HANDBOOK OF PSYCHOLOGY - PART 3 pptx

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PERRI 121 CLASSIFICATION OF OBESITY 121 “Ideal Weight” 122 Body Mass Index 122 The WHO Classification System 122 Measurement of Abdominal Fat 123 EPIDEMIOLOGY OF OBESITY 123 CONSEQUENCES OF OBESITY 124 Impact on Morbidity 124 Impact on Mortality 125 Psychosocial Consequences 125 Economic Costs of Obesity 125 CONTRIBUTORS TO OBESITY 126 Genetic Contributors 126 Environmental Contributors 126 TREATMENT OF OBESITY 128 Lifestyle Interventions 128 Pharmacotherapy 129 Bariatric Surgery 130 STRATEGIES TO IMPROVE LONG-TERM OUTCOME 131 Very Low-Calorie Diets 131 Extended Treatment 132 Relapse Prevention Training 133 Telephone Prompts 133 Food Provision/Monetary Incentives 133 Peer Support 133 Exercise/Physical Activity 134 Multicomponent Posttreatment Programs 135 Summary 135 FUTURE RESEARCH DIRECTIONS 135 Address Unrealistic Weight-Loss Expectations 135 Match Treatments to Clients 136 Test Innovative Models 136 Examine Schedules of Follow-Up Care 136 IMPROVING THE MANAGEMENT AND PREVENTION OF OBESITY 136 Managing Obesity 136 Prevention of Obesity 137 CONCLUSION 138 REFERENCES 138 Over the past two decades, the prevalence of overweight and obesity in the United States has increased dramatically (Flegal, Carroll, Kuczmarski, & Johnson, 1998). More than half of all Americans are now overweight or obese (Mokdad et al., 1999), and the trend toward increasing prevalence has not abated (Mokdad et al., 2000). Concern about this epidemiclike trend stems from an overwhelming body of evidence demonstrating the negative health consequences associated with increased body weight. Being overweight or obese substantially raises the risk for a variety of illnesses, and excess weight is associated with increased all-cause mortality (Pi-Sunyer, 1999). Consequently, millions of Americans stand poised to develop weight-related illnesses such as cardiovascular disease, hypertension, diabetes melli- tus, and osteoarthritis. As the second leading contributor to preventable death in the United States (McGinnis & Foege, 1993), obesity constitutes a major threat to public health and a signi“cant challenge to health care professionals. In this chapter, we provide a review of research related to understanding and managing obesity. We begin with the as- sessment and classi“cation of obesity, andwe describethe epi- demiology of bodyweight inthe United States.We summarize the physical, psychosocial, and economic consequences asso- ciated with excess body weight, and we examine prominent biological and environmental contributors to obesity. Next we describe current treatments of obesity, including behav- ioral (lifestyle) interventions, pharmacotherapy, and bariatric surgery; we give special attention to what may be the most problematic aspect of obesity treatment, the maintenance of lost weight. We conclude our review by discussing recom- mendations for the management and prevention of obesity. CLASSIFICATION OF OBESITY Obesity is de“ned as an excessive accumulation of body fat„excessive to the extent that it is associated with negative 122 Obesity health consequences. An individual is considered obese when body fat content equals or exceeds 30% to 35% in women or 20% to 25% in men (Lohman, 2002). However, this decep- tively simple de“nition obscures the complexities involved in the measurement and classi“cation of body composition. Direct measurement of body fat can be accomplished through a variety of methods, including hydrostatic (underwater) weighing, skinfold measurement, bioelectrical impedance, dual energy x-ray absorptiometry (DEXA), and computer- ized tomography (CT). Direct measurement is typically either expensive (as is the case with DEXA and CT) or inconvenient (as is the case with hydrostatic weighing and skinfold measures). Consequently, for practical purposes, overweight and obesity often have been de“ned in terms of the relation of body weight to height. “Ideal” Weight Actuarial data from insurance companies have provided tables of •idealŽ weights for mortality rates (Metropolitan Life Insurance Company, 1983). For many years, 20% or more over ideal weight for height was commonly used as the de“nition of obesity (National Institutes of Health [NIH] Consensus Development Panel on the Health Implications of Obesity, 1985). In recent years, however, the limitations of this approach have become increasingly apparent. For exam- ple, insurance company data are not representative of the U.S. population, particularly for women and minorities (Foreyt, 1987). In addition, alternative weight-to-height indices have shown greater correspondence to direct mea- sures of body fat and to the negative health consequences of obesity (L. Sjöstrom, Narbro, & Sjöstrom, 1995). Body Mass Index Body Mass Index (BMI), also known as Quetelet•s Index, is an alternative weight-to-height ratio that has gained general acceptance as the preferred method for gauging overweight. BMI is calculated by dividing weight in kilograms by the square of height in meters (kg/m 2 ). BMI can also be calcu- lated without metric conversions by use of the following formula: pounds/inches 2 ϫ 704.5. BMI is not encumbered by the problems inherent in de“ning •ideal weight,Žand it corre- sponds more closely to direct measures of body fat than alternative weight-to-height ratios (Keys, Fidanza, Karvonen, Kimura, & Taylor, 1972; L. Sjöstrom et al., 1995). While BMI provides an •acceptable approximation of total body fat for the majority of patientsŽ (National Heart, Lung, and Blood Institute [NHLBI], 1998 p. xix), it does not discriminate between weight associated with fat versus weight associated with muscle. For example, an athlete may have a high BMI as a result of the higher body weight associ- ated with greater levels of muscle mass rather than excess fat. In addition, because one can be overfat, even in the context of a healthy BMI, other measures such as waist measurement should be used concurrently for a comprehensive assessment of a person•s •risk due to weightŽ status. Table 6.1 presents body weights (in pounds) by height (in inches) that correspond to BMI values of 18.5, 25, 30, 35, and 40. These selected values correspond to the various cut points used by the World Health Organization (WHO) system to cat- egorize overweight and obesity. The WHO Classification System The WHO (1998) has developed a graded classi“cation sys- tem for categorizing overweight and obesity in adults accord- ing to BMI. In the WHO system, overweight is de“ned as a BMI Ն 25, and obesity is de“ned as a BMI Ն 30. The WHO system, which has also been accepted by NIH (NHLBI, 1998), employs six categories based on the known risk of co- morbid conditions associated with different BMI levels (see Table 6.2). For example, the risk of comorbid conditions is considered •averageŽ in the normal weight category and •very severeŽ in the obese class III category. Thus, the WHO classi“cation system facilitates the identi“cation of individu- als and groups at increased risk of morbidity and mortality, and it allows for meaningful comparisons of weight status within and between populations. TABLE 6.1 Body Mass Index Body Mass Index 18.5 25 30 35 40 Height Body Weight 58 89 119 143 167 191 59 92 124 149 174 198 60 95 128 153 179 204 61 99 132 158 185 211 62 100 136 164 191 218 63 104 141 169 197 225 64 108 145 174 204 232 65 111 150 180 210 240 66 115 155 186 216 247 67 118 159 191 223 255 68 122 164 197 230 262 69 125 169 203 236 270 70 130 174 207 243 278 71 133 179 215 250 286 72 136 184 221 258 294 73 139 189 227 265 302 74 144 195 234 273 312 Epidemiology of Obesity 123 TABLE 6.2 World Health Organization Classification of Overweight According to BMI and Risk of Comorbidities Category BMI (kg/m 2 ) Disease Risk Underweight Ͻ18.5 Low* Normal weight 18.5…24.9 Average Overweight Ն25.0 Pre-obese 25.0…29.9 Increased Obese Class I 30.0…34.9 Moderate Obese Class II 35.0…39.9 Severe Obesity Class III Ն40.0 Very severe *There is an increased risk of other clinical problems (e.g., anorexia nervosa). Measurement of Abdominal Fat The health risks associated with obesity vary signi“cantly ac- cording to the distribution of body fat (WHO, 1998). Upper body (abdominal) fatness is more closely associated with ab- normalities of blood pressure, glucose tolerance, and serum cholesterol levels than is lower body obesity (Pouliot et al., 1994). Consequently, individuals with abdominal obesity incur increased risk for heart disease and for type 2 diabetes mellitus. Because abdominal fatness can vary substantially within a narrow range of BMI, it is important in clinical set- tings to include a measure of abdominal obesity (James, 1996). For example, the waist-hip ratio (WHR) represents one method of identifying individuals with potentially health-compromising abdominal fat accumulation. A high WHR (de“ned as Ͼ1.0 in men and Ͼ.85 in women) re”ects increased risk for obesity-related diseases (James, 1996). Evidence, however, suggests that a simple measure of waist circumference may provide a better indicator of abdominal adiposity and the likelihood of detrimental health conse- quences than does the WHR (James, 1996; Thomas, 1995). A waist circumference measurement greater than 40 inches in men and greater than 35 inches in women confers increased risk for morbidity and mortality (James, 1996; NHLBI, 1998; Pouliot et al., 1994). EPIDEMIOLOGY OF OBESITY Data from recent population surveys (Flegal et al., 1998; Kuczmarski, Carrol, Flegal, & Troiano, 1997) indicate that 19.9% of the men and 24.9% of the women in the United States are obese (i.e., BMI Ͼ 30). An additional 39.4% of men and 24.7% of women are overweight (i.e., BMI of 25.0 to 29.9). Collectively, the data show that the majority (54.9%) of adults in the United States, approximately 97 million peo- ple between the ages of 20 to 74, are overweight or obese. The rates of obesity are highest among African American women (37.4%) and MexicanAmerican women (34.2%), and additional percentages of each of these groups (29.1% and 33.4%, respectively) are overweight (Flegal et al., 1998). Table 6.3 presents the current prevalence rates of overweight and obesity by gender and by race/ethnicity. Socioeconomic and age-related differences in obesity rates are also evident in the population surveys. Women with lower income or lower levels of education are more likely to be obese than those of higher socioeconomic status, and obe- sity rates generally increase with age across all groups. Cur- rent rates of obesity by age group for men and women are shown in Figure 6.1. Note that the obesity prevalence peaks at ages 50 to 59 for both men and women. Dating back to 1960, national surveys have assessed height and weight in large representative samples of the U.S. population. These data, from the National Health Examination Survey (NHES; Kuczmarski, Flegal, Camp- bell, & Johnson, 1994) and the National Health and TABLE 6.3 Prevalence of Overweight and Obesity by Gender and Race/Ethnicity BMI (Weight Category) Ն25.0 25.0…29.9 Ն30.0 (Overweight or (Overweight) (Obese) Obese) Gender, Race/Ethnicity % % % Women White 23.1 22.4 45.5 African American 29.1 37.4 66.5 Mexican American 33.4 34.2 67.6 All 24.7 24.9 49.6 Men White 39.6 20.0 59.6 African American 36.2 21.3 57.5 Mexican American 44.0 23.1 67.1 All 39.4 19.9 59.3 Source: Data from NHANES III (Flegal et al., 1998). 20–29 30–39 40–49 50–59 60–69 Figure 6.1 Current prevalence of obesity (BMI Ն 30) in United States. Source: Data from NHANES III; Flegal et al., 1998. 124 Obesity Nutrition Examination Surveys I, II, III (NHANES I-III; Flegal et al., 1998; Kuczmarski et al., 1994) allow a com- prehensive examination of the changing rates of overweight and obesity over the past four decades. NHES evaluated data collected from 1960 to 1962 and reported an over- weight prevalence of 43.3% in adults. Nearly a decade later, the data from NHANES I, conducted in 1971 to 1974, indicated an overall prevalence of 46.1%, a level which re- mained relatively constant during the next decade, as re- ”ected in the 46.0% prevalence observed in NHANES II, conducted in 1976 to 1980. However, the results of NHANES III, conducted in 1988 to 1994, revealed an alarming increase in the prevalence of overweight individu- als to 54.9%. Particularly disturbing were the rates of obe- sity (BMI Ͼ 30), which increased 10% among women and 8% among men during the 14 years between NHANES II- III (Leigh, Fries, & Hubert, 1992). Figure 6.2 presents the prevalence rates of obesity from the four population surveys conducted between 1960 and 1994. CONSEQUENCES OF OBESITY Impact on Morbidity Obesity has a substantial adverse impact on health via its as- sociation with a number of serious illnesses and risk factors for disease. Obesity-related conditions include hypertension, dyslipidemia, type 2 diabetes mellitus, coronary heart disease (CHD), stroke, gallbladder disease, osteoarthritis, sleep apnea, respiratory problems, and cancers of the endometrium, breast, prostate and colon. Some of the more prominent comorbidities of obesity are described next. Hypertension. The prevalence of high blood pressure in adults is twice as high for individuals with BMI Ͼ 30 than for those with normal weight (Dyer & Elliott, 1989; Pi-Sunyer, 1999). Mechanisms for increased blood pres- sure appear to be related to increases in blood volume, vascular resistance, and cardiac output. Hypertension is a risk factor for both CHD and stroke (Havlik, Hubert, Fabsitz, & Feinleib, 1983). Dyslipidemia. Obesity is associated with lipid pro- “les that increase risk for CHD, including elevated levels of total cholesterol, triglycerides, and low-density lipopro- tein (•badŽ) cholesterol, as well as low levels of high- density lipoprotein (•goodŽ) cholesterol (Allison & Saunders, 2000). Type 2 Diabetes Mellitus. Data from international studies consistently show that obesity is a robust predictor of the development of diabetes (Folsom et al., 2000; Hodge, Dowse, Zimmet, & Collins, 1995; NHLBI, 1998). A 14- yearprospective study concluded that obese women were at 40 times greater risk for developing diabetes than normal- weight, age-matched counterparts (Colditz et al., 1990). Current estimates suggest that 27% of new cases of type 2 diabetes are attributable to weight gain of 5 kg or more in adulthood (Ford, Williamson, & Liu, 1997). Moreover, ab- dominal obesity is a speci“c majorrisk factor fortype 2 dia- betes (Chan, Rimm, Colditz, Stampfer, & Willett, 1994). Coronary Heart Disease. Overweight, obesity, and ab- dominal adiposity are associated with increased morbidity and mortality due to CHD. These conditions are directly related to elevated levels of cholesterol, blood pressure, and insulin, all of which are speci“c risk factors for car- diovascular disease. Recent studies suggest that, com- pared to a BMI in the normal range, the relative risk for CHD is twice as high at a BMI of 25 to 29, and three times as high for BMI Ͼ 29 (Willett et al., 1995). Moreover, a weight gain of 5 to 8 kg increases CHD risk by 25% (NHLBI, 1998; Willett et al., 1995). Stroke. The Framingham Heart Study (Hubert, Feinleib, McNamara, & Castelli, 1983) suggested that overweight may contribute to stroke risk, independent of hypertension and diabetes. Later research established that the relation- ship between obesity and stroke is clearer for ischemic stroke versus hemorrhagic stroke (Rexrode et al., 1997). Recent prospective studies show a graduated increase in risk for ischemic stroke with increasing BMI (i.e., risk is Figure 6.2 Prevalence of obesity (BMI Ն 30) in United States. Source: Data from NHANES I, II, and III; Flegal et al., 1998. NHES I (1960–1962) NHANES I (1971–1974) NHANES II (1976–1980) NHANES III (1988–1994) Percent Men Women Consequences of Obesity 125 75% higher with BMIs Ͼ 27; 137% higher with BMIs Ͼ 32) (Rexrode et al., 1997). Gallstones. Obesity is a risk factor across both age and ethnicity for gallbladder disease. The risk of gallstones is 4 to 6 times higher for women with BMIs Ͼ 40 compared to women with BMIs Ͻ 24 (Stampfer, Maclure, Colditz, Manson, & Willett, 1992). Sleep Apnea. Sleep apnea is a serious and potentially life- threatening breathing disorder, characterized by repeated arousal from sleep due to temporary cessation of breath- ing. Both the presence and severity of sleep apnea, is associated with obesity, and sleep apnea occurs dispropor- tionately in people with BMIs Ͼ 30 (Loube, Loube, & Miller, 1994). Large neck circumference (Ն 17 inches in men and Ն 16 inches in women) is highly predictive of sleep apnea (Davies & Stradling, 1990). Women’s Reproductive Health. Menstrual irregularity and amenorrhea are observed with greater frequency in over- weight and obese women (Hartz, Barboriak, Wong, Kata- yama, & Rimm, 1979). Polycystic ovary syndrome, which often includes infertility, menstrual disturbances, hir- sutism, and anovulation, is associated with abdominal obesity, hyperinsulinemia, and insulin resistance (Dunaif, 1992; Goudas & Dumesic, 1997). Impact on Mortality Not only does obesity aggravate the onset and progression of some illnesses,it alsoshortens life(Allison, Fontaine,Man- son, Stevens, & Van Itallie, 1999). Studies show that all-cause mortality ratesincrease by 50% to 100% when BMI is equal to or greater than 30 as compared with BMIs in the normal range (Troiano, Frongillo, Sobal, & Levitsky, 1996). Indeed, more than 300,000 deaths per year in the United States are attribut- able to obesity-related causes (Allison et al., 1999). Psychosocial Consequences Many obese people experience social discrimination and psychological distress as a consequence of their weight. The social consequences associated with obesity include bias, stigmatization, and discrimination„consequences that can be highly detrimental to psychological well-being (Stunkard & Sobal, 1995). Social bias results from the widespread, but mistaken, belief that overweight people lack self-control. Negative attitudes toward obese people, which are pervasive in our society, have been reported in children as well as adults, in health care professionals as well as the general pub- lic, and in overweight individuals themselves (Crandall & Biernat, 1990; Rand & Macgregor, 1990). An obese person is less likely to get into a prestigious college, to get a job, to marry, and to be treated respectfully by a physician than is his or her nonobese counterpart (Gortmaker, Must, Perrin, Sobol, & Dietz, 1993; Pingitore, Dugoni, Tindale, & Spring, 1994). Indeed, obesity may well be the last socially acceptable object of prejudice and discrimination in our country. Despite the negative social consequences of overweight, most early studies have reported similar rates of psy- chopathology in obese and nonobese individuals. However, these studies suffered from a number of limitations, for exam- ple, failing to account for gender effects (Wadden, Womble, Stunkard, & Anderson, 2002). More recent studies have at- tempted to rectify this.Alarge-scale, general population study (Carpenter, Hasin, Allison, & Faith, 2000) recently showed that obesity was associated with a 37% greater risk of major depressive disorder, as well as increased suicidal ideation and suicide attempts among women but interestingly, not among men, for whom obesity was associated with a reduced risk of major depression. A consistent “nding is the higher levels of body image dissatisfaction that are widely reported by obese individuals. Body image dissatisfaction is particularly ele- vated in women with higher socioeconomic status, those who were overweight as children, and bingeeaters (French, Jeffery, Sherwood, & Neumark-Sztainer, 1999; Grilo, Wil”ey, Brownell, & Rodin,1994). In contrast,members ofcertain mi- nority groups, particularly, Hispanic and African Americans, are less likely to display disparaging attitudes toward obesity in either themselves or others (Crandall & Martinez, 1996; Kumanyika, 1987; Rucker & Cash, 1992). In fact, Black women often ascribe positive attributes such as stamina and authority to being large (Rosen & Gross, 1987). In contrast to studies of obese persons in the general pop- ulation, research on psychological disturbance in people pre- senting for treatment at obesity clinics shows a clear pattern of results. Obese help-seekers display higher rates of psycho- logical distress and binge eating when compared to normal- weight individuals and to obese persons who are not seeking help (Fitzgibbon, Stolley, & Kirschenbaum, 1993; Spitzer et al., 1993). Economic Costs of Obesity The economic impact of obesity is enormous. In 1995, the total costs attributable to obesity amounted to $99.2 billion (Wolf & Colditz, 1998). This total can be further viewed in terms of direct and indirect costs. Direct costs (i.e., dollars expended in medical care due to obesity) amount to approxi- mately $51.6 billion and represent 5.7% of national health [...]... Association, 282, 1 530 …1 538 Allison, D B., & Saunders, S E (2000) Obesity in North America: An overview Medical Clinics of North America, 84, 30 5 33 2 Apfelbaum, M., Vague, P., Ziegler, O., Hanotin, C., Thomas, F., & Leutenegger, E (1999) Long term maintenance of weight loss after a very-low-calorie-diet: A randomized blinded trial of the ef“cacy and tolerability of sibutramine American Journal of Medicine,... (NHLBI, 1998; Pi-Sunyer, 1999) Thus, lifestyle interventions are recommended as the “rst-line of professional intervention in a stepped-care approach to the management of overweight and obesity (NHLBI, 1998) The long-term effectiveness of lifestyle interventions has remained an area of considerable concern During the year following behavioral treatment, participants typically regain 30 % to 40% of their lost... extended contact) in three of the studies permits a rough comparison of the groups with and without extended treatment (see Figure 6.2) The groups without extended contact maintained about two-thirds (66.5%) of their initial weight reductions Judging the effects of the extended-treatments by comparison with the Strategies to Improve Long-Term Outcome 133 Telephone Prompts Figure 6 .3 Long-term weight losses... comprehensive handbook (pp 510…515) New York: Guilford Press Kramer, F M., Jeffery, R W., Forster, J L., & Snell, M K (1989) Long-term follow-up of behavioral treatment for obesity: 142 Obesity Patterns of weight gain among men and women International Journal of Obesity, 13, 124… 136 Krosnick, A (2000) The diabetes and obesity epidemic among the Pima Indians New England Journal of Medicine, 97(8), 31 37 Kuczmarski,... Nezu, A M (1988) Effects of four maintenance programs on the long-term management of obesity Journal of Consulting and Clinical Psychology, 56, 529… 534 Perri, M G., Nezu, A M., McKelvey, W F., Shermer, R L., Renjilian, D A., & Viegener, B J (2001) Relapse prevention training and problem-solving therapy in the long-term management of obesity Journal of Consulting and Clinical Psychology, 69, 722…726... means of long-term care Wing, Jeffery, Hellerstedt, and Burton (1996) examined the impact of weekly posttreatment calls designed to prompt self-monitoring of body weight and food intake The interviewers, who were not the participants•therapists, offered no counseling or guidance Participation in the telephone contacts was associated with better long-term outcome, but it did not enhance maintenance of. .. the addition of exercise or physical activity can improve long-term outcome in the treatment of obesity (Garrow, 1995) Wing (1999) recently reviewed the results of randomized controlled trials of exercise in the treatment of obesity Wing found that only 2 of 13 studies showed signi“cantly greater initial weight losses for the combination of diet plus exercise versus diet alone, and only 2 of 6 studies... posttreatment programs The components of exercise-focused program included supervised exercise, incentives for exercise completion, and relapse prevention training aimed at the maintenance of exercise The weight-focused maintenance program included problem solving of barriers to weight-loss progress The results of a longterm follow-up showed that participants in the weight-focused program had signi“cantly... changes in risk factors for disease and improvements in quality of life (Atkinson, 19 93) represent important indicators of success Improvements in the quality of diet should be a component of care independent of whether weight reduction is an identi“ed objective of care (Hill, Drougas, & Peters, 19 93) Reductions in amounts of dietary fats, particularly saturated fats, can improve health as well as assist... Treatment of Obesity may represent relatively favorable outcomes In addition, mean weight changes provide only a partial view of longterm outcome A fuller perspective may be gleaned from an examination of categories of partial success For example, Kramer, Jeffery, Forster, and Snell (1989) reported an overall mean weight loss of 2.7 kg at 4.5-year follow-up However, an analysis by categories of relative . 191 2 23 255 68 122 164 197 230 262 69 125 169 2 03 236 270 70 130 174 207 2 43 278 71 133 179 215 250 286 72 136 184 221 258 294 73 139 189 227 265 30 2 74 144 195 234 2 73 312 Epidemiology of Obesity. Prevention Training 133 Telephone Prompts 133 Food Provision/Monetary Incentives 133 Peer Support 133 Exercise/Physical Activity 134 Multicomponent Posttreatment Programs 135 Summary 135 FUTURE RESEARCH. about two-thirds (66.5%) of their initial weight reductions. Judging the ef- fects of the extended-treatments by comparison with the Strategies to Improve Long-Term Outcome 133 Figure 6 .3 Long-term