Working with patients with weight-related chronic disease

There is considerable need for effective mental health treatment for patients with weight-associated health conditions. One in every 10 people in the United States has diabetes, for example, and they are 2 to 3 times more likely to have depression than people without the disease. One in 20 adults has coronary artery disease, and those suffering from heart failure, stroke, or a heart attack are at risk for depression, anxiety, and posttraumatic stress disorder (PTSD), according to the U.S. Centers for Disease Control and Prevention (CDC). And according to the CDC, having poor mental health can make it difficult for patients with these diseases to follow their medical treatment plans, which many times include losing weight as a cornerstone.

Psychologists often use such interventions as cognitive behavioral therapy (CBT) and psychoeducation to treat higher-weight patients struggling with chronic disease. The emphasis is on goal setting and problem-solving to lose pounds (Levinson, C. A., et al., The Behavior Therapist, Vol. 46, No. 7, 2023opens in new window).

Some patients will succeed with CBT and psychoeducation, but many do not: In randomized controlled studies, dieters did not lose significantly more weight than controls, and in prospective diet studies without controls, up to two thirds of dieters ended up weighing more than when they started (Hunger, J. M., et al., Social Issues and Policy Review, Vol. 14, No. 1, 2020opens in new window).

“One major problem with recommending weight loss for clients is that weight-loss interventions are ineffective,” said Margit Berman, PhD, an associate professor of clinical psychology at Augsburg University in Minneapolis. “A second problem is that weight-loss efforts are not neutral or free of risk.” They can lead to yo-yo dieting and a sense of failure and raise the risk of physical and mental health problems, she said (Markowitz, S., et al., Clinical Psychology: Science and Practice, Vol. 15, No. 1, 2008opens in new window; Kim, M. K., et al., Circulation, Vol. 138, No. 23, 2018opens in new window).

As a result, Berman and other psychologists who are experienced in working with this population are advocating for a different approach.

There is some evidence that a nondieting, weight-acceptance approach is effective at improving mental health and empowering patients to advocate for themselves in a world that stigmatizes weight (Dugmore, J. A., et al., Nutrition Reviews, Vol. 78, No. 1, 2020opens in new window).

Helping patients out of the negative cycle of ineffective dieting does not mean embracing the antidiet messaging of some large beverage, food, and supplement companies that encourages the unfettered consumption of their processed products. Practitioners should counsel patients to be wary of such messaging, especially from online influencers who are paid to promote these companies’ goods.

The World Health Organization (WHO) defines obesity—a term that proponents of body positivity say pathologizes fat people—as “abnormal or excessive fat accumulation that presents a risk to health.” Its prevalence has increased globally since the 1970s, according to the WHO. The National Health and Nutrition Examination Survey estimates that 42.5% of U.S. adults now have obesity, with the lowest prevalence among non-Hispanic Asian adults (17.4%) and the highest percentages among non-Hispanic White (42.2%), Hispanic (44.8%), and non-Hispanic Black adults (49.6%).

“There are a number of factors that go into the development of obesity,” said Tiffany Powell-Wiley, MD, MPH, an investigator with a joint appointment at the National Heart, Lung, and Blood Institute and the National Institute on Minority Health and Health Disparities. They include biology and genetics as well as social determinants of health such as access to healthy foods, opportunities for physical activity, exposure to racism, and income and job opportunities, said Powell-Wiley ( Progress in Cardiovascular Diseases , Vol. 78, 2023 opens in new window).

“When we try to make it as though it’s really about willpower and it’s only about what the patient can do, then we are stigmatizing the patient in some ways,” said Powell-Wiley.

It is important for clinicians to recognize the complexity behind variance in body weight, said Catharine Devlin, PsyD, CEDS-C, a clinical psychologist and a certified eating disorder specialist. “By and large, behaviors account for so little of the variance, and yet we’re making clients feel like it’s their fault” when clinicians unquestioningly advise behavior changes to promote weight loss, said Devlin, the founder of Birch Tree Psychotherapy in Chicago and South Barrington, Illinois.

Patients have likely already suffered adversity because of their weight. In national surveys, the Rudd Center for Food Policy and Health at the University of Connecticut found that 40% of adults with higher weight say they have experienced some form of weight stigma in their lives, whether it is unfair treatment, teasing, bullying, victimization, or discrimination, said psychologist Rebecca M. Puhl, PhD, the center’s deputy director. Family members and health care providers, including doctors, nurses, nutritionists, and mental health professionals, are some of the most common sources of weight stigma, often “assuming that people with higher weight are lazy, lacking in motivation, have poor self-control, and are at fault for their weight,” she said.

Psychologists may want to examine their own implicit biases and assumptions, said Devlin, who recommends they take the online Implicit Association Test for weight offered by Project Implicit, which was founded in 1998 by scientists from the University of Washington, Harvard University, and the University of Virginia to educate the public about bias and to collect data and conduct research.

Weight stigma has far-reaching consequences. “It is associated with increased risk of eating disorders, anxiety, depression, death by suicide, and poorer health outcomes,” said Cheri A. Levinson, PhD, an associate professor in the Department of Psychological and Brain Sciences at the University of Louisville who directs its Eating Anxiety Treatment (EAT) Laboratory and Clinic and has studied harms ( The Behavior Therapist , Vol. 46, No. 7, 2023 opens in new window). Weight stigma can also lead to lower patient trust in providers, poorer provider-patient communication, reduced quality of patient care, inadequate medical equipment to accommodate patients of diverse body sizes, poorer patient adherence and treatment outcomes, and patient avoidance and delay of care, according to Puhl’s research ( Gastroenterology Clinics of North America , Vol. 52, No. 2, 2023 opens in new window).

The most studied comprehensive lifestyle interventions for weight management have been face-to-face, weekly group meetings led by teams of experts from psychology, nutrition, and kinesiology, said Hollie Raynor, PhD, RD, LDN, a clinical psychologist and registered dietitian and the executive associate dean of research and operations in the College of Education, Health, and Human Sciences at the University of Tennessee, Knoxville. Participants discuss progress in reaching dietary and physical activity goals, solve problems, and share their challenges and successes. A psychoeducational component focuses on a behavioral strategy, such as goal setting, self-monitoring, or stimulus control, and a homework assignment to work on goals, said Raynor.

The focus is on changing behaviors to “improve health and help individuals with their weight, be that weight loss, weight-loss maintenance, or weight-gain prevention,” said Raynor. In scientific studies of these programs, “we see a large amount of variability in terms of response,” she said.

The Look AHEAD trial, funded by the National Institutes of Health, followed for almost 10 years adults with Type 2 diabetes who were overweight or had obesity, making it one of the longest studies of a comprehensive lifestyle program. Participants were randomized to either the intervention, which promoted weight loss through caloric restriction and increased physical activity, or to the control arm to receive diabetes support and education. The largest changes in behaviors and weight occurred at around 6 months. “But then there are challenges with maintenance over time,” said Raynor. Members of the intervention group lost, on average, 8.6% of initial body weight versus 0.7% for controls in the first year, but they regained weight and, by study’s end, had lost 6.0% versus 3.5% for controls (The Look AHEAD Research Group, New England Journal of Medicine, Vol. 369, No. 2, 2013opens in new window).

Still, on average, they did lose weight. However, that average figure “hides a difficult reality,” said Berman, in that close to half the people in the intervention arm of the study either gained back all the weight they lost by year 4 or never lost any weight at all (The Look AHEAD Study Group, Diabetes Care, Vol. 39, No. 8, 2016opens in new window).

Randomized controlled studies like the Look AHEAD trial involve “motivated participants, in highly controlled settings, doing state-of-the-art treatments, with perfectly trained clinicians—the best-case scenario,” said Berman, adding that the results are difficult to replicate in real life. In addition, 6% weight loss, or 12 pounds for someone weighing 200 pounds, is much less than the amount most patients expect to lose when they diet, she said.

“Even as an obesity intervention researcher, I don’t feel like the intervention I research is the right thing for every single person,” said Raynor. “People should go through that process with their health care providers to determine what is the right choice for them.”

“It is important for psychologists to understand that the relationship between weight and chronic disease is not a simple causal relationship” so that they do not reinforce the message to patients that the primary solution to chronic illness is weight loss, said Devlin. “The relationship between weight and disease is also confounded with weight stigma and weight cycling [losing and gaining weight repeatedly], which have negative health consequences that are often attributed to ‘obesity,’” she said.

When looking at the broad population, research shows that obesity increases the risk for high blood pressure and high cholesterol (risk factors for heart disease), Type 2 diabetes, asthma and sleep apnea, gallbladder disease, and stroke. According to the CDC, 13 cancers are associated with obesity, including thyroid, breast, ovarian, and pancreatic cancer. Obesity is typically defined as a body mass index (BMI) of at least 30.

But the picture becomes muddied at the individual level. Overall weight is less important than how fat is distributed, according to research. People who have more visceral adipose tissue—the fat that wraps around organs deep inside the abdomen and produces proteins and hormones that lead to chronic, low-grade inflammation—are at higher risk for diabetes and cardiovascular disease than someone who stores fat in their hips or buttocks or under the skin. Research has shown that “humans exhibit remarkable variability in body fat distribution for a given BMI” (Neeland, I. J., et al., Circulation, Vol. 137, No. 13, 2018opens in new window). In June 2023, the American Medical Association distanced itself from BMI, calling it “an imperfect way to measure body fat.”

The accuracy of BMI as a proxy for health risk is complicated by the obesity paradox. People with obesity who have established cardiovascular diseases, heart failure, end-stage renal disease, and cancer have a better prognosis compared with so-called normal-weight people (Neeland, I. J., et al., Circulation, Vol. 137, No. 13, 2018opens in new window).

In studies, the impact of comprehensive lifestyle programs for weight loss on physical health outcomes and mortality is mixed. For example, the Look AHEAD trial did not achieve its end point of reducing cardiovascular events and was ended several years early (The Look AHEAD Research Group, New England Journal of Medicine, Vol. 369, No. 2, 2013opens in new window).

On the other hand, results of the Diabetes Prevention Programopens in new window, a major study sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), showed that modest weight loss, dietary changes, and increased physical activity can reduce the incidence of Type 2 diabetes in people at high risk for the disease (Diabetes Prevention Program Research Group, New England Journal of Medicine, Vol. 346, No. 6, 2002opens in new window).

Perpetual dieting carries risks for patients’ mental and physical health, said Berman. Repeated failure at reaching unrealistic goals can increase risk for depression, and weight cycling can harm mental and physical health, she said (Quinn, D. M., et al., PLOS ONE, Vol. 15, No. 9, 2020opens in new window; Gaesser, G. A., & Angadi, S. S., iScience, Vol. 24, No. 10, 2021opens in new window). In Devlin’s clinical experience, she has found that chronic dieting can lead to or exacerbate eating disorder behaviors, which are strongly associated with negative health outcomes.

Psychologists may find their higher-weight patients asking for advice about taking GLP-1 receptor agonists, a new class of drugs that has been approved by the U.S. Food and Drug Administration for diabetes management and more recently for weight loss under the names Wegovy and Zepbound.

Oprah Winfrey, Tracy Morgan, Emily Simpson, and other celebrities have talked publicly about taking the drugs, and demand is outstripping supply. In one clinical trial of semaglutide, the active ingredient in Wegovy, participants lost, on average, 15.2% of their body weight at 104 weeks with medication plus lifestyle changes. That compares with 2.6% weight loss for controls (Garvey, W. T., et al., Nature Medicine, Vol. 28, 2022opens in new window). More recent clinical trials found that the drugs significantly cut heart failure symptoms and the risk of heart attack and stroke. The journal Science named GLP-1 drugs the Breakthrough of the Year (Couzin-Frankel, J., Science, Vol. 382, No. 6676, 2023opens in new window).

But the drugs are prohibitively expensive and often not covered by insurance. They have side effects, like nausea and vomiting, and weight loss seems to plateau after a year. If a patient stops taking the drug, much of the weight returns, and the health benefits disappear.

Psychologists can help patients who ask about the drugs gain a deeper understanding of them. “And clients should know that we don’t have long-term data on either efficacy or safety” because trials of the drugs lasted no more than 2 years, said Berman. For example, both Wegovy and Zepbound have a boxed warning of a risk for thyroid C-cell tumors, based on animal studies, but it will take years to know whether they are associated with a higher risk in humans for this rare cancer (Ruder, K., JAMA, Vol. 330, No. 22, 2023opens in new window).

Evidence supporting nondieting, self-acceptance approaches for enhancing physical health in patients with chronic diseases should be considered preliminary, but nondieting approaches “have substantially lower attrition,” said Berman, and research suggests that they are comparable or superior to weight loss in terms of psychological outcomes (Dugmore, J. A., et al., Nutrition Reviews, Vol. 78, No. 1, 2020opens in new window; Rauchwerk, A., et al., Journal of Nutrition Education and Behavior, Vol. 52, No. 11, 2020opens in new window). In her practice, Berman uses a treatment approach and training for clinicians that she has developed called Accept Yourself which follows these principles.

Psychologists should first be prepared to advocate for weight acceptance, said Berman. For example, “Can we get ourselves on wellness committees in our workplaces, which are often very weight focused, and work for change there?” she asked.

Psychologists should also be prepared to speak with a patient’s health care providers, said Berman. For example, Rachel Millner, PsyD, CEDS-S, CBTP, a clinical psychologist and certified eating disorder specialist in Newtown, Pennsylvania, discusses with doctors how weight-loss attempts are often unsuccessful and how weight cycling is harmful, and she will ask them to offer the same care and advice they would offer a thin person.

Both Berman and Millner also help patients become better self-advocates. “Some of my clients do well with writing out some boundaries before they go to the doctor’s appointment because they know that when they get there, it’s too hard for them to speak up,” Millner said. They will hand the doctor the document, which might say, “Don’t weigh me; don’t discuss my weight.”

“I’ve coached patients to say, ‘I have knee pain and you’re telling me to lose weight, but I’m just curious, what would you say to a thinner person who also has knee pain?’” said Lauren Muhlheim, PsyD, FAED, CEDS-S, a clinical psychologist and certified eating disorder specialist in Los Angeles, adding that there are always other solutions, such as pain management or physical therapy. “Physicians just don’t often consider them when they see a patient in a larger body,” said Muhlheim.

Psychologists may want to work with patients on body image and self-acceptance, said Muhlheim, who uses a CBT workbook on self-compassion. “When people in larger bodies are sold weight loss, they’re often kind of putting their lives on hold and waiting for their lives to start until after they’ve achieved this weight loss,” she said.

Instead, Muhlheim’s goal is to help them start building a life now. For example, she encourages patients to clean their social media feeds and unfollow influencers who are promoting a thin ideal. “I encourage people to deliberately follow more diverse bodies,” Muhlheim said.

While Berman’s approach of self-advocacy and self-acceptance does not focus primarily on patients changing individual behaviors, it does include the principle of eating for well-being. “That means having flexible, individualized eating behavior that is based on internal hunger cues, not a number on a scale or a calorie target,” she said, adding that listening to and trusting one’s body can be a radical idea for patients with a long history of weight stigma and multiple weight-loss attempts. When it comes to exercise, clinicians should support movement as a joyful aspect of life and not a moral requirement, said Berman.

Sometimes medical providers make recommendations that can be harmful to patients with eating disorders, Devlin said, because they may not be well versed in psychology. “I have a client with Type 1 diabetes who is struggling with high blood sugar at night, and she also has an eating disorder. Her endocrinologist told her, ‘Don’t eat after 8 p.m.,’ which is a terrible idea because then she’s going to start night eating.” In patients with eating disorders, loss of control over food consumption is a common effect of attempts at dietary restraint, she said. Psychologists should be prepared to educate such a provider, said Devlin, who also recommended that psychologists not experienced in eating disorders refer the patient out or consider getting trained.

Levinson recommends that clinicians think carefully about the office environment and ask themselves if they have chairs, for example, that are suitable for all body types or pictures on the wall of only thin people.

“It is really important to think about creating an inclusive environment,” she said.