Psychological Impact and Considerations for Treating the Obese Patient

Anthony N. Fabricatore, Ph.D. Assistant Professor of Psychology Center for Weight and Eating Disorders University of Pennsylvania School of Medicine

Overview
Psychological Aspects of Obesity
Assumptions Data

The Toxic Environment Discussing Weight Control Psychological Considerations in Treatment

Childhood?

Mood?

Job? Education?

Relationship with Men?

Relationship with Mother?

Friends?

Negative Attitudes Toward Obese Individuals

Apparent at age 3 1
Operate in multiple settings 2,3
Social Education Employment Health care implicit and explicit
1. Cramer & Steinwert. J Appl Devel Psychol 1998;19:429-51 2. Puhl & Brownell. Obes Res 2001; 9:788-805. 3. Fabricatore et al. in Brownell et al. Weight Bias 2005.

Explicit Attitudes of Physicians

Characteristics associated with obese patients 1,2
Noncompliant Dishonest Unpleasant Lazy Sloppy Ugly

Similar findings in nurses, PTs, psychologists, etc.

1. Klein et al. J Fam Pract 1982; 14:881-88. 2. Foster et al. Obes Res 2003; 11:1168-77.

Implicit Attitudes of Health Care Professionals

Vignettes to 122 PCPs Complaint: 2 migraines/wk X 2 years Sex and BMI (23, 30, 36 kg/m2) varied Procedures?
% of physicians

25 20 15 10 5 0

Refer to Psychologist
23 15 3

BMI=23

BMI=30

BMI=36

Time I Would Spend w Pt

35 30 25 20 15 10 5 0
31.1 25 22.4

Minutes

Hebl & Xu. Int J Obesity 2001; 25:1246-52

BMI=23

BMI=30

BMI=36

Psychoanalytic Thought
Oral-stage fixation Survey found psychoanalysts commonly linked weight gain in obese patients to:
Disappointment in love relationships Fear of competition Fear of heterosexuality Inability to deal with negative affect Feelings of being unloved/unloveable
Glucksman et al. J Amer Acad Psychoanalysis 1978; 6:103-115

Obesity and Psychopathology

1.6 1.5 1.4 1.3 1.2 1.1 1 0.9 0.8 0.7 0.6 1.47 1.28 1.21

Odds Ratio

0.78 Major Depression Anxiety Disorder Bipolar Disorder Substance Use Disorder

Simon et al. Arch Gen Psychiatry 2006; 63:824-830.

Gender Moderates the ObesityDepression Relationship

1.6
Obese Men

1.4

1.37 1.2

Obese Women

1.23

. Odds Ratio

1.2
1.02

1 0.8 0.6 0.4 Major Depression Suicide Ideation Suicide Attempt

Carpenter et al. Am J Public Health 2000; 90:251-257.

0.63

0.63

Risk of Depression Increases with Obesity Severity

5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 < 18.5 18.5 - 24.9
1.33 1.13 1 0.96 1.9 4.63

Odds Ratio

25 - 29.9

30 - 34.9

35 - 39.9

>/= 40

Body Mass Index (kg/m 2)

Onyike et al. Am J Epidemiol 2003; 158:1139-47.

Quality of Life Impairments May Account for Increased Depression

22 20 18 16 14

Unimpaired Physical Function Impaired Physical Function

b b b

BDI-II Score

12 10 8 6 4 2 0 40-49.9 50-59.9 BMI Decade 60+

ab

Fabricatore et al. Obes Surg 2005; 15:304-09.

The Question of Causation

Most studies cross-sectional Longitudinal studies
Depression Obesity (adolescents) Obesity Depression (adults)

Potential 3rd variables

Medication usage Affect dysregulation/coping deficits

Berkowitz & Fabricatore. Psychiatr Clin N Am 2005; 28:39-54.

Binge Eating Disorder (BED)

Recurrent episodes of binge eating, an episode being characterized by both of the following:
Eating, in a discrete amount of time (e.g., within a 2hour time period), an amount of food that is definitely larger than most people would eat during a similar period of time in similar circumstances A sense of lack of control during the episodes, for example, a feeling that one cant stop eating or control what or how much one is eating

Marked distress about binge eating Frequency of 2 days per week for 6 months Does not occur only during the course of bulimia nervosa or anorexia nervosa

Binge Eating Disorder?

Abnormal for circumstances?

Marked distress?

Psychiatric Comorbidity of BED

No BED but Obese
6 5 5.4 5.3 4.9

BED (any weight)

***

***

***
3.7

Odds Ratio

4 3 2 1 0.8 0 Major Depression GAD Panic Attacks Nicotine Dependence Poss ETOH Use D/O 0.7 1.9 1.4 1.5 1.2 1.8 1.6

**

Suicide Attempts

Grucza et al. Comprehensive Psychiatry 2007; 48:124-31.

Overview
Psychological Aspects of Obesity
Assumptions Data

The Toxic Environment Discussing Weight Control Psychological Considerations in Treatment

Overweight and Obesity Among U.S. Adults

70 60
.

Obesity

Overweight

50
Prevalence (%)

40 30 20 10 0 1960-62 1971-74 1976-80 1988-94 1999-2002 2003-2004

NHANES Data Collection Period

Flegal KM et al. JAMA 2002;288:1723-27 Hedley AA et al. JAMA 2004;291:2847-50 Ogden CL et al. JAMA 2006;295:1549-55

Extreme Obesity is Increasing Rapidly

Sturm R. Arch Intern Med 2003;163:2146-48

The Toxic Environment

Physical Activity is
To be avoided Nearly unnecessary Limited by infrastructure

Brownell KD & Horgen KB. Food Fight. New York: McGraw-Hill; 2003.

The Toxic Environment

High-Calorie Food is
Highly palatable Inexpensive Heavily advertised Nearubiquitous

Brownell KD & Horgen KB. Food Fight. New York: McGraw-Hill; 2003.

Overweight and At Risk Status Among 2-19 year-olds in the U.S.

35 30

Overweight

At Risk

.
25

Prevalence (%)

20 15 10 5 0 1971-1974 1976-1980 1988-1994 1999-2002 2003-2004

NHANES Data Collection Period

Adapted from Jolliffe D. Int J Obesity 2004;28:4-9 Ogden CL et al. JAMA 2006;295:1549-55

Fast food restaurants clustered around schools

Mean distance from school to nearest FFR = 500 m (< 5 min walk) 78% of schools had > 1 FFR within 800 m (1/2 mi.) Density around schools 3-4 times chance rates.
Austin et al. Am J Public Health 2005; 95:1575-81.

Overview
Psychological Aspects of Obesity
Assumptions Data

The Toxic Environment Discussing Weight Control Psychological Considerations in Treatment

Discussing Weight
How you present the information can be just as important as the information itself.
Terms Approach Expectations

Language Matters
Weight a Excess Weight b BMI b b Weight Problem b Unhealthy Body Weight c Unhealthy BMI d Heaviness e Large Size e Obesity

e Excess Fat
f Fatness

2
Very Desirable

-1

-2 Very Undesirable

Wadden & Didie. Obes Res 2003;11:1140-46

Approaches to Discussing Weight Control

1. If you dont lose some weight, youll drop dead of a heart attack by age 50!

2. If you really want to lose weight, just eat less and exercise more. 3. As you know, weight impacts health in a lot of ways. What are your thoughts about your weight and health?

Setting Realistic Expectations

The initial goal of weight loss therapy for overweight patient is a reduction in body weight of about 10% Moderate weight loss of this magnitude can significantly decrease the severity of obesityassociated risk factors.

Should Unrealistic Expectations be Changed?

The Theory
Lose 10% I want to lose 30% I failed

Depression?

Binge?

Regain?

Cooper et al. CB Txt of Obesity 2003.

Should Unrealistic Expectations be Changed?

The Data
Difficult to alter patients expectations 1 Greater goals related to greater results 2,3 Unmet goals 3
Less satisfied with treatment, but.. No greater risk of drop-out No greater risk of regain No greater risk of depression
1. Wadden et al. J Consult Clin Psychol 2003; 71:1084-89. 2. Linde et at. Obes Res 2004; 12:569-76. 3. Fabricatore et al. Int J Obesity. In press

Overview
Psychological Aspects of Obesity
Assumptions Data

The Toxic Environment Discussing Weight Control Psychological Considerations in Treatment

A Guide to Selecting Treatment

Treatment
25-26.9 27-29.9 With comorbidities

BMI Category
30-34.9 35-39.9 > 40

Diet, exercise, & behavior therapy Pharmacotherapy Bariatric Surgery

With comorbidities

With comorbidities

+
With comorbidities

Behavioral Assessment
Presence of eating disorder?
Active bulimia or purging

History of anorexia or bulimia

Active BED
(assuming no other pathology)

Does BED Require Special Treatment?

16 14 12 10 8 6 4 2 0 Baseline Posttreatment 12-Month F/U
ns

Binge Days in Previous 28

CBT

BWLT

ns

Munsch et al. Int J Eat Disord 2007; 40:102-113.

Changes in Weight in Women Assigned to CBT or BWLT

100
CBT

95
Weight (in kg)

90 85 80 75 0
Treatment BWLT

6
Months

12
Follow-up

18

Marcus et al. Ann Behav Med 1995;17:5090

Behavioral Assessment
Psychopathology?
Severe Untreated Suicidal
Sibutramine only: on SSRI

Moderate and treated

Mild and treated

Behavioral Assessment
Substance Use?
Current Alcohol/Drug Abuse/Dependence In remission Caffeine/tobacco dependence (surgery) Recreational drug use
Moderate alcohol use

Behavioral Assessment
Capacity to provide informed consent
Cognitive abilities Uncontrolled psychosis Uninformed about risks of method

Demonstrated adherence to health behavior change

Previous weight loss Smoking cessation Substance use reduction Medication adherence

Conclusions
Anti-obesity bias is rampant
Be aware of attitudes/assumptions and effects Be sensitive in discussing weight

Obesity associated with mood & anx d/os

Moderating variables Causation?

Food environment is an etiological factor in obesity Psychosocial factors may affect outcomes of treatment, but more study is necessary.