How Psychology Could Help Reverse the Trend in Obesity
It would be an understatement to state that obesity has become a major problem in society due to increasingly sedentary lifestyles in many developed countries into the new millennium (The British Nutrition Foundation, 1999), quite literally about 1 in 3 people in America in 1987 were classified obese (Najjar MF, 1987) and most likely many more today (Najjar MF, 1987). Obesity is commonly classified as a body mass index (BMI) of 27 or roughly 120% of a desirable height for weight(Johanna T. Dwyer, 1994). Morbidity steadily rises above a BMI of 25 (The British Nutrition Foundation, 1999) , and aside from the enormous health risks conveyed (cardiovascular disease, non-insulin-dependent diabetes, hypertension among other debilitating conditions) (Claude Bouchard, 2000), there can also be considerable emotional distress associated with the stigma of linked to obesity (The British Nutrition Foundation, 1999, pp. 83-91). To be discussed will be obesity that has its roots in overeating primarily and the body’s natural accumulation of adipose tissue and not so much patho-biologically determined sort. However, there is at least some research to suggest that psychology plays a role perhaps almost as important as physiological and genetic factors (Gary D. Foster, 1994, pp. 140-166). Physiological and genetic factors undoubtedly feature prominently in obesity (The British Nutrition Foundation, 1999, pp. 72-80) but by the same token, many varied and complex psychological mechanisms also come into play due to obesity which provide some insight, at least, into the psychological causes of obesity (Gary D. Foster, 1994, pp. 140-166) and perhaps means of treatment hopefully allowing the medical institution to reverse the upward trend in obesity in Western society.
The book Obesity: Pathophysiology, Psychology and Treatment describes obesity rather eloquently: ‘Being Fat in a Thin World’. While previously culture may have dictated that the svelte ideal was not the perfect body shape particularly during the Renaissance (Gary D. Foster, 1994, p. 141), today it is evident that with our modern society’s pre-occupation, even obsession with this slender bodies and the lowering of the breast to waist ratio (Garner DM, 1980), the slimming of the ideal has been mirrored by the weight gain of the real (Gary D. Foster, 1994). There has, indeed, been a greater emphasis on attractiveness (i.e. thinness) in women than in men: the ratio of ads and articles for diet foods in women’s compared to men’s magazines was 63:1 and many portray unrealistic if not impossible aesthetic or emotional standards (Gary D. Foster, 1994). Regrettably, discrimination is highly prevalent. People from children, age 6 right to people into their 50’s and 60’s considered obese people to be less intelligent, hard-working and successful than non-obese persons1,2,3 and contrary to what may be intuitive, it seems that both obese adults and children had lower levels of depression and low self-esteem than their non-obese counterparts4,5 suggesting an evolutionary basis behind obesity trends. Clearly, obesity lies at the heart of much psychology that is not always immediately obvious or intuitively acceptable.
In scientific circles, psychological models of obesity on both genetic or environmental origins, manifest their causes most clearly into 3 broad divisions: those who have emotional disorders, appetite/satiety disorders or dietary restraint theory (The British Nutrition Foundation, 1999). Elaborating, emotional disorders are normally thought of as being caused by personality predisposition (Kaplan & Kaplan, 1975) ranging from theories about conflict and defence (Mills, 1994) to the suggestion of low self control among obese people (Gary D. Foster, 1994), particularly important in this being stress, which proves important in treatment. Appetite/satiety disorders also know as externality theories tend to state that a higher responsiveness to higher fat content leads to a positive energy balance (Schacter et al., 1968) although this theory started to lose favour for dietary restraint theory which posits that restricting food intake leads to an evolutionary response causing the person to value energy rich foods more highly when it was found that neither fat nor thin people showed much capacity to regulate their intake in relation to internal cues (Rodin, 1980). None of these key points appears to vary from culture to culture (Gary D. Foster, 1994). There are, in fact, many different ‘psycho-stereotypes’ that draw variously on these theories.
Binge eating disorder, emotional eating, food addiction, night eating syndrome and body image dissatisfaction as well as various psychological factors in sport and exercise participation are just some of the psycho-stereotypes which obese people may suffer from, nor may it be simply restricted to one of these as many may adhere to two or more of these stereotypes if not all. Binge eating disorder or BED describes, according to the American Psychiatric Association’s Diagnostic and Statistical Manual (DSMIV), “the obsessive consumption of large amounts of food with a subjective sense of loss of control, at least twice a week”. This causes marked distress (Brody et al., 1994) and constitutes some 20%-30% of all obese patients attending clinics (Spitzer et al., 1992). Restraint theory identifies emotional eating as a lack of restraint due to emotional arousal (Herman & Mack, 1975) and while conferring increased susceptibility to obesity cannot really solely induce expression. Food addiction bears some similarities to other addictions (Orford, 1984) however differs in that it seems that it is a psycho-biological challenger for anyone of any weight to consume less than their energy needs. Night eating syndrome is a condition in which the sufferer will wake in the night with a variable level of consciousness and with certain ‘automaticity’ (The British Nutrition Foundation, 1999) and there is much debate as to its causes and few systematic studies of the syndrome have been undertaken (The British Nutrition Foundation, 1999). It would seem strange that body image dissatisfaction should cause greater consumption but there are a number of snowball mechanisms that lead to weight gain mostly centred about body image: mainly negative experiences with physical activity and sport dictating an indoor life and may even be discriminated by their doctor and other health-care staff who may themselves feel disgusted by fat patients (Maddox et al., 1968). Obesity is a complex iceberg whose surface, it seems, we are only just starting to scratch with even the reasonably comprehensive description being, in fact, simplistic and more research would seem in hand (The British Nutrition Foundation, 1999, pp. 83-91).
Psychology is the study of behaviour, the mind and behaviour (Gross, 2005) so it would only follow that any psychological therapies would involve altering the mind and behaviour. Behavioural weight control has a long history having been first applied in the 1960’s and early 1970’s and had a true behaviourist approach to obesity in that therapies were born out of learning theory which states that all things can be learnt or unlearnt depending on conditioning from the environment (operant conditioning) and later on vicarious conditioning with SLT (Wing, 2002, p. 301). These conjectured that it would be possible that through conditioning it would be possible to assist people in their pursuit to lose weight (Wing & Jeffery, 1979). Later research focussed on the role of emotion in exercise especially that of motivation and satisfaction to varying degrees of success6,7. Neither of these approaches worked much long-term as it seemed that motivation could not be maintained over these prolonged periods. Certainly, social support programs served to great effect (Wing and Jeffery 1999) although; most startlingly this was one of the few programs that managed to maintain weight loss in full to this day whereas a control group in comparison with the 6 month period of those not given social support. It also seems that the media can be exploited again with surprising empirical efficacy8,9. It seems that the very aspect of obesity that makes it so difficult to quantify: its complexity may also make it much easier to treat in that it can be treated effectively at every stage of its life cycle, but like a malignant cancer, every person have their own tailored treatment as no two cases of obesity have exactly the same causes.
Admittedly, simply assuring the mental health of obese people is not enough; there must be some biological treatment to assist their weight loss the two main problems being how obtain and maintain motivation and overcoming the biological causes of obesity. It is evident that sometimes simple mind over matter cannot work with certain biological causes, say, the way a cocaine addict’s brain changes. Despite the scientific establishment not having undertaken any studies on the differences in brain structure in binge eaters and food addicts, it is likely that there would be many similarities (Gross, 2005), (Orford, 1984). It is this question of physiological vs. psychological dependence that even rivals the nature nurture debate. Perhaps the answer for treating obesity in its many forms may lie in treating obesity as a mal-adaptation, an evolutionary vestige that may once have been fruitful but is not longer. (Gross, 2005, pp. 127,128). Perhaps we need to examine this, true, from a psychological perspective but consider this as more than just something that can be overcome by sheer will-power (Gross, 2005, p. 126) and think about using buffer drugs to alter physiology, and neuro-physiology specifically the reward or dopamine system (Gross, 2005, pp. 56, 58, 126 132, 150, 782) like methadone. Perhaps altering the action of the endocrine system, which must be done with caution, may allow for a kind of food castration by providing a sensation of satiety, for instance individuals lacking the hormone leptin may find themselves unable to feel full and usually find themselves obese in infancy and morbidity in adolescence as a consequence is not uncommon (The British Nutrition Foundation, 1999). Promising research continues into leptin and the ventromedial nucleus (the part of the brain thought to induce sensations of satiety) as into gene therapy to look at ways of inducing a kind of artificial fullness or lower the facility with which weight is gained respectively. I suppose this is an admission of the limits of what psychology is able to effect, like chemicals have only a certain capacity to affect behaviour so does psychology only partially affect physiology and, if only we could choose our parents.
Psychology alone can only do so much but psychology to help biological dieting (caloric restriction, increase in physical activity, metabolic aids such as electrolytes) it far more powerful. Motivation, emotions and the influence of other people plays an important role in obesity and therefore its treatment. According to Maslow, 1954, there is a hierarchy of ‘needs’ that every person seeks to satisfy at the bottom being physiological needs like food, drink, elimination, rest etc. and at the top self-actualisation or realising one’s full potential. Now, it is unlikely that obese people feel satisfy some of their lower needs like esteem/respect of others and love and belongingness (Gross, 2005). Perhaps, the unreasonable effectiveness of social support in losing weight could be justified by an attempt to fulfil these human needs (Gross, 2005). It would seem that personality traits would affect the perceived importance and thus strength of this motivation as well as physiological constants such as pleasure derived from achievement or competitiveness (The British Nutrition Foundation, 1999). It appears personality which may be affected by externalities affects this motivation(Gross, 2005). Research suggests that we are most malleable when we are young giving us the idea that we should be looking into treating obesity at a young age, as not only could this help form positive habits that will probably last a lifetime but also prevent a problem before it starts (the more weight gained: the more weight needs to be lost) (The British Nutrition Foundation, 1999). Social support also shows great promise, with external monitoring and familial counselling (Wing, 2002). Dieting appears to have a psychology of its own as well with a more recent study by Dax Urbszat, C. Peter Herman, and Janet Polivy10 giving us the conclusion that there are a number of deviant psychological complexes that come into play with dieting with their humorous title ‘Eat, drink and be merry for tomorrow we diet’ basically summing up the conclusions which were actually quite complicated referring to time of food consumption, quantity, quality and again vary according to personality. Their study suggests that dieters should not so much ‘diet’ to lose weight but ‘diet’ to obtain fitness and health as this mentality prevents that common binge reaction to predicted food shortage and diet procrastination10.
Obesity, in its many manifestations is evidently a serious problem. There are many different causes of obesity including emotional, addictional and restraint theory which posits that dieting makes people desire fattier foods. Some of the different ‘psycho-stereotypes’ include those of the binge, emotional or night eater and are also related to complexes that centre about physical activity. Obtaining and maintaining motivation appear to be two fundamental problems in aiding weight loss and may be assisted with the use of social support from external bodies such as the media and by being monitored by their families. It also seems that the dieting mentality may have the opposite to the desired change in weight and it would seem that a new and radically different strategy focussing around health and not so much weight loss per se is to be called for. Obesity is a sad state of being in the ‘thin’ world of ours and it’s clearly going to be a tough nut to crack, but with more research, a greater appreciation and understanding of this debilitating condition, we as a society will come through this in the same way we have dealt with any health crisis; I am hopeful for the future.
A Note on the Sources:
After a flurry of research in the 1960’s to 1980’s there does not seem to have been much research, may I suggest, because of a sort of learned complacency that there does not appear to be any quick fix and it seems that obesity is here to stay. This is logically incorrect as a reduction in research may have, at any rate, in part at least lead to insufficient tools with which to combat obesity. Many factors may be at play here including, it seems an innate prejudice against obese people shared by physicians and psychologists alike (Gary D. Foster, 1994). It seems that much of this research remains pertinent however new developments in technology as well as the overall, progression in the times means that some of this will obviously not be as true as it might and should be. As I mentioned earlier, we have only scraped the tip of the obesity epidemic, one whose symptoms and causes are just as diverse as any other biological disease and I certainly believe more research needs to undertaken not only to repeat former experiments but to investigate new hypotheses and novel means of looking into how psychology, but not just psychology, can help reverse this upward trend we are seeing in obesity. Chiropractic treatments and hypnosis merit greater research however preliminary empirical trials have indicated inefficacy and so have not been touched upon in this discussion. Like with any disease obesity in society seems to have peaked and is now flat-lining in terms of its prevalence, new treatments and increased awareness that obesity is a medical condition that can be treated and not an innate deficiency (of willpower) on the part of the obese person as it was, unofficially (Medscape, 2009). That said, a new wave of research that seems to have some staying power appears to be born out of the ashes of the old research10; again I reiterate, I am hopeful for the future.
Brigham, T. A. (1989). Managing Everyday Problems. New York, NY: Guilford Press.
Claude Bouchard, P. (2000). Physical Activity and Obesity. Lower Mitchham, South Australia: Human Kinetics Publishers, Inc.
Forgas, J. P. (1991). Emotion & Social Judgments. Tokyo: Pergamon Press.
Garner DM, G. P. (1980). Cultural expectation of thinness in women. Psychol Rep .
Gary D. Foster, M. &. (1994). The Psychology of Obesity, Weight Loss and Weight Regain Research and Clinical Findings. In G. L. Kanders, Obesity Pathophysiology Psychology and Treatment (pp. 140-166). London: Chapman & Hall.