Obesity and the Mind:

A Chicken-and-Egg Problem
Karen B. Grothe, PhD, ABPP, LP
National Press Foundation
February 23, 2016

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Disclosure
Relevant financial relationships
None
Off-label investigational uses
None

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Objectives
Discuss psychological factors that influence:
Obesity
Treatment of obesity
Behavioral intervention

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Source: The Obesity Society Infographic Task Force, November 2015

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Obesity and Depression

Age-adjusted percentage of adults aged 20 and over who were obese, by sex and depression status: United States, 20052010

50
45
40
35
30
Percent 25
20
15
10
5
0

46.7

43.2
33

Total

36.8
32.6

Men

33.4

Women

Depression No Depression
Pratt LA, Brody DJ. Depression and obesity in the U.S. adult household population, 20052010. NCHS data brief, no 167. Hyattsville, MD:
National Center for Health Statistics. 2014.
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Obesity and Depression

Longitudinal analysis
Obese persons: 55% risk of depression
Depressed persons: 58% risk of obesity
No differences between men and women
More pronounced among Americans

Floriana S. Luppino, MD; Leonore M. de Wit, MS; Paul F. Bouvy, MD, PhD; Theo Stijnen, PhD; Pim Cuijpers, PhD; Brenda W. J. H. Penninx,
PhD; Frans G. Zitman, MD, PhD. Overweight, Obesity, and Depression: A Systematic Review and Meta-analysis of Longitudinal Studies. Arch
Gen Psychiatry. 2010;67(3):220-229. doi:10.1001/archgenpsychiatry.2010.2;
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Trauma history
Extreme obesity associated with history of rape,
molestation, crime victimization, PTSD
National sample of 3,012 women
Obesity surgery samples
20-32% childhood sexual abuse
For some patients, weight is protective

Felitti, 1993; Brewerton et al., 2015 King et al, 1996; Buser et al., 2004
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Emotional eating
Affect regulation, escape, physiological
Varies by individual
Emotional eaters consume more sweet,
high-fat foods
Men: meal-type comfort foods
Women: sweet snacks, carbohydrates
Varies by emotion
Can impact entire process of ingestion
Environmental influence
Konttinen et al., 2010; Wansink et al., 2003, 2014; Evers et al., 2013
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Eating changes in response to stress

80%
70%
60%
50%
40%
30%

eat more
eat less

20%
10%
0%

Krumcher & Meyer (1963) Pudel (1984)

Popper et al. (1989)Weinstein et al. (1997)

Macht 2008
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Night Eating Syndrome

Morning anorexia
Evening hyperphagia
25-50% caloric intake after evening meal

Awakening once/night x 3 nights/week

Consumption of high calorie snacks during
awakenings
More common during stressful periods
Up to 40% of patients
Allison & Stunkard, 2004
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Binge Eating Disorder

Large amount, short time, loss of control
Rapid, secretive, until uncomfortably full
Prevalence:
3-5% of women, 2% of men
10-15% treatment seeking
Equally distributed by race

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 2013.
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Binge Eating and Depression

20
18
Beck16
Depression Inventory
14
12

Binge eating
Non binge-eating

10
8
6
4
2
0

Marcus et al.,
Telch
1988
& Agra,
Wadden
1994 et al.,
Brody
1993etKuehnel
al., 1994
& Wadden,
Mussell
1994
et al., 1996

Wadden et al., 2002

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Food Addiction
Similar symptomatology to substance dependence
Behavioral and neurophysiological evidence
Brain + environment interaction
Connection with BED
24% of those with FA did not have BED
Prevalence: 11% to 57%

Koball AM, Clark MM, Collazo-Clavell M, Kellogg T, Ames G, Ebbert J, Grothe KB. The relationship among food addiction, negative mood, and
eating-disordered behaviors in patients seeking to have bariatric surgery. Surg Obes Relat Dis. 2015 Apr 22. PMID:26183302.
DOI:10.1016/j.soard.2015.04.009.
Marcus MM, Wildes JE. Disordered eating in obese individuals. Curr Opin Psychiatry 2014, 27:443-447.DOI:10.1097/YCO.0000000000000103
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Impact on Treatment

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Depression and Bariatric Surgery

22% to 55% lifetime history of depression
40% of patients on antidepressant
Depression does not always resolve
Long-term postoperative use of psychotropics
RYGB may affect absorption, distribution,
elimination
Risk for poor weight outcomes
Increase risk of self-harm
Bhatti et al., 2015;Legenbauer et al., 2012; Mitchell et al., 2013; Roerig et al., 2012; Steffen et al., 2012
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Trauma History
Attrition
Increased distress
Lose less weight in BWLP
Equivalent weight loss 2 years post surgery
Increased risk of psychiatric hospitalizations

Buser et al., 2004; Clark et al., 2007

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Food Addiction & Weight Loss

FA related to less weight loss
after brief BWLP
post-bariatric surgery
FA not related to weight loss outcomes
or attrition in BWLP
2 years post RYGB

Burmeister et al., 2012; Clark & Saules, 2013; Koball et al., 2015; Lent et al., 2013
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Alcohol and Bariatric Surgery

n = 1,945
Pre-Op

Year 1

Year 2

AUD

7.0%

7.9%

10.7%

Alcohol-related harm

6.1%

7.3%

9.8%

Alcohol dependence

2.6%

3.8%

6.0%

AUDIT 8

2.4%

3.6%

6.4%

Preop vs. yr 1 p=.29; Preop vs Yr 2 p < .001; 1 yr vs 2 yr p=.02

King et al., JAMA 2012;307:2515-2525

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Alcohol and Bariatric Surgery

Swedish Obese Subjects
Control

Banding

VBG

GBP
12
10
8

Proportion of patients reporting medium risk alcohol consumption (% )

6
4
2
0

1 2 3 4 6 8 10

Follow-up time, year

Svensson et al., 2013 Obesity

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Source: The Obesity Society Infographic Task Force, November 2015

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Typical Dieters Loss/Gain Course

Weight

Time
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Obesity Treatment
Amount of
weight loss
Increased
risks

Bariatric surgery

25-45%

Endoscopic procedures

15-20%

Medications for weight loss

10-15%

Lifestyle Modification
Diet

Physical Activity

Behavior change

10%

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Expert panel report: Guidelines (2013) for the management of overweight and obesity in adults.
Obesity 2014 22(S2): S41-S410
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Behavioral Intervention
Used interchangeably with lifestyle intervention
Diet
Physical activity
Behavior therapy
Techniques to replace maladaptive behaviors
with new eating and activity habits

Sarwer, Green, Vetter, Wadden. Behavior therapy where are we now?

Curr Opin Endocrinol Diabetes Obes 2009;16:347-352.
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Behavior Therapy for Obesity

Selfmonitoring

Goal Setting

Stimulus
Control

Cognitive
Restructuring

Social
Support
Mindful
Eating
Wadden et al. Circulation 2012
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Self-monitoring
15
10
5
0
-5
Mean weight Change (lbs) -10
-15
-20
-25
-30
1

-35

3
4
Quartiles of Monitoring

Baker, Raymond C., and Daniel S. Kirschenbaum. Self-Monitoring May Be Necessary for Successful Weight Control.
Behavior Therapy 24, no. 3 (1993): 37794. doi:10.1016/S0005-7894(05)80212-6.
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Self-monitoring
Consistent predictor of weight loss
Calorie intake underestimated up to 50%
High frequency + consistency = more weight loss
Electronic tools may be better
Food, weight, physical activity

Burke LE, Wang J, Sevick MA. Self-monitoring in weight loss: A systematic review of the literature. J Am Diet Assoc 2011;
111:92; Peterson et al., Obesity 2014;22:1962-1967.
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Identify and Manage Triggers

People
Places
Times of day
Emotions
Social events
Certain foods

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Challenge Your Triggers

Avoid, limit, or master triggers
to stay on track
Use a food diary or other
self-monitoring device
Use rewards (not food!)
Mindfulness approach

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Outcomes
Weight loss indicated and desired
Lifestyle interventions
8 kg in 6 months (~5 - 10%)
Greater than usual care
Variability

Source: UConn Rudd Center for Food Policy & Obesity

Expert panel report: Guidelines (2013) for the management of overweight and obesity in adults. Obesity 2014 22(S2): S41-S410
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Relationship Between Physical Activity and

Maintenance of Weight Loss
100

P<0.001

80

60
Subjects Exercising (% )
40

20

Not Maintained

Maintained

Kayman S, Bruvold W, Stern JS. Maintenance and relapse after weight loss in women: behavioral aspects. Am J Clin Nutr 1990;52:800-807.
Wyatt H, Catenacci VA. The role of physical activity in producing and maintaining weight loss. Nat Clin Pract Endocrinol Metab 2007;3(7):518-29.
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Summary
Many psychological aspects to eating and weight
Depression can lead to obesity and vice versa
For some people, weight is protective
Self-monitoring dietary intake is best predictor of
weight loss
Physical activity is best predictor of weight loss
maintenance

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Weight Bias
Negative attitudes that negatively influence
interactions
Observed in children, parents, health care
providers, media
Affects employment, education, health care
Social, psychological, physical consequences
Stigmatizing videos with online news stories
http://www.uconnruddcenter.org/media-gallery
Puhl et al. Headless, hungry, and unhealthy: A video content analysis of obses persons portrayed in online news. J
Health Comm 2013;0:1-17
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Questions & Discussion

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