Social Phobia

Obesity is defined with the body mass index (BMI)

Body Mass Index (BMI) is a relationship between weight and height that is associated with body fat and health risk. Weight is converted to kilograms; height is converted to meters and then squared. Thus, BMI = kg/m2.

Body Mass Index

Advantages of the BMI

  • It's easy to look up on a chart
  • Many studies have identified the health risks associated with a wide range of BMIs (both high and low values.)
  • Disadvantages of the BMI

  • It can misclassify up to one out of four people.
  • It does not take into account location of body fat.
  • It cannot accurately classify elderly individuals who are frail and sedentary.
  • It cannot accurately classify body builders.
  • It does not distinguish between body fat and lean body mass.
  • Obesity increases the risk of developing physical conditions including:

  • high blood pressure
  • type 2 diabetes
  • heart disease (high cholesterol)
  • stroke
  • gall bladder disease
  • joint pain from excess uric acid (gout)
  • sleep apnea (interrupted breathing during sleep)
  • cancer of the breast, prostate, colon, kidney, endometrial
  • osteorthritis (wearing away of joints)
  • premature death (300,000/yr in U.S., 2nd only to smoking)
  • Obesity increases the risk of mental conditions including: Negative self-image (Holm et al, 2001)

    Epidemiology: Where and among whom is obesity a problem?

  • According to the Center for Disease Control and Prevention (CDC) more than 60% adult Americans are overweight or obese.
  • Percent of adults in the U.S. who were overweight in: 1980: 33% 1999: 35%
  • Percent of adults in the U.S. who were obese in: 1980: 15% 1999: 27%
  • Number of states where the obesity rate was greater than 15% in: 1991: 4 1998: 37
  • State with the greatest percentage of obese people: Mississippi (22%)
  • State with the smallest percentage of obese people: Arizona (12.7%) Mokdad found Colorado lowest
  • Annual number of deaths attributed to excess weight and inactivity: 300,000
  • According to the Behavioral Risk Factor Surveillance System

    (Mokdad et al., 2001) study of 184,450 adults in the U.S. in 2000, regarding the prevalence of obesity:

    Obesity % by Gender

    Male 20.2%
    Female 19.4%

    Obesity % by Age

    age 18-29 13.5%
    age 30-39 20.2%
    age 40-49 22.9%
    age 50-59 25.6%
    age 60-69 22.9%
    age 70+ 15.5%

    Obesity % by Education

    Less than High School 26.1%
    High School grad 21.7%
    Some College 19.5%
    College degree+ 15.2%

    Obesity % by Physical Activity

    Inactive 27.0%
    Irregularly active 28.2%
    Regular, not intense 30.5%
    Regular, intense 14.3%

    Obesity % Fruit and Vegetable Consumption

    less than 1 4.0%
    1 to <3 33.1%
    Intake 3 to <5 38.5%
    >=5 24.4%

    Weight Control Practices

    People trying to lose wt. 38.5%
    Trying to maintain wt 35.9%
    Neither 25.6%

    Neural Mechanisms Associated with Obesity

    The hypothalamus controls energy homeostasis and the motivation to eat, that is, it contains axons and synapses of neurons that control feeding. The lateral hypothalamus is associated with hunger and the medial hypothalamus is associated with satiety. Lateral hypothalamus (LH) cells are inhibited by increases of norepinephrine and disinhibited by norepinephrine depletion.

    Norepinephrine or epinephrine and dopamine can act in the lateral hypothalamus (LH) to curb feeding. However, dopamine agonists help restore reactivity to food and excess dopamine in parts of the striatum or accumbens may be a source of obesity. Thus, DA seems to potentiate feeding and reward in the accumbens and suppress feeding in the LH.

    Serotonin either potentiates the paraventricular nucleus medial hypothalamus (PVN-MH) satiety system or inhibits the LH feeding system.

    Appetite for specific macronutrients is controlled by specific neurotransmitters. Serotonin affects diet choice and is itself affected by the diet under certain circumstances.

    Etiology: Models that theorize on the causes for obesity.

    Caused by energy intake persistently exceeding metabolic energy expenditure- eating too much, exercising too little, or a combination of both.

    Once attributed mainly to lack of will power, obesity is now understood to result from a complex interaction of genetic, developmental, metabolic, behavioral and environmental factors.

    80% of obese patients are FH+ for obesity. Learned dietary habits may account for some obesity but twin studies and animal breeding studies indicate genetics is also a risk factor for obesity.

    Developmentally, the number of fat cells is established early in life and not very susceptible to change. Overweight children establish more adipocytes and maintain them into adulthood.

    Hunger is the metabolic signal to eat. Satiety is the feeling that results from hunger being satisfied. Most people are predisposed to a preference for higher fat foods, which are slower to produce satiety than low fat foods.

    The olfactory system plays a role in hunger and satiety.

    Appetite, the desire to eat, can be increased by psychological factors like thoughts or feelings. Binge eating can be a reaction to stress.

    Obese people are more susceptible to external stimuli to eating such as food cues in the environment and they are less responsive to internal hunger. Some obese people are unable to distinguish hunger from other sources of dysphoria.

    A decrease in the amount of daily activity related to work, transportation and personal chores is believed to contribute to the high percentage of overweight and obesity today.

    Recommendations for Treatment of Obesity

    Dietary Therapy

    Dietary therapy involves instruction on how to adjust a diet to reduce the number of calories eaten.  Strategies of dietary therapy include teaching about calorie content of different foods, food composition (fats, carbohydrates, and proteins), reading nutrition labels, types of foods to buy, and how to prepare foods.

    Physical Activity

    Moderate physical activity, progressing to 30 minutes or more on most or preferably all days of the week is recommended for weight loss.

    Behavior Therapy

    Behavior therapy involves changing diet and physical activity patterns and habits to new behaviors that promote weight loss. Behavioral therapy strategies for weight loss and maintenance include:

  • Learning to recognize external cues to eating. This can be done by recording diet and exercise patterns in a diary.
  • Learning new eating patterns, such as eating more slowly, eating sitting down, not eating while watching television.
  • Identifying high-risk situations (such as having high-calorie foods in the house), and consciously avoiding them.
  • Operant conditioning such as rewarding specific actions, such as exercising for a longer time or eating less of a certain type of food.
  • Changing unrealistic goals and false beliefs about weight loss and body image to realistic and positive ones.
  • Developing social supports (family and friends) or participating in a support group such as Overeaters Anonymous.

    Four common behaviors of successful weight losers

    (Bren, 2002)

    (study of 3,000 Americans that lost an average of 60 lbs and kept it off 6+ years)

    Drug Therapy

    Drug therapy is recommended as a treatment option for persons with:

    Drug therapy may be used for weight loss and weight maintenance.

    Three weight loss drugs, approved by the US Food and Drug Administration (FDA) for treating obesity, are orlistat, phentermine, and sibutramine. Orlistat (Xenical) is a lipase inhibitor that works by blocking about 30% of dietary fat from being absorbed. It is the most recently approved weight loss drug Phentermine is a cerebral stimulant that suppresses the appetite by increasing norepinephrine levels. It has been available for many years. The use of phentermine alone has not been associated with the adverse health effects of the fenfluramine-phentermine (fen-phen) combination. Tolerance to amphetamines is common. Sibutramine (Meridia) is an antidepressant that suppresses appetite by inhibiting reuptake of serotonin, norepinephrine and dopamine. It is approved for long-term use. Although prolonged use of serotonergic agonists for depression has been associated with weight gain.


    Obesity surgery is recommended as a treatment option for persons with obesity that have a BMI > 40 or a BMI of 35 to 39.9 with serious medical conditions. Obesity surgery is used to modify the stomach and or intestines to reduce the amount of food that can be eaten.


    Bren, L. (2002). Losing weight: more than counting calories. FDA Consumer 36(1) 18-26.

    Holm, K., Li, S., Spector, N., Hicks, F., Carlson, E., & Lanuza, D. (2001). Obesity in adults and children: a call for action. Journal of Advanced Nursing.36(2). 266-269.

    Kaplan, H.I. & Sadock, B.J. (1998). Synopsis of psychiatry. 8th Ed. Baltimore, M.D., Williams & Wilkins.

    Mokdad, A., Bowman, B.A., Ford, E.S., Vinicor, F., Marks, J.S., & Koplan, J.P. (2001) The continueing epidemics of obesity and diabetes in the United States. Journal of the American Medical Association. 286(10) 1195-1200.

    Stunkard, A.J., & Wadden, T.A. (1993). Obesity theory and therapy. New York, NY: Raven Press, Ltd.