LEARNING OBJECTIVES

This is a beginning to intermediate level course. After completing this course, mental health professionals will be able to:

• Discuss how biogenetic, sociocultural, familial, and intrapsychic factors contribute to the development of obesity
• Diagnose psychiatric conditions associated with weight problems
• Describe the medical complications associated with obesity
• Promote prevention and early intervention strategies
• Debunk the dieting myth
• Plan a course of treatment, establish realistic goals, and chart a patient's progress

INTRODUCTION

Welcome to Weight Matters: The Etiology and Treatment of Obesity. This two-hour course will help you gain a working knowledge of the etiology and treatment of obesity so you can provide better psychological care. The course focuses primarily on the range of factors that contribute to the development of obesity, physiological and psychological ramifications of long-term weight problems, and the various forms of treatment. Information includes etiology, diagnosis, assessment, and comprehensive treatment planning. Case studies will highlight the different aspects of treatment so you can integrate this course into private practice and clinical settings.

Prerequisite: Feast or Famine: The Etiology and Treatment of Eating Disorders course which includes etiology, diagnostic criteria, comprehensive treatment planning, assessment, and holistic treatment approach. It is highly recommended that you complete the introductory course first, although with appropriate experience and knowledge of the topic, you may jump directly to this advanced course. You can review Feast or Famine: The Etiology and Treatment of Eating Disorders at any time if you have questions about the general treatment of eating disorders.

CHAPTER I: ETIOLOGY

A. INCIDENCE

Here is some food for thought:

• In 2009, 34.6% of adults were overweight, 33.8% were obese, and only 31.6% were at a healthy weight
• In 2009, 33% children and youth, ages 2-19, were already overweight or obese*
• Nearly 70% of cardiovascular disease cases are related to obesity
• Obesity doubles the chances of developing high blood pressure
• An estimated 70% of diabetes risk can be attributed to excess weight
• Obesity increases the death rate from cancer by 50%-60%
• On average, obese individuals pay $1429 (42%) more in healthcare costs than normal weight individuals
• Annual number of deaths attributed to obesity is 112,000

(Sources: National Institutes of Health, 2010; *HealthierGeneration.org, 2010)

Ethnicity: Compared with white Americans, overweight and obesity occurs at higher rates in African American and Hispanic Americans. Asian Americans have a low prevalence of obesity. Women and persons of low socioeconomic status have a higher incidence of weight problems. Cultural factors related to dietary choices, physical activity, and acceptance of weight interferes with weight loss efforts. Listed below are comparative statistics regarding the prevalence of obesity among three adult racial groups (National Institutes of Health, 2010).

B. DEFINITIONS

The National Institutes of Health (2010) provides definitions for overweight and obesity along with how both are measured.

Overweight is defined as a body mass index (BMI) of 25 to 29.9. Body weight comes from fat, muscle, bone, and body water. BMI correlates with body fat but does not directly measure body fat. Therefore, people, such as athletes, can have a BMI that identifies them as overweight even though they do not have excess body fat.

Obesity is defined as having excess body fat with a BMI of 30 or higher.

Body Mass Index (BMI) is the most commonly used method to measure body fat. The BMI is a calculation based on a ratio of body weight to height. It is not gender or age specific. BMI does not directly measure percent of body fat, but it is a more accurate indicator of overweight and obesity than relying on weight alone.

• BMI formula: Multiply weight in pounds by 704.5 then divide the result by height in inches. Divide that result by height in inches a second time.
• You can automatically calculate a BMI on the following website: National Institutes of Health Body Mass Index
• BMI weight categories (National Institutes of Health, 2008):
• Underweight: BMI < 18.5
• Normal weight: BMI = 18.5-24.9
• Overweight: BMI = 25-29.9
• Obese: BMI > 30
• Extreme Obesity: BMI > 40

Weight Percentages is another method to calculate overweight or obesity. A number of organizations offer tables based on age, height, and weight. The Metropolitan Life Insurance Company Weight Table is often utilized for this purpose. See Metropolitan Life Insurance Company Weight Table for the Met Life Weight Tables. Weight falls in one of four categories depending on how much above normal an individual’s weight is for her/his height and age.

• Overweight = 10%-20% above normal
• Mild obesity = 21%-40% above normal
• Moderate obesity = 41%-100% above normal
• Severe obesity = 100+% above normal

This kind of information does not measure overall health. Muscle mass is not accounted for and muscle weighs 20% more than fat. One person can be normal weight but have high blood pressure, cancer, heart disease, etc. Another person who is overweight can also be physically fit and healthy.

Body Fat Distribution matters. Where fat collects on the body affects the chances of developing health problems.

• Pear-Shaped: Women typically have what is called a “pear” shape meaning that fat collects around the hips and buttocks.
• Apple-Shaped: Men usually build up fat around their bellies, creating the shape of an “apple.”

This does not mean that either gender can’t have the opposite described shape; they can. If an individual carries fat mainly around the waist (meaning it’s surrounding the internal organs, especially the heart), they’re more likely to develop obesity-related problems (National Institutes of Health, 2004). An apple-shaped person and a pear-shaped person can weigh the same, yet the apple shape will be more at risk for heart disease, diabetes, or cancer. This is because “visceral fat” around the abdomen produces more inflammatory and clot-promoting compounds than “subcutaneous fat” distributed around the rest of the body (Underwood and Adler, 2004). Women with a waist measurement of more than 35 inches or men with 40 inches or more have a higher risk because of their fat distribution (National Institutes of Health, 2004). Hormone replacement therapy may prevent increase in abdominal fat in women just past menopause (Cartwright, 2000).

C. NATURE VERSUS NURTURE CONTROVERSY

People with weight problems have been considered weak-willed failures for not controlling the amount of food they consume. However, the issue is more complicated than that. Biogenetic, sociocultural, familial, and intrapsychic factors all work together to create and exacerbate overweight and obesity.

Genetics and environment work in tandem. People are born with certain biological predispositions. The environment in which individuals grow up either enhances these traits or minimizes them. It is as if genetics are the ammunition in a gun and the environment either pulls the trigger or puts the gun down. Genetics and environment (societal and familial) lay the foundation for how people view and deal with food, the habits they form, their lifestyle choices, self-perceptions and mood, resiliency during stress, and— ultimately—what they’ll weigh.

D. BIOGENETIC FACTORS

Researchers have found genetic and biological components that make someone more susceptible to weight gain.

1. HUMAN EVOLUTION

Obesity is a condition of the modern age. For millions of years, food was not readily available and it took great effort to stay alive. The human body is biologically wired to live with food scarcity. Early ancestors foraged for tubers, nuts, shoots, and fruits. The sugar content of fruit was a highly sought after concentrated energy source; as a result, our physiology adapted by developing a sugar craving. Then 2.5 million years ago, humans began eating animals (a good source of protein, vitamins, minerals, and fatty acids), which increased height, brain size, and complex cognitive functions. Wild game was low in fat, around 4% (compared with 36% for modern grain-fed beef). Life was also strenuous. Humans walked, chased, were chased, and climbed daily (Lemonick, 2004). A low-fat/high-fiber diet and intense physicality created fit and lean individuals.

Weight increased once humans domesticated farming and ranching. Widespread access to all kinds of foods, including processed sugar, worsened the weight situation. When the technology of the industrial revolution made physical movement less necessary, weight increased again. To this day, the body conserves excess calories in the event of a famine, and has never really adjusted to the availability of mass produced foods and lowered physical activity.

2. GENETICS

Body and Brain: The hypothalamus is crucial in the central regulation of energy homeostasis. There is growing consensus that the expression of appetite is chemically coded in the hypothalamus. Researchers identified a complex neuronal pathway, which involves neurotransmitters (i.e., adrenaline, dopamine, and serotonin), many cerebral nuclei, and a large number of neuropeptides that regulate the drive to eat, the utilization of food, and thus the maintenance of a proper rate of energy reserves in adipose tissue (Magnati and Dei Cas, 2000).

The body has short-term and long-term food intake regulating mechanisms. In the short-term, receptors in various parts of the stomach and small intestine along with gut peptides (i.e., cholecystokinin-CCK, bombesin, neurotensin, and glucagons-like peptides released when food hits the gut) signal the brain to help regulate the amount and duration of a single meal. Long-term regulation occurs from signals emanating from a “sensor” of body weight or body fat, most likely in adipose tissue (Pi-Sunyer, 1997).

Research Findings: Scientists are looking for “an obesity gene.” There is no unifying theory that ties all the information together to understand why different receptor genes mutate and make certain people vulnerable to developing obesity. Nor do researchers know what percentage of individuals has a genetic problem versus poor lifestyle habits, and/or binge eating disorder. Most likely, obesity is a polygenic condition in which numerous genes interact with each other and the environment to express the obesity phenotype (Pi-Sunyer, 1997).

Clearly, the rapid increase in the prevalence of obesity in westernized countries is the result of environmental factors that interact with genetic predispositions (Leibel, 1997). Without a condition in which food is so abundant and movement is lacking, these genes may not express themselves. Research suggests that:

• In twin studies, up to 80% of obesity risk is conferred by genes (Leibel, 1997)
• In nuclear families, the heritability ranges from 10%-50% (Bray, 1997)
• Between 30%-40% of the variance in weight is genetically determined, whereas the rest is environmentally determined (Pi-Sunyer, 1997)

From a biological perspective, obesity is a result of a long-term imbalance between energy intake and expenditure. This dysregulation is informed by genetic differences between the obese and the non-obese (Leibel, 1997). Below are various investigations into the biogenetic causes of obesity:

Prohormone Convertase 1 (PC1): Research suggests that a mutation in this endopeptidase leads to a defect in the processing of proinsulin to insulin. When this mutation exists, high concentrations of proinsulin circulate in the blood following glucose ingestion, but virtually no insulin is present. It is suspected that appetite is stimulated, so food intake increases at the same time as energy is conserved and/or calories are stored in fat, causing weight gain (Leibel, 1997).

Leptin: This peptide is produced in adipose tissue, secreted into the blood, and transported to the hypothalamus where it acts via a leptin receptor to suppress food intake and raise energy expenditure. In this way, leptin regulates body fat. Research suggests that plasma leptin levels correlate well with body mass index and total body fat. The higher the levels, the fatter a person is (Pi-Sunyer, 1997). Excess amounts of leptin increase food intake and decrease energy expenditure leading to weight gain (Bray, 1997). There is no evidence of a mutated leptin gene producing abnormal leptin in obese people. They may have leptin resistance due to a problem in the receptor or signal transduction pathway. More studies are needed to clarify leptin’s role in weight regulation (Pi-Sunyer, 1997).

Melanocortin 4: This receptor gene has been linked to obesity. One study focused on this gene’s role in binge eating behavior. This gene makes a protein (by the same name), which helps stimulate appetite in the brain’s hunger-regulating hypothalamus. If the gene is mutated, too little protein is made, which leaves the body feeling overly hungry. Of the 469 severely obese participants, 25% were binge eaters. Just 5% of the total group had the mutated gene. All members of this subgroup were binge eaters, compared with 14% of the rest of the group that did not have the mutated gene (Branson et al., 2003).

Prader-Willi Syndrome: This syndrome affects one in 12,000 to 15,000 children. These children are born constantly hungry and are unable to feel full, which makes them obsessed with food or eating. This disease is caused by deletion of the long arm of Chromosome 15, which adversely affects the hypothalamus, the appetite control center. These children may fail to grow and mature normally. They will also have a certain facial structure, disruptive behavior problems, breathing difficulties, obsessive-compulsive behaviors, learning disabilities, and diminished intelligence. The primary treatment approved by the Food and Drug Administration is injections of the growth hormone Genotropin. The Prader-Willi Syndrome Association has created a modified food pyramid for these children. Behavior modification and increased exercise are also important (Brody, 2002).

Metabolic Predictors: There are three predictors of weight gain: resting energy expenditure, elevated respiratory quotient, and insulin sensitivity. Studies originally conducted with Pima Indians in Arizona over a five-year period found familial patterns in their obesity (Pi-Sunyer, 1997).

• Resting Energy Expenditure: Individuals tended to have a low resting metabolic rate and gained more weight over this period.
• Elevated Respiratory Quotient (RQ): Individuals with higher RQ’s were more likely to gain weight. Their bodies oxidized more carbohydrates and deposited more fat.
• Insulin Sensitivity: Individuals with the greatest sensitivity gained weight. The mechanism proposed is that the fat cells, by being insulin sensitive, readily use carbohydrates for fuel in muscle and allow dietary fat to be directly deposited in fat cells where gradual accretion occurs. This process is aided by high levels of lipoprotein lipase (in adipose tissue), which allows free fatty acids to enter fat cells and be stored. As the person gains weight and fat, fat and muscle cells become more insulin resistant, lipoprotein activity decreases, and the accretion of fat slows down and finally stops.

Interestingly, the Pima Indians who reside in Mexico do not have obesity problems. Their diet of beans, corn, and rice hasn’t changed much over the years—and they have a higher rate of physical activity (Cartwright, 2000).

Man-Made Chemicals: A variety of chemicals found in everyday products have made their way into our bloodstream and may have a profound effect on fetal and early childhood metabolic functioning leading to obesity. Based on research conducted by Grun and Blumberg, they propose an environmental obesogen hypothesis write that exposure to toxic chemicals initiate or exacerbate the development of obesity and associated health consequences. These chemicals include bisphenol A (a plastic strengthener found in baby bottles, sippy cups, juice bottles, CD's, DVD's, and resin lining of food and beverage containers), phthalates (a plastic softener found in rubber duckies, vinyl shower curtains, certain medical tubings, IV bags, fragrances, body lotions, nail polishes, and shampoos), organotins (in food packaging and water pipes) and diethylstilbestrol. These create a metabolic dysfunction that programs the exposed individual to have a lifelong thrifty metabolism (Grun, F and Blumberg, B., 2007).

Brain Chemistry and Food: Food alters the brain’s neurochemical system to calm a person down and numb out unpleasant affect or memories. Carbohydrate ingestion increases the brain’s uptake of tryptophan, the amino acid precursor to serotonin, enhancing serotonin synthesis and release (Lieberman et al., 1986). Serotonin induces relaxation and ultimately puts us to sleep at night.

Chocolate contains over 400 chemicals. It is rich in fat and contains lipids that are chemically and pharmacologically related to anandamide, a brain lipid that mimics the psychoactive effects of marijuana (di Tomaso et al., 1996). Chocolate also contains phenylethylamine, which resembles the structure and effects of amphetamines. Lastly, chocolate contains methylxanthines (theobromine and caffeine), which elevate mood and energy levels. Chocolate’s aroma, sweetness, texture, and the ability to melt at human body temperature (i.e. “melts in your mouth”) are sensually reinforcing. Chocolate cravings are present in 40% of females and 15% of males. Premenstrual cravings are sufficient to account for the greater prevalence of craving among women (Michener and Rozin, 1994).

When people turn to certain foods to mitigate the intensity of emotions, they choose items that are high in sugar, salt, fat, and carbohydrates. The most common items are cookies, cakes, candy, chocolate, or chips. Obese carbohydrate cravers (CC) reported feeling more depressed than obese non-carbohydrate (NC) cravers. After eating a high-carbohydrate lunch, CC felt less depressed whereas NC felt more depressed, less alert, fatigued, and sleepy. Raising brain serotonin in depressed individuals reduces depression. This has the opposite effect in those who are not depressed (Lieberman et al., 1986).

Research suggests that high levels of fat and fructose may alter the brain chemistry by muting the signals that would normally tell an individual to stop eating. These signals are produced by peptides, which are regulated by a number of hormones including insulin, ghrenlin, and leptin. Normally, these hormones help maintain stable body weight by adjusting levels of peptides that control eating. However, a diet loaded with fat and fructose gets in the way of normal weight regulation. In addition, as body fat increases, the brain loses its ability to respond to these hormones. What’s worse is that researchers found that the more humans are exposed to fats and sugars, the more they crave them (Shell, 2002).

E. SOCIOCULTURAL FACTORS

1. THE FOOD INDUSTRY

Westernized societies manufacture and market highly processed, calorically dense, conveniently located, and tasty foods. The fast-food industry alone spends $3 billion a year to advertise their products (Huiett and Matchette, 2002). Temptation to eat these foods is strong—they are everywhere. How to eat and exercise is governed by the airwaves and popular written word. Making money is the underlying factor that drives this information. Sensible eating principles are rarely promoted simply because they don’t sell well.

In 1995, the American Academy of Pediatrics stated that advertising to young children is inherently exploitative. With this in mind, the food industry spends around $10-15 billion to influence the behavior of children. By contrast, the federal budget for nutrition education is equal to one-fifth of the advertising budget for Altoid mints. It is easy to see why children consume 15% of their total calories from fast food, 10% from sugar-sweetened soft drinks, and only half of the recommended amount of vegetables and fruits (Brownell and Lugwig, 2002).

In schools, budget-challenged cafeterias offer fewer healthy food options. Many of the contractors who bid for school lunches do not have a record of providing healthy choices. At the same time, schools receive money from food companies to place soft drink and snack vending machines in lunchrooms. Fast food chains have also infiltrated the schools. Schools don’t put resources towards nutrition or exercise classes, and parents are so busy that they don’t have time to prepare three balanced meals a day for their families.

In 1969, 80% of kids played sports every day; today, only 20% do (Time, 2004). Kids spend more time than ever in front of the TV or computer. By age 18, teens will have seen 350,000 commercials. A full 50% of 7^th to 12^th graders have a TV in their room. Of all the prime time and weekend daytime commercials, 25% advertise food, 50% of which are “junk” food (Ontario Media Literacy, 2004).

2. THE TOXIC FOOD ENVIRONMENT

Kelly Brownell, Ph.D., a leading expert in the treatment of eating disorders at Yale University, believes weight problems are not so much a lack of self-control or genetics. He acknowledges both play a role. An overabundance of unhealthy, heavily advertised, low-cost foods creates a “toxic food environment.” He cites strips of fast food restaurants, the barrage of burger advertising on television, and rows of candies at the checkout counter of convenience stores. Then, once obesity has occurred, medical and psychological interventions are costly and don’t have high success rates for permanent weight loss (Murray, 2001).

3. WHAT WE REALLY EAT

Americans tend to underestimate how much they’re eating, sometimes by as much as 50%. This may explain why people don’t understand how their style of eating leads to weight gain. Listed below are government-recommended versus typical restaurant servings (UC Berkeley Wellness Letter, 1997):

4.  HUNGER AND FOOD INSECURITY

Food insecurity is defined as the unavailability of or inability to acquire nutritionally adequate and safe food. In many low-income neighborhoods, there are few grocery stores so individuals rely on convenience stores and fast food restaurants to feed themselves and their families. According to the Census Bureau and U.S. Department of Agriculture, 30 million Americans are affected by hunger and food insecurity. The lack of healthy food options and money to purchase these kinds of foods contribute to the rise in obesity in low-income individuals (CenterOnHunger.org, 2010).

F. FAMILIAL FACTORS

Within the family, attitudes about weight, food, and meal times have a profound influence on children and adolescents. Mothers who diet have daughters who diet. Parents that are overweight or obese are more likely to have children who have weight problems. Parents that use food to cope with the stresses and strains of everyday life are more likely to have children who will do the same.

Children and adolescents who are depressed or anxious can wind up turning to food to decrease the intensity of their emotions. Some are filling an empty void. If they continue to overeat or binge, they may develop binge-eating disorder. They will also gain weight, sometimes to the point of becoming obese. Some learn to purge in order to prevent weight gain, leading to bulimia nervosa.

There are certain family dynamics that leave young people more susceptible to developing problems with food, weight, and body image (Fairburn et al., 1997; Taylor and Altman, 1997). Listed below are the 15 most salient family factors:

• Parent(s) expect their children to be successful and achievement oriented
• Parent(s) push their children to be perfect in attitude and appearance
• Parent(s) chronically criticize their children and/or each other
• There are many family conflicts without the ability to resolve them
• The expression of painful or “negative” emotions is discouraged
• Children feel disconnected from one or both parents
• Parent(s) are either overinvolved or underinvolved with children
• Parent(s) are controlling
• Parent(s) emphasize weight and thinness
• There is a family history of eating disorders (e.g., parent(s) diet; used food to cope; are obsessed with their own size, shape, or weight; talk about weight; express body hate; judge people with weight problems)
• Children are given food to soothe painful feelings
• There is physical, emotional, or sexual abuse
• Parent(s) use or abuse substances in order to deal with life’s problems
• Parent(s) are obese and/or get migraines
• Parent(s) have an affective disorder (e.g., depression)

G. INTRAPSYCHIC FACTORS

Vast population studies have shown poor mental health and impaired psychological functioning among obese patients (Traveso et al., 2000). McElroy et al. (2004) reviewed overweight, obesity, and mood disorder articles from 1966-2003. The most rigorous clinical studies suggest:

• Children and adolescents with major depressive disorder may be at risk for developing overweight problems
• Patients with bipolar disorder may have elevated rates of overweight, obesity, and abdominal obesity
• Obese persons seeking weight-loss treatment may have elevated rates of depressive and bipolar disorders

The most rigorous community studies found:

• Depression with atypical symptoms in females is significantly more likely to be associated with overweight than depression with typical features
• Obesity is associated with major depressive disorders in females
• Abdominal obesity may be linked with depression in females and males
• Most overweight and obese persons don’t have mood disorders

In a family history study of 88 bariatric clinic patients, morbidly obese female subjects are more likely than a comparison group to have first-degree relatives with a history of depression, bipolar disorder, antisocial personality disorder, and other psychiatric disorders. This study has limitations in that the reliability and validity of the interviews were not assessed, males and normal controls were not included, and only parents and siblings were interviewed (Lee et al., 1999).

CHAPTER II: PSYCHIATRIC CONDITIONS

The information below is provided as a review of the diagnostic criteria and statistics from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994).

A. MOOD DISORDERS

1. MAJOR DEPRESSION

Diagnostic Criteria: The essential feature of a major depressive episode is a period of at least two weeks in which the person either has depressed mood or loss of interest or pleasure. These symptoms impair social, occupational, or other areas of functioning. In children and teens, the mood can be irritable rather than sad. Five (or more) of the following symptoms have been present:

• Depressed mood for most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful)
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
• Significant weight loss when not dieting or weight gain (i.e., a change of more than 5% of body weight in a month)
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation/retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive/inappropriate guilt (which may be delusional) nearly every day (not just self-reproach/guilt about being sick)
• Diminished ability to think/concentrate, or indecisiveness, nearly every day
• Recurrent thoughts of death (not just a fear of dying) or suicidal ideation without a specific plan, or a suicide attempt, or a specific plan for committing suicide

2. DYSTHYMIA

Diagnostic Criteria: The essential feature of dysthymia is chronically depressed mood for most of the day more days than not for at least two years. In children and teens, the mood looks more irritable than sad. Additional symptoms (at least two to make a diagnosis) include:

• Poor appetite or overeating
• Insomnia or hypersomnia
• Low energy or fatigue
• Low self-esteem
• Poor concentration or difficulty making decisions
• Feelings of hopelessness

There is also a prominent presence of low interest and self-criticism, seeing self as uninteresting or incapable.

3. ATYPICAL DEPRESSION

Diagnostic Criteria: The essential features are mood reactivity and at least two of the following features during most of the recent 2-week period (or most recent 2-year period for dysthymic disorder):

• Increased appetite or weight gain
• Hypersomnia
• Leaden paralysis
• Long-standing pattern of extreme sensitivity to perceived interpersonal rejection

4. GENERALIZED ANXIETY DISORDER

Diagnostic Criteria: The essential feature of generalized anxiety disorder is excessive anxiety and worry about a number of events or activities for more days than not for a period of six months. The person finds it difficult to control the worry. Anxiety, worry, or physical symptoms cause clinically significant distress in social, occupational, or other important areas of functioning. Anxiety or worry is associated with three (or more) of the following:

• Restlessness or feeling keyed up or on edge
• Being easily fatigued
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event. The person finds it hard to keep worrisome thoughts from interfering with tasks at hand and struggles to stop worrying.

4. MEDICAL CONDITIONS AND MOOD DISORDERS

Research and anecdotal evidence makes a connection between health concerns and affective disorders. Depression and/or anxiety can contribute to or be the result of medical problems.

Diabetes and Depression: These often go hand in hand. Type 2 diabetes accounts for 90% of cases and is caused, in part, by obesity. Studies have found that diabetes doubles the chances of developing depression compared with those who don’t have diabetes. Depression raises diabetic complications, leads to poor physical and mental functioning, and reduces medication compliance. Depression is treated with psychotherapy and/or medication, which can also increase follow through with diabetic medication and monitoring, and changes in eating and exercise habits (National Institutes of Health, 2004).

Heart Disease, Depression, and Anxiety: These also have a relationship. Depression and anxiety may increase blood pressure, affect heart rhythms, alter blood clotting, and elevate insulin and cholesterol levels. These risk factors, along with obesity, are symptoms that predict and are a response to heart disease. Chronically elevated levels or stress hormones (e.g., cortisol and adrenaline) also result from depression and anxiety. When stress hormones are high, the body’s metabolism is diverted away from the type of tissue repair needed in heart disease. In addition, one in three individuals who have survived a heart attack experience major depression (National Institutes of Health, 2004).

B. BINGE-EATING DISORDER

Approximately 15%-50% (with a mean of 30%) of individuals in weight-control programs have binge-eating disorder (American Psychiatric Association, 1994). Of the overall obese population, a subset struggles with binge-eating disorder (BED). Statistics on binge-eating disorder include:

• Interview-based studies indicate that less that 5% of obese individuals seeking weight-loss treatment meet the criteria for BED. About 10% to 25% report binge eating without meeting the full criteria of BED. BED appears to be common among the morbidly obese who seek bariatric surgery with a prevalence of 1.4% to 49% (median 20%) ( de Zwaan in Grilo and Mitchell, 2010)
• Females are 1.5 times more likely than males to have this eating pattern (American Psychiatric Association, 1994)
• 53.7% reported onset of binge eating by age 10 (Abbott et al., 1998)
• 15.6% report chemical dependency (Santonastaso et al., 1999)
• Personality disorders: paranoid, borderline, histrionic (Abbott et al., 1998)
• 39.4% indicated they dieted before binge eating; 46.5% did binge eating before their first attempt to diet (Abbott et al., 1998)
• In females with and without BED, the prevalence rates of psychiatric disorders in first-degree relatives are (Lee et al., 1999):
• Affective disorders: 10.5% (BED) versus 8% (non-BED)
• Substance use disorders: 18.4% (BED) versus 15.2% (non-BED)
• Anxiety disorders: 4% (BED) versus 2.7% (non-BED)
• Obesity: 26.8% (BED) versus 18.7% (non-BED)

Research suggests that obese binge eaters differ from obese non-bingers in several ways. They appear to be different in terms of eating pathology and general psychopathology (Lee et al., 1999). Obese binge eaters have:

• Higher levels of dietary restraint and preoccupation with eating
• A history of more severe weight cycling
• Significantly greater comorbid psychopathology, especially depression
• Reported feeling ineffective, are perfectionistic, have lower self-esteem, are impulsive, and have less interoceptive awareness
• Fared more poorly in traditional weight loss treatment programs

Diagnostic Criteria: Binge-eating disorder was proposed as a new category and not an official diagnosable mental disorder. The criterion includes:

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
• eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances
• a sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating and cannot control what or how much is eaten)
• Binge-eating episodes are associated with three (or more) of the following:
• eating much more rapidly than normal
• eating until feeling uncomfortably full
• eating large amounts when not feeling physically hungry
• eating alone because embarrassed by how much one is eating
• feeling disgusted with oneself, depressed, or guilty after overeating
• Marked distress regarding binge eating is present.
• Binge eating occurs, on average, at least 2 days a week for 6 months.
• Binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise) and does not occur exclusively during the course of anorexia nervosa or bulimia nervosa.
• Diagnose as Eating Disorder Not Otherwise Specified (NOS).

Those with binge-eating disorder overeat in two kinds of ways:

• Bingeing: Eating large amounts of food again and again can eventually turn into an addictive habit. Bingers can consume as many as 20,000 calories in one sitting, although the average binge ranges from 1,500 to 3,500 calories (Kaye et al., 1993). Distress comes more from loss of control than from quantity eaten (Spitzer et al., 1991). Frequent bingeing for a sustained period of time can turn into binge-eating disorder.
• Grazing: This is when someone eats from morning until night or for blocks of time without having designated meal times. The day becomes one long snacking event. The problem with this style of eating is that grazers don't know how much they’re eating and often don't pick healthy kinds of foods. They'll grab something quick and easy like candy or chips. Weight gain occurs because they're overfeeding their bodies on unhealthy foods.

CHAPTER III: MEDICAL COMPLICATIONS

1. OVERVIEW OF MEDICAL CONDITION

The conditions listed below are found more frequently and are more serious in people who are overweight and obese (Berg et al., 1997).

• Dermatologic:
• Yeast/fungal infections
• Naval infection
• Rashes
• Skin ulcers
• Dermatitis (inflammation of the skin, like eczema)
• Cardiovascular:
• Coronary heart disease
• Hypertension
• Circulatory problems
• Vascular insufficiencies (lack of blood flow to legs and feet)
• Varicosities (bulging veins, like hemorrhoids)
• Tissue dependencies (accumulation of fat beneath skin)
• Gastrointestinal:
• Hiatus hernia (stomach moves into the chest)
• Esophageal reflux
• Gall bladder disease
• Endocrine:
• Diabetes
• Edema
• Stein-Leventhal syndrome (polycystic ovarian disease)
• Cushing’s disease (tumor in adrenal gland releases too much steroid causing abnormal hair growth and hump on lower part of neck)
• Reproductive:
• Cancer of breast, uterus, and ovaries
• Preeclampsia/eclampsia (high blood pressure during pregnancy and the dumping of protein through the urine)
• Infertility
• Irregular menses or amenorrhea
• Incontinence
• Respiratory:
• Sleep apnea
• Obesity hyperventilation
• Pickwickian syndrome (trouble with breathing)
• Asthma
• Degenerative Diseases:
• Arthritis
• Joint disease
• Lower back pain

2. MAJOR DISEASES

Diabetes is one of the major illnesses of obesity. According to the National Institutes of Health (2010), “diabetes is a disorder of metabolism-the way our bodies use digested food for growth and energy. Most of the food we eat is broken down into glucose, a form of sugar in the blood. Glucose is the main source of fuel for the body. After digestion, glucose passes into the bloodstream. For glucose to get into the cells, insulin must be present. Insulin is a hormone produced by the pancreas, a large gland behind the stomach. When we eat the pancreas automatically produces the right amount of insulin to move glucose from our blood into our cells. In people with diabetes, however, the pancreas either produces little or no insulin, or the cells do not respond appropriately to the insulin that is produced. Glucose builds up in the blood, overflows into the urine, and passes out of the body. Thus, the body loses its main source of fuel even though the blood contains large amounts of glucose.” There are three types of diabetes:

Type 1 diabetes is an immune disease. This results when the body’s system for fighting infection (the immune system) turns against a part of the body. The immune system attacks the insulin-producing beta cells of the pancreas and destroys them. The pancreas then produces little or no insulin. A Type I diabetic must take insulin daily to live. Scientists do not know why this occurs, but they believe autoimmune, genetic, and environmental factors, possibly viruses are involved. This type accounts for 5%-10% of the diabetes in the United States, affecting both men and women equally and more common in Caucasians. The symptoms are increased thirst and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. Without insulin treatment, the person can lapse into a coma.

Type 2 diabetes accounts for 90% of diabetic cases, and is associated with older age, obesity (85% of Type 2 diabetics are overweight), family history of diabetes, previous history of gestational diabetes, physical inactivity, and ethnicity. It is more common in African Americans, American Indians, Hispanic Americans, Asian Americans, and Pacific Islander Americans. Type 2 diabetes is being diagnosed in children and adolescents more frequently. Type 2 diabetes is part of a metabolic syndrome that includes obesity, high levels of blood lipids, and high blood pressure. Initially, individuals with this diabetes develop insulin resistance, a disorder where muscle, fat, and liver cells do not utilize insulin correctly. The pancreas produces more insulin in the beginning, but slowly looses its ability to secrete insulin, and the timing of insulin secretion becomes abnormal. As time goes on, insulin production declines.

Symptoms include nausea, fatigue, frequent urination or infections, unusual thirst, weight loss, blurred vision, and slow healing of sores or wounds. Some people don’t have any symptoms at all. In fact, about one-third of those who currently have type 2 diabetes don’t know it.

Many individuals can control blood glucose by adhering to a careful diet and exercise program, losing excess weight, and taking oral medication. The longer the diabetes persists, the more likely insulin injections will be needed.

Gestational diabetes occurs during pregnancy, mostly with African Americans, Hispanic Americans, and American Indians. After delivery, it usually remits, although the mother has an increased risk of developing type 2 diabetes later on.

By losing just 5 to 7 percent of your body weight and engaging in moderate intensity exercise for 30 minutes a day, 5 days a week may prevent or delay the onset of type 2 diabetes.

Heart Disease is another major illness of obesity. According to the National Institutes of Health (2010), “heart disease means that the heart and circulation (blood flow) are not functioning normally. If you have heart disease, you may suffer from a heart attack, congestive heart failure, sudden cardiac death, angina (chest pain) or abnormal heart rhythm. During a stroke, blood and oxygen do not flow normally to the brain, possibly causing paralysis and death. Heart disease is the leading cause of death in the U.S., and stroke is the third leading cause.” Overweight individuals are more likely to have high blood pressure, high level of triglycerides (blood fats) and LDL cholesterol (a fat-like substance called “bad cholesterol”), and low levels of HDL cholesterol (the “good cholesterol”)—all risk factors for cardiovascular disease. More body fat means that there are higher levels of substances that cause inflammation, raising the risk of heart disease. Smoking also increases the chances of developing heart disease.

The keys to controlling risk factors are regular exercise, good nutrition, and smoking cessation. Losing 5 to 10 percent of your weight can lower your chances of developing coronary heart disease or having a stroke. If you weight 200 pounds, this means losing only 10 pounds. Lifestyle changes are number one on the list. Medications and even surgery may be required once heart disease develops.

Metabolic Syndrome is a group of obesity-related risk factors for coronary heart disease and diabetes. A person must have three or more of the following risk factors (National Institutes of Health, 2008):

• A Large Waistline: 35 inches for women and 40 inches for men
• High Triglycerides: 150 mg/dL or higher
• Low Levels of HDL ("Good") Cholesterol: below 50 mg/dL in women and below 40 mg/dL in men
• High Blood Pressure: 130 mm Hg or higher for systolic (top number) and 85 mm Hg or higher for diastolic (bottom number)
• High Fasting Glucose (Sugar): a fasting blood sugar of 100 mg/dL or higher

Cancer risk is increased with being overweight. According to the National Institutes of Health (2010), “cancer occurs when cells in one part of the body grow abnormally and out of control and possibly spread to other parts of the body. Cancer is the second leading cause of death in the US.”

Being overweight is linked to the development of several types of cancer including colon, esophagus, kidney, uterine, and postmenopausal breast cancer in women. It is not known how being overweight affects cancer risk. One theory is that fat cells make hormones that affect cell growth and lead to cancer. Eating and physical activity habits that lead to being overweight may also contribute.

Avoiding weight gain may prevent the development of cancer. Losing weight, healthy eating, and physical activities may lower cancer risk.

Osteoarthritis is a common joint disorder that causes bone and cartilage (tissue that protects the joints) to wear away most often in the knees, hips, and lower back. Extra weight puts pressure on both. Plus people with more body fat may have higher levels of substances that causes inflammation in the joints, raising the risk of osteoarthritis.

Sleep Apnea is more prevalent in people who are overweight. According to the National Institutes of Health (2010), “sleep apnea is a condition in which a person stops breathing for short periods during the night. A person who has sleep apnea may suffer from daytime sleepiness, difficulty concentrating, and even heart failure.”

Individuals who are overweight tend to have more fat around their necks, making the airway smaller, thus making breathing difficult, snoring loud, or breathing stop altogether. Fat stored in the neck and body can cause inflammation (also a risk for heart disease).

Losing weight often improves sleep apnea because neck size decreases as does inflammation.

Gallbladder Disease and gallstones are more common in overweight individuals. According to the National Institutes of Health (2010), “gallstones are clusters of solid material that form in the gallbladder and are made mostly of cholesterol, sometimes causing abdominal or back pain.”

Overweight individuals may produce more cholesterol and/or have an enlarged gallbladder, which may not work properly. Fast weight loss (3 pounds or more a week) can actually increase chances of developing gallstones. Slow weight loss (1/2 to 2 pounds a week) is less likely to cause gallstones.

CHAPTER IV: PREVENTION AND EARLY INTERVENTION

A. PREVENTION

Prevention is the best way to stop weight problems altogether. Once someone is overweight or obese, the chance of successfully losing weight and keeping it off is small. Only 5%-10% of dieters maintain weight loss for two or more years.

Obesity is now called an epidemic, yet there has not been a comprehensive public health approach, only individual intervention when a person decides to lose weight. Low-income groups are especially affected with the lack of health care options; grocery stores in their neighborhoods; fruits, vegetables, or grains offered by federal commodities programs; information on healthy eating; and safe exercise environments (Lyons, 1997).

Home: Prevention includes teaching parents healthy eating and exercise habits they can pass on to their children. Parents role model eating patterns and food choices. Thus far, there is no overarching plan by the government or private industry to educate parents on balanced eating. It is not provided to new mothers nor is it offered in any educational system, unless a student opts to take a nutrition course as an elective.

Schools: Parents, PTA’s, teachers, and students will have to be proactive and demand, and even expect, salad bars, a deli sandwich station, fruits, and vegetables instead of fried foods, fast foods, chips, candy, and soda. The argument has been that healthy foods cost more, but this isn’t so. The estimated cost of daily portions (recommended by the federal Food Guide Pyramid) of fruits and vegetables is 64¢, yet only 7% of the population eats this amount (Time, 2004). Some school systems are now banning food and drink corporations from placing their items in schools, and are hiring food service companies to provide healthy choices. According to the United States Department of Agriculture (Tyre, 2002):

• 10 states restrict junk food sales in schools
• 12 states have nutritional legislation pending for schools
• 8 states have some current rules and pending laws for schools

B. EARLY INTERVENTION

The National Institutes of Health (2010) has created guidelines to help parents with their overweight children. They state that “healthy eating and physical activity habits are key to your child’s well being. Eating too much and exercising too little can lead to overweight and related health related problems that can follow children into adult years. Take an active role in helping your child and family learn healthy eating and physical activity habits that may last a lifetime.”

The National Institutes of Health suggests involving the whole family in building healthy habits. This will benefit everyone without singling out an overweight child. They state, “Do not put your child on a weight-loss diet unless your healthcare provider tells you to. If children do not eat enough, they may not grow and learn as well as they should.” Recommendations include:

• Be a Positive Role Model
• Choose healthy foods and active pastimes for yourself
• Children are good learners and learn from what they see.
• Be Supportive
• Tell your child that he or she is loved, special, and important
• Accept your child at any weight
• Listen to your child’s concerns about his or her weight
• Encourage Healthy Eating Habits
• Buy and serve more fruits and vegetables
• Buy fewer soft drinks and high fat/high calorie snacks like chips, cookies, and candy
• Eat breakfast every day
• Plan healthy meals and eat together as a family
• Eat fast food less often
• Offer your child water or low-fat milk more often than fruit juice
• Do not get discouraged if your child will not eat a new food the first time it’s served
• Try not to use food as a reward when encouraging kids to eat
• Start with small servings and let your child ask for more if he or she is still hungry
• Provide healthy meals and snacks in moderation (i.e., fresh fruit, canned fruit in light syrup, dried fruits, fresh vegetables, reduced fat cheese or small amount of peanut butter on whole-wheat crackers, low-fat yogurt with fruit, graham crackers, animal crackers, or low-fat vanilla wafers.
• Encourage Daily Physical Activities
• Set a good example
• Encourage your child to join a sports team or class at school
• Be sensitive to your child’s needs
• Be active together as a family
• Do not encourage pre-adolescent children to participate in adult-style physical activities as their bodies are not ready yet
• FUN physical activities are best for kids (e.g., riding a bike, climbing on a jungle gym, swinging on a swing set, jumping rope, playing hopscotch, and bouncing a ball)
• Kids need 60 minutes of physical activity a day, but not all at one time
• Discourage Inactive Pastimes
• Set limits on the amount of time your family spends watching TV and videos, and playing video games
• Help your child find FUN things to do besides watching TV (e.g., acting out favorite books or stories or doing a family project)
• Read together instead of watching TV
• Encourage your child to get up and move during commercials
• Discourage eating in front of the TV

These strategies promote healthy weight in children who don’t have a problem and help children who need to lose weight by altering the way they think about and deal with food and exercise.

CHAPTER V: THE DIETING MYTH

A. DIETING

For those who are overweight and obese, making lifestyle changes is the most effective strategy for weight loss. Dieting is different than lifestyle changes. There are subtle yet important distinctions. Dieting is a “limitation on the amount of food a person eats.” Lifestyle changes indicate a feasible plan that incorporates eating and exercise. Many diets offer a “maintenance eating regimen” once the diet is completed that is much healthier and more balanced than the actual diet. Lifestyle change eating approximates the maintenance portion of a diet plan.

Dieting has been the standard method for weight loss. If diets worked, dieters would diet once, lose weight, and keep it off. Yet that is not what happens.

1. THE DIET INDUSTRY

Weight loss is a $40 billion a year industry. Products range from diet drinks and food to pills, exercise equipment, and special regimens. In 1992, the National Institutes of Health held a conference to review the state of the art of dieting and found that it “often had no data with which to answer questions about voluntary weight loss and control methods” (Rosenthal, 1993). Companies don’t need to substantiate claims of effectiveness or success. The Federal Trade Commission has yet to increase regulation on advertising of diet and weight loss programs (Lyons, 1997). Listed below is a variety of statistics related to dieting:

• According to George Hsu, M.D., Eating Disorders Program director at Tufts University School of Medicine, dieting is the single most likely culprit for the rising rates in eating disorders (Goleman, 1995).
• 35% of “normal” dieters will progress to pathological dieting. Of those, 20%-25% will develop a partial- or full-syndrome eating disorder (Shisslak and Crago, 1995).
• 46% of 9- to 11-year-olds are “sometimes” or “very often” on diets while 82% of their families are “sometimes” or “very often” on diets (Gustafson-Larson and Terry, 1992).
• 91% of college women surveyed attempted to control their weight through dieting, 22% dieted “often” or “always” (Kurth et al., 1995).
• $54.74 is the average cost of one pound lost on a medically supervised liquid diet. In one study, 255 participants each lost an initial 47 pounds, spending a combined total of $677,720 (Rubin, 1994).

Advertising in general and the diet industry in particular often play on people’s insecurities. A person can wind up feeling like a weak-willed failure for not sticking to a diet, looking like a supermodel, or having the kind of lifestyle that thin people have. Wherever pockets of insecurities lay, advertising will exploit these emotions.

2. SNACK AND FAST FOOD INDUSTRIES

On the other side, the snack and fast food industry is a multibillion-dollar enterprise. These high-fat, high-sugar, and high-salt foods are everywhere. Whereas in the 1960’s, the average portion size of a fast-food French fries pack contained 200 calories, the extra large sizes are now around 600 calories. Soft drinks are no longer only 12 ounces (140 calories). They are as large as 64 ounces (740 calories). Moreover, highly processed foods lose much of their nutritional value. Supersizing food and beverages has added an average of 300 calories a day since the 1980’s, creating a weight gain of 25 to 30 pounds a year (Blake and Durschlag, 2004).

3. WHY DIETS FAIL

No commercial dieting program has demonstrated long-term results in weight maintenance (Lyons, 1997). In spite of 90%-95% of dieters failing to keep weight off in the long term, they continue to try one product after another with less and less hope of attaining permanent weight loss. Research suggests that dieting (eating less than 1,200 calories a day) causes more problems that it eliminates.

• Diets teach people to diet. They don’t teach a style of eating they can do long-term. Diets only offer a quick-fix temporary solution without a plan to maintain weight loss.
• Dieters feel deprived and will eventually binge on all the “bad” foods they could not have while on a diet. They can fall into a cycle of yo-yoing between starving and overeating.
• Dieters awaken during the night and eat to stop hunger pangs. Night eating often remits once the person gets enough food during the day. To break the habit, they can practice resting after awakening, and wait to fall asleep.
• Dieting fights against the body’s weight-regulating mechanism by slowing the metabolism down. The body thinks it’s in a famine and burns fewer calories. When people fall off the diet, they eat more, but their metabolism is sluggish so they gain weight.
• Dieting pushes fat cells to store fat by making these fat cells larger, stronger, and more resistant to weight loss. When the body doesn’t get enough food, it stores incoming food in fat cells.
• Dieters can lose as much muscle (the one active tissue that burns calories and fat on an ongoing basis) as fat on a restrictive diet. The body will actually burn muscle before it burns fat.
• With each round of dieting, dieters can gain 10% more body weight once they stop the diet and revert to old behaviors.

4. POPULAR DIET PLANS

High-Protein Diets: These diets promote eating eggs, cheese, beef, and bacon. Some newer versions allow chicken and fish. They ban most carbohydrates (e.g., grains, fruits, and the sweeter-tasting vegetables). Carbohydrates are chemical compounds made up of carbon, oxygen, and hydrogen atoms. Proteins contain these compounds plus nitrogen. The body uses carbohydrates to produce energy. Simple carbohydrates include soft drinks, candies, fruits, honey, jelly, syrup, table sugar, and desserts. Complex carbohydrates are grains and starchy foods like breads, rice, pasta, potatoes, cereals, corn, and beans (McBarron, 1998). Cartwright (2000) describes the theory behind high-protein diets, how they work, and the problems that result from these diets.

• Theory: Carbohydrates provoke hunger, causing a person to overeat and gain weight. Carbohydrate consumption releases insulin, the “fat-producing hormone,” so the diet eliminates or substantially reduces carbohydrates. Protein and fat are increased to satisfy hunger. This formula leads to weight loss without food cravings.
• How These Diets Work: Ketosis is induced, which causes fat burning.
• Problems: Rapid weight loss is due to water rather than fat loss. What leaves with the water are B-vitamins, calcium, and potassium. This can eventually lead to osteoporosis. Fatigue, nausea, dehydration, dizziness, headache, mental confusion, and sleep problems (due to reduced serotonin) are also problems. There is also a long-term risk of kidney damage. The result is that people fear carbohydrates (they avoid breads, cereals, corn, potatoes, and fruits) but they also miss them (i.e., the nutrients and mood stabilizing properties). In reality, many people cannot stay on such a restrictive meal plan. When they go off the diet, they eat all the foods they couldn’t before, feel badly about it, and gain weight.

Carbohydrates have been blamed for America’s burgeoning weight problems. This is true and not true. Carbohydrates are currently a weight-gain food source because Americans have drastically increased carbohydrate intake. From 1971 to 2000, women increased their carbohydrate caloric intake by 22% and men increased theirs by 7%. Most of the increase was from cookies, soda, and pasta (Centers for Disease Control and Prevention, 2004).

• In 1971, women ate an average of 1,542 calories a day, compared with 1,877 calories in 2000
• In 1971, men ate an average of 2,450 calories a day, compared with 2,618 calories in 2000
• For women, carbohydrate intake jumped from 45% of daily intake to 52%
• For men, carbohydrate intake jumped from 42% to 49%

If Americans reduced or eliminated snack foods and ate as they did 30 years ago, weight loss would occur. Healthier eating means fewer calories consumed.

Carbohydrate Addiction Diets: Cartwright (2000) describes the theory behind these diets, how they work, and the problems that result.

• Theory: These diets promote eating high protein and modified carbohydrates to help decrease hyperinsulimia, food cravings, and the addictive hunger cravings for carbohydrates, thus leading to weight loss.
• How These Diets Work: Eating two Complimentary Meals (e.g. high in fiber; low in fat and carbohydrate) produces less insulin, pushing the body to burn stored fat. Then, when unlimited food is consumed at a Reward Meal, the body doesn’t produce as much insulin as normal because it was “fooled” by the Complimentary Meals into making less insulin.
• Problems: The pancreas produces insulin based on current food consumption and blood sugar levels, not production based on food intake at previous meals. Food cravings and addictions have a strong psychological component, which is not taken into account.

The best method for controlling food cravings and intake is eating three balanced meals rather than restricting and overeating.

Low-Fat Diets: These diets were very popular in the 1980’s and 1990’s. Since high-protein diets have become blockbusters, many people think eating large amounts of fat is okay. People who tried these diets often fear fats and continue to restrict fats even though they haven’t lost any weight over the years.

• Theory: Fat makes people fat, so the only way to get rid of fat is to eat much less fat. Many diets promote eating 20% or less of calories from fat.
• How These Diets Work: Like any other diet, people lose weight because calories are restricted—all calories, including fat.
• Problems: Consuming excess calories, regardless of if it’s from fat (protein or carbohydrates) leads to fat storage and weight gain. So, no one food is the culprit. Dieters are encouraged to eat non- and low-fat foods. Many of these processed foods are loaded with sugar. Instead of eating a couple of cookies, people eat the whole box and still aren’t satisfied (fats are physiologically satisfying). Hours or days later, they reach for fat-filled foods and overeat them, which eventually leads to weight gain.

Low-Calorie Diets (LCD): Calories are restricted to 800 to 1,500 calories per day (National Institutes of Health, 2008). As stated previously, if a person restricts calories, weight will come off. However, diets below 1,200 calories are hard to maintain. Fatigue, dizziness, and general malaise sets in with long-term undereating. Hunger eventually develops and the dieter overeats because of feeling too hungry.

Very Low Calorie Diets (VLCD): These are medically supervised and monitored restrictive diets for moderately to extremely obese patients who consume 800 or fewer calories per day (National Institutes of Health, 2008). Optifast is a nutritional supplement drink that is made by Novartis. Patients are placed on a 420 calorie a day diet in which they drink the supplement five times a day. For some, this is too strict. In that case, Optitrim, another nutritional supplement drink is combined with one 300-calorie meal, bringing up the calories to 1,000 a day. Both supplement drinks contain less than 100 calories per drink (Zimmerman, 2002).

Once individuals reach their target weight, they add real food at meal times. Many VLCD programs require participants to attend a weekly support group with a nutritionist for up to 10 weeks to support incorporating food back into a normal eating plan (Zimmerman, 2002).

Anecdotally, many of these patients reported being able to stick to the liquid meals because they didn’t have to worry about food. However, transitioning from the liquid portion of the diet to real food became problematic. Initially, they could follow the plan, but as time went on, old habits, bingeing behaviors, or overeating crept back in. Many report gaining some or all of weight back. Therapy with an eating disorder specialist in addition to the support groups offers these dieters a better chance of eliminating bingeing and overeating. Behavior changes and coping strategies are reinforced on a weekly basis.

5. THE REAL SKINNY

Diets promote the idea that to be healthy, people MUST reach their ideal weight. In fact, a weight loss of 5%-10% can do much to improve health by lowering blood pressure, cholesterol levels, and risk for type 2 diabetes (National Institutes of Health, 2008).

CHAPTER VI: TREATMENT OPTIONS

Treatment for obesity falls into one of two categories: changing eating and exercise habits, or surgery. For those who are overweight, making lifestyle changes is the most effective strategy and surgery is not recommended.

A. LIFESTYLE CHANGES

1. METHOD OF CHOICE

The National Institutes of Health (2010) states that, “experts agree the best way to reach a healthy weight is to follow a sensible eating plan and engage in regular physical activity. Weight-loss programs should encourage healthy behaviors that help you lose weight and that you can maintain over time.” The National Institutes of Health suggests safe and effective weight-loss programs should include:

• Healthy eating plans that reduce calories but do not rule out specific foods or food groups
• Tips to increase moderate intensity physical activity
• Tips on healthy behavior changes that also consider cultural needs
• Slow and steady weight loss of 1/2 to 2 pounds per week (weight loss may be faster at the start of a program)
• Medical care if you are planning to lose weight by following a special formula diet
• A plan to keep the weight off after you have lost it

2. TREATMENT FORMAT

Clinicians working with obese patients who have BED face the challenge of encouraging weight loss or at least preventing additional weight gain. Therapeutic goals include cessation of binge eating, weight loss or halting weight gain, improvement in physical health, and reduction in psychological disturbance (de Zwaan in Grilo and Mitchell, 2010). Although psychological disturbances are often not the primary cause of obesity, behavior modification can be helpful for weight reduction (Rosenbaum et al., 1997). Psychotherapy is the latest innovation in the treatment of obesity so that issues that cause overeating are dealt with (Zimmerman, 2004). Individual and group therapy during and after weight loss will increase the chances of long-term success.

Cognitive-Behavioral Therapy: There is general consensus in the field that CBT is currently the best established form of psychotherapy for binge-eating disorder either in an individual or group therapy format (Grilo and Mitchell, 2010).  

Interpersonal Therapy: This form of therapy has also been found to be effective with binge-eating disorder (Grilo and Mitchell, 2010). Interpersonal Therapy (ITP) focuses on disturbances in social functioning that are associated with the onset and maintenance of the disorder. (Wilfley and Cohen, 1997).

For more details on these treatment modalities, refer to the course, Feast or Famine: The Etiology and Treatment of Eating Disorders.

Psychological approaches to treat BED have resulted in little weight loss at the end of treatment. It might be that the calories previously consumed during the binge-eating episodes become distributed over non-binge meals after treatment (De Zwaan in Grilo and Mitchell, 2010). Reduction in calories without being restrictive and consistent exercise increases the chances of permanent weight loss.  

These will be addressed in the Psychotherapy section below.

Group Therapy: This therapy is specifically designed to support behavior changes, develop strategies to keep lifestyle changes in place, and offer camaraderie. Groups can be therapist-led or self-help, such as Overeaters Anonymous (be aware that some groups advocate their meal plans). Make sure that the group’s goals are in alignment with your therapeutic goals.

Nutritional Counseling: You may want to send your patient to a dietician who can create a personalized weight loss plan and adapt it over time. Choose someone who has training and experience in working with weight problems and eating disorders so your patient is not placed on a restrictive or fad diet.

Motivated individuals (no matter what they weigh) can create long-term weight loss by changing their eating and exercise habits. Even surgery patients and those who take weight-loss medications must change behaviors or weight will not stay off. Making lifestyle changes is the least invasive and risky way to lose weight.

When you interview a new patient, ask yourself if you have the expertise and experience to treat this person. The most difficult situation for both therapist and patient is for the therapist to be in over her head. You must understand the nuances of treating obesity. You will have to know the ways in which these patients get tripped up in making behavioral changes, and when emotional issues are interfering along with how to address them. If you believe you cannot manage the case, refer out to someone whom you know has the experience.

3. DIETARY CHANGES

Below is an overview of changes patients will need to make. If you’d like more details, consider taking the course Feast or Famine: The Etiology and Treatment of Eating Disorders.

New Skills: When working with overweight or obese individuals, your role is to offer sound nutritional advice and techniques to alter eating and exercise habits. Below are changes patients need to make to produce permanent weight loss:

• Give up overeating and dieting
• Eat three moderate meals a day
• Follow a sample meal plan and plan meals every day
• Consume a minimum of 1,200 calories a day
• Learn how to measure moderate portion sizes
• Keep lots of healthy foods around and limit processed snack foods
• Create an eating environment by setting the table and eating there
• Make one change at a time
• Choose whole grains and limit sugar intake
• Choose non-hydrogenated fats. Hydrogenated fats (Crayhon,1997):
• Increase the number of fat cells and promote obesity
• Raise total cholesterol
• Lower HDL (“good cholesterol”) and raise LDL (“bad cholesterol”)
• Promote inflammation
• Reduce the body’s ability to rid toxins, carcinogens, and drugs
• Dangerously alters cell membrane functions throughout the body
• Decrease immune function
• Satisfy cravings by including sweet or salty treats once or twice a week
• Figure out how to eat in restaurants
• Avoid dehydration because being thirsty can be misinterpreted as hunger, and water helps fat move out of fat cells and to be used by the body
• Keep food charts for a period of time to learn what healthy eating is
• Distinguish physical hunger from emotional hunger
• Drop the “bad” foods list because anything can be eaten in moderation
• Deal with emotions instead of using food
• Stop weighing in if there’s disappointment with progress

Three Moderate Meals a Day: People who want to lose weight must eat three meals a day (with or without snacks) with a minimum intake of 1,200 calories. Teens, young adults, and males will require meal plans with calories between 1,500 and 5,000. A dietitian can calculate the exact amount of calories required and which are the best sources of food from which to obtain these calories.

Sample Meal Plan (Price, 1999):

Plan Meals: The Food Guide Pyramid (United States Department of Agriculture, 2006) recommends:

• 4 servings of fruit
• 5 servings of vegetables
• 6 servings of grains (bread, cereal, rice, and pasta)
• 6 ounces of protein (meat, poultry, fish, dry beans, eggs, and nuts)
• 3 cups of dairy (yogurt, milk, and cheese)
• 6 teaspoons of oil
• 267 calories from discretionary foods (e.g., 4 teaspoons of solid fat and 8 teaspoons of sugar)

Simple rules help people plan meals:

• Don’t skip meals.
• Include snacks if hungry between meals to tide over to the next meal.
• At each meal, make sure that at least three of the first five food groups (i.e., grain carbohydrates, fruits, vegetables, proteins, and dairy) are included as shown in the meal plan. This ensures well-rounded eating.
• Eat two grain carbohydrates per meal (minimum of 6 a day).
• Eat protein two times a day.
• Eat dairy two times a day.
• Eat fruits and vegetables with and between meals.
• Include healthy fats.
• Do food charts for a few months to assess quantity/quality of food choices.

Measure Moderation: Portion size counts! The best way to measure serving size is for people to use the palms of their hands. Everyone’s hand fits his body size. Anything that will fit into one hand is one serving.

• One piece of bread is about the size of one whole hand.
• One serving of rice or potatoes would fit under the dome of the hand placed on a plate.
• Two servings of cereal would be both hands cupped together with the cereal held inside.
• One serving of protein is the size and thickness of just the palm.
• One serving of fruit or vegetables fits into one cupped hand.
• One serving of candy, cookies, or nuts fit into one cupped hand.

Of all the diets on the market, Weight Watchers offers balanced eating. So, if your patient wants to try a commercial diet, this is the one to choose. The system is based on points, so that when the person has used up all of her points, eating for the day is finished. Where people are tripped up is allowing too few points each day (in an attempt to lose weight quickly), and ultimately feeling hungry or deprived, which leads to rebound overeating. Keeping track of what is eaten every day builds awareness and new healthy eating rules.

Simple Weight Loss Formula: It takes eating 100 fewer calories a day to lose 10 permanent pounds in one year, 200 fewer calories to lose 20 pounds, and 300 fewer calories to lose 30 pounds. Conversely, all a person has to do is eat 100 more calories a day to gain 10 permanent pounds in a year, and so on. As stated previously, Americans are over-consuming 300 more calories of carbohydrate-filled snack foods a day (a weight gain of 30 pounds a year) than 30 years ago.

4. EXERCISE

Why Exercise Matters: Increased physical activity not only raises caloric expenditure, it also promotes dietary compliance (Rosenbaum, 1997). For obese individuals (especially those who are “apple-shaped”), visceral fat is the first to disappear when they exercise, thus removing the fat around the heart and other organs (Underwood and Adler, 2004). Exercise is the number one way to help maintain a healthy weight. Exercise alone can produce weight loss in people who never change their eating habits. When they do alter what they eat, the results are more dramatic.

Muscle is the one active tissue in the body that continually burns fat. More muscle means more calories are burned during the day. The metabolic rate rises during exercise and extends up to six hours post-exercise. One pound of muscle burns 35 calories whereas one pound of fat burn 2 calories. Exercise also increases fat-burning enzymes and muscle mass (including the heart muscle); oxygenates blood; lowers blood pressure, and releases endorphins and the neurochemical, norepinephrine, which aids in stress management.

Starting at age 40, women lose ½ a pound of muscle per year while replacing it with fat. By the age of 80, they have only ⅓ as much muscle as they had when they were 40. Unused (unexercised) muscle atrophies and the percentage of body fat increases. Regular strength training (weight lifting) can reverse the effects of aging as measured by muscle mass, body fat content, bone density, flexibility, and balance. Through cardiovascular exercise and strength training, the body can burn 15% more calories a day (Williams, 1997).

Encourage patients to choose an exercise that interests them and that they will do on a long-term basis. Sometimes an exercise buddy can help them keep the commitment to exercise. If they haven’t been exercising and you’re concerned about their health, recommend that they receive a physician’s clearance first. Patients who are just starting out will have to begin slowly in order to avoid injury or burn out.

Simple Exercise Formula: Moderate exercise means doing some form of cardiovascular workout (walking, running, swimming, biking, hiking, boat rowing, etc.) at least 3 to 7 times a week for half an hour to 1 hour (maximum) a day. Strength training (e.g., weight lifting) two to three times a week is as important as cardiovascular training.

5. COMPLIANCE

Teaching patients these skills sounds deceptively simple. The principles are basic, but achieving compliance is difficult because:

• Few diet books promote moderate eating and exercise, so patients have a hard time finding this kind of do-it-yourself program.
• They have faulty diet information that they’ll tenaciously cling to and you’ll have to debunk.
• They don’t have enough nutritional education to understand labels, what healthy fats are, what an appropriate portion size is, how to create three healthy meals a day, what to do when stressed and eating is not an option, how to stay motivated and committed, and how to navigate restaurant eating.
• They want to lose weight quickly. Therefore, they may bristle at the idea of following a sensible plan that won’t give them the results they want right away.
• They become overzealous, and either eat too little and/or exercise too much (even though that’s not what you recommended) but ultimately cannot maintain the extreme changes.
• They become discouraged and feel like giving up when they can’t stick to the new plan or lose weight as they thought they would.
• They don’t realize that changing habits is hard work that takes conscientious effort every day.
• It takes effort to purchase and prepare healthier foods.
• They’ll revert to old behaviors as they struggle to put new principles into action.
• Without ongoing support or feedback from an expert, they don’t know what to do in new situations.
• Once sugar, fat, and/or salt intake is reduced, cravings for these substances persist for days or weeks, and reemerge periodically depending on stress, hormone fluctuations, or after eating them for a special occasion.
• The person gives up on exercise because it’s physically demanding in the beginning and changes in body size or shape don’t occur rapidly.
• Binge eaters and those with depression or anxiety need psychotherapy to help them deal with emotional eating. If they don’t work with an eating disorders specialist, behavior change techniques are often not utilized in treatment, so the underlying issues may be addressed but the unhealthy food habits continue.
• Low-income individuals have fewer resources for information than others do. They may have less access to healthy foods or grocery stores.
• You will encounter all of the above. Plus, patients will:
• not follow through with recommendations
• become resistant to change
• get frustrated with the process
• blame you for the slow progress
• challenge your expertise in nutrition and exercise

Training, experience, and broad research knowledge will help you provide encouragement and techniques these patients need to eventually make permanent lifestyle changes that lead to long-term weight loss.

B. PSYCHOTHERAPY

Treatment information is based on Healing the Hungry Self: The Diet-Free Solution to Lifelong Weight Management (Price, 1999) and clinical experience. More detailed information is provided in Feast or Famine: The Etiology and Treatment of Eating Disorders.

1. PSYCHOTHERAPY OPTIONS

Individual, group, family, and couples therapies are outpatient treatment options. Most patients require a combination of modalities. A psychiatrist, dietician, and nutritionist many also be needed as part of the treatment team.

Cognitive, behavioral, interpersonal, and psychodynamic therapies are the most common forms of therapy utilized with eating disordered patients.

• Cognitive Behavioral Therapy is proven to produce greater overall improvement with distorted thinking and unhealthy behaviors than other forms of treatment for binge-eating disorder (Wilfley and Cohen, 1997).
• Interpersonal Therapy focuses on disturbances in social functioning associated with the onset and maintenance of the disorder. Treatment addresses grief, interpersonal disputes, role transitions, and interpersonal deficits (Wilfley and Cohen, 1997).
• Psychodynamic Therapy can be used in addition to the above therapies to explore the family environment, negative beliefs, sense-of-self, identity issues, defense mechanisms, unresolved childhood and adolescence issues, transference, and countertransference.

2. TREATMENT GOALS

The American Psychiatric Association (2000) provides the following goals.

• Restore healthy eating patterns
• Treat/remediate physical complications
• Correct dysfunctional thoughts, attitudes, and feelings
• Treat associated Axis I and Axis II psychopathology including deficits in mood regulation, self-esteem, and behavior
• Enlist family support and provide family counseling where appropriate
• Prevent relapse

In addition to the above:

• Reduce and eventually eliminate bingeing
• Provide education regarding nutrition
• Discuss that natural weight loss occurs when eating is normalized
• Build coping strategies and self-regulatory skills
• Teach assertiveness and communication skills
• Address body disturbances
• Encourage exploration of sexuality fears
• Focus on maturity fears
• Instigate steps towards separation and individuation

3. HOLISTIC TREATMENT APPROACH

When you conduct therapy with an eating disordered patient, you must address the whole person. Four important “selves” make up an individual: the physical self (physical body), the emotional self (emotional reactions and experiences), the mental self (beliefs and thought processes), and the spiritual self (soul/spirit). Each “self” played a role in creating and sustaining the eating disorder. Healing must include all four selves.

The recovery process encompasses four major components. Patients must:

• Develop a style of eating and exercise they can do for the rest of their lives without ever having to diet again
• Make peace with weight, shape, and appearance
• Let go of old negative beliefs by adopting more positive and realistic ones
• Build coping strategies to manage the ups and downs of life

Healing the Physical Self: Information provided in Lifestyle Changes addresses how to alter eating and exercise behaviors.

Healing the Emotional Self: Cognitive therapy focuses on helping patients identify, understand, and process unpleasant affect, thereby increasing their capacity to self-soothe in ways that are more functional. Behavior therapy offers hands-on tools to help them move through emotions. There is a variety of reasons why individuals binge. These include:

• To numb feelings
• To comfort or nurture
• To calm down or create relaxation
• To distract or avoid difficulties
• To control something when life feels beyond control
• To momentarily fill an internal emptiness
• To procrastinate attending to responsibilities
• To alleviate boredom
• To feel energized
• As a reward or punishment
• As a celebration
• To feel cleansed and renewed

Strategies to Cope with Emotions: The only way patients stop using food to cope is to learn to tolerate feelings and do something constructive (not destructive) with them. These include:

• Removing themselves from the eating environment
• Sitting with and moving through feelings
• Catching critical internal dialogue as soon as it starts
• Talking about feelings with others
• Journaling, painting, or drawing feelings
• Pampering themselves
• Getting out to exercise (in moderation)
• Isolating eating behaviors and get back on track the very next meal
• Distracting themselves by getting involved with something else (that is not destructive) until the desire passes

Improve Body Image and Self-Acceptance: Listed below are a number of steps patients can take to improve body acceptance:

• Stop weighing themselves
• Don’t stare into the mirror or pinch folds in body
• Curtail criticizing size and appearance
• Make realistic affirmations about their bodies
• Change negative beliefs by adopting more realistic ones
• Develop body wisdom by appreciating how amazing the body is
• Respect and don’t take for granted their health
• Understand and address fears around sexuality

Healing the Mental Self: Interpersonal and psychodynamic therapeutic strategies are helpful when working with underlying factors that produce an eating disorder. The focus is the relationship with the self and other people.

Beliefs are the underpinnings of sense-of-self. They’re formed in childhood and adolescence and reinforced throughout life. Once a belief solidifies, incoming information is skewed to fit the belief, affecting how a person feels, thinks, and ultimately, which decisions are made (Lazaris, 1986). In this way, beliefs create reality. The critic, child, adolescent, and healer within actively participate in the maintenance of beliefs. At some point in therapy, patients will explore:

Beliefs and Attitudes → Feelings and Thoughts → Decisions and Choices

• Identifying and changing negative beliefs (unworthy, unlovable, unintelligent, unattractive, unimportant, etc.)
• Reducing perfectionistic drives
• Addressing distorted thinking
• Understanding the role of self-monitoring behaviors
• Letting go of people-pleasing behaviors
• Becoming more assertive (versus passive or aggressive)
• Learning to live in the present

Healing the Spiritual Self: Many patients describe feeling empty inside. Part of what is missing is a strong positive sense-of-self. What may also be lacking is a spiritual connection to something outside of them. Seeking a spirituality that honors the spirit and tends to the soul places their struggles in a larger context and provides comfort during difficult moments.

C. MEDICAL

1. BARIATRIC SURGERY

According to the National Institutes of Health (2010), “gastrointestinal surgery is an option for people who are severely obese and cannot lose weight by traditional means or who suffer from serious obesity-related health problems. Surgery promotes weight loss by restricting food intake and, in some operations, interrupting the digestive process. As in other treatments for obesity, the best results are achieved with healthy eating and exercising behaviors and regular physical activity.”

Over 63,000 surgeries were performed in 2002, according to the American Society for Bariatric Surgery (Mayo Clinic, 2004). By 2004, the estimates were 110,000 a year with most of the patients being women in their childbearing years (The Associated Press, 2004).

The major criterion for surgery is having a BMI above 40, which is excess weight of about 100 pounds for men and 80 pounds for women. People with a lower BMI (between 35 and 39.9) with Type 2 diabetes, heart disease, or sleep apnea may also be candidates for surgery.

There are three categories of gastrointestinal surgery (also called bariatric surgery)—restrictive, malabsorptive, and combined restrictive/malabsorptive. Both alter the digestive process by closing off parts of the stomach to make it smaller.

Restrictive operations only limit food intake. They do not interfere with the normal digestive process. A small pouch is created at the top of the stomach where food enters from the esophagus, initially holding about 1 ounce of food and eventually expanding to 2-3 ounces. The small outlet delays emptying, causing a feeling of fullness. After surgery, patients can no longer eat large amounts of food. Food has to be soft, moist, and well chewed (1/2 to 1 cup of food) to avoid discomfort and nausea. Patients who choose restrictive procedures generally are not able to eat as much as those who have combined operations.

• Adjustable gastric banding (AGB): A hollow band made of silicone rubber is placed around the stomach near the upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is inflated with a salt solution through a tube that connects the band to an access port placed beneath the skin. The band can be tightened or loosened over time to alter the size of the passage by raising or lowering the amount of salt solution.

Advantages: Easier to perform and generally safer than some malabsorptive operations. AGH is usually done via laparoscopy (smaller incisions, less tissue damage, shorter operating time, and shorter hospital stay). This procedure can also be reversed and result in few nutritional deficiencies.

Disadvantages: These patients generally lose less weight than those who have malapsorptive operations and are less likely to maintain weight loss in the first year after the procedure. In the first year, patients lose about half their body weight. Some patients gain weight by eating soft high-calorie foods. Others are unable to change their eating habits. Success depends on adopting long-term health eating and exercise habits.

Risks: A common risk is vomiting, which occurs when a patient eats too much or the narrow passage into the stomach is blocked. The bands can slip or wear away, saline can leak, the staple line can break down, and stomach acids can leak into the abdomen requiring emergency surgery. In less than 1% of cases, infection or death from complications can occur.

Combined restrictive/malabsorptive operations are the most common bariatric procedures. They restrict the amount of food intake, calories, and nutrients the body absorbs. These procedures create a direct connection from the stomach to the lower part of the small intestine, thus bypassing portions of the digestive tract.

• Roux-en-Y bypass (RGB): This surgery is the most common and most successful combined surgery in the US A small stomach pouch is created to restrict food intake. Then a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the stomach, the duodenum, and the first part of the jejunum. This bypass reduces the amount of calories and nutrients the body absorbs. Gallstones are created by rapid weight loss. Patients take medication after the operation to dissolve gallstones. Rarely, the gall bladder is removed.
• Gastric Sleeve (GS): This is usually performed as the first stage of the biliopancreatic bypass with a duodenal switch in patients who may be at high risk for complications from more extensive types of surgeries. Risk comes from body weight or medical conditions. A GS operation restricts food intake and does not lead to decreased absorption of food. However, most of the stomach is removed, which may decrease the production of the hormone ghrelin, thus reducing hunger more than the AGB.
• Biliopancreatic diversion (BPD): This is a more complicated operation where lower portions of the stomach are removed. The small pouch that remains is directly connected to the final segment of the small intestine, completely passing the duodenum and jejunum. This surgery does lead to weight loss. It is used less frequently because of the high risk for nutritional deficiencies. A variation, called a “duodenal switch,” is to leave a larger portion of the stomach intact including the pylori valve that regulates the release of stomach contents into the small intestine, and keeps a small part of the duodenum in the digestive pathway.

Advantages: Most patients lose weight quickly and continue this for 18-24 months. With the Rou-en-y, many patients keep 60-70 percent of their excess weight off for two years or more. This makes combined operations more effective in improving health problems associated with obesity.

Disadvantages: These procedures are more difficult to perform. Because food bypasses the duodenum and jejunum, long-term nutritional deficiencies can occur. Iron, calcium, and vitamin B-12 are not absorbed, leading to anemia, osteoporosis, and related bone diseases. Patients need nutritional supplements and those who had BPD surgery must also take fat soluble A,D, E, and K vitamin supplements. “Dumping syndrome” may develop when stomach contents move too rapidly through the small intestine causing nausea, weakness, sweating, faintness, and diarrhea after eating.

Risks: There is an increased risk of infection, abdominal hernias, and death. Both techniques can be performed through laparoscopy. The smaller incision reduces blood loss, hospitalization time, and fewer complications. The super-obese (350 pounds or more) may not be good candidates.

Overall Risks

The National Institutes of Health (2010) states, “Surgery to produce weight loss is a serious undertaking. Anyone thinking about surgery should understand what the operation involves.” Patients and physicians should carefully consider the following risks:

Risks:

• Around 24% of patients have presurgical depression or postoperative mood changes that are not improved by the achieved weight loss.
• Nearly 30% of patients who have surgery develop nutritional deficiencies such as anemia, osteoporosis, and metabolic bone disease. These deficiencies can be avoided if vitamin and mineral intake are high enough.
• Women of childbearing age should avoid pregnancy until their weight becomes stable because rapid weight loss and nutritional deficiencies can harm a developing fetus. After the death of a Massachusetts woman and her 8-month-old fetus 18 months after her stomach-stapling surgery, warnings are being devised to address this problem (The Associated Press, 2004).
• Patients who don’t make changes in eating can stretch their stomachs and gain back some or all of the weight. Without lifestyle changes, the chances of success lessens. Those with binge-eating disorder have an especially hard time making behavioral changes, and can binge back the weight.
• Patients are placed on very restrictive diets because of their tiny stomachs. They’re encouraged to make 75% of their meal protein and no fat. They can eat fruits and vegetables (Zimmerman, 2004).
• An estimated 30% of individuals seeking bariatric surgery have been reported to meet the criteria for binge eating disorder. A review of the literature shows that binge eaters mare more likely to retain eating pathology post-surgery and have poorer long-term weight loss outcome Niego, et al., 2007)

Latest Medical Surgery: The Implantable Gastric Stimulator (IGS) is a pacemaker-like device that is implanted in the abdominal wall and attached to the stomach muscle through two electrodes, making the person feel fuller faster. Because hunger is only one reason why someone overeats, this device does not help everyone. It is currently in late-stage trials (Underwood and Adler, 2004). The device can be implanted laproscopically, so there were no intra-operative surgical or long-term complications, though there were three (out of 20 surgery patients) who had intraoperative gastric penetrations without sequelae. Patients were advised to follow a low-calorie diet and behavior modification (Favretti et al., 2004).

Cost of Surgery

Gastrointestinal surgery costs $15,000 to $50,000. Medical coverage varies by state and insurance provider. Some insurance companies require candidates to pay for pre-surgery exercise programs and document attempts to lose weight for three years in a row. Managed care in California is more willing to send patients for surgery, but their reimbursement rates are lower and this limits the doctor’s ability to take these cases (Clark, 2004). Now that Medicare defines obesity as a medical problem, it will remove barriers to covering anti-obesity treatments such as surgery, although weight-loss drugs won’t be covered because the new Medicare drug benefit begun in 2006 bars payment (Weise, 2004).

Surgery Recommendations

The National Institutes of Health (1991) convened a panel and made five recommendations:

• Patients seeking therapy for severe obesity for the first time should be considered for treatment in a nonsurgical program with integrated components of dietary regimen, appropriate exercise, and behavioral modification and support.
• Gastric restrictive or bypass procedures should be considered for well-informed and motivated patients with acceptable operative risks.
• Patients who are candidates for surgical procedures should be selected carefully after evaluation by a multidisciplinary team with medical, surgical, psychiatric, and nutritional expertise.
• The operation is to be performed by a surgeon substantially experienced with the appropriate procedures and working in a clinical setting with adequate support for all aspects of management and assessment.
• Lifelong medical surveillance after surgery is a necessity.

Psychological Assessment for Surgery

If you are a therapist or counselor and have been asked by a bariatric surgeon to determine whether an individual is psychologically ready to undertake weight-loss surgery, you will need to ask a number of questions in order to make a proper assessment and recommendation. You don’t have to ask all the questions. If you receive a “No” response at the beginning of a category, move on to the next one.

1. Motivation for Surgery:
1. Tell me about yourself.
2. Why are you considering surgery now?
3. Why is a physician recommending surgery now?
4. What physical or emotional factors have become unbearable?
2. History of Weight Problems:
1. How long have you had a weight problem?
2. Were you ever a “normal” weight?
3. What did you do to maintain that weight?
4. Is there obesity in your family?
5. Did your family sit down to meals?
6. What was a typical day of eating at your house?
7. When did your eating habits change for the worse?
8. Have you had periods of time where you were eating healthily and exercising regularly?
9. How was that for you?
10. What did you weigh then, and were you happy with it?
3. History of Health Problems:
1. How is your health right now?
2. What kinds of health problems do you have?
3. Do you have diabetes? Describe the nature and severity.
4. Do you have heart disease or heart problems? Describe the nature and severity.
5. Do you, or have you had, cancer? Describe the nature and severity.
6. Do you have degenerative diseases like arthritis, joint disease, or lower back pain? Describe the nature and severity.
7. Do you have respiratory problems like sleep apnea, trouble breathing, or asthma? Describe nature and severity.
8. Do you have trouble getting around?
4. History of Weight Loss Attempts:
1. Have you tried to lose weight before?
2. What diets have you tried?
3. Were any successful? For how long?
4. Have you tried any prescription medication to lose weight?
5. Which one(s)? Were any successful?
6. Have you tried to make changes in your eating and exercise habits that are practical and do-able?
7. Would you have made more progress if you could have had ongoing support with from a therapist, counselor, or group?
8. At this point, are you willing to consider making realistic changes in eating and exercise along with professional support?
5. Presence of Eating Disorder:
1. Do you restrict food?
1. When and how often?
2. Did you end up overeating at some point?
2. Do you binge or graze?
1. How often?
2. What are your binges like?
3. Can you stop them if you want to?
4. How do you feel after a bingeing or grazing session?
3. Do you throw up your food?
1. How often?
2. Do you purge every time you binge?
3. Can you stop yourself from throwing up?
4. How do you feel after throwing up?
4. Do you take laxatives? (Also ask about diuretics and enemas)
1. Which ones and how often?
2. Do you take them after every binge?
3. Can you decide to not take them and carry through with it?
4. How do you feel after taking them?
5. Do you take diet pills?
1. Which ones and how often do you take them?
2. Are they making you lose weight?
3. How do you feel while taking them?
6. Do you take Syrup of Ipecac?
1. How often?
2. How is it affecting your health?
7. How often do you exercise and what do you do?
8. Do you take other drugs to take away your appetite?
9. Do you use sugar substitutes (e.g., Aspartame/NutraSweet, saccharine, Splenda)
1. In soft drinks and/or food?
2. How much and how often?
10. Do you have any eating rituals (Price, 1999)?
1. Do you separate foods on the plate into distinct piles?
2. Do you eat only one kind of food at a time?
3. Do you eat so quickly that you don't taste food?
4. Do you chew food and spit it out instead of swallowing it?
5. Do you binge on “junk food” and diet on “healthy food?”
6. Do you wait until evening to eat your first meal?
7. Do you eat “forbidden” foods in secret?
11. Why do you do these behaviors (Price, 1999)?
1. Because you're physically hungry and feel deprived of food?
2. To numb your feelings?
3. To comfort and nurture yourself?
4. To distract yourself and avoid difficulties?
5. To alleviate boredom?
6. To feel in control when life feels beyond your control?
7. To calm down and create relaxation?
8. To momentarily fill an internal emptiness?
9. To procrastinate attending to responsibilities?
10. To feel energized?
11. To punish yourself or someone close to you?
12. To reward yourself?
13. Can you see how many functions your eating disorder has?
12. What is your biggest fear in giving up your eating disordered behaviors?
13. What is your weight and height?
1. What do you wish you weighed?
14. What have you eaten today?
15. Describe to me what you eat on a typical day.
16. When did your eating disorder begin?
1. What was going on in your life at that time?
2. Take me through the start of your eating disorder up until now.
17. Have you been in treatment for an eating disorder?
1. What kind of treatment (i.e., individual, inpatient, intensive outpatient, group)?
2. How did the treatment help you?
3. What changes have you made and continued?
4. What was not helpful?
5. What changes are the hardest to make?
6. Assess where the resistance to change is.
6. Presence of Mood Disorders:
1. Have you been diagnosed previously with a mood disorder?
2. Are you depressed?
1. How depressed on a scale of 1-10?
2. Discuss severity of depression and how it is affecting person’s life.
3. Are you having thoughts of harming yourself (if depression is high)?
4. Have you had thoughts of harming yourself in the past?
5. When you tried to hurt yourself (commit suicide), when and how did you carry it out?
3. Are you anxious?
1. How anxious on a scale of 1-10?
2. Discuss severity of anxiety, whether it’s generalized or panic attacks, and how anxiety is affecting the patient’s life.
3. Do you have obsessive thoughts about food, weight, or body shape?
4. How well are you sleeping at night?
5. If symptoms of manic-depression are brought up by the patient, ask further about symptoms and effects on person’s life.
7. Personality Disorders:
1. Start to assess the information you are being given to see if any characteristics of a personality disorder stands out.
2. Ask how these factors affect the patient’s relationships, work situation, and sense-of-self.
8. Self-View:
1. How do you see yourself?
2. Do you like yourself?
3. What would you change about yourself?
4. What do you think about your body?
5. Could you like your body even if you didn’t lose all the weight you think you should?
6. Could you imagine being able to accept your weight and appearance?
7. Do things in your life feel out of control?
8. How do you cope with disappointment?
9. Substance Abuse:
1. Are you drinking alcohol?
1. What do you drink and how often?
2. When and where?
3. Can you stop now and not drink again?
2. Are you using drugs?
1. Which ones and how often?
2. When and where?
3. Can you stop now and not use drugs again?
4. What is your previous substance abuse treatment?
1. Was it helpful?
2. Are you in any substance abuse treatment now?
3. Is it helping?
10. Self-Injurious Behaviors:
1. Have you ever cut, burned, or stabbed yourself (self-mutilation)?
2. Are you overworking?
3. Have you ever stolen anything or shoplifted?
4. Have you been sexually promiscuous?
11. Support Systems:
1. Are you in a relationship?
2. How is that working out?
3. Is your weight affecting the relationship?
4. Do you have children?
5. How is your relationship with your children?
6. What are your partner and/or children’s’ eating habits like?
7. If you decide to have this surgery, what kind of support do you think you’ll receive?
8. What will it be like to change the way you eat when your family members will be keeping their eating habits?
9. How are your relationships with friends?
10. How are your relationships at work?
12. Work or School:
1. Are you currently working or attending school?
2. How do you like your job or school?
3. Is your weight affecting your job or school?
13. Expectations of Surgery:
1. What outcome do you expect from the surgery?
2. How will you feel if you don’t lose all the weight?
3. Do you think your body image will change?
4. Are you hoping the surgery will make you feel happier in life?
14. Awareness of Surgery Risks:
1. Have you been informed of the risks of the actual surgery and post-surgery complications?
2. Knowing the risks, are you willing to have the surgery?
3. What is your biggest fear or concern?
15. Post-Surgery Lifestyle Changes:
1. What will be the most difficult adjustment?
2. Are you willing to take supplements for the rest of your life?
3. What do you think it will be like to eat only an ounce of food at a time?
4. How do you think you’ll handle holidays and special occasions?
5. Do you think you will be able to stop overeating or bingeing (if these behaviors are present)?
6. Are you willing to start and continue with an exercise regime?
7. Are you willing to follow all of your physician’s recommendations?

Once you have an idea of this individual’s level of functioning, expectations from the surgery, awareness of benefits and risks, and how she will be affected emotionally by the surgery, you can make a recommendation to the physician about the appropriateness of surgery for this person.

Role of Therapy

Therapy can serve as an adjunct to surgery by supporting behavior changes that make post-surgery weight loss successful. Without changing eating and exercise habits, weight reduction is not a guarantee. By receiving sound psychotherapeutic cognitive, behavioral, and insight-oriented strategies, patients have a better chance of sticking to dietary recommendations and exercise regimens.

2. LIPOSUCTION

Abdominal fat, especially in people with an apple-shaped figure, encourages ill health by pumping inflammatory proteins and gets in the way of the body’s ability to use insulin (Gorman, 2004). Conventional wisdom has held that reducing the amount of body fat, no matter how it’s done, promotes health. Liposuction seemed like an obvious method to remove fat quickly from the very area of the body that influences high blood pressure, heart disease, and diabetes.

Large-volume abdominal liposuction has been proposed by physicians as a potential treatment for the metabolic risk factors of coronary heart disease in obese women. Klein et al. (2004) evaluated the insulin sensitivity of liver, skeletal muscle, and adipose tissue, along with the levels of inflammatory mediators and other risk factors in 15 obese women before and 10 to 12 weeks after the liposuction. The results indicated that liposuction decreased the volume of subcutaneous abdominal adipose tissue by 44% in non-diabetics and 28% in diabetic subjects. Liposuction did not significantly alter obesity-associated metabolic abnormalities such as:

• Insulin sensitivity of the muscle, liver, or adipose tissue
• Plasma concentrations of C-reactive protein, interleukin-6, tumor necrosis factor alpha, and adiponectin
• Blood pressure and plasma glucose, insulin, and lipid concentrations

Therefore, decreasing adipose tissue mass alone will not achieve the metabolic benefits of weight loss. Fat cells under the skin are removed but the visceral fat that surrounds the organs is still there. The fat cells that remain are large, producing more harmful proteins than small ones. This is because liposuction does not reduce the size of a fat cell, only how many the patient has (Gorman, 2004).

D. PSYCHOPHARMACOLOGICAL

In the document, Prescription Medications for the Treatment of Obesity, the National Institutes of Health (2010) states that:

• Weight-loss medications should be used only by patients who are at increased medical risk because of their obesity, and should not be used for “cosmetic” weight loss or for those who are mildly overweight
• While most side effects of prescription medications for obesity are mild, serious complications have been reported.
• There are few studies lasting more than 2 years evaluating the safety or effectiveness of weight loss medications.
• Until more information on their safety or effectiveness is available, using combinations of medications is not recommended, except as part of a research study.
• Weight-loss medications should always be combined with a program of healthy eating and regular physical activity.

1. PRESCRIPTION MEDICATION CATEGORIES

Appetite Suppressants. Most weight loss medications approved by the Food and Drug Administration are appetite-suppressants. They lead to weight loss by decreased appetite or increased feeling of fullness. This is accomplished by increasing brain serotonin or catecholamine. The two most commonly prescribed appetite suppression medications in the US are not recommended due to the strong potential for abuse and dependence.

Lipase Inhibitors. Xenical (orlistat) is the only lipase inhibitor. It works by reducing by about one-third the body’s ability to absorb dietary fat. The drug blocks the enzyme lipase, which breaks down dietary fat. Thus, the body cannot absorb the fat, so fewer calories are taken in.

FDA Approved Weight Loss Medications

• Xenical (Orlistat): A lipase inhibitor. Side effects include cramping, intestinal discomfort, diarrhea, passing gas, and leakage of an oily stool. These are generally mild and temporary, but can become worse if patient eats foods high in fat. Orlistat also reduces some vitamin absorption, so a multivitamin should be taken 2 hours before taking the medication. Orlistat is approved for use for ages 12 and above.
• Meridia (Sibutramine): An appetite suppressant. Side effects include a small increase in blood pressure and heart rate, which concerns some patients. Other side effects include dry mouth, headache, constipation, and insomnia. People with poorly controlled blood pressure, heart disease, irregular heart beat, or stroke should not take this medication. Blood pressure should be monitored.
• Tenuate (Diethylproprion): An appetite suppressant. Side effects include nervousness, sleepiness, and euphoria. People with high blood pressure, heart disease, or glaucoma should not use these drugs.
• Bontril, Plegine, Prelu-2, X-Tropine (Phendimetrazine): An appetite suppressant. Side effects are the same as Diethylpropion.
• Adipex,P, Fastin, lonamin, Oby-trim (Phentermine): An appetite suppressant. Same side effects as diethylpropion and phendimetrazine. Fenfluramine and Dexfenfluramine were withdrawn from the market in 1997. Taken alone or in combination with phentermine (“fen/phen”) were linked to developing valvular hear disease and primary pulmonary hypertension (PPH), a potentially fatal disorder that affects blood vessels in the lungs. There have been a few cases of PPH reported with the use of phentermine alone.
• Cimetidine: This medication is in trials and not approved by the FDA.
• Rimonabant: This medication is in trials and not approved by the FDA.

What to Expect: These medication are modestly effective, leading to an average weight loss of 5 to 22 pounds above what would be expected with obesity treatments that do not use drugs. Over the short-term, weight loss can improve blood pressure, triglycerides, blood cholesterol, and insulin resistance.

Maximum weight loss occurs within 6 months of starting a medication. If a patient has not lost 4 pounds in 4 months, that medication is unlikely to help. Once patients stop the medication, weight gain occurs in the majority of users, unless healthier eating and exercise habits have replaced old behaviors. Remember that obese patients are 20%-100% overweight, which is why 5-22 pounds of weight loss is relatively small. Most practitioners recommend that patients make enduring changes in their eating and exercise habits, which is ultimately what leads to permanent weight loss.

Most weight loss medications approved by the Food and Drug Administration (FDA) are for short-term use, meaning a few weeks or months. Only Orlistat and Sibutramine are approved for longer-term use in significantly obese patients.

Other Medications (not approved by the FDA to treat obesity). These medications are used "off-label," meaning that the medication is approved for one condition but is prescribed by a physician to treat another condition for which the FDA has not given approval. In addition, using medications for longer than recommended (e.g., taking Subutramine or Olistat for more than "a few weeks") is considered off -label use.

• Antidepressants. A variety of SSRI antidepressants have been studied to assess their effectiveness in treating BED. The results have been mixed. Prozac (fluoxetine), Luvox (fluvoxamine), Celexa (citalopram), Zoloft (sertaline), and Lexapro (escitalopram) have had uneven results in reducing binge eating episodes. None are helpful in promoting weight loss in overweight or obese patients (Bodell and Devlin in Grilo and Mitchell, 2010).
• In one study, Wellbutrin (buproprion) showed that patients taking this drug maintained weight loss for up to one year.
• Seizure Medications. Topamax (opiramate) and Zonegran (zonisamide) have shown to cause weight loss. Both are being studied to see if they are useful in treating obesity.
• Diabetes Medications. Glucophage (metformin) may produce small amounts of weight loss in obese individuals who also have Type 2 diabetes. It is not clear how this medication works, although research suggests hunger and food intake for those taking metformin.
• Drug Combinations. The combination of febfluramine and phentermine is no longer available because fenbluramine has been withdrawn from the market when it was found to cause some people to develop serious heart and lung disorders. Little information is available on other drug combinations such as fluoxetine/phentermine, Phendimatrazine/Phentermine, or Orlistat/Sibutramine.
• Drugs in Development. Many medications are being tested. Currently, these are only available in drug trials.

2. OVER-THE-COUNTER DIET PILLS

Buyer beware! Many nutritional supplements make claims about effectiveness and success. If you’ve paid attention to advertising and the “buzz,” you’ll see the trends of what is popular. Manufacturers recommend that users following a sensible eating and exercise plan—if a person does this, why would he need the pill? Listed below is a variety of diet pills on the market:

• Chromium Picolinate claims to increase lean muscle mass and decrease body weight by potentiating the action of insulin and regulate blood sugar. Studies suggest that the effects are small compared with those of a well-balanced eating and exercise plan (Cartwright, 2000).
• Pyruvate claims to increase metabolism, utilize fat, and improve exercise performance. In animal (not human) studies, metabolism did increase. Seven obese persons taking pyruvate while on a low-calorie liquid diet had greater weight loss than those using a placebo. Side effects include gas, diarrhea, and bloating if taken in large amounts (Cartwright, 2000).
• Chitosan claims to reduce fat absorption by acting as a “fat magnet” to stop fat from entering the blood. Randomized placebo-controlled double blind study of overweight volunteers did not show a greater weight loss than individuals taking a placebo (Cartwright, 2000).
• Cellasene® claims that cellulite will disappear in 8 weeks without changing eating or exercise by increasing blood circulation to fat deposits under the skin, reducing fat buildup, and stimulating metabolism. Two small Italian studies are cited by the manufacturer but they have not been published in any scientific journal (Cartwright, 2000).
• Cortislim® claims that when the body is under stress, it releases a stress hormone called cortisol that increases appetite and stores fat. Cortislim supplements work with the body’s metabolism to control cortisol levels to help the taker lose weight. No studies on effectiveness have been published in any major scientific journal.

With the information provided in this course, you can help patients make choices about the best method for weight loss in order to meet their individual needs. The more knowledge they have about the benefits and risks of each weight loss option, the more likely they will make a decision that is right for them.

Final Thoughts: Thank you for taking this course. I hope you found it helpful and useful. If you would like to know more about the treatment of eating disorders, consider signing up for Feast or Famine: The Etiology and Treatment of Eating Disorders and Dying to Eat: The Treatment of Severe Eating Disorders.

Resources

American Society for Bariatric Surgery
100 S.W. 75^th Street, Suite 201
Gainesville, FL 32607
(352) 331-4900
www.asbs.org

National Institutes of Health
9000 Rockville Pike
Bethesda, MD 20892
www.nih.gov

Overeaters Anonymous
World Service Office
P.O. Box 44020
Rio Rancho, NM 87174
(505) 891-2664
www.overeatersanonymous.org

Prader-Willi Syndrome Association
5700 Midnight Pass Road
Sarasota, FL 34242
(800) 926-4797
www.pwsausa.org

United States Department of Agriculture
www.MyPyramid.gov

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