Obesity Family Stressor 1 Running Head: Obesity

Family Health Stressor Overweight & Obesity Linda F. Houts Missouri State University

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

Obesity Family Stressor 3 every major maternal demographic (DHSS, 2004). Fortypercent 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

Obesity Family Stressor 4 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

Obesity Family Stressor 5 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

Obesity Family Stressor 6 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)

Obesity Family Stressor 7 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.

Obesity Family Stressor 8 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).

Obesity Family Stressor 9 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

Obesity Family Stressor 10 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

Obesity Family Stressor 11 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

Obesity Family Stressor 12 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

Obesity Family Stressor 13 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

Obesity Family Stressor 14 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

Obesity Family Stressor 15 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,

Obesity Family Stressor 16 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

Obesity Family Stressor 17 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

Obesity Family Stressor 18 function in the treatment of the excess body weight and obesity.

Obesity Family Stressor 19 Resources American Accredited Healthcare Commission (2007) Step 1: The benefits of a healthy weight. September 24, 2007 from http://adam.about.com/care/weightloss/weight_step1.html American Heart Association. (2006) Shape of the Nation Report. Status of Physical Education in the USA. National Association for Sports and Physical Education an association of Alliance for Health, Physical Education, Recreation and Dance. American Obesity Association (2002) Finally a cure for obesity! Retrieved on October 9, 2008 from http://obesity1.tempdomainname.com/subs/fastfacts/obes ity_women.shtml Bihr, M. A. & Klein, T. L. (2005) Step by Step: Toward Missouris Future. Missouri Youth Initiative, Volume 15, No. 4, August 2005. Carter, B. & McGoldrick, M. (2005). The expanded family life cycle; individuals, family and social perspective. 3rd Edition. Boston: Allyn and Bacon. Centers for Disease Control and Prevention. Obesity and Overweight for Professionals: Causes/DNPAO/CDC (2009) Retrieved on

Obesity Family Stressor 20 Causes and Consequences. Retrieved June 28, 2009 from http://www.cdc.gov/obesity/causes/index.html Centers for Disease Control, Division of Nutrition, Physical Activity on Obesity, National Center for Chronic Disease Prevention and Health Promotion. (2008) Introduction. Retrieved on October 9, 2008

from http://www.cdc.gov/print.do?url=http%3A%2F %2Fwww.cdc.gov%2Fnccdphp%2Fdnpa% Centers for Disease Control: Morbidity and Mortality Weekly Review (2003). Prevalence of physical activity, including lifestyle activities among adults-United States, 2000 - 2001. Popkin, B. E., (September, 2007) CIGNA Behavioral Health (2006) Primary care physicians and childhood obesity issues: Issuing behavioral prescriptions. Retrieved September 24, 2004 from

http//apps.cignabehavioral.com/web/basicsite/bulletinB oard/childhoodObesityIssues.jsp Ferraro, F., Muelenhamp, J., Paintner A., Wasson, K. & Hoverson (2008) Aging, body image, and body shape; report. The Journal of General Psychology, 14(4), 379391. Friedman, J. (2008) CBT for BED. Obesity Management. 4(3) No. 5. 245-248.

Obesity Family Stressor 21 Gamm, L. D., Hutchison, L. L., Dabney, B.J. & Dorsey, A.M., editors (2003). Rural Healthy People 2010: A Companion Document to Healthy people 2010. Volume 1. College Station, Texas, Southwest Rural Health Research Center. Gatchel, R. & Oordt, M. (2003) Clinical health psychology and primary care; practical advice and clinical guidance for successful collaboration. Washington, D.C.: American Psychological Association. Kaiser Family Foundations, State Health Facts.Org (2008) Missouri: Obesity. Retrieved June 28, 2009 from http://www.statehealthfacts.org/profileind.jsp? cat=2&sub=26&rgn=27 Kime, N. (2009) How children eat may contribute to rising levels of obesity; childrens eating behaviours: an intergenerational study of family influences; report. International Journal of Health Promotion and Education 47(8) 4-14. Rhee, K. (2008) Overweight and obesity in Americas children: causes, consequences, solutions; section one: home, school, community: childhood overweight

and the relationship between parent behaviors, parenting style, and family functioning. The Annals of

Obesity Family Stressor 22 the American Academy of Political and Social Science, 615(12) 1-17. Rich, L. E. (2004) Bringing more effective tools to the weight-loss table Psychologist help Americans slimmeddown through self-monitoring, augmented behavioral therapies and meditation among other strategies. American Psychological Association. Retrieved on October 9, 2008 from http://www.apa.org/monitor/jan04/bringing.html Schumann, S. & Hickner, J. (2009) Suspect and eating disorder? Suggest CBT. The Journal of Family Practice, 58(5) 265-266. Senekal, M., Steyn, N., Mashego, T., & Nel, J. (2001) Evaluation of body shape, eating disorders and weight management parameters in black female students of urban and rural origins, South African Journal of Psychology, 31(1), 45. Swami, V., Furnham, A., Amin, R., Chaudhri, J., Josht, K., Jundi, S., Miller, R., Mirza-Begum, J., Begum, F., Sheth, P. & Tovee, M. (2008) Lonelier, lazier, and teased: the stigmatizing effect of body size; report. The Journal of Psychology 148(17) 577-587. The world is fat. Scientific American, 2007, 88-95.

Obesity Family Stressor 23 University of Missouri Extension, Central Missouri Regional Council. (2007). Nutrition and Health Trend Statistics. Retrieved June 29, 2009 from Yuen, F., Skibiniski, G., & Pardeck, J. (2003) Family health social work practice; a knowledge and skills casebook. Binghamton, NY. Zastrow, C.H., and Kirst-Ashman, K.K. (2007) Understanding Human Behavior and the Social Environment 7th edition. United States: Brooks/Cole.