A new study by Genevieve Garlepy and colleagues from McGill University, Montreal, QC, published online in Social Psychiatry and Psychiatric Epidemiology, shows that the presence of psychological distress (a non-specific measure of mental health that captures negative mood states, including symptoms of depression and anxiety) can double the risk for obesity related disability.
The researchers examined 12 year longitudinal data on 8,062 adults from the representative Canadian National Population Health Survey.
After adjusting for sociodemographic and other health variables, participants with both obesity and repeated distress (n=138) had double (HR 2.8) the risk of disability compared to those with obesity (HR 1.4; n=955) or distress alone (1.8; n=1,044).
The authors conclude that recurrent psychological distress combined with obesity markedly amplifies the risk for disability normally associated with either of these conditions.
A number of factors may explain this relationship:
1) Depressive and anxious symptoms may impact self-perceived health and functional capabilities, which may subsequently affect the decision to participate in certain roles or tasks.
2) Psychological distress can intensify the perception of symptoms and pain associated with obesity, which may interfere with the ability to perform some tasks.
3) Distressed individuals tend to adopt unhealthy lifestyle, including unhealthy eating, smoking, and physical inactivity which can exacerbate the risk and severity of obesity and obesity related diseases, increasing the likelihood for disability. Psychosocial disadvantages might also impede treatment seeking and adherence to treatment.
4) Weight discrimination may limit social support, which usually acts as a buffer for the effects of ill physical and mental health on disability. Weight discrimination may also stifle employment opportunities, which can affect socioeconomic status.
Whether or not primarily targeting excess weight or helping patients better coping with recurrent distress is more effective in preventing disability in obese individuals may be an interesting question for a prospective interventions trial.
If I had to predict the outcome, I would likely pick the latter. Indeed, I would argue that in these individuals, psychological distress may well be one of the underlying factors for the development of obesity (or increasing weight gain) and would thus need to be managed first in order to prevent further weight gain or effectively reduce weight.
Simply expecting these individuals to lose weight with “diet and exercise” is unlikely to result in any meaningful sustainable weight loss.
Gariepy G, Wang J, Lesage A, & Schmitz N (2010). Obesity and the risk of disability in a 12-year cohort study: the role of psychological distress. Social psychiatry and psychiatric epidemiology PMID: 20848077
The tremendous economic impact of obesity on individuals has been well documented. Previous studies have shown that the lifelong earnings of obese men and women are substantially lower that the lifetime earnings of non-obese individuals, in part due to decreased upward socioeconomic mobility. Obesity is also linked to early disability and absenteeism- a substantial cost to the economy.
Now Houston and colleagues from Wake Forest University, Winston-Salem, North Carolina, USA, in a study published in Obesity, suggests that early obesity predicts early retirement.
Data from the Atherosclerosis Risk in Communities (ARIC) were analysed for participants aged 45-55 years at baseline (n = 6,483) with regard to the associations between weight status at age 25 and ages 45-55 and age at early retirement (prior to age 65) over 9 years of follow-up.
After adjustment for gender, race, education, household income, health insurance status, occupation, occupational physical activity, marital status, smoking, and field center, overweight and obesity were associated with early retirement (increased risk between 20 and 60%) in all groups but white women. Furthermore, overweight at age 25 and obesity at ages 45-55 were associated with early retirement for health reasons among African-American and white men and women.
These findings are interesting, because with the high prevalence of obesity amongst the retiring baby-boomers, the vast numbers of active work years at stake are significant. Readers of these pages may recall that the true annual cost of obesity in Australia was recently estimated at a staggering $ 58 Billion – a number that could translate to $95 Billion for Canada.
Last week, the Supreme Court of Canada passed a ruling that would entitle severely handicapped individuals to be accommodated on airlines and specifically extended this ruling to include individuals, who were severely handicapped because of excess weight. This ruling resulted in a flood of raves and rants on why the Supreme Court would promote obesity by accommodating rather than punishing obese people for their laziness and indulgence. The Globe & Mail commentator went as far as to imply that by extending the ruling to obese individuals, the Supreme Court was in fact undermining the case for people with “real disabilities”.
In light of this ridiculous and discriminating accusation, I could not help but write the following letter to the Globe & Mail:
As Medical Director of one of the largest medical obesity programs in the country, I am appalled at the notion that including obesity in the recent Supreme Court judgement on accommodation of disabled people on airline flights, should be considered by the Globe & Mail commentator as anything but fair. To be clear, this ruling does not provide free rides for anyone with a few pounds excess weight – this ruling is specific in that it addresses the issues of individuals, who suffer from a condition so disabling that they require help with even the most basic functions. The idea that someone with such severe disabling obesity, has gained that amount of weight (often several hundred excess pounds) simply by lack of willpower or sheer laziness rather than some underlying genetic, mental heath or medical issue is not only naïve but also reflects the prevailing negative stereotyping, prejudice and discrimination toward obese individuals, that appears to be perfectly acceptable even to otherwise compassionate and reflective individuals. But that is not even the point.
The point is that the Globe & Mail commentator, unlike the Supreme Court, uses causality as a criterium for judging which disability is deserving of special accommodation and which is not. By those standards, it would be fair to ask if the person claiming disability due to a spinal cord or brain injury from a motor vehicle accident was in fact observing the speed limit at the time of the accident or if the person who suffered a disabling stroke always religiously took her blood pressure medications and passed on the salt. Singling out individuals disabled by severe obesity as the only group undeserving of special accommodation is blatant discrimination and belies even a remote understanding of the complex and heterogeneous nature of this unfortunate condition that today befalls so many in our society. Individuals disabled by severe obesity are neither more nor less deserving of accommodation than are folks who loose their eyesight to diabetes, their limbs to smoking, their kidneys to analgesic abuse or their mobility to a reckless sporting injury.
Arya M. Sharma, MD
Professor of Medicine and Medical Director of the Alberta Health Services (Edmonton Area) Weight Wise Program, Edmonton Alberta.
Obviously, I have no idea whether or not the G&M will chose to print or respond to this letter.
For anyone interested in the issue of Weight Bias, this is the topic of a whole supplement to this month’s issue of OBESITY, which includes 14 research articles on the “New Science of Weight Bias: a Significant Social Problem“.
Given the strong relationship between excess weight and emotional, physical and economic health, it may be reasonable to pose the question whether obesity is a risk factor for early disability?
This question was just addressed by Martin Neovius and colleagues from the Karolinska Institute, Stockholm, Sweden, who examined the association between obesity status in young adulthood and disability pension in Sweden (International Journal of Obesity).
The aim of this study was to investigate risk of future disability pension according to body mass index (BMI) in young adulthood. BMI was measured at military conscription (1969-1994) in 1,191,027 young male recruits. Date and cause of disability pension, death and emigration dates were collected from national registers (1971-2006).
During 28.4 million person-years, 60,024 subjects were granted disability pension. The hazard ratios (HRs) for overweight (1.36), moderate (1.87) and morbid obesity (3.04) were significantly elevated compared to normal weight individuals.
Excess disability was associated with problems related to circulatory, musculoskeletal, tumor, nervous system, and psychiatric disorders.
Based on these data, the authors suggest that productivity losses associated with adverse BMI in young adulthood appear to be large (a rather stark understatement, if I ever heard one).
Remember, this was a study on people whose BMI’s were high as far back as 1969. Given our present obesity epidemic in children and young adults, I wonder what disabilty rates will look like 20 years from now.
I don’t want to be the fella spreading doom and gloom all over, but it sure makes me wonder whether, despite all the talk, we are really doing all we can to prevent and treat obesity.