The Psychological Burden of Obesity


The disease of obesity is associated with a significant psychosocial burden. Many people who are obese also struggle with problems related to their mood, self-esteem, quality of life, and body image.


This emotional distress probably plays a role in seeking treatment, but it can also affect the success of treatment.
Weight loss is associated with improvements in psychosocial status and functioning, apart from physical health reasons.
These positive changes are often most profound among those who have lost a large percentage of their weight, as is often seen with bariatric surgery.
Those who experience weight regain, regardless of the approach to weight loss, are also at risk of unwanted psychological symptoms reappearing.
Obesity is associated with several comorbidities, including cardiovascular disease, type 2 diabetes, sleep apnea, osteoarthritis, and various forms of cancer.
Obesity and its comorbidities also carry a significant psychosocial burden, affecting many areas of psychosocial functioning.
It has been suggested that between 20% and 60% of people with obesity, and particularly those with extreme obesity, suffer from a psychiatric illness.
Extremely obese people, for example, are nearly five times more likely to have experienced a major depressive episode in the past year than those of average weight.
This relationship between obesity and depression appears to be stronger for women than for men, perhaps due to society’s emphasis on thinness as a characteristic of female beauty.
Approximately one third of candidates for bariatric surgery show clinically significant symptoms of depression at the time of surgery.
This can be explained by the experience of stigma and discrimination related to weight, the presence of physical pain or other deficiencies in the quality of life, or the appearance of eating disorders.
Eating disorders
Messy eating is common among people with obesity. Many patients presenting for weight loss treatment eat for emotional reasons.
Others have difficulty controlling their meal frequency, portion sizes, or eating behavior in response to the bombardment of food propaganda from modern society.
The most common eating disorder among people with obesity is binge eating disorder, which only occurs in a minority.
Binge eating disorder is characterized by the consumption of a large amount of food in a short period of time (less than 2 hours), during which the individual experiences a loss of control.
As a result, the individual eats much faster than normal, until he is uncontrollably full, in the absence of hunger, and often eats alone and then finds himself unhappy with himself.
In smaller percentages of obese patients, bulimia nervosa occurs, where bingeing is accompanied by self-induced vomiting or other compensatory behaviors, such as excessive exercise.
About 5% of people with obesity suffer from nocturnal eating syndrome, an eating, sleeping, and mood disorder defined with nocturnal awakenings to eating.
The most common anxiety disorder in bariatric surgery candidates is social anxiety disorder, found in 9% of patients.
Given Western society’s emphasis on thinness as a marker of physical beauty, it is not surprising that people with extreme obesity experience increased anxiety in social situation.
Social anxiety, unless it is of paralyzing intensity, is not believed to contraindicate weight loss treatment.
However, clinical experience suggests that uncontrolled anxiety can have a negative impact on participation in weight loss treatment in all its forms.
A small minority of obese people, who present for weight loss treatment, actively abuse substances.
Surprisingly, two studies suggest that people with extreme obesity and a lifetime history of substance abuse experience greater weight loss than those without a history of substance abuse.
These people are believed to have likely developed self-regulation and impulse control strategies that helped them overcome their struggles with drugs and alcohol and similarly helped them control their eating habits.
Mental health treatment:Many obese patients have turned to mental health treatments to modify their habits or address the emotional consequences of the disease.
The use of psychiatric medications, particularly antipsychotics. and some classes of antidepressants, can contribute to weight gain and can adversely affect weight loss efforts.
Obesity can affect a person’s self esteem. For some people, it can be difficult to recognize and appreciate their talents and abilities due to their struggles with their weight.
Quality of life and body image: Obesity also negatively affects health-related quality of life. These deficiencies are likely to motivate many people to seek weight loss treatment.
Body image is an important aspect of the quality of life for many people. Body image dissatisfaction is common in overweight people, as well as in women and girls of average weight.
The degree of dissatisfaction seems to be directly related to the amount of excess weight that a person is, although people can show dissatisfaction with their whole body or with specific characteristics.
Physical abuse is equally common among people with obesity. Approximately 50% of people with extreme obesity have suffered some form of emotional neglect during their childhood.
This can range from verbal abuse, emotional neglect, or other family dysfunction associated with separation, divorce, substance abuse, etc., of a nuclear family member.
People with obesity are less likely to finish high school, are less likely to get married, and generally earn less money compared to people of average body weight.
Obese people are often discriminated against in various settings, including education and work and even healthcare settings.
Improved health and longevity are probably a central motivation for weight loss treatment for many obese people.
At the same time, concerns about physical appearance and body image are likely to influence the decision to participate in treatment.
These people may have unrealistic beliefs about the impact of weight loss on other areas of their lives, and they may feel disappointed if those beliefs are not met.
These unrealistic expectations were believed to put people at risk of regain weight.
However, the massive weight loss typically seen with bariatric surgery can result in the development of sagging skin on the abdomen, thighs, legs, and arms that can lead to dissatisfaction with body image.
This may lead some patients to see a plastic surgeon for body contouring surgery. Others may have expectations about the impact of weight loss on their interpersonal relationships.
Many people may think that as they lose weight and feel better about themselves, their social or romantic relationships will improve. This happens for many people.
However, for some, the experience of a major weight loss becomes an unsettling experience.
Some people may experience unwanted attention related to their weight loss and physical appearance that can make them feel uncomfortable.
Others may be upset or angry at the fact that people who treated them as invisible before are now friendly and sociable.
People seeking weight loss treatment should consider the potential impact of their weight loss on their marital and sexual relationships.
Some think that these relationships will improve with weight loss. However, body weight can play a much more complex role in some relationships.
In general, psychosocial evaluation has two purposes, in case of surgery:
1- can identify possible contraindications for surgery, such as substance abuse, poorly controlled depression or other major psychiatric illness.
2- the evaluation acquires a more psycho educational component. About the patient’s knowledge of bariatric surgery, weight history, and diet.
Modification of eating style and physical activity habits and potential obstacles and resources that can influence long-term results.


Weight loss is associated with improvements in morbidity and mortality. Weight losses of 3% to 5% are considered clinically significant if they are associated with improvements in body weight.
Weight-related comorbidities.
Larger weight losses are often associated with dramatic improvements in many weight-related health conditions.
Weight loss is also associated with significant improvements in psychosocial status. Most psychosocial characteristics:
Including symptoms of depression and anxiety, health and weight-related quality of life, self-esteem, body image, and sexual functioning improve with weight loss.
The impact of weight loss on formal psychopathology such as:
Major depression can inhibit patients’ ability to make necessary behavioral and dietary changes.
In general, active substance abuse, active psychosis, bulimia nervosa, and severe uncontrolled depression are considered contraindications to bariatric surgery.
However, the presence of severe psychopathology must be balanced against the severity of obesity and related health problems.
While people with severe psychopathology or other neurocognitive problems may have less than optimal results compared to people without those conditions.
It is estimated that they may still experience more dramatic weight loss and improvements in physical and mental health than seen with lifestyle modification or drug therapy alone.
Suboptimal weight loss:
Approximately 25% of people who succed weight loss, begin to regain large amounts of weight in the first years.
Sub-optimal results are typically attributed to psychosocial and behavioral problems, such as poor adherence to the maintenance diet, with return of maladaptive eating behaviors.


-Jensen MD, Ryan DH, Hu FB, et al. 2013 guideline for the management of overweight and obesity in adults. Circulation. 2013; 129: S102–38.
-Sheets CS, Peat CM, Berg KC, et al. Post-operative psychosocial predictors of outcome in bariatric surgery [review] Obes. Surg. 2015, 25 (2): 330–45.
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