MIND OVER BODY MASS
Musings on Non-Medical Aspects of
Weight and Well-Being
John T. Chibnall, PhD
Department of Psychiatry
Saint Louis University School of Medicine
The Medicalization of Obesity
“Medicalization”
…the process by which a “way of being”
is transformed into an “illness” and put
under the auspices of medicine
Unfortunately…
“Ways of being” that are typically medicalized
are those that conflict with the “highest” values
of a society. Ours:
Health
‰ Beauty
‰ Non-Deviance
‰
Recent Examples:
Smoking (health)
‰ Drug use (health/deviance)
‰ “ADHD” (health/deviance)
‰ Poverty (deviance)
‰ Homosexuality (deviance)
‰
and…
‰
Obesity/Overweight (health/beauty/deviance)
UNFORTUNATELY…
Medicalization retains the taint of
“moral depravity” connected to these
“ways of being,” but removes the guilt
(“medicine is science, and these poor
people are sick”)….
Recent NON-Examples:
‰
Underweight (…looks “healthy,” doesn’t it?)
‰
Overwork / Hard driving (good for business…)
‰
Cosmetic surgery (…looks good, doesn’t it?)
‰
Driving a car (everybody does it… but it’s far
and away the leading cause of accidental death)
‰
Gun ownership (protection from deviants…
but it’s in the top 10 causes of accidental death)
‰
Getting medical care (for health… but it’s the
3rd leading cause of death in America… the
Medical Errors Syndrome??)
All of these have direct or indirect negative
health effects…
So, why aren’t they “illnesses”?
Because they are CONSISTENT with the
society’s “highest” values…
Bottom Line… DON’T BUY IT:
‰
Being overweight is NOT an illness
‰
Being overweight is NOT a sin
‰
Being overweight is NOT immoral
‰
Being overweight is NOT deviant
THIS is what it is…
Obesity
Illness
Psych
Distress
In our society, obesity makes people…
Depressed
‰ Anxious
‰ Low in self-esteem
‰ Less outgoing / More socially isolated
‰ Negative in body image
‰ Less satisfied with sex
‰
BOTH because they are more ill/disabled and
because of medical/social/cultural stigma
(Jorm et al., 2003; Elsenbruch et al., 2003; Hassan et al., 2003; Melchionda et al.,
2003; Karlsson et al., 2003; Larsson et al., 2002; Kawachi, 1999; Hill & Willams,
1998)
Depression, anxiety, low self-esteem, social
isolation, negative self image produce…
Increased risk for:
‰ Cardiovascular disease
‰ Poor health habits
‰ Low motivation
‰ Post-CABG mortality
‰ Post-stroke mortality
‰ Type 2 diabetes
‰ Hypertension
‰ Substance abuse
‰ Respiratory syndromes
‰ Chronic pain
(Arroyo et al., 2004; Goodwin et al., 2004; Carney et al., 2003; Berkman et al., 2003; Yan et al.,
2003; Dahlen & Janson, 2002; Geerlings et al., 2002;
Excess weight, therefore, imposes burdens from
multiple domains…
Medical
‰ Emotional
‰ Social
‰ Moral
‰ Self / Psychological
‰
So, we’ll do ANYTHING TO LOSE
WEIGHT…
ENTER…
Complementary & Alternative “Medicine”
‰
Study: National Health Interview
Survey, CDC, National Center for
Health Statistics
‰
> 31,000 U.S. respondents:
¾
62% used CAM in previous 12
months
¾
What kinds of CAM?
(Barnes et al., 2004)
‰
Order of prevalence for CAM
“therapies”:
¾
Prayer: individual, group, church
¾
Natural therapies/Supplements/Etc
¾
Meditation/Yoga/Massage therapies
¾
Chiropractic/Manipulation/Etc
¾
Nutrition/Diet therapies
(Barnes et al., 2004)
Weight Loss and CAM: Natural Therapies/Supplements
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
‰
Ayuruedin (herbal)
Chromium picolinate (mineral+acid)
Chitosan (ground shell of lobster)
Ma Huang (ephedra; evergreen shrub)
Garcinia cambogia (rind of brindleberry)
Glucomannan (root of konjac)
Guar gum (Indian cluster bean)
Plantago (husk of plantago seed)
Yerba (S. Am. evergreen shrub)
Yohimbe (C. African evergreen shrub)
Capsaicin (red peppers)
L-Carnitine (amino acid)
Fucus (seaweed)
Gingko biloba (leaf of maidenhair tree)
Pectin (fruit fiber)
Grape seed extract
Lecithin (lipid)
Horse chestnut (ground seeds of same)
St. Johns Wort (herbal)
Fillet of a fenny snake, eye of newt, toe of frog,
wool of bat, tongue of dog, adder's fork, blindworm's sting, lizard's leg, owlet's wing…
Systematic Reviews:
‰
Pittler & Ernst, Am J Clin Nutrition, 2004
‰
Allison et al., Critical Rev Food Sci Nutriion, 2001
‰
Morelli & Zoorob, Am Fam Physician, 2000
‰
Egger et al., Med J Australia, 1999
Conclusions:
‰
There is little convincing evidence of the
efficacy of any of these “treatments” in
weight loss/control
‰
None are recommended
Weight Loss and Other Therapies…
Little-to-No Evidence of Efficacy:
‰ Acupuncture
‰ Appetite suppressants (e.g., hydroxycitric acid)
‰ Hypnosis
‰ Biofeedback
Fair-to-Good Evidence of Efficacy:
‰ Cognitive/Behavioral therapy
‰ Health-Centered wellness programs
‰ Exercise programs
‰ Multidisciplinary programs
‰ Twelve-Step type programs (Overeaters
Anonymous, Weight Watchers)
‰ Psychotherapy
(Corsica & Perri, 2003; Kaukua et al., 2003; Lacey et al., 2003; Bacon et al., 2002;
Mattes & Bormann, 2000; Nieman et al., 2000; Hunter et al., 1997)
Study: Bacon et al., 2002, Int J Obesity:
‰ Non-Diet Wellness Program vs. Diet Program
‰ Obese, chronically dieting women
‰ 1 year; weekly groups
Non-Diet Wellness Program focus:
‰ Metabolic fitness
‰ Eating behavior/cognitions
‰ Acceptance of self
‰ Positive body image
‰ Depression
Diet Program focus:
‰ Exercise
‰ Energy-restricted diet
Results:
Women in wellness program had significant
improvements in:
‰ Metabolic fitness
‰ Eating control
‰ Body image
‰ Self esteem / Depression
‰ But NO weight loss
‰ 8% quit prematurely
Women in diet program had significant
improvements in:
‰ Metabolic fitness
‰ Eating control
‰ Weight loss
‰ 41% quit prematurely
What about
Spirituality/Religion?
Research indicates that
religiousness/spirituality has positive
mental and physical health associations
(Larson DB, et al., “Scientific Research on Spirituality and Health:
A Consensus Report,” Rockville, MD: NIHR, 1998)
Mental Health
Among those with stronger spiritual well-being and/or
positive religious behaviors:
‰
Lower prevalence of impulse disorders and
externalizing disorders, including:
¾ Suicide, substance abuse, antisocial behavior
(Baetz et al., 2002; Gartner et al., 1991; Kendler et al., 2003)
‰
Lower prevalence of depression in Caucasians, African
Americans, Hispanics, elderly, HIV/AIDS patients…
(Baetz et al., 2002; Brown et al., 1990; Ellison, 1995; Kendler et al., 2003; Kennedy et
al., 1996; Koenig et al., 1997;Levin et al., 1996; McCullough & Larson, 1999;
Meisenhelder & Chandler, 2000a, 2000b; Simoni & Ortiz, 2003)
In controlled trials of psychotherapy with
strongly religious clients (including Muslims
and Christians), attention to spiritual/religious
issues yielded:
‰
Greater or faster efficacy in reducing:
¾ Anxiety
¾ Anger
¾ Somatization
¾ Depression
¾ Emotion suppression
(Carson & Hues, 1979; Carlson et al., 1988; Propst et al., 1992; Azhar et al., 1994;
Carone & Barone, 2001; Carter, 2002)
Physical Health
Service
Attendance
Religiosity
Risk of Morbidity/Mortality
----
• Coronary Artery Disease
• Emphysema
• CABG
Spiritual
Well-Being
• Type 2 Diabetes
++
Religious
Struggle
• All-Cause Inpatient
Hospitalization
(Comstock & Partridge, 1972; Oxman et al., 1995; Pargament et al., 2001; Newlin et al., 2003)
Well-Being: 40+ studies in past 5 years...
↑ Spiritual well-being
=
for:
• breast, ovarian cancer
• prostate cancer
• substance abuse
• sickle cell anemia
• HIV/AIDS
• old-age frailty
• renal transplant
• kidney dialysis
• dementia caregiving
↑ Quality of life
↑ Psychological adjustment
↓ Negative emotions
• hospice
• chronic mental illness
• diabetes
• post-stroke
• ALS
• chronic pain
• cystic fibrosis
• post-CABG
• post-loss grief
Weight/Obesity
‰
University of Minnesota church-affiliated
weight-loss program:
¾ Spirituality improved program adherence
and enhanced self-efficacy and eating
control
(Reicks et al., 2004)
‰
Overeaters Anonymous:
¾ Spirituality predicted womens’ ratings of
program success
(Westphal & Smith, 1996)
‰
Church-based weight loss program for obese,
hypertensive African American women:
¾ Significant decreases in weight and BP
¾ Community social support of church viewed
as key to program success
(Kumanyika & Charleston, 1992)
‰
Spiritual Feminism:
¾ Spirituality predicts positive body image
(Chapkis, 2003)
What Explains These Findings?
Hypotheses:
1. Health behaviors associated with
religion mediate disease risk (tobacco,
alcohol, drugs, diet, exercise, sex)
2. Social support from a religious
community mediates stress, coping,
and adaptation
(Benson, 1996; Levin, 1996; Strawbridge et al., 2001)
3. Relaxation response produced by ritual
and worship mediates positive
immunological and endocrinological
events
4. Faith-based optimism, hope, solicitude
mediate positive placebo responses
(Benson, 1996; Levin, 1996; Strawbridge et al., 2001)
Medicine, Illness, and Meaning: Who Are We?
Sp
t
iri
Em Mi
nd
ot /
io
ns
...Who we are; what we become; how we function,
survive, and heal is a complex interaction...
Re
la
tio
ns
h
ip
s
Bo
dy
=
• Well-Being
• Health
• Life Quality
• Adjustment
• Reaction
• Coping
• Recovery
(Barnard, 1984, 1985, 1988; Hamilton, 1998; McSkimming et al., 1997)
“...a loveless world is a dead world, and
always there comes an hour when one is
weary of prisons, of one’s work, and of
devotion to duty, and all one craves for is a
loved face, the warmth and wonder of a
loving heart.”
• Albert Camus, The Plague, 1948