Psychological Impact and Considerations for Treating the Obese Patient

1
Psychological Impactand Considerations
forTreating the Obese Patient

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

2
Overview

• Psychological Aspects of Obesity
• Assumptions
• Data
• The Toxic Environment
• Discussing Weight Control
• Psychological Considerations in Treatment

3
Childhood?
Mood?
Job?
Education?
Relationship with Men?
Relationship with Mother?
Friends?
4
Negative Attitudes Toward Obese Individuals

• Apparent at age 3 1
• Operate in multiple settings 2,3
• Social
• Education
• Employment
• Health care implicit and explicit

• Cramer Steinwert. J Appl Devel Psychol
  199819429-51
• Puhl Brownell. Obes Res 2001 9788-805.
• Fabricatore et al. in Brownell et al. Weight Bias
  2005.

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Explicit Attitudes of Physicians

• Characteristics associated with obese patients
  1,2
• Noncompliant Lazy
• Dishonest Sloppy
• Unpleasant Ugly
• Similar findings in nurses, PTs, psychologists,
  etc.

• Klein et al. J Fam Pract 1982 14881-88.
• Foster et al. Obes Res 2003 111168-77.

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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?

Hebl Xu. Int J Obesity 2001 251246-52
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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
6103-115
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Obesity and Psychopathology
Simon et al. Arch Gen Psychiatry 2006 63824-830.
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Gender Moderates the Obesity-Depression
Relationship
Carpenter et al. Am J Public Health 2000
90251-257.
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Risk of Depression Increases with Obesity Severity
Onyike et al. Am J Epidemiol 2003 1581139-47.
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Quality of Life Impairments May Account for
Increased Depression
b
b
b
a
ab
a
Fabricatore et al. Obes Surg 2005 15304-09.
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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 2839-54.
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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 2-hour 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

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Binge Eating Disorder?
Abnormal for circumstances?
Marked distress?
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Psychiatric Comorbidity of BED





Grucza et al. Comprehensive Psychiatry 2007
48124-31.
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Overview

• Psychological Aspects of Obesity
• Assumptions
• Data
• The Toxic Environment
• Discussing Weight Control
• Psychological Considerations in Treatment

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Overweight and Obesity Among U.S. Adults
Flegal KM et al. JAMA 20022881723-27 Hedley AA
et al. JAMA 20042912847-50 Ogden CL et al. JAMA
20062951549-55
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Sturm R. Arch Intern Med 20031632146-48
Extreme Obesity is Increasing Rapidly
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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.
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The Toxic Environment

• High-Calorie Food is
• Highly palatable
• Inexpensive
• Heavily advertised
• Near-ubiquitous

Brownell KD Horgen KB. Food Fight. New York
McGraw-Hill 2003.
21
Overweight and At Risk Status Among 2-19
year-olds in the U.S.
Adapted from Jolliffe D. Int J Obesity
2004284-9 Ogden CL et al. JAMA 20062951549-55
22

• Fast food restaurants clustered around schools
• Mean distance from school to nearest FFR 500
  m (lt 5 min walk)
• 78 of schools had gt 1 FFR within 800 m (1/2
  mi.)
• Density around schools 3-4 times chance rates.

Austin et al. Am J Public Health 2005 951575-81.
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Overview

• Psychological Aspects of Obesity
• Assumptions
• Data
• The Toxic Environment
• Discussing Weight Control
• Psychological Considerations in Treatment

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Discussing Weight

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

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Language Matters
Very Desirable
Very Undesirable
Wadden Didie. Obes Res 2003111140-46
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Approaches toDiscussing Weight Control

• If you dont lose some weight, youll drop dead
  of a heart attack by age 50!
• If you really want to lose weight, just eat less
  and exercise more.
• As you know, weight impacts health in a lot of
  ways. What are your thoughts about your weight
  and health?

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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 obesity-associated risk
factors. NIH/NHLBI. Obes
Res 1998651S
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Should Unrealistic Expectations be Changed?

• The Theory

I want to lose 30
I failed
Lose 10
Depression?
Binge?
Regain?
Cooper et al. CB Txt of Obesity 2003.
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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

• Wadden et al. J Consult Clin Psychol 2003
  711084-89.
• Linde et at. Obes Res 2004 12569-76.
• Fabricatore et al. Int J Obesity. In press

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Overview

• Psychological Aspects of Obesity
• Assumptions
• Data
• The Toxic Environment
• Discussing Weight Control
• Psychological Considerations in Treatment

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A Guide to Selecting Treatment
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Behavioral Assessment

• Presence of eating disorder?

Active bulimia or purging
History of anorexia or bulimia
Active BED (assuming no other pathology)
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Does BED Require Special Treatment?
ns
ns
Munsch et al. Int J Eat Disord 2007 40102-113.
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Changes in Weight in Women Assigned to CBT or BWLT
CBT
Weight (in kg)
BWLT
Follow-up
Treatment
Months
Marcus et al. Ann Behav Med 1995175090
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Behavioral Assessment

• Psychopathology?

Severe Untreated Suicidal
Sibutramine only on SSRI
Moderate and treated
Mild and treated
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Behavioral Assessment

• Substance Use?

Current Alcohol/Drug Abuse/Dependence
In remission Caffeine/tobacco dependence
(surgery) Recreational drug use
Moderate alcohol use
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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

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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.