By Rebecca Camilleri and Rebecca Mathews
With half of all Australian adults being overweight it would seem that the Australian population is losing the battle with obesity. Not surprisingly an increasing number of GPs are seeking adjuncts to regular medical treatment. Many are looking for more holistic solutions in treating this alarming health trend, and turning to psychologists and cognitive behavioural therapy to help them treat sufferers of obesity.
The Better Outcomes in Mental Health Care initiative brings psychologists into GP consulting rooms and allows patients with mental health problems to access psychologists via GP referral. While the initiative is not directed at obesity, some GPs have recognised the importance of using this partnership to address the underlying causes of the condition.
Dr Chris McAuliffe, GP Advisor to the National Primary Mental Health Initiative at the Australian Divisions of General Practice (ADGP), believes successful treatment relies on joint efforts from health professionals.
“I think there are increasing opportunities for GPs and psychologists to work collaboratively,” she says. “This is a positive experience for GPs and for psychologists.”
“In some physical disorders there are significant issues that would benefit from assessment and management by psychologists in conjunction with medical care.” Obesity is a physical condition that has major social and psychological dimensions.
Obesity is a major source of distress for individuals and not limited to issues of physical health. Cognitive behavioural therapy (CBT) is an effective treatment for obesity. It addresses various problematic aspects of the condition - eating behaviour (including the emotions that underlie eating patterns), the level of involvement in physical activity, body image dissatisfaction and participation in social life.
Statistics reveal that Australia is now ranked as one of the fattest developed nations, closely behind the US. The 2001 National Health Survey found half of Australians aged 18 years and over to be overweight or obese. In 1989 the rate was just under 40 per cent. This means, in just over 10 years, the proportion of Australian adults who are overweight or obese increased by about 10 per cent. If this trend continues, it is estimated at least 60 per cent of the Australian population aged 18 and above will be overweight or obese by 2010. That figure could rise to 65 per cent in 2020.
Dr McAuliffe is alarmed by the prevalence of obesity among both adults and children and the subsequent chronic health risks associated with this growing epidemic - including the increased risk of developing diabetes, heart disease, and some forms of cancer. Type 2 diabetes traditionally affects older adults and is triggered by weight gain, inactivity and stress. In recent years there has been a worrying increase in Type 2 diabetes among much younger people. “It really is a concern when you see a 20-year-old with Type 2 diabetes,” says Dr McAuliffe.
Causes of obesity - complex and varied
Many factors have been attributed to the rise in obesity, namely sedentary lifestyles and a growing reliance on convenience foods. However, the development of obesity is likely to be multifaceted with both environmental and biological factors implicated as predisposing individuals to obesity.
Dr McAuliffe says the key issue is that people are less active. “If you sit still for a long period of time you are not burning up energy, which means poorer fitness and a slower metabolic rate.
“We have so many labour saving devices so people are less active than they used to be. Access to snack, takeaway and pre-packaged foods add to the problem,” explains McAuliffe. The ‘natural’ diet of our ancestors has been superceded by high-fat, low-fibre foods that promote weight-gain.
It is also clear that there are genetic differences in people’s susceptibility to obesity - namely differing metabolic rates. However, while genes play an important factor, it is the individual’s level of food consumption and inactivity that determine weight gain.
“It gets back to assisting people to change their behaviour. There might be barriers or impediments and they need to be treated in a way that sustains behaviour change and weight loss,” she says.
In addition to the environmental issues, psychological factors have also been shown to impact on various aspects of health - including obesity. For example, stress can have a negative impact on lifestyle and is likely to make an indirect contribution to obesity. When people are stressed their food and alcohol intake often increases. There may also be underlying personal issues that, when not dealt with, may lead to a lack of energy or motivation and an increase in food consumption is often seen by an individual as one way of dealing with (or avoiding) the problem.
Furthermore, the consequences associated with obesity can in themselves lead to a range of mental health issues - depression, anxiety and low self-esteem all exacerbate the problem (and the result is a vicious circle).
Treating obesity with multidisciplinary teams
Obesity treatment aims to achieve realistic weight loss and to improve overall health, physical functioning and quality of life. Even an initial 10 per cent weight reduction is considered to be a successful outcome and has been shown to result in significant health and psychological benefits.
Appropriate and realistic goal setting can be a challenge when working with obese individuals. Research shows that sufferers often have unrealistic weight loss expectations. Furthermore, weight loss can plateau after a period of time and this can be a difficult stage in an individual’s treatment - especially when motivation to continue may already be low. An important inducement to continue with treatment is to focus therapy on health and psychological benefits such as perceptions of wellbeing and social participation rather than on just weight-loss. Hence, the aim of treatment should be to return to a weight that is healthy, that improves quality of life, and that can be successfully maintained.
Dr Trina Gregory, a mental health GP at the ‘8 to 8’ Medical Centre in Port Macquarie, NSW, introduced a weight clinic that is used in many of the practice’s Mental Health Three Step case studies. The Three Step program is a framework for managing mental health disorders in a primary care setting involving holistic patient assessment, mental health planning and review.
Dr Gregory recognised that the Better Outcomes in Mental Health Care philosophy could help tackle the entwined problems of obesity and depression in the coastal town, which has high levels of unemployment. “What we found were very overweight and depressed people, especially women, who did not exercise and who were unemployed,” she says. “They were depressed so they would comfort eat. If someone is depressed and they comfort eat there is no point just treating the depression. You have to break the cycle.”
Kylie Ball, Research Fellow at the School of Exercise and Nutrition Sciences at Deakin University, has been closely monitoring Australian obesity trends and analysing the reasons why, despite increased awareness and focus on healthy living and fitness, Australians continue to gain weight at a startling rate. Her work highlights the urgent need for more innovative approaches to prevent weight gain.
“Some of the most effective strategies for encouraging healthy living, exercise and positive eating habits come from CBT,” says Ball.
In order to address obesity effectively and to achieve long-lasting maintenance of weight loss one must also address problems that underlie the condition, such as beliefs about self-image and possible relationship difficulties. When successful in treating obesity, CBT produces changes that are not limited to physical gains, but also in improved self-esteem and quality of life. However, CBT, as a treatment for obesity, is demanding and a lot of work is expected of the client.
Psychological interventions including psycho-education, stimulus control strategies (to counteract triggers for eating), self-monitoring, behaviour modification (to reduce excessive eating and promote a pattern of regular eating behaviour) and cognitive therapy work towards implementing lifestyle changes and addressing underlying psychological issues. These strategies have proven to be important adjuncts to normal medical intervention. The most recent “Clinical Practice Guidelines for the Management of Obesity in Children and Adolescents” (published by the Australian National Health and Medical Research Council) identifies behavioural interventions to be an important component of weight loss programs for obese individuals. In addition, family-based treatments have been shown to be effective in tackling childhood obesity.
Further, vigilance in monitoring daily eating and exercise regimes has been identified as predictive of long-term success in obesity treatment.
“Many weight loss programs fail to take into account all levels of influence affecting the individual, such as social, environmental and psychological factors. We need to consider multiple strategies, and those with the most promise are multifaceted,” explains Ball.
While psychological interventions for obesity have been traditionally behavioural based, the introduction of cognitive therapy has shown promising results in dealing with weight regain by addressing the underlying issues. Unrealistic expectations and a lack of motivation can result in a post-treatment relapse. Individuals with obesity may feel stigmatised by the community and are therefore less likely to be involved in community groups, which may otherwise provide much needed stimulation and support. Part of working with obese individuals includes tackling feelings of self-worth and acceptance and increasing interest and involvement in community activities. Cognitive therapy aims to address the destructive thinking patterns that prevent social involvement occurring.
Dr Rob Trigger, who represented the ADGP at last year’s obesity conference and specialises in treating young people, reinforces the idea that GPs and other health professionals have a vital role to play in treating obesity and related issues. “If they see a young person who is obese they need to form an alliance with him or her,” he says. “We are often dealing with their unhappiness. We need to look at what is happening in these young people’s lives and how we as health professionals can help them to deal with difficult issues”.
Most health professionals agree that a holistic, integrated approach is more successful for lasting, long-term results in the treatment of obesity. CBT, along with diet, exercise and medical supervision for physical aspects of the condition, is the best approach to treating this serious health concern. Nevertheless, the majority of obese individuals do not receive a multifaceted treatment model. The formation of GP-psychologist partnerships could address this serious issue.
Cooper Z. & Fairburn C.G. (2001). A new cognitive behavioural approach to the treatment of obesity. Behaviour Research and Therapy, 39, 499-511.