Chronic stress affects the hippocampus, the brain structure that provides information on how the environment is organized (Sapolsky 1996). Thus, stress may fragment and distort a person’s assessment of their environment and impair their learning and memory (Ivy 2010). This phenomenon has many implications for health care providers. For example, receiving a diagnosis of diabetes or any other medical problem is usually traumatic and stressful. Initially, patients may have difficulty understanding and assimilating medical or dietary recommendations, because the world with which they must interact has become radically different. Some time and/or help to adjust to the diagnosis may reduce the stress and therefore increase the patient’s ability to understand, accept, and act on the information that is provided. Patients, seen in clinical practice, report that after learning new coping strategies for stress, it becomes much easier to follow dietary recommendations.
Sensitivity to Stimuli and Avoiding Monotony
Obese people are more inclined to act impulsively, avoid monotony, and respond to external cues, such as the sight or availability of food, than are people of normal weight (Rydén 2004). Instead of keeping up with dietary routines, the person easily gives in to satisfy a craving. A conflict between enjoying instant rewards and achieving long-term results develops. Stress overload sometimes decreases the threshold for responding to external cues for eating. The media and “soap operas” often portray life to be a matter of passion or pain. On the contrary, much of life consists of following routines and is often a rather monotonous story, quite unlike television drama. Establishing healthy dietary habits is especially helpful for people with low impulse tolerance.
Unsatisfactory Sleep and Fatigue
Excessive eating and obesity have been associated with disturbed or unsatisfactory sleep (Vardar 2004, Patel 2004). Many obese people suffer from sleep apnea (WHO 2009), and abdominal obesity has been strongly associated with sleep disturbances. Lack of sleep has been associated with increased levels of cortisol (Chaput 2010), and increased cortisol levels have been associated with abdominal obesity (Zinn 2010).
The literature also reports a social prejudice, even among health care personnel, against obese people as lazy and lacking willpower (Puhl 2009). In order to fight this prejudice, obese people sometimes feel the need to work harder and longer than normal-weight people. Some may unconsciously believe that excessive eating will give them strength, and they ignore sensations of fatigue or lack of energy while working harder. This trend, obviously, leads to more fatigue and can ultimately result in further weight gain.
Inability to Differentiate Between Physical and Emotional Sensations
People who grew up in an environment where neither physical nor emotional needs were met may be unable to accurately differentiate among various unpleasant physiological and emotional states (Bruch 1973, Rydén 2004). These people may overeat in response to virtually any internal arousal state. They interpret emotional distress as hunger and/or craving.
Anxiety and Other Painful Feelings
Anxiety is a general uneasiness in which someone feels a sense of danger or of an impending catastrophe. The intensity can vary. Psychological defenses protect against anxiety (Freud 1979). Some people use excessive eating as a defense against anxiety (Rydén 2004, Mills 1994, Slochower 1980, 1981). Eating and the resulting feelings of physical satisfaction can also soothe and comfort other feelings, such as anger, depressed mood, sorrow, shame, guilt, and loneliness (Adolfsson 2002, Wilson 2003, Poston 2000, Bulik 2007).
Sexual Issues
Sexual satisfaction and intimacy are important parts of life that contribute to physical and emotional well-being. Physical satisfaction that is achieved from eating can balance various forms of distress: sex anxiety, anger, sadness, sorrow, and loneliness (Cooper 1986, McDougall 1989, Rydén 2004). Oxytocin is a “calmness hormone,” released by massage, sexual arousal, and orgasm as well as by the consumption of fat (Carmichael 1987, Uuvnäs Moberg 1999). Some people achieve a feeling of balance and peace through intimate relationships that provide sexual satisfaction and support in times of distress. Others find this balance and peace through the consumption of fat.
Changes in behavior and/or in weight may impact relationships. Jeffery (2002) reports an association between weight change and the relationships between spouses. Sometimes the connection between obesity and sexuality is used to stabilize an unhealthy relationship, so that partners perceive weight changes as a threat to the relationship as they know it. If a formerly obese partner becomes more sexually active after weight reduction, it disturbs the status quo and may cause relationship problems (Marshall 1977). If sexual intimacy has previously provoked anxiety or trauma, some people learn to depend on their obesity to avoid sexually intimate situations (Wiederman 1999). King (1996) reports that obese victims of sexual abuse experience more difficulties losing weight than those who were not sexually abused, unless they receive treatment for their trauma. Because the long-term effects of sexual abuse can interfere with obesity treatment, a history of sexual abuse may be an important pretreatment variable to consider (Feldman 2007).
Interruption of Group Expectations
Eating has a social function (Jastran 2009). Meals often bring people together. Food preferences and eating and meal habits may express belonging in a social network. Social gatherings and social traditions are often centered on shared meals, where eating can function as a “social glue” and hide interpersonal discomfort. If a person’s food choices differ from the group’s usual menu, then that “glue” may deteriorate. Figure 4 illustrates how a change in one member of a group will often require change for the other members of the group.
Figure 4—Symbolic Illustration of How Change in One Area Causes Change in Another
If one person (white piece) changes, those close to him or her are also forced to change. This compounds the difficulty of lifestyle change because not only must an individual work at making the behavior change a lifestyle habit, but he or she must also deal with the responses of others to that change.
A family is a type of system in which the members know what to expect from each other. If one family member makes a lifestyle change, the family system changes, which affects the other members in that system. When one member threatens the status quo, the group’s initial reaction is to make another change, hoping to reestablish homeostasis. This reactive manipulation may include flattery, aggression, nagging, threats, or even rejection from the group. One client reported a friend telling her directly that their friendship was over if the client lost weight. Though logic questions the quality of these relationships, rejection is not a price that everybody is willing or ready to pay. Thus, it is important to address reactions and problems that might arise if the homeostasis in a social system is disturbed. Otherwise, family members’, friends’, or colleagues’ responses may block behavior change efforts (Papero 1990). A systems approach that addresses the deleterious impact of psychosocial stressors on health and lifestyle issues would help participants achieve the greatest benefits from lifestyle change activities (Porter 2010).
Physical Activity
Reduced physical activity increases risks for metabolic syndrome (Eckel 2005, Pritchett 2005). As the world has entered the 21st century, our desire for convenience, comfort, and speed has continued to influence decisions that affect our everyday lives, including how we prepare food (i.e., someone else does it) and design buildings (elevators are more convenient than stairs). But this ideological shift has even changed the way we view other less obvious lifestyle habits, such as how we clean (convenient devices never require scrubbing or any sweat), how we interact with our environment (power tools and fancy motorized kitchen utensils remove the need for working hard), and how we relax (remote controls clutter coffee tables like magazines did in years past). Driving through a fast food restaurant after working late and eating in front of the television has become normal behavior.
The 2008 Physical Activity Guidelines for Americans (CDC 2011b) recommend 150 minutes of moderate-intensity (brisk walk) aerobic activity, 75 minutes of vigorous-intensity aerobic