This is a beginning to intermediate level course. After completing this course, mental health professionals will be able to:
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.
Here is some food for thought:
(Sources: National Institutes of Health, 2013; *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, 2013).
The National Institutes of Health (2013) 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.
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.
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.
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, 2013). 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, 2013). Hormone replacement therapy may prevent increase in abdominal fat in women just past menopause (Cartwright, 2000).
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.
Being overweight and obese results from an energy imbalance. To keep up basic life functions, the body needs a certain amount of energy (calories) from food. When the number of calories ingested equals the number of calories burned, body weight tends to remain the same. When people eat more calories than they burn, they gain weight leading to being overweight or obese (National Institutes of Health, 2013).
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.
Researchers have found genetic and biological components that make someone more susceptible to weight gain.
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.
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:
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).
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).
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 7th to 12th 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).
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).
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):
Official USDA Serving
|Chips||2 ounces||3 ounces +|
|French fries||3 ounces||6-8 ounces|
|Ice cream||1/2 cup||1 cup +|
|Pasta with sauce||1 cup||3 cups|
|Popcorn||2 cups||8-12 cups|
|Meat||3 ounces||6-16 ounces|
|Soda||8 ounces||16 ounces +|
|Muffin||2 ounces||4-6 ounces|
|Salad dressing||2 tablespoons||4 tablespoons|
|Sandwich||4 ounces||9-12 ounces|
|Pizza slice||5 ounces||9 ounces +|
Brain research suggests clinical similarities between food addiction and drug dependence. There is evidence that bingeing on sugar-dense palatable foods increases extracellular dopamine in the striatum and therefore possesses addictive potential. Also, elevated blood glucose levels catalyze the absorption of tryptophan through the LNAA (large neutral amino acid) complex and its conversion into the mood-elevating neurochemical serotonin. For some, palatable foods have palliative properties and can be viewed as a form of self medication. There are a number of biological and psychological similarities between food and drugs, such as craving and loss of control. However, there is one difference: acute tryptophan depletion does not seem to induce relapse in recovering drug-dependent persons (Fortuna, 2012).
Obese women with binge eating disorder who met the “food addiction” criteria on the Yale Food Addiction Scale had significantly higher levels of depression, negative affect, emotional dysregulation, eating disorder psychopathology, and lower self esteem. (Gearhardt, 2012)
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).
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:
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:
The most rigorous community studies found:
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).
The information below is provided as a review of the diagnostic criteria and statistics from the Diagnostic and Statistical Manual of Mental Disorders, Fifh Edition (DSM-V) (2013).
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly attributable to another medical condition.
These symptoms cause clinically significant distress or impairment in social, occupational, or other areas of functioning.
The episode is not attributable to the physiological effects of a substance or to other medical condition.
Note: The criterion above represent a major depressive episode.
The occurrence of a major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorders.
There has never been a manic or hypomanic episode.
This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder.
Depressed mood for most of the day more days than not as indicated by either subjective account or observation by others, for at least two years. Note: In children and adolescents, the mood can be irritable and duration must be at least 1 year.
Presence, while depressed, of two (or more) of the following:
During the 2-year period (1 year for children and adolescents) of the disturbance, the individual has never been without the symptoms listed above for more than 2 months at a time.
Criteria for major depressive disorder may be continuously present for 2 years.
There has never been a manic episode or hypomanic episode, and criteria have never been met for cyclothymic disorder.
The disturbance is not better explained by persistent schizoaffective disorder, schizophrenia, delusional disorder, or other specified or unspecified schizophrenia spectrum and other psychotic disorder.
The symptoms are not attributable to the physiological effects of a substance abuse (e.g., a drug of abuse, a medication) or other medical condition (e.g., hypothyroidism).
The symptoms can cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Note: Because the criteria for major depressive episode include four symptoms that are absent from the symptom list for persistent depressive disorder (dysthymia), a very limited number of individuals will have depressive symptoms that have persisted longer than 2 years but will not meet the criteria for persistent depressive disorder. If the full criteria for major depressive episode have been met at some point during the current episode of illness, they should be given a diagnosis of major depressive disorder. Otherwise a diagnosis of other specified depressive disorder or unspecified depressive disorder is warranted.
Please refer to the DSM-V for the five specifiers to make an accurate diagnosis.
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
The individual finds it difficult to control the worry.
The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for more days the past months:
The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in school, social, occupational, or other important areas of functioning.
The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or other medical condition (e.g., hypothyroidism).
The disturbance cannot be explained by another mental disorder (e.g., anxiety or worry about having panic attacks in panic disorder, negative evaluation in social anxiety disorder [social phobia], contamination or other obsessions in obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptoms disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).
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, 2013).
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, 2010).
Of the overall obese population, a subset struggles with binge-eating disorder (BED). Statistics on binge-eating disorder include:
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:
Those with binge-eating disorder overeat in two kinds of ways:
The conditions listed below are found more frequently and are more serious in people who are overweight and obese (Berg et al., 1997).
Diabetes is one of the major illnesses of obesity. Diabetes is a disease in which blood sugar levels are above normal. High blood sugar is a major cause of coronary heart disease, kidney disease, stroke, amputation, and blindness. Type 2 diabetes is the most common type of diabetes in the United States. It is not known exactly why people who are overweight are at risk to develop this disease. It may be that being overweight causes cells to change, making them resistant to the hormone insulin. Insulin carries sugar from the blood to cells, where it is used for energy. Insulin resistance means that the person’s blood sugar cannot be taken up by the cells resulting in high blood sugar. Also, the cells that produce insulin must work extra hard to keep sugar normal. This may cause cells to fail.
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, and physical inactivity.
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.
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.
Coronary Heart Disease is another major illness of obesity. Coronary heart disease means that the heart and circulation (blood flow) are not functioning normally. Often, a person’s arteries have narrowed. 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. With a heart attack, the flow of blood and oxygen in the heart is disrupted, damaging portions of the heart muscle. 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 weigh 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:
A person with metabolic syndrome is twice as likely to develop coronary heart disease and five times more likely to develop type 2 diabetes. Approximately 27% of Americans have this syndrome. It is also strongly linked to obesity, especially abdominal obesity. This kind of obesity carries high risks such as raising blood pressure and triglycerides, lowering good cholesterol and contributing to insulin resistance.Individuals who are overweight or obese and have this syndrome should lose 10% of their body weight and engage in at least 30 minutes of moderate-intensity exercise a day.
Cancer risk is increased with being overweight. Cancer occurs when cells in one part of the body, such as the colon, grow abnormally and out of control. These cells sometimes spread to other parts of the body, like the liver. Cancer is the second leading cause of death in the United States.Being overweight is linked to the development of many types of cancer including colon, esophagus, kidney, plus uterine, and postmenopausal breast cancer in women. Gaining weight during adulthood increases these cancers even if the weight gain does not lead to being overweight or obese. 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 cause inflammation in the joints, raising the risk of osteoarthritis. Weight loss of at least 5 pounds may decrease stress on the body areas mentioned above.
Sleep Apnea is more prevalent in people who are overweight. Sleep apnea is a condition in which a person stops breathing for short periods of time during the night. A person who has sleep apnea often suffers 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 and inflammation decreases.
Gallbladder Disease includes gallstones and inflammation or infection of the gallbladder and is more common in overweight individuals. 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 produce more cholesterol (a fat-like substance found in the body), which is a risk factor for gallstones. Plus they may develop an enlarged gallbladder which means the organ does not work properly.
Rapid weight loss of more than 3 pounds a week can increase the chances of developing gallstones. Weight loss of ½ to 2 pounds a week lessens this likelihood. Reaching a healthy weight reduces the overall risk.
Fatty Liver Disease occurs when fat builds up in the liver cells and causes inflammation and injury in the liver, sometimes leading to liver damage, cirrhosis (build-up of scar tissue that blocks proper flow of blood in the liver), or liver failure. It can occur in people who drink little or no alcohol. People who are overweight or obese are more likely to have “pre-diabetes” or diabetes and consequently more likely to have fatty liver disease. Both diseases are linked though the cause is unknown.
Losing weight and exercising can help control blood sugar levels and reduce build-up of fat in the liver.
Pregnancy complications are an increased risk of being overweight and obese. Both mother and baby can be adversely affected. These complications include gestational diabetes (high blood sugar), pre-eclampsia (high blood pressure), and/or cesarean delivery or complications from this kind of delivery. Overweight or obese pregnant women are more likely to develop insulin resistance, high blood sugar, and high blood pressure. There are also associated risks with surgery, anesthesia, increased operative time, and blood loss.
Losing weight can reduce these health risks including the risk of developing diabetes later in life.
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. Parent's 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: The United States Department of Agriculture’s (2013) Healthy, Hunger-Free Kids Act of 2010 required the development of national nutritional standards for all foods sold in schools. An interim rule will be effective on August, 27, 2013. There are a number of food and beverage requirements. They include:
Competitive foods must also contain per item as packaged:
The National Institutes of Health (2013) 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:
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.
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.
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:
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.
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).
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.
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.
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).
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.
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.
Low-Calorie Diets (LCD): Calories are restricted to 800 to 1,500 calories per day (National Institutes of Health, 2013). 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, 2013). 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.
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, 2013).
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.
The National Institutes of Health (2013) 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:
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.
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:
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.
Plan Meals: The Choose My Plate guidelines (United States Department of Agriculture, 2013) provides daily recommendations for all food groups. Thes include:
Sample Meal Plan (Price, 2013)
|2 Ounces of Grain||1/2 Cup Oatmeal with Honey|
|1 Cup of Fruit||1 Banana|
|1 Cup of Dairy||1 Cup Yogurt|
|1 (Optional) Cup of Fruit||1 Apple|
|2 Ounces of Grain||2 Slices of Sandwich Bread|
|3 Ounces of Protein||3 Ounces Sliced Turkey|
|1 Cup of Vegetables||Lettuce, Tomato, and Avocado|
|1 Cup of Dairy||2 Slices of Cheese|
|1/3 (Optional) Cup of Protein||1/3 Cup Trail Mix|
|2 Ounces of Grain||2 Cups Pasta Noodles|
|3 Ounces of Protein||3 Ounces of Beef for Sauce|
|1-2 Cups of Vegetables||1-2 Cups Tomato/Vegetable Sauce|
|1 Cup of Dairy||1 Cup Grated Cheese|
|1 Dessert (Optional)||1 Cup Rice Pudding|
Simple rules help people plan meals:
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.
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.
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 ˝ 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.
Teaching patients these skills sounds deceptively simple. The principles are basic, but achieving compliance is difficult because:
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.
Case Vignette 1: Phillip is a 32-year-old construction company owner who struggled with weight problems much of his life. He grew up in a large Midwestern family. Almost every weekend there were family get-togethers where food was abundant. Spare ribs, pot roast, fried chicken, mayonnaise potato salad, baked potatoes smothered in butter and sour cream, whip cream-based fruit salad, plus pies, cakes, and cookies–all home made. Regular meals weren’t much different, and as a result, Phillip’s immediate family members are 50 to 150 pounds overweight.
During college, Phillip was the trimmest he’d ever been. He played college baseball, which encouraged daily fitness training and healthier eating. After graduation, he worked hard to build his business. This is when his eating habits reverted to the way he was raised. Most of his family followed him west, so the family gatherings continued. He ate three to four times what his wife ate and twice as much as his friends did. Fast food was one of his favorite on-the-go meals. Often he’d double the order and eat it all. Phillip was referred to me by his psychiatrist after two different diet drugs failed to produce any significant weight loss.
Psychotherapy with an eating disorders specialist seemed like the next step to help Phillip make changes in eating and exercise habits. In the first session, he said his parents have many obese-related medical problems, but don’t follow their doctor’s advice to eat healthier or exercise. His older sister had adjustable gastric banding surgery 7 years ago. Phillip said he’d considered surgery for a while, but once he saw what his sister had gone through, he changed his mind. He said she vomits every day and has yet to lose more than 20 of the 90 pounds that was expected. She eats the same kinds of food and feels too heavy to exercise. She is now considering roux-en-Y bypass surgery. He said that, for 7 years, his sister has been seeking the quick fix, which hasn’t been so quick. His other siblings are obese, but haven’t made any decisions regarding what to do about it.
When he started therapy, his family pooh-poohed his decision. None of his family had ever gone to therapy. Phillip had no history of binge eating. He overate because of training and habit, and as a result was 85 pounds heavier than what his physician recommended. He had no idea what balanced and moderate eating looked like. After analyzing his eating habits and food choices, new meal plans were created and a realistic exercise routine was devised. Phillip came every other week for eighteen months. Every session was spent on encouraging him to change one old habit at a time. For instance, he often skipped breakfast, and by 10 a.m., he was famished. He would find the closest fast food drive through where he ordered two hamburgers with fries and a large shake. By 3 p.m., he was eating a box of donuts. Then for dinner, he had three servings of whatever his wife prepared. She grew up with healthier habits, but Phillip could make anything tastier with gobs of butter, sour cream, salad dressings, and extra servings.
His path of change over the months looked something like this: he began having cereal, milk, and a banana for breakfast; and one hamburger, fries, and drink for lunch. He eventually dropped the fries and committed to eating fast food only two or three times a month. He had 2 power bars for a snack and cut back on gooey toppings for dinner. He continued to make small changes each week so that after one year, he was having the cereal combination for breakfast, one power bar for a snack, a deli sandwich with iced tea for lunch, a yogurt and 2 fruits for a snack, and for dinner he ate the same amount as his wife. He cut out ice cream shakes, candy and donuts from the convenience store, most fast food, soft drinks, butter, mayonnaise, and sour cream, and reduced his portion sizes by two-thirds. He also started to walk on a treadmill before work. This took lots of effort to get up every day. In the beginning, exercise was 10 minutes long and sporadic. At the one-year mark, he was walking 25 days a month for 40 minutes each day. At the end of therapy, he was eating about 1,600 calories a day, down from 3,000 to 5,000, and exercising 45 minutes most mornings. He lost 70 pounds. His family was amazed that what he was doing actually worked. He was very pleased with the results.
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.
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.
The American Psychiatric Association (2000) provides the following goals.
In addition to the above:
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:
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:
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:
Improve Body Image and Self-Acceptance: Listed below are a number of steps patients can take to improve body acceptance:
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
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.
Case Vignette 2: Evelyn is a 54-year-old insurance sales representative who has struggled with her weight much of her life. She entered therapy three months ago into a medically supervised very low calorie diet where her goal was to lose 110 pounds. She like the diet drinks because she didn’t have to think about food–food was not an option. Evelyn said she’d binged since her early teenage years, and because of this, her weight kept going up. She had tried many diets but couldn’t stick to them. They felt too restrictive and she eventually binged back all the weight plus more.
So, in desperation and frustration, she opted for a VLCD. Since she was not bingeing, therapy focused on how to develop healthy eating principles, ways to cope with emotions without turning to food, continuing walking during the lunch period, and her conflicted feelings about food (her mother hid food from her and her brother while her live-in aunt spoiled them with sweet treats when mom wasn’t looking). She didn’t think bingeing would ever be a problem again because she was dealing with life. When she lost all the weight and started to incorporate real food slowly, she attended the medically supervised support groups. Initially, Evelyn did well. She followed the meal plan to the letter. But when a holiday party undid her good intentions, she ate every dessert she could get her hands on without being too obvious. She was devastated!
Over the next 3 months, she struggled with normal eating and bingeing. She’d buy large containers of almonds, hoping to take just a handful, but ended up eating 10,000 calories of nuts instead of dinner. Her weight increased and exercising decreased. Evelyn’s bingeing to numb out reemerged. She gained back almost 40 pounds. Her body image and worth suffered. She was highly self-critical and angry with herself. Every session was spent exploring the stresses that led her to binge and coming up with ways she could have handled it without reaching for food. She also dealt with the important role food played in her childhood. She felt her aunt showed love through food whereas mom withheld love and food.
Evelyn’s meal plan was refined so that she could make sensible choices with a minimum of cooking. Every day she practiced putting new lifestyle principles into place, and slowly over the next 8 months, she was able to reduce the bingeing, join a gym and exercise with a trainer, stay away from buying food in bulk, and follow a sensible meal plan. Her bingeing went from 3 or 4 times a week to 2 or 3 episodes a month. Evelyn was within 20 pounds of her goal weight and satisfied with staying there. With another 6 months of therapy, her food, exercise, and weight stabilized.
The information below comes from the National Institutes of Health (2013). Severe obesity is a chronic condition that is difficult to treat with diet and exercise alone. Bariatric surgery is an operation on the stomach and/or intestines that aids weight loss in patients with extreme obesity. The surgery restricts food intake, which reduces the risk for type 2 diabetes and promotes weight loss. Some surgeries also interrupt how food is digested, preventing some calories and nutrients (like vitamins) from being absorbed. The best results happen when patients follow surgery with healthy eating patterns and regular exercise.
Clinically severe obesity in adults is defined as having a BMI ≥ 40 or BMI ≥ 35 with a serious health problem linked to obesity such as Type 2 diabetes, heart disease, or sleep apnea. The FDA has approved use of an adjustable gastric band (ASB) for patients with BMI ≥ 30 who also have at least one condition linked to obesity such as heart disease or diabetes. In youth, extreme obesity is defined as having a BMI ≥ 40, being their adult height, and experiencing serious health problems such as type 2 diabetes or sleep apnea. Both groups are candidates for bariatric surgery if they have tried to lose weight for 6 months and have not had success.
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).In 2005, 171,000 were performed (National Association for Weight Loss Surgery, 2013).
There is no method, including surgery, which is guaranteed to produce and maintain weight loss. Some surgery patients may experience weight loss but don’t meet their goals. Many gain the weight back over time. Poor eating habits such as snacking on high calorie foods or not exercising affect the success of surgery. Post-surgery problems like separated stitches or a stretched stomach pouch may affect the amount of weight loss.
In normal digestion, as food moves through the digestive tract, digestive enzymes and juices digest and absorb nutrients and calories. The stomach holds about 3 pints of food at any one time. Stomach contents move to the duodenum (first part of small intestine) where bile and pancreatic juice speed digestion. Most of the calcium and iron are absorbed here. The other two parts of the 20 foot small intestine absorb everything else. Food particles not digested in the small intestine stay in the large intestine until eliminated.
Bariatric surgery restricts food intake. Most surgeries are done by laparoscopy because the small ½ inch cuts create less tissue damage, allows earlier hospital discharges, and poses fewer post-surgery complications. Some severely obese patients who have had previous stomach surgery, severe heart or lung disease, or weigh more than 350 pounds may need an “open” surgery approach in which the stomach is cut open in the standard manner.
There are four types of bariatric operations offered in the United States: Adjustable gastric banding (ASB), Roux-en gastric bypass (RYGB), biliopancreatic diversion with a duodenal switch (BPD-DS), and vertical sleeve gastrectomy (VSG).
Side Effects of Bariatric Surgeries: Initial side effects can include bleeding, infection, diarrhea, leaks from the site where the intestines are sewn together, and blood clots in the legs that can move to the heart or lungs. Later side-effects can include poor nutrient absorption, especially in patients who do not take prescribed minerals and vitamins. This can lead to permanent damage to the nervous system. Resulting diseases include pellagra (lack of vitamin B3-niacin), beri beri (lack of vitamin B1-thiamin), and kwashiorkor (lack of protein). Patients can also develop strictures (narrowing of the sites where the intestines are joined) and hernias (part of an organ bulging through a weak area of muscle).
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 laparoscopically, so there are 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 $20,000 to $25,000. 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).
The National Institutes of Health (1991) convened a panel and made five recommendations:
Psychological Assessment for Surgery
Some patients need emotional support to help them though changes in body image and personal relationships post-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.
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.
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:
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).
According to the National Institutes of Health (2013), prescription weight-loss medications should only be used if there is an increased medical risk due to a weight problem. The individual should have previously tried to lose weight through diet and physical activity. These medications are not for cosmetic weight loss.
Prescription weight-loss drugs are approved for those with a:
Most of the FDA approved medications are for short-term use, which means a few weeks. However many doctors give the medications “off label” for a longer period of time. Orlistat (Meridia/Alli) is the only one approved for long-term use but its safety and effectiveness has not been established beyond two years. All approved drugs have a myriad of side-effects.
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. Xenical was a prescription medication until 2007, then was approved for over the counter and renamed Alli. 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
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.
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.
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:
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.
American Society for Bariatric Surgery
100 S.W. 75th Street, Suite 201
Gainesville, FL 32607
National Institutes of Health
9000 Rockville Pike
Bethesda, MD 20892
World Service Office
P.O. Box 44020
Rio Rancho, NM 87174
Prader-Willi Syndrome Association
5700 Midnight Pass Road
Sarasota, FL 34242
United States Department of Agriculture
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