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 settings2,3 • Social • Education • Employment • Health care – implicit and explicit • Cramer & Steinwert. J Appl Devel Psychol 1998;19:429-51 • Puhl & Brownell. Obes Res 2001; 9:788-805. • Fabricatore et al. in Brownell et al. Weight Bias 2005.

5. 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; 14:881-88. • Foster et al. Obes Res 2003; 11:1168-77.

6. Refer to Psychologist Time I Would Spend w Pt 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; 25:1246-52

7. 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

8. Obesity and Psychopathology Simon et al. Arch Gen Psychiatry 2006; 63:824-830.

9. Gender Moderates the Obesity-Depression Relationship Carpenter et al. Am J Public Health 2000; 90:251-257.

10. Risk of Depression Increases with Obesity Severity Onyike et al. Am J Epidemiol 2003; 158:1139-47.

11. Quality of Life Impairments May Account for Increased Depression b b b a ab a Fabricatore et al. Obes Surg 2005; 15:304-09.

12. 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.

13. 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 can’t 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

14. Binge Eating Disorder? Abnormal for circumstances? Marked distress?

15. Psychiatric Comorbidity of BED *** *** *** ** * Grucza et al. Comprehensive Psychiatry 2007; 48:124-31.

16. Overview • Psychological Aspects of Obesity • Assumptions • Data • The “Toxic Environment” • Discussing Weight Control • Psychological Considerations in Treatment

17. Overweight and Obesity Among U.S. Adults 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

18. Extreme Obesity is Increasing Rapidly Sturm R. Arch Intern Med 2003;163:2146-48

19. 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.

20. 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 2004;28:4-9 Ogden CL et al. JAMA 2006;295:1549-55

22. 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.

23. Overview • Psychological Aspects of Obesity • Assumptions • Data • The “Toxic Environment” • Discussing Weight Control • Psychological Considerations in Treatment

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

25. 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 Language Matters Very Desirable Very Undesirable Wadden & Didie. Obes Res 2003;11:1140-46

26. Approaches toDiscussing Weight Control • “If you don’t lose some weight, you’ll 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?”

27. 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 1998;6:51S

28. 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.

29. 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; 71:1084-89. • Linde et at. Obes Res 2004; 12:569-76. • Fabricatore et al. Int J Obesity. In press

31. Overview • Psychological Aspects of Obesity • Assumptions • Data • The “Toxic Environment” • Discussing Weight Control • Psychological Considerations in Treatment

32. A Guide to Selecting Treatment

33. Behavioral Assessment • Presence of eating disorder? • Active bulimia or purging • History of anorexia or bulimia • Active BED • (assuming no other pathology)

34. Does BED Require Special Treatment? ns ns Munsch et al. Int J Eat Disord 2007; 40:102-113.

35. Changes in Weight in Women Assigned to CBT or BWLT CBT Weight (in kg) BWLT Treatment Follow-up Months Marcus et al. Ann Behav Med 1995;17:5090

36. Behavioral Assessment • Psychopathology? • Severe • Untreated • Suicidal Sibutramine only: on SSRI • Moderate and treated • Mild and treated

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

38. 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

39. Conclusions • Anti-obesity bias is rampant • Be aware of attitudes/assumptions and effects • Be sensitive in discussing weight • Obesity associated with mood & anx d/o’s • Moderating variables • Causation? • Food environment is an etiological factor in obesity • Psychosocial factors may affect outcomes of treatment, but more study is necessary.