Psychological aspects of severe obesity13

Albert J Stunkard and Thomas A Wadden

ABSTRACT Studies of several overweight persons con- neous grouping. Are they similar enough to each other that they
ducted before their undergoing antiobesity surgery have shown can be profitably compared with other groups? Particular per-
1) that there is no single personality type that characterizes the sonality types and specific emotional conflicts are no longer ac-
severely obese; 2) that this population does not report greater corded the strong causal role in somatic illness that they once
levels ofgeneral psychopathology than do average-weight control enjoyed. The genetic endowment and personal experiences of
subjects; and 3) that the complications specific to severe obesity severely obese persons could, however, be sufficiently similar to
include body image disparagement and binge eating. Studies confer upon them certain common and distinctive character-
conducted after surgical treatment and weight loss have shown istics.
1) that self-esteem and positive emotions increase; 2) that body The first clinical investigations of severe obesity agreed that
image disparagement decreases; 3) that marital satisfaction in- there was great heterogeneity in the psychological features of

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creases, but only if a measure of satisfaction existed before sur- these persons. They have since been followed by more systematic
gery; and 4) that eating behavior is improved dramatically. The studies ofdefined populations. Four such studies have used clus-
results of surgical treatment are superior to those for dietary ter analysis to define specific subtypes of severely obese persons
treatment alone. should be aware that severely obese
Practitioners (3-6). The studies were exemplary. Their samples were relatively
persons are subjected to prejudice and discrimination and should homogeneous (all were persons seeking surgical treatment for
be treated with an extra measure ofcompassion and concern to severe obesity), all utilized highly standardized information oh-
help alleviate their feelings of rejection and shame. Am J tamed from the Minnesota Multiphasic Personality Inventory
C/in Nuir I992;55:524S-32S. (MMPI) and similar techniques of cluster analysis were em-
ployed. Nevertheless, each study reported a different number of
KEY WORDS Severe obesity, psychological status, surgical subtypes (from 3 to 10) and the subtypes differed among these
treatment of obesity, weight reduction studies. There could not be a better demonstration of the het-
erogeneity ofthe psychological aspects of severely obese persons.

Introduction
General psychopathology among obese persons
“Obesity creates an enormous In
psychological burden. . . .

terms ofsuffering, this burden may be the greatest adverse effect Marked obesity
of obesity” (1). This conclusion of the 1985 Consensus Confer-
Studies that have assessed conventional measures of psycho-
ence on Obesity applies to all obese persons. It is particularly
pathology in persons with lesser than severe degrees of obesity
true of the far smaller number (< I %) (2) of persons who suffer
have found little evidence ofincreased psychological disturbance.
from severe obesity (45.4 kg or 100% overweight). This report
This finding is particularly true ofpopulation studies; nine studies
describes what is known about the psychological aspects of per-
ofadults and three of children, reviewed by Wadden and Stun-
sons with severe obesity.
kard (7), showed little difference between obese and normal-
It must be noted at the outset that we have distressingly little weight populations.
information about the psychological aspects of severely obese
Although 10 uncontrolled studies ofclinical populations found
persons. Almost everything that we know about the psychological
elevated levels of psychopathology among obese persons, the
aspects of persons with severe obesity is derived from persons levels were no higher than those found among medical and sur-
who have sought surgical treatment for their obesity. Such per-
gical patients (8). Among controlled studies, four found no dif-
sons represent only a fraction of all severely obese persons, and
ference between obese and nonobese persons (9- 1 2) and two
this sample may be highly biased.
showed only small differences (13, 14). A review ofthese reports
Despite the limitations, there is one redeeming feature of this
information. It describes persons seeking treatment and so is
concerned with precisely those persons for whom such infor- I From the Department of Psychiatry, University of Pennsylvania,
mation is of immediate practical irnportance. Philadelphia.
2 Supported in part by a Research Scientist Award to AJ Stunkard
The heterogeneity of severely obese persons and a Research Scientist Development Award to TA Wadden, both from
the National Institute of Mental Health.
The first question to be asked about the psychological aspects 3 Address reprint requests to AJ Stunkard, Obesity Research Group,
of severely obese persons is whether they represent a homoge- 133 South 36th Street, Suite 507, Philadelphia, PA 19104.

524S Am J C/in Nutr l992;55:524S-32S. Printed in USA. © 1992 American Society for Clinical Nutrition
 PSYCHOLOGICAL ASPECTS OF SEVERE OBESITY 525S

concluded that “epidemiological and clinical studies refute the TABLE 1

popular notion that overweight persons as a group are emotion- Percentage of obese individuals with significant psychopathology
ally disturbed” (7). This conclusion is remarkable testimony to
Significant
the resilience of the human spirit. Obese people are subject to
pathology Disorder
intense prejudice and discrimination, as will be discussed in a
later section. %

Severe obesity Atkinson and Ringuette (IS) 62 Depressive disorder

The very low prevalence ofsevere obesity makes it impossible (n = 21)
to conduct the kind of population studies that have been made Fink et al (16) (n = 31) 58 Depressive disorders
of obese persons in general. There are, however, eight reports referred for
psychiatric
of clinical assessments of severely obese persons, as noted in
consultation
Table 1 (1 5-22). Note that the rates of significant psychopa-
Larsen and Torgersen (17) 40 Axis I disorders,
thology range from 0% to 62%. The reason for this wide dis- (n = 89) adjustment disorder
crepancy is not apparent, and it suggests caution in the inter- with depression
pretation of these results. Nevertheless, there is reason to pay Valley and Grace (18) 29 History of inpatient
closer attention to the three studies that show rates between 23% (n = 56) treatment
and 29%. All three had reasonably large sample sizes, were based Halmi et al ( 19) (n = 80) 29 Lifetime diagnosis of
on structured interviews, and involved robust diagnoses. In both affective disorder,
the study ofGertler and Ramsey-Stewart (20)(23%) and of Halmi by interview
Gertler and Ramsey-Stewart 23 “Affective disorder”
et al (19) (28.7%), the outcome measure was a lifetime diagnosis
(20) (n = 53)

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of affective disorder established by a structured interview based
Wise and Fernandez (21) 8 “Definable psychiatric
upon DSM-III criteria (23). Although the study by Valley and
(n = 24) illness”
Grace (18) did not involve a psychiatric diagnosis, its outcome Castelnuovo-Tedesco and 0 No serious psychiatric
measure, “inpatient psychiatric history,” appears to be robust. Schiebel (22) (n = 12) illness. Personality
None of these three studies included a control group but a disordersin 10.
useful comparison may be derived from the epidemiologic survey
by Weissrnan and Myers (24) that used Research Diagnostic
Criteria, which are quite similar to those of DSM-III (23). The
is surprising when one considers the psychological pressures that
rate ofaffective disorders in this survey was 24.7%, not apparently
they face. The contempt for obesity is widespread, and obese
different from the rates of the three studies considered above.
persons are subject to intense prejudice that cuts across age, sex,
Although conclusions from this analysis are risky, there appears
race, and socioeconomic status (7, 27, 28).
to be no evidence of an increased rate of major psychiatric dis-
Prejudice and discrirnination against obese persons begin in
order in these severely obese persons. Two studies included con-
childhood. Children as young as 6 y old describe silhouettes of
trol groups in their assessment of severely obese persons. In the
an obese child as “lazy, dirty, stupid, ugly, cheats, and liars”
first, Holland et al (10) compared 16 normal-weight persons
(29). When shown black and white line drawings of an obese
with 16 moderately obese and 16 severely obese persons on a
child and children with various severe handicaps, including
variety of psychological measures. The study was very well con-
missing hands and facial disfigurement, both children and adults
trolled and confined to white lower-class women attending non-
rated the obese child as the least likable (30-32). Sadly, obese
psychiatric medical clinics. The only differences that were found
persons themselves manifest precisely the same kind of prejudice
were between the normal-weight group on the one hand and the
(29, 31).
two overweight groups on the other, and there were very few
As they become older, obese persons face discrimination, the
such differences, notably on the items “eating when not hungry”
behavioral enactment ofprejudice. Numerous studies have doc-
and “eating when anxious and depressed.”
umented the stigmatization of obese persons in most areas of
It is possible that the small sample size precluded finding dif-
social functioning.
ferences in the study by Holland et al (10), but no such limitation
Canning and Mayer (33) reported lower acceptance rates into
afflicted the study by Hafner et al (25) of 142 severely obese
prestigious colleges for obese high school students compared
women who were compared with an age-matched normal pop-
with normal-weight students, even when controlling for all other
ulation. These authors found that the obese patients showed
relevant variables. Similarly, Pargarnan (34) found obese students
higher levels of phobic anxiety, sornatization, and depression
seriously underrepresented in a private college.
than the normal-weight control group on the Crown Crisp Ex-
When they seek employment (35), and on the job (36), obese
periential Index (26). They note, however, that the elevations
persons face further discrimination. Roe and Eickwort (37) re-
on these scales were “clinically modest, and fall well short of
ported that 16% ofemployers said that they would not hire obese
levels reported by psychiatric patients.” These systematic studies
women under any condition and an additional 44% would hire
thus agree with clinical interview studies that severely obese per-
them only under special circumstances. A careful study of ex-
sons do not show unusual levels ofpsychopathology by conven-
ecutives revealed that discrimination against the obese is further
tional measures. This finding thus parallels that of studies of
manifested in their earning potential; it has been estimated that
overweight persons who are less than severely obese.
each pound of fat costs an executive $l000/y (38). The armed
Prejudice and discrimination forces, police, fire departments, and airlines will not enlist se-
The fact that severely obese people may show no higher levels verely obese persons and reprimand or discharge persons who
of general psychopathology than do persons of normal weight fail to maintain a weight acceptable to these employers (27). The
526S STUNKARD AND WADDEN

full extent of job-related discrimination against the obese is weight reduction, including, notably, members ofhospital staffs.
probably seriously underestimated because of a reluctance of It seems more reasonable to ascribe the antipathy of physicians
employers to acknowledge their biases (27, 35). to their assimilation ofprevailing negative attitudes towards obese
Weight-related discrimination extends to other social insti- persons.
tutions, including marriage. For example, when marrying, almost
twice as many obese women (22%) fell as rose in social class
Psychopathology specific to obese persons
(39, 40).
A very recent study by Rand and Macgregor (41) documented In the face of this intense psychological assault it is truly sur-
for the first time the perception ofprejudice and discrimination prising that severely obese persons show no greater disturbance
experienced by severely obese persons. It was carried out on 57 than persons of average weight on conventional measures of
consecutive patients before surgery and again 14 mo later, after psychopathology. It is true that they, like their nonobese peers,
an average weight loss of 45.5 kg. A 20-item questionnaire de- suffer from the same gamut ofernotional disorders. Furthermore,
signed for the purpose ofthe study revealed two major findings. many overweight persons suffer from psychological problems
Preoperatively, patients reported a truly overwhelming amount specific to obesity: binge eating, disparagement ofthe body image,
of prejudice and discrimination; postoperatively, patients re- and a tendency toward other disorders noted below.
ported experiencing almost none.
Table 2 shows five ofthe more striking examples of prejudice Binge eating
and discrimination. More than 80% of patients answered “al- For a behavior that is so critical to obesity, the eating behavior
ways” or “usually” in response to questions about perceiving ofobese persons has received surprisingly little attention. Binge
themselves to be physically unattractive, beliefs that others make eating by obese persons was described as early as 1959 (44), but
disparaging comments about their weight, their dislike of being it was soon subsumed under the category of bulirnia nervosa

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seen in public, and feeling that they are discriminated against and further studies ofthe behavior were confined largely to per-
when applying for jobs. sons ofnormal weight who combined their binging with vomiting
One finding is particularly important for physicians (and other and/or laxative abuse. A few studies in the past assessed disor-
health-care personnel) who care for severely obese persons. Sev- dered eating by obese persons, noting binge eating, night eating,
enty-eight percent ofthese patients reported that they had always snacking, difficulty in stopping eating, and consuming of large
or usually “been treated disrespectfully by the medical profession meals (45, 46). But interest in quantitative studies of disordered
because of my weight.” Studies of the attitudes of physicians eating among obese persons is ofquite recent origin. These stud-
toward obese persons indicate that the perceptions of their pa- ies have been summarized and extended in a paper describing
tients may be fully justified. Thus, Maddox and Liederman (42) “binge-eating disorder,” the characteristics of which are listed
reported a survey of77 physicians in which they described their in Table 3 (47).
obese patients as “weak-willed, ugly and awkward.” Acknowl- Careful studies of binge eating defined by these or similar
edging physicians’ antipathy to obese persons, Keys (43) sug- criteria have found the disorder rare among persons of normal
gested that it is based on the belief that overweight persons are weight. The frequency, however, among obese persons applying
self-indulgent and “hence at least faintly immoral and inviting to weight-reduction programs ranges between 20% and 46%,
retribution.” It has been suggested that the negative attitudes of with a value as high as 72% in an Overeaters Anonymous group
physicians towards obese persons may be based on their unsuc- (47). The samples of obese persons from whom those estimates
cessful efforts at treatment. This explanation may apply to the were derived were on average less than severely obese, although
relatively small number of physicians who treat obese persons. they included some severely obese persons. The frequency of
It does not, however, apply to the far larger number of physicians binge eating among severely obese persons is probably higher.
whose contacts with obese persons have not included efforts at Thus, Figure 1 from Telch et al (48) shows that the prevalence

TABLE 2
Responses of morbidly obese patients to questions concerning their weight an d psychosocial functioning

Unattractive Attractive

Very Somewhat Very Somewhat

% %

How physically attractive do you feel, taking everything into account? 96.5 3.5 0 0

Always Usually Sometimes Never

At work, people talk behind my back and have a negative attitude toward
me related to my weight. 80.7 10.5 3.5 5.3
I feel that my weight has negatively affected whether or not I have been
hired forajob. 67.3 20.4 10.2 2.2
I do not like to be seen in public. 66.7 17.5 14.0 1.8
I feel that I have been treated disrespectfully by the medical profession
because ofmy weight. 45.5 32.7 16.4 5.5
 PSYCHOLOGICAL ASPECTS OF SEVERE OBESITY 527S

TABLE 3 obesity, the disorder afflicts most severely obese persons. This
Diagnostic criteria for binge eating disorder greater prevalence is probably attributable to the greater degree
ofobesity in childhood and adolescence ofpersons who became
A. Recurrent episodes of binge eating, an episode being characterized
severely obese adults, as well as to the greater measure of censure
by the following:
1) Eating, in a discrete period oftime (eg, in any 2-h period), an they received.
amount of food that is definitely larger than most people would
Other problems specific to obese persons
eat during a similar period of time.
2) A sense oflack of control during the episodes (eg, a feeling that Overweight individuals, and severely obese persons in partic-
one cannot stop eating or control what or how much one is ular, are likely to experience a number ofother psychosocial ills
eating). that are not measured by standard personality and psychopa-
B. During most binge episodes, at least three of the following
thology inventories. Such adverse effects involve weight-specific
behavioral indicators of loss of control:
problems, such as lack ofconfidence due to inability to maintain
I) Eating much more rapidly than usual.
2) Eating until feeling uncomfortably full. a weight loss, a sense of isolation attributable to the failure of
3) Eating large amounts of food when not feeling physically family and friends to understand the frustration of a weight
hungry. problem, or the humiliation that arises from the failure to fit
4) Eating large amounts of food throughout the day with no into theater or airplane seats.
planned mealtimes. Studies of severely obese persons before and after weight loss,
5) Eating alone because of being embarrassed by how much one is although unsatisfactory in many ways, provide one method of
eating. assessing the psychosocial problems specific to these persons.
6) Feeling disgusted with oneself, depressed, or feeling very guilty Frequently, patients recognize the full extent of their suffering
after overeating.
only in retrospect, after successful weight reduction. Thus, we

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7) Eating large amounts of food because one is upset, anxious,
will examine briefly studies of psychosocial function before and
lonely, depressed, or bored.
C. The binge eating occurs, on average, at least twice a week for a after surgical treatment of obese persons.
6-mo period.
D. Marked distress regarding binge eating.
Psychological function before and after surgical
E. Does not currently meet the criteria for bulimia nervosa or abuse
treatment
medication (eg, diet pills) in an attempt to avoid weight gain.

During the past decade, gastric restriction procedures have

supplanted the earlier intestinal bypass surgery for severe obesity.
ofbinge eating rises sharply with increase in the body mass index. Despite the different methods of action, the psychological
Spitzer and colleagues (47) have reported similar findings, as changes accompanying weight loss by these two procedures ap-
pear similar. Accordingly, we will combine the results of psy-
have Kolotkin et al (49).
Obese binge eaters report significantly greater psychological chological assessment of patients who underwent either proce-
dure.
distress than do obese nonbingers, including depression, anxiety,
and obsessive-like behavior (48-52). Moreover, these individuals Ifthe difference in psychological functioning before and after
weight loss can be taken as a measure ofthe psychological burden
are at increased risk of terminating treatment prematurely and
rapidly regaining lost weight when treated by a conventional ofsevere obesity, this burden appears very great. We will consider
1 200-kcal diet (5 1 ). Further research is clearly needed on this it in five areas.
problem but it appears that binge eaters have special treatment
Psychosocial function
needs regardless ofthe type ofobesity therapy selected: behavioral
or surgical. Weight-loss surgery greatly improves the psychosocial func-
tioning of obese patients. This finding, first reported by Solow
Disparagement ofthe body image

Disparagement of the body image is a common problem of

severely obese persons. This disorder has been defined as a belief
(I)
that one’s body is grotesque and loathsome and that others view I-
U
it with hostility and contempt. Body image disparagement takes w
the form of an overwhelming preoccupation with obesity; “it
(I)
makes no difference whether the person be also talented, wealthy, IL.
or intelligent; his weight is his only concern, and he sees the 0
whole world in terms of his weight (53). z
Lu
Not all obese persons have negative feelings toward their bod- U
ies. The disturbance is most commonly found in persons with Lu

childhood onset oftheir obesity, who have a generalized neurotic

disturbance and whose parents and friends have scorned them
for their weight. The disturbance, which appears to develop in BMI CATEGORY
adolescence, represents an internalization of parental and peer FIG 1 . The percentage of the total number of subjects in the sample
criticism and persists in the absence of continued derogation. meeting the full DSM-III criteria for bulimia (obese binge eaters) is shown
Despite the fact that body image disparagement is found in for each ofeight Body Mass Index (BMI) categories. Those not meeting
fewer than one-half of persons with childhood onset of their the DSM-III category for bulimia are also shown (48).
528S STUNKARD AND WADDEN

et al (54) in 1974, has been the subject of remarkable consensus TABLE 4

in subsequent reports (22, 55-65). Many of the psychosocial Percentage of obese persons reporting body image disparagement
benefits ofweight loss are the direct result of increased mobility before and after surgery
and stamina (22, 65, 66), which, coupled with lessened self-con-
Body image disparagement
sciousness (64), encourage patients to explore social and voca-
tional activities formerly inaccessible to them. The capacity to Severe Mild Absent
pass through supermarket and subway turnstiles, ride on public
transportation, and to fit into airline and theater seats is a pow- Beforesurgery(%) 70 18 11
erful incentive to patients who had formerly been denied these After surgery (%) 4 49 46
activities. Many show “a dramatic increase in their participation
in sports, dancing, and organized group activities” (67). Patients
whose immobility and embarrassment had prevented them from
seeking or holding a job report successful employment, while
A concrete measure of body image disparagement is “mirror
those who had been employed often changed from unsatisfactory avoidance” (74). Most persons with body image disparagement

jobs and/or report “increased productiveness, income, and job distinctly dislike looking at themselves in the mirror and they
satisfaction” (59). Sixty-five percent of the homemakers in one go to great lengths to avoid even inadvertent glimpses of them-
study reported that they were functioning far better in this ca- selves in large store windows. Surgical treatment radically reduces
the rate of mirror avoidance. Rand and Kuldau (67) reported
pacity 1 y after surgery (67).
Closely connected with the increased mobility and stamina that two-thirds of their severely obese patients avoided looking
are improvements in mood (65), self-esteem, and interpersonal in mirrors before surgery; after surgery 60% of those who had

and vocational effectiveness. A large majority of patients in all avoided mirrors no longer did so. One-halfofthe patients studied

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studies report satisfaction with the outcome of surgery. Asser- by Halmi et al (7 1) reported mirror avoidance before surgery;

tiveness and self-confidence increase and there is a lessening of after surgery 84% noted that the problem became less severe

the patient’s passive dependency and self-denigration (22, 55, and 50% found it much less severe.
59, 65). Many subsequent investigators have confirmed Solow’s The very recent study by Rand and Macgregor (73) deserves

(65) report that 3 y after surgery most patients felt “greater con- mention in relation to the issue of changes in disparagement of
the body image. As noted above, severely obese persons report
fidence in their own resources . . . reduction in resignation and
in a self-reinforcing sense of entrapment, and escape from a overwhelming prejudice and discrimination directed against
chronic sense of helplessness, hopelessness, and released fail- themselves because of their weight. Fourteen months after sur-

ure (60). gery and a weight loss that averaged 45.5 kg, these same patients
More systematic measures ofimprovernent after surgery have reported a dramatic decrease in their perceptions of these neg-
followed the earlier clinical reports. Thus, Saltzstein and Gut- ative attitudes. Whereas before surgery 80.7% reported “always”

mann (68) reported that 50% of their patients showed positive experiencing a negative attitude toward them because of their
weight, after surgery 87.3% “never” reported such attitudes.
changes in their MMPI profiles after surgery, while another 30%
Similarly, whereas 77. 1% had reported that their children pre-
had normal preoperative profiles that remained so. Improved
self-concept was reported by 85% ofpatients and increased energy ferred that they not attend school functions “always” or “usu-
level and activity and improved interpersonal relationships by ally”, after surgery 100% reported that this “never” occurred. It
70%. Gentry et al (69) reported increased self-confidence and is gratifying that patients report such striking reductions in neg-
ative attitudes but it is not clear that reductions in negative at-
increased social activity in 80% oftheir patients. Finally, Larsen
and Torgersen (70) found that patients moved from the patho- titudes are sufficient to account for the marked alteration in
logical to the normal range on the oral dimension oftheir Basic body image disparagement that we have noted. Thus, many of
the favorable results of surgery were noted within 6 mo, at a
Character Inventory.
time when patients were still severely obese and when prejudice
Disparagement ofthe body image must objectively have been only modestly reduced. The authors
Body image disparagement rarely remits spontaneously. Thus, did not assess objective measures ofprejudice and it seems quite
it is noteworthy that patients begin to report its alleviation within possible that the patients’ perceptions were favorably affected

6 mo of surgery (22, 54, 67). The study of Halmi et al (71) by factors other than their interpersonal environment.
showed that 70% ofpatients reported severe body disparagement
Marital and sexual relations
before surgery and only 1 1% reported its absence. By contrast,
4% reported severe disparagement after surgery, and nearly One measure of the psychosocial outcome of surgical treat-
one-half were symptom free (Table 4). ments of obesity is marital function. Tension and discord in
Similar results were reported by Gentry et al (69) with a fall marriages has been reported after surgery, arising from patients’
from 76% to 24% among patients who reported that they were increased self-assertiveness and from their assumption of a wider
“very dissatisfied” with their body image before surgery. The range ofsocial roles (22, 59, 75). One study attracted considerable
patients of Harris and Green (72) likewise reported that they attention with its report that surgery for severe obesity exacer-
liked their bodies more after surgery and felt significantly more bated marital discord and frequently led to divorce (75). An
attractive and less self-conscious. Perhaps the most striking results ingenious study by Rand et al (64) provided an alternative ex-
were reported by Rand and Macgregor (73). Ninety-six percent planation of such findings. They noted that surgery usually had
of their patients had seen themselves as “very unattractive” be- a positive effect on marital relationships even though there was
fore surgery. This value fell to 0 after surgery, while 3.2% con- a high rate of divorce among patients postoperatively. The use
sidered themselves “very attractive” (41). of a control group explained this apparent paradox. Conflicted
 PSYCHOLOGICAL ASPECTS OF SEVERE OBESITY 529S

marriages among the nonobese control persons, as well as among

obese ones, tended to end in divorce. Unconflicted marriages
among both groups, on the other hand, tended to endure. There
was, however, a higher rate of conflicted marriages among se-
verely obese persons than among nonobese persons. It was this
high rate ofconflicted marriages, rather than the surgery, which
accounted for the higher rate of divorce. The study of Rand et
al (64) and our clinical experience agree that divorce by severely
obese persons after weight loss may be an indication of improved
psychological functioning that enables patients to leave unhappy
marriages.
Unlike the problems that accompanied weight loss in patients
in conflicted marriages, Rand and Macgregor (73) noted un-
equivocal improvement in unconflicted marriages. Both patients ‘3
:E
and spouses reported an increase in the frequency of sexual re-
lations and in the spouses’ appraisal of the patient as sexually
attractive. At a 5-y follow-up all patients who had judged their
marriages as “satisfactory” reported improved marital function- TYPE OF FOOD

ing and heightened sexual satisfaction (76). The recent report FIG 3. Mean changes in frequency of eating different types of food
by Hafner et al (77) strongly supports these findings.
reported by 80 patients after gastric surgery for morbid obesity (78).
Sexual relations are particularly responsive to weight loss. Both

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the frequency of sexual relations and the satisfaction that they
engender are increased (54, 59, 65). Consonant with these irn-
provements in psychosexual functioning is the awakening in Changes in food preference after surgical treatment of obesity
women of interest in their personal appearance, including fash- have been as striking as those in eating behavior itself. Consid-

ionable dresses, lipstick, and other facial makeup (22). ering only gastric restriction surgery, several authors have noted
a decrease in preference for concentrated carbohydrates and
sweetened high-fat foods that have been implicated in carbo-
Other eating behavior
hydrate craving. A study by Halrni et al (78) quantified these
The availability of comparison groups for the assessment of changes, as illustrated in Figure 3. Several ofthese findings were
binge eating makes it less necessary to rely on the before-and- noted also by Saltzstein and Gutmann (68) and Hams and
after kind of analysis that has been applied to other behaviors. Green (72).
Nevertheless, such an analysis is instructive. It is perhaps not
Depressive response to weight reduction
surprising that gastric restriction procedures normalize eating
behavior: a 25-mL pouch makes binging impossible and severely Obese people frequently attempt to lose weight and the nature
limits meal size. It is therefore noteworthy that intestinal bypass of their emotional response to weight loss may be viewed as a
resulted also in a normalization of eating behavior, despite the psychological characteristic. It is noteworthy that significant
absence of limitations on the amount that could be ingested at weight loss by persons of normal weight is accompanied by a
one time. Figure 2 shows the frequency of disordered eating starvation syndrome consisting ofdepression, anxiety, weakness,
behavior reported by a sample of69 severely obese persons before and preoccupation with food (79). Similar symptoms have been
and after jejunoileal surgery. Note the decrease in binge eating reported by obese persons when they attempt to lose weight by
and difficulty in stopping eating. dieting (80), although the incidence ofsuch problems is reduced
when diet is combined with group behavioral treatment (81).
The benign emotional responses ofobese persons to weight loss
by surgical means are therefore surprising. After both jejunoileal
Much
Less
bypass surgery and gastric restriction surgery, patients lose large
amounts ofweight with little or none ofthe psychological distress
they had experienced during dieting. After jejunoileal bypass
surgery patients reported far less depression, anxiety, irritability,

Slightly + and preoccupation with food than they did during attempts to
Less diet, and half of the patients reported an increase in positive
emotions such as self-confidence and elation (46). These results
were confirmed and extended by Bray et al (45) who compared
the effects of dieting with those ofjejunoileal bypass in a group
Snacking Nioht Size of Craving
ofseverely obese persons on a metabolic ward. During 1 mo on
Eating Difficulty Food an 800-cal diet, these patients too became depressed; after in-
binges stopping consumption eating meals sweets
eating
testinal bypass, depression was relieved and weight loss con-
tinued.
Behavior The biological significance of these findings has been height-
FIG 2. Changes in eating patterns of 69 jejuno-ileal bypass patients ened by the experience with gastric restriction surgery, a com-
aftersurgery (46). pletely different form of treatment. After this surgery, patients
530S STUNKARD AND WADDEN

also reported far fewer symptoms. Among a series of8O severely 100-

obese patients studied by Halmi et al (7 1), severe depressive 91.5%

89.4%
90-
reactions were reported by 15% and moderately severe depression
by another 26% during prior efforts at weight reduction by di-
0) 80 -
eting. Only a minority of patients did not report some degree C.)
of depression, and even fewer reported no anxiety, irritability, 0)
70 -
or preoccupation with food.
By contrast, the emotional response ofthese patients to gastric 60
bypass surgery was far more benign, even while they were losing
far more weight than in their earlier efforts. Figure 4 shows that 50
Deaf Dyslexic Diabetes Bad acne Heart Leg Legally
about half the patients reported the absence ofdysphoric mood disease amputated blind
after surgery and that another
5-1 5% reported less dysphoria.
Similarly favorable results
been reported by four other
have FIG 5. Owning one’s disability as reported by 47 formerly obese pa-
groups (21, 68, 72, 82), although their comparisons were with tients. In contrast to the usual pattern ofpreferring one’s own disability
the preoperative period rather than with periods when patients to others, 100% of formerly obese patients said that they would prefer
were losing weight by dieting. to be deaf, dyslexic, diabetic, or have bad acne than to be obese again.
A large majority (91.5% and 89.4%) said that they would prefer to have
The psychosocial benefits in these studies were not confined
a leg amputated or be blind rather than to be obese again. [Figure plotted
to a lessening ofnegative ernotions. Halfofthe patients of Halmi
from data in Rand and Macgregor (41)].
et al (7 1 ) reported much more elation and self-confidence and
75% reported increased feelings of well being. Saltzstein and
Gutmann (68) noted that 70% of their patients reported that obese persons prefer their obesity to the other disorders. Leg

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their energy level was greater than it had been during the im- amputation was preferred by 91 .5% and legal blindness by 89.4%.
mediate postoperative period. When asked to choose between being normal weight or a severely
obese multimillionaire, all patients said that they would prefer
to be of normal weight (41) (Fig 5).
The perceived liability of severe obesity: owning one’s
These findings provide eloquent testimony to the pain of obe-
disability
sity; they call for ever more compassion and empathy on the
part of those of us who treat obese persons. CI
It seems fitting to close this account with a dramatic example
of how severely obese persons have perceived their disorder.
Rand & Macgregor (41) quantified these perceptions by an References
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