Morbid Obesity

Many in our society believe that obesity is a negative factor in physical, emotional, and social well-being. Additionally, it is commonly accepted that excess body weight is linked to many physical and emotional ailments. For many, obesity is a personal problem: in desperate attempts to lose weight, the obese seek help from countless resources such as physicians, support groups, weight management counselors, fitness experts, and even from various drug and herbal remedies.

In this search for help, the reality is that most patients—typically women—end up weighing even more after completing weight-loss programs. Obesity is a lifelong, multifactorial, congenital disorder causing excessive fat deposits; there are often associated medical, psychological, physical, social, and economic problems (Brownell, 1995). The obese constitute 40% of the United States (U. S. ) population, encompassing approximately 85 million people (NIDDK, 2006).

Morbid obesity is typically defined as a Body Mass Index (BMI) of greater than 40 (Brownell, 1995). The statistics on morbid obesity vary depending on the definition. Morbid obesity affects between 2 million and 5 million people in the U. S. (ObesityHelp, 2002). Obesity has reached a crisis point throughout the nation and beyond (World Health Organization Statistics, 1998). Physical consequences of morbid obesity include living with physical and medical comorbidities such as diabetes mellitus, hypertension, skeletal problems (e.

g. , knee and hip replacements), upper gastrointestinal concerns (e. g. , gall bladder and appendix removal, reflux disease, and esophagus diseases), circulation problems (e. g. , stroke, heart attack, aneurism, and gout), and elimination diseases (e. g. , flatulence and bowel obstructions, kidney and liver problems, colon problems). Some patients with obesity limit contact with their primary care physician because of the way they look and expectations of hearing the same speech about their excess weight from their physician.

This lessened contact may mean that diseases go undiagnosed, even to the point at which they become life-threatening (Wadden et al. , 2002). Some of the consequences of morbid obesity are social and economic outcomes. Poor social functioning (lacking social graces, getting along with others, team work, and speaking abilities), poor management of finances (impulsivity and spending habits), and discrimination and prejudicial mistreatment by others (teasing, abusiveness, cruelty from coworkers and bosses, outright firing, raise refusals, and unsuccessful job interviews) (Wadden et al.

, 2002). For many patients struggling with morbid obesity, the external indicators such as discrimination, physical limitations, and social rejection become internalized in the form of emotional symptoms such as shame, disgust with appearance, situation avoidance, depression, anxiousness and hopelessness. The causes of obesity are many, varied, and controversial, but it is possible that they stem from a combination of biological, psychological, social, and economic influences (Brownell, 1995). Etiology of Morbid Obesity

Obesity seems to be caused by the interaction of a variety of factors: “social, behavioral, cultural, physiological, metabolic, and genetic” (NHLBI, 1998, p. vii). Although heredity exerts a strong influence, the environment also plays an important role. Bjorntorp (1992) observed, “The genes do not produce obesity in the absence of an environment that fosters a positive energy balance, in the same way as scurvy does not develop without a severe deficiency of ascorbic acid” (p. ix). Bray (as cited in Wadden et al. , 2002) commented, “Genes load the gun, the environment pulls the trigger” (p. 512).

Any genetic predisposition to obesity must be expressed in a specific environment. The current environment for most Americans combines the availability of high-fat foods with a lifestyle that provides little opportunity for daily exercise (Reto, 2003). The causative factors of obesity are not universally agreed upon. In a survey of Minnesotans taken in August through September (2004), 825 people believed that obesity is encouraged by culture, 71% believed obesity to be a disease, 56% believed obesity to be an addiction, and 45% believed surgery is appropriate for patients with obesity (SNG Research Corporation, 2004).

While there is some disparity regarding etiology, there is common agreement that something must be done. Morbid obesity is seen as a serious disease with a malignant nature which is often unremitting, punishing, lethal, and involuntary. “I can not identify another group that is doomed to failure, by the very nature of recommended treatments and social and personal expectations of what is necessary, than the morbidly obese” (Reto, 2003, p. 44). In Western culture, the technological advancements can make self-care activities, including eating, drinking, and sleeping difficult to accomplish for the morbidly obese.

With the fast pace of everyday life, eating quickly and gaining little exercise is the reality for most patients. Our culture encourages fast foods with high fat, sugar, and carbohydrate content such as Burger King’s Monster Burger and neighborhood convenience stores’ Big Gulp. Addressing most physical concerns involves a physician or other medical personnel. Medical issues begin to be examined through a safe and cautious assessment. A primary care doctor usually performs a physical examination with routine tests.

Morbid obesity most generally is not diagnosed as a disease, but as a symptom to other pain-causing conditions. Obesity and morbid obesity are not curable at this time and need to be looked at from biologists to find the causes (Herbert, Christman, & Laird, 2006). Wadden & Foster, (2000) hypothesized that obesity and morbid obesity have many commonalities with addiction: Because addictions, like morbid obesity are multidimensional, and (they) disrupt so many aspects of living, the best programs provide a combination of therapies and other services, such as referral to other medical, psychological, and social services.

The treatment components and services to be employed must be tailored to meet the needs of individual patients, including where they are at in the recovery process (p. 449). Biological research, in inherited genetics, for example, is advancing but more work is needed in pinpointing the definite causes of morbid obesity. Biological research focuses on factors such as lipids, enzymes, particular genes, and chemical transmitters that have drawn attention as possible reasons for morbid obesity. The role of the neurotransmitter serotonin is being studied, especially in impulsivity and addictions (Moeller, 2001).

Wang (2003) states this type of research is very complicated, and the funding for such an undertaking is lacking. Many of the studies utilizing Positron Emission Tomography Scanning (PET) and/or examination of G-12 genes and neurotransmitters are impressive but definitive hypotheses have as of yet to be proven (Wang, 2003). Research is now starting to focus on the social mores involved with our consumption of huge amounts of food and beverages. Being responsible for ourselves and members of this planet makes good sense, but many have difficulty following that ideal.

Until morbid obesity is universally accepted as an illness and funds are allocated for research resulting in a cure, many patients with morbid obesity will have to suffer from this disease. The disease can have consequences of a serious nature. These consequences can be physical, emotional, social, and economic (Brownell, 1995). Characteristics of Morbid Obesity Prevalence Bjorntorp (1996) warned that the “pandemia of obesity” (p. 973) exists in alarming proportions. It is a problem of global concern, occurring in Europe, Australia, South America, and parts of Asia, as well as in North America (NIDDK, 2006).

Worldwide, there may be as many as 1 billion overweight adults; at least 300 million of them may be classified as obese (Hedley et al. , 2004). In the United States, it is estimated that almost two thirds of all adults are overweight or obese, including more than 30% who may be classified as obese and almost 5% who may be classified as morbidly obese (NIDDK, 2006). The prevalence of obesity in the United States has increased approximately 75% in less than two decades (Wadden & Foster, 2000).

Obesity has also become more common in all 50 states, in both males and females, in all racial and ethnic groups, and on all educational levels (NIDDK, 2006). Physical Costs The health risks of obesity have received wide publicity and are well documented. Being overweight increases the risk for as many as 30 different conditions (American Obesity Association [AOA], 2005) including diabetes, heart disease, stroke, hypertension, gallbladder disease, osteoarthritis, breathing problems such as sleep apnea, and some types of cancer.

Obesity may also be associated with high cholesterol, pregnancy complications, menstrual problems, stress incontinence, and increased risk during surgery (NIDDK, 2006). These increased health risks have led as many as 300,000 American adults to die each year from causes that may be attributed to unhealthy diets and sedentary lifestyles (NIDDK, 2006). Clearly, as peoples’ weight increases, their health risks also increase (NIDDK, 2006). But these health risks can be reduced.

At one time, it was estimated that, if all obese Americans could achieve their ideal weight, life expectancy would increase by 7 years or more. In comparison, the prevention and cure of cancer would have increased life expectancy by only 3 years or less (Wadden & Foster, 2000). Economic Costs Obesity takes its toll not only on the individual, but on society as a whole by increasing health care costs. On a global scale, it has been estimated that obesity may account for between 2% and 10% of the total health care costs of various countries (Wadden et al. , 2002).

In the United States alone, the annual cost of obesity has been estimated at $117 billion (NIDDK, 2006). If the problem of obesity were solved, there might be an annual savings of almost 53 million days of lost work, or about $4 billion in wages. A managed care organization of 200,000 members might save $10 million annually, if its members had a moderate 10% weight loss (Wolf, 1998). There are economic costs to the individual as well. In hopes of losing weight, consumers spend more than $33 billion annually on commercial products and services (NIDDK, 2006).

Additionally, money is spent on treatment, ranging from minimally priced self-help groups to surgery and medically supervised programs that cost thousands of dollars (Wolf, 1998). Psychological Costs Although the physical consequences may be severe, the negative psychological and social effects can be even worse (Wilson & Brownell, 2004). In our culture, thinness may be even more desirable for cosmetic reasons than for medical reasons. A slim body is associated with “competence, success, control, and attractiveness,” while an obese one brings to mind, “laziness, self-indulgence, and a lack of willpower” (Wilfley & Rodin, 1995, p.

78). The obese are faced with prejudice and discrimination in many areas of life, often resulting in psychological distress for those who exceed societal weight standards (Wilson & Brownell, 2004). There seems to be a positive correlation between distress and the degree a person is overweight. Therefore, the negative psychological and social effects of obesity may be most pronounced in the morbidly obese. These negative psychological effects have led to widespread dieting. Dieting is so prevalent among women that it has been called a “normative” condition in our society (Wilfley & Rodin, 1995).

As many as 55% of American women may have dieted at some time in their lives (Wilson & Brownell, 2004). Individuals hope that, by losing weight, they will gain societal approval. Commonly, dieting may work for a while, but, in general, long-term results are not good (Brownell, 1995). It has been estimated that 80 to 95% of Americans who lose weight regain the entire amount in only as much time as it took to lose it (Wilson & Brownell, 2004). Treatment of Morbid Obesity Early attempts at treating obesity involved the medical profession, since the condition was recognized as a health risk, as well as a cosmetic problem (Brownell, 1995).

The cause of obesity seemed to be obvious–energy intake exceeding energy output–so a “simple” answer was sought. In order to lose weight, patients were instructed to restrict their eating to a caloric level below what was required for sustenance. In the mid-20th century, several self-help groups arose, shifting some of the treatment away from the medical profession. Groups such as Overeaters Anonymous (OA) and Take Off Pounds Sensibly (TOPS) were followed by other programs of a more commercial nature, such as Weight Watchers (Stunkard, 1992).

In the 1960s and 1970s, psychologists became involved in treating the condition. Obesity was an ideal target for behavioral treatment, because the outcome of intervention was clearly measurable in terms of the amount of weight lost (Stunkard, 1992). Since Stuart (1967) and others introduced behavior modification into obesity treatment in the 1960s, behavioral programs have become more complex. They now include a variety of strategies in areas such as nutrition, exercise, social relationships, and cognitive restructuring (Wilson & Brownell, 2002).

In the 1970s and 1980s, as more physiological discoveries were made about the biological basis of body weight, a rather pessimistic outlook developed regarding the potential hope of finding a solution to the problem. Professionals expressed doubt regarding the possibility that personal efforts to control weight could ever achieve permanent results (Brownell, 1995). This helped fuel a zealous anti-dieting movement that developed in response to the apparent lack of success of existing weight control methods (Stunkard, 1992).

The advocates of this non-dieting approach proclaimed that “diets don’t work” and that dieting is not only ineffective, but may be dangerous as well. It was alleged that dieting can cause binge eating, so the ultimate consequence of caloric restriction would be a return to the original weight or higher (Wilson, 2002). In recent decades, the medical profession reentered the picture, suggesting that very-low-calorie diets (VLCDs) combined with behavioral treatment may be the long awaited answer to the problem. Examples of such programs are Optifast, Health Management Resources, and Medifast (Tsai & Wadden, 2005).

Although thisdevelopment brought renewed hope, long-term outcomes have not been good (Tsai & Wadden, 2005). With the Internet came other options, such as eDiets. com, which offered individuals advice and long-distance support (Tsai & Wadden, 2005). The debate regarding the pros and cons of dieting continues. It is obvious that, healthy or not, a program of restricted eating will be effective in producing weight loss (Bjorntorp, 1992). However, because relapse is common, it appears that there is a point at which many dieters abandon the behaviors that lead to successful weight loss or management (Wilson & Brownell, 2002).

Research has identified some of the antecedents and consequences of relapse, but little is known about the relapse experience itself. Although cognitive restructuring is often included as a part of comprehensive weight loss programs, existing research has done little to explore the role of cognitions during relapse (Wadden & Foster, 2000). The Problem of Relapse Several decades ago, Stunkard and McLaren-Hume (1959) proclaimed, “Most obese persons will not stay in treatment. Of those who stay in treatment, most will lose weight, and of those who lose weight, most will regain it” (p.

79). Recognizing that it is easier to lose weight than to maintain the loss, Bjorntorp (1992) observed that everyone can burn fat, “provided drastic enough measures are taken. To dispose of body fat is thus not the problem. What we badly need to know is why it is so difficult to prevent the ‘replenishment’ … following significant weight loss” (p. x). Despite the extensive commitment, effort, and sacrifice that are often involved in losing weight by means of caloric restriction or exercise, a lower weight is not easily maintained.

Individuals who achieve better physical health and societal approval by losing weight commonly regain it. They revert to a less healthy physical state, as well as a less desirable appearance, that puts them at risk for societal prejudice and discrimination once again. Although they know that overeating or diminished exercise may result in gaining weight, they abandon healthy behaviors that were once effective in producing success (Wilson & Brownell, 2002). The situation is puzzling. People who regain weight appear to be unable or unwilling to maintain the behaviors that helped them achieve their goal.

They evidently trade the hard-earned goals of lower weight, societal approval, and better physical health for the immediate gratification of more unhealthy behaviors. Individuals who intentionally lose large amounts of weight develop effective strategies through which they achieve success. Simply stated, they know what works. When relapse occurs, such behaviors may be altered or abandoned. Psychology and Morbid Obesity Morbid obesity is often regarded by psychiatrists and psychologists as a behavioral dysfunction that patients should have the will power to correct.

Psychologists and other “experts” are not immune from the prevailing cultural attitudes even though such helping professionals occupy a powerful position in our culture. Awareness of this special designation or responsibility requires communications and actions to a much higher standard of conduct (Connors & Melcher, 1993). To further emphasize the negative psychological impact of morbid obesity, Rand and MacGregor (1991) found that patients with obesity would prefer being of normal weight with major physical disabilities rather than being morbidly obese millionaires.

The psychodynamic theory originated by Sigmund Freud may have contributed to the current attitude of some professionals toward patients with morbid obesity. Additionally, Freud may have contributed to the practice of placing psychological labels on the obese. Freud proposed that compulsive eating and alcoholism were the effects of unconscious anger, depression, sexual abuse, or unrequited need for love (Connors & Melcher, 1993). From the days of Freud to the present, we have created the psychological profile for patients with morbid obesity: this view often sees obesity as an affect-driven behavior.

Another psychiatrist, Yalom, was instrumental in contributing to society’s contempt of fatness (Connors & Melcher, 1993). Yalom (1989) wrote of his scathing disgust of fat women: I have always been repelled by fat women. I find them disgusting: their absurd sideways waddle, their absence of body contour—breasts, laps, buttocks, shoulders, jawlines, cheekbones, everything, everything I like to see in a woman, obscured in an avalanche of flesh…How dare they impose that body on the rest of us? He goes on to say:

But when I see a fat lady eat, I move down a couple of rungs on the ladder of human understanding. I want to tear the food away, to push her face into the ice cream and say, stop stuffing yourself, haven’t you had enough… I’d like to wire her jaws shut. (p. 88–89) While trying not to be too hard on the experts of the day for their judgments on patients with obesity, “it is imperative that we as therapists refrain from forcing our clients to adapt to our biases in such a fashion, thus retraumatizing clients already suffering from life histories of non-acceptance” (Connors & Melcher, 1993, p.

5). Unfortunately, psychological evaluations for certain psychopathologies have not proven effective in the development of time-saving treatment plans, in predicting treatment success or failure or in making assessments part of the psychologists’ responsibilities in the bariatric surgery treatment teams (Reto, 2003). The studies suggest that there is no single personality type that characterizes the severely obese and that this population does not have greater levels of psychopathology than controls (Stunkard, 1992).

Personality profiling and assessing psychological factors have been found to be of very limited value in predicting weight loss (Larsen et al. , 2004). In the ASBS study (1997), researchers found that the more distressed patients are by their obesity, the more likely they are to lose weight. The study also found that severe psychopathology, to the extent that psychiatric treatment or admission to a hospital was required, appeared to have been a negative predictor of outcome. The social, legal, and economic results from having morbid obesity can be framed in the negative.

For example, current research suggests that patients with obesity complete fewer years of school and are less likely to be married, and have, in general lower household incomes (Stunkard, 1992). Weight appears to be an important determinant of socioeconomic status, especially for women (Reto, 2003). Patients with obesity suffer tremendously as the result of prejudice and discrimination in many areas (Bjorntorp, 1992). Physical Risks of Morbid Obesity The next step in understanding morbid obesity is to view obesity from a physical risk-benefit perspective.

The physical health risks of patients with morbid obesity involve increased rates of all cause comorbidities, such as choking on food that is consumed in huge mouthfuls, compared to patients of average weight (Larsen et al. , 2004). It appears that there is an increased mortality rate among patients with obesity. In addition to obesity itself, other factors contributing to death include heart disease, certain forms of cancer, complications from type II diabetes, and other diseases influenced by body size and social causes (Stunkard, 1992).

Hubert, Feinleib, and McNamara (1983) found as early as the 1980’s that obesity is an overall risk factor in premature deaths. Additionally, some current practitioners agree that obese patients have a higher mortality rate than do patients of normal weight; however, this may be because of the campaign designed to convince the public and medical profession that an ideal body weight exists that correlates with optimum life expectancy (Larsen et al. , 2004).

To illustrate the point of mortality and complications, some obese popular movie and rock stars have died an early death from complications of their obesity, including choking, heart attacks, and taking drugs to speed up their metabolism in an attempt to lose weight. For example, Mama Cass Elliott died from choking, John Candy died from choking/heart attack, and John Belushi died from drug-taking. Body size may also affect diagnostic judgments, as obese patients are more often viewed more negatively in terms of both physical and psychological health (Larsen et al.

, 2004). Generally, some medical professionals agree that obesity and its complications may cause premature death. Not surprisingly, however, there is disagreement here as well. Some obesity research reports longer-term and more conclusive findings that provide support for the argument that obesity/morbid obesity is not necessarily associated with higher mortality rates, except in cases of extreme overweight (Stunkard, 1992). Conclusion Obesity, a complex, multifactorial, and chronic disease affecting both physical and mental health, is a problem of worldwide concern.

In addition to its physical, psychological, and social effects on individuals, the condition results in great economic costs to society. Obesity now accounts for a significant proportion of the total health care cost of many countries and is becoming increasingly prevalent on a global scale. Because it is so difficult to manage, a researcher once stated that “a person is more likely to recover from most forms of cancer” than from obesity (Brownell, 1987, p. 214).

This has led to the development of a multibillion dollar industry Often, through the use of weight loss products and services, short-term success is achieved, but relapse is common and weight is regained. For decades, researchers and clinicians have attempted to counter obesity, yet no clear answer has been found. Despite individual and collective efforts to understand the condition, it remains a dilemma for health care professionals and researchers, as well as for the individuals who are afflicted. References American Obesity Association (2005). AOA fact sheets: Health effects of obesity.

Retrieved 2008, from http://www. obesity. org/subs/fastfacts/Health_Effects. shtml Brownell, K. D. (1995). Definition and classification of obesity. In K. D. Brownell & C. G. Fairburn (Eds. ), Eating disorders and obesity: A comprehensive handbook (pp. 386-390). New York: Guilford Press. Brownell, K. D. (1987). Obesity: Understanding and treating a serious, prevalent, and refractory disorder. In T. D. Nirenberg & S. A. Maistro (Eds. ), Developments inthe assessment and treatment of addictive behaviors (pp. 213-241). Norwood, NJ:Ablex. Bjorntorp, P. (1992). Foreword. In T. A. Wadden & T. B.

VanItallie (Eds. ), Treatment of the seriously obese patient (pp. ix-x). New York: Guilford Press. Bjorntorp, P. (1996). On the integration of research. International Journal of Obesity, 20, 973. Connors, M. E. , & Melcher, S. A. , (1993). Ethical issues in the treatment of eight dissatisfied clients. Professional Psychology: Research and Practice, 24(4), 404–408. Dymek, M. , le Grange, D. , Neven, K. , & Alverdy, J. (2002). Quality of life after gastric bypass surgery: A cross-sectional study. Obesity Research, 10(11), 1135–1142. Hedley, A. A. , Ogden, C. L. , Johnson, C. L. , Carroll, M.

D. , Curtin, L. R. , & Flegal, K. M. (2004). Prevalence of overweight and obesity among U. S. children, adolescents, and adults, 1999-2002. JAMA, 291, 2847-2850. Herbert, A. , Christman, M. , & Laird, N. (2006). Genetic link to obesity. Science, 312(5771), 155. Hubert, H. B. , Feinleib, M. , & McNamura, P. M. (1983). Obesity as an independent risk factor in gross obesity. Circulation, 67, 968–977. Larsen, J. K. , Geenen, R. , Maas, C. , de Witt, P. , van Antwerpen, T. , Brand, N. et al. (2004). Personality as a predictor of weight loss maintenance after surgery for morbid obesity.

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The final research paper would explore efforts undertaken around the world to prevent obesity in children in order to prevent diabetes. According to a report published by the World Health Organization, “more than 22 million children under five years old …

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