Unraveling obesity: Why psychology, social factors matter more than just diet, exercise

When a person goes to a doctor’s office and is greeted by a nurse, the first thing the patient will do is step on a scale.

Using a simple formula, the nurse will calculate the patient’s body mass index, the doctor will assess the patient and determine whether the patient is obese. BMI is an imperfect measure, but is the general standard for determining whether a person is obese, overweight, normal weight or underweight.

The doctor may explain to a patient that obesity can lead to devastating and lethal impacts on any number of organs: the heart, liver, kidneys and so on.

What the doctor may not talk to patients about is the brain’s role in obesity.

Often the medical prescription for curing obesity is the information that is widely known: reduce calorie intake; eat foods that are healthy; eliminate junk food high in sugar and other highly processed foods; increase physical activity to burn more calories; burn more calories than you consume; diet; and exercise. The simple, traditional prescription for losing weight is an easy formula.

Except that it’s not.

The Southeast Missourian spent several weeks interviewing local and national experts on obesity, seeking explanations as to why such a large percentage of the population in Southeast Missouri and across the country is classified as obese.

Experts say obesity is interconnected to simple and complicated psychology as well as socioeconomic conditions, food engineering and our social programming.

Knowing how our brains react to foods, how foods are connected to our emotions, how our social lives and mental illnesses tie into obesity are just as important, if not more so, than knowing the tangible and intuitive solutions.

Depression, for example, is closely tied to obesity. Depression can push people into isolation where they tend to eat more and exercise less. But the effects of being obese can also lead to depression, creating a cycle of overeating that exacerbates both problems.

A growing amount of effort is leaning into addressing the psychological hurdles obese people face. Even pharmaceutical interventions are changing to indirectly target the brain, as a fairly new type of drug reduces a person’s feelings about hunger.

Addressing the obesity problem on a personal and wider level requires reaching beyond fruits and vegetables, calories and running shoes. It requires understanding of what’s going on in our heads and our society, several experts told the Southeast Missourian.

Obesity, the numbers

Obesity is ubiquitous, particularly in Southeast Missouri.

The obesity rate of adults in the 8th Congressional District was 40.1% as of 2021, according to a Congressional District Health Dashboard established by the Department of Population Health and the NYU Grossman School of Medicine. That number was about 7% higher than the national average and about 3% higher than the state average and the city of St. Louis.

According to the same dashboard, 30.4% of adults in the 8th District report no leisure-time physical activity, which is about 6% higher than the national average.

The life expectancy in the 8th Congressional District is nearly three years less than the U.S. average of 78.7 years, though obesity and inactivity only play a role in that figure. For example, smoking rates, firearm suicides, breast cancer deaths, high blood pressure and frequent mental distress are among other factors the 8th District rates worse in than the national average, according to the dashboard.

In its 2022 Community Health Needs Assessment, Saint Francis Medical Center listed obesity (along with nutrition and activity) as well as mental and behavioral disorders as the top two priority health needs in the area. When broken down further by county, obesity was ranked as the top health need in Cape Girardeau, Scott and Stoddard counties. The strategies cited to address obesity all involved exercise and feeding and food production programs; it included no mention of psychology or mental health interventions.

A health needs assessment conducted by what used to be known as Southeast Hospital, showed that 30.5% of the population in Bollinger and Cape Girardeau counties were obese. That would be approximately 36,000 adults aged 20 and older.

The dopamine loop

Reversing an unhealthy diet and sedentary lifestyle begins with untangling poor habits, which means untangling our brains. There are surface-level psychological reasons why someone is attached to eating poorly. Those are spurred by what’s described as a dopamine loop. In other cases, especially in cases of binge-eating disorder, a specific psychological condition where people use food in much the same way others use alcohol, drugs or sex, which is to mask feelings or emotions, often tracing back to trauma. The psychological attachments to food cover a wide spectrum.

At its most simple psychological level, people are susceptible to all kinds of stimuli, some unconditioned (such as smells that provoke hunger signals) or conditioned (such as clocks) that lead to unconditioned responses — which are baked into our natural reflexes — and conditioned responses — which are also reflexive but learned over time, sometimes without realizing. In the case of food, and many other vices, short-term positive reinforcements can lead to poor long-term outcomes.

All sorts of prompts are convincing our brains that we are hungry when we are not, because eating junk food or comfort food can make people feel better, when consuming them at excessive levels makes us unhealthier.

“So you have all these like external cues, and then you also have internal cues, which are your hormones, hunger signals, and your thoughts about food,” said Dr. Travis Masterson, an assistant professor and the director of a technology laboratory at Penn State University, who has studied how technology and media can influence eating behavior. “And you're gonna have a bunch of things that influence that over the day. If you smell the brownies cooking in your kitchen, you're gonna start salivating, and you're gonna be drawn to the kitchen, right? So that's like a biological manifestation, is you're starting to salivate. Psychological manifestation is like, you're getting pulled towards the kitchen, right? And so obviously if there's brownies in your kitchen, you're gonna consume them. And so in the short term, you're increasing your food intake, and you're increasing your food-seeking behavior, right? And in the long term, there's a couple of things that happen. One is, you're obviously going to gain weight, but you also get into this pattern of incentive sensitization. For example, let's say I see a McDonald's commercial. In the McDonald's commercial, the burger looks amazing, right? Better than it's ever looked in real life. It's so juicy and dripping and perfect. And so you see that cue, and you're like, ‘I'm gonna go get that,’ and you go out and get McDonald's. Now, it might not look that way when you get it, but it tastes really good when you eat it. And so you have a really positive response to that, and it creates, essentially, a feedback loop. The next time you see that cue for McDonald's, whether it's the arches or, you know whatever's on TV, you're gonna have a positive effect associated with that. And you're more receptive to the message, so then you're more likely to go seek out the food again. And so then people go, ‘Well, it's like, really hard for me to stop doing this.’ Yeah, because you're in this perpetual loop of positive feedback.”

Kristerpher Brimberry, a Saint Francis psychiatric nurse practitioner based in Poplar Bluff, added that this dopamine loop is complicated by foods that are rich in sugars or fats or fried foods that stimulate dopamine in higher degrees because of their flavors. And those foods are the most accessible foods in our society. Fast-food restaurants and convenience stores can be found almost anywhere. Such foods are often high in calories and low in vitamins and nutrients.

“It’s easier to get your hands on them, where healthy foods are much more expensive and almost more difficult to obtain because of price,” he said. “It’s a multifaceted problem that we have experienced, especially in America. It has led to obesity, which has led to increased depression, increased anxiety and stressful situations related to health and health conditions.”

Terri Leist, a registered nurse and health care home director at Community Counseling Center, has been untangling her own obesity knots for quite some time. Once weighing in at 340 pounds, Leist, 52, has formed healthy eating habits and shared her journey in real time on her YouTube channel. She has lost 180 pounds. She has worked to understand not just what foods will help her lose weight, but also why she had a bad relationship with food in the first place.

“You really have to get to the root cause,” she said. “Like I know for me that I had, as a child, what seemed like a traumatic experience for me. I’ve had to discover that I used food to create a large suit of armor so that I was unattractive to deflect people’s attention. So what I had to learn was, why am I eating? Is my stomach growling? Is it for comfort? Am I sad? Am I happy? Am I excited? And so learning why somebody is eating is like one of the first things to losing weight. And then as far as dopamine, well, food is where I got my dopamine, right? And I was a binge eater. So on the weekend, I would eat like five bags of chips, three family sized bags of candy and tons of sour cream and pizzas. So that is where I got my dopamine.”

Leist said when she began cutting her food intake, she transferred some of that dopamine craving to online shopping, which also was not healthy. Now she directs her dopamine desires to more positive things such as cleaning her house, because, she said, when she was 340 pounds she was physically unable to thoroughly clean like she can now. She said earlier in her journey, she would spend Saturdays cooking healthy meals she could warm up in the week ahead. She said she convinced herself that she was cooking for the health of her future self.

Through her YouTube channel, which now has 12,500 subscribers, Leist said others have connected with her, saying they also saw food as their “suit of armor” from a traumatic experience or the death of a close family member.

Increased risks

Obesity is associated with a significantly increased risk for: schizophrenia, schizoaffective disorder, bipolar disorder, depressive episodes, recurrent depression, dysthymia (a chronic form of depression), anxiety disorder, somatization disorders (when physical symptoms such as pain results in major distress), eating disorders and personality disorders, according to a study from the Medical University of Vienna, as cited by Psychology Today.

A separate international meta-analysis study done in 2010 by many researchers from several institutions sought to determine whether overweight and obesity increase the risk of developing depression and whether depression increases the risk of developing overweight and obesity. The results showed that obese individuals had a 55% increased risk of developing depression over time, whereas depressed people had a 58% increased risk of becoming obese. Those associations were stronger than that between depression and being overweight. The study noted that there could be genetic and biological pathways, though a biological link “remains complex and not definitive.” The study added that “psychological pathways should be mentioned” because “thinness is considered a beauty ideal” leading to “body dissatisfaction and decreased self-esteem, which are risk factors for depression.”

The authors noted that the study’s findings are important for clinical practice. “Because weight gain appears to be a late consequence of depression, care providers should be aware that within depressive patients, weight should be monitored. In overweight or obese patients, mood should be monitored. This awareness could lead to prevention, early detection and co-treatment for the ones at risk, which could ultimately reduce the burden of both conditions.”

Separated care

Despite this study and others that establish a link between psychology and obesity, many local health care professionals say medical care and psychological care often operate in silos.

Savannah Musgrove, clinical program specialist and internship coordinator at Community Counseling Center, has experience in counseling people with mental health conditions. She also has personal experience battling weight and eating well. She has lost 75 pounds in her weight loss journey. As a mental health professional, she understands the connections that food can play in mental illnesses, particularly the dopamine loop.

Musgrove is also aware how people dealing with obesity and mental health problems often have to deal with each issue separately, which can create disjointed care.

“It is separate,” she said. “Like even our psychiatrists, they don’t call a primary care doctor. And primary care doesn’t call psychiatry. They will let the medical doctor take care of that. So psych doctors, they don’t discuss obesity with the client. So they're just two separate places. They're just not integrated yet.”

Leist, the nurse who has lost 180 pounds, said she would recommend anyone who is obese to consider therapy to identify root causes.

Brimberry, the Poplar Bluff psychiatric mental health nurse practitioner, said the merging of the two disciplines can create a holistic approach to overcoming obesity.

“A holistic view is if the medical doctor sees the patient, they've been diagnosed with obesity, morbid obesity, it does run in their family. It's like they're hopeless,” Brimberry said. “So they come in, they're hopeless. They feel helpless. They're not losing any weight. They've tried all these diets, they tried all these medications. Some people, you know, they even resort to drugs, and that's where you start to self-medicate. So if people are self-medicating and or being medicated in other ways, and they fail, this is like a last-ditch hope. So not only is the endocrinologist or the primary doctor, kind of advocating for the patient in a major way, by sending them to psych; it's also advocating for them holistically by applying what they've learned in the endocrinology office, related to obesity, related to comorbidities that may come along, like increased blood pressure, increased heart rate, increased cholesterol, leading to a heart attack or stroke or, you know, it's holistic, all across the board.”