**1. Introduction**

#### **1.1. Obesity: a modern global epidemic**

Developing new and better treatment for obesity and its related chronic clinical complications is one of the major challenge that world healthcare systems are facing today, both from a clinical and economic perspective [1]. It is well known that obesity is a worldwide chronic disease, whose treatment is complicated by its interaction with other chronic illnesses or chronic disorders [2]. In fact, as excess weight increases, so do risks of developing heart disease, type 2 diabetes, sleep apnea, osteoarthritis, and several types of cancer, among other conditions. The excessive weight gain has a relevant impact on most national health administration policies, creating a significant economic burden and requesting new strategies to be dealt with [3]. For example, evidence from the literature suggest how, in USA, obesity treatment costs have raised from 78.5 \$ billion, back in 1998, to 147\$ billion, in 2008, affecting the annual US medical's economic balance by 10% of its total. It seems this problem is going to increase over time, unless new health policies will be soon adopted. In recent years, the prevalence of obesity has reached epidemic proportions. Worldwide, over 1 billion people could be considered over weight, with nearly 300 million fitting the criteria for obesity (**Figure 1**). By 2020, nearly half of the USA population could meet the World Health Organization criteria for obesity, and it is estimated that by 2030, up to 90% of the population will be showing a body mass index (BMI) > 25.0. Generally, obesity is explained and understood through two simple factors: dysfunctional feeding and lack of proper physical activity [1]. This interpretation of the phenomenon seems, however, extremely reductive, greatly simplifying a much more complex

reality. For example, the recent proliferation of genetic studies has shown that about 5–6% of the obesity's cases can be defined as monogenic, with a single responsible mutation of the patient's clinical picture. Otherwise, genetics determines a predisposition to weight gain that manifests itself only by interacting with environmental factors. It is calculated, however, that genetic factors are relevant in at least 70% of cases. According to Keith et al. [4], obesity treatment should be individually tailored, and realistic goals should be clearly set before starting. Scientific literature is full of examples about how interventions exclusively aimed at weight loss results in bankruptcy over time, with a regaining of the weight lost during hospitalization within 3 years [5, 6]. It becomes clear that the multifactorial nature of this pathology requires multidisciplinary interventions, able to combine the different needs and urges of each individual, from a clinical, psychological, and social perspective. Psychological factors, in particular, influence both weight loss and, more importantly, long-term weight loss maintenance. Cognitive-behavioral

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**Figure 2.** Dysfunctional eating behaviors.

**Figure 1.** Measure of obesity and overweight.

reality. For example, the recent proliferation of genetic studies has shown that about 5–6% of the obesity's cases can be defined as monogenic, with a single responsible mutation of the patient's clinical picture. Otherwise, genetics determines a predisposition to weight gain that manifests itself only by interacting with environmental factors. It is calculated, however, that genetic factors are relevant in at least 70% of cases. According to Keith et al. [4], obesity treatment should be individually tailored, and realistic goals should be clearly set before starting.

Scientific literature is full of examples about how interventions exclusively aimed at weight loss results in bankruptcy over time, with a regaining of the weight lost during hospitalization within 3 years [5, 6]. It becomes clear that the multifactorial nature of this pathology requires multidisciplinary interventions, able to combine the different needs and urges of each individual, from a clinical, psychological, and social perspective. Psychological factors, in particular, influence both weight loss and, more importantly, long-term weight loss maintenance. Cognitive-behavioral

**1. Introduction**

**1.1. Obesity: a modern global epidemic**

150 Cognitive Behavioral Therapy and Clinical Applications

**Figure 1.** Measure of obesity and overweight.

Developing new and better treatment for obesity and its related chronic clinical complications is one of the major challenge that world healthcare systems are facing today, both from a clinical and economic perspective [1]. It is well known that obesity is a worldwide chronic disease, whose treatment is complicated by its interaction with other chronic illnesses or chronic disorders [2]. In fact, as excess weight increases, so do risks of developing heart disease, type 2 diabetes, sleep apnea, osteoarthritis, and several types of cancer, among other conditions. The excessive weight gain has a relevant impact on most national health administration policies, creating a significant economic burden and requesting new strategies to be dealt with [3]. For example, evidence from the literature suggest how, in USA, obesity treatment costs have raised from 78.5 \$ billion, back in 1998, to 147\$ billion, in 2008, affecting the annual US medical's economic balance by 10% of its total. It seems this problem is going to increase over time, unless new health policies will be soon adopted. In recent years, the prevalence of obesity has reached epidemic proportions. Worldwide, over 1 billion people could be considered over weight, with nearly 300 million fitting the criteria for obesity (**Figure 1**). By 2020, nearly half of the USA population could meet the World Health Organization criteria for obesity, and it is estimated that by 2030, up to 90% of the population will be showing a body mass index (BMI) > 25.0. Generally, obesity is explained and understood through two simple factors: dysfunctional feeding and lack of proper physical activity [1]. This interpretation of the phenomenon seems, however, extremely reductive, greatly simplifying a much more complex

**Figure 2.** Dysfunctional eating behaviors.

therapy (CBT) appears as the treatment of choice in psychological therapies for obesity and other eating disorders (**Figure 2**), highlighting significant results even at longitudinal level [7]. Within this chapter, the main therapeutic components of this approach will be presented, in addition to numerous clinical examples to better understand how CBT seems to be the most effective treatment in responding to the multidimensionality of a clinical condition, such as obesity.

four-step goal-setting program guiding dietitians in the implementation of goal setting strategies in nutritional counseling. The program is based on of four specific steps: recognizing a need for change, establishing a goal, adopting a goal-directed activity and self-monitoring it, and finally self-rewarding goal attainment. Industrial psychology has examined goal characteristics considering properties, components and types. Properties include goal's difficulty, specificity, and proximity. According to Latham [8], proximal, specific, but achievable goals provide higher performance. Components include feedbacks, which improve goals achievement and internal or external rewards, which can motivate goal process. Three kinds of goal setting have yet been investigated: self-set, assigned-prescribed, and participatorycollaborative. When goal difficulty is held constantly, there would be no significant differences between different types of goals [8]. Setting goals is necessary, but it is not enough developing motivation to achieve the goal itself. A person has to be interested in the achieving process and free from significant goal conflicts. Thus, goal setting can lead to higher performances. Setting specific goals in order to achieve a task and providing performance feedback leads to better performances [8, 16]. Setting goal has a positive effect on performance throughout three motivational mechanism/steps, described by Latham [16]: effort, persistence, and concentration. Goal setting helps a person to try hard and for a longer time, with less distraction. This appears to be true when the task is not too challenging or difficult for the person itself. Setting high goals has benefits on cognitive and motivational processes in terms of stimulating strategic analysis [8]. Strategic analysis leads to a fixation on a series of short-term goals easier to reach, helping individuals into the process of achievement of long-term goals. Setting smaller steps to reach bigger goals also provides feedbacks and rewards sooner than longer goals. Strategic analysis is often subject to personal abilities and characteristics. For example, complex tasks are often perceived as impossible to achieve by people who think that it is useless spending energies for something they cannot realize [12]. Perceived self-efficacy influences problem solving and analytic thinking [17]. A person with higher levels of self-efficacy can develop more effective strategies, learns more from feedback, and sets higher goals than other person with lower selfefficacy. The results suggest that greater self-efficacy leads to higher goals, leading to higher performance, leading to greater self-efficacy [12]. Strecher and colleagues [12] provided practical recommendations for the inclusion of goal setting into behavior changes programs. First, it is important to start from an analysis of the problem and the patient's commitment addressing the problem. The second step is to know which tasks are required to address the problem. For complex tasks, every specific behavior which leads to address the problem should be organized in a strategic plan. Furthermore, for each behavior there are levels of self-efficacy perceived by the person that should be determined in order to achieve the behavior. During the goal setting process, it is important to make sure that every selected goal is difficult enough to be achieved eliciting effort from the client. Goal should be considered difficult, but realistic at the same time. Finally, the authors recommend providing feedback regularly, always about an individual's own performance. In the obesity treatment, setting specific goals requires to decide the amount of weight loss per week/month [17]. Short-term goals should be expecting a decrease of body weight by 5–10% within 6 months of therapy. When goals have been achieved, results' maintenance, and if desired further weight loss, become new challenge. Providing constant observation, monitoring, and encouragement for the patients appear to be significantly important in

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order to prevent relapses.

Specifically, CBT's core strategies will be presented and analyzed: goal setting, self-monitoring, stimulus control, problem solving technique, and cognitive restructuring technique together with patient expectations for treatment and motivational readiness will be investigated in the context of psychological treatment of the obese subject. The application of these strategies and related results is a major issue, emphasizing the need for further studies on the phenomenon of obesity, given the excellent results achievable in the short term, with significant weight loss, but the difficulties in keeping the results obtained in the long run [7]. As already explained, obesity is a chronic condition, and CBT treatments must focus on different outcomes, considering weight loss as a consequence of a change in the individual's eating behavior rather than as a major and only result to be pursued [7]. Researches in this field have brought to the development of different therapies for the treatment of obesity. They focused on the specific situations and other modalities characterizing the patients' eating behavior. Typical treatments for obesity aim to help patients to change their eating behaviors throughout diets and improvements in their physical activity. They include a number of cognitive-behavioral techniques such as self-monitoring of weight and weight-related behaviors (e.g., caloric intake and physical activity), cognitive restructuring, and social support. Behavioral strategies could be aimed to change bad eating habits while cognitive restructuring and problem solving could improve emotional self-regulation and prevent stress-related relapse. Life style changing support interventions including goal setting and self-monitoring strategies and are central to improve self-control in obese and overweight individuals and are equally important in case of eating disorder to support more emotional oriented component of CBT interventions.
