Case Scenario

For more than 10 years, I have been caring for a patient who is obese. Despite my counseling efforts, the patient has gained 200 lb (91 kg) during this time and now weighs 450 lb (204 kg). He shows no interest in losing weight, and I suspect secondary gain. From early childhood, he has had to care for his mother, who has been immobilized because of her obesity. His indifference to my counseling attempts has led me to think he wants to be disabled, too. Perhaps he hopes that someone will take care of him as he has taken care of his mother. There is no way for me to introduce this idea directly to my patient. He has no insight into his situation. Even if I cannot impact his obesity, is there another way that I can help him? Is psychotherapy helpful for patients who are obese?

Commentary

Assuming that medical causes of weight gain (e.g., hypothyroidism, hypercortisolism) have been ruled out, the physician should consider social, psychological, and environmental factors that may explain the patient’s weight gain and his apparent indifference. First, it is important to know what treatments and counseling the patient has been offered for weight management. The National Heart, Lung, and Blood Institute guideline¹ for the evaluation and treatment of obesity recommends that patients be provided with a comprehensive lifestyle program including dietary therapy, counseling to increase physical activity, and a behavior modification plan.

Physicians often are too busy to provide the recommended care themselves and are not reimbursed for doing so. However, it is their responsibility to refer patients to facilities (e.g., commercial programs, specialty weight loss clinics affiliated with hospitals or academic medical centers, community centers, public health clinics) that can provide this treatment. Although modest, the weight loss associated with these treatments is clinically significant and superior to self-help programs or minimal care.^2,3 We recognize that comprehensive weight loss treatment, which usually is not covered by health insurance, may not be accessible to some patients; however, there are low-cost options available. For example, TOPS (Take Off Pounds Sensibly;http://www.tops.org) is a nonprofit program that offers group counseling for a small annual fee.⁴

Whether there is underlying psychopathology that would explain this patient’s weight gain and demeanor is an important question. If the patient indeed wants to become sick enough to require constant care or assistance with activities of daily living, and if the patient’s secondary gain is not obvious to him, then factitious disorder (i.e., the feigning of symptoms or signs of illness or the self-infliction of true disease with the intent of assuming the sick role) should be considered. However, other less pathologic alternatives should be considered before the patient is diagnosed with factitious disorder. It is possible that what seems like indifference actually is helplessness.

Most patients who are extremely obese have made several previous weight loss attempts without long-term success. Therefore, they may believe that additional efforts are futile. The patient in the scenario also may hold one of several other erroneous beliefs that would inhibit weight loss: (1) weight is primarily a cosmetic issue, and because appearance is not a concern, there is no reason to lose weight; (2) weight is fully determined by genetic factors, and attempts to lose weight are as useless as attempts to grow taller; or (3) ideal weight must be achieved to derive health benefit; therefore, modest weight loss is not valuable.

Many persons who are obese report feeling that their physicians do not believe or understand them.⁵ Although this perception may be caused by patients’ psychological characteristics, patients are sometimes responding to how their physicians communicate with them. Research has shown that persons who are obese prefer that their physicians use the objective term “weight” when discussing their health, although other terms (e.g., weight problem, body mass index, excess weight) are acceptable.⁶ The terms “excess body fat” and “obesity” are considered offensive by many patients.⁶ Additionally, a lose-weight-or-else approach, although motivating for some patients, may be paralyzing for others. The message simply to “eat less and exercise more” is potentially insulting, because it implies that this task, with which the patient may have struggled for years, is an easy one to accomplish.

We recommend that physicians educate their patients about the relationship between excess weight and health and then ask for patients’ thoughts on the issue. This approach can facilitate a discussion (not a lecture) on the benefits of losing weight and is consistent with the principles of motivational interviewing.⁷ Motivational interviewing is a means of helping patients discover and resolve the discrepancies between their current behavior (e.g., eating fast food several times per week) and their long-term goals (e.g., improve mobility and increase longevity).⁷

An acceptable, less time-consuming alternative to motivational interviewing is explaining to the patient the association between weight and medical comorbidity and then positively phrasing a recommendation for weight loss: “Losing 10 percent of your current weight would improve your blood pressure” as opposed to, “If you don’t lose weight, you will eventually develop congestive heart failure.”

We caution physicians against assuming that obesity is caused by a psychiatric disorder or dysfunctional unconscious motivations. There is no consistent evidence to suggest that any such relationships exist. Although large studies have shown an association between morbid obesity and depression, research has not determined whether obesity causes depression, depression causes obesity, or other factors are primary to both conditions.⁸

If alternative explanations have been ruled out and psychopathology is suspected, the next step is consultation with a psychiatrist or psychologist. Major depression, for instance, can be treated with psychotherapy with or without medication, and treatment for this disorder may allow the patient to better manage his weight. If the diagnosis is factitious disorder or a personality disorder, treatment will be challenging. If there is no psychiatric diagnosis, referral to a comprehensive weight management program that includes behavior modification is appropriate.

Behavior modification is considered an important component of weight loss therapy¹ and consists of training in goal-setting, self-monitoring, stimulus control, problem solving, coping skills for social occasions and eating outside of the home, and relapse prevention.⁹ Patients participating in behavior modification programs lose approximately 9 percent of their initial weight during the active phase of treatment.¹⁰ A randomized trial¹¹ demonstrated that 40 weeks of behavior therapy plus sibutramine (Meridia) facilitated a weight loss of 26 lb 11 oz (12.1 kg) at one year compared with 11 lb (5.0 kg) for sibutramine alone and 14 lb 13 oz (6.7 kg) for behavior therapy alone.¹¹

Specific to the patient in the scenario, the physician has taken the first step by advising the patient multiple times to lose weight. However, the physician has been unable to help him lose weight. Referral to a psychiatrist or psychologist should help to clarify the patient’s psychiatric diagnosis (if any) and to direct the patient toward appropriate treatment. We hope that all physicians are able to develop a systems-based approach to help their patients with weight management.