Contributing factors and clinical issues in obesity.

Overweight and obesity have become a national epidemic in which nearly 65 percent of the U.S. adult population is overweight or obese. (1) The current prominence that overweight and obesity receive as a national public-health issue requires a broad approach in raising public awareness and education; however, it is important to take a community approach when addressing this issue, vs. an individual approach that ultimately places the only responsibility for change with the overweight individual.

While overeating may be a compulsive behavior, it is only so when characterized by an inability to control how much and how often one eats. It is important when diagnosing an eating disorder, particularly compulsive overeating, that we distinguish between out-of-control behavior and poor lifestyle choices.

Overweight and obesity lead to a conservative 300,000 deaths annually (2) and place individuals at greater risk for diabetes, heart disease, hypertension, musculoskeletal conditions, stroke, some cancers and depression. The effects of overweight and obesity impact health care expenditures and productivity more than smoking and alcohol use do. (3) Employers recognize the importance of developing strategies to address the issue of obesity, whether through fitness centers, incentives, or creative benefit designs for health coaching and other wellness programs.

As organizations begin to offer such programs, it is important that it be done sensitively so as not to single out individuals because of their physical appearance. Overweight and obese individuals are viewed as lazy, incompetent, or personally flawed when in fact this is not true. They are the target of real or perceived discrimination, which serves to continue the cycle of stress, shame, guilt, depression and overeating.

Contributing factors

There are a number of factors that can contribute to an individual's obesity; however, there is no single understood cause. Research suggests that the most common causes may be environmental factors, genetic predisposition and learned behavior. No two individuals have the same life experiences, environmental influences, or genetic profile; so too there is no one factor that contributes to an individual being overweight.

Understanding contributing factors will assist in serving the needs of obese individuals as well as in prioritizing society's responsibility in addressing this issue. Factors include:

* Lifestyle influences -- How much a person eats and how much physical activity he or she engages in significantly affect weight. High-fat, high-calorie and convenience meals are often the norm for busy people. Lack of physical activity is all too common, according to the Centers for Disease Control and Prevention (CDC). (4)

* Psychological influences -- Guilt and out-of-control feelings commonly associated with overeating contribute to overindulgence to reduce the feeling of stress, shame and guilt. This creates a never-ending and dangerous cycle. Using food to solve personal problems or to fulfill other unmet emotional needs contributes to excessive overeating and obesity.

* Family influences -- Family learning also has a significant impact on eating behavior. Parents with poor eating, activity and coping habits teach their children the same behaviors.

* Genetic predisposition and medical conditions -- There is a genetic predisposition to obesity unrelated to the lifestyle environment. Medical conditions such as hypothyroidism, depression and certain neurological problems can interfere with the body's ability to maintain a healthy weight. (5)

* Unmanaged stress -- The release of stress-fighting hormones is inhibited by diets high in fats and non-complex carbohydrates. The body's attempt to self-regulate hormonal imbalances, created by stress, results in food cravings for high-fat, non-complex carbohydrate foods. Stress hormones maintain the stress response at a heightened level of alert, resulting in the formation of surplus fat cells, blood pressure elevation and salt retention when unmanaged stress persists.

* Cultural influences -- Food consumption is not simply a way for the body to obtain nutrition, but a way to nurture, celebrate and mourn. Unlike abstinence from alcohol or tobacco, abstinence from food is impossible.

* Age and gender influences -- Although weight gain is more prevalent in middle age for both men and women, it can occur at any age. Men tend to burn fat more easily with less physical activity than women, due to more lean muscle mass. For women, body fat levels, energy levels, and desire and craving for food are often determined by fluctuating female hormones.

* Income influences -- Less healthy foods and high-convenience fast foods can be purchased more economically than nourishing selections can.

Clinical considerations

Since the contributing factors associated with obesity are many, so too are the interventions to address this issue. Simply assuming that an obese individual only needs to change addictive or compulsive behavior associated with their eating negates the many other influences beyond the psychological factors.

When assessing the needs of an overweight individual, the following should be components of a therapist's or counselor's approach:

* A comprehensive diagnostic assessment with multiple screenings and preliminary identification of medical issues.

* Wellness education and prevention information on causes and resources to address obesity.

* Consultation, guidance and coaching to support the individual.

* Case management, including referral to other resources and follow-up.

* Development of a multidisciplinary network of referral sources.

The Stages of Change Model presented by prochaska and DiClemente (6) provides an adaptable framework of five stages (precontemplation, contemplation, preparation, action and maintenance) through which a participant passes in making a lifestyle change. In this framework, change is seen as a process in which an individual enters and exits a stage at any point, often returning to previous stages. This model has been proven effective in modifying lifestyle behaviors (7) and is recommended as part of a therapist's approach.

Counseling strategies in this model include:

* Assess the individual's stage of change. Administration of a decision balance scale can help determine the stage of change and the likelihood of the individual's making a change.

* Motivational interviewing, empathy, providing options and avoiding confrontation are preferred interview techniques.

* Make the individual aware of the consequences of the issue if left unaddressed, and offer the individual the opportunity to express feelings about the consequences. It is important to consider the impact of concerns about weight on the individual's physical and social environment. Focus attention on the individual's perception of self with and without the problems with weight.

* Address ambivalence and encourage the participant to identify the benefits of the change. Acknowledge the psychological aspects of overweight and obesity, including rejection of peers, possible discrimination, and feelings of failure, low self-esteem and depression.

* Verify commitment and plan with participants in the preparation stage. A self-efficacy questionnaire will identify the individual's assessment of his/her own ability to be successful and will allow the therapist and individual to create a plan to remove barriers to success.

* Provide positive feedback and encourage use of self-rewards for participants in the action and maintenance stages. This is critically important, no matter how small the change may be.

When the individual's ambivalence about making a change is addressed and the value the participant places on a changed behavior is greater than the value placed on existing behavior, change is more likely to occur. It is more important that the individual identify what he/she can change, and believe he/she can make a change, rather than the therapist's assessment of what can and cannot be accomplished. When the individual takes ownership of and feels confident with the change plan, success will occur.

References

(1) 2003 Chartbook on Trends in the Health of Americans, CDC National Center for Health Statistics 

(2) Actual Causes of Death in the United States, Journal of the American Medical Association, 1993

(3) The Effects of Obesity, Smoking, and Drinking on Medical Problems and Costs, Journal of Health Affairs, March/April 2002

(4) Understanding Adult Obesity, NIH Publication No. 01-3680

(5) Understanding Adult Obesity, NIH Publication No. 01-3680

(6) Prochaska, J.O., "Transtheoretical model: Stages of Change". Cancer Prevention Research Center, University of Rhode Island. http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm

(7) Velicer, W.F., Prochaska, J.O., Fava, J.L., Nornam, G.J. & Redding, C.A. "Smoking cessation and stress management: Applications of the Transtheoretical Model of behavior change." 1998. Homeostasis, 38, 216-233.

By Kathy Greco, LMSW, CEAP, and Rich Paul, MSW, CEAP

Kathy Greco is the director of Health and Performance Initiatives for managed behavioral health care company ValueOptions. She is responsible for account management and strategic implementation of new product development initiatives and services. She can be reached at [phone] or [e-mail]. Rich Paul is the vice president of Health and Performance Solutions within ValueOptions' Employer Solutions Division. He is responsible for oversight of EAP operations, product development and best practices supporting all workplace-based services and products. He can be reached at [phone] or [e-mail].