Abstract: 

Abstract

Eating disorders are severe psychiatric illnesses, causing immense suffering for patients, but also for their families and friends. Ambivalence about change and treatment resistance are common, and relapse rates are high. Patients with eating disorders tend to be highly self-critical and self-attacking, much more so than other psychiatric populations. In this project interpersonal- and attachment theoretical principles were applied in an attempt to understand how and why these disorders are so strongly associated with how patients evaluate and treat themselves (self-image). The first aim was to study connections between self-image and eating disorder symptoms in different groups, to learn more about the quality and strength of such associations (Studies I and II). Further, according to interpersonal theory, we treat ourselves a certain way because important others, attachment figures primarily, have treated us that way. Some patients with eating disorders seem to spontaneously conceptualize their illness as an entity or a voice that they relate to. Therefore, the second aim was to test whether eating disorders could be re-conceptualized as dyadic relationships, possibly triggering attachment mechanisms (i.e. guided by the same mechanisms as other important relationships), and influencing how patients treat themselves as a result (Studies III and IV). All studies were cross-sectional. In Studies I and II, healthy, non-help-seeking and clinical groups of individuals aged 13-25 rated eating disorder symptoms and self-image. Boys (both healthy and clinical) were included in the first study, but all other samples were female. In Studies III and IV patients rated the relationship between themselves and their illness, attachment behaviours, symptoms and self-image. In Studies I-II, strong associations between specific aspects of self-image (primarily self-blame, and self-acceptance/love inversely) and symptoms were found. These associations were stronger in healthy girls compared to healthy boys, in clinical groups compared to healthy groups and in patients with anorexia nervosa compared to patients with bulimia nervosa. Older age seemed to weaken these associations except in the non-help-seeking group where associations were strong regardless of age. In Study III, patients seemed able to conceptualize their disorders as highly negative and enmeshed dyadic relationships. Higher eating disorder control and patient submission were associated with more severe symptomatology. Patients who reacted negatively toward their eating disorder had less symptoms and more positive self-image. In Study IV, attachment behaviours were correlated with aspects of the patient – eating disorder relationship, and as hypothesised from interpersonal theory and supporting attachment processes being active, for some individuals it seemed as if actions of their eating disorder matched their self-image. Placing eating disorders within a relational framework offers an explanation for how and why symptoms are related to self-image. It also offers a language that may help some patients and clinicians understand and work towards letting go of the illness. A focus on intrapersonal processes in the patient – eating disorder relationship and their potential connection to attachment-related issues may inform therapist interventions that could facilitate the development of a secure therapeutic relationship, and ultimately aid recovery.

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https://openarchive.ki.se/xmlui/handle/10616/46047

The path to an eating disorder (ED) always leads through a borderland, which, in this thesis, is referred to as disordered eating (DE) (Neumark-Sztainer, Wall, Eisenberg,
Story, & Hannan, 2006; Waaddegaard, Thoning, & Petersson, 2003). In this borderland, people tend to make unhealthy eating choices, such as greatly reducing their
food intake, self-inducing vomiting, or engaging in binge eating, but not to the extent that they would receive an ED diagnosis. Nevertheless, DE can have a strong
negative effect on psychological health. Approximately 15%–52% of all adolescents, depending on the gender and the study’s focus, are found within the borderland
between a healthy diet accompanied by psychological well-being and full-blown ED (e.g. Hautala et al., 2011; Herpertz-Dahlmann et al., 2008). While most of these
individuals return to a more or less healthy diet after engaging in DE for some time, others continue to engage in DE and also tend to have trouble regulating their
emotions, depression, and low self-esteem. For these reasons, DE itself, apart from being a springboard to EDs, is well worth exploring.
At the outset of this thesis, an instrument assessing DE among 1265 adolescents (54.5% girls) was validated. This easily administered questionnaire, referred to by the
acronym SCOFF (Morgan, Reid, & Lacey, 1999), comprises five questions assessing possible eating disturbances that are all answered using a “yes”/“no” answer format.
The results showed that more girls than boys suffered from DE, and that girls also suffered from more severe DE, which is in line with previous research (e.g. Hautala et
al., 2008). Additionally, this assessment of the SCOFF gave rise to the question of whether a positive answer on only certain items (instead of the stipulated cut-off of
two) is necessary for indicating the possible presence of DE among adolescents, such as the item assessing whether individuals had ever vomited because they felt
uncomfortably full.

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Bratman first proposed orthorexia nervosa in the late 1990s, defining it an obsession with eating healthy food to achieve, for instance, improved health. Today, in the Swedish media, excessive exercising plays a central role in relation to orthorexia. A few review articles on orthorexia have been conducted; however, these have not focused on aspects of food and eating, sport, exercise, or a societal perspective. The overall aim of this study was to provide an overview and synthesis of what philosophies of science approaches form the current academic framework of orthorexia. Key questions were: What aspects of food and eating are related to orthorexia? What role do exercise and sports play in relation to orthorexia? In what ways are orthorexia contextualized? Consequently, the concept of healthism was used to discuss and contextualize orthorexia. The method used was an integrative literature review; the material covered 19 empirical and theoretical articles published in peer-reviewed journals. This review demonstrates a multifaceted nature of orthorexia research; this field has been examined from four different philosophies of science approaches (i.e., empirical-atomistic, empirical-atomistic with elements of empirical-holistic, empirical-holistic, and rational-holistic) on individual, social, and societal levels. The majority of the articles followed an empirical-atomistic approach that focused on orthorexia as an individual issue, which was discussed using healthism. Our analysis indicates a need for (a) more empirical-holistic research that applies interpretive qualitative methods and uses a social perspective of health, e.g., healthism and (b) examining the role of sports and exercise in relation to orthorexia that takes the problematizing of "orthorexic behaviours" within the sports context into account.

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Börje Lech, 2012: Conciousness about own and others´affects.

Abstract(en) :It is essential for individuals’ well-being and relationships that they have the ability to consciously experience, express and respond to their own and others’ affects. The validity of a new conception of affect consciousness (AC), incorporating consciousness of both own and others’ affects, was investigated in this thesis. The clinical usefulness of the new conception was explored and an interview (affect consciousness interview – self/other; ACI-S/O) intended to capture this new definition was validated. In study I the interrater reliability and the concurrent validity of the ACI-S/O were assessed and found to be acceptable. There were significant differences in all variables of ACI-S/O between the four groups that participated in the study. Joy and interest had the highest ratings in all groups and guilt and shame had the lowest. By means of a factor analysis, two factors, labeled “general affect consciousness” and “consciousness about shame and guilt,” were obtained. General affect consciousness was related to different aspects of relational and emotional problems and possibly protection against them. In study II the clinical implications of AC were further explored in relation to eating disorders (ED). The level of AC in the ED group was compared with a comparable non-clinical group. The relation between AC and aspects of ED pathology were explored, as well as whether AC should be seen as a state or trait in patients diagnosed with ED. ACI-S/O was not significantly related to ED pathology or general psychological distress. There were no significant differences in AC between the different sub-diagnoses of ED but there were between the ED group and the non-clinical group. Significant pre-post correlations for both factors of ACI-S/O were found, indicating that AC could be seen as a stable dimension that might be important for ED pathology but is unrelated to ED symptoms. In study III the relationship between AC and self-reported attachment style (ASQ) was explored in a non-clinical group and three patient groups. There were significant correlations between all scores on ACI- S/O and the ASQ, with the exception of consciousness about guilt. Multiple regression analyses showed that AC, and especially others’ affects, contributed significantly to the ASQ subscales. AC and in particular own joy and others’ guilt and anger seem to be of importance for attachment style. In study IV the importance of AC for the treatment process was explored. Patients’ AC before therapy was significantly correlated with patients’ positive feelings towards their therapists but not with their alliance ratings. Patients’ warm and positive feelings were related to pre-therapy AC, whereas negative feelings were related to low alliance ratings in the previous sessions.

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Josefin Westerberg Jacobson, 2010: Wish to be thinner: Development end prediction of disturbed eating. A longitudinal study of Swedish girls and young women

The overall aim of this thesis was to examine the development and prediction of disturbed eating attitudes in girls aged 7–20 years. The four studies are part of a seven-year longitudinal project including 1279 girls in several age groups (7, 9, 11, 13, 15 years at inclusion) and their parents.

Study I showed that among girls aged 11 and 13 years, in addition to a positive relation between disturbed eating attitudes and age, eating attitudes, higher BMI than peers, a less healthy relation to family, and fathers’ eating attitudes, predicted disturbed eating attitudes two years later. Study II demonstrated that girls aged 9–15 years, who wished to be thinner dieted more often, thought that they would be more popular if they were thinner, were skipping meals more often and had a higher BMI, over five years, compared with the girls without such a wish. Study III demonstrated an increasing trend in the wish to be thinner and dieting attempts between the ages of 9 and 18 years. Motives for wishing to be thinner were, e.g., “to feel better about yourself” and “to correspond to the societal ideal”. A majority of the girls adopted healthy weight control practices, but unhealthy and extreme methods were also used. In Study IV, among girls aged 9 and 13 years, a wish to be thinner, fathers’ eating attitudes and mothers’ perfectionism contributed most to the prediction of disturbed eating attitudes seven years later. Protective factors were low BMI and more healthy eating attitudes moderated by high self-esteem, and low-to-medium degree of perfectionism.

In conclusion a wish to be thinner, higher BMI than peers, girls’ and fathers’ disturbed eating attitudes, mothers’ perfectionism and a less healthy relation to family predict the development of disturbed eating attitudes in girls. Low BMI and more healthy eating attitudes especially influenced by high self-esteem, and a low-to-medium degree of perfectionism protect against it. The “thin-ideal” is internalized early in girls and it is important to take a critical stand against the thinness ideal in our society, especially in families, and schools.

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Sanna Aila Gustafsson, 2010: The importance of being thin: Perceived expectations from self and others and the effect on self-evaluation in girls with disordered eating

The overall aims of this thesis were to examine personal standards, self- evaluation and attitudes to eating and weight in the development of dis- turbed eating in adolescent girls, and to examine how adolescent girls with a clinical eating disorder reflect upon and deal with perceived expectations in daily life.

Studies I and II were quantitative studies, conducted in a population- based longitudinal study. Studies III and IV were qualitative interview stud- ies of girls who were suffering from eating disorders and the data were analysed using a phenomenographic approach.

Study I showed that high personal standards expressed in a competitive way were specific for the girls with disturbed eating. These girls also re- ported a negative physical self-evaluation and often believed that thinness would make them more popular. In study II variables concerning attitudes to eating and weight and physical self-evaluation emerged as risk factors for disturbed eating, whereas personal standards or self-evaluation in gen- eral did not. Protective factors were a low BMI, healthy eating attitudes, an accepting attitude towards body size and a positive self-evaluation. Three categories of perceived expectations were described in study III: expecta- tions from others, self-imposed expectations and conflicting expectations. Many informants had problems identifying expectations that were not explicit and they interpreted them as self-imposed. In study IV the various ways in which the informants reflected on dealing with these expectations were summarized into three qualitatively different conceptions: being one- self, adapting to different situations and presenting oneself in a positive light. These conceptions were expressed in five patterns of action, which could have various functions for different individuals and in different situa- tions.

The results suggest that in order to prevent and treat eating disorders and related problems it is essential to integrate both intrapersonal and contextual factors that contribute to the development and maintenance of these conditions.

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Jennie Ahrén-Moonga, 2009: An eating disorder is more than just disordered eating: Bio-psycho-social perspectives

Modjtaba Zandian, 2009: You are how you eat: Decelerated eating may protect from obesity and eating disorders

Joakim de Man Lapidoth, 2009: Binge eating in surgical weight-loss treatments: Long-term associations with weight loss, health related quality of life (HRQL) and psychopathology

Objective. Previous studies that have investigated the relation between binge eating and long-term outcome of bariatric surgery have shown mixed results. Does binge eating before or after bariatric surgery affect long-term BMI, health related quality of life (HRQL) or psychopathology after surgery? The objective of the present study was to address these questions that might help decide to what extent binge eating needs to be addressed in the context of bariatric surgery. Method. We assessed 173 bariatric patients, pre- to 3 years after surgery, regarding weight, binge eating, HRQL and psychopathology.Results. Binge eating, pre- and post-treatment, were unrelated to long-term BMI outcome. Binge eating post-treatment was associated with more psychopathology, and lower HRQL.Conclusion. Pre- or post-treatment binge eating does not predict long-term BMI outcome, hence exclusions from surgery for only this reason is difficult to motivate. However, results show that binge eating post-surgery is common, and is associated to more psychopathology and lower HRQL. The poor psychological health status of post-surgical patients with binge eating also motivates studies with longer follow-ups, to investigate whether post-surgical binge eating might increase the vulnerability for future weight regain and complications, beyond three years. The high rate of binge eating after surgery and its negative association with HRQL and psychopathology indicates that we need to be observant of the occurrence and potential effects of binge eating in the context of bariatric surgery.

Tabita Björk, 2008: Measuring eating disorder outcome: Definitions, dropout and patients' perspectives

Örebro universitet, Medicinsk fakultet.

Background: Despite a plethora of research, there are serious limitations in our

knowledge of outcome in eating disorders. Almost all studies have been compromi-

sed by the problem of treatment dropout or non-participation in follow-ups. There

exists a lack of consensus in definitions of outcome and choice of outcome measures,

and there is a dearth of studies focusing on how patients subjectively perceive reco-

very. The overall aim of this thesis was to address problems in measuring outcome

after treatment for eating disorders, with an emphasis on methodological issues.

Specific areas of investigation included non-participation in long-term follow-ups,

the role of self-image in treatment dropout, outcome among patients who drop out,

patients’ subjective perspectives of recovery, and the impact of different methods

of measuring outcome.

Method: Four quantitative studies (I, II, III and V) were conducted within the frame-

work of a large Swedish multi-centre study of eating disorders, which adopted a pro-

spective, longitudinal and naturalistic design. Study IV was a qualitative investigation

encompassing interviews with former ex-patients who were considered recovered.

Results: Study I suggested that the reasons for non-participation in research were

mainly patient related (69%). Those declining further participation in follow-ups

were reported significantly lower levels of obsession-compulsion and anxiety, while

those not traceable reported significantly higher levels of hostility at admission. Study

II suggested that patients who dropped out from treatment initially presented with

less negative self-image and fewer psychological problems compared to those who

remained in treatment. Low levels of self-blame discriminated dropouts from com-

pleters and remainers, and significantly predicted treatment dropout. Study III found

no significant differences between dropouts and completers at follow-up, with the

exception that dropouts were more dissatisfied with treatment. However, patterns of

treatment response revealed that those who completed treatment made significantly

greater changes in terms of reduced eating disorder symptoms, fewer psychological

problems and a more positive self-image compared to dropouts. Study IV found

that patients who had recovered from an eating disorder tended to describe other

dimensions of outcome than those usually reported in follow-ups. Patients tended

to view recovery in terms of being able to relate in a relaxed and accepting manner

to food, their bodies, themselves as individuals, and their social environment. Some

perceived recovery in terms of coping better with emotions, while others experienced

themselves as healthier than people generally regarding food and weight. Study V

applied some of the most frequently used outcome measures for eating disorders

and found marked variations in the number of patients who could be considered in

remission. Overall remission rates varied from 24.3% to 77.8%, depending on the

outcome measure used.

Discussion: The results suggest that non-participation and dropout are not unitary

phenomena. There is also a need for greater consensus on how eating disorder out-

come should be measured. This is necessary in order to make comparisons between

different outcome studies meaningful, and to elucidate the overall picture of eating

disorders outcome.

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Karin Nilsson, 2007: Recovery from adolescent onset anorexia nervosa:a longitudinal study

Caroline Björck, 2006: Self-image and eating disorders

Karolinska Institutet, Stockholm Negative self-image is considered typical of eating disorders. The present thesis aimed to study clinically relevant aspects of self-image in adult patients taking part in a large naturalistic and longitudinal project at specialist units for eating disorders in Sweden. Self-image was measured using the Structural Analysis of Social Behavior (SASB), and examined together with clinical and background variables at initial presentation and at follow-up. Important aspects of treatment, such as diagnosis, treatment satisfaction, outcome and dropout were the focus of four studies. In Study I, eating disorder patients were found to have more negative interpersonal profiles compared to controls. When diagnostic groups were compared, patients with anorexia nervosa were more self-controlling, self-hating and self-blaming, as well as less self-emancipated and self-loving. Patients with binge eating disorder were more self-affirming than patients with anorexia nervosa and bulimia nervosa, as well as less self-controlling than patients with anorexia nervosa and patients with atypical eating disorders. In Study II, patients who became unsatisfied with treatment were characterised by significantly more negative self-image, as well as higher levels of eating disorder and psychiatric symptoms compared to satisfied and highly satisfied patients. Unsatisfied patients expressed higher expectations of treatment interventions focusing on insight and lower expectations of interventions focusing on control. Overall satisfaction with treatment was predicted by interventions focusing on support and control of eating problems. In Study III, high levels of self-hate were significantly related to poor outcome; other variables related to poor outcome included low occupational status, problematic interpersonal relationships, eating disorder symptoms, high levels of self-emancipation, and psychiatric symptoms. In Study IV, patients who dropped out had less negative self-image and fewer psychological problems at intake compared to patients who had completed treatment or who were still in treatment; low levels of self-blame predicted dropout. Results of these studies suggest that eating disorder patients have significant problems with negative self-image. Examining self-image at initial assessment may help to identify patients at risk for negative therapeutic interactions. It may be especially important for therapists to pay attention to underlying interpersonal dynamics, to avoid being drawn into interactions that confirm negative self-image and are detrimental to treatment . Läs mer & ladda ner avhandlingen här

Linda Johansson, 2006: The role of cognitive processes in eating pathology.

Martin Neovius, 2005: Diagnostic tests for adiposity and metabolic risk factors in adolescence: Results from the Stockholm weight development study (Swedes)

Background: Despite growing concern about the development of pediatric obesity, there is still controversy about its classification. International classification systems have been proposed and national systems are in use in many countries, often in parallel. Most proposed classification systems are distribution-based and not anchored to either fatness, metabolic risk or risk of adult obesity.

Aims: To assess the diagnostic accuracy of BMI, WC and W-ER for fatness, the characteristics of commonly used classification systems, and to estimate the relationship between diagnostic tests for overweight, insulin resistance and cholesterol profile.

Design: SWEDES is a prospective cohort study of 481 children followed from birth until age 17y, and their mothers. BMIdevelopment was assessed retrospectively from healthcare records, and clinical measurements at age 17y were performed. Measurements included height, weight, WC, HC, body composition (FM, FFM), and blood samples. Proposed classification systems for childhood and adolescent obesity were evaluated by use of ROC analyses. Through regression analyses, the association between different screening measures and insulin resistance (HOMA-IR) was also investigated.

Results: The IOTF/Cole classification system was found to be highly specific (0.95-1.00), but insensitive for fatness, especially in females (0.22-0.25). The outcome was shown to be fairly insensitive to the choice of gold standard to define fatness. The same characteristics remained in longitudinal analyses when using BMI at different ages as diagnostic tests for both BMI-based and FMIbased overweight in late adolescence. Using alternative measures as indicators of total fatness revealed that WC and BMI display similar diagnostic accuracy, while WHR performs significantly worse, also when evaluated against blood variables. In boys, the associations between simple anthropometric measures and insulin resistance were weaker than for detailed body composition measures, while in girls no significant associations were observed. The associations between BMI in childhood and adolescence and blood variables were non-existent or weak, implying that anchorage of classification against such outcomes may be complicated.

Conclusion: Currently proposed BMI-based classification systems for adolescent overweight are highly specific, but less sensitive for fatness as well as for metabolic risk. The awareness about the trade-offs involved in applying such classification systems should be raised, since it may affect efficiency in the usage of healthcare and public health resources. A classification system designed for international monitoring cannot be optimal for the different needs of risk group stratification in such different settings as specialized care, public health and targeted prevention. Misuse is likely to result in wasted resources as well as foregone health improvements.

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Ingrid Larsson, 2005: Human body composition. Reference data and anthropometric equations. The metabolic syndrome and risk

The determination of body composition is a key to the understanding of the relation between obesity and disease. In order to evaluate body composition data, reference values are needed. Since methods with high validity and reproducibility are expensive and often time consuming, simpler techniques based on anthropometry are needed. The prevalence of the metabolic syndrome is increasing. Consensus regarding a clinically useful definition of the syndrome predicting mortality and related morbidity is needed.Aims: 1) to establish population-based sex- and age-specific reference data with respect to dual energy x-ray absorptiometry (DEXA) determined body composition, 2) to examine if individual rather than fixed total body potassium/fat-free mass (TBK/FFM) ratios could improve FFM determinations, 3) to establish and validate optimal weight-for-height indices for prediction of body fat, and, 4) to analyse associations between definitions of the metabolic syndrome and mortality and atherosclerotic morbidity.Methods: 1135 men and women, 37-61 years of age from the Swedish Obese Subjects (SOS) reference study. In addition, 149 subjects aged 30-58 years from the intervention trail XENical in the prevention of Diabetes in Obese Subjects (XENDOS) were included in prediction of body fat. Body mass index (BMI) ranged from 17.6 to 46.1 kg/m2. Body composition was measured by DEXA, and TBK was determined by whole body counting. Anthropometric measurements: body weight, height, waist and hip circumferences and sagittal trunk diameter. Biochemistry: diabetes- and cardiovascular risk factors and hepatic function tests.Results: The prevalence of obesity in the SOS reference study was 10% in both men and women. At BMI 25 kg/m2, relative (absolute) body fat was 24% (19 kg) in men and 36% (25 kg) in women. Secular increases in abdominal fat distribution were observed in women but not in men. In sex-specific equations, TBK/FFM could be predicted from weight, height and age with errors <5%. Body fat in kg could be optimally and linearly predicted by weight/height (W/H) whereas percent body fat was optimally and curvilinearly predicted by BMI. Percent body fat asymptotically reached an upper maximal value of 56% in men and 52% in women. All-cause mortality was increased significantly in subjects with the metabolic syndrome according to WHO but not according to the EGIR (European Group for the study of Insulin Resistance) or the ATPIII (Adult Treatment Panel-III) definitions of the metabolic syndrome. Incident atherosclerotic morbidity was related to the WHO and EGIR definitions of the metabolic syndrome but not to the ATPIII definition.Conclusions: 1) Sex- and age-specific reference data on body composition has been provided. 2) In each sex, TBK/FFM can be predicted from age, weight and height. 3) Body fat in kg should be predicted from W/H rather than percent body fat from BMI. 4) Inclusion of glucose intolerance and/or insulin resistance as obligatory criteria in the definition of the metabolic syndrome seems to be important for the prediction of mortality and incident atherosclerotic morbidity. Läs mer & ladda ner avhandlingen här

Barbro Thurfjell, 2005: Adolescent Eating Disorders in a Sociocultural Context.

Adolescence means an increased risk for eating disorders (ED) and the female gender is the most important risk factor. Empirical studies of the perceptions of gender ideals—as potential mediating factors between the socio-cultural context and ED—were this thesis’ primary goals. Further aims implied evaluating the psychometric properties of the Eating Disorders Inventory for Children (EDI-C) and providing normative data for boys and girls concerning self-assessed ED symptoms and related psychological traits.

The EDI-C has satisfying psychometric properties, and normative data are now provided. The vast majority of preadolescent and adolescent boys and girls (n=4725) are not preoccupied with weight concerns, but 1–3% of the boys and 9–20% of the girls here indicate feelings of anxiety and problematic attitudes. An increase of self-reported ED symptoms occurs during female preadolescence and early adolescence.

Responses to three open-ended questions—addressing perceived and personal gender ideals of adolescent boys (n=347) and girls with (n=204) and without (n=417) an ED—indicate that girls are, compared to boys, more involved in images of ideals. The perceived ideal man and ideal woman differ in body size and strength. This corresponds with different health risk behaviours reported in boys (body building) and girls (dieting). Awareness of media ideals and an ability to discriminate them from individual values was common in the normal groups and in girls who had recovered from an ED. A poor outcome was associated with thinness stated as ideals of the media, without mentioning good looks. Factors that could predict outcome at the 3-year follow-up of an ED in adolescent girls were: good looks (media ideal), maturity fears, profession (individual ideal), sexual debut, and vomiting.

The addition of a gender perspective would add a dimension to programmes aiming at preventing and treating ED in adolescence.

Ingela Melin, 2004: Motivating clinical treatment of obesity: Methods, education, supervision and outcome.

Obesity has become an important health problem worldwide. It increases the medical risks and affects daily living. Environmental factors such as diet and sedentary lifestyle are likely to be the cause. In Sweden, the number of obese people has nearly doubled during the past 20 years and now totals nearly 500 000. Obesity continued to increase in the Swedish population between 1996/97 and 2000/01. In economic terms, the direct health care cost may be approximately 2 % of the total expenditure for health and medical service and corresponds to a cost of approximately three billion SEK per year. The indirect cost due to absence from work and early retirement are at least equally high. The aim of this thesis was to study the effect of education, supervision of health care professionals and theimplementation and outcome of a structural behaviourally oriented psycho-educational treatment programme to motivate clinical treatment of obesity. PAPER I describes an extensive structural behavioural treatment programme based on conventional treatment of patients. PAPER II analyses the effects of education, supervision of health professionals and the introduction of a structural behavioural treatment programme, and furthermore studies what factors facilitate the implementation and start up of obesity treatment programmes. PAPER III analyses and describes the results in four different group treatment settings in Swedish health care for long-term treatment of obese subjects. The four programmes included all the behaviour modification but differed regarding components and follow Up. PAPER IV explores analyses and describes the outcome and the problem of dropout among obese o utpatients in an academic obesity unit. It also illustrates the reasons for drop out, and investigates the patients' diagnoses, attendance at group meetings and at the complementary treatment.

MAIN RESULTS AND FINDINGS. A structural behavioural treatment programme could motivate and facilitate the implementation of obesity treatment in large scale in health care and also increase the possibility for weight maintenance in the patients. Education of health care professionals is a good investment. Significantly more of those who started the behavioural treatment programme had previous theoretical education and clinical experience of obesity. Guidance and supervision of the health care professionals had a significant positive influence on starting up the treatment program. Significantly more of those who started up the behavioural treatment programme had a go-ahead from the management and support from physicians, and were part of a team or had a colleague to work with. In addition, they could also find the time to organise and plan the treatment. Education, workplace organisation, and a structural behavioural treatment programme, seem to be significant factors in facilitating and increasing the likelihood for a start. Outcome - The structural behavioural treatment programme produced a small weight reduction, maintained after two years, and the programme has been working satisfactorily as a cornerstone in different settings. The programme can be adjusted to various complementary treatments and produced weight reduction for healthy obese subjects as well as for obese subjects with medical complications. We found no significant differences between weight reduction after two years and the type of treatment studied, the amount of complementary treatment available and the number of health care professionals involved in the treatment. The effects of the complementary treatment gradually subside. After two years, the results of the weight reduction of the four treatments programmes are similar. However, this could at least partly be due to the fact that obese patients with more problems were recruited to the more comprehensive programmes. This study has highlighted the difficulties of long-term clinical treatment of obese outpatients even in the specialised obesity clinic. The findings demonstrate that educated and experienced personnel, together with an extended package of treatment options, are not enough to keep patients in treatment for two years. Even though the dropout rate was high, two thirds of the included subjects reduced their weight - a satisfactory result in a clinical setting. These results show that implementation of this structured behavioural treatment model for weight management is feasible and effective in different health care settings. Läs mer & ladda ner avhandlingen här

Birgitta Adolfsson, 2004: Obesity, life style and society: Psychological and psychosocial factors in relation to body weight and body weight changes

This dissertation consists of two cross-sectional population studies (studies I and IV), and two prospective studies (studies II and III).

In study I the relative importance of obesity for self-rated health with focus on age and gender differences were examined among 5,080 (2,366 males) participants in a national survey. Data were gathered through questionnaires. An inverse association was found between BMI and self-rated health. The relation was most pronounced among middle-aged men and women. An association between obesity and functional impairment, chronic disease and an impaired mental well-being was found for both men and women. For women there was also an association between obesity and chronic pain.

In study II a qualitative method was used to examine which factors 15 participants in a one-year behaviour modification weight reduction programme considered important for eating habits and weight change. The participants were interviewed three times during the programme and once one year after the programme had ended. The interviews were analysed with a qualitative method, grounded theory. External stimuli, stress and emotional reasons affected eating habits before the programme started and one year after the programme had ended. Non-sufficient support was another reason mentioned as reason for regain of lost weight.

In study III an association between locus of control orientation and weight loss was examined in a one-year follow up of 41 participants in a weight reduction programme. A questionnaire with 40 questions was used to assess the locus of control orientation before the programme started and one year later. There was no change in locus of control orientation after one year. The weight loss after one year was positively associated with an initial internal locus of control orientation.

In study IV a representative sample of 2,810 subjects from a population study was interviewed on sexual satisfaction, sexual abuse and life satisfaction. Age and gender were controlled for in the analyses. The older group of obese men reported a decrease in sexual desire compared with five ears earlier and the older group of overweight men reported involuntary participation in sexual activities more often than the normal weight group. Though the older group of obese women more often than the other BMI-groups were diagnosed with a lingering disease, there was no difference in satisfaction with physical health between the BMI-groups.

An inverse association between BMI and self-rated health as well as an association between obesity and impaired physical and mental well-being implies a dialogue between care taker and care giver on which treatment would match the caretaker's current needs for an improved well being. The results indicate that unless the factors behind an excessive eating are addressed in obesity treatment, they will obstruct the weight reduction and maintenance of lost weight. An internal locus of control orientation could be supported in weight reduction treatment. Untreated experiences of sexual trauma could be an important pre-treatment variable to consider in weight reduction programmes.

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