The Patient Faced with His/Her Obesity 
OBJECTIVE:  NUTRITION n°61 (January 2002) 
By Prof. Daniel RIGAUD 
University Teaching Hospital (CHU) Le Bocage, DIJON 
 
As a result of the discovery of obesity's genetic aspects, its psychological determinants are sometimes overlooked.  Obesity, a complex disorder, is the result of genetic, metabolic, psychological and behavioral factors.  Appropriate management should take into account obesity's psychosocial aspects, the eating disorders that obesity may betray and the psychological impact of treatment. 
 

 
 
The dramatic leaps that the discovery of leptin and the genetic aspects of the disease represent, sometimes lead us to overlook the psychological determinants affecting the progression of some (if not all) types of obesity. 
In fact, obesity is more complex as it is the result of genetic, metabolic, psychological and behavioral factors. 
 
Psychiatric disorders and obesity 
 
Numerous cross-sectional or longitudinal scientific studies have found that psychiatric disorders or specific psychological profiles are no more frequent in obese subjects or in future obese subjects than in the general population.  However, it would hardly be scientific to deny that emotional determining factors are involved in the pathogenesis of certain types of obesity and the psychoaffective, emotional and behavioral consequences, sometimes play a major role in the perpetuation of certain types of overweight. 
 
There is no higher incidence of different types of neuroses (anxiety, obsessive compulsive disorders...) various psychotic conditions or depressions (idiopathic or seasonal) in obese adults and children than in normal weight subjects.  On the contrary, a chronic depressive condition tends to promote anorexia and moderate weight loss. 
However, it is apparent that a depressive state facilitates weight gain in patients who are genetically predisposed or have a specific background.  Snacks consisting of eating between meals, a reduction in physical activity and the effect of certain medicinal treatments (neuroleptics, tricyclic anti-depressants, high dose sedatives) may also participate in this process.  Sometimes physical overactivity, as a means of "dealing with" depression may perhaps account for the fact that some patients gain weight when depression is treated. 
 
Psychosocial aspects of obesity 
 
The origins of obesity do not lie in a specific psychiatric profile or in a previous traumatic context:  There is no higher incidence of rape, incest, or object loss (death, break up), or of failure at school, on average, in obese subjects than in the rest of the population. 
However, it is possible that the patient's feeling when faced with an aggressive event is more important than the event itself. 
Nonetheless, it should be kept in mind that the pathogenesis of obesity in a given subject occurs in a specific context.  These days society no longer considers "fat people" as role models.  It no longer attributes an elite social value to overweight persons, neither in men (overweight and sexual powers) nor in women (overweight and fertility).  In our countries, access to food no longer is a focus for the ruling class because all foods, or nearly all, are available at all times for everyone. 
The current tendency is towards control, "total control" and "thin is beautiful".  A person should be a good manager of his or her physical form and his or her diet, muscular if possible and a sports enthusiast.  Therefore, a certain form of rejection of "fat people" has appeared, fed by the medias which "produce diets" all year long.  Thus, many obese subjects feel guilty about being fat and especially about not being able to lose weight.  Having a bad image, obesity is badly tolerated by patients who feel guilty about not being able to lose weight. 
 
The obese person is not deliberately trying to be fat, nor not to lose weight, and thus to worsen his/her diabetes, dyslipoproteinemia, hypertension or his/her sense of ill-being.  Rather, he/she tends to be confronted with a metabolic and behavioral neurosensory context which act in unison to "maintain" obesity in spite of the patient's real desire to find a way out!  This is why it is exhausting and tiresome to try to lose weight, especially when the weight loss is about 8 kg per year (that is to say less than one kilo per month) and not one kilo per week.   
 
Obesity and eating patterns 
 
There is not one but several types of obesity:  between obesity associated with a genetically programmed defect in energy expenditure and obesity secondary to an uncontrollable compulsion to eat, there is a world of difference. 
Overweight is in itself an aggressive agent, both physically and psychologically.  And yet, it cannot be denied that some subjects respond to "chronic moderate stress" by eating more.  
Furthermore, it is essential to keep in mind that many obese subjects see their weight problem aggravated by an eating disorder which they conceal from their therapist: snacking and compulsive eating out of anxiety or boredom, but also out of guilty feelings of not succeeding.  Some statistics report 30 to 45% of patients consulting a specialized weight loss service have eating disorders (figure 1). 
However, it does not appear that there is a higher incidence of a previous history of anorexia or bulimia nervosa in obese subjects than in normal weight subjects.  In a population of 490 bulimic or anorexic patients followed for 10 years, "overweight" as defined medically was only observed in 4 cases and obesity (body mass index (BMI) > 30 kg/(m)2) only once.  In a population of 1890 obese subjects, a previous history of anorexia or bulimia nervosa was observed in only 0.5% of cases. 
 
Psychological impact of treatment 
 
Obesity may lead both patients and physicians to a poorly adapted weight management, a source of eating disorders.  The sometimes harmful role of obesity treatment in the pathogenesis of certain eating disorders is beginning to be better understood:  inappropriate, overly restrictive, overly strict diets lasting too long, imbalanced diets, anorexigenic medications, feelings of guilt or rejection. 
 
Indeed, an overly restrictive diet may induce harmful responses, both metabolic as well as psychological.  From a metabolic standpoint, such a regimen may trigger the following. 
• an energy sparing metabolism through decreased energy expenditure at rest (basal metabolism) and decreased thermogenesis, which inhibits weight loss; 
• an increased hunger and interest for "food".  A subject on a restrictive diet whether obese or not, develops behavior patterns that he/she does not control and which tend to greater "effectiveness" in acquiring food:  feeling of malaise, difficulties in concentration, difficulty in falling asleep, "moodiness" etc.  
In some patients, restrictive diets may also reactivate anxiety, a depressive state, sleep disorders and nervousness (impulsiveness).  
 
 
An overly restrictive diet may result in three types of psychological responses:  
• any ban (in this case eating) induces frustration and, often, behaviors of opposition and compensation, 
• any frustration increases the patient's sensitivity to other types of frustrations:  decreased tolerance to "psychological aggressions". 
• the guilt feeling of not being able to succeed leads to adaptive compensatory behaviors:  dissimulation, including to oneself (involuntary under-evaluation of foods ingested), rejection, lack of self-esteem leading to an increased risk of eating disorders. 
 
Conversely, in some cases, management or the sole fact of losing weight initially may enhance the patient's self-esteem and diminish certain eating disorders (figure 1). 
 
Lastly, in some patients, hyperphagia is a response to a feeling of ill-being:  weight loss in these persons stimulates their instability and sometimes leads to eating disorders. 
 
Psychosocial treatment 
 
Diets fail because following them represents a major constraint for the patient.  Explaining what controls body weight, the ins and outs of weight loss, what the subject can expect from a diet and weight loss, what diets will not provide them, and working on thoughts that emerge before an "uncontrolled act" of eating are so many things that will make it possible for the patient to work in depth.  
It is now known that this approach called "cognitive-behavioral therapy", produces a more durable weight loss (figure 2). 
 
Conclusion 
 
The subject's psychological characteristics intervene in the pathogenesis of obesity in how it is experienced and in the success of its management.  
Moreover, recent prospective studies suggest that a rigid dietary behavior, a disorganized diet, difficulty in "facing" psychological aggressions, and excessive impulsiveness have a negative prognostic value (less weight loss), as much as, if not more than genetic or metabolic factors.

 
Professor Daniel RIGAUD 
University teaching Hospital 
(CHU Le Bocage, DIJON)

 
BIBLIOGRAPHY 
1 - Rigaud D. Les déterminants de la prise alimentaire. Gastroentérologie  ; ed. M. Mignon. Editions Ellipse/Aupelf (Paris) 1992, 18-24. 
2 - Wadden TA, Stunkard AJ. Psychosocial consequences of obesity and dieting. In « Obesity : 2nd edition », ed. Wadden TA, Stunkard AJ. Raven Press 1993 ; 163-178.    
3 - Basdevant A, Laville M et al. Recommendations pour le traitement de l’obésité. Cahiers de Nutrition 1998 ; 33 (supplément 1) : 1-48.    
4 - Obésité de l’enfant : Dépistage et prévention. Cahiers INSERM Juin 2000. 
 
Insert 1.

 
Insert 2.

 
 

Figure 1 
Study conducted on obese patients who had never previously consulted for weight loss.  
Damatte-Fauchery C., Rigaud D. (personal results) 
 
 

Figure 2 : Weight loss at 3 years for 88 obese subjects  
During the first 3 months, 30 patients had 2 periods (of 3 weeks) of a 600 kcal/day diets, interrupted by phases of a 1,500 kcal/day dietary regimen and then were left on a 1,500 kcal/day diet for 2 years (VLCD group).  
30 patients received solely cognitive-behavioral therapy (Behavioral therapy) and 28 patients received both types of therapy (VLCD and behavioral therapy). It can be seen that the weight loss is higher in the latter group at 1, 2 and 3 years (red column).     
D Rigaud (personal results).