What does food mean to you?
The rise of obesity is global with an alarming trend in
our adolescents. Obesity is caused by greater caloric intake over expenditure. While genetics plays a role in obesity it is
currently an issue that does not allow for intervention. However environment and psychological areas can be modified to overcome
obesity. A surge of obesity has lead to the search for innovative new treatments. Diets, exercise, pills, surgical treatments
encompass the different modes of treatment. Bariatric surgery results in effective weight loss for about 2-3 years. However
as more and more people have got the surgery we have seen an increase in the number of cases of weight regain after 3years
of surgery. Diets and medications are effective but have led to weight regain after the diet/medication is discontinued.
Hunger and Satiety
Hunger and satiety are controlled by areas in the brain viz: the hypothalamus.
Much of the current research is focused on understanding the implication of various neuropeptides and neurotransmitters in
the etiology of obesity and abnormal eating behaviors. Many patients report that they are never hungry. This may be because
they have from an early age eaten in response to stimuli other than hunger. Food is a means of comfort. The stimulus to eat
is something other than hunger.
patients who are seeking bariatric surgery, when they have spent most of their lives ignoring their hunger and satiety,
it is unlikely that they are suddenly going to be more attentive to these stimuli. In the immediate post operative period
patients do have strong reactions of pain and vomiting to eating more than the post op diet. However after 2-3 years some
patients tend to start "grazing", eating small amounts of food all day; and start regaining their weight. The
patients who have been emotional eaters, or binge eaters are more prone to developing this and thus weight regain. They have
learned to deal with stress anger boredom with food and cannot help but continue to resort to "comfort eating".
Some patients report they have "never
been hungry". Others who eat when they are not hungry, over eat or eat impulsively can become "grazers" resulting
weight regain. Abnormal eating behaviors where food is not just a response to hunger have to be re directed. The difference
between psychological/ emotional hunger and physical hunger have to be relearned. This is done effectively by Cognitive behavior
therapy CBT. This mode of treatment is the only effective and most long lasting method of reducing abnormal eating behaviors.
This gives the patient a feeling of control and improves self esteem and allows the patient to pursue goals with the
surgery, nutrition and exercise. Behavioral treatments are designed to change the way patients think and hence their behaviors.
This website is devoted to educating patients as well as professionals about the psychological aspects about obesity.
Almost 80-90% of patients who see me report
emotional eating. The commonest emotion being boredom. Other emotions that people have felt trigger their eating are anger,
sadness, anxiety, stress, happiness. Sometimes patients eat "socially". They get together with friends and family
over food. It is what food means to us in society. It is no longer just something we eat to nourish us, but what we do when
we get together with friends and family. It is more than habit it is "tradition". There are other myths that we
have related to food. As one patient said Fridays is "all you can eat night". We had another patient say that after
a hard day she has to eat more at night in order to get "energized". Patients with diabetes also frequently will
eat in response to what they feel may be "hypoglycemia". They do not check their sugar. Are they anxious? or are
they truly hypoglycemic. When they feel better with this eating does it increase the learned behavior and perpetuates eating
in response to "hypoglycemia”? All important questions.
Binge Eating Disorder
This disorder has a 40% prevalence in
obese patients. However in our study of obese patients seeking bariatric surgery the prevalence rises to about 70%. It characterized
by the following:
episodes of binge eating (at least twice per week for 6 months)
Marked distress with at least three of the following:
- Eating very rapidly
- Eating until uncomfortably full
- Eating when not hungry
- Eating alone
- Feeling guilty or disgusted after a binge
No recurrent compensatory purging, exercising, or fasting
Absence of anorexia
The most important aspect
of this disorder is the feeling of "lack of control". It is thus very similar to other addictions, like drugs or
alcohol. It is an impulse control disorder.
At Total Wellness patients will have treatment tailored to their needs with access to cognitive
behavior therapy, medication exercise and nutrition.
So what’s your score? The red number at the end of
each response indicates the score for each response. A score of 17 and over indicates BED a higher score indicates increased
severity of the disorder
How is binge eating disorder treated?
As with most psychiatric conditions both medications
as well as psychotherapy help.
Cognitive behavior therapy is a mode of treatment that has been proven to be useful for anxiety,
depression and Bulimia Nervosa. Please review details in our section on Cognitive behavior therapy (CBT) on this website.
Briefly CBT is a tool used to change the erroneous beliefs that patients have about food and their body. The focus
is not on weight loss but on reducing abnormal eating behaviors. This gives the patient a sense of control that helps
improve self esteem. Our patients have lost weight while in the CBT group, but that is not the focus of treatment.
such as Topiramate have helped patients in group to lose weight and reduce frequency of binge episodes. Antidepressant
and medications that reduce anxiety can also help when patients have been eating in response to emotions of stress and
anxiety. I have been seeing bariatric patients since 1999. An increasing number of patients have sought bariatric
surgery to treat obesity. Binge eating disorder is fairly common in Bariatric patients. For the last 5 years I have
seen many patients in the post operative period with varying degrees of weight regain. Typically this is more common in patients
with emotional eating and binge eating prior to surgery. I have conducted the CBT groups for the last 2 years with success
full reduction in abnormal eating behaviors as well as improved morale and weight loss. It is important that all patients
have access to CBT and medications to optimize the outcomes of surgery.
At Total Wellness
patients will have treatment tailored to their needs with access to cognitive behavior therapy, medication, exercise and nutrition.
phone (410 6050180) for further questions.
Binge eating disorder is characterized by:
Recurrent episodes of eating uncontrollably indicated by
1. eating more rapidly than usual
eating until feeling uncomfortably full
3. eating large amounts of food when not hungry
5. No planned
6. eating in response to emotions
7. guilt about
Binge eating occurring at least twice a week for a 6 month period.
Do you have binge eating disorder?
Complete the following questionnaire. It is adapted from the Binge eating scale developed by Drs Gormally, Daston, Black and
Riardan. If you score greater than 16 you may have binge eating disorder. A higher score denotes greater severity.
- I don’t feel self conscious about my weight or body size when I am with others.(0)
- I feel concerned
about how I look to others, but it doesn’t make me disappointed with myself.(1)
- I get self –conscious about my appearance and weight which makes me disappointed in myself.(2)
- I feel very self conscious about my weight and frequently feel intense shame and disgust for myself. I try to avoid
social contact because I am self conscious.(3)
- I don’t have any difficulty eating slowly in the proper manner.(0)
- I may “gobble
down” foods , but I don’t end up feeling stuffed because of eating too much.(1)
- At times I tend
to eat quickly and then, I feel uncomfortably full afterwards.(2)
- I have a habit of eating quickly without
really chewing my food. Afterwards I usually feel uncomfortably stuffed because I have eaten too much.(3)
- I feel capable of controlling
my eating urges when I want to.(0)
- I feel like I have failed to control my eating more than the average
- I feel utterly helpless when it comes to feeling in control of my eating urges.(3)
- I feel so helpless about controlling my eating urges, that I have become very desperate about trying to get in control.(3)
- I don’t
have the habit of eating when I am bored.(0)
- I sometimes eat when I am bored, but often am able to get my mind
- I have a regular habit of eating when I am bored, but occasionally, I can use some other activity
to get my mind off eating.(0)
- I have a strong habit of eating when I am bored, nothing seems to help me when
I am bored.(2)
- I am
usually physically hungry when I eat something.(0)
- Occasionally I eat something on impulse even when
I am not physically hungry.(1)
- I have a regular habit of eating foods that I may not enjoy, to satisfy a hungry
feeling even though physically I do not need the food.(2)
- Even though I may not be physically hungry
I get a hungry feeling in my mouth that only seems to be satisfied when I eat food, like a sandwich that fills my mouth. I
sometimes spit the food out so I don’t gain weight. (3)
- I don’t feel any guilt or self hate after I overeat.(0)
- After I overeat I occasionally feel guilt or self hate.(1)
- Almost all the time I feel a strong sense
of guilt or self hate.(3)
- I don’t lose total control of my eating
when dieting even after periods when I overeat. (0)
- Sometimes when I eat a “forbidden food “
on a diet, I feel like I “blew it” and eat even more.(1)
- Frequently I have a habit
of saying to my self, “I have blown it now, why not go all the way” when I overeat on a diet. When this happens
I eat even more.(2)
- I have a regular habit of starting strict diets for myself, but I break the diets by going on an
eating binge. My life is “feast or famine”.(3)
- I rarely eat so much food that I feel uncomfortably stuffed afterwards.(0)
- Usually about once a month I eat such a quantity of food, I end up feeling stuffed (1)
- I have regular periods during the month where I eat large amounts of food, either at meal times or snacks.(2)
- I eat so much food that I regularly feel quite uncomfortable after eating and sometimes a bit nauseous.(3)
- My level of caloric does not go very high
or very low on a regular basis.(0)
- Sometimes when I overeat I will try to reduce my caloric intake to
almost nothing to compensate for the excess calories I’ve eaten.(1)
- I have a regular habit of
overeating during the night. It seems to be my routine to not be hungry in the morning but eat more during the night. (2)
- In my adult years I have week long periods where I overeat followed by periods
where I starve myself. (3)
- I usually am able to stop when I want to. I know when enough is enough.(0)
- Every so often I feel a compulsion to eat which I cannot seem to control. (1)
- Frequently I experience
strong urges to eat which I am unable to control, but at other times I am able to control my eating urges.(2)
- I feel incapable of controlling my urges to eat. I have a fear of not being able to stop eating voluntarily.(3)
- I don’t have a problem
stopping eating when I am full. (0)
- I usually can stop eating when I feel full, but occasionally overeat
leaving me feeling uncomfortably stuffed.(1)
- I have a problem stopping eating once I start and usually I feel
uncomfortably stuffed after I eat a meal.(2)
- I regularly eat uncontrollably and feel uncomfortably stuffed. (3)
· I seem to eat just as much with others as when I am by myself. (0)
· Sometimes when I am with other people I don’t eat as much because, I am self conscious about my eating. (1)
Frequently I eat only a small amount of food when others are present,
because I am embarrassed about my eating. (2)
am very embarrassed about my overeating and I pick times to overeat when I know no one will see me. (3)
- I eat three meals a day with an occasional between meal snack.(0)
- I eat three meals a day, but I also snack between meals.(1)
- When I am snacking heavily
I skip regular meals.(2)
- There are regular periods where I seem to eat continually with no planned meals.(3)
- I don’t
think much about trying to control unwanted eating urges.(0)
- At least some of the time I am preoccupied
with trying to control my eating urges.(1)
- I frequently spend more time thinking about how much I ate or
trying not to eat anymore.(2)
- It seems like most of my waking hours are preoccupied by thoughts about eating
or not eating. It’s a constant struggle trying not to eat.(3)
- I don’t think about food a great deal.(0)
- I have strong cravings
for food but the last only briefly.(1)
- I have days when I cannot think I of anything else but food.(2)
- Most days I am preoccupied by food. I feel like I live to eat.(3)
- I usually know whether or not I am hungry. I take the right portion
- Occasionally I feel uncertain about knowing whether or not I am physically hungry and its hard
to know how much food I should take to satisfy me. (1)
- Even though I might know how many calories
I should eat, I don’t have any idea what is the “normal” amount of food for me. (2)
Psychological Aspects of Obesity
Obesity is deeply intertwined with psychological issues such as depression,
anxiety, body image and stigma. Stigma often starts early in adolescents but is seen at all
ages and groups. It has been called the "last acceptable prejudice'. The vicious circle of depression and emotional eating perpetuates
a behavior that is difficult to break. Recent studies have shown that obese patients have higher rates of depression and other
psychiatric illnesses. It has also been shown that depressed patients tend to lose less weight after bariatric surgery compared
to the non depressed.
While many psychotropic
medications can cause weight gain there are weight neutral antidepressants that can reduce depression without weight
gain. It is very important to treat depression and anxiety in the obese patient because these illnesses can cause the
patient to binge and use food to "medicate" their symptoms. There are many limitations that obesity puts
on the patient. On a daily basis the obese patient has many more obstacles to deal with for normal day to day functioning.
Tying shoe laces, picking up things from the floor sometimes washing ones self can become very difficult and a source of much
distress and depression. Judicious use of the appropriate medication can reduce the depression and help the patient deal
with their symptoms. I feel it is very important to educate the patient of possible side effects and the fact that beneficial
effects take about 2-3 weeks with most antidepressants. While all antidepressants are equally effective I use the one that
is most effective for my patients because of its other effects like increasing energy or reducing anxiety or promoting sleep. Many
patients get depressed after bariatric surgery, because they "lose their friend" the food! The reality of not being
able to eat is very hard for many patients.
my patients are also on many other medical medications for their various other illness co morbid with obesity such as hypertension,
diabetes, increased cholesterol, Degenerative joint disease, Polycystic ovarian syndrome. One has to also use an antidepressant
that has fewer drug drug interactions. Most patients do well when started on an antidepressant or anti anxiety medication.
They report more motivation and improved ability to deal with food cravings.
Obese patients have shown body image and sexuality significantly
lower than non obese people. This is more pronounced in women and perhaps represents the cultural bias we have in our
society for women and weight. Sexuality and Obesity are homeostatic and therefore sexuality is reduced when weight
is gained and it improves when weight is lost. This can result in sexual problems after bariatric surgery,
where one partner has suddenly lost a lot of weight and "tipped the sexual balance". It is therefore important to
address these issues with the bariatric patients to improve their outcomes. Body image problems also surface in the post operative
period for the bariatric patient; they lose 50-70% of their excess fat in 18 months to two years. Body image and intimacy
groups can help the patient address these issues should they arise in the post operative period.
Please reference an article on Body Image and sexuality in obese patients
seeking bariatric surgery in the Bariatric Times.