Besity: Anthony N. Fabricatore and Thomas A. Wadden

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10.1146/annurev.clinpsy.2.022305.095249
Annu. Rev. Clin. Psychol. 2006. 2:35777

doi: 10.1146/annurev.clinpsy.2.022305.095249
c 2006 by Annual Reviews. All rights reserved
Copyright
First published online as a Review in Advance on January 16, 2006
OBESITY
Annu. Rev. Clin. Psychol. 2006.2:357-377. Downloaded from arjournals.annualreviews.org

by University of California - Los Angeles on 07/20/06. For personal use only.
Anthony N. Fabricatore and Thomas A. Wadden

University of Pennsylvania, School of Medicine, Department of Psychiatry, Weight and
Eating Disorders Program, Philadelphia, Pennsylvania 19104-3309;
email: fabricat@mail.med.upenn.edu; wadden@mail.med.upenn.edu
Key Words
weight loss, overweight, body mass index
Abstract The prevalence of obesity is growing at an alarming rate. Thus,

investigation into the etiology, comorbidities, and treatment of obesity has burgeoned
in recent years. While novel therapiesboth behavioral and pharmacologicalhave
been developed and tested, the mean weight losses achieved with nonsurgical approaches have remained virtually unchanged over the past 20 years. Fortunately, the
modest weight losses achieved with these methods are associated with significant
reductions in obesity-related health problems. With the most intensive available treatment (i.e., bariatric surgery), many patients achieve remission of comorbid conditions.
This article defines obesity and provides an overview of the disease conditions associated with excess weight. Treatment options and outcomes are reviewed and future
stepsincluding efforts to prevent obesityare identified. Finally, the literature on
the relationship between obesity and depression is examined.
CONTENTS
INTRODUCTION: THE OBESITY EPIDEMIC . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Definitions and Comorbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Health Effects of Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Treatment Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
LIFESTYLE MODIFICATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outcomes of Lifestyle Modification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Improving Weight Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The National Weight Control Registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
What Is the Optimal Diet for Long-Term Weight Control? . . . . . . . . . . . . . . . . . . .
What Is the Optimal Exercise Regimen for Long-Term Weight Control? . . . . . . . .
From Efficacy to Effectiveness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PHARMACOTHERAPY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Long-term Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BARIATRIC SURGERY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
MOVING TOWARD PREVENTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBESITY AND DEPRESSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The Obesity-Depression Relationship in Women Versus Men . . . . . . . . . . . . . . . .
Extreme Obesity Increases the Risk of Depression . . . . . . . . . . . . . . . . . . . . . . . . .
CONCLUSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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INTRODUCTION: THE OBESITY EPIDEMIC

The World Health Organization (WHO) estimated that a billion adults worldwide
are overweight, including 300 million who are obese (WHO 2002). Accordingly,
the WHO has described obesity as a global epidemic (WHO 1998). The problem of excess weight is particularly pronounced in the United States, where the
prevalence of obesity among adults doubled from 15% in 19761980 to 30.6% in
20012002 (Flegal et al. 2002, Hedley et al. 2004). The number of children and
adolescents who are considered overweight (i.e., 95th percentile for age and sex)
or at risk for overweight (i.e., 85th percentile) has similarly increased in recent
years and suggests that the obesity crisis in the United States will only continue to
grow (Ogden et al. 2002).
Definitions and Comorbidities

The body mass index (BMI) is a ratio of weight to height that is used to estimate
obesity. BMI is calculated as weight in kilograms divided by the square of height in
meters. (Alternatively, BMI can be figured by multiplying weight in pounds by 703
and dividing that product by the square of height in inches.) Weight classifications
according to BMI are as follows: underweight, BMI < 18.5 kg/m2 ; average weight,
BMI 18.524.9 kg/m2 ; overweight, BMI 25.029.9 kg/m2 ; and obesity, BMI
30 kg/m2 . Obesity is further categorized as Class I (mild, BMI 30.034.9 kg/m2 ),
II (moderate, BMI 35.039.9 kg/m2 ), or III (severe/extreme, BMI 40 kg/m2 ).
For reference, Table 1 displays the weights that correspond with the BMI ranges
described above for individuals of three sample heights.
The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health concluded that the risks of heart disease, type 2 diabetes, sleep
TABLE 1
Weights corresponding to body mass index ranges for three sample heights
Height
Body mass index

(kg/m2 )
162.6 cm (64 in.)
172.7 cm (68 in.)
182.9 cm (72 in.)
<18.5 kg/m2
<48.9 kg (107.8 lbs)
<55.2 kg (121.7 lbs)
<61.9 kg (136.4 lbs)
18.524.9 kg/m2
48.965.9 kg
(107.8145.4 lbs)
55.274.4 kg
(121.7164.0 lbs)
61.983.4 kg
(136.4183.4 lbs)
25.029.9 kg/m2
66.079.2 kg
(145.5174.5 lbs)
74.589.2 kg
(164.1196.9 lbs)
83.5100.1 kg
(184.0220.8 lbs)
30.034.9 kg/m2
79.392.3 kg
(174.6203.6 lbs)
89.3104.2 kg
(197.0229.8 lbs)
100.2116.8 kg
(220.9257.6 lbs)
35.039.9 kg/m2
92.4105.5 kg
(203.7232.8 lbs)
104.3119.1 kg
(229.9262.6 lbs)
116.9133.5 kg
(257.7294.5 lbs)
40 kg/m2
105.6 kg (232.9
lbs)
119.2 kg (262.7
lbs)
133.6 kg (294.6
lbs)
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apnea, osteoarthritis, and asthma are strongly and positively associated with BMI
(NHLBI 1998). Other studies have suggested that obesity increases the risk of
cancer morbidity and mortality (Bergstrom et al. 2001, Calle et al. 2003).
Excess weight also is associated with increased all-cause mortality. A study
published by researchers at the Centers for Disease Control and Prevention estimated that poor diet and physical activity accounted for 365,000 (15.2% of
total) deaths in the United States in 2000 (Mokdad et al. 2005). Although one
recent study found that overweight was not associated with excess deaths (Flegal
et al. 2005), another large investigation concluded that overweight women and
men lived 3.3 and 3.1 fewer years, respectively, than their average-weight counterparts, controlling for the effects of smoking (Peeters et al. 2003). Obesity increased the risk of death and shortened life expectancy (by 5.8 years for women
and 7.1 years for men) in those studies (Flegal et al. 2005, Peeters et al. 2003).
These data run contrary to the position of some who suggest that the obesity
epidemic is a myth fueled by cultural hysteria and moral panic (Campos
2004).
The Health Effects of Weight Loss

The morbidity and mortality figures cited above may be of concern to individuals
who are above their recommended body weights. Fortunately, however, intentional
weight loss is associated with clinically significant improvements in health. An
evidence-based report published by the NHLBI (1998) found that reductions of as
little as 5%10% of initial body weight are associated with beneficial reductions
in blood pressure, lipids, and other metabolic abnormalities.
Findings from the Diabetes Prevention Program (DPP) also support the benefits of modest weight loss (DPP Research Group 2002a). In this large, multisite,
randomized controlled trial, 3234 overweight and obese adults with impaired glucose tolerance (i.e., were at risk for developing type 2 diabetes) were assigned to
one of three conditions: (a) placebo, (b) metformin (800 mg twice per day), or
(c) a lifestyle modification program designed to induce a weight loss of 7% of
initial body weight and increase physical activity to at least 150 minutes per week.
Participants who received lifestyle modification (which is described in detail below) lost approximately 7% of their initial weight after six months and maintained
a loss of about 4% three and a half years later. Perhaps the most important finding
of the DPP, however, is shown in Figure 1; participation in lifestyle modification
reduced the four-year incidence of diabetes by 31% compared with metformin and
by 58% compared with placebo.
Although these results are impressive, investigators still do not know whether
intentional weight loss reduces mortality, as demonstrated by a randomized trial.
To address this issue, the Look AHEAD (i.e., Action for Health in Diabetes) study
will compare the incidence of fatal and nonfatal myocardial infarction and stroke
over an average of 10 years (Look AHEAD Research Group 2003). Participants
in this ongoing trial are more than 5000 overweight and obese adults with type 2
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FABRICATORE
Cumulative Incidence
of Diabetes (%)

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40
Placebo
30
Metformin
20
Lifestyle
10
0
0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

Year
Figure 1 Cumulative incidence of diabetes according to Diabetes Prevention Program (DPP) study group. The diagnosis of diabetes was based on the criteria of the
American Diabetes Association. The incidence of diabetes differed significantly among
the three groups ( p < 0.001 for each comparison). Reprinted with permission from
c 2002 Massachusetts Medical Society. All
DPP Research Group (2002a), copyright
rights reserved.
diabetes who receive either an intensive lifestyle modification program or a limited educational program in addition to standard medical care. The findings of
this study will provide a firm basis for setting public policy concerning weight
management.
Treatment Options
Broadly, three clinical weight loss options exist for overweight and obese individuals: (a) lifestyle modification (i.e., diet, exercise, and behavior therapy),
(b) pharmacotherapy, and (c) bariatric surgery. Which treatment option is appropriate is a function of the patients weight, health status, previous weight loss
attempts, and preferences. Table 2 summarizes the treatment algorithm published
by NHLBI and the North American Association for the Study of Obesity (NAASO)
in the Practical Guide: Identification, Evaluation, and Treatment of Overweight
and Obesity in Adults (hereafter, Practical Guide; NHLBI & NAASO 2000).
The following sections describe each of these treatments and their associated
outcomes.
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TABLE 2
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A guide to selecting treatmenta

BMI category (kg/m2 )
Treatment
2526.9
2729.9
3034.9
3539.9
40
Diet, physical
activity, and
behavior
therapy
With
comorbidities
With
comorbidities
+b
With
comorbidities

Pharmacotherapy
Surgery
With
comorbidities
a
Table reprinted from The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in
Adults (NHLBI & NAASO 2000).
b
The + represents the use of indicated treatment regardless of comorbidities.
LIFESTYLE MODIFICATION
The Practical Guide recommends a program of diet, exercise, and behavior therapy for all persons with a BMI 30 kg/m2 and those with a BMI 25 kg/m2
with medical comorbidities (NHLBI & NAASO 2000). Such programs are usually
offered in academic medical centers and are delivered to groups of 812 persons.
Treatment also may be delivered to individuals, but group-based programs produce slightly larger weight losses, regardless of patients preferences for group or
individual treatment (Renjilian et al. 2001). Sessions are frequently 6090 minutes
in length and are held weekly for approximately six months. The intervention is
typically delivered by professionals with expertise in psychology, nutrition, exercise physiology, or health education, who instruct patients in self-monitoring,
decreasing energy intake, increasing energy expenditure, and overcoming barriers to treatment adherence (DPP Research Group 2002b, Wadden & Butryn
2003).
Outcomes of Lifestyle Modification

Several reviews have shown that standard lifestyle modification programs yield
weight losses of 7%10% of initial body weight with four to six months of treatment (Wadden & Butryn 2003, Wing 2002). Foster and colleagues (1997), however, found that persons entering lifestyle modification would like to lose two to
three times this amount. Counseling patients on the average reductions achieved
with lifestyle modification does not appear to alter patients great expectations
for weight loss (Wadden et al. 2003) and may not even be necessary. Linde and
colleagues (2004) reported no adverse psychological consequences of having unrealistically high expectations and suggested that higher goals may even be positively
associated with long-term weight loss.
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Clinicians and researchers have attempted to improve the outcomes of lifestyle

modification by making a number of alterations to standard programs. Two methods for enhancing weight loss, both of which involve increasing dietary structure,
have been identified. First is the use of specific, structured meal plans. Wing and
colleagues (1996) found that participants who were given meal plans (i.e., menus,
recipes, and grocery lists) to facilitate adherence to a diet of 12001500 calories
per day lost significantly more weight (12 kg) than those who were instructed
to consume the same number of calories but were provided with no additional
structure (8 kg).
Ditschuneit and associates (1999) found that meal replacement products (i.e.,
portion- and calorie-controlled shakes with an appropriate nutritional balance)
are another means of enhancing dietary adherence and, thus, weight loss. Participants in their study were instructed to consume a self-selected low-calorie diet of
12001500 calories per day (i.e., the conventional foods group) or an isocaloric
diet in which two meals and two snacks each day were replaced with portioncontrolled, formulated products (i.e., the meal replacement group). Participants in
the meal replacement group lost more than five times as much weight as those in
the conventional foods group (7.1 kg and 1.3 kg, respectively) after three months
of treatment. A recent meta-analysis confirmed the benefits of meal replacement
products (Heymsfield et al. 2003).
Improving Weight Maintenance

The added structure of using meal plans and meal replacements is likely beneficial
because it limits food choices and the potential for error in calculating calorie intake. In addition to optimizing weight loss, these strategies also appear to facilitate
the maintenance of weight loss. Wing and colleagues (1996) found that participants who were provided with meal plans not only lost more weight at six months
than those who were not given meal plans, but also maintained significantly greater
reductions after 12 months of follow-up (6.9 kg and 3.3 kg, respectively). Similarly, the meal replacement study by Ditschuneit et al. (1999), described above,
included a second phase in which all participants, regardless of original group
assignment, were encouraged to replace one meal and one snack with formulated
products each day beginning at month three and continuing for the next four years
(Flechtner-Mors et al. 2000). As can be seen in Figure 2, the added structure of
meal/snack replacements appeared to induce weight loss in the group originally
assigned to conventional foods and to facilitate the maintenance of weight loss in
the group that used meal replacements in the first phase of the study. Randomized controlled trials are now needed to evaluate the long-term benefits of meal
replacement products used for two or more years.
Another means of improving the maintenance of weight loss is to offer extended contact with the treatment provider. As stated above, the mean weight
loss achieved with four to six months of lifestyle modification is approximately
7%10% of initial body weight. Without further treatment, however, participants
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Figure 2 Mean ( SEM) percentage change from initial body weight in patients
during 51 months of treatment with an energy-restricted diet (1200 to 1500 kcal/day).
Patients received either a conventional energy-restricted diet (control group A) or
a diet with two meal and snack replacements (group B) for three months. During
the remaining four years, all patients received one meal and snack replacement daily.
c 2000 North
Reprinted with permission from Flechtner-Mors et al. (2000), copyright
American Association for the Study of Obesity. All rights reserved.
typically regain about one-third of their lost weight in the following year, and
many patients return to their baseline weights over five years (Wadden & Butryn
2003). A study by Perri and colleagues (1988) revealed that participants who continued to meet with their provider twice a month for a year after completing the
initial 20-week treatment maintained a weight loss of 11.4 kg, compared with 3.6
kg among patients who did not receive continued contact. Thus, most lifestyle
modification programs now include a maintenance phase of treatment, in which
contact continues on a monthly or twice-monthly interval after the initial weightloss phase. Extended contact with a treatment provider likely engenders a feeling
of accountability that motivates long-term adherence for persons who have lost
weight.
The National Weight Control Registry

Investigators potentially can identify strategies to facilitate weight maintenance
by studying individuals who have been successful in this regard. The National
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Weight Control Registry is a database of such individuals, who have achieved and
maintained a weight loss of at least 13.6 kg (30 lbs) for at least one year. The average
registrant has lost 33 kg and has maintained at least a 13.6 kg reduction for more
than five years (Klem et al. 1997). Participants report that they continue to follow
a low-calorie diet, regularly monitor their body weight, and expend approximately
25003300 calories per week in physical activity (Wing & Phelan 2005). Thus, it
appears that the strategies necessary for weight maintenance are quite similar to
those required for weight loss.
What Is the Optimal Diet for Long-Term Weight Control?

Lifestyle interventions typically recommend a low-calorie diet in which 55% of
calories come from carbohydrate, 25%30% from fat, and the remainder from protein (e.g., Brownell 2000, DPP Research Group 2002b). This macronutrient content
is consistent with the recommendations of the NHLBI Practical Guide (NHLBI
& NAASO 2000) and with the reported diet of successful weight-maintainers
enrolled in the National Weight Control Registry (Klem et al. 1997).
The optimal macronutrient content, however, for weight loss and improvements in health is a topic of lively debate. Investigators, for example, have now
compared high-protein, low-carbohydrate diets to low-fat diets in at least six randomized controlled trials (Brehm et al. 2003, Foster et al. 2003, Golay et al.
1996, Meckling et al. 2004, Samaha et al. 2003, Stern et al. 2004, Yancy et al.
2004). In both self-help and lifestyle modification programs, the prescription
of a high-protein, low-carbohydrate diet induced greater weight losses at three
and six months than a low-fat diet (e.g., Brehm et al. 2003, Foster et al. 2003,
Samaha et al. 2003). At one year, however, the differences in weight reductions
were no longer significant (Foster et al. 2003, Stern et al. 2004). More studies of
longer duration are required to evaluate the long-term safety and efficacy of these
diets.
A recent randomized controlled trial compared weight losses and health improvements across several popular diets (Dansinger et al. 2005). One hundred
sixty overweight or obese adults were assigned to one of four groups. The four
diets emphasized calorie restriction (i.e., the Weight Watchers group), carbohydrate restriction (i.e., the Atkins group), fat restriction (i.e., the Ornish group), or
macronutrient balance (i.e., the Zone group). All participants, regardless of dietary
condition, received four one-hour sessions with a dietitian and physician over the
first two months of the study. All groups achieved and maintained significant weight
losses at two, six, and twelve months. There were, however, no differences between
groups at any time. Similarly, there were no between-groups differences in cholesterol (total, high-density lipoprotein, and low-density lipoprotein), triglycerides,
blood pressure, glucose, insulin, or C-reactive protein at 12 months.
Dansinger and associates (2005) concluded that the magnitude of the weight
reductions and health improvements are a function not of the macronutrient composition of the diet, but of the extent to which the diet is followed. For a given
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individual, therefore, it appears that the optimal diet for enduring weight control
is the one that he or she can most easily adhere to long-term.

What Is the Optimal Exercise Regimen

for Long-Term Weight Control?
Instructions and strategies to increase physical activity are integral components of
lifestyle modification. Exercise not only carries cardiovascular and psychological
benefits (Wood et al. 1991, Poirier & Despres 2001), but also contributes to energy
deficit and, thus, weight loss. Maintaining a high level of physical activity also
appears to be an important factor in long-term weight control, as suggested by data
from the National Weight Control Registry. Walking, cycling, strength training,
and aerobics are the activities most commonly reported by Registry members
(Klem et al. 1997), but the type of exercise is probably less crucial to long-term
weight control than the amount of exercise in which a person engages. A study
by Jeffery and colleagues (2003) found that lifestyle modification participants
who were given an energy expenditure goal of 2500 calories per week maintained
significantly greater weight losses than did their counterparts who were given a
standard, yet more modest, goal of expending 1000 calories per week in physical
activity (8.5 and 6.1 kg, respectively, at 12 months; 6.7 and 4.1 kg, respectively, at
18 months).
As is the case with dietary recommendations, the optimal exercise prescription
is likely that which can be maintained long-term. In contrast to dietary adherence,
however, it appears that less structure is beneficial for facilitating adherence to
physical activity recommendations. Persons instructed to exercise at home or in
multiple short bouts accumulate more physical activity than do those instructed to
exercise in supervised groups or in one long bout, respectively (Jakicic et al. 1995,
Perri et al. 1997). Decreasing the structure of physical activity reduces barriers,
such as lack of time, that may prevent regular activity.
Lifestyle activity represents another means of increasing energy expenditure.
Methods of increasing lifestyle activity might include walking (instead of driving)
to complete errands, choosing a distant parking spot, or opting for the stairs instead
of the escalator or elevator. Programmed activity, on the other hand, is what may
be referred to as a workout. It typically requires a discrete period of time (i.e.,
3060 minutes) and is completed at a relatively high intensity (i.e., 60%80%
of maximal heart rate). Andersen and colleagues (1999) compared the effects
of programmed and lifestyle activity among women who were participating in
a lifestyle modification program. They found that both types of activity, when
combined with a low-calorie diet, produced a weight loss of approximately 8 kg in
16 weeks. Those who were instructed to increase their lifestyle activity regained
marginally ( p = 0.06) less weight after one year of treatment than did those
who completed programmed exercise (0.1 kg versus 1.6 kg, respectively). Thus,
lifestyle activity appears to be just as effective for weight lossand may be even
more effective for weight maintenancethan structured, programmed activity.
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From Efficacy to Effectiveness

As noted previously, lifestyle modification programs are frequently provided in
academic medical centers. However, there clearly are not enough programs to
serve the millions of Americans who are attempting to control their weight. Thus,
efforts to disseminate treatment to community centers, worksites, primary care
practices, and the Internet are required to meet the growing demand for weight
loss therapies, fueled by the ever-increasing prevalence of obesity.
Currently, self-help and commercial programs are perhaps the largest providers
of lifestyle modification. Although programs such as Weight Watchers, Jenny
Craig, L.A. Weight Loss, Overeaters Anonymous, Take Off Pounds Sensibly
(TOPS), and eDiets.com are widely available, data on their effectiveness are largely
lacking (Womble et al. 2002). The Weight Watchers program, which has been
the subject of three published controlled trials, has been the most thoroughly researched of the commercial and self-help weight loss programs (Tsai & Wadden
2005). The largest of those trials found that participants in Weight Watchers lost
4.3 kg and 2.9 kg at one and two years, respectively, compared with losses of
1.3 kg and 0.2 kg among controls who received two 20-minute sessions with a
nutritionist and various self-help resources (Heshka et al. 2003). Data from competing commercial programs are not available. Clearly, there is a need for more
empirical scrutiny of the most popular weight control programs.
PHARMACOTHERAPY
The Practical Guide indicates that pharmacotherapy may be an appropriate treatment option for persons with a BMI 30 kg/m2 or 27 kg/m2 in the presence
of weight-related comorbidities (NHLBI & NAASO 2000). Seven medications
are currently approved by the Food and Drug Administration for the treatment of
obesity, but only twosibutramine and orlistatare approved for long-term use
(Kaplan 2005, Klein 2004).
Sibutramine is a combined serotonin-norepinephrine reuptake inhibitor that
appears to help limit food intake by decreasing hunger and increasing satiety
(http://www.rxabbott.com/pdf/meridia.pdf). Orlistat, by contrast, acts within the
digestive tract: It is a lipase inhibitor that effectively blocks the absorption of approximately one-third of the fat consumed in a meal (http://www.rocheusa.com/pro
ducts/xenical/pi.pdf). Because the undigested fat is passed in stools, consuming a
high-fat diet (e.g., >20 g of fat per meal or >70 g per day) can lead to undesirable
gastrointestinal side effects. Thus, patients are negatively reinforced to eat a diet
low in fat.
Both drugs induce greater weight losses than placebo (Arterburn et al. 2004,
Li et al. 2005). For example, sibutramine (15 mg) was associated with a 7.4%
weight loss at six months, versus 1.2% for placebo in one large investigation (Bray
et al. 1999). Similarly, a six-month randomized controlled trial found reductions
of 9.8% and 6.5% for orlistat and placebo, respectively (Van Gaal et al. 1998).
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Long-term Pharmacotherapy
Experts currently encourage the long-term use of antiobesity agents in recognition
of the chronic nature of obesity (Klein 2004). Just as antihypertensive, antidiabetic, and lipid-lowering medications are used to maintain normal blood pressure,
glucose, and cholesterol values, respectively, antiobesity agents should not be discontinued after an initial satisfactory weight loss is achieved (Wadden et al. 2002).
This position is supported by two-year trials in which patients lost weight with
pharmacotherapy and were then randomized to continued medication or placebo
for weight maintenance. In the STORM trial (i.e., Sibutramine Trial of Obesity
Reduction and Maintenance), 605 obese participants were treated with 10 mg
of sibutramine daily plus a limited dietary intervention for six months (James
et al. 2000). Those who achieved at least a 5% weight reduction (77% of participants) received either sibutramine or placebo for the next 18 months. Participants
switched from sibutramine to placebo maintained a weight loss of 4.9 kg at 24
months, whereas those who remained on medication maintained a significantly
larger reduction of 8.9 kg. Similar results have been found with orlistat. At least
two studies have found significantly less weight regain among patients treated with
orlistat (120 mg three times a day) for two years than among those who received
orlistat in year one and placebo in year two (Davidson et al. 1999, Sjostrom et al.
1998).
Although it is clearly effective, there are significant barriers to the pharmacologic treatment of obesity. Most insurance plans do not reimburse the cost of these
medications, which frequently exceeds $100 a month (Li et al. 2005). Thus, patients are forced to pay out-of-pocket for weight loss medications, whereas drugs
for hypertension and lipid disordersoften the result of obesityare covered.
Many investigators believe that weight loss medications are stigmatized in the
same manner as obese individuals themselves (Wadden et al. 2002).
BARIATRIC SURGERY
Bariatric surgery is the most intensive treatment option and is reserved for individuals with extreme obesity (i.e., BMI 40 kg/m2 ) or those who have a BMI
35 kg/m2 plus serious weight-related health problems (NHLBI & NAASO 2000).
Extreme obesity has become increasingly common among American adults in recent years. From 1986 to 2000, the prevalence of persons with a BMI 40 kg/m2
quadrupled, and the prevalence of those with a BMI 50 kg/m2 increased fivefold
(Sturm 2003). The number of bariatric surgeries performed in the United States has
increased even more rapidly, from approximately 16,000 in 1992 to about 103,000
in 2003 (Steinbrook 2004).
The most commonly performed procedure in the United States is the Roux-enY gastric bypass (Buchwald & Williams 2004). The creation of a small stomach
pouch (30 mL) dramatically restricts food intake, and the bypassing of up to 60 cm
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Effects of bariatric surgery on obesity-related conditionsa
Condition
Median (range)
preoperative
prevalence
Median (range) percentage

of patients whose condition
improved or resolved
postoperatively
Type 2 diabetes (21 studies)
11% (3%100%)
100% (64%100%)
Hypertension (19 studies)
38% (16%83%)
89% (25%100%)b
Dyslipidemia (11 studies)
32% (3%65%)
88% (60%100%)
Table created from data published in Maggard et al. (2005).
These figures represent full resolution of hypertension. Improvement was reported in 95%100% (median = 100%)
of patients with hypertension at baseline.
of small intestine reduces absorption of nutrients and, thus, calories (Maggard et al.
2005, Pories et al. 1995). A meta-analysis found that gastric bypass is associated
with average postoperative weight losses of 43.5 kg at one year and 41.5 kg at
three or more years (Maggard et al. 2005).
Adjustable gastric banding, which is often performed laparoscopically and
known as the lap-band procedure, has been performed routinely in Europe
for at least a decade and is becoming increasingly popular in the United States
(Buchwald & Williams 2004). Unlike the gastric bypass, the lap-band procedure
is purely restrictive in that portion sizes are limited by reducing stomach capacity
with a circumgastric band. This surgery induces mean reductions of 30.2 kg at one
year and 34.8 kg at three or more years (Maggard et al. 2005).
As shown in Table 3, bariatric surgery is associated with significant improvements in obesity-related comorbidities. Surgery, however, is not without risks.
Gastric bypass and adjustable gastric banding are associated with early (i.e.,
<30 days after surgery) mortality rates of 0.3%1.0% and 0%0.4%, respectively
(Maggard et al. 2005). The risk of having surgery, however, may be less than the
risk of foregoing it. Christou and colleagues (2004) examined five-year mortality
data for patients who elected to undergo bariatric surgery and controls (matched
on age, sex, and age of morbid obesity onset) who did not undergo surgery. They
found that <1% of the 1035 surgery patients died during that time, compared with
>6% of the 5746 controls.
MOVING TOWARD PREVENTION

The research reviewed in the previous sections indicates that several obesity therapies can induce clinically significant reductions in weight and related health complications. Despite the development and proliferation of weight loss programs,
products, and procedures, however, the prevalence of excess weight continues to
increase. Clearly, clinical weight loss interventions will not provide a solution to
the growing obesity crisis.
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Many experts encourage targeting the culturenot the individualfor intervention (Horgen & Brownell 2002, Nestle & Jacobson 2000). They argue that
the obesity epidemic will continue to escalate until public policy forces sweeping
changes in our food and activity environments. Brownell and colleagues use the
term toxic environment to describe a society in which energy-dense food is inexpensive, readily available, highly palatable, and heavily advertised, while physical
activity is implicitly or explicitly discouraged by technological advances and the
design of neighborhoods and work places (Battle & Brownell 1997, Horgen &
Brownell 2002).
The increasing prevalence of obesity, type 2 diabetes, and markers of heart
disease among children (Cook et al. 2003, Kaufman 2002, Ogden et al. 2002)
may provide the impetus for supporting broad policy measures that encourage
healthy eating and physical activity. Regulating the advertising of unhealthy foods
to children may prove an important step in changing the food culture. Children
view an estimated 10,000 food-related commercials per year, most of which advertise calorie-dense foods of limited nutritional value (Brownell & Horgen 2004).
Harrison & Marske (2005) found that convenience foods, fast foods, and sweets
comprised 83% of the 725 foods advertised during 40 hours of the most popular
television programs among children aged 611 years. The authors estimated that a
2000-calorie diet of the advertised foods would provide 20%30% more saturated
fat and sodium, and 64% less fiber, than is recommended. Furthermore, a diet of
foods advertised in commercials specifically intended for children would provide
inadequate levels of fiber, vitamin A, calcium, and iron, but would supply nearly
one cup of sugar each day.
Additional evidence points to an unhealthy eating environment for children.
Austin and colleagues (2005), for instance, plotted the locations of all schools and
fast-food restaurants within the city limits of Chicago. They found that the average
distance between a school and the nearest fast-food restaurant was 600 meters and
that 78% of schools had at least one such restaurant within 800 meters (0.5 miles).
Additionally, there were three to four times as many fast-food restaurants within
1500 meters of a school as would be expected by chance.
Studies such as those cited above suggest that parents, educators, and health
care professionals who attempt to encourage or model healthy eating for children
face substantial environmental barriers. Brownell & Horgen (2004) have proposed
a number of policy measures that may reduce such obstacles to healthier eating and increased physical activity. Although a detailed discussion of potential
changes is beyond the scope of this paper, Table 4 includes some representative
recommendations.
Some may argue that personal responsibility, and not policy change, should be
emphasized in confronting the obesity epidemic. This stance seems to imply that
reaching and maintaining a healthy weight is a simple matter of willpower and that
obese persons lack self-control. Individuals with obesity, in fact, often are viewed
as lazy, unmotivated, and stupid by members of the public as well as by health
care professionals (Teachman & Brownell 2001). Many persons attribute excess
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A selection of recommended actions for changing the toxic environmenta
Encourage political leaders to be bold and innovative in addressing the obesity crisis and to
remove political barriers to taking action.
Consider changing the price structure of food, first by lowering the cost of healthy foods and
perhaps by increasing the cost of unhealthy foods.
Create a superfund to promote healthy eating, perhaps from assessments placed on food
advertisements or small taxes on the sale of unhealthy foods.

Require food labeling at restaurants.

Support programs that teach children about nutrition and activity.
Earmark transportation funding to increase activity (bike paths and walking paths, buses with
bike racks, traffic calming, etc.).
a
Table created from text of Brownell & Horgen (2004), pp. 30913, with permission of The McGraw-Hill Companies.
weight not to genes or to an obesigenic environment, but to emotional distress.

The following section reviews the empirical evidence regarding the relationship
of obesity to mood disturbance.
OBESITY AND DEPRESSION

Early investigations of the psychological and psychiatric correlates of obesity
were frequently comparisons of the personalities and symptom profiles of obese
versus nonobese persons. Results of those studies were mixed; some found that
obesity was related to increased psychopathology, while others reported a protective effect of obesity (e.g., Moore et al. 1962, Stewart & Brook 1983, Wadden
& Stunkard 1985). Regardless of the direction of the relationship, however, the
observed differences between obese and nonobese individuals were not clinically meaningful. This first generation of studies that examined the relationship between obesity and psychopathology was criticized for its methodological
flaws (Friedman & Brownell 1995). Namely, these investigations typically lacked
large, representative samples and did not employ clinically validated measures of
psychopathology.
The quality of research in this area has improved considerably. In addition to addressing the limitations of the early studies cited above, recent investigations have
sought to identify risk factors for psychopathology (particularly for depression)
among obese individuals. This shift in focus signals researchers recognition that
people with obesity are a heterogeneous group and that there is likely greater variability in psychological functioning among obese persons than between persons
with and without this condition. Large epidemiological investigations and clinical trials have identified two obese subgroupswomen and those with extreme
obesitythat are at increased risk of depression.
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The Obesity-Depression Relationship in Women Versus Men

Three population studies found that the relationship of body weight to depression
differs between the sexes. The first study examined data from the first National
Health and Nutrition Examination Survey, which was conducted from 19711975
and compared rates of depression across BMI quintiles for women and men (Istvan
et al. 1992). Depression was 38% more common [odds ratio (OR) = 1.38, 95%
confidence interval (CI): 1.071.69] among women in the highest BMI quintile
(>28.96 kg/m2 ) than in women in the lower four quintiles. Men in the highest BMI quintile (>28.7 kg/m2 ), however, were no more likely to be depressed
than were their counterparts with lower BMIs (OR = 0.97, 95% CI: 0.48
1.47).
Carpenter et al. (2000) similarly found that obese women were 37% more likely
to report a history of depression in the past year than were women with a BMI
of 20.829.9 kg/m2 . Suicidal ideation and past-year suicide attempts also were
more common among obese versus nonobese women, but those increases were
not statistically significant. In the same study, excess weight was found to have a
protective effect for men such that past-year depression and suicide attempts were
both 37% less likely (95% CIs: 0.600.67 and 0.480.83, respectively) among
obese versus nonobese men.
Finally, Onyike et al. (2003) analyzed data collected from 19881994 as part
of the third National Health and Nutrition Examination Survey. Similar to the two
previous epidemiological studies cited above, this investigation found that obesity
was significantly related to depression for obese women (OR = 1.82, 95% CI:
1.013.30) but not for obese men (OR = 1.73, 95% CI: 0.565.37).
It is well documented that the prevalence of depression is higher among women
than among men in the general population (Am. Psychiatr. Assoc. 2000, Kessler
et al. 1993). It is not surprising, therefore, that the relationship between obesity and
depression is moderated by gender. Some researchers have posited that females not
only have a greater biological and psychological vulnerability to depression than
do males, but also are more likely to experience acute and chronic stressors that
would activate a predisposition to depression (Nolen-Hoeksema 2002). Consistent
with this idea, research has found that women experience greater dissatisfaction
with weight and shape than men do, and that dissatisfaction increases with BMI
(Cash 2002). Women also are subject to greater degrees of weight-related stigma
and discrimination than are men (Puhl & Brownell 2001). These factors may not
fully account for, but almost certainly contribute to, the differential relationship
between obesity and depression across genders.
Extreme Obesity Increases the Risk of Depression

Onyike and colleagues (2003) discovered that only the most obese individuals are
at increased risk of depression. These researchers separated their sample of 8410
persons according to weight class (i.e., underweight, average weight, overweight,
and class I, II, and III obesity) and found that the risk of depression was not
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4.63
4.5
4

Odds Ratio
3.5
3
2.5
1.9
2
1.5
1.33
1.13
0.96
18.5 - 24.9
25 - 29.9
0.5
0
< 18.5
30 - 34.9
Body Mass Index
35 - 39.9
>/= 40
(kg/m2)
Figure 3 Odds ratios of past-month depression across BMI categories, adjusted for
age, race/ethnicity, education, marital status, physicians health rating, dieting for medical reasons, use of psychiatric medicines, cigarette smoking, and use of alcohol, marijuana, and cocaine. Data from Onyike et al. (2003).
significantly greater for overweight, class I obese, or class II obese men or women
than for their average-weight counterparts. Individuals with class III (i.e., extreme)
obesity, however, were more than four times as likely as persons of average weight
to meet criteria for major depression (OR = 4.63, 95% CI: 2.0610.42). Figure 3
depicts the odds of depression across BMI categories, adjusted for age, education,
marital status, and several health-related variables.
The findings cited above are consistent with those of smaller, clinical studies. As
compared with less-obese individuals who sought behavioral and pharmacological
weight loss interventions, extremely obese persons who sought bariatric surgery
were found to have lower self-esteem and higher depression scores (Berkowitz
& Fabricatore 2005). Extremely obese persons also have greater impairments
in health-related quality of life than do their less obese peers (Kolotkin et al.
2002).
Some evidence suggests that the relationship between BMI and depression
may be mediated by impairments in health-related quality of life. Several studies
have found that BMI, impaired quality of life, and symptoms of depression are all
positively associated (Dixon et al. 2003, Doll et al. 2000, Kolotkin et al. 2002).
Fabricatore and colleagues (2005), however, found that BMI was unrelated to
depression after impairments in health-related quality of life were included in
multivariate models. Results from this cross-sectional study await replication in a
longitudinal investigation.
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373

CONCLUSION
Obesitywhich is increasingly prevalent in the United States and throughout the
worldis a serious medical condition that is associated with increased morbidity
(e.g., diabetes, cardiovascular disease, sleep apnea, osteoarthritis) and mortality.
Additionally, some obese persons (i.e., women and those with a BMI 40 kg/m2 )
are at elevated risk of depression.
Many available treatments result in clinically significant weight losses and
improvements in weight-related comorbidities. Facilitating the long-term maintenance of such losses, however, remains a challenge to clinicians and researchers.
Thus, obesity must be considered a refractory condition that requires chronic
care.
Barriers to obesity treatment include lack of or limited third-party payment for
weight loss therapies and an environment that is not conducive to weight control.
As long as societal norms include overconsumption of calorie-dense foods and
the built environment implicitly discourages energy expenditure, even the bestdesigned and most powerful treatments will be insufficient to curb the epidemic
of excess weight. Prevention efforts must be undertaken on a grand scale in order
to reverse the increasing prevalence of obesity and related disorders.
DISCLOSURE
TW is a consultant to Abbott Laboratories, which produces the weigh-loss medication sibutramine (Meridia).
The Annual Review of Clinical Psychology is online at
http://clinpsy.annualreviews.org
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February 24, 2006
16:34
Annual Reviews
AR271-FM
Annual Review of Clinical Psychology

Volume 2, 2006

CONTENTS
THE HISTORY AND EMPIRICAL STATUS OF KEY PSYCHOANALYTIC
CONCEPTS, Lester Luborsky and Marna S. Barrett
DOCTORAL TRAINING IN CLINICAL PSYCHOLOGY, Richard M. McFall
METHODOLOGICAL AND CONCEPTUAL ISSUES IN FUNCTIONAL
MAGNETIC RESONANCE IMAGING: APPLICATIONS TO
SCHIZOPHRENIA RESEARCH, Gregory G. Brown and Lisa T. Eyler
THE USE OF STRUCTURAL ANALYSIS OF SOCIAL BEHAVIOR (SASB) AS
AN ASSESSMENT TOOL, Lorna Smith Benjamin, Jeffrey Conrad
Rothweiler, and Kenneth L. Critchfield
1
21
51
83
REINTERPRETING COMORBIDITY: A MODEL-BASED APPROACH TO

UNDERSTANDING AND CLASSIFYING PSYCHOPATHOLOGY,
Robert F. Krueger and Kristian E. Markon
WOMENS MENTAL HEALTH RESEARCH: THE EMERGENCE OF A

BIOMEDICAL FIELD, Mary C. Blehar
POSTTRAUMATIC STRESS DISORDER: ETIOLOGY, EPIDEMIOLOGY, AND
TREATMENT OUTCOME, Terence M. Keane, Amy D. Marshall,
and Casey T. Taft
111
135
161
THE PSYCHOPATHOLOGY AND TREATMENT OF BIPOLAR DISORDER,

David J. Miklowitz and Sheri L. Johnson
199
ATTEMPTED AND COMPLETED SUICIDE IN ADOLESCENCE,

Anthony Spirito and Christianne Esposito-Smythers
ENDOPHENOTYPES IN THE GENETIC ANALYSES OF MENTAL

DISORDERS, Tyrone D. Cannon and Matthew C. Keller
SCHIZOTYPAL PERSONALITY: NEURODEVELOPMENTAL AND
PSYCHOSOCIAL TRAJECTORIES, Adrian Raine
AUTISM FROM DEVELOPMENTAL AND NEUROPSYCHOLOGICAL
PERSPECTIVES, Marian Sigman, Sarah J. Spence, and A. Ting Wang
OBESITY, Anthony N. Fabricatore and Thomas A. Wadden
MILD COGNITIVE IMPAIRMENT AND DEMENTIA,
Marilyn S. Albert and Deborah Blacker
237
267
291
327
357
379
vii
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viii
16:34
Annual Reviews
AR271-FM
CONTENTS
COGNITION AND AGING IN PSYCHOPATHOLOGY: FOCUS ON

SCHIZOPHRENIA AND DEPRESSION, Philip D. Harvey, Abraham
Reichenberg, and Christopher R. Bowie
CONTINGENCY MANAGEMENT FOR TREATMENT OF SUBSTANCE

ABUSE, Maxine Stitzer and Nancy Petry
PERSONALITY AND RISK OF PHYSICAL ILLNESS, Timothy W. Smith and
Justin MacKenzie
RECOVERED MEMORIES, Elizabeth F. Loftus and Deborah Davis
389
411
435
469
INDEX
Subject Index
ERRATA
An online log of corrections to Annual Review of Clinical Psychology chapters
(if any) may be found at http://www.AnnualReviews.org
499

Besity: Anthony N. Fabricatore and Thomas A. Wadden

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17 Feb 2006 11:20

Annu. Rev. Clin. Psychol. 2006. 2:35777

Annu. Rev. Clin. Psychol. 2006.2:357-377. Downloaded from arjournals.annualreviews.org

Anthony N. Fabricatore and Thomas A. Wadden

weight loss, overweight, body mass index

Abstract The prevalence of obesity is growing at an alarming rate. Thus,

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INTRODUCTION: THE OBESITY EPIDEMIC

Definitions and Comorbidities

Body mass index

162.6 cm (64 in.)

172.7 cm (68 in.)

182.9 cm (72 in.)

<48.9 kg (107.8 lbs)

<55.2 kg (121.7 lbs)

<61.9 kg (136.4 lbs)

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The Health Effects of Weight Loss

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0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0

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A guide to selecting treatmenta

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The + represents the use of indicated treatment regardless of comorbidities.

Outcomes of Lifestyle Modification

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Clinicians and researchers have attempted to improve the outcomes of lifestyle

Improving Weight Maintenance

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The National Weight Control Registry

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What Is the Optimal Diet for Long-Term Weight Control?

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What Is the Optimal Exercise Regimen

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From Efficacy to Effectiveness

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Effects of bariatric surgery on obesity-related conditionsa

Median (range) percentage

Type 2 diabetes (21 studies)

Hypertension (19 studies)

Dyslipidemia (11 studies)

Table created from data published in Maggard et al. (2005).

MOVING TOWARD PREVENTION

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A selection of recommended actions for changing the toxic environmenta

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Require food labeling at restaurants.

weight not to genes or to an obesigenic environment, but to emotional distress.

OBESITY AND DEPRESSION