Quality of life relating to physical and mental health can be a key element in the treatment of obese adults. For this reason, interdisciplinary clinical measures including cognitive and behavioral therapy may produce more significant outcomes for these people, reducing not just weight but also symptoms of depression.
This is the main conclusion of a study conducted in Brazil by the Obesity Research Group at the Federal University of São Paulo (UNIFESP) in Santos, São Paulo state, and published in the journal Frontiers in Nutrition.
Considered one of the world's major public health problems, obesity has more than doubled in Brazil in 17 years and is now increasingly frequent among children and young adults. Between 2002 and 2019, the proportion of obese adults rose from 12.2% to 26.8%. Among women, it reached 29.5% (versus 21.8% among men). The proportion of overweight adults rose from 43.3% to 62.1%, or almost two-thirds of all Brazilians, according to the 2019 National Health Survey.
"The interdisciplinary and cognitive-behavioral therapy program was more effective than the physical exercise and education and health programs. It promoted greater behavioral changes than the other two programs in factors relevant to weight control, such as activity level and dietary intake, resulting in more weight loss. Changes in almost all the variables investigated were observed, including reductions in weight, body mass index, absolute fat mass, waist circumference, hip circumference, and neck circumference. The program was shown to be effective in increasing quality of life in all domains (physical, psychological, social, environmental), and reducing symptoms of depression," the researchers conclude in the article.
The study involved professionals in the areas of nutrition, psychology, physical education and physical therapy. It was supported by FAPESP via two projects (11/51723-7 and 15/06630-1). It also received funding from the Ministry of Education's Coordination for the Improvement of Higher Education Personel (CAPES) and the National Council for Scientific and Technological Development (CNPq), an arm of the Ministry of Science, Technology and Innovation (MCTI).
For Amanda dos Santos Moraes, first author of the published study, psychological aspects are proving to be essential in the treatment of obesity. "This is an innovative factor, combining interdisciplinary therapy with the cognitive-behavioral approach to the treatment of obesity. Cognitive aspects are increasingly being taken into account for the treatment of adults with obesity," she said.
"Cognitive-behavioral therapy is the most widely accepted intervention for weight loss in the psychologist's clinical practice. This approach focuses on the central thoughts and belief systems of individuals who may have inadequate feelings and behaviors triggered by dysfunctional thoughts about body weight and obesity. In our study, we observed more frequent interventions and a greater reduction in symptoms of depression for the group given cognitive-behavioral therapy than the other two groups."
According to Danielle Arisa Caranti, co-principal investigator for the study alongside Ricardo José Gomes, interdisciplinary therapy is rarely used by professionals affiliated with the SUS, Brazil's national health system, but focusing on interprofessionality and mental health should be a priority in future public policy to address the obesity epidemic.
In the article, the researchers note the high cost of treating obesity for health systems in many countries. The World Obesity Federation estimates that there are some 800 million people with obesity in the world and projects that the medical consequences of the disease will cost more than USD 1 trillion in 2025.
In Brazil, the cost of the procedures associated with overweight and obesity is estimated at USD 2.1 billion per year. In 2019 alone, for example, high blood pressure accounted for 20.6% of the conditions or problems assessed in over 105 million patient visits, while 8.3% related to diabetes and 2.5% to obesity.
Obesity is a chronic disease characterized by an excessive accumulation of body fat. The most widely used diagnostic criterion for adults is body mass index (weight over height squared). According to the World Health Organization (WHO), a BMI in the range of 25-29.9 kg/m² is overweight, and 30 kg/m² or higher is obese.
A high BMI is a major risk factor for cardiovascular disease, musculoskeletal disorders (especially osteoarthritis), psychological problems and cancer. More recently it has been associated with severe conditions in COVID-19 patients.
The causes of obesity include genetic, behavioral and environmental factors. Other drivers of the rising prevalence of obesity are unhealthy eating and lack of regular exercise.
"The most commonly accepted paradigm in relation to weight loss has been that an imbalance between food intake and physical activity is the main cause of overweight and obesity. However, this simple view does not take into account many other factors related to the problem, such as the influence of the modern lifestyle that stimulates overeating, or the role of adipose tissue in body homeostasis and energy balance," the authors state in the article.
According to the researchers, "It is essential to develop more powerful strategies to address this obesity epidemic and help individuals lose weight, as well as assist them in adopting and maintaining a healthy lifestyle in a 'toxic' environment that promotes excessive food consumption."
A recent meta-analysis that examined the worldwide prevalence of attempts to control weight showed that 42% of the general population of adults were trying to lose weight, while 23% were trying to maintain their weight. Other studies have shown that a 5% weight reduction is sufficient to improve health.
The study conducted by the Brazilian group included a quantitative and qualitative survey as well as a randomized clinical trial. It analyzed and compared the effects of three different long-term treatments on anthropometric profiles, eating behavior, anxiety and depression, and quality of life.
The Obesity Research Group at UNIFESP's Interdisciplinary Laboratory on Metabolic Diseases recruited the volunteers. Of the 150 who initially agreed to participate in the study, 98 were selected on the basis of the study criteria. They were aged between 30 and 50, and had BMIs between 30 and 39.9 kg/m². Most were women, generally more disposed to seek treatment for obesity than men.
The volunteers were divided randomly into three groups: one for education and health (basically lectures on health), another for physical exercise (according to a training program), and a third for interdisciplinary and cognitive-behavioral therapies (including resistance training, nutritional guidance, and physical and psychological therapy).
Forty-three volunteers remained until the end of the program, which lasted 30 weeks. In the education and health group, quality of life improved significantly. The exercise group lost a considerable amount of weight and quality of life also improved.
The interdisciplinary and cognitive-behavioral therapy group achieved the most substantial progress, with improved anthropometrics and quality of life in all domains (physical, psychological, social, and environmental), as well as positive changes in eating behavior and less depression. This group had the lowest dropout rate (42%).
Fundação de Amparo à Pesquisa do Estado de São Paulo
Moraes, A. D. S., et al. (2021) Cognitive Behavioral Approach to Treat Obesity: A Randomized Clinical Trial. Frontiers in Nutrition. doi.
"The reality in the SUS is very different now. We have few physical education professionals, for example. Interdisciplinary therapy costs more and also requires knowledge of interprofessionality so that all those involved can work toward the same goals and use collaborative practices. As far as the applicability of the study is concerned, this is an aspect that needs to be taken up by healthcare services and for treatment of chronic diseases."
Danielle Arisa Caranti, Study Co-Principal Investigator,FAPESP