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Obesity Is Not A Mental Illness



Before, I get into the promised review of the obesity papers in the January issue of the Canadian Journal of Psychiatry, I would like to set the stage by clarifying that I certainly do not consider obesity to be a mental illness.

Thus, I very much opposed the notion (proposed by some) to include obesity as a diagnosis in the the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and was very much relieved to see this proposal being rejected.

Although the brain is the ultimate regulator of energy balance and there is a significant and relevant relationship between mental health and the propensity for weight gain (as will be discussed in forthcoming posts), obesity itself is hardly a mental illness. In fact, the vast majority of overweight and obese individuals do not have any mental health problems that would be in any form or fashion differentiate them from the non-obese population.

This situation, however, is markedly different in the ‘weight-loss-seeking’ obese population, where an increased prevalence of mental health problems has been well documented. This is why clinicians dealing with obese patients, particularly those seeking obesity treatment need to be well versed in the diagnosis and basic principles of managing mental health problems.

What is also indisputable is the fact that for patients with mental health problems, weight management can prove particularly challenging.

When we consider how difficult implementing and maintaining the often complex regimens for weight management can be for most people, it should be no surprise that adding the additional burden of mental illness can make such efforts almost impossible.

Add to this the fact that many of the psychiatric medications can further promote weight gain, and we can easily see why obesity has become such an important challenge in light of the increasing use of such medications (whether indicated or not).

Remember, that in this discussion we are talking about significant and major mental health problems like depression, bipolar disorder, psychosis, anxiety, PTSD, or addictions. We are not talking about simple ‘overeating’ associated with stress, boredom, social pressures, or other factors that have little to do with severe mental health problems and should rather be considered completely normal and natural human behaviours.

Thus, it is important that in any discussion of the clinically important relationship between obesity and mental illness, we make sure that we do not add the stigmal of the latter to the already widespread stigma of the former.

In other words, while mental health problems can undeniably contribute to or complicate obesity, let us by no means assume that everyone with excess weight must somehow have a mental health problem – the vast majority of overweight and obese individuals do not.

Nonetheless, clinicians need to be well aware of this relationship, be able to identify it where it exists, and provide or refer individual obese patients, for whom this may well be a problem, to the appropriate services.

I would certainly love to hear from any readers who have experienced that addressing their mental health issues did indeed help them better manage their weight or from readers where their mental health problems are making contributing to their weight gain.

AMS
Saskatoon, Saskatchewan

26 Comments

  1. Glad you clarified that Arya!

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  2. ADD diagnosed as an adult at the Weight Wise Clinic has revolutionized my life! The lack of impulse control greatly contributed to weight gain. Life certainly looks different now!

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  3. Glad to read this. Every time I am told I need to go back on my medication to help with my mental health issues I cry. I know that I will gain a significant amount of weight (on my petite frame). I hate that I have to make that choice. The frustrating thing is that my mental health also effects my energy levels and ability to do the necessary steps to be healthy. I have to try twice as hard when I am on my medication as when I am in a more ‘normalized’ state. As well, the extra weight really demotivates me as I have major body image issues. Sometimes I think I am in a never ending negative cycle.

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  4. I received a bipolar II Dx a a little over 10 years ago, at the same time I was dealing with hypothyroid. Since then, my weight has varied up and down over a 40 pound range… most due to medication changes. If I have to choose between weight and sanity, I’ll take sanity, thank you much. I’m back to where I was when this all started — 30 pounds “overweight” (in theory) and pretty darn healthy, from a cardiovascular/lipid/glucose standpoint.

    When I’d get in the depressive cycles, I’d get very simplistic advice of “you just need to get some exercise.” Yes, exercise is good for depression. But quite frankly, some days it was a victory to brush my teeth and show up for work. Plus, some of the meds I took to keep my brain from trying to kill me were extremely sedating. It’s more difficult than you think to start an exercise program when the meds make you sleep 10+ hours and you’re trying to hold down a full-time job to get the insurance so you can afford the meds.

    I’m not trying to make excuses here. My point is… folks, this is harder than it looks.

    It was only when I could start healing mentally that I had the motivation to start taking better care of my body. I needed enough meds so that I wasn’t so depressed I wanted to stay in bed all day. I needed to find a cocktail that didn’t knock me out completely.

    Many people with mental illnesses are fighting for their lives right now, right this moment. Bipolar has about a 15% lifetime suicide risk. When I was at my worst, I had bigger priorities than whether my pants fit or not. And I STILL have bigger health priorities than whether my pants fit or not.

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  5. I was diagnosed with PTSD back in the early 90’s after a work assignment to the former Yugoslavia during their war …. I gained about 200lbs over 6 years and couldn’t get it down for the next 10 years. Finally bariatric surgery helped break the cycle, I lost the weight and I am slowly making healing progress on the PTSD without medication while keeping active and eating healthy. I am still overweight (the chart consider me borderline to obese) but feeling healthy & energetic and besides the “off day” PTSD doesn’t impact my life much any more … down the road I will hopefully have completely recovered.

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  6. I wonder. To which factors do researchers (or professionals in the health care fields) attribute the “markedly different” prevalence of fat people with “normal” mental problems vs. fat people-seeking-weight-reduction who are also diagnosed with serious mental illnesses? Surely the professionals have theories or hypotheses to explain this profound finding. It would be fascinating to hear more about their interpretations of these research results (and to see the research reports/evidence that resulted in this remarkable conclusion.)

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  7. I’ve been battling chronic depression for over 40 years, trying just about every med there is. When I’m depressed, I sleep and eat. When I was 20 I was active, had a busy life and weighed 135 lbs., at 60 I weigh 350 lbs. Although I was able to hold down a job for most of those 40 years, it was sitting at a desk and that’s about all I could manage activity-wise. I can’t help but wonder what my life would have been like and what size I would be if I hadn’t been depressed.

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  8. I absolutely believe that obesity should be included in the Diagnostic and Statistical Manual of Mental Disorders. I have been working with weight loss surgery patients for over ten years because I am one too. I successfully lost half my weight and kept it off. It is very common for an obese person that has weight loss surgery to cross addict to shopping, sex, gambling, alcohol and/or drugs if they are not given the proper education and work on the problems for the addiction. Alcoholism was not considered a disease until 1956 and I believe it is only a matter of time before obesity and the very real problem of food addiction is validated. I have also seen people get sober in AA and gain weight because they switched to another coping mechanism and are seeking weight loss surgery. I suffered from severe depression but it is better managed when I’m not carrying 130 extra pounds. Perhaps you are saying that obesity does not mean you are mentally ill (as in bi-polar, schizophrenic, etc.) but I consider addiction a reason for obesity to be included. Addiction is uncontrolled use despite negative consequences. Obese people have mirrors and we know how we are treated in society and we make much less money. If it was so easy to lose the weight we would because NOBODY wants to be obese. Another fact is many women that are obese have experienced severe trauma in childhood or were mentally or sexually abused. Weight loss surgery and learning how to conquer our demons that caused our food addiction is still a very new field. I’ve known and corresponded with literally thousands of post-ops and the story is very nearly always the same. That’s why I believe many professionals are pushing for this change.

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  9. Hi Doc:

    One thing I do before I do a posting is read the other postings–so that I am not duplicating too much information. However, as a Mental Health Consumer and an Obese individual I can relate to many of the comments made thus far. My weight gain started in group theropy many of the others would tell there problems and becuase there was nothing I could or should have done to help I felt powerless this feeling was treated by over eating, which in many ways did not help me either. the 16 hours per week over two years was a real help for me so were the four other clinics (anxiety, self-esteem, anger management, and assertiveness training) about 30 hours each. While this is a lot of treatment the program was developped to teach me to prevent and/or notice relaps before they became critical–which has worked. the biggest hurtle I have found since gaining the weight is the failure to follow thruogh on lossing the weight (which has not happened) the failure to follow through comes in the form of meal planning. When I do meal plan I either over plan or fail to plan. Even though I have lost 20% of my starting weight I can not wrap my head around meal planning–I can not tell if that is a side effect of the depresion or just me being me. It might be easier to servive a nuclear war then is it to meal plan and follow through.

    There are a raft of mental health medications some with weight gain as a side effect others without that side effect. Finding a medication that works and does not cause weight gain is possible but it is tough trying to decide which is more important not wishing you were dead versus wishing that you do not look several months along.

    Maybe with Mental Illness Awareness week there should be a type of theme developed to address the weight gain and medication issue.

    Thank you

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  10. I, too, have struggled with depression for most of my life (since age 7). It has definately been intertwined with my overweight/obesity. In my n=1 case, I am sure that the depression has been exacerbated by the seemingly endless negative judgements and shaming I received both within and outside of the home about my weight and therefore about myself. Young children can struggle to separate behaviour/appearance and identity – I saw that in my own kids. I think that the stigma attached to overweight/obesity can have a powerful effect on a person’s self-image and if it starts young, it could be very difficult for that person to recognise that their value/worth is not solely derived from their appearance. The resulting poor self-esteem and negative self-talk become a significant risk factor for development of a mood disorder.

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  11. As has already been mentioned, depression can have a major impact on weight management whether or not the overweight/obesity caused the depression. Excessive sleep or insomnia, very low energy/motivation levels, inability to organise healthy meals, overeating, and in some cases self-medication with alcohol can all contribute to weight gain while being depressed. A catch-22 is that many anti-depressants and anti-psychotics used to treat depression may result in metabolic disturbance and weight gain. The atypical anti-psychotics are also linked to development of Type II diabetes. Unfortunately, for those like myself who have a treatment-resistant major mental illness, it may come down to treating the mental illness at the risk of weight and other problems. As a loved one said to me, “you can live with diabetes, but not if you’ve comitted suicide”. The hope has to be that as the mental illness is controlled, and better still, remits, that weight management becomes easier to accomplish.

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  12. K,
    You focus on how being depressed might cause someone to gain weight, and those are certainly legitimate points. However, being treated like a worthless piece of garbage, being bullied, and being excluded can certainly contribute to depression. I’m not trying to imply that once someone loses weight, their depression will disappear. I’m just saying that weight bias can be damaging to mental health.

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  13. That’s often called the chicken or the egg. Are you depressed because you’re obese or are you obese because you’re depressed and you look to food to self medicate the pain away. In my case it was BOTH! I knew because I had educated myself that losing the weight would not make my life perfect but I still struggled with depression that is being managed now by the best anti depressant I’ve found so far.

    Lucy A. I can deeply relate to you. With over 100 pounds to lose meal planning was what I was told to do but deep down it was easier to move a mountain because deep down I had tried every diet known to man for 30 years and I always was a failure. More shame and guilt and blame and every emotion that were the ones that only brought me further down. Please don’t beat yourself up because it only debilitates you further. This may seem impossible but until you actually practice feeling better you can’t break out of the darkness so try to get up every day and make a list of the things you are grateful for. Take each day’s plan as one day chunks. “Just for today I will do _____”. Gradually you might find there will be more good days than bad and when you feel better you don’t immediately look to food to make you feel better. I have no idea if you’ll see this but I hope you do and I just wanted to let you know I understand more than you know.

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  14. Lucy – you raise some good points, but while there are a number of psych meds out there, it is not always possible to find a combo that is effective + weight-neutral for a particular person — especially when dealing with bipolar disorder. Picking meds by their side effects can end up badly. And many with serious MI have to take multiple meds to manage symptoms.

    Part of it is the old saw that “your mileage may vary.” Psych meds often cause wildly different reactions in different people. I’ve yet to find a cocktail that is effective for me that doesn’t put at least a few extra pounds on me. Add to that, switching meds too often if they’re working for you comes with its own dangers.

    When someone goes on zyprexa and gains 25 pounds in a month, clearly that’s an unacceptable side effect. But what if they go on seroquel and gain 25 pounds in 2 years and level off there? Our weight-obsessed culture freaks out about this, even though the person may have significantly improved quality of life.

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  15. @DeeLeigh – I think you misunderstand my post. I absolutely agree that weight bias can be damaging to mental health and I experienced what you described. I was trying to show how my weight influenced and exacerbated my depression (but it is not the only cause – there is a heavy genetic loading in my family). I also agree that losing weight will not make depression disappear (I speak from experience). Any progress with depression will depend on learning to challenge and correct the negative self-talk, self-image, beliefs and coping mechanisms that a person has irrespective of their weight.

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  16. @ksol – your point about the individual variability of not just the desired effect, but also the side effects of psych meds is excellent. I can very much relate to the difficulty in finding an effective drug cocktail. Switching drugs can be fraught with risk especially if you have to have a wash-out period from the old med before starting the new drug. It becomes a situation of trade-offs – drug A helps me to sleep, but I gained 20kg in the 1st 12 mths of taking it and it makes it very hard to get moving in the mornings. Yet, without decent sleep, my MI deteriorates rapidly. Another medication I take has a primary side effect of weight gain – I can’t quantify the effect on me, but I need the drug to mitigate one of the side effects of drug A. These side effect burdens can seem great and it’s tempting to try and wean off the drugs (switching is no longer an option as I’ve tried every other class of drug used to treat my MI). However, I am certain that if I wasn’t on this drug cocktail I would eventually suicide. The daily struggle to manage my weight and avoid the complications of the meds and being overweight is an improved quality of life compared to being actively suicidal and unable to function in this world.

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  17. I don’t know if obesity should be considered a mental health issue or not but what I do know is that getting therapy helped with the other issues that were the underlying causes to why I was obese.
    Obesity is about so much more then eating to much and not exercising enough. There is an old adage, “It’s not so much what you are eating, It’s what’s eating you” and that could not be more true in my case. It is also about more then addiction. For me the obesity was a tool, a shield… I hid behind the mountain of fat, in an unconscious and misguided effort to protect myself.
    I don’t think Obesity itself is a mental disease as much as a symptom of mental or emotional dis-ease,
    Dealing with the issues of abuse and neglect, learning to become more open and allow myself to become vulnerable, learning how to deal with stress, these things helped me not only to get a handle on why I ate the way I did, but helped me to just plain be happier and more at peace with who I am.

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  18. The connection for me is, I think, a common one.  I never had a weight problem for the first 33 years of my life, even after bearing two children.  I did, however, have a fairly long-standing problem with depression and anxiety, and had been on imiprimine, which caused me to gain about five to ten pounds over several years. Soon after Prozac became widespread, I requested to be switched to it because “it actually causes weight loss!”  In the first few months I was on it, I did lose a few pounds and experienced fewer side effects than on the imiprimine.  But starting with the fourth or fifth month, I began to gain weight.  It was like a switch was flipped—I put on seven to ten pounds a month even though my eating habits and activity levels were unchanged.  When I asked my psychiatrist, she said that Prozac was not responsible, and when I attempted to go off it, I experienced an awful “rebound” depression until I went back on it.  Meanwhile, my primary care doctor did not believe me when I told him my eating and activity levels were unchanged, and suggested Weight Watchers and exercise.  At that point I had already cut back my calories to 1200-1300 calories a day to try to stem the weight gain, so the Weight Watchers plan contained 50% more food than I was already eating.  By the time I was switched to Zoloft 15 months later, I had gained 65 pounds, and my blood sugar was registering above 100 (prediabetic range).  I believe that the Prozac fundamentally changed my insulin resistance level.  I have carried that 65 pounds now for twenty years, unable to lose it without regaining it.  My depression has continued to wax and wane, but many different ssris ( and other drugs) seem to increase my weight and it has been very very difficult to treat my depression without worsening my metabolic situation, and vice-versa.  It has also added to my depression, discouragement and anxiety because everywhere I go I am confronted with the stigma of obesity as well as the information that it is going to kill me.  So I feel squeezed between two serious conditions (obesity and depression), and no one seems to know how to help me.   

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    • 1. Or we move less or we eat more or any other combination like: we move more and we eat more . Anyway ,increasing weight is the result of eating more calories than we spend by movement (excluding water retention). There is no way around this simple equation.
      2. When we go older, we move less
      3. Obesity of our days is so common that It cannot be explained by genetics or mental disease . What, millions of people got the same mutation?
      4. Food is everywhere cheap exposed colorful and varied
      5. Some people by constitution are more prone to addiction than others
      6. Food is very addictive but legal.
      7. To fight obesity, we must tax calories, make them expensive. We should have kitchens with doors, and smaller fridges , There should be a world policy to decrease sugar production. And may other things.
      8. A mental disease ? It is just a terrible addiction.

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  19. I actually laughed out loud when I read the title to your blog post today. Getting my head in the right place has been one of the most important aspects of my weight loss journey which is currently at 108 pounds. I am one of the fortunate few in the Cardston Lifestyles program, where we meet on a weekly basis as a support group for people with weight loss issues. We have attending with us a mental health professional and a nurse from the Lifestyles program. Without this group maybe I could have lost the weight but I highly doubt that I could have kept it off. For me it has been 25% meeting with a nurse every week (accountability), 25% journaling food, 25% activity/preparing food, and 25% meeting with a support group every week. Also thank for your support of our program, it has changed my life, my families life and my communities life.

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  20. I think the problem is we’re not dealing with monolithic “obesity,” but rather “obesities,” different issues resulting in a higher weight. Some people may have a naturally large body size, and can only get down to a “healthy” weight through eating disorders. Some hay have messed up their metabolism through dieting. Some may have elevated weight through poor health habits and actually CAN lose significant weight through small lifestyle changes (these are the people who post in these discussions “I started walking and lost XX pounds — that’s all YOU have to do.) Some might have medication issues, or weight-inducing illnesses.

    Some might lose weight when a mental illness is treated, while some may require treatment that saves their life but adds pounds. For some, a higher body size might be problematic (beyond just stigma and vanity). For others, they can be healthy and big.

    My belief is there are a number of experiences. Witnessing to our own experience is one thing. The danger is when we try to extrapolate to every other person.

    I had thyroid cancer. The standard treatment is to remove the thyroid, give you an oral dose of radioactive iodine and then give you high doses of thyroid hormone for life. If we decided THIS was “cancer,” and when you went in to the doctor with, say breast cancer and the doc said “Well, we’ll remove your thyroid, give you radioactive iodine, and suppress your TSH for life,” you’d rightfully think he/she was nuts. Yet, every time someone goes into the doc with the wrong number on the BMI scale, they get told “Eat less, move more” and probably get handed a 1200 calorie diet (which I, frankly, consider starvation.)

    I believe that health is not weight. I believe adding movement and good food, getting your head on straight, getting any underlying medical issues are ALL good for health, regardless of what the scale says.

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  21. My weight is 73 kg, height 5 feet, age 56 female. I have hypothyrodism. Kindly give me tips to reduce weight.

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  22. I will be very interested to read your upcoming posts on this issue, it’s something I’ve given a lot of thought to in relation to my own weight struggles. Episodes of depression have been intertwined with weight gain through my life (probably exacerbated by weight cycling due to dieting when I was a young teen.) It’s become a chicken vs. egg question for me, as in which came first – the depression or the body image issues/disordered eating? A tendency toward weight gain does run in my family, but so do mental disorders (depression, anxiety attacks) and addictive behaviour (chain-smoking, alcoholism, overspending, overeating.) And FWIW, my morbidly obese grandmother outlived the two grandparents who were alcoholics and heavy smokers by about 20 years.

    My physical health is good for someone my size – I’m 5’9″, 44 years old, Class 2 obese and would probably be a Stage 1 on the EOSS – I’m borderline hypertensive and have mild sleep apnea (both are being treated.)

    I’ve only recently started taking anti-depressants after a prolonged depression that lasted a couple of years. Previously I had intermittent episodes of mild to moderate depression, usually brought on by difficult personal circumstances, that resolved on their own. I’ve responded well to the medication and it hasn’t caused any further weight gain, so now I’m working on normalizing my eating patterns (they became very chaotic while I was depressed) and increasing my activity level. I did manage to stay active during my depression – I take regular dance lessons and joined a troupe a couple of years ago – but I was constantly tired. Now I have a lot more energy.

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  23. @ksol – Well said! Your comment about there being a variety of “obesities” rather than a singular “obesity” with a singular cause is very apt. I believe many people, including many medical professionals, tar obese people with the same brush and that this results in stigma. We often tar ourselves with this brush.

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  24. This is a really great post.

    Labelling, if not done with utmost care, can lead to serious confusion. Diagnosing mental health status by virtue a person’s physical appearance is ludicrous! Can you imagine if this was done for any other characteristic?

    Obesity is the result of an energy imbalance, and the rise in obesity is in part due to our changed environment that allow and encourage increased caloric consumption.

    Expertise in pharmacology is far from my list of abilities (so, I’m not entirely sure about the mechanisms that control metabolic regulation with the use of anti depressants/psychotics). However, I’m not sure this is the issue: the point is to clarify that obesity, in itself, does not express an underlying issue of mental illness. In SOME cases, it MAY contribute to a person’s motivation to consume more food, but this does not mean that obesity is some how the litmus test for whether a person has depression/anxiety/ schizotypal issues. Talk about a primitive synopsis of two extremely complicated conditions!

    Let’s take some celebrity examples to emphasize this point. Christopher Hitchens was notably chubby (before he died of cancer, I should note). Same goes for Winston Churchill, Salman Rushdie, Al Gore, do we want to put Angela Merkel, at times Meg Whitman, Christina Hendricks, Oprah Winfrey in the mix to illustrate the sheer silliness of the broad hypothesis that ‘obesity represents mental illness’ ?!. Now, let’s take other notable psychopaths in the media that are defined by their slimness- reality stars, spooky puppet spokesmodels for bad political choices, you get the point- right? Obesity itself is not a sign of mental illness.

    Let’s identify a gross misperception and oversimplification when we see one. We still don’t have the answer or cure for obesity, but summing up the situation in such a basic way (i.e. Obesity is the Result of Mental Illness, thus all Obese People are Mentally Ill), is… well… pretty medieval.

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  25. Dr. Mickey Stunkard’s early research into the data gathered by the Midtown Manhattan Study found that mental illness was no more prevalent among the obese than among the general population and yet our culture steadfastly insists that if you’re very overweight there must be something “wrong” with you. Too many times I’ve heard it said that if the “problem” is not immediately apparent, just keep looking until you find something. This bias has created the paradigm that dictates “It’s what’s eating you,” putting the responsibility upon the fat person to find and fix what’s “broken” or be doomed to remain fat forever. I recently read an article in which a nutritionist describes fat as a cry for help. *groan*

    I believe the obesity epidemic is being driven in part by our culture’s assumption that mental issues underlie overweight, thereby leading to the promotion of ineffectual weight loss methods. We won’t successfully address the obesity epidemic until we acknowledge what constitutes actual mental health factors and what’s simply bias.

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