Obesity and the role of psychology
More than half of Australian adults are either overweight or obese with a total estimated annual cost to Australia of $21 billion (Colagiuri et al., 2010). Obesity’s relationship with chronic disease involves avoidable suffering that impacts heavily on the public health system through exacerbation of co-morbid conditions and consumption of hospital inpatient/outpatient resources.
Systemic responses to weight problems tend to be polarised between the primary and tertiary interventions of dietetic advice and bariatric surgery. Both are important weight reduction interventions. However, because diets don’t work (Mann et al., 2007), and people often don't want or can’t access surgery, there is a significant gap in service delivery for the overweight and obese. Further, because poor bariatric surgery matching can be psychologically detrimental, candidates require detailed pre-surgical preparation and post-surgical support to optimise outcomes.
Psychologists, have a key role in understanding and responding to this service delivery gap. Given their experience in research, program development and outcome evaluation, public health psychologists have an especially important role in developing alternatives for those unlikely to benefit from dieting alone or who cannot or choose not to undergo surgery.
Reconceptualising the aetiology of obesity
One of the impediments to optimal treatment matching and effective intervention is the failure to understand causality. Obesity is often seen as the primary presenting problem, rather than the secondary impact of various presenting problems. Seeing obesity as an energy-in/energy-out=residual stored equation can miss the critical question of whether obesity is primarily a physiological or psychological issue for the individual. Weight is physiological, but eating is behavioral and motivated by clusters of intra-personal, socio-historical and environmental factors.
There are many investigators who have proposed that obesity’s aetiology needs to be reconceptualised to target more than diet, exercise and motivation for change. They propose that understanding it as a problem of Eating Style (e.g., Van Strien, et al., 1986), or an individual’s relationship with food can help produce more effective interventions by reframing and resituating the problem for the individual.
Three Eating Style types have been identified (Van Strien et al., 1986). External eaters tend to be governed by the environment and external influences. Restrained eaters tend toward the yo-yo weight loss/gain patterns related to psychological inflexibility. Emotional eaters tend to rely on food to regulate positive and negative emotional states. In this model, Eating Styles are not considered as categorical but rather people tend toward one, with secondary features of others.
Innovation to address the service delivery gap: the “Food for Thought” program
A client driven approach is central to the operation of the Food for Thought program at the Tasmanian Health Service’s Northern Integrated Care Service (THSNICS). The THSNICS integrates service delivery from primary health providers, while interfacing with the acute public health system. Psychologists within the THSNICS work across primary and acute service delivery domains, providing psychological care for people with chronic and acute medical conditions.
Designed in collaboration with the University of Tasmania, the Food for Thought program is an innovative, eight week psycho-dietetic group program, co-facilitated by a psychologist and dietitian, for people with long term weight problems.
The program neither sets weight loss goals nor promotes a dieting/exercise regime. Rather, its outcomes (recently presented at the 2016 Eating Disorder & Obesity Conference) are achieved through accommodation of the unique needs of each individual’s Eating Style profile via the delivery of psycho-education, insights and strategies adapted from several international evidence-based psychological, dietetic and health approaches.
Comprehensive mixed methods evaluation demonstrated exciting outcomes, including food-related behavioural shifts, significant shifts in measures of external and emotional eating styles and quality of life domains, and objective outcomes like Body Mass Index and weight reductions. Qualitative feedback showed program participants viewed their relationships with food markedly differently post participation. These outcomes, and the high levels of participant retention and satisfaction with the intervention, contributed to the Food for Thought program receiving the Consumer Centred Pathways Award at the 2015 Tasmanian Allied Health Professional Awards.
Weight, psychology and public health
The application of psychological knowledge and expertise can assist our understanding of obesity’s causal and perpetuating factors: fundamental problems of orientation, adjustment and attachment in the individual’s long term relationship with food. Psychologists working with other disciplines in implementing the scientist-practitioner model of health research and program development contribute to addressing Australia’s major health issues.
The Food for Thought program is an innovative example of where psychology is improving outcomes for individuals with long term weight problems. The public sector provides ideal environments for the design, delivery, and evaluation of innovative obesity interventions, and the Food for Thought program illustrates how public sector psychologists can lead research in the delivery and evaluation of vital innovations in health interventions.
The author can be contacted at [email protected]