons and convenience factors have been designed to make our lives easier. So when I was a child, we'd get up and turn the television over. So even watching the telly had a degree of activity that now does not.

A 100 years ago, there was not the television for activity, people would be out, children would be outside playing. Parents would be knitting or sewing busy around the house, playing games, all of those things take up more energy. So the environment we live in is designed for us to be sedentary, to use as little energy as possible.

We're also surrounded by really tasty energy dense food. It's everywhere. We live fortunately in a period of plenty. 

Zoe Williams: So we've got genetics as a major cause, the environment has changed for all of us. What are some of the other causes of obesity beyond that?

Petra Simic: Well, activity. I mean, is a massive change. So where people are just not as active as usual and particularly where people are not doing regular exercise. They don't need to do regular exercise, they're jumping in their cars. Perhaps as children, and we see this, around 20% of children that are now really struggling with their weight, where they're not outdoors and exercising.

And that lack of activity means that you reduce your muscle mass if you're not using your muscles, they don't grow. And the reduced muscle mass means your metabolic rate drops.

So activity is a really important determinate of that, particularly in the weight maintenance phase. So getting people to lose weight is one thing, getting them to maintain that weight loss.

Zoe Williams: Yeah. - Incredibly challenging. Thank you for that. Really, really, really interesting.

Okay, so Bianca, I want to explore with you a little bit more about the mental health implications of essentially living with obesity. We know that lots of people live all of their lives with obesity. And I think we often talk about as doctors and the media about the physical complications that can come with that, but perhaps we don't talk enough about how it can impact somebody's emotional health.

So from your experience as a CBT therapist, which I'd like to tell us a bit more about as well, what you actually do, what's your experience been?

Bianca Clarke: So CBT stands for cognitive behaviour therapy, and it was developed in the 50s. And so it's been around for quite a long time. And what it does is it helps us to be much more aware of our thoughts, our feelings, and our behaviours.

And what we know is that there is a real link between those three things. And what we do is we try to help people recognise when there's unhelpful patterns of thinking, also unhelpful behaviours that they might be engaging in and then how that then affects their mood or even their motivation levels.

What we find is that when there are patterns of unhelpful thoughts and behaviours, that really can have a big impact on the way people feel. But also the things that they're doing, their ability to reach their goals, their ability to do the things that they want to do in life.

And so what we try to do is we guide people through different tools and techniques that they can use to try to have more balanced ways of thinking. So maybe a more healthier perspective on situations and things, but also to engage in more helpful behaviours as well. And what we'll hopefully find is that as people's thinking patterns and their behaviours start to be more healthy and more balanced, that that will then improve their mood and improve their ability to work towards their goals. And so when it comes to things like weight loss, it can be really helpful.

So CBT was initially developed for depression and then anxiety, but we also find that it's helpful for smoking cessation, managing addictions and also weight management too.

And if we can change some of those maybe imbalance perspectives on things, especially when it comes to weight gain, sometimes we might find that we have quite distorted patterns of thinking. So we might find ourselves thinking in quite all or nothing ways, maybe having perfectionist type thoughts and all of those things can sometimes hinder our ability to keep moving towards our weight loss goals, or just generally our weight management goals, and living that healthier lifestyle.

Zoe Williams:  And so do you have quite a lot of patients referred to you to support them with weight management.

Bianca Clarke: Sometimes, yeah, so sometimes people will come to me because they want to embark on a weight loss journey and they want a bit of help with that.

So CBT can help guide them through that process and help them to change some of those negative thoughts, but also to maybe engage in more helpful behaviours to work towards their goals. But also we do find that clients who've been referred for depression and anxiety. Sometimes they struggle with their weight as well. Because there is a correlation, there is weight gain or even weight loss is a symptom of depression and anxiety too.

So sometimes people can be referred for weight management, but other times it'll be for depression, and there are symptoms of weight changes related to that.

Zoe Williams:  And I can almost see there's a pattern of, like a vicious cycle there, isn't there?

If somebody is unhappy about their body size, that can lead to depression, if they have depression, that typically can lead to people gaining weight and certainly impact on motivation.

So what sort of emotional struggles do people describe to you when they have been struggling with their weight? Is depression quite common?

Bianca Clarke: Yeah, depression is a really common one. Low self-esteem, body image type issues, anxiety sometimes to leave the house or to go to certain places because they're worried about how their size might be perceived by other people at times. So it can have a really big effect on people's emotions, but also the way they think about themselves and their own self image.

Sometimes people can find that they're quite critical of themselves as well, they might punish themselves in some way. And it's kind of like there's an inner critic in their mind. Sometimes it's telling them off and telling them that they shouldn't look a certain way.

Zoe Williams: And that's really not helpful, is it? 'Cause that's gonna set them back, not help them. And I think that's why as society,nwe really do have a responsibility to lift this stigma because it doesn't help people, in fact it makes it more difficult for them.

Bianca Clarke: Definitely.

Zoe Williams: As a CBT therapist, how important is it for people to learn to change their mindset? I think often for so many years, the advice has been, just eat less or eat more healthily or move more, but actually how crucial is it to support that person in shifting a mindset if they're going to be successful on a weight loss journey?

Bianca Clarke: I think it's really important, mindset is one of the most important things. Because that mindset, if we are having negative thoughts about our self, which sometimes we will, but if they become a bit too much, we're having lots of them, it becomes really overwhelming. And can really just hold us back, can make us feel a lot lower and just stop us going for that thing that we want to get to.

Zoe Williams: It can be difficult though, can't it, to not strive for perfection, especially when we live in this world where we're shown these idealistic body shapes, body sizes and images. They're everywhere that we go.

Do we just need to be a bit kinder to ourselves, bit more self acceptance, and especially when it comes to things like our body weight? Because we know actually that the link between body weight and health, whilst there is one is massively overemphasized in some scenarios.

Bianca Clarke: Yeah, I agree, it's difficult to not strive for perfection because there's so much that we see on social media or just those societal standards, this kind of drive for thinness sometimes.

And also if it's not a drive for thinness, there's this ideal body shape that keeps changing over time. You know, 10 years ago, the ideal body was different to what it is now and what are we gonna do?

Are we gonna keep striving for that every time and keep changing ourselves?

Zoe Williams: It just means that you never end up being happy with what you've got.

Bianca Clarke: Exactly.

Zoe Williams: Because something often unachievable is usually desirable. (chuckles)

Bianca Clarke: Exactly, yeah. It's often something that's quite unachievable and when we think about it with filters and perfect poses and things like that, a lot of what we see.

Zoe Williams: It's getting worse.

Bianca Clarke: Yeah, a lot of what we see actually isn't real life. And a lot of people are striving for those things that aren't actually real life.

So we're often striving for this perfect ideal, but does it actually even exist? And it's worth thinking about, as we strive for perfection, some of us, that there will be costs to that and thinking, what are the costs for striving for perfection?

Could it be that I'm missing out on time with my family because I'm constantly trying to strive for this ideal body shape? Could it be that I'm damaging my body in any kind of way because of what I'm trying to do?

And it's worth of thinking about that, what are those costs to perfection? And also thinking, do I need to be perfect? Is it okay to just be okay?

And given that our genetics do play a part as well, sometimes we might not even reach this ideal that we are hoping for.

Zoe Williams: Probably we all experience it to some extent, when you look back at pictures when you were younger and you think, gosh, I look great there. I wish I knew then how great I looked. And then you think about yourself now, you're like, oh no, but right now you look in the mirror. And I think, hopefully fingers crossed if we all lived to a very healthy but old age, look back on what a loss if you've spent all your life.

Trying to be something that you're not rather than just celebrating exactly what you are. And I think, again, it's just, people need to know this, that they're not on their own, despite what they may have heard, this is really, really difficult to achieve.

And actually losing weight is not that difficult. Anyone for two weeks, most people can stick to some probably unrealistic, unhealthy regime, but to keep that weight off when your genetics and your biology are fighting against you, I think even the most motivated person in the world, it is very difficult to ignore the signal of hunger.

It's a raw human need to have food. And if you feel hungry and there is food available and food around you, it's difficult. And we all experience different levels of hunger and require different amounts of food before we feel full and satisfied. And that's just one element of it. Isn't it?

Petra Simic: And most people that lose weight, those people that have effective weight loss will regain it by five years, 80% of people will regain it. So it's almost like changing the dialogue. It's not around this permanent weight loss that may not be achievable. In fact, we know it's not from the statistics and the research. But what is achievable for you as an individual with your genetics and your environment and what's maintainable and might that just be enough to keep you happy and healthy and that kind of, in that happy medium. And I think that's really important.

And those kind of conversations are the ones that I have, and I'm sure you do, Zoe and Bianca, about getting people's objectives to something that's realistic and achievable.

Zoe Williams: Realistic. Well, I think depending what person's objectives are, if we're understanding that your genetics kind of give you a possibility, a range of possibilities, which will be different for every person. So, you know, we're not saying that if you have genetics, that mean you are much more likely to have a larger body. You can't lose weight, it's not that it's not possible, it's just that your range of possibilities and the amount of effort that will be required to get you to a certain place will vary from person to person. But I think an important thing of what we're saying here is that in order for people to make relatively small changes to their weight, which can give them improved physical health, significant improved physical health, what is the mental health cost of that?

And if we're thinking about health, there are many more ways to improve your health, even if your weight remains the same.

So I think often, I think we're learning in the medical world now that it's not all about weight loss. Sometimes maintaining weight and thinking about being more active, not to lose weight, or the other benefits or improving the nutrition in your diet. Not focused on eating less, but eating more of the foods that really nourish your body and things like sleep.

Actually, all those things can improve your health and actually can make it easier to possibly sometimes lose weight is a bit of a positive side effect as well.

Petra Simic: Well, scales just measure our total existence, right? Our body's force against gravity, it doesn't tell you whether that's made up of muscle or a litre bottle of water that you just drank.

And to your point, I can have people that work really hard on their exercise and diet, the scales don't change, but their body shape changes because their muscle mass goes up, which has a massive positive impact on their health and their long term weight and outcomes.

So I think that's the other thing to recognise, weight is a number on a scale. And you can't compare it from one person to another, people have different builds, but it is your personal tool. And that along with your shape and size can be the thing you can use to monitor, but you really shouldn't, compare your weight to other people.

You see a lot of that going on unless they are your identical twin, I would strongly. Strongly counsel against it.

Zoe Williams: And these are the limitations of BMI. Well, it's important to have a measure for us as healthcare professionals and for the population at large focusing too much on BMI, you know, it has its limitations.

So sort of to wrap things up then, what I'd love to do is ask you both for some tips, some tips that you would share with people.

So Petra, what advice would you give to someone who has tried every diet under the sun? Their weight's been up and down, up and down, they lose weight, but then it comes back and they want a more sustainable approach to weight loss.

Petra Simic: Okay, so I don't recommend one type of diet above others. It's really more about behaviour and attitude. So there's five main things.

The first thing is be realistic. 5% weight loss will give you health benefits. And if you do it slowly, it's likely to stay off, because if you do it slowly, it's very likely that whatever you've changed is sustainable and pleasant enough for you to continue to do. So losing less than, or approximately one pound a week is amazing weight loss, and is likely to be maintainable. And you're likely to do it for long enough to lose the weight. And so being realistic is important. If you've got a lot of weight to lose, then it may be that you'll never get into a normal weight category, and losing 5% and maintaining might be enough to make a difference.

Get support is the other thing. So think about who are your cheerleaders, those people that will back you whatever you are doing and who are your saboteurs. (chuckles). So who are those people that you know will take you off that wagon at the first opportunity? Make sure you're close to your cheerleaders and you either avoid your saboteurs or you have really frank conversations with them.  'Cause they probably don't realize they're doing it. 

Zoe Williams: They're usually trying to help.

Petra Simic: They think they're helping they're to make, you feel you'll feel better if you have this chocolate bar. So know who are your cheerleaders and saboteurs, getting support.

Maintenance rather than loss. So remembering what we've said, it's really hard to maintain. So maintaining it is more important than the weight that you lose. So if you've lost some weight and you kind of fall off the wagon a bit, if you can maintain that, that's an amazing achievement.

And timing. So to Bianca's points, if you are going through a massive life change, if you are stressed, if you think you've got anxiety or depression, it is now the right time to give yourself this monumental task that's gonna take a lot of psychological energy and commitment. And I often advise people that although they want to lose weight right now, it may be better to get in a better mental frame of mind before you do it. Because failing at that will just be another reason to feel bad about yourself.

And overall be kind. - Yeah. You know, be kind to yourself, this isn't your fault. You do have tools that can improve things and change things, but it's tough and hard and won't happen overnight. So those are my tips.

Zoe Williams: They're really good. And Bianca, any tips that you would like to share. I guess from a more of a mindset perspective, people is battling their weight, battling with their mental health, where to start and what can they do?

Bianca Clarke: I think again, echoing what Petra said is that sometimes we do just need to be kind to ourselves. A lot of us aren't really taught how to manage our mindset when it comes to weight loss or managing our weight. A lot of us know what to do physically or kind of a bit of what we know physically, but mentally, it's a bit more difficult. So just being kind to yourself, if you are struggling with the mindset side of things.

And I think along with kindness, compassion, self compassion is a big thing for weight management. It's also a big thing just for loving yourself anyway. So just to improve your own self esteem, your own body image, I think that's really important before we even embark on a weight loss journey.

Body positivity and weight loss, or even weight gain can exist in the same space. So just because we want to lose weight doesn't mean that we can't be positive about our body.

Because there's so much more that our bodies can do. And really remembering that, that there's so much more to our bodies than the way it looks or the size it is.

There's so much more that our body is great for really.  And really recognizing that.

And so building compassion, especially self-compassion, it's something that recent studies have actually found that has a real direct link with our ability to maintain a weight loss journey. And often there are setbacks on any weight loss journey and it helps us to be able to pick ourselves up a bit easier when we are self compassionate.

And so just one way that we can be more self compassionate is to really just think about one key thing, so just one thing that we actually like about ourselves. For some people that's really difficult. Because we are quite used to just seeing the negative side of things. If we are just constantly looking at the negatives in the mirror, picking out more and more negatives each time, we get quite focused on those and then forget about those little positives that are there.

So just identifying one thing as a start, even writing it down, reading it every morning and really reminding yourselves of that can be really helpful to start building a bit of compassion.

Zoe Williams: Definitely. I think generally we are really kind to the people that we love and care about and we're even pretty kind to people that are complete strangers.

And then when it comes to ourselves, we can be really cruel and we at least deserve to give ourselves as much kindness. As we would for someone we were meeting for the first time, don't we?

Thank you both so much. That was, I think a really important conversation to have with some really key, valuable takeaway tips as well. So thank you.