Weight Management

Health Psychology Spring 2011

Measurement of Obesity
Body Mass Index (BMI) Weight in kilograms/height in meters squared Non-Metric Conversion Formula: (Weight in lbs/height in inches2) X 704.5 Most commonly used scientific tool to represent relative weight Highly correlated with body fatness in most populations

Measurement of Obesity
Waist Circumference Independent predictor of risk factors and morbidity Waist circumference is positively correlated with abdominal fat content Loses incremental predictive power in those with BMI > 35 Men > 102 cm (> 40 inches) Women > 88 cm (>35 inches)

Defining Overweight and Obesity

OBESITY CLASS BMI (kg/m2) Disease Risk Men < 40 in Women < 35 in < 18.5 18.5 24.9 25.0 29.9 I II Extreme Obesity III 30.0 34.9 35.0 39.9 > 40.0 Increased High Very High Extremely High High Very High Very High Extremely High Disease Risk Men > 40 in Women > 35 in

Underweight Normal Overweight Obesity

Obesity Trends* Among U.S. Adults BRFSS, 1990, 1998, 2007

(*BMI u30, or about 30 lbs. overweight for 54 person) 1998 1990

2007

No Data

<10%

10%14%

15%19%

20%24%

25%29%

30%

Obesity Rates by Race/Ethnicity (2003)

40

30 Percent Female Male

20

10

0 White AA H/L

Prevalence of Overweight and Obesity by Race

WOMEN MEN

WHITE

49.2%

61.0%

AFRICAN-AMERICAN

65.8%

56.5%

MEXICAN-AMERICAN

65.9%

63.9%

Why Treat Overweight and Obesity?

Second leading cause of preventable death in United States An estimated 97 million people in US are overweight (BMI of 25-29.9) or obese (BMI >30) Increased risk of all-cause mortality and morbidity from hypertension, dyslipidemia, Type II diabetes, coronary heart disease, stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and endometrial, breast, prostate, and colon cancers

Mortality and Obesity



Mortality varies with degree of overweight.

Rates rise above average as BMI exceeds 28 BMI > 35 is associated with approximately twofold increase in total mortality.

For persons with BMI > 30, mortality rates from all causes, especially cardiovascular disease, are increased by 50 -100 percent

Obesity & Mental Health

Early studies did not find a relationship between obesity and psychological well being Recent studies have found gender differences in psychosocial adjustment to obesity
 

Obese women were 37% more likely than non-obese women to meet criteria for depression Obese men were less likely to meet criteria for depression compared to non-obese men

Causes of Obesity
Societal Factors
  

Larger portion sizes Fewer healthy choices Sedentary lifestyle Genetics (metabolism, appetite, # & size of fat cells)

Biological Factors


Causes of Obesity
Behavioral Factors
 

Caloric intake Physical Activity SES Food choices Discrimination

Evidence in African American, Hispanic, & Asian populations

Social Factors
  

Treatments for Obesity

CBT Physical Activity Very Low Calorie Diets (VLCDs) Pharmacotherapy Weight Loss Surgery Combined Therapy

Behavior Therapy: Diet & Exercise

Self Monitoring
  

Caloric intake Physical activity Triggers

Stress Management Nutritional training



Balanced deficit diet Food availability

Stimulus control


Behavior Therapy: Diet & Exercise

Contingency management


Rewards for meeting goals Exercise program (weight training vs. aerobic activity) Life-style activity Modification of self-defeating thoughts and feelings Realistic expectations Body image acceptance

Increased physical activity

 

Cognitive restructuring
  

Behavior Therapy: Short-Term Effectiveness

More than 150 trials of behavior therapy for obesity
 

Attrition rates low Virtually no negative side effects

Weight losses of 19 pounds or 9% reduction in body weight typical Recent studies show that extending treatment (20 weeks or more) and including exercise improves outcome

Behavior Therapy: Long-Term Effectiveness

After behavioral treatment, most studies show a gradual but reliable return to baseline weights (Med Exerc Nutr Health 1995; 4: 255-272). Maintenance more likely to occur when participants are provided post-treatment programs When maintenance programs end, participants gradually regain weight (J Consult Clin Psychol 1988;56: 529-534).

VLCDs: Short-Term Effectiveness

800 calories per day or less Large and rapid initial weight losses (2 to 3 times that produced by LCDs). The large weight reductions produced by VLCDs are rarely maintained Exercise and maintenance programs improves long-term effectiveness Long-term effectiveness generally equivalent to that of conventional treatment.

Pharmacotherapy for Obesity

Noradrenergic drugs (appetite suppressant)
  

Enhances the release of Norepinephrine and Serotonin High degree of variability in therapeutic response Potential for increased heart rate and blood pressure Inhibits pancreatic lipase Prevents absorption of fat Used in combination with a reduced calorie diet

Orlistat
  

Weight Loss Surgery

Only as a last resort


Only for clinically severe obesity (BMI > 40 or > 35 with comorbid risk factors) and only if other treatments have failed and patient is at high risk for obesity related morbidity or mortality Band placed where esophagus and stomach meet which restricts food intake Stomach size decreased and part of small intestines removed

Gastric banding


Gastric bypass


Recommendations
Combined therapy of low calorie diet, behavior therapy and increased physical activity provides the most successful therapy for weight loss and maintenance 6 months of intervention should be tried before considering pharmacotherapy or weight loss surgery

Working With Obese Clients

Media portrayals of obese persons


Stereotypes/Attitudes?

Working With Obese Clients

Employment Discrimination* (Gender-based)
   

Hiring Compensation Promotion Career advice

Source: Ding & Stillman (2005)

Working With Obese Clients

Survey of obese patients (Wadden et al 2000)


Nearly 2 out of 3 obese patients believe provider doesnt understand difficulties

A study comparing case reports in which patient only differs in weight (Hebl & Xu, 2001)


Providers indicated they had more negative feelings and would spend less time with obese patient.

Working With Obese Clients

Bagely et al. (1989)


24% of nurses said they were repulsed by obese persons

Maroney & Golub (1992)



31-42% of nurses said they would prefer not to care for obese persons at all

Implicit Attitudes of Health Care Providers (Schwartz et al. 2003)

Objective


Examined obesity-related implicit attitudes of health care providers

Participants
 

N = 389 (198 women; 191 men) 89% had professional degrees

Implicit Attitudes of Health Care Providers (Schwartz et al. 2003)

Methods


IAT
Good-Bad Lazy-Motivated Stupid-Smart Worthless-Valuable

Explicit Bias Scale

Implicit Attitudes of Health Care Providers (Schwartz et al. 2003)

Results
   

Implicit Bias observed Explicit Bias observed Strongest predictor of bias??? Positive professional and personal experiences associated with less bias

Working With Obese Clients

Davis-Coelho, Waltz, & Davis-Coelho (2000)


Examined therapist attitudes and treatment recommendations towards overweight clients Randomly selected 500 APA members
40% response rate

Methods
 

Sent case description and photo of a female client

Randomized overweight vs. normal weight

Working With Obese Clients

Results
    

Psychologists under 40 predicted lower client effort for overweight client Female psychologists predicted poorer prognosis Younger psychologists predicted poorer prognosis Increasing sexual satisfaction was tx goal for overweight client but not normal weight client Normal weight more likely to receive adjustment disorder diagnosis despite no mention of identifiable stressor

Physical Inactivity

Recommended Physical Activity

30 Minutes of moderate physical activity 5 days per week
 

60% not physically active on regular basis 25% are sedentary Ethnicity Gender Income Education Region

Predictors of physical inactivity

    

Social Factors & Physical Activity

Access to parks and sidewalks Neighborhood safety High crime * (women) Seeing others active * (men)

Sallis et al., 2007

Race/Ethnicity & Physical Activity

Hispanic/Latino have lowest rates independent of social class However, Latinos tend to engage in more domestic and work related physical activity They also work more hours, leaving less time for leisure-related physical activity Most studies do not account for these findings
Source: Marquez & McAulley (2006)

Assessment of Physical Activity

Self-report


Tend to overestimate physical activity Measure distances traveled (counting steps) Measures acceleration; greater acceleration equals more energy Most times heart rate is linearly related to energy expenditure

Pedometer


Accelerometer


Heart Rate Monitor



Physical Activity & Chronic Disease

Cardiovascular Disease (CVD)
  

Exercise reduces the risk of cardiovascular mobidity and mortality Primary and secondary prevention strategy Decreased chest pain and reduced progression of atherosclerosis Recent review found that 75% of participants experienced significant decreases in BP More research needed with minority populations

Hypertension
 

Physical Activity & Chronic Disease

Chronic Obstructive Pulmonary Disease (COPD)
  

Reduction in dyspnea (difficulty breathing) Increases health related quality of life Possible improvement in cognitive performance Physical activity provides a preventative effect for developing some types of cancer (colon, breast) Physical activity can prevent the loss of lean muscle mass, increase appetite, and improve quality of life for individuals undergoing cancer treatment

Cancer
 

Physical Activity & Chronic Disease

Diabetes Mellitus
 

Enhances insulin transport of glucose into cells Increase insulin sensitivity in muscle

Psychological functioning (Martinsen, 2008)



Reviewed the literature on the relationship between exercise and depression and anxiety

Physical Activity & Psychological Functioning

Depression
   

Studies suggest regular exercise as beneficial as psychotherapy and pharmacotherapy Adding to treatment does not seem to enhance treatment although it may reduce relapse rates Type of activity not predictive of success 30 minutes 3-5 days per week needed to experience benefits