**4. Cognitive restructuring**

The aim of cognitive-behavioral therapy (CBT) is to promote an emotional change, from a maladaptive functioning to an adaptive functioning. Cognitive schemas are defined as internally stored representations of stimuli, ideas, or experiences [36]; managing information-processing systems to provide meaning and engaging other mechanism such as motivational, affective, and physiological ones. This functional feature of human cognition elicits a vicious cycle contributing in the symptoms maintenance, since maladaptive beliefs and schemas guide cognitive evaluation [36]. These distorted beliefs are dysfunctional as they appear to be structurally inflexible, rigid with negative idiosyncratic thoughts regarding self, world, and interpersonal relations [36]. Assuming schema's pivotal role in psychopathological disorders, maladaptive beliefs' modification is essential for promoting significant emotional change and, consequently, symptom reduction [36]. Recent literature has already highlighted the key role plays by dysfunctional thoughts concerning caloric intake, body shape, body image, and weight in ED. However, as they mediate the effectiveness of therapy, focusing and changing core beliefs are still necessary. Moreover, it is assumed that other irrational beliefs may impact eating behavior: low global selfvalue [37], mood intolerance linked with poor mood-regulation strategies, high levels of clinical perfectionism, and interpersonal issues [38]. Cognitive-behavioral therapy is the treatmentof-choice for BED. Several studies have tested the efficacy of CBT in reducing binge behavior frequency [38]. CBT appears less effective when BED is in association with obesity, especially in long-term weight loss maintenance [1]. Since obesity has a multifactorial etiology, the best intervention approach seems to be an integrated treatment made up of nutritional intervention, physical reconditioning program, and cognitive-behavioral psychotherapy [1]. Moreover, in interventions, specifically intended for childhood obesity, family, and peer background must be taken into account in order to promote a long-term weight loss maintenance [38], since they play a key role in shaping and supporting healthy-habits. Cognitive restructuring is the key technique used to promote a change in beliefs and thoughts. It could be defined as a collaborative intervention focused on the identification, discussion, and substitution of dysfunctional thoughts and appraisals identified as significant factors in the psychopathology development [39]. This intervention aims to modify a dysfunctional content, reducing maladaptive thoughts' activation, and promoting adaptive beliefs' adoption. An effective restructuring intervention is based on three main components: collaborative empiricism, verbal interventions, and empirical hypothesis testing. Collaborative empiricism is a process aiming at setting common treatment goals, in order to promote therapeutic alliance and client engagement. Collaborative empiricism is more effective when clients attribute behavioral change to his own effort rather than to external intervention. Cognitive disputing is one of the main verbal interventions. It could be defined as an evaluation process focuses on logical coherence, functional and heuristic value, empirical evidence of a theory (e.g., irrational beliefs), and other alternative (e.g., new adaptive thoughts), through use of questions [40]. Depending on the question's content, three types of disputing can be recognized: logic, empiric, and pragmatic. The first type of disputing assess the logical coherence of client's beliefs ("Do you think it is logical that the person's value depends on the respect shown by her/his colleagues?"); the empiric disputing verifies if the client's thoughts are coherent with the facts and evidence ("What evidence do you have about your intolerance regarding the lack of respect that your colleagues provide you? You're just alive, right?"); the latter investigates the functional and utility value of dys/functional beliefs ("How useful is it to believe that it's intolerable not to be respected?"). Gearhardt et al. [41] suggests to redirect dysfunctional selftalk due to a training aimed to modify irrational thoughts and beliefs to improve longer term compliance with diet plans and physical activity. Cognitive restructuring, briefly detailed above, improve strategies strictly linked to previously illustrated goal setting and self-monitoring interventions, help overweight persons to the long-term achievement of weight loss. From a cognitive-behavioral perspective, the ability to detect, focus, and directly change irrational beliefs could be strengthen through promotion of distraction, defined as the ability to redirect from food craving to engaging and more functional activities or thoughts. Distraction could play a core role in management of difficult thoughts often linked with different forms of overeating and consist in directly teaching overweight to change activities coherently with emerge of craving. Stress management techniques have to be included in CBT interventions for obesity for individuals showing high level of emotional eating or stress-related craving [13]. Classical approach to stress management is equally effective with more recent mindfulness-based interventions aimed to cope internal or externally perceived stress source. In conclusion, obesity is a complex chronic condition that needs a multidisciplinary, multicomponents approach, but the CBT contribution could not be more central. Self-management techniques and more cognitive-emotional approaches concur to promote lifestyle change in obese individuals, teaching new wave to cope with stress, difficult thoughts, food craving, and to support changes related to eating habits and physical activity patterns. Best practice maximizing long-term weight loss and relapse prevention should include increasing social support, managing emotions, adaptive problem solving,

Cognitive-Behavioral Therapy: Current Paths in the Management of Obesity

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and incorporating reinforcing, rewarding activities, and also exercise, relaxation [6].

\*, Roberto Cattivelli2,3, Anna Guerrini<sup>2</sup>

\*Address all correspondence to: alessandro.musetti@unipr.it

2 Department of Psychology, Catholic University of Milan, Italy

3 Istituto Auxologico Italiano IRCCS, Italy

The authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials

Francesco Vailati Riboni2,3, Giorgia Varallo2,3, Gianluca Castelnuovo2,3 and Enrico Molinari2,3

1 Department of Humanities, Social Sciences and Cultural Industries, University of Parma,

, Anna Maria Mirto3

,

**Conflict of interest**

**Author details**

Alessandro Musetti<sup>1</sup>

Parma, Italy

discussed in this manuscript.

the lack of respect that your colleagues provide you? You're just alive, right?"); the latter investigates the functional and utility value of dys/functional beliefs ("How useful is it to believe that it's intolerable not to be respected?"). Gearhardt et al. [41] suggests to redirect dysfunctional selftalk due to a training aimed to modify irrational thoughts and beliefs to improve longer term compliance with diet plans and physical activity. Cognitive restructuring, briefly detailed above, improve strategies strictly linked to previously illustrated goal setting and self-monitoring interventions, help overweight persons to the long-term achievement of weight loss. From a cognitive-behavioral perspective, the ability to detect, focus, and directly change irrational beliefs could be strengthen through promotion of distraction, defined as the ability to redirect from food craving to engaging and more functional activities or thoughts. Distraction could play a core role in management of difficult thoughts often linked with different forms of overeating and consist in directly teaching overweight to change activities coherently with emerge of craving. Stress management techniques have to be included in CBT interventions for obesity for individuals showing high level of emotional eating or stress-related craving [13]. Classical approach to stress management is equally effective with more recent mindfulness-based interventions aimed to cope internal or externally perceived stress source. In conclusion, obesity is a complex chronic condition that needs a multidisciplinary, multicomponents approach, but the CBT contribution could not be more central. Self-management techniques and more cognitive-emotional approaches concur to promote lifestyle change in obese individuals, teaching new wave to cope with stress, difficult thoughts, food craving, and to support changes related to eating habits and physical activity patterns. Best practice maximizing long-term weight loss and relapse prevention should include increasing social support, managing emotions, adaptive problem solving, and incorporating reinforcing, rewarding activities, and also exercise, relaxation [6].
