Psychological Issues Associated With Obesity

Etiology

The psychological effects of obesity arise from a combination of biological, psychological, and social factors, indicating a multifaceted origin.

Biological Etiologies 

Genetic factors significantly influence the relationship between obesity and psychological well-being, with specific genes predisposing individuals to obesity itself as well as to related mental health conditions.[8][9] This genetic predisposition underlies the interactions between physical health and mental health, where the balance of hormones regulating hunger, satiety, and stress, such as leptin, ghrelin, and those involved in the hypothalamic-pituitary-adrenal (HPA) axis, can be disrupted by obesity.[9][10] Such hormonal imbalances may lead to altered cortisol levels, contributing to stress, anxiety, and depression.[10] Furthermore, obesity is associated with chronic low-grade inflammation, which has been linked to an increased risk of depression through its effects on brain function.[11] Insulin resistance, another consequence of obesity, affects cognitive changes and mood disorders, highlighting insulin's critical role in brain function and neurotransmitter signaling.[12] Research also suggests that obesity can alter brain structure and function, particularly in areas involved in emotion regulation, reward processing, and decision-making, potentially leading to psychological disorders.[13] The emerging understanding of the gut-brain axis points to how obesity-induced changes in the gut microbiota can influence neurotransmitter production and behavior.[14]

Psychological Etiologies

The psychological effects of obesity can be deeply intertwined with emotional and behavioral factors, where psychological vulnerabilities may predispose individuals to obesity and vice versa. For instance, stress and emotional distress are significant contributors; individuals may turn to food as a coping mechanism for managing stress, leading to a cycle of emotional eating and weight gain.[15][16] This behavior not only increases the risk of obesity but can also exacerbate feelings of guilt and shame, further impacting mental health.[15] The stigma associated with obesity can lead to social isolation. low self-esteem and body image dissatisfaction, contributing to depressive symptoms and anxiety. This social isolation can create a feedback loop, where reduced social support and increased loneliness make it harder to engage in healthier behaviors or seek help.[4][15][7][5][6] Additionally, body image dissatisfaction is a critical psychological factor; societal pressures to adhere to specific body standards can lead to a negative self-image and low self-esteem among individuals with obesity.[15][7][5][6][4] This dissatisfaction can contribute to mood disorders, anxiety, and eating disorders. Childhood experiences and trauma can also play a role in shaping eating behaviors and self-esteem, affecting weight in the long term.[15][5][6][4]

Social Etiologies

The social etiologies of the psychological effects of obesity include factors related to the environment and community infrastructure, such as geographical differences in obesity prevalence, the impact of food availability, and the quality and type of food accessible in various neighborhoods.[17] Transportation and neighborhood walkability also significantly influence physical activity levels and weight status.[17] Moreover, neighborhood socioeconomic status, along with perceptions of crime and safety, can affect physical activity and dietary choices, contributing to the obesity epidemic.[17] The social etiologies of the psychological effects of obesity are further compounded by societal stigma and discrimination, as well as environmental stressors.[5][4] These include not only the physical environment but also the social climate in which individuals with obesity experience marginalization and prejudice. Discrimination in healthcare, employment, and social interactions can lead to increased stress, exacerbating the psychological burden of obesity.[5][4] This societal stigma can also hinder individuals from seeking medical care or participating in physical activities, reinforcing a cycle of adverse psychological effects and unhealthy behaviors.[17][5][4]

Ultimately, these biological, psychological, and social factors can create a vicious cycle, perpetuating and amplifying the psychological effects of obesity.

Epidemiology

There is a strong association between obesity and psychological issues, particularly mood disorders like depression. Several key findings from the research around the world:

• Individuals living with obesity have 18% to 55% increased odds of developing depression, while the risk of being classified as having obesity in people with depression is increased by 37% to 58%.[18]
• In an Austrian study, 2 out of 5 people who are overweight or obese are diagnosed with a psychiatric disorder, especially mood, anxiety, psychosis spectrum, or eating disorders.[19]
• The global burden of both obesity and mood disorders, including anxiety and depressive disorders, has increased substantially between 2010 and 2021. The age-standardized DALY rates for anxiety disorders and depressive disorders increased by 16.7% and 16.4% respectively during this period. Similarly, the age-standardized YLD rates for diabetes, which is primarily driven by the rise in type 2 diabetes and obesity, increased by 25.9% globally.[20]

The relationship between obesity and depression appears to be bidirectional and more substantial in women compared to men. In the USA, Younger individuals, non-Hispanic whites, and those with higher educational attainment show a stronger association between obesity and mood disorders.[21][5] The relationship between obesity and depression is complex, with some studies finding depression as a risk factor for obesity, particularly atypical depression. In contrast, others show obesity increases the risk of depression. The impact of the obesity-depression combination on prognosis had mixed results, with factors like depression subtype, age, and sex influencing the association.[22]

Pathophysiology

The pathophysiology of the psychological effects of obesity can be categorized into biological, psychological, and social factors, each contributing uniquely to the overall impact on mental health.

Biological

Adipose tissue in obese individuals secretes various hormones and signaling molecules known as adipokines, which play crucial roles in metabolism and immunity. These include anti-inflammatory adipokines in lean individuals and pro-inflammatory cytokines in obese individuals. These pro-inflammatory cytokines, such as TNF-alpha and IL-6, along with hormones like leptin, resistin, and visfatin, contribute to the development of chronic low-grade inflammation seen in obesity.[23][24] Leptin, associated with appetite and energy balance, is secreted in proportion to fat storage, while adiponectin decreases in proportion to fat storage.[25] All of these can affect mood and cognition by altering neurotransmitter function.

Stress represents a condition where homeostasis is jeopardized, prompting the body to activate various responses to reinstate equilibrium. Stress regulation primarily occurs within the body through the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system.[25][10] The HPA system regulates many of the body’s physiological processes, such as digestion, sexuality, energy storage and expenditure, mood, and emotions, mainly through the activity of cortisol.[26][27][26] Cortisol mainly increases blood glucose through gluconeogenesis and suppresses the immune system. CRF overexpression can cause inflammation and produce symptoms of anxiety that lead to a vicious cycle of stress-induced stress.[28][29][26]

The brain is vital in managing stress reactions, involving the hippocampus, prefrontal cortex, and amygdala, central to learning, decision-making, and emotion regulation. Under stress, the hippocampus and prefrontal cortex can shrink, whereas the amygdala becomes more active, disturbing the brain's stress management system.[27] Chronic stress leads to ongoing activation of the stress hormone pathway, causing changes in brain communication that heighten pleasure from rewards and increase anxiety and fear.[16][30] This results in a heightened response to rewards, like the pleasure from eating high-calorie, sugary foods, making them seem more rewarding when stressed. This creates a cycle where consuming such foods temporarily eases stress, but the decrease in pleasure signals afterward heightens the desire for more, establishing a loop of stress-eating.[31][32][33][34]

Psychological

Psychological factors play a significant role in the pathophysiology of the psychological effects of obesity. Moreover, body image dissatisfaction, low self-esteem, and maladaptive coping strategies are prevalent among those with obesity, where negative self-views related to body weight and shape can evoke shame, guilt, and social isolation, thereby increasing psychological distress.[15]

At the forefront is the detrimental impact of negative body image and dissatisfaction, often intensified by societal beauty standards, which can precipitate low self-esteem, depression, and anxiety as individuals struggle with their self-perception and societal evaluations.[15][5][6][27][4] The multifaceted stress associated with obesity, including health worries and societal stigma, challenges effective coping mechanisms, leading to maladaptive behaviors such as overeating.[16] This is closely tied to emotional dysregulation, where individuals may resort to food for comfort amid emotional turmoil, fueling a cycle of emotional eating, weight gain, and further psychological distress.[16]

Compounded by social isolation and stigma, discrimination across various contexts can induce loneliness and social withdrawal, heightening the risk for mood disorders.[30] The relationship between obesity and increased instances of anxiety and depression is notably bidirectional; mental health disorders can drive behaviors that foster obesity, and conversely, obesity can escalate the risk of such disorders.[32] The negative influence of obesity on self-esteem and self-efficacy, particularly regarding efforts to lose weight, can undermine motivation and intensify feelings of helplessness. At the same time, the overall quality of life suffers due to the physical limitations, health complications, and emotional distress associated with obesity, diminishing engagement in enjoyable activities and life satisfaction.[34][31] Social withdrawal can also impact employability, affecting work experience, social skills, and the professional competencies necessary for securing employment, and mental health disorders may further obstruct an individual's ability to work, exacerbating social isolation, inactivity, and financial difficulties.[35]

Social

Social factors also contribute to the pathophysiology of the psychological effects of obesity. Weight-related stigma, discrimination, and societal pressures can lead to chronic stress, social exclusion, and diminished access to resources and opportunities. These social factors can exacerbate psychological distress and contribute to the development of mood disorders and other mental health issues.

Social stigma and discrimination against individuals with obesity play a significant role, as societal attitudes and biases can lead to exclusion, marginalization, and negative stereotyping in various contexts, including healthcare, workplace, and educational settings.[4][27][6][5][15] This societal stigma not only exacerbates psychological distress, such as anxiety and depression but also hinders individuals from seeking medical care or participating in physical activities due to fear of judgment and humiliation.[16][27][4][5][15][32][6] Furthermore, the impact of media portrayal of ideal body types contributes to body dissatisfaction and self-esteem issues, fueling the cycle of emotional distress and unhealthy eating behaviors as coping mechanisms. Social isolation resulting from stigma and discrimination can lead to a decreased support network, exacerbating feelings of loneliness and vulnerability to mental health disorders.[30] Economic factors also play a role, as obesity can affect employment opportunities and earning potential, leading to socioeconomic disadvantages that compound stress and limit access to healthy lifestyle options.[35][31] The cumulative effect of these social determinants on individuals with obesity can lead to a deterioration in mental health, creating a feedback loop that perpetuates obesity and its psychological effects.

History and Physical

When evaluating individuals with obesity and assessing for its potential psychological effects, healthcare providers should obtain a complete history that includes:

1. Medical history
2. Psychiatric history
3. Weight history
4. Diet/Nutrition history
5. Physical activity
6. Sleep history
7. Social history

A complete physical examination should be conducted and include:

1. BMI
2. Weight circumference
3. Body habitus
4. Vitals
5. Mental status examination

Evaluation

Evaluating the psychological effects of obesity in a clinical setting involves a comprehensive approach that addresses both the mental and physical aspects of obesity.

Identifying obese individuals is typically done with a standard screening tool for obesity, such as the measurement of body mass index (BMI). BMI is calculated using weight in kilograms divided by the square of height in meters.

Begin with a detailed clinical interview that includes questions about the patient's weight history, diet and exercise habits, and any attempts at weight loss. Importantly, it explores the patient's emotional and psychological well-being, focusing on body image concerns and experiences of bullying or discrimination related to weight.

Various factors, including biological, psychological, and socio-cultural influences, contribute to their weight status. 

1. Medical history and physical examination: Begin by gathering information about the individual's medical history, including any underlying medical conditions (such as thyroid disorders or polycystic ovary syndrome) or medications that may contribute to weight gain. A thorough physical examination can also identify any physical health issues related to obesity, such as hypertension or joint problems.

2. Dietary habits and nutritional assessment: Assess the individual's dietary habits, including their typical food intake, eating patterns, and any disordered eating behaviors. A nutritional assessment can provide insight into nutritional deficiencies or excesses that may be contributing to weight gain.

3. Physical activity and exercise habits: Evaluate the individual's level of physical activity and exercise habits. Lack of physical activity is a common contributor to obesity, so understanding the individual's activity level can help identify opportunities for intervention.

4. Psychological and emotional factors: Explore the individual's psychological and emotional relationship with food, eating behaviors, and body image. This may involve assessing for symptoms of depression, anxiety, or other mental health conditions that can contribute to overeating or unhealthy eating patterns.

5. Social and environmental influences: Consider the individual's social and environmental context, including family dynamics, cultural factors, socioeconomic status, and access to healthy food options and recreational opportunities. These factors can significantly impact an individual's ability to maintain a healthy weight.

6. Behavioral patterns and coping mechanisms: Investigate the individual's coping mechanisms and behavioral patterns related to food and stress management. This can involve exploring whether the individual uses food as a coping mechanism for emotional distress or uses maladaptive behaviors such as binge eating or restrictive eating.

7. Motivation and readiness for change: Assess the individual's motivation and readiness to make lifestyle changes to improve their health and well-being. This can involve exploring their goals, beliefs about their ability to change, and any perceived barriers to making healthy lifestyle changes.

8. Support systems and resources: Identify the individual's support systems and available resources that can assist them in making and sustaining lifestyle changes. This may include family support, community programs, healthcare professionals, and access to mental health services.

9. Collaborative goal setting and treatment planning: Work collaboratively with the individual to develop a personalized treatment plan that addresses their specific needs, preferences, and goals. This plan may include dietary modifications, increased physical activity, behavioral therapy, and/or medical interventions as appropriate.

10. Follow-up and monitoring: Schedule regular follow-up appointments to monitor progress, provide ongoing support, and adjust the treatment plan as needed based on the individual's response and changing circumstances.

Additionally, it is crucial to assess the patient's psychological history, including any past or present symptoms of depression, anxiety, eating disorders, mood swings, or other mental health concerns. One can utilize standardized mental health screening tools to identify symptoms of common psychological conditions associated with obesity, such as depression with the Patient Health Questionnaire (PHQ-9) and anxiety with the Generalized Anxiety Disorder (GAD-7) questionnaire. Furthermore, it is essential to assess disordered eating behaviors, which can range from binge eating disorder to restrictive food intake issues. The Eating Disorder Examination Questionnaire (EDE-Q) is a self-reported instrument designed to identify eating disorder symptoms and concerns about eating, weight, and shape. Inquire about their body self-image, body dissatisfaction, self-esteem, coping mechanisms, stressors, and any history of trauma or adverse life events.

Furthermore, evaluating the impact of obesity on the patient's quality of life using instruments like the Impact of Weight on Quality of Life-Lite (IWQOL-Lite) questionnaire can help further understand the broader effects of obesity on daily functioning and well-being.

Additional laboratory tests such as a complete blood cell count (CBC), thyroid function tests (TFT), electrolytes (including calcium, phosphate, and magnesium), Vitamin B12,  Liver function tests, Lipid profile and HbA1C may be helpful to rule out organic causes of both obesity and psychological symptoms.

Treatment / Management

A significant number of therapeutic options exist for both obesity and psychiatric symptoms together, as well as separately. Here, we will focus on therapeutic options that target both. A combination of treatments is optimal when pursuing therapeutic options in a clinical setting. 

It has been established that having a healthy diet and regular exercise promotes positive physical and psychological health.[36] This method should be used concurrently to supplement all additional therapeutic options.

Several psychotherapeutic interventions are available, which include motivational interviewing, cognitive behavior therapy, dialectical behavior therapy, and interpersonal psychotherapy. More recently, mindfulness-based interventions that target stress, negative thoughts, and eating behaviors have been shown to help obtain positive outcomes.[37][38] Behavior interventions are most effective when they are combined with diet and exercise.(A1)

Medications exist for treating either obesity or psychiatric conditions, but they may be used in combination when both are evident. FDA-approved medications for obesity include phentermine, orlistat, liraglutide, semaglutide, diethylpropion, phentermine/topiramate, naltrexone/bupropion, setmelanotide, and phendimetrazine. While for depression and anxiety, Selective serotonin reuptake inhibitors (SSRIs), Serotonin/norepinephrine reuptake inhibitors (SNRIs), Atypical antidepressants, Serotonin-Dopamine Activity Modulators (SDAMs), Tricyclic antidepressants (TCAs), and Monoamine oxidase inhibitors (MAOIs) may be used.

A more novel technique that has emerged is repetitive Transcranial Magnetic Stimulation (rTMS). This involves placing a magnetic coil over the target area of the brain and directly stimulating it. The dorsolateral prefrontal cortex (DLPFC) is an area that is frequently targeted for both weight loss and depression. It was found that when rTMS targeted the DLPFC, it was effective in reducing food intake and weight loss and treating treatment-resistant depression.[39][40][41](A1)

The primary indications for bariatric surgery are severe obesity, failure of other weight loss methods, the presence of obesity-related health conditions, and the patient's readiness and ability to commit to the necessary lifestyle changes after the procedure.[42]

The critical steps for a psychological evaluation of an obese individual before weight loss surgery are:

• Clinical Interview: The psychologist will conduct a thorough clinical interview to assess the individual's:[43]
  • Reasons and motivations for seeking weight loss surgery
  • Realistic expectations about the surgery and outcomes
  • Weight and diet history
  • Current eating behaviors and patterns
  • Understanding of the surgery, risks, and required lifestyle changes
  • Social support system and household eating habits
  • Psychiatric and substance abuse history
• Psychological Testing: The psychologist will administer standardized psychological assessments, which commonly include:[44]
  • Minnesota Multiphasic Personality Inventory-3 (MMPI-3)
  • Millon Behavioral Medicine Diagnostic (MBMD)
  • Personality Assessment Inventory (PAI) 
• Evaluation of Psychological Factors: The psychologist will assess the individual's:[44]
  • Self-motivation and self-control 
  • Self-efficacy in weight management 
  • Locus of control beliefs about weight and health 
  • Self-esteem 
  • Body image and outcome expectations 

This comprehensive psychological evaluation aims to ensure the individual is psychologically ready and equipped to undergo the significant physical and behavioral changes required for successful long-term weight loss after bariatric surgery.

Differential Diagnosis

Psychological issues associated with obesity can manifest in various ways, and it's essential to consider a range of differential diagnoses when evaluating an individual's mental health. Here are some common psychological issues that may be associated with obesity and their potential differential diagnoses:

1. Depression differential diagnoses: Major depressive disorder, persistent depressive disorder (dysthymia), bipolar disorder, adjustment disorder with depressed mood, grief/loss reactions.

2. Anxiety disorder differential diagnoses: Generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobias, obsessive-compulsive disorder, post-traumatic stress disorder (PTSD).

3. Eating disorders differential diagnoses: Binge eating disorder, bulimia nervosa, avoidant/restrictive food intake disorder (ARFID), other specified feeding or eating disorder (OSFED), rumination disorder, pica.

4. Body dysmorphic disorder differential diagnoses: Obsessive-compulsive disorder (OCD), social anxiety disorder, gender dysphoria, delusional disorder (somatic type), psychotic disorders.

5. Low self-esteem and poor body image differential diagnoses: Adjustment disorder with mixed anxiety and depressed mood, social anxiety disorder, body dysmorphic disorder, narcissistic personality disorder, avoidant personality disorder.

6. Stress and coping difficulty differential diagnoses: Adjustment disorders, post-traumatic stress disorder (PTSD), generalized anxiety disorder, depression, somatic symptom disorder.

7. Impulse control disorders differential diagnoses: Binge eating disorder, intermittent explosive disorder, compulsive buying disorder, kleptomania, gambling disorder.

8. Substance use disorders differential diagnoses: Alcohol use disorder, substance use disorders involving stimulants, opioids, or certain medications used for weight management, such as appetite suppressants.

9. Cognitive functioning and executive dysfunction differential diagnoses: Attention-deficit/hyperactivity disorder (ADHD), mild cognitive impairment, neurocognitive disorders (eg, due to medical conditions such as hypothyroidism or neurodegenerative diseases).

10. Sleep disorders differential diagnoses: Obstructive sleep apnea, insomnia disorder, hypersomnia disorder, circadian rhythm sleep-wake disorders.

11. Trauma and PTSD differential diagnoses: PTSD, adjustment disorders, acute stress disorder, other anxiety disorders, depression.

Conducting a thorough assessment to differentiate between these potential psychological issues and determine the most appropriate treatment and intervention strategies is essential. A multidisciplinary approach involving mental health professionals, physicians, dietitians, and other healthcare providers may be necessary to address the complex interplay between obesity and psychological well-being.

Prognosis

While obesity-related psychological effects can have a significant impact on prognosis, many individuals experience improvements in psychological well-being with appropriate treatment and support.

Overall, the prognosis of obese individuals suffering from the psychological effects of obesity depends on various factors, including the severity of psychological symptoms, access to treatment, and the effectiveness of interventions aimed at addressing both physical and mental health issues. Early identification and management of psychological distress in individuals with obesity are essential for improving prognosis and long-term health outcomes.

Complications

Psychological issues associated with obesity can contribute to a range of complications that impact mental health, physical health, and overall well-being. Here are some potential complications:

1. Worsening mental health conditions: Psychological issues such as depression, anxiety, and low self-esteem can exacerbate existing mental health conditions or contribute to the development of new ones. For example, obesity-related stigma and discrimination may lead to increased social anxiety or body image concerns.[45]

2. Poor treatment adherence: Individuals with obesity and co-existing psychological issues may struggle to adhere to recommended lifestyle changes or medical treatments, leading to poorer health outcomes and increased risk of complications.[46]

3. Increased risk of eating disorders: Psychological issues such as binge eating disorder or emotional eating may develop or worsen in individuals with obesity, leading to disordered eating patterns that further contribute to weight gain and health complications.[47]

4. Social isolation and relationship difficulties: Obesity-related stigma and body image concerns can impact social relationships, leading to feelings of isolation, loneliness, and interpersonal difficulties. This social isolation can further exacerbate psychological distress and contribute to poorer mental health outcomes.[35]

5. Reduced quality of life: Psychological issues associated with obesity can significantly impair quality of life, affecting various domains such as physical functioning, emotional well-being, social relationships, and overall life satisfaction.[35]

6. Increased risk of substance use: Some individuals may turn to substances such as alcohol or drugs as a way of coping with psychological distress related to obesity, leading to an increased risk of substance use disorders and further health complications.[48]

7. Impaired coping skills and stress management: Psychological issues can impair an individual's ability to cope with stress effectively, leading to maladaptive coping strategies such as emotional eating or avoidance behaviors, which can further contribute to weight gain and psychological distress.[21]

8. Sleep disturbances: Obesity and psychological issues such as anxiety or depression are associated with an increased risk of sleep disturbances such as insomnia or obstructive sleep apnea, which can further impact mental health and exacerbate obesity-related health complications.[35]

9. Chronic health conditions: Psychological issues associated with obesity can contribute to the development or exacerbation of chronic health conditions such as cardiovascular disease, diabetes, hypertension, and metabolic syndrome, further compromising overall health and well-being.[49]

10. Increased mortality risk: Obesity and co-existing psychological issues are associated with an increased risk of premature mortality, highlighting the importance of addressing both physical and mental health concerns in this population.[35]