Is Obesity Really an Internal Medicine Problem?

Background

Obesity is a chronic and multifactorial disease and has become a worldwide epidemic with devastating health and economic consequences. In 2015, there were an estimated 603.7 million adults and 107.7 million children with obesity worldwide and the rate of obesity had doubled in nearly half of countries since 1980 [1]. Obesity is a disease that can directly reduce life expectancy [2,3]. Obesity affects essentially every organ system in the body and is a risk factor for many morbid conditions, the most impactful of which are Type 2 Diabetes (T2DM), Hypertension (HTN), dyslipidemia, Cardiovascular Disease (CVD), and some cancers [4].

The problem of excess

Excess is thus both excess of desires-an emotional excess-and excess of things (like food): the more you have, the more you desire [5]. We live with the culture of too much and the commercial push towards hyper-consumption is very strong. There is a lot of food available, food designed and produced to cause pleasure in those who consume it so as to induce greater consumption than what would happen with simpler and less refined food.

Compensatory use of food

Pathological eating behaviours and addictive processes have been implicated in the multifactorial development and maintenance of obesity [6]. Food Addiction (FA), is defined as hedonic eating behaviours that include the consumption of highly palatable foods [7], and that are associated with addictive psychological and behavioural symptoms such as cravings, altered tolerance, loss-of-control food consumption and withdrawal [8]. Although the concept of FA is widely debated [7,9], emerging literature has identified some potential points of consensus, e.g., that addictive-like eating patterns do exist, and that mechanisms contributing to substance-related and addictive disorders, e.g. alcohol and substance use disorders are also implicated in excessive eating and obesity [7,10]. The problem is not just addiction: overweight and obese patients often use food in a compensatory way without falling into addiction. Emotional Eating (EE) may be defined as a tendency to eat in response to negative emotions and energy-dense and palatable foods, and is common amongst adults with overweight or obesity. There is no ubiquitous definition of EE, but EE is commonly defined as responding to negative feelings (e.g., stress, upset, or furiousness) for temporary comfort by overconsuming energy-dense and palatable foods [11-14]. Theories suggest such behaviours may become coping strategies and foreshadow unhealthy eating habits, causing weight gain [13,14]. Other theories suggest that reported positive emotions (e.g., joy or excitement) may also lead to EE and are commonly followed by negative feelings such as shame [15]. Whilst some individuals who engage in EE may meet the diagnostic criteria for Binge Eating Disorder (BED) [16] (eating in a discreet period of time, an amount of food that is definitively larger than what most individuals would eat in a similar period of time, under similar circumstances with a sense of lack of control over eating during the episodes) [17] others with EE episodes have no diagnosed eating disorder [15]. That said, EE is a form of disordered eating and is a developmental pathway to obesity [18]. At least 40% of individuals living with obesity are reported to experience EE [19].

Doctor’s lack of training in psychology

The teaching of Psychology within Medicine has gone through a course related to the revision of medical education in general, which itself is very dependent on sociocultural, political, scientific and technological contexts. Even though there is a consensus towards the Behavioural and Social Sciences (BSS) concepts that are most relevant for medical training, it is still necessary to thoroughly research what prevents the complete integration of these subjects in medical education [20]. It would be stimulating to reflect over the position of Psychology in the medical curriculum, emphasises the role attributed to biomedical sciences, considered as an indispensable component, designated as “need to know” and the behavioural and social sciences, considered as interesting but not essential, or “nice to know”. Without calling into question the biomedical sciences as a fundamental core of medical education, one should nevertheless recognize the need for psychology as the basis of the “need to know” [21]. We should then look at obesity by giving greater weight to the psychological dynamics of the patient, trying to adequately treat the psychological and psychiatric aspects of the disease.

The question

Is obesity really a pathology exclusively of the internal medicine doctor or is it a psychiatric pathology that is often not managed adequately? In my experience I am becoming more convinced that the obese patient is mainly a psychiatric patient and as such should be managed primarily by an adequately trained psychiatrist as it happens for other addictions and for other eating disorders.

1. Afshin A, Forouzanfar MH, Reitsma MB, Sur P, Estep K, et al. (2017) Health effects of overweight and obesity in 195 countries over 25 years. The New England Journal of Medicine 377(1): 13-27.
2. Fontaine KR, Redden DT, Wang C, Westfall AO, Allison DB (2003) Years of life lost due to obesity. JAMA 289(2): 187-193.
3. Berrington de Gonzalez A, Hartge P, Cerhan JR, Flint AJ, Hannan L, et al. (2010) Body-mass index and mortality among 1.46 million white adults. The New England Journal of Medicine 363(23): 2211-2219.
4. Pi-Sunyer FX (1999) Comorbidities of overweight and obesity: current evidence and research issues. Medicine and Science in Sports and Exercise 31(11): S602-S608.
5. Abbott A (2014) The problem of excess. Sociological Theory 32(1): 1-26.
6. Davis C (2017) A commentary on the associations among 'food addiction', binge eating disorder, and obesity: Overlapping conditions with idiosyncratic clinical features. Appetite 115: 3-8.
7. Gearhardt AN, Hebebrand J (2021) The concept of food addiction helps inform the understanding of overeating and obesity: Debate Consensus. Am J Clin Nutr 113(2): 274-276.
8. Kalon E, Hong JY, Tobin C, Schulte T (2016) Psychological and neurobiological correlates of food addiction. Int Rev Neurobiol 129: 85-110.
9. Carbone EA, Aloi M, Rania M, de Filippis R, Quirino D, et al. (2023) The relationship of food addiction with binge eating disorder and obesity: A network analysis study. Appetite 190: 107037.
10. Rogers PJ (2017) Food and drug addictions: similarities and differences. Pharmacol Biochem Behav 153: 182-190.
11. Gibson EL (2012) The psychobiology of comfort eating: Implications for neuropharmacological interventions. Behav Pharmacol 23(5-6): 442-460.
12. Konttinen H (2020) Emotional eating and obesity in adults: The role of depression, sleep and genes. Proc Nutr Soc 79(3): 283-289.
13. Van Strien T (2018) Causes of emotional eating and matched treatment of obesity. Curr Diabetes Rep 18(6): 35.
14. Fuente González CE, Chávez-Servín JL, de la Torre-Carbot K, Ronquillo González D, Aguilera Barreiro MdlÁ, et al. (2022) Relationship between emotional eating, consumption of hyperpalatable energy-dense foods, and indicators of nutritional status: A systematic review. J Obes 2022: 4243868.
15. Reichenberger J, Schnepper R, Arend AK, Blechert J (2020) Emotional eating in healthy individuals and patients with an eating disorder: Evidence from psychometric, experimental and naturalistic studies. Proc Nutr Soc 79(3): 290-299.
16. Greeno CG, Wing RR (1994) Stress-induced eating. Psychol Bull 115(3): 444-464.
17. American Psychiatric Association (2022) Diagnostic and statistical manual of mental disorders (5^th edn,) American Psychiatric Association, Arlington, VA, USA.
18. Eichen DM, Chen E, Boutelle KN, McCloskey MS (2017) Behavioral evidence of emotion dysregulation in binge eaters. Appetite 111: 1-6.
19. Roosen MA, Safer D, Adler S, Cebolla A, Van Strien T (2012) Group dialectical behavior therapy adapted for obese emotional eaters: A pilot study. Nutr Hosp 27(4): 1141-1147.
20. Peters S, Litva A (2006) Relevant behavioural and social science for medical undergraduates: A comparison of specialist and non-specialist educators. Med Educ 40(10): 1020-1026.
21. de Visser R (2009) Psychology in medical curricula: “need to know” or “nice to know”? The European Health Psychologist 11: 20-23.