Ask the Experts: How Does Mental Health Impact Obesity?

by Robert Kushner, MD; Ryan Marek, PhD; and Wendy Pruim, OAC Mental Health Committee Member

Fall 2024

This section of Weight Matters Magazine brings you insightful discussions with experts who offer valuable advice on various health topics. In this issue, we asked a panel of experts to share their thoughts on how mental health impacts obesity. Here’s what a medical doctor, a psychologist, and a person with personal experience had to say.

Answer Provided by Robert Kushner, MD

As a physician, it’s important to assess the mental health of all patients, including those with obesity. There are several conditions I routinely evaluate because of their impact on treatment outcomes. Obesity is linked to a higher risk of depressive disorders, and the relationship goes both ways. Depression can influence emotional and psychological behaviors that affect eating habits, social life, mood, and activity levels. At the same time, depression can result from the weight stigma many people with obesity face. Regardless of how the relationship starts, both obesity and depression are linked to higher risks of heart disease, diabetes, and limited physical function.

Weight stigma is especially troubling because it often leads to poorer health outcomes like binge eating, reduced exercise, and increased stress. Experiencing stigma, which often begins in childhood through teasing, can harm body image and self-esteem into adulthood for both boys and girls. This can lead to long-term physical and mental health issues, such as diabetes and high cholesterol. When people internalize this stigma and believe negative stereotypes about themselves, their mental and physical health can suffer. This can result in harmful eating patterns, less success with weight management and increased self-criticism.

Body dissatisfaction is also tied to low self-esteem, which can predict depression. Low self-esteem is more common in people with chronic illness and can lead to unhealthy behaviors as a way to cope with negative emotions and stress. It’s thought that low self-esteem may be one reason why internalized weight bias can worsen other health problems.

Stress is another factor that can impact mood and weight. People often try to cope with stress by eating or engaging in other soothing behaviors. Studies show that stress can increase cortisol levels, leading to cravings for high-calorie, high-fat and sugary foods. This, in turn, can lead to weight gain, obesity, poor sleep and inactivity. This creates a vicious cycle where stress and obesity feed into each other.

As a clinician, my job is to assess a patient’s mental health to see if psychological or emotional conditions might interfere with weight management. If needed, we address these conditions with behavioral therapy or referrals to a health psychologist.

Answer Provided by Ryan Marek, PhD

Mental health has a significant impact on obesity, with many layers to consider. People with obesity often face stigma, even from those they trust, such as their doctors. This can damage their confidence and self-esteem, leading to depression, stress and anxiety. The cycle continues as poor mental health worsens obesity. When people feel ashamed, they may avoid medical appointments for fear of being criticized for their weight. Depression, stress and anxiety can also affect appetite, which increases vulnerability to overeating or binge eating. This makes mental health care an essential part of obesity treatment, regardless of whether someone has a diagnosed mental health condition. A multidisciplinary approach to care provides patients with tools to tackle both the physical and psychological aspects of obesity, empowering them to better handle difficult situations and feelings.

In my practice, I work with patients preparing for bariatric surgery. For many, it’s their first time meeting with a mental health provider, and they may make light of it, saying things like “I’m not that crazy” or “Did I pass the test?” I always reassure them that our sessions are not about judgment. We are here to understand what will help them succeed and identify potential challenges. Psychological tests help us assess symptoms of depression or anxiety and address any issues before surgery. Our goal isn’t to prevent surgery but to break the cycle between mental health and obesity by providing the right support.

Answer Provided by Wendy Pruim, OAC Mental Health Committee Member

I don’t consider myself an expert in anything except my own experiences — and even that’s up for debate! I’ve lived a life overshadowed by obesity, so I do have a thing or two to say about its connection to mental health. Obesity is a complex medical condition that can’t be dealt with in isolation. We are whole people, and treating any disease requires treating the whole person.

I’ve lost a significant amount of weight—numerous times! As a teen, I lost enough weight to fit into Sasson jeans (you had to be there). That didn’t last. In college, I participated in a doctor-supervised program and lost over 100 pounds. That didn’t last. I’ve tried many diets, losing 20 pounds here and there, and that didn’t last either. I had gastric bypass surgery and lost more than 170 pounds, but I regained that too. Most recently, I’ve lost more than 120 pounds on an obesity medication, but I’m terrified of what will happen if I need to stop.

Throughout all of this, I never had the one thing that would likely have been most helpful—professional mental health care. I passed the required mental health consultation before surgery and I had realistic expectations. I knew surgery wasn’t a miracle cure; it was just a tool. When I lost weight, I was more “acceptable” to others, but I was still the same person inside. I wasn’t sure if that person was worth much. So, I regained the weight.

Not everyone’s obesity is the same. What works for one person may not work for another. However, a core part of any treatment plan should involve helping us separate ourselves from the false narratives we’ve been bombarded with, allowing us to see ourselves as whole people with a medical condition we want to address. It should also provide us with the tools we need to keep up the fight because this isn’t a “one and done” situation — it’s a lifelong journey. I believe obesity is one of those diseases that can go into remission but always lurks in the background, with the potential to resurface at any moment. It’s a daily mental battle to stay the course, and I believe mental healthcare should be prioritized just as much as physical care.

There is so much stigma heaped upon us by society, focusing on a person’s weight and equating it with their overall worth. As we work on physically treating our obesity and coping with society’s perception of us, we also need to focus on our headspace to understand it all and adjust our internal dialogue. If we neglect our mental healthcare, we risk finding ourselves right back where we started.

About the Authors:

Robert Kushner, MD, is a Professor of Medicine and Medical Education at Northwestern University Feinberg School of Medicine, and Director of the Center for Lifestyle Medicine at Northwestern Medicine in Chicago, IL. He is a founder of the American Board of Obesity Medicine (ABOM), past President of The Obesity Society (TOS), and past board member of the Obesity Action Coalition (OAC). Dr. Kushner has also served as the Chair and Co-Chair of the planning committee for OAC’s Your Weight Matters Annual Convention. Additionally, he serves on the Medical Advisory Board for Eli Lilly and Company, for which he receives compensation.

Dr. Ryan J. Marek is an Associate Professor in the Department of Psychology and Philosophy at Sam Houston State University, where his research focuses on health psychology and presurgical psychological assessment. He earned his Ph.D. in Clinical Psychology from Kent State University and has extensive clinical experience, including rotations at the Cleveland Clinic and the Medical University of South Carolina. Dr. Marek’s work emphasizes how psychological factors influence medical outcomes, particularly in surgical settings. He has over 50 peer-reviewed publications and is the lead author of the book Presurgical Psychological Assessment: Evidence-Based Practices and Procedures.

Wendy Pruim, a long-time Obesity Action Coalition (OAC) Community Member, serves on the organization’s Mental Health Committee and is a passionate advocate for comprehensive obesity care. She emphasizes the critical need for mental health support as a vital part of treatment and contributes her insights and patient perspective to help improve OAC’s mental health resources.

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