Obesity
Obesity is determined by complex biopsychosocial factors. Negative psychological experiences play a significant role, with up to half of adults attending specialist obesity services having experienced childhood adversity. The experience of stress as an adult, caused by factors like financial insecurity and mental illness, has also been linked to an increased risk of obesity (1). Both adults and children who live with obesity often experience stigma and discrimination, which itself is associated with worsening health outcomes. Obesity is recognised both as a complex disease, and as a risk factor for other non-communicable diseases such as cancer and Type 2 diabetes and decreased life expectancy. Estimates of the cost of obesity to Scotland put the total economic cost at as much as £4.6 billion per year (2). Research also suggests that overweight and obesity status has an impact on future generations (3).
Scotland has among the highest levels of obesity prevalence for men and women in Organisation for Economic Cooperation and Development (OECD) countries. Around two-thirds of all adults (67%) were living with overweight in Scotland (including obesity) in 2022, with a higher prevalence in men than women (4). There is an inequality in obesity risk with people who live in communities marginalised by poverty at an increased risk. Average BMI is patterned by level of deprivation with those from the most deprived areas consistently showing higher BMIs compared to the least deprived. In 2022, 36% of children were outwith the healthy weight category in Scotland (4). Consideration should be given to whether adults or children entering weight management services have (or may have) a diagnosis of Attention Deficit Hyperactivity Disorder or Autism (5), as this could potentially impact their ability to engage in a standard weight management programme.
This information is for commissioners and providers of health care to consider the evidence base for the delivery of psychologically informed interventions for people who are overweight or obese. This information is also for people overweight or obese, their families, and carers. This topic page covers approaches for the management of obesity in children, young people and adults. Full guidance on assessing and managing obesity can be found in the NICE guidelines for Obesity (6,7). These guidelines are under review and an update is due in late 2024. The SIGN Guidelines for Obesity (2010) were withdrawn in 2020. The clinical term obesity is used in this document but other descriptions such as “people living with a higher weight” may be preferred when working with service users.
Exclusions for topic
This topic neither covers other physical health conditions that are associated with obesity (diabetes, cancer) nor the management of complications arising from obesity. It also does not cover the use of psychotropic medicines/drugs or bariatric surgery treatments for the management of obesity.
For comorbid conditions such as Diabetes, Cardiovascular and Asthma, please consult with the relevant section of the Matrix for further information about psychological interventions for these conditions.
Interventions and Therapies
Multicomponent lifestyle programmes that address three lifestyle areas related to overweight and obesity — diet, physical activity and psychological approaches to behavioural change (behavioural/cognitive-behavioural) — are more effective than single component interventions (6,7). Comprehensive interventions – that is, interventions that address all 3 areas - are more effective that those that which address only 1 or 2 (6,8,9).
Family/significant other support can also help to maximise treatment outcome and is fundamental to work with children and young people who often have smaller influence on health choices than adults in their life. Contextual influences on health behaviours (e.g. social, biological and psychological factors) should be directly considered and addressed when planning and delivering interventions with individuals and families. This may involve multi service/agency working, especially with children and young people.
Staff working across various psychological practice types (Informed, Skilled, Enhanced and Specialist) can all contribute to good psychological care within Obesity Multidisciplinary Teams. Clinicians/interventionists should receive specialist training in behavioural/cognitive behavioural strategies to support weight management interventions, as well as training around trauma informed practice and awareness in basic mental health awareness and management.
Psychosocial components typically implemented within a comprehensive weight management programme include (6,7):
Children
- Stimulus control
- Self-monitoring
- Goal setting
- Rewards for reaching goals
- Problem solving
- Praising success
- Parents to role-model desired behaviours
Considerations in the management of obesity in children are similar to those in adults but should include attention to child related elements such as developmental and relational context, growth* and pubertal status, psychosocial distress, and the family’s willingness and ability to support lifestyle changes. Baygi et al (2023) (10) found that the inclusion of Cognitive Behavioural Therapy and/or Motivational Interviewing components (as with adults) may improve outcomes, however the relative contribution of each of these components are not yet clear. More research is needed in the area of psychological aspects of Pediatric Obesity, for example in trauma informed, family based, and systems-based interventions in children living with obesity. Further consideration also needs to go to the areas of eating disorders, and web-based interventions (11).
*Please note for some children who are still growing, the goal may be to lose body fat rather than lose weight per se.
Adults
- Self-monitoring of behaviour and progress
- Stimulus control (where the person is taught how to recognise and avoid triggers that prompt unplanned eating)
- Cognitive restructuring (modifying unhelpful thoughts/thinking patterns)
- Goal setting
- Problem solving
- Assertiveness training
- Slowing the rate of eating
- Reinforcement of changes
- Relapse prevention
- Strategies for dealing with weight regain
Carraça et al (2021) (12) reviewed the evidence around behaviour change techniques in the context of adult based physical activity and obesity. They found that behavioural practice and rehearsal was helpful for face-to-face interventions, while goal setting, social incentives and graded tasks were found to be helpful for digital interventions.
Overview of Evidence for Older People
The types of lifestyle interventions for weight loss, recommended for adults, can also be considered for older people, as they have clear benefits for obesity-related complications, and functional impairments (13). Clinicians are advised that there are differences in presentation of psychological problems in later life and to consult Delivering Effective Psychological Therapies and Interventions to Older People for further information on factors relevant to practice.
Overview of Evidence for People with Learning Disabilities
Research is required in the evaluation of the effectiveness of comprehensive lifestyle programmes for overweight or obese adults with a formal intellectual disability diagnosis (14,15).
Settings, mode and frequency of intervention
Settings: Weight management programmes have been found to be clinically effective and well suited for those who engage in treatment and complete the programme in both primary and secondary care. Referral to more specialist services (e.g. dietitians, psychologists, physiotherapists) is required for the most complex presentations. Comprehensive weight loss interventions can be provided in individual or group sessions.
Mode of delivery: Group interventions have been found to be equally as effective as individual approaches (16), and offer the advantage of increased clinical capacity, and the opportunity for peer support from others with similar lived experience (17,18). For adults, electronically delivered weight loss programmes (including by telephone) that include personalised feedback from a trained interventionist can be prescribed for weight loss (8) and it is important to consider personal choice regarding mode of delivery. Digital weight loss interventions are more effective when more intense contact is used (19). Lau et al (2017) (20) found that digital based weight loss programmes were effective for women living with overweight or obesity in the perinatal period.
Some commercial-based programs that provide a comprehensive lifestyle intervention can be prescribed as an option for weight loss provided there is peer-reviewed published evidence of their safety and efficacy (9). Across all formats of delivery, weight loss maintenance should be considered a main goal (9). Where these programmes are being prescribed on the NHS and Partnership settings, screening for eating disorders is recommended.
Frequency of sessions: More frequent support should be offered initially (e.g. a minimum of 3 months of fortnightly sessions), followed my monthly maintenance/ monitoring sessions, and more frequent interventions achieve better outcomes (21).
Psychological support and Mental Health in the context of obesity
Services should aim to provide fully integrated psychological support or at minimum, agree supplemental psychological support through local pathways, where such support is not included in the intervention. In the context of mental health difficulties, individuals should be supported in changing health behaviours, and be assisted to manage overweight and obesity in partnership with one or more healthcare professionals. Weight management interventions should be tailored to the individual and supported by self-management techniques and regular review by a healthcare professional.
Those living with mental illness, including severe and enduring presentations, should not be excluded from weight management programmes, as evidence suggests such individuals can do as well as those with no or less intense/severe difficulties. Eating meets a range of psychological and social needs and for many people, overeating develops as a way to regulate emotions and cope with emotional distress (1).
Tailoring of treatments is required, with access to mental health specialists recommended to support engagement and adherence (22-25). Joint working between mental and physical health professionals and services is essential (26).
Eating Disorders
Eating disorders such as binge eating, and bulimia, or eating disorders unspecified, are a significant component of obesity/common comorbid symptoms for many seen in weight management services, and symptoms can be significantly reduced through psychological intervention, (see Matrix eating disorders). Engagement with a lifestyle programme to encourage weight loss is contraindicated where an individual meets criteria for Bulimia Nervosa or other recognised eating disorders (other than Binge Eating Disorder). All eating disorder treatments should be in line with national guidelines for Disordered Eating (26,27) and in line with Matrix recommendations from within the adult eating disorders section.
Clinical judgement based on the person’s history (including treatments accessed), or familial history of eating disorders, especially in the case of children and young people, needs to be taken into consideration for treatment options.
Binge Eating Disorder
People living with overweight or obesity who meet diagnostic criteria for Binge Eating Disorder can be seen within weight management programmes (28, 29); however, assessment for symptoms of disordered eating, and provision of additional psychological support, where needed, would be recommended prior to, and/or potentially alongside lifestyle intervention. When there is no history of therapy to address BED, and based on the clinician’s individual formulation of the presenting problems, it is recommended to treat the eating disorder first to gain more control over eating disorder cognitions and behaviours in order to support future weight loss interventions. Psychosocial screening/assessment is essential on entry/re-entry into weight management programmes to ensure appropriate matching of interventions based on individuals presenting problems and treatment history. Treatment can be delivered either via the specialist weight management service (where available and when addressing higher weight is an appropriate treatment goal) or via mental health services such as local Primary Care, Community Mental Health Teams or Eating Disorder Services, matched with the level of need of the person.
Cognitive behavioural therapy or interpersonal psychotherapy should be considered for first-line therapy for adults with binge eating disorder (27). See the Binge Eating Disorder Section of the Matrix for further details.
Bariatric Surgery considerations for Adults
Alongside lifestyle interventions, bariatric (weight loss) surgery, in the context of a multidisciplinary weight management team, may be offered to clients meeting eligibility criteria in NHS Scotland. For those who meet bariatric surgery eligibility criteria, low intensity behavioural lifestyle interventions should be integrated into the pre- and post-operative care pathway. Psychological assessment is recommended as best practice and should be part of a multi-disciplinary assessment and preparation pathway for people seeking surgery (30, 31), and mental health status is an important consideration throughout the treatment pathway (32). Multicomponent lifestyle advice should be part of the bariatric surgery pathway, pre- and post-surgery (via tier 3/4 specialist services), to enhance surgical outcome (6,33,34). Clinicians working in bariatric services/teams should therefore receive appropriate specialist training relevant to the surgical intervention(s) being offered, plus training in behavioural strategies to support weight management and surgical interventions.
Established guidance for the psychological assessment of an individual’s preparedness for surgery should inform multidisciplinary decisions (35). Individuals should not be ruled out on the basis of mental health histories. Mental health assessment is recommended as a priority to manage expectations for both individuals and the multidisciplinary team. Clarification should be made that weight loss interventions are not mental health interventions. Maximising mental health ahead of surgery is essential as well as ensuring post-surgical support is also in place. Where people are not proceeding for Bariatric Surgery, they should be offered care for their identified mental health issues (36). The assessment and treatment of disordered eating before surgery should be particularly prioritised to enhance readiness, given evidence that such behaviours are likely to re-emerge 1-2 years post-surgery (32) and can detrimentally influence outcomes, physical and psychological. This also highlights the essential need for access to psychological support following surgery to aid adjustment and coping. Where such care is not available within weight management/bariatric services, liaison/joint working with mental health services is recommended.
Medication/injections to treat obesity
There is evidence for the use of medications/injections to treat obesity (6,37), however research is required to evaluate the psychological aspects of these treatments.
Insufficient Evidence/Further Research Needed
- There are no large-scale studies with evidence for the inclusion of “Third Wave” interventions such as Mindfulness, Compassion based intervention, and Acceptance and Commitment Therapy in weight management settings but interest in these approaches may yield studies for future consideration (1,38).
- There is little evidence for the use of inpatient weight management approaches.
- There is also emerging evidence that positive childhood experiences, such as supportive communities and resilience within wider family systems can buffer effects of ACES and may mitigate the risk of obesity (39).
- Further research is required into electronic apps, and obesity interventions that are conducted remotely (see Matrix Digital section for further information).
- More research is required to investigate the complex societal and public health factors related to obesity and interventions that may be helpful and cost-effective in the longer term.
- More research is needed regarding access pathways to weight management services for people with Binge Eating Disorder (1,28,29).
| Recommendation | Who For? | What intervention | Type of Psychological Practice | Level of Evidence | Efficacy |
| First line intervention | Children with a range of BMI percentiles, where 91-97th percentile = overweight, and 98th percentile = obese. | Comprehensive weight loss interventions should include all 3 of the following elements:
|
Skilled/ Enhanced/ and Specialist | A | Low-Medium |
| Recommendation | Who For? | What intervention | Type of Psychological Practice | Level of Evidence | Efficacy |
| First line intervention | Adults with a range of BMI (overweight BMI>25 and obese BMI>30)
People who meet bariatric surgery eligibility criteria |
Comprehensive weight loss interventions of up to 12 months should include all 3 elements as follows:
|
Skilled/ Enhanced/Specialist
Enhanced/ Specialist |
A | Medium |
| First line intervention | People who have a Binge Eating Disorder | Cognitive behavioural therapy or interpersonal psychotherapy should be considered for first-line therapy (27). (see Matrix BED). | A | low-highfor reduction in binge eating episodes |
Leading contributions from Mairi Albiston - Head of Programme for Physical Health (NES), Ross Shearer - Consultant Clinical Psychologist, (NHSGGC), Marie-Claire Shankland - Head of Programme for Specialist Services Psychology (NES) and Fiona Campbell - Consultant Clinical Psychologist (NHS Grampian).
We would also like to thank the following for their contributions: Sarah Anderson, Lindsay Chapman, Suzanne Connolly, Hannah Dale, Alan Gillies, Kirsten Hunter, Meryl James, Leeanne Nicklas, Vivien Swanson, and Kellie Turner.
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