It is practically impossible these days to pick up a newspaper or magazine, turn on the television, or check Internet headlines without being hit with information on how to feed and take care of our bodies. We are barraged with results of studies advising us what foods to eat and avoid, flooded with cautions about the dangers of being overweight or obese, hounded to eat more nutritiously, and bombarded with suggestions on how to food shop, cook, and exercise for optimum health and longevity. Trying to keep abreast of the latest news on decreasing free radicals and increasing fiber, the benefits of organic foods, the hazards of pesticides, and the health claims of dark chocolate, green tea, and red wine sometimes seems like a full-time job.
Moreover, due to the nature of scientific study and the lag time between conclusions and publication and dissemination of results, it is not unusual for research that is true today to be proven false tomorrow. Nor is it uncommon for research projects to contradict and even disprove one another. Many studies are longitudinal and take decades to produce results, and often, conclusions must be replicated before they are considered valid. The most reliable and accurate studies are those that use a double-blind approach and are funded by independent, unbiased laboratories—not the citrus growers studying oranges or a pharmaceutical company researching weight-loss drugs. In fact, the most useful information generally comes from meta-analyses of numerous studies over time.
If mental health practitioners cannot keep up with all that is going on in allied health professions (including biochemistry, fitness, and nutrition), how can clients, many of whom are burdened with depression, anxiety, personality and psychotic disorders, and extraordinary stresses? Although we can try to be well informed, many of our clients are barely squeaking by financially, socially, or emotionally and have no time for or interest in following the latest news on health care. Often they rely on us, along with their doctors and other professionals, to tell them how to take care of their health. That makes it important for us to recognize in broad terms what promotes good health and what harms it, what clients can do to develop a healthier lifestyle and what is out of their control.
Because we must view an individual holistically, therapists can no longer treat only the mind and ignore the body. While we cannot be expected to know the ins and outs of nutrition (I don’t and I am in a closely associated field), it is reasonable to expect us to become acquainted with the basics of nutrition, the benefits of exercise, and the health risks of being over- and underweight. This is especially true now that we know beyond a shadow of a doubt that the foods we eat and the lifestyle choices we make have a huge impact on our moods, thinking, and behavior.
Educating clients about the risks of being over- and underweight and malnourished assists them in several ways. First, helping clients understand that they are at risk due to weight-related health problems may gently nudge them out of denying that dysfunctional eating has no negative consequences. It is our job to keep stoking the fires of discomfort so that they do not slip back into denial and forget that they are responsible for their actions. Second, talking about nutrition and malnutrition gives clients opportunities to make small decisions even when they are unwilling to completely overhaul their eating habits. They may seek a nutritional consult, begin taking vitamins, or have their cholesterol tested. Even small changes like these may start the ball rolling in the right direction.
Health Problems Related to Being
Underweight or Undernourished
Because a client is thin or underweight (or has a minimum BMI) does not indicate that he is either healthy or unhealthy. A slim client may have a tiny appetite, may eat only small amounts of nutritious foods, have a job that keeps him active, and/or exercise regularly. Or he may just be metabolically lucky! Neither he nor we can decide if he is of sound body unless he has regular checkups, including age-related screenings and blood work. A slender client who fails to exercise may or may not be healthier than one who exercises but remains overweight.
It can be difficult to assess current or future medical problems of clients who are underweight because so much of the health information we receive warns of obesity risks, with very little information (other than what we know about the dangers of anorexia and bulimia) pertaining to low weights. Moreover, a client who is underweight may not be anorexic and may wholeheartedly believe that keeping a low weight is what he is supposed to do to stay healthy. Because so many Americans carry around excess pounds, it makes sense that most medical warnings are geared to this population. Unfortunately, for those who intentionally seek ultraslimness, this message comes across in black and white as fat is unhealthy and thin is healthy, and clients who are underweight may not think of themselves as candidates for malnutrition or medical maladies.
Health problems of underweight clients vary according to the reason their weight is low. There is a world of difference between how we would treat a client who intentionally rigidly restricts her food intake in order to be pencil thin and another who remains underweight because she regularly runs late and skips breakfast, lives on coffee and cigarettes, or forgets to eat because she is too scattered and overwhelmed. We might consider the first client to have an eating problem, and the second to lack adequate self-care skills. However, both might have a BMI of 18.5 or lower, which is considered underweight and may endanger health.
While neither client might meet a diagnosis of anorexia nervosa—the refusal to maintain a minimum, healthy weight—both are putting their physical welfare in jeopardy by weighing too little. Health problems may include anemia, nutrient deficiencies, heart irregularities, delayed wound healing, loss of skin elasticity, diminished immune response, amenorrhea (loss of periods for women), bone loss and osteoporosis, decreased muscle strength, trouble regulating body temperature, difficulty fighting off infection and disease, and even increased risk of death (“Anorexia Nervosa,” Mayo Clinic Web site). Moreover, any client below minimum weight who fails to meet weight criteria for anorexia might still have serious psychopathology that compromises her health.
It is possible that the restrictive eater might eat more nutritiously than the “forgetful, scattered” one, so that even if she has a below-minimum BMI, she likely will be in better general physical shape because of higher-quality food choices. We need to take care not to focus only on a client’s weight as an indicator of ill health, but must look at what and how much she eats (and, of course, whether the food stays down) as well as the lifestyle choices she makes. It is crucial that we and the client know the cause of her being underweight, especially because conditions such as cancer, HIV, Crohn’s disease (a lifelong inflammatory bowel condition), and celiac disease (a condition in which the body’s immune system responds to gluten by damaging the lining of the small intestine) may cause initial weight loss (without other major symptoms) and lead to further medical problems.
To assess if the client might have a medical/health
problem causing low weight, ask:
1. Do you find that you eat a normal amount, even a lot, but are unable to maintain a healthy weight? How long has this been going on?
2. Have you considered that you may have an underlying medical condition that is keeping your weight low?
3. Does Crohn’s disease or celiac disease run in your family?
Health Problems Related to Being Overweight
Scientific literature typically describes a “J-shaped curve,” emphasizing that most mortality is associated with obesity rather than being underweight. However, there are recent challenges to these conclusions, such as: “Thus overweight status (BMI ≥25.0) was associated with longevity due to lower mortality from cardiovascular disease in very elderly subjects, whereas underweight was associated with short life due to higher mortality from cancer.” (“Overweight Associated with Longevity in an 80-year-old Community-based Population,” Metabolic Syndrome Institute Web site) and “In conclusion, overweight status in an 80-year-old population was found to be associated with longevity and underweight status with short life” (“Association Between Body Mass Index and Mortality in an 80-year-old Population,” Medscape Web site). It is surprising for most of us to learn that, in some cases, being overweight correlates with longevity and underweight with higher rates of mortality.
A more accurate assessment of weight risk may be found in a March 5, 2008, New York Times article: “The curve for risk, in terms of weight, is a bell-shaped curve. . . . There is an ideal weight, above and below which your risks increase. We know about the risks when you’re above. The problem is, we don’t know what the increased risk factors are with the other side. But the all-out result is that our longevity is reduced’’ (Blumenthal, 2007, 1). This quote tells us that we should be concerned about the risks of obesity, but that the subject is more complicated than we would like to think and that we should be very careful, as clinicians, not to pass on misinformation to clients.
Rather than lecture or use scare tactics with heavy clients, we are better off explaining that conclusions are confusing and contradictory and stating right off the bat how much we know about the subject. If we have limited knowledge, we need to say so. We also must make clients aware that doctors are not omniscient gods and that the subject of weight and appetite is enormously complicated and cannot be reduced to simplistic sound bites. Last, we must encourage clients to take responsibility for themselves by staying abreast of new information about weight, eating, nutrition, health, and longevity as best they can.
That said, the major medical consensus today is that being overweight or obese can lead to any number of serious conditions and diseases that may severely reduce the quality of life and decrease longevity. There is no end to the number of books, Web sites, study results, and articles warning about the dangers of unhealthy eating and carrying around excess pounds. For instance, according the the U.S. Department of Health and Human Services, “an estimated 300,000 deaths per year may be attributable to obesity, [. . .] the risk of death rises with increasing weight, [and] even moderate weight excess (10 to 20 pounds for a person of average height) increases the risk of death, particularly among adults aged 30 to 64 years, and [. . .] individuals who are obese (BMI > 30) have a 50 to 100% increased risk of premature death from all causes, compared to individuals with a healthy weight” (“Overweight and Obesity: Health Consequences,” U.S. Department of Health and Human Services Web site). This data is controversial, as several recent well-done studies suggest that being moderately overweight may not be associated with excess mortality.
The specific conditions and illnesses that are associated with being overweight include cardiovascular disease, diabetes, cancer, respiratory problems, musculoskeletal conditions such as arthritis and joint problems, reproductive complications, urinary problems, and metabolic syndrome.
Health Risks of Obesity versus
Risks of Weight-Loss Surgery
For some clients, the health risks of obesity and the difficulty of losing weight or maintaining a comfortable weight are so great that weight-loss surgery is recommended and undertaken. This decision should never be taken lightly and is an excellent topic to discuss in therapy. However, clients may be reluctant to bring up the issue for fear that the therapist will disapprove, judge them for “taking the easy way out,” or try to dissuade them from going ahead with it. Although it is not our job to know everything about weight-loss surgery, it is important that we know the basics (at least as much as the client knows!) in order to converse intelligently on the subject.
Weight-Loss Surgery
Several procedures fall under this umbrella and are designed to produce weight loss by limiting the amount of food that can be eaten or absorbed. Current National Institutes of Health guidelines state that these surgeries are appropriate for people whose BMI is 40 or greater (about 100 pounds overweight) or for those who have a BMI of 35 with two or more significant obesity-related problems. The Weight Center at Massachusetts General Hospital and Harvard Medical Center maintains that “the risk of death due to bariatric surgery is below 1%, with about 10% of patients experiencing complications” (Tsao, 2004).
Mortality and complication rates depend on the procedure: In several large studies, the mortality rate associated with bariatric surgery was 0.1% to 2.0%. In a meta-analysis by Buchwald et al., operative mortality rates were 0.5% for gastric bypass, 0.1% for gastric banding, and 1.1% for malabsorptive procedures. (Bushwald, Avidor, Braunwald, Jensen, Pories, Fahrbach, Schoelles, 2004). Nonfatal perioperative complications include venous thromboembolism, anastomotic leaks, wound infections, bleeding, incidental splenectomy, incisional and internal hernias, and early small-bowel obstruction. In the Swedish Obesity Subjects trial, postoperative complications occurred in 13% of patients (DeMaria, 2007).
Outcome studies on improved health due to these surgeries vary and most are conducted for a mere 2-year period. Some of the research that has been conducted has been funded by surgery centers or companies that have a stake in study results. Clearly more long-term, unbiased studies are needed to understand what results are lasting and what complications may arise down the road.
Reviewing 136 studies on the results of weight-loss surgery, researchers found that it “reversed diabetes in 77% of obese patients, eliminated high blood pressure in 62%, and lowered cholesterol in at least 70%” (Taso, 2004). One study of 20,000 obese people in the United States and Sweden showed that “those who underwent surgery had a 30 to 40 percent lower risk of dying over the next seven to 10 years than those who went without the operations” (Stein, 2007).
However, another study involving about 1,200 Swedish people, half of whom had stomach-reducing surgery, found that initial numbers for such measurements as blood pressure, cholesterol, and blood sugar were vastly improved postsurgery but “within two years after the operation, any beneficial blood pressure and cholesterol effects were gone.” Another study on postliposuction patients had similar conclusions (Kolata, 2007).
Gastric-Bypass Surgery and Gastroplasty
Bypass surgery, which is irreversible, reroutes the digestive system, which may lead to nutritional deficiencies that can cause severe health complications. Gastroplasty (“stomach stapling”) does not involve “rerouting” and it is also irreversible. The only reversible procedure thus far is gastric banding. Potential side effects include “dumping syndrome,” a combination of nausea, chest and abdominal cramps, sweating, and diarrhea, malabsorption of nutrients, vitamin deficiencies, and chronic abdominal pain. These symptoms are often avoided by eliminating foods that are high in sugar and fat from the diet. A rare, but possibly fatal, complication comes from leakage in the staple line.
Lap-Band
This procedure, which is reversible, creates a small pouch in the upper stomach that promotes feelings of fullness.
One obvious problem for the obese postsurgery is failure to engage in a more healthy lifestyle, which includes not only eating nutritiously and engaging in exercise, but reducing stress and getting sufficient sleep. Therapists treating clients who have had these surgeries need to help them monitor their health, especially in terms of negative surgical side effects. The medical community may want to play down these effects, fearing that too much discussion will drive patients away. However, clients need to be able to make informed decisions.
Although some clients go all out and make sufficient lifestyle changes to eat less and exercise more, many do not. They react similarly to those embarking on a diet—gung ho at the start followed by a decrease in motivation because modifying eating is so difficult. They may employ magical thinking along the lines of surgery “curing” their eating problems, or believe that they can continue to overeat or eat unhealthily because they have had the surgery. These clients require the same help and support that we give to people who have not had weight-loss surgery. Treatment needs to focus on why they make the food choices they do, ambivalence about weight reduction, and how to cope with difficult emotions without food.
Liposuction
Also known as lipoplasty, liposuction is a body-shaping cosmetic surgery that removes fat from different body sites, including the abdomen, arms, thighs, neck, backs of arms, calves, face, and buttocks. Complications include allergic reactions to medications or surgical materials, infection, skin damage, contour irregularities, embolisms, and fluid imbalance. The best candidates have average or slightly above-average weight, have firm and elastic skin, are in good general health, and have pockets of fat that do not respond to reduction through diet and/or exercise.
At the other end of the spectrum from clients who seek out doctors to alter their insides or outsides are those who hate going to the doctor and avoid doing so, even when they are sick or have health problems. They may be fearful of hearing bad news or have had previous negative experiences with the medical community. This is especially true of clients who are excessively under- or overweight and suffer body shame and fear of how the health workers will react to their body size. Clients who are above or below average weight often complain of being lectured, talked down to, humiliated, and blamed for their medical problems by doctors, nurses, dieticians, physical therapists, and other health practitioners. Although some clients may be especially sensitive to being judged and may overreact to even the slightest criticism, there is good reason to believe that health professionals and paraprofessionals treat them differently because of their size.
Specifically, clients describe the following kinds of interactions. At times when they seek medical help for a specific problem, the practitioner makes the visit about eating and weight. This is especially true if clients are morbidly obese or grossly underweight. Clients are often so uncomfortable during the visit that they leave without being examined or having their health questions addressed. Moreover, if they later become acutely ill, they are less inclined to seek medical help and end up putting themselves at risk.
Clients also report being shamed about being too large or too thin, sometimes directly and sometimes in thinly veiled remarks made by medical personnel. This shame goes deep, to the point that some over- or underweight clients never look at their bodies, or catch a glimpse of themselves in a mirror and are repulsed. Being weighed at the outset of a doctor’s visit is an extremely angst-ridden moment and some clients decline or refuse to step on the scale, only to be told that they must because it is “procedure.” Underweight clients often prefer to be examined wearing at least some of their clothes because of their extreme discomfort being naked.
As clinicians, we may say that it is the client’s shame that we need to deal with and that she need not feel it. Although this is partially true, it is also important for the health community to make facility visits (in the office, clinic, laboratory, and hospital) as comfortable as possible for all their patients and prioritize concerns such as whether it is more important to hear what a patient has to say and examine them or to weigh them. Generally, it is possible for medical staff to work around these issues, and their efforts go a long way toward helping over- or underweight clients become more at ease in these settings, which, in turn, encourages them to seek medical care when needed.
Overweight clients frequently describe being lectured about obesity, then given a diet plan to follow or a referral to a weight-loss program like Weight Watchers or Overeaters Anonymous to which they are encouraged to go. Although there may be some discussion about stressors in a patient’s life causing overeating, she is not generally given a referral to a psychotherapist to help her cope more effectively. Underweight clients may even find themselves pushed toward eating disorder clinics and rehabilitation centers to force them to gain weight, and describe times when doctors refuse to treat them unless they comply. On the other hand, because anorexia nervosa is characterized by a high degree of denial, many clients who claim that they are naturally thin may have serious eating problems.
To assess the client’s feelings
about the medical/health profession, ask:
1. What are your general experiences with doctors and health practitioners?
2. What are your specific experiences with them regarding your weight or eating?
3. How concerned are you about the health risks of overeating/being overweight or undereating/being underweight?
4. What would make you more inclined to seek medical help (for instance, changing doctors, having a friend come along to appointments, preparing more for doctors’ visits in therapy)?
5. How can I help make your experiences with the medical community go more smoothly?
Undoubtedly, most medical professionals are concerned about their patients’ health and well-being. It is easy to understand how they come to feel helpless (as we often do) when they fail to see underfed patients gain weight or overweight ones lose it. It is not hard to appreciate their frustration when patients fall into denying, ignoring, or minimizing weight problems or become defensive as soon as the subject is raised. Practitioners know the life-threatening health risks for both populations and may see their patients as ticking time bombs. Believing that they have little or no impact on patients, they may give up or heavy-handedly pressure them to achieve or maintain a healthy weight. Many practitioners, unfortunately, fail to realize that building rapport with patients and creating a climate of trust, understanding, support, and good will goes a long way toward helping them share concerns and change behavior.