by Alicia R. Ruelaz, MD
Dr. Ruelaz is from Cedars-Sinai Medical Center, Department of Psychiatry, and Associate Director, Consultation-Liaison Division Faculty Psychiatrist, Cedars-Sinai Center for Weight Loss, Los Angeles, California.
Key Words: overweight, obesity, psychological, quality of life, acceptance
Objective. To enhance the psychiatrist’s understanding of the effect of overweight and obesity on their patients’ quality of life and psychological wellbeing and to examine how this can be improved, even in those patients who remain overweight.
Design /Setting/Participants/Measurements. Publications from disciplines, such as medicine, anthropology, finance, pediatrics, dietary, and surgery, are examined for insights into the psychological and societal factors associated with obesity, as well as the effects of different treatments on patients.
Results. Being overweight or obese in this society is disparaged, even by young children. A negative body image can lead to psychological distress. This can affect one’s wellbeing, even to the extent of affecting one’s earning potential. When comparing our culture to a non-Western one, such as Fiji, it can be seen that a large factor in this may be our society’s ideals, particularly for its female members. Those who are overweight can receive physical and psychological benefits from learning to accept their weight, even in the absence of weight loss. Also, regardless of the weight attained, an overweight person’s quality of life can improve from the state of losing weight.
Conclusion. Despite the societal implications and difficulties with being overweight, how one feels about his or her weight can determine how much of an effect it has on one’s quality of life. A psychiatrist who is aware of this is in a position to assist their overweight patients in order to mitigate these negative effects.
Worldwide, more than one billion adults are overweight, and at least 300 million of these adults are clinically obese. This trend is particularly prominent in the United States and seems poised to continue. A recent survey of children ages 6 through 9 years found that 31.5 percent of them are at risk of becoming overweight or were already overweight. As physicians, psychiatrists are well aware of the health consequences of overweight and obesity. As those entrusted with patients’ mental wellbeing, psychiatrists are in a position to mitigate some of the negative psychological consequences these patients face due to their overweight or obesity. Though the work in this area has been less extensive than that delineating the physical sequelae, several disciplines have unique insights to offer. As psychiatrists, how can we utilize these insights to support the mental wellbeing of our patients struggling with issues of weight?
Psychological Consequences of Obesity
Studies of obese individuals show high rates of psychiatric comorbidities, including eating disorders (especially binge eating disorder), depression, anxiety, and personality disorders. Other research supports the idea that body mass index (BMI) correlates with body dissatisfaction, body distortion, and self-consciousness. The level of BMI has also been associated with depression in young women. Of patients presenting to receive bariatric surgery, it has been estimated that the incidence of psychiatric pathology may be between 30 and 50 percent. This pathology is usually responsive to treatment and may not hinder the patients in receiving the surgery. In fact, symptoms of some psychiatric pathology may actually decrease after weight loss surgery.
What is the role of body weight in these associations? Even at an early age, obese children are described by other children as “lazy, dirty, stupid, ugly, cheats and lies.” Children pick up on the fact that being overweight is bad and develop concerns about their own weight that can be associated with depressive symptoms. However, not all overweight children react to this in the same way. A study looking at third grade children in northern California found a modest association between depressive symptoms and BMI in female, but not in the male, children. Some of the questions on these surveys assessed overweight concerns. After controlling for the level of overweight concerns, BMI was no longer significantly associated with depressive symptoms. The opposite was not true, however; after controlling for BMI, overweight concerns remained associated with depressive symptoms. This implies that it is whether or not a child is concerned with his or her weight, rather than what his or her actual weight is, that correlates with the child being depressed. On the other hand, it may be that those with more depressive symptoms are more likely to have concerns about their weight. This is seen in adults where it has been noted that, regardless of body habitus, body image disparagement decreases when self-esteem and positive emotions increase.
Feelings or concerns regarding weight can be a product of the culture in which one is raised. It has been said that in American culture, the self is defined by one’s appearance. This may be particularly true for women. As women tend to be more concerned with social relationships, they may be more likely to focus on changing their bodies so that they reflect positive qualities that are associated with being well liked. In America, the firm, developed body shows that one not only cares about the way he or she looks but also that he or she has willpower, the ability to control impulses, and the ability to shape one’s own life. According to Becker, “The self constructs a particular image by choosing from a field of bodily symbols that may equate obesity with indulgence, laziness, or sheer ineptitude in managing self-preservation; thinness with embodied restraint; and toned musculature with disciplined work on the body. In short, bodies exist not only to live with and think with but also to struggle against in forging a personal identity.” For those unable to achieve this ideal, dissatisfaction with oneself may result.
Looking at another culture can provide a contrast from which to see how members of this culture might be impacted by these ideals. A study of Fijian women by an American physician noticed a sharp rise in eating disorders with the introduction of television into the country. She evaluated 17-year-old girls in 1995 and found that only three percent of them were vomiting to control their weight. After three years of Western programming, they were evaluated again. At that time, five times as many 17-year-old girls (15%) reported this type of vomiting. This correlated with the amount of television watched, as those who watched television at least three nights per week were 50 percent more likely to see themselves as too fat and 30 percent more likely to diet, even if they were not overweight. The culture in Fiji is unique in that one’s social position is based on how well one can feed other people. At the time of the study, 84 percent of the adult village women were overweight or obese. This may change, however, as the society is exposed to the values of other cultures. Comments made by the adolescent girls seemed to reflect a changing attitude toward self image and weight (e.g., “… in order to be like them, I have to work on myself, exercising, and my eating habits should change.”)[7,10]
It is this concern over weight that has led to weight loss becoming a huge industry in this country. The cost of obesity has been estimated to be $100 billion per year. A survey performed in 1996 reported that more than two thirds of American adults were trying to lose weight or forestall weight gain.11 And, in the year 2000, $34. billion was spent on weight loss products and services.
This may be a sound investment in that weight actually may be connected to a person’s earning potential. A study of 7,300 people performed in 2005 noted that overweight Americans who lose weight tend to build more wealth as they lose. This was seen to be an increase of $11,880 in white women whose BMI went down by 10 points. In black women, the wealth increase was $4,480, and in white men it was $12,720. Weight fluctuations in black men did not affect their wealth. On the other hand, if white women increased their BMI, there was a large wealth decline, which was only a medium-sized drop for black women and did not affect men.
Benefits of Weight Loss
Psychiatrists see many overweight and obese patients in their practices, particularly those who experience weight gain from psychotropic medications. How can psychiatrists support their patients’ mental health and wellbeing while they struggle with weight concerns and attempts at weight loss? As noted previously, by increasing self esteem and positive emotions, body image disparagement decreases. The idea of helping patients to accept themselves no matter what their weight can be valuable not only for their mental health but actually have physiological consequences as well. This was demonstrated in an approach to treating obesity called the Health at Every Size model. In an experiment testing this model, it was compared to a standard dieting intervention in a study of obese female subjects aged 30 to 45. Both groups had 24 weekly sessions of 90 minutes each. The Health at Every Size group were taught to first disentangle their self worth from their weight. Then, they were taught to let go of restrictive eating and replace it with internally regulated eating.
Nutrition education focused on eating foods that promoted health, and the exercise component focused on activity that helped participants enjoy their bodies. They were followed up over the next two years, and 58 percent of dieters and 92 percent of the Health at Every Size group completed the program. The dieters lost five percent of their initial weight, whereas the weight did not change in the Health at Every Size group. Despite the lack of weight loss, however, the Health at Every Size group had a sustained decrease in their systolic blood pressure and decreased total cholesterol where the dieters did not have this change. In addition, the Health at Every Size group reported improved self esteem. At follow-up, 100 percent of the Health at Every Size group reported feeling better about themselves and zero percent reported feeling like a failure. Despite losing more weight, the dieting group had only 47 percent of their members report feeling better about themselves, and 53 percent actually said they felt like failures.
Psychiatrists may feel wary of supporting the wellbeing of a patient whose weight makes weight loss imperative. However, this study is thought-provoking in that by helping patients to accept themselves no matter what their weight, psychiatrists can help the patients to have physiological benefits as well as increased self esteem, which may assist the patients in becoming empowered to make the difficult dietary and exercise changes necessary for weight loss.
As self-acceptance can have effects on physiological parameters, losing weight can have psychological benefits that may be related to the physical state of losing weight, regardless of the eventual weight loss attained. A study of patients who had received weight loss surgery showed that even those who had lost weight but remained obese had major improvements in the medical comorbidities of obesity. Also, their overall quality of life became similar to that of the normal community sample. Those patients that lost weight to achieve a BMI of 30 to 35 were still obese, but, when compared to people already at that BMI who had not lost weight, the weight loss subjects had increased physical function, increased general health, increased energy, increased social function, and decreased depressive symptoms. It is not known whether this may be metabolic alterations that cause neurochemical changes leading to greater happiness or if the ability to lose weight in people who had been discouraged by previous efforts might account for the improvements in mental health.
So how can a psychiatrist initiate discussions about weight without offending their overweight patients? A study involving surveys of primary care patients found that overweight patients fell into two groups: those satisfied with their current weight and those not satisfied with their current weight. Those overweight patients who were satisfied with their weight were less likely to think that their weight was a problem or to have tried to lose weight, and a large number of them stated that they had no motivation to lose weight. The overweight patients who had answered that they were not satisfied with their weight, however, stated that they knew their weight to be a problem, were motivated to lose weight, and most had already tried to lose weight. So, rather than starting a conversation with patients about weight by telling them your own thoughts, it can be less alienating to ask them if they are satisfied with their weight. If they are overweight and satisfied, self-acceptance may be less of an issue than education regarding the medical dangers of overweight. If they are not satisfied, talking to them about what they have already tried and encouraging them to accept themselves by acknowledging their previous hard work can be empowering for those that see themselves as unsuccessful in this area. To keep these patients motivated, the psychiatrist should focus on self-acceptance and health promotion rather than success and failure by the numbers on the scale.[15,16]
Obesity is prevalent in our society with psychological and societal factors complicating the physical co-morbidities associated with it. The mind and body are interconnected in that self acceptance can alter even physiological parameters outside of weight loss. Also, weight loss itself can alter psychological states even in patients who remain obese. With the insight gained by knowledge of the psychological and societal factors associated with weight, psychiatrists are in a unique position to support the overall wellbeing of patients struggling with weight.
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