New research shows that obesity is partly in the mind

With almost 30% of Australians classified as being obese it is becoming a significant health and safety issue for businesses which want employees to operate at peak performance, with obese staff members more likely to suffer from diabetes, hypertension, heart disease, cancer and accidents.

Companies are recognising that and have boosted efforts to counter those problem areas, including medical check-ups, setting up cycling clubs, and installing lockers and showers to encourage staff to exercise.

The research found that obesity in children, adolescents and adults can be linked to cognitive functions, particularly executive function, which controls tasks such as reasoning and planning.

It sheds new insight on the cognitive impact of obesity, including how it could possibly prevent staff from operating at peak performance via the impairment of executive function and it also provides hope for companies seeking to assist staff to battle obesity.

The research indicates that obesity may not be due to a lack of willpower and suggests that helping staff is more complicated than simple motivation and provision of exercise equipment.

It holds out hope for cost effective corporate programs for treatment using cognitive remediation therapy to improve executive functioning.

“Effective cognitive remediation therapy might help businesses help their employees control their weight,” says Evelyn Smith, co-author of the research paper recently published in the Obesity Reviews journal.

Obesity has been called an epidemic, with more than 25% of Australian men and 24% of women hugely overweight.

In the US, the fattest country in the world, 32% of men and 35% of women are obese. Some estimates put obesity in Australia close to or at 30%.

“I think we are catching up,” says Steve Hambleton, president of the Australian Medical Association (AMA).

Experts say this could be the first generation that may not live as long as its parents due to obesity, with current treatments – including more radical procedures such as surgery –not solving a problem that’s exacerbated by poor diet, lack of exercise and consumption of tobacco/alcohol in a long-term, cost-effective manner, according to Hambleton.

Human genetics are based on the hunter-gatherer way of living, Hambleton says, with people designed to have survival periods between meals. A human can exist without food for several weeks and still have enough energy to be capable of gathering food.

“We’re physiologically designed to put aside a bit for rainy days,” Hambleton says.

“Of course it never rains. There is ready access to enormous quantities of high-energy food. That’s where our problem is – enormous access to the wrong sorts of foods and it’s cheap.”

Ten years ago obesity was thought to be confined to lower socioeconomic groups but recent research shows that it straddles the social strata and it can affect anyone.

Weighing up costs

The obesity surge is growing in importance for companies as the impact of the disease increases according to health economist at Access Economics Lynne Pezzullo.

Hambleton describes the costs as real and major but difficult to quantify, saying obesity leads to increases in absenteeism and increased risk of diabetes, higher risk of heart attack and stroke, premature departure from the workplace and a greater risk of accident.

“If a chair is designed for 80kg then you have a 120kg person sitting on it you’re going to have a problem,” he says.

A 2010 study published in The Medical Journal of Australia found overweight and obese Australian adults cost the economy $21 billion in direct health care costs and other direct expenses plus an additional $35.6 billion in government subsidies.

It found the direct cost of people being overweight and obese was significantly higher than previous estimates and the bill will rise as more Australians tip the scales, creating individual and societal financial incentives for people to slim down.

In 2006 Access Economics released a report for Diabetes Australia on the economic costs of obesity and an updated report in 2008 found the financial cost of obesity was $8.28 billion.

The major cost was productivity costs of $3.6 billion (44%), well above health system costs of $2 billion (24%) and carer costs of $1.9 billion (23%). The net cost of loss of wellbeing was a massive $49.9 billion, taking the total cost of obesity to $58.2 billion.

But the precise impacts of obesity on business are hard to quantify particularly given a lot of the costs are borne by obese people themselves says Pezzullo.

“There is a substantial productivity loss from various conditions. It’s quite difficult to quantify as we haven’t got a study that looks at that,” she says.

The UNSW research paper, which reviewed 38 recent studies, provided insight into how obesity could be affecting staff performance.

Previous research had shown that obese adults and children were more likely to have lower cognitive performance but it was not entirely clear which aspects of cognition were affected.

Smith and her colleagues undertook a systematic review of research to try to identify those aspects.

“Deficiencies were found most consistently in the area of executive function,” Smith says, with some of the major characteristics of executive dysfunction including difficulty with goal setting, difficulty adapting to change, low tolerance for failure and not taking responsibility.

Counting on cognitive reserve

Smith is reluctant to directly link executive dysfunction to poor workplace performance, in part due to not wanting to stigmatise obese people.

“On average obese individuals have lower performance on executive function,” Smith says.

“But you can’t say all of them will.”

And cognitive reserve must be factored in, she says. For instance an obese person may be a brilliant manager because his or her excellence is so elevated that they still stand out relative to their peers so it would be folly for an employer to reject a highly talented potential employee because of their weight.

But it’s hard not to leap to the conclusion that obese people are not performing at their peak.

Hambleton says companies, particularly larger companies, are taking action.

One strategy is the annual executive medical. Beyond the test itself there’s value in telling people they will have a test which may trigger the individual to act pre-emptively along with demonstrating that the company is interested in their wellbeing.

“There’s a culture in the corporate world to be seen in the gym. If you go to a hotel gym at six in the morning all those people are sweating,” Hambleton says.

But current strategies to combat the obesity epidemic are not working.

“They work short term but not in the long term,” Smith says.

Fad diets can lead to quick weight loss but it isn’t sustained over longer periods of a year to five years.

Anti-obesity pills are available but they can increase the risk of heart attacks and reality TV shows that focus on weight loss may highlight the issue but invariably show people shedding kilos with the help of a personal trainer and cook.

Hambleton says they may not be cost-effective options for the rest of the population and says surgery is right at the end of the line.

“While 60% of those who have a surgical intervention will lose 60% of their excess weight it’s not really what you would want to spend money on if you could intervene earlier,” Hambleton says.

How weight gain goes out of control

The UNSW paper helps to explain why weight loss for obese people is so difficult and why existing treatments may not always be effective and it raises the possibility that obesity is at least in part a neurological condition, not just a so-called lifestyle disorder.

A vicious cycle may also be present where obesity impairs executive function and that impairment can exacerbate weight gain.

“Weight gain might be out of people’s control if they have low levels of executive function,” Smith says.

And that has significant implications for how businesses support staff if weight gain is not entirely in the control of obese people simply providing gyms, health equipment and fitness programs may not be enough.

Businesses may also have to focus on mental and cognitive aspects of treatment.

Smith and her colleagues are trialling cognitive remediation therapy which is designed to improve neurocognitive abilities including attention, memory and executive function on obese people.

“By increasing the levels of cognitive function this may aid in helping individuals make suitable lifestyle decisions and stop the vicious cycle,” says the paper A Review of the Association Between Obesity and Cognitive Function across the Lifespan: Implications for Novel Approaches to Prevention and Treatment.

Cognitive remediation therapy has been effective in treating conditions such as anorexia nervosa and helping sufferers to gain weight and maintain it long term. As with obesity anorexia sufferers have cognitive deficits that maintain the disorder.

In the specific domain of feeding behaviour obese individuals are too flexible, cannot plan a diet and fail to associate health outcomes with food choices, which are all aspects of impaired executive function, the paper said.

“Although hypothetical it is possible that cognitive remediation could treat obesity by helping individuals maintain a healthy lifestyle long term,” the researchers say.

Ten people who are taking part in an executive function training trial at UNSW attend 50-minute sessions twice a week over four weeks. The trial will conclude at the end of 2012 after the participants’ one-year follow-up.

“The program simply aims to improve all aspects of executive function and generalise this to real life and eating,” Smith says.

The training focuses on shifting perspectives and includes training in attention-switching tasks.

For example people may be presented with the word red but in a blue colour. They have to mention blue and ignore what the word says.

“It’s hard,” Smith says. “The brain has to shift that perspective.”

People claim their brain hurts at the end and according to Smith magnetic resonance imaging shows changes in the brain.

New solutions are needed to address obesity according to Hambleton who adds that the UNSW research should trigger more research into cognitive performance and obesity.

“We have to research it and take a closer interest,” he says.

The paper noted the “urgency to invest in novel obesity research and institute informed public health programs”.

Smith believes training practitioners in cognitive remediation therapy so it can be delivered to the public is one solution.

“However surgery for the morbidly obese may be the only way,” she says.

Hambleton hopes the new research will bring on some fresh ideas.

“It’s fair to say we don’t have solutions … maybe there is something else we should be looking at,” he says.

This story was first published at Knowledge@Australian School of Business.