1.6.5 Anxiety Disorders

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The link between obesity and depression

has been repeatedly conrmed. However, it

seems to be minimal or even non-existent in

cohorts without a desire for treatment. This

changes in patients with a desire for treatment.

According to a meta-analysis of longitudinal

studies, obese people, for example, have a 55%

higher risk of developing depression than

healthy people; conversely, the probability of

developing obesity is 58% higher in people

suffering from depression.

Practical Tip

The preoperative diagnosis of depression

seems to be associated with less weight loss

after bariatric surgery. On the other hand,

the depressive symptoms seem to be sig-

nicantly reduced in the majority of

patients after surgery, although in some

cases this success may weaken over the fol-

lowing years.

1.6.5 Anxiety Disorders

Anxiety disorders include

1. the generalised anxiety disorder with per-

sistent, quasi “free-oating” fears that are

not limited to certain environmental con-

ditions,

2. panic disorder with recurrent severe anxi-

ety attacks that are not limited to a specic

situation or circumstances, and

3. phobias, where the fears are caused by

clearly dened, actually harmless situa-

tions. A frequent phobic disorder, even in

obese patients, is the social phobia with

the fear of being judged by other people,

which leads to the avoidance of social situ-

ations.

Anxiety disorders are the most common

mental disorders in developed countries. Up

to 25% of the population are affected within

their lifetime. In addition, anxiety disorders

generally have a negative impact on the course

of chronic diseases. However, the connection

between anxiety disorders and obesity is less

clear than that for depression. In a meta-

analysis, obese people were found to be 40%

more at risk of having a concurrent anxiety

disorder. This interrelation seems to increase

with higher BMI and is most pronounced in

anxiety in the context of post-traumatic stress

disorders and social anxiety. No statement

can be made about the direction of a possible

causality or bidirectionality on the basis of

the studies available to date.

1.6.6 Neglect, Abuse and

Post-traumatic Stress

Disorder

There is a well-established link between child

abuse and the development of chronic physical

illness. Accordingly, the connection between

physical and sexual abuse in childhood and

the development of obesity is well established.

A meta-analysis showed a 36% increased risk

for the development of obesity.

Post-traumatic stress disorder (PTSD) is

characterized by psychological reactions that

occur against the background of a stressful

event with exceptional threat. Typical charac-

teristics are re-experiencing of the traumatic

event through intrusive thoughts, nightmares

and ashbacks, vegetative hyperexcitability

and often pronounced avoidance behaviour.

Fifty percent of all patients with PTSD show

abdominal obesity. The probability of obesity

is signicantly higher in these patients than in

healthy people. In a German prospective lon-

gitudinal study, the risk of developing obesity

in women, but not in men, was associated

with the presence of manifest or subsyndro-

mal PTSD.

1.6.7 Eating Disorders

Disturbed eating behaviour has often been

associated with the development of over-

weight and obesity. Relevant eating disorders

associated with obesity include binge-eating

disorder and bulimia nervosa. Binge-eating

disorder is dened by eating large quanti-

ties of food much faster than usual without

a physiological feeling of hunger, associated

J. Ordemann et al.

with a loss of control. At least one attack per

week over a period of 3 months is required for

diagnosis. In addition, feelings of shame or

guilt usually occur as a consequence. In con-

trast to bulimia nervosa, whose core criterion

is also eating attacks, there is no regular com-

pensatory behaviour such as vomiting, taking

laxatives or pronounced food restriction.

Binge-eating disorder is the most common

eating disorder with a prevalence of about

1–3%. In obese cohorts with a desire for surgi-

cal treatment, however, the prevalence is sig-

nicantly higher at up to 50%, which in turn

points to an increased psychological comor-

bidity in this patient group. In contrast to

anorexia and bulimia nervosa, binge-eating

disorder also affects men to a relevant extent,

accounting for about one third of cases.

In a population-based study in 14 coun-

tries, it was shown that 33% of all patients

with bulimia nervosa and 42% of all patients

with binge-eating disorder are obese. In addi-

tion, the proportion of patients with binge-

eating disorder seems to increase in higher

BMI ranges.

Other unfavourable eating habits relevant

for the care of obese patients are

5 Night-eating syndrome, which is charac-

terised by an intake of food in the evening

or at night,

5 Sweet-eating syndrome, characterized by

excessive consumption of sweet foods, and

5 the so-called “grazing” with a repeated

and unplanned intake of small amounts of

food between regular meals.

However, these denitions are inconsistent

and their character as independent diseases is

currently under discussion.

1.6.8 Personality andPersonality

Disorders

Personality traits can be both protective and

risk factors for the development of obesity.

For example, obsessive-compulsive disor-

ders can be associated with restrictive eating

habits and reduced body weight. In contrast,

personality traits such as neuroticism (emo-

tional vulnerability, often associated with

anxiety, depression, hostility and annoyance),

increased impulsiveness or dependence on

rewards have been shown to increase the like-

lihood of obesity. Neuroticism also appears

to be associated with a more frequent occur-

rence of eating attacks in the context of emo-

tional eating. Reward dependency appears to

be associated with binge-eating disorder. In

contrast, protective effects have been found

for characteristics such as conscientiousness

or self-control with regard to increasing body

weight.

Eating disorders can also be associ-

ated with disorders of affect regulation and

impulse control, as found in emotionally

unstable personality disorders (so-called bor-

derline personality disorders). The prevalence

in various clinical obesity populations var-

ies widely, averaging about 25%. In addition,

up to about 30% of all obese patients with a

binge-eating disorder appear to have a bor-

derline personality disorder, again with large

uctuations in frequency.

1.6.9 Substance Abuse

Alcohol abuse seems to occur in obese

patients with a desire for obesity surgery treat-

ment with a frequency comparable to that of

the general population. There is currently no

reliable interrelation between postoperative

weight loss and the development of alcohol

abuse. According to the few studies available

to date, patients with an alcohol abuse in

their preoperative history are apparently at

increased risk of relapse after bariatric sur-

gery (and especially after a gastric bypass).

This could apply not only to alcohol abuse

and addiction, but also to other substance-

bound and behavioural addictions.

1.6.10 Suicidal Tendencies

While an increased BMI is associated with

the increased incidence of mental disorders,

various studies suggest that there is an inverse

relationship between increased BMI and the

risk of a completed suicide. However, the nd-

ings are very inconsistent with regard to the

Obesity

risk of suicide attempts and suicidal thoughts

or tendencies, and may depend on subgroup

characteristics such as psychological comor-

bidity, age, gender, and country of origin.

Even if the frequency and severity of psycho-

logical problems and illnesses initially decrease

signicantly after bariatric surgical procedures,

the suicide risk after bariatric surgery seems to

increase slightly overall. In a review, possible

factors that could mediate an increased suicide

risk after surgery were discussed. Reasons could

be the persistence of somatic comorbidities,

insufcient weight loss or the (re)appearance

of psychological symptoms. Biological aspects

of altered gastrointestinal anatomy, such as

increased alcohol sensitivity or postprandial

hyperinsulinemic hypoglycaemia, and factors

that are difcult to modify, such as genetic varia-

tions, are also possible.

1.6.11 Social Inequality

Like other chronic diseases and life expec-

tancy in general, obesity is associated with

socioeconomic parameters, with a higher

social position being associated with a lower

BMI.This correlation is more pronounced in

women than in men. In addition, it is inter-

esting to note that studies have shown that

a higher prevalence of obesity is associated

with more pronounced social injustice in the

form of income inequality, but not with the

average income of an economy. Furthermore,

an American prospective social-epidemio-

logical study showed that moving from one

neighbourhood with a high poverty index to

another with a low poverty index led to reduc-

tions in pronounced obesity and diabetes.

Psychosocial stress associated with social dis-

advantage is commonly cited as the mediating

variable for this interrelation.

References

1.1 to 1.3

Blass EM, Anderson DR, Kirkorian HL et al (2006)

On the road to obesity: television viewing increases

intake of high-density foods. Physiol Behav 88:

597–604

Duffey KJ, Popkin BM (2011) Energy density, portion

size, and eating occasions: contributions to increased

energy intake in the United States, 1977–2006. PLoS

Med 8:e1001050

Ng M, Fleming T, Robinson M et al (2014) Global,

regional, and national prevalence of overweight and

obesity in children and adults during 1980–2013: a

systematic analysis for the Global Burden of Disease

Study 2013. Lancet 384:766–781

Nielsen SJ, Popkin BM (2003) Patterns and trends in food

portion sizes, 1977–1998. JAMA 289:450–453

Robert Koch-Institut (2008) Lebensphasenspezische

Gesundheit von Kindern und Jugendlichen

in Deutschland. Ergebnisse des Nationalen

Kinder- und Jugendgesundheitssurveys (KiGGS).

Gesundheitsberichterstattung des Bundes. http://

www. rki. de/DE/Home/hompage_node. html. (19.

April 2016)

Robert Koch-Institut (2014) Übergewicht und Adipositas.

Faktenblatt zu GEDA 2012: Ergebnisse der Studie

“Gesundheit in Deutschland aktuell 2012”. http://

www. rki. de/DE/Content/Gesundheitsmonitoring/

Gesundheitsberichterstattung/GBEDownloadsB/

GEDA12. pdf. (19. April 2016)

Wyatt HR, Peters JC, Reed GW etal (2005) A Colorado

statewide survey of walking and its relation to exces-

sive weight. Med Sci Sports Exerc 37:724–730

1.5

Carey VJ, Walters EE, Colditz GA etal (1997) Body fat

distribution and risk of non-insulin-dependent dia-

betes mellitus in women. The Nurses’ Health Study.

Am J Epidemiol 145:614–619

Knowler WC, Barett-Connor E, Fowler SE etal (2002)

Reduction in the incidence of type 2 diabetes with

lifestyle intervention or metformin. N Engl J Med

346:393–403

Tuomilehto J, Lindström J, Eriksson JG et al (2001)

Prevention of type 2 diabetes mellitus by changes in

lifestyle among subjects with impaired glucose toler-

ance. N Engl J Med 344:1343–1350

J. Ordemann et al.

2.1 Therapeutic Goals

U.Elbelt

The aim of the therapy is sustainable weight

reduction and the prevention or improvement

of obesity-related comorbidities and second-

ary diseases. The high prevalence of obesity

is mostly explained by over-nutrition and lack

of exercise in the context of the prevailing

lifestyle. Accordingly, the interdisciplinary S3

Guidelines of the German Obesity Society

(DAG), the German Diabetes Society (DDG),

the German Nutrition Society (DGE) and

the German Society of Nutritional Medicine

(DGEM) from 2014 focus on nutrition, physi-

cal exercise and behavioural therapy as the

basis of obesity treatment. The basic pro-

gram aims for weight reduction in the rst

phase and sustained loss of weight in the

second phase. The therapeutic goals should

be a weight reduction of >5% of the initial

weight for persons with a BMI of 25–35kg/

within 1year, and a weight reduction of

>10% of the initial weight for persons with a

BMI > 35kg/m

. Furthermore, for persons

with a BMI≥28kg/m

with concomitant risk

factors and/or comorbidities (or BMI≥30kg/

) additional drug therapy may be initiated

following insufcient weight reduction due

to lifestyle changes within 6months or rapid

weight regain after a phase of weight reduc-

tion.

2.2 Nutrition Therapy

H.Berger and U.Elbelt

Diets aimed at weight reduction are available

in numerous variations. The best known are

5 calorie-reduced diet according to the

Weight-Watchers principle with calcula-

tion of the daily energy intake according

to a point system (1 point corresponds to

approx. 50kcal, target: 24–32 points/day,

corresponding to 1200–1600kcal/day)

5 fat and energy reduced diets (<30% fats),

5 Atkins diet with reduced carbohydrate

intake of up to 50g/day,

5 drastic reduction of the daily calorie intake

(<1000kcal) by using regulated formula-

tions (protein-rich drinks with added vita-

mins and minerals).

An effective nutrition therapy must be

adapted to the individual needs of the patient.

According to the S3 guidelines of the profes-

sional societies, a step-by-step scheme should

be followed, which takes this into account.

The primary focus of the dietary change is

on a reduction of the total calorie intake.

In the rst stage, a reduction in fat and/or

carbohydrate intake alone, especially sugar

consumption, can lead to a lower energy

intake. In the second stage, a calorie decit

of 500–1000kcal daily compared to the pre-

vious calorie intake should be aimed for by

an energy-reduced mixed diet (DGE 2009).

The calorie restriction should allow a weight

loss of 0.5kg/week. An energy-reduced mixed

diet is characterised by a diet rich in bre and

protein as well as fat-moderated food selec-

tion and a high proportion of vegetables (and

fruit). The nutrient composition should cor-

respond to the reference values with 50–55%

carbohydrates, 30% fat and 15–20% protein

of the total energy intake (DGE etal. 2008).

At the third or fourth stage, individual meals

or all meals can be replaced by regulated for-

mulation drinks.

Three ground-breaking randomised stud-

ies have compared the success of different

dietary regimes. These studies are therefore

described in more detail below:

5 With regard to weight reduction, an Israeli

study found that a calorie-reduced Medi-

terranean diet and a carbohydrate but not

calorie-reduced diet (“low- carbohydrate

diet”) were signicantly superior to a fat

and calorie-reduced diet (“low-fat diet”)

over a period of 2years (Shai etal. 2008).

These two diets were also superior to the

low-fat diet with regard to a favourable

inuence on the lipid pattern. Common to

all diets was the signicant initial weight

loss until the sixth month of the interven-

tion, followed by a renewed weight gain in

the following year (exception: Mediterra-

nean diet) and a subsequent phase of

U. Elbelt et al.

weight stabilisation, so that the weight loss

at the end of the second year of the study

was 2.9±4.2kg for the fat-reduced diet,

4.4 ± 6.0 kg for the Mediterranean diet

and 4.7 ± 6.5 kg for the carbohydrate-

reduced diet. The participants were char-

acterised by a high level of dietary

adherence, which at the end of the second

year was still at about 85%. This can cer-

tainly also be explained by the way the

study was conducted, as the participants

were recruited via their place of work and

the food in the staff canteens was also spe-

cically labelled.

5 A study carried out with a higher number

of subjects (N=811) on the effect of diets

with different proportions of the macro-

nutrients fat, protein and carbohydrates

for the total daily energy intake showed no

relevant difference after 2 years with

regard to the weight loss achieved (Sacks

etal. 2009). Depending on the type of diet,

the weight loss was between 3.0 kg (for

“low fat, high carb”) and 4.0kg (for “low

fat”). One explanation for the only slightly

different results in weight development is

certainly that the desired differences in the

composition of the macronutrients could

not be achieved as intended. However, in

all the dietary forms investigated, a signi-

cant increase in the weight loss achieved

was found in relation to the intensity of

training (measured by participation in

nutritional counselling time units).

5 The decisive inuence of treatment adher-

ence is impressively demonstrated in a

study by Dansinger et al.(2005). In this

study over 12 months with 160 partici-

pants (average age 49years, average BMI

35kg/m

), who had a BMI above 27kg/m

and at least one other cardiovascular risk

factor, the participants were randomly

assigned to the following diet forms: Diet

according to Ornish with a predominantly

vegetarian diet and a reduction of the fat

content to 10%, calorie-reduced diet

according to the Weight-Watchers princi-

ple (see above), carbohydrate-reduced diet

according to Atkins (see above) and Zone

diet with a macronutrient content as con-

stant as possible (40% carbohydrates, 30%

fats and 30% proteins) of the daily energy

intake. In the rst 2months of the study,

the participants received four nutritional

training sessions of 60 min each. At the

end of the study, no difference in daily

energy intake was observed between the

groups. Likewise, no signicant difference

was observed for weight loss achieved dur-

ing one year, which was most pronounced

in the “Ornish group” with 3.3 ± 7.3 kg

and least pronounced in the “Zone group”

with 2.1±4.8kg. At monthly intervals, the

dietary adherence of the participants was

assessed for all intervention groups using a

scale (no dietary adherence corresponds to

1, perfect dietary adherence corresponds

to 10). Initially, the average for all groups

was between 6 and 7, but then dropped sig-

nicantly after 1month and after 1 year

the average was only between 2 and 4. The

correlation between weight loss and self-

estimated dietary adherence was highly

signicant regardless of the type of diet.

The latter study shows very well that the sus-

tained motivation to change one’s diet is cru-

cial for long-term success.

Practical Tip

The possibility to constantly integrate the

change in diet into the patient’s everyday

life is of special importance. Therefore, the

individual nutritional preferences and eat-

ing habits of the patient have to be taken

into account when making dietary recom-

mendations.

Therapists should have a repertoire of nutri-

tional interventions and adapt them speci-

cally to individual needs.

Very low calorie diets using regulated

formulation drinks should only be used for

targeted short-term weight loss (e.g. before

elective joint replacement). The daily calorie

intake should not go below 800kcal and a

sufcient uid intake of approx. 2.5–3l daily

should be ensured. In addition, the regulated

formulation products used should comply

with the German Dietary Regulations (§7,

Conservative Treatment ofObesity

§4a, §21a and Appendices 2, 6, 17), which

specify the nutrient composition of “dietary

foods” (DGE 2009). Low-calorie diets should

not be followed for longer than 12 weeks.

Renewed weight gain after the end of the high

calorie restriction phase is usually rapid and

pronounced.

2.3 Physical Exercise

U.Elbelt

In addition to nutrition therapy, physical exer-

cise has so far been attributed a decisive role

in weight reduction by increasing energy con-

sumption. Increased physical exercise alone,

however, has at best only a small weight-

reducing effect; only the combination with a

reduction in caloric intake enables weight loss

(Franz etal. 2007). In the interdisciplinary S3

guideline, the following recommendations for

physical activity are given:

5 For effective weight loss, physical exercise

for >150min/week (with the aim of achiev-

ing an energy expenditure of 1200–

1800kcal/week) is recommended.

5 Strength training alone is not suitable for

weight reduction.

5 In the case of grade II or III obesity, activ-

ities that are stressful for the musculoskel-

etal system should be avoided.

5 An increase in everyday physical activity

should be aimed for.

5 Independent of weight reduction, physical

activity leads to health benets.

Before starting physical exercise, contraindi-

cations for additional physical activity should

be excluded.

Increased physical activity is particularly

important for maintaining successful weight

loss. If weight loss is achieved by reducing

calorie intake, the resting energy expenditure

is mainly determined by body weight (7 Sect.

1.2). After termination of the “diets,” which

are usually carried out only temporarily, this

resulting “energy gap” must be permanently

bridged. This can only be achieved by con-

tinuing strict calories restriction and/or by

increasing thermogenesis through increased

physical activity. Possible strategies for clos-

ing this “energy gap” are described in detail

by Wing and Hill (2001). In their observa-

tional study, the behaviour of more than 3000

participants in the National Weight Control

Registry (NWCR) in the USA was recorded.

The participants had lost an average of 30kg

of weight and were able to maintain this

weight loss over an average of 5.5years. The

following behavioural patterns characterise

these successful participants with sustained

weight control:

5 90% of the participants were able to

change their diet permanently and increase

their physical activity. The necessity of

using both strategies (dietary change and

increased physical activity) for sustained

weight maintenance is also evident from a

meta-analysis that takes into account 80

randomised clinical studies with a total of

26,455 participants and an observation

period of at least 1year (Franz etal. 2007).

Thus, the combination of dietary change

and increased physical activity was supe-

rior to dietary change or increased physi-

cal activity alone—apart from additional

drug interventions.

5 The participants behaved very calorie-

restrictively, they had an average caloric

intake of only 1381 kcal/day; they also

adhered a fat-reduced diet (24% fat, 19%

protein, 56% carbohydrates).

5 The participants carried out regular self-

monitoring with nutrition and physical

exercise documentation as well as assess-

ment of body weight (44% daily).

5 The participants were able to increase their

additional physical activity (“regular

planned exercise”) to about 2800 kcal/

week (corresponding to 1h of brisk walk-

ing per day). The most frequent additional

physical activity was walking, followed by

cycling, weight training and aerobics.

These ndings were also conrmed in a

10-year follow-up analysis (Thomas et al.

2014).

U. Elbelt et al.

Practical Tip

It is important to discuss realistic options

for increasing physical activity. Physical

activity should be integrated into everyday

life through increased leisure activities and

active commuting (avoiding transporta-

tion). Using pedometers and documenting

the daily step count is a useful strategy.

2.4 Lifestyle Change:

Psychotherapy

andPsychoeducation

T.Hofmann

In addition to the already mentioned causes

of obesity, increased body weight is often the

result of eating habits that are not adapted

to biological and psychosocial needs in the

long term. However, individual nutritional

(and physical activity) behaviour should not

be misinterpreted as weakness of will alone

(7 Sect. 1.5.1), with family members in par-

ticular, but also doctors seem to be the most

frequent sources of such stigmatisation. The

individual eating behaviour, as described in

7 Sect. 1.2, is rather to be seen as the result

of complex genetic, biological-physiological,

psychological and socio-cultural factors and

may be inuenced by medical drug therapy.

A psychotherapeutic approach should there-

fore be focused on psychosocial causes or

consequences of obesity. This can include the

development of tasks for dealing with stigma-

tisation and self-esteem problems that often

result from stigmatisation, but also inter-

ventions to improve stress management, to

obtain sustainable social support or to deal

with external stimuli that initiate unfavour-

able eating behaviour. In addition, techniques

of self- observation (diet and physical exercise

diaries, regularly documented weight control)

play an important role. It has to be considered

whether the initial therapeutic goal should

not be achievement of weight reduction, but

rather improvement of overall quality of life.

In any case, realistic weight goals should be

dened at the beginning in order to avoid

being confronted with failures at an early

stage due to exaggerated expectations regard-

ing the extent of weight reduction. A further

aim of psychotherapeutic interventions is to

achieve a structured but exibly controlled

eating behaviour, as it will not be possible to

maintain a permanent caloric restriction. It

is also important to discuss the possibility of

setbacks and to identify suitable coping strat-

egies. Group therapies have the advantage,

despite their reduced options to individualise

treatment, of being able to use group dynamic

and interpersonal aspects, which often play a

special role in the treatment of obese patients.

Specic psychotherapy for manifest men-

tal disorders such as depression, anxiety dis-

orders or eating disorders, which are clearly

more common in obese patients who wish to

be treated, should be offered in addition to

obesity treatment, if only to improve the qual-

ity of life.

In addition to the treatment of anxiety

disorders and depression, there is also good

evidence of psychotherapeutic treatment for

binge-eating disorder, which is particularly

relevant in the context of obesity treatment.

There is evidence of effectiveness especially

for cognitive behavioural therapy and inter-

personal psychotherapy. These good results

can be maintained for the most part even in

the longer course over 2years. Guided self-

help programmes can also be effective for the

treatment of mild forms of binge-eating with

still maintained self-esteem and pronounced

body image disorders. On the other hand,

simple weight reduction programmes based

on behavioural therapy are not suitable for

signicantly reducing eating attacks in the

context of binge-eating disorders. It should

be noted that even the successful treatment of

a binge-eating disorder does not lead to pro-

nounced effects in terms of weight loss.

Overall, the direct and indirect metabolic

effects of chronic stress for the aetiology of

obesity are probably still underestimated.

In this respect, it will be interesting to see

whether psychotherapeutic interventions

Conservative Treatment ofObesity

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1.6.5 Anxiety Disorders

1.6.7 Eating Disorders

1.6.9 Substance Abuse

1.6.10 Suicidal Tendencies

1.6.11 Social Inequality

References

1.1 to 1.3

Further Reading

2.1 Therapeutic Goals

2.2 Nutrition Therapy

2.3 Physical Exercise