Family Health Stressor Overweight and Obesity

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Obesity Family Stressor 2

Family Health Stressor Overweight & Obesity

Overweight and obesity is increasing in virtually

every ethnic, racial and socioeconomic population, in both

genders and in every age group (AOA, 2002) it is second

leading cause of preventable death in the United States,

exceeded only by smoking (AAHC, 2007). Quality of life

decreases and chronic medical conditions increase with

increasing body mass. Overweight and obesity is a serious

problem in the United States doubling in both children and

adults in the last twenty years (Gamm, Hutchison, Dabney, &

Dorsey, Vol.1, 2003). Obesity is a social problem affecting

well-being of individuals, families and society as a whole

(CDC, HC, AAG 2008). It now threatens to shorten the lives

of many people, is directly related to numerous health

complications, physical disability, reduced quality of

life, psychosocial issues and discrimination (Gamm,

Hutchison, Dabney, & Dorsey, Vol.1, 2003).

Population At Risk

All Americans, urban, suburban and rural at every age

and every socioeconomic level are at risk for issues

related to excess body mass. Between 1983 and 2003 Missouri

experienced large increases in overweight and obesity in


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every major maternal demographic (DHSS, 2004). Forty-

percent of Missouri children and adolescents are at risk of

becoming overweight or obese (Bihr & Klein, 2005), while

thirteen percent already are (Gamm, Hutchison, Dabney, &

Dorsey, Vol.1, 2003). As of 2008, 71.7 percent of adult

males and 56.9 percent of adult females in Missouri were

overweight or obese, above the national averages of 69.0

percent and 52.2 percent respectively (KFF, 2008).

Overweight and obesity is a serious issue resulting in

loss of physical functioning, loss of productivity, pain

and suffering, psychosocial issues, depression and

premature death (CDC, 2008). It is clear simply by the

magnitude of this issue every physical and mental health

practitioner should expect to interact with clients related

to the physical, emotional or social effects related to

overweight or obesity at some point in practice.

Cause & Complications

A persons body weight is a result of the complex

interaction of genes, metabolism, behavior, environment,

culture and socioeconomic status (CDC, 2007). Obesity has

been linked to substantially increased mortality risk from

all causes. Including arthritis, type 2 diabetes,

hypertension, birth defects, breast cancer, endometrial


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cancer, colon cancer, dyslipidemia, stroke, cardiovascular

disease, gallbladder disease, sleep apnea and respiratory

problems, infertility, obstetric and gynecological issues

and complications, urinary stress incontinence,

osteoarthritis and psychosocial disorders (CDC, 2008).

Complications and medical conditions as a result of excess

body weight are common and relatively easy to develop.

Gaining as little as five percent or 11 to 18 pounds over a

normal body weight can increase risk of type 2 diabetes and

heart disease. When BMI exceeds 30 the risk of death

related to obesity increases by 50% (AOA, 2002).

Adolescents who are overweight face increased health

risk, as excess body weight tends to persist into

adulthood. Chronic health conditions and increased risks

related excess adolescent body weight include

atherosclerosis, diabetes, coronary heart disease, hip

problems and gout (Gamm, Hutchison, Dabney, & Dorsey,

Vol.1, 2003).

Family Health Considerations

Overweight and obesity has dramatic implications for

the health of individuals, families and communities. Body

weight issues may be a primary, secondary or tertiary cause

of disability, stress, distress, depression or other


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psychosocial, emotional or familial issues related poor

health, disability of a family member, premature mortality,

and or familial conflict (AOA, 2002). Overweight and obese

individuals also often suffer stigma and discrimination

(Gamm, Hutchison, Dabney, & Dorsey, Vol.1, 2003) as a

result of American societies depreciation of the overweight

and obese and a pro-slender muscular bias (Swami, Furnham,

Amin, Chaudhri & Josht, 2008). Stigma and discrimination

suffered by one family member often affects the whole

family or extended family unit (Zastrow, 2007), and may

underlie issues prompting clinical intervention.

There has been a great deal of research related to

overweight and obesity over the last few years, but a clear

path to successful holist social level prevention remains

elusive. What is known at this time is that numerous

environmental and behavioral factors significantly

contribute to the imbalance that results in weight gain

leading to increasing body weight, overweight, obesity and

the psychosocial issues related to them for individuals and

families. Because behavior and environment contribute

substantially to weight issues it is in these areas the

most benefit can be gained (CDC, 2009).

Changes in micro and mezzo level cognitive, behavioral

and social relationships and settings have been shown to


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provide benefit (CDC, 2008). Between 300,000 and 600,000

lives could be saved in the United States each year if

Americans would maintain healthy body weights (AAHC, 2007).

The serious and far reaching changes within the social

environment have and continue to make it increasingly

difficult for individuals and families to engage in health

promoting behaviors including participating in daily

regular physical activity which has been found to

substantially contribute to the maintenance of a healthy

body weight (MMWR, 2003).

It is currently believed based upon previous research

and program efforts that for interventions to be successful

they must incorporate a decrease in fat and calorie intake

and an increase in physical activity across time. Changes

in multiple social settings increase success including

home, family, work, school and community. Macro level

societal changes such as media and healthcare policy would

also be beneficial in helping Americans lead healthier and

more physically active lives (Gamm, Hutchison, Dabney, &

Dorsey, Vol.1, 2003) and should be a focus for all

clinicians seeking to improve the psychosocial welfare of

Americans.

While there is compelling evidence that physically

active people are less likely to become obese (Shah, 2007)


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in 2001 less than half of the adults in the United States

were active enough to meet the recommendations for physical

activity consistent to reduce the risk premature mortality

(MMWR, 2003). As of 2007 only 32.8% of Missouri adults

engaged in regular, vigorous, sustained physical activity.

Clinical Considerations

The research has consistently shown that just 5%-10%

of body weight loss can ameliorate many of the chronic

medical conditions associated with overweight and obesity.

Small changes in multiple areas that are emotionally,

physically, economically and socially sustainable should be

emphasized (CDC, 2007). Compelling evidence that physically

active people are less likely to become obese (Shah, 2007)

and should be a primary emphasis in any holistic

intervention plan of treatment with a goal of 30 to 60

minutes of moderate to intense physical activity each day a

minimum of three days each week (AHA, 2006). Coupled with

reduced calorie and fat consumption and increased fruit,

vegetable and fiber consumption. In effect increasing

nutrients and activity while decreasing calories in order

to reach a total calorie deficit weekly or monthly as may

be appropriate based on client need and primary problem

presentation.


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It is critical practitioners be prepared and adept at

operating within a multidisciplinary team with the client

as a central figure if true long-lasting change is to be

maintained. It is critical that practitioners are acutely

aware of the pressures body weight and the stresses related

to overweight and obesity and related complication have on

clients and family systems. Especially in light of the fact

that eating disorders often go undetected and untreated

because most patients do not actively volunteer information

related to weight, food and eating behaviors and a vast

majority of clinicians across care fields fail to ask

(Schumann & Hickner, 2009). Overweight, obesity and related

psychosocial and medical complications must be considered

and assessed as a regular point of interest in any family

health assessment. It is currently estimated that as few as

10% of those who suffer with disordered eating and food

issues ever receive any treatment (Schumann & Hickner,

2009). In addition, to delving into familial patterns and

practices surrounding health including medical conditions,

home practices and compliance with medical and care

regimens. Data shows that family plays a role in

development of asthma and diabetes, a clear indication of

the importance of family influence on physical health and

well-being (Yuen, Skibinski & Pardeck, 2003).


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Biopsychosocial and biobehavioral treatments have been

found to be effective in the treatment of overweight and

obesity and may include gradually restricting and or

eliminating stimuli that elicit maladaptive eating patterns

and behaviors (Gatchel & Oordt, 2004). Family involvement

in the treatment of body weight issues and medical regimen

maintenance has been show to increase compliance and

promote weight loss (Yuen, Skibinski & Pardeck, 2003).

Client sensitivity to familial criticism are associated

with high rate of relapse (Yuen, Skibinski & Pardeck,

2003). Clinicians should explore how each individual and

family react to stress, the attitudes and behaviors

surrounding health services and practices, the relationship

between family functioning and individual well being

including the physical, mental, emotional and social

aspects (Yuen, Skibinski & Pardeck, 2003).

Gatchel and Oordt offer guidance for successful

collaboration with primary care providers suggesting a

three part process for treatment plan development for

overweight and obese clients including, classification of

degree of issue, the more severe the problem the more

aggressive and intensive the treatment. A stepped care

approach, least invasive, least expensive and least

dangerous treatments first, ranging from self-directed to


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commercial or behavioral programs to in-patient or surgical

interventions. All should include private counseling in

order to increase efficacy and long=term weight

maintenance. Selection of a specific program should be

based on individual needs and preferences of the client and

not on clinician preference or regimentation of services

(Gatchel & Oordt, 2004).

Dieting issues clinicians should be aware of include

the use of diet to achieve substantial weight loss for

those with substantial looming or advancing complications.

Very low calorie diets, 800 calories per day and low

calorie diets 800 to 1500 calories per day are now

considered safe for outpatient populations. Collaboration

with other professional should be emphasized as support and

oversight can improve outcomes and decrease complications

(Gatchel & Oordt, 2004). Mental health practitioners should

seek permission to discuss clients cases as may be

appropriate or necessary with physicians, dietitians or

other professionals with which the client is closely

working to increase client benefit and decrease conflicting

recommendations. It is critical that respectful mutuality

in professional relationships be cultivated in this type of

an arrangement ensuring the client is not faced with


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conflicting or competing orders or regimens that could

exacerbate client stress (Gatchel & Oordt, 2003).

When working with children and adolescents clinicians

must work within the family unit and often a multiple

disciplinary team in order to meet the unique challenges of

adolescents with body weight issues and complications.

Research has suggests that chaotic food and eating routines

can be targeted as a focus for behavior change. Finding

that ordering eating within the family context can be used

effectively to promote health within the family environment

(Kime, 2009). Ordered lifestyle as a basic framework,

including family members eating together in the same room

at a table without external influences, increasing the

inherent value of meal time as an occasion focusing on

mealtime and togetherness (Kime, 2009). In addition to

targeting individual and parenting behavioral based

practices to increase making fruits and vegetables easily

accessible, placing appropriately nutritious prepared

within easy reach in appropriate portion sizes, recognition

and conscious understanding that individuals and parents

have substantial influence over food availability within

the home and that availability and accessibility of foods

are strong predictors of consumption (Rhee, 2008). Physical

activity frequency, duration and intensity are also related


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to social environment and specific attention should be

focused on increasing physical activity frequency, duration

and intensity within the family system and not simply

focusing on the individual who has developed issues or

complications. The data clearly shows that risk factors

often impact the whole or extended family system (CDC,

2008).

Careful consideration and attention should be given to

increasing positive interaction and reducing criticism of

depressed children or adolescences with the body weight

issues or complications as depression often increases

vulnerability to family criticism and family criticism is

associated with high rates of relapse. Marital conflict

should also be addressed as it frequently accompanies

depression and can impair the functionality of families and

limit support available to children with chronic health

issues (Yuen, Skibinski & Pardeck, 2003).

In addition to children and adolescences, other

populations of special attention for clinicians should be

the aging and persons of color. The aging population was

previously believed to be at low risk for eating and weight

related disorders, but as the population of the United

States has aged, like wise has overweight and obesity

issues expanded to this population. Issues within the aging


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population may be compounded, especially for aging

overweight or obese women. As overweight and obese women

often bear the brunt of severe social criticism related to

body weight, often popularly characterized as diseased,

unhealthy, lazy, weak and or impulsive (Gamm, Hutchison,

Dabney, & Dorsey, Vol.1, 2003). As women age they are more

likely, as compared to aging males, to show a preference

for thinner bodies compounding the numerous physical

changes that accompany aging. (Ferraro at el. 2008).

Research has found the salience of body image as a

pervasive concern for women across the life cycle and is

often compounded by aging, with the increased likelihood of

weight related medical and health complications (Ferraro,

Muehlenkamp, Paintner, Wasson, Hager & Hoverson 2008), loss

of support systems through death or relocation and other

age related physical, social and environmental pressures.

American society powerfully and pervasively

stigmatizes the overweight and obese through a social

ideology that attributes negative life outcomes to negative

personal characteristics (Swami et al. 2008). Compounding

this slender bias is the youth culture, in effect doubling

the pressure of older women to meet social expectations of

slenderness (Swami, Furnham, Amin, Chaudhri & Josht, 2008),

and youth, all while the normal age related life cycle and


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role changes of aging continue to mount increasing pressure

for those at risk within this population. One critical

consideration for clinicians is the finding that overweight

older women have been found to be significantly more

concerned with their bodies than normal weight women of the

same age, this could reflect a logical understanding of the

health related risk surrounding overweight and obesity

rather than simply internalization of the slender social

standard (Swami et al., 2008). Clinicians should be aware

of this and assess older women presenting with body weight

related issues for psychosocial distress compounded by the

normal aging process and role change related to the family

life cycle being conscious to address any findings

appropriately (Carter & McGoldrick, 2005).

Research now suggests that body weight dissatisfaction

and assimilation of Western beauty ideals or thinness

cultural norms have been found at increasing rates in black

female student of divergent backgrounds both urban and

rural. Findings suggesting similar prevalence of hazardous

weight management practices, disordered eating attitudes

and behaviors, and retrained eating patterns, to white

groups (Senekal, Steyn, Mashego & Nel (2001). Problems with

body shape dissatisfaction, disordered eating behaviors and

attitudes and dietary restraint are highly interrelated and


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should be examined closely by clinicians (Senekal, Steyn,

Mashego & Nel (2001). The number of weight loss attempts

was found to be lower in black females they were found to

more often use hazardous methods (Senekal, Steyn, Mashego &

Nel (2001). Clinical consideration and investigation should

be detailed as to previous weight loss methods used, age

related developmental milestones, familial and social

internalization of idealized thinness, which may be

underlying womens weight loss attempts. Efforts should be

made to emphasize health rather than the thinness ideal and

the inherent value of every individual regard less of body

weight.

Another issue of concerning overweight and obesity

treatment is binge eating disorder (BED) which has been

found to be triggered by negative affective states and

dietary restraint related to weight loss efforts (Friedman

2008). Clinicians need to be cognizant of the recurrent

nature of BED and treat accordingly. Clinicians should

focus on acute episode behavioral techniques and relapse

prevention while encouraging and supporting clients to

adhere to calorie restricted dietary interventions and

regimens (Friedman, 2008). Careful assessment to determine

underlying issues including client feelings of being out of

control with food, eating until vomiting or feeling sick,


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food seeking behaviors including leaving the home to obtain

food for the purposes of binging (Friedman, 2008).

Cognitive behavioral therapy (CBT) or other behavior

modification interventions should be used to reduce

reoccurrence and relapse. Standard protocol for CBT for BED

has been found to be effective in treatment of BED, which

includes a physical and dietary assessment to rule out

medical causes or complication, dietary support and

nutrition therapy. Individual therapy, daily-self

monitoring, journaling and prescribed eating pattern to

reduce compulsive eating and removing emotional decision

making from eating schedule and food choice.

Psychoeducation to identify common cognitive distortions,

automatic thoughts and affective triggers and behavioral

strategies have been shown to be very useful in delaying

acting upon binge urges (Friedman, 2008). A useful tool in

relapse prevention can be the use of structured planned

binges suggestions include choosing in advance the time,

limiting the trigger foods to a total of 300 calories,

after dinner with at least one other person in the room

(Friedman, 2008). Planned binges serve to diffuse tension

related to not binging, removing the function of the binge

behavior reducing its desirability and allowing for

variety, making client dietary restrictions easier to


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adhere to, the ultimate goal of planned binges should be

one bi-weekly planned binge of 300 calories or less

(Friedman, 2008).

In addition to the numerous issues previously

discussed it is valuable to note that assessment of current

medication regimen is also of great value to a clinicians.

Numerous medications have weight gain as a well known side.

As well as there are several medications currently that

have been shown to benefit weight loss efforts and weight

maintenance Gatchel & Oordt, 2003). It can be of great

benefit to understand and examine current medical regimens

with a holistic understanding of the side effects, intended

or unintended, as well as the pharmaceutical resources

available to assist clients in meeting their weight loss

goals.

Overweight and obesity is increasing in virtually

every ethnic, racial and socioeconomic population, in both

genders and in every age group (AOA, 2002). As the second

leading cause of preventable death in the United States,

(AAHC, 2007) clinicians must be aware of the challenges and

resources available to serve this increasing and

increasingly vulnerable population. With emphasis on

quality of life and amelioration of chronic medical

conditions mental health practitioners can serve a vital


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function in the treatment of the excess body weight and

obesity.


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Documents

Family Health Stressor Overweight and Obesity