Psychological
Considerations for Obese
People with Diabetes
Geraldine Abbatiello, PhD, GNP, PMHNP, RN
Complex Illness Management
Overview
 Psychological Aspects of Food and Eating
 Psychological Aspects of Disease
 Obesity
 Diabetes
 Disordered thinking
 Psychological Considerations in Treatment
Psychology and Food
Over one’s lifetime, we grow with food like a beautiful
leather glove. Alas, sometimes, with age or lifestyle the
glove gets tight or doesn’t fit the needs. A change
needs to occur to our relationships.
The same is true with food.
Let’s look at this.
Overview
 Psychological Aspects of Obesity
 Discussing Weight Control
 Psychological Considerations in Treatment
 Challenges
Biological Aspects of Eating
versus
Psychosocial/Cultural
Hunger > Repletion > Satiety > Depletion > Hunger
Versus
Eating Disorders: Disruption in this process
Food serves a purpose…
Correct?
 Nutrition… life preservation
 Safety, security, comfort
 Cultural and social role
 Self-esteem
 Celebratory role
 Reward and punishment
 Coping strategy
Childhood?
Mood?
Job?
Education?
Relationships?
Relationship
with Mother?
Friends?
Why are we talking about this?
Feel better > Improve health
Increased self-worth > Improve mental
health
Do more > Improve quality of life
What else …?
Attitudes toward Obesity
Negative
Psychological
Social
Environmental
Employment
Medical
Positive
Psychological
Family
Cultural
Society
Financial
Explicit & Implicit Attitudes
Characteristics:
 Noncompliant
 Emotionally limited




1.
2.
Lazy
Dishonest
Sloppy
Unpleasant
– Ugly
Klein et al. J Fam Pract 1982; 14:881-88.
Foster et al. Obes Res 2003; 11:1168-77.
Psychological attitudes:
 Low self-esteem
 Poor self-worth
 Limited coping skills
 Mood changes
 Anxiety
 Depression
 OCD
 Victim cycle
Messages over lifetime










You did well
You did badly
You deserve this
You don’t deserve this
You feel guilty
You need to give this up
It’s OK to eat extra sometimes
You have large bones… everyone in family is fat
Fat is beautiful
Thin is in and you’re not
Cause and effect of distorted
thinking
Reflected in
 Mood problems
 Eating disorders
 Thought disorders …what and why I am
eating
 Bodily changes…messages about me and
food
 Relationships with others
Obesity
 Is a complex chronic disease
 Multifactorial
 Impressions associated with weight





Cute (roly-poly)
Pudgy
Distracting
Disgusting
Hopeless
Obesity is multifactorial
 Biologic
 Genetic
 Emotional
 Social
 Cultural
Change the way we look at our
weight

Am I feeling helpless or hopeless about food
- Can I change my mind?

Does the thought of exercise overwhelm me?
- Can I chose one exercise and feel empowered?.

Can I see myself healthier looking?
5A's Obesity Management
 Ask (permission)
 Assess (causes)
 Advise (risks vs benefits)
 Agree (goal & plan)
 Assist (reframe, remotivate, resources,
reeducate)
 2012 Canadian obesity network
www.obesitynetwork.ca
Goal of Weight Change
 Measured improvements
 Modest reductions (5%)
 Quality of life
 Self-esteem
 Higher energy levels
 Best weight vs Ideal weight
Risk of Depression Increases with Obesity
Severity
5
4.63
4.5
Odds Ratio .
4
3.5
3
2.5
1.9
2
1.5
1
1.33
1.13
1
0.96
0.5
< 18.5
18.5 - 24.9
25 - 29.9
30 - 34.9
Body Mass Index (kg/m2 )
Onyike et al. Am J Epidemiol 2003; 158:1139-47.
35 - 39.9
>/= 40
The Question of Causation
 Most studies are cross-sectional
 Longitudinal studies
 Depression  Obesity (adolescents)
 Obesity  Depression (adults)
 Potential 3rd variables
 Medication usage
 Affect dysregulation/coping deficits
Berkowitz & Fabricatore. Psychiatr Clin N Am 2005; 28:39-54.
Stereotypical Misconceptions
 There is no evidence to support that
obesity is the result of unconscious,
unresolved drives or issues, unconscious
anger, depression, sexual abuse, or a
need for love!
Psychological Evaluation
 Identify eating triggers
 Recognize potential
conflicts about weight
 Somatization
 Low self-esteem
 Anxiety
 Depression
 Obsessions/compulsions
 Psychoses
 Paranoid ideation
Behavioral Health Evaluation
 Etiology is multifactorial
 Many develop dysfunctional behavior as
a consequence of their obesity
 Certain eating and lifestyle issues may
not be conducive to a good outcome
after surgery
Support Groups Key to Success
 Role models
 Reinforce a sense of belonging and camaraderie
 Can see other members’ surgical results; good and/or bad
 Teleconferencing
 Bring family/friends
Psychological & Physical Changes
 Improvement in body image/ less negatively selfconscious
 Improved energy
 Improved mobility (can exercise)
 Better mood and self-esteem; fewer mood swings
 Increased ability to explore social and vocational
activities
Grieving & Loss
 Thoughts and behaviors about food change
 Relationship with food will change
 Relationship with others may change
Bariatric Surgery & Psychiatric
Assessments
 Almost all programs in the US require a
mental health consultation pre-op
 Typical contraindications: active
substance abuse, active psychosis,
bulimia nervosa, and severe,
uncontrolled depression
Pharmacologic Uses in Bariatrics
Over the Counter
Anti-diabetics
Anti-psychotics
Anti-convulsants
29
Drugs
Non-prescription diet pills
Phentermine (Suprenza)
Orlistat (Alli)
Phentermine-topiramate (Qysmia)
Locaserin (Belviq)
Commitment to Change
 Nutritional preparation
 Psychological preparation
 Smoking cessation
 Exercise
 Financial considerations
What is this double message
 Sexy weight loss =
Ten percent?
Psychological Assessment Prior to
Bariatric Surgery
 Biological
 Psychological
 Environmental
 Nutritional Evaluation
Post Bariatric Surgery
 Crisis of adjustment
 Ongoing motivation
 Changes in patterns of thinking
 Changes in patterns of eating
 Changes in patterns of socializing
How long does it take to change?
 Studies show 6 months for attitude
changes
 Body Image
 Notion of food
 Socializing over food
Conclusion of the psychosocial/cultural
aspect of weight loss
 Mind is very powerful
 Watch your thoughts
 Use your resources in own psyche
 Use your family and friend network as well
 Community resources
 Learning new skills for coping
 Coping with food
 Coping with being thinner
Summary of Diabesity
 Goals: Enhance quality of life using interdisciplinary team:
Ask, Assess, Advise, Agree, Assist
 Personal, family, and community changes in food choices and
energy expenditure can result in decreased diabetes, comorbid
illnesses and improved health (Shadi Chamany, MD, MPH)
 Achieve and maintain healthy eating habits while preserving
the pleasure of eating (Lorena Drago MS, RD, CDN, CDE)
 Reduction of diabetes and comorbid illnesses using bariatric
surgery as a treatment modality (Bradley Schwack, MD)
 Understanding how the mind, body, and culture interact to
effect choices for diabetes management in obese patients
(Geraldine Abbatiello, PhD, NP)