We are into a new year, and among many New Year’s resolutions we hear is the resolution to take off body weight. That people are going for a new start, a chance to begin again, is actually good; it brings new hope and vigor to the issue. But sadly, most Americans making this resolution find themselves starting anew at a weight higher than they were the previous new year when they made the same resolution. Despite ourselves, we diet, exercise, and take off some pounds and then return to our previous behaviors that got us to wanting to take off the pounds in the first place.
Can psychiatry get into the body weight adventure and begin to lead the way to solutions? What I hope to do in this new column, “Weighty Issues,” is to share some of what I have learned in becoming an obesity medicine specialist, and learn from other experts who have been assessing and treating overweight and obesity for years.
I also hope to learn and share what we as psychiatrists are doing to manage our own weight (as many of us sit for a living) and lifestyles.
Coming to terms
About two-thirds of Americans are by medical calculations overweight, with half of that proportion actually medically obese. It is well-known that being overweight is a major risk factor for most of the illnesses that cause morbidity and early death among Americans. But this public health crisis was only classified an illness by the American Medical Association in 2013. What took us so long?
The topic of over body weight and psychiatry has been heavy on my mind for many years. It always puzzled me that psychiatry concentrated on anorexia nervosa, bulimia, and binge eating but was largely not focusing on the issue that was creeping up around us and becoming the major public health concern: that of overweight and obesity.
I knew that we were to concern ourselves only with illness but by ignoring the issue we, along with the rest of medicine, have promoted major, chronic illnesses of diabetes, heart disease, cancer, and so on. Fortunately for us, the AMA declared obesity a medical illness, but unfortunately, the way the reimbursement reads for treating obesity, one must be a sort of primary care physician or surgeon to get paid for the work. To my way of thinking, psychiatrists are the best physicians to be working in the field of overweight and obesity medicine, because we – more than any other medical specialty – understand that thoughts and feelings are involved in behavior. We understand that to be successful long-term in any endeavor, one must understand and harness one’s thoughts and feelings.
Moreover, we, more than physicians in other specialties, understand that the treater’s simple transference and countertransference, and the patient’s transference, can determine the trajectory and outcome of the treatment process. Additionally, psychiatrists regularly see their patients more often and over longer periods of time than do other physicians while developing and maintaining respectful and supportive relationships that can best handle the very personal issue of weight.
Surgery often not the answer
After having been a part of many psychiatric and psychological pre–bariatric surgery screenings over many years and having known many patients, friends, and colleagues who had undergone the different surgical treatments for overweight with complications and/or obesity, only to see them, many years later, larger than they were before the surgical intervention, I began to think that cutting it out was not the only definitive way to get better health measures. I knew that each surgical candidate really meant it when they pledged to follow through indefinitely but that feelings and life had intervened, and those were more powerful than surgery. That led me to think like a psychiatrist, and learn from and keep on learning from the feelings throughout life’s challenges and not like a surgeon, whose view is “once it is cut out, it is finished.”
It even led me to think medically radical thoughts that rapid weight loss through diet and lifestyle intervention, such as the weight loss that is achieved through surgery, could be a very good thing with one major caveat … long-term intervention (psychiatry, the discipline, knows something about long-term intervention). That kind of thinking led me to try to register for a lifestyle program that was sold out at that time. A course in Obesity Medicine, the crux of the matter, was not sold out. I took one course and was hooked, learning all that I did not know about overweight and obesity, and realizing just how complicated the matter of weight actually is.
In time, I studied and learned more, saw more patients, and became a diplomate of the American Board of Obesity Medicine ( ABOM ). Of the approximately 1,300 diplomates of the ABOM, only 15 identify as having psychiatry as their primary specialty. The board reports that there may be other psychiatrists who are also boarded in internal medicine or pediatrics or surgery, but specific information is not available.
Those of us who prescribe typical and atypical antipsychotic agents and some of the older and newer antidepressants are familiar with the weight gain that can be attendant to these medications. We also are familiar with metabolic syndrome, which can be associated and our need to follow fasting blood glucose and lipid levels as well as waist circumference, height, and weight.
Many of us also will educate our patients about eating fewer sweets and drinking fewer sugar sweetened beverages, consuming fewer starches, and we will advise our patients to increase their exercise. We may even prescribe metformin if the fasting blood sugar and hemoglobin A1C begin to creep upward. In addition, we are constantly trying to offset the side effects of medications that we prescribe for very serious illnesses. In short, psychiatrists already are in the obesity medicine arena.
Addressing personal challenges
Talking the talk and walking the walk is so important in the area of overweight and obesity. I have struggled with overweight most of my adult life and have been “overnutritioned” – the Chinese term for overweight, off and on during my career in psychiatry. During my obesity medicine studies, I took my own weight and lifestyle seriously, and lost a significant amount of weight. Friends and patients asked me if I were well. Over time, some patients who had been with me for years volunteered how they felt about my voluntary weight loss. Most said that I no longer looked powerful; some said that I looked like a lightweight – not a serious person.
Interestingly, over time, all of my patients who had weight issues of their own began to manage their own weight better, and began to talk about their feelings and relationship to food, exercise, and weight. We have all realized that there is more under that puffy cover than meets the eye and that it insulates a whole host of stuff. Calories in and calories out become a superficial path toward a solution.
Regarding simple transference and countertransference … many physicians have powerful adverse feelings about patients who are overweight or obese and really struggle with working with these patients. One of my friends, a family medicine specialist, told me that he cannot look at them and has told his staff not to assign those patients to him, because they do not comply and then do not come back to follow up. It is likely that his patients pick up on his disdain, anger, and lack of hope for them, and do not return in order to protect their feelings. Interestingly, this friend has struggled with his own weight throughout his professional life. Perhaps psychiatry could be useful to the myriad of other physicians like my friend who have visceral reactions to patients with weight issues so that the physicians can be kinder to themselves and their patients can receive the care, understanding, and respect that they deserve.
Attaining and maintaining a healthy weight across the life cycles is a complicated thought-, feeling-, and event-filled endeavor. I look forward to sharing basic science, clinical science, research, and anecdotal reports as we explore “Weighty Issues.”
Dr. Harris, a diplomate of the American Board of Obesity Medicine, is in private practice in adult and geriatric psychiatry in Hartford, Conn. She also works as a psychiatric consultant to continuing care retirement organizations and professional groups. Dr. Harris, a former president of the Black Psychiatrists of America, is a Distinguished Fellow of the American Psychiatric Association. Besides psychotherapy, her major clinical interests include geriatrics and the interface between general medicine and psychiatry.