New study: Weight control failure and suicidal ideation

Title: Association between weight control failure and suicidal ideation in overweight and obese adults: a cross-sectional study

Authors: Ju, Han, Lee, Kim, Park, and Park

Source: BMC Public Health. Epub 23 Nov 2015. Link to free full text

Super-quick summary: A cross-sectional study of ‘overweight’ and ‘obese’ individuals in Korea found that failed weight-loss attempts were associated with suicidal ideation in ‘obese’ women but not men. There was no effect in ‘overweight’ men or women.

In more detail:

What they did

Korea has the highest suicide rate of any OECD country. Unsurprisingly, suicidal ideation is a major predictor of suicide attempts, and over a-third of people who think about committing suicide later follow through. Researchers have previously explored the link between suicidal thoughts and  a number of health behaviours, health conditions, and sociodemographic characteristics, but few studies have looked at the role of weight status, and none have been conducted in adults.

The researchers used data from over 45,000 participants collected between 2008 and 2012 in the Korea National Health and Nutrition Examination Surveys. Interviews were conducted by trained medical staff and dietitians and height and weight were measured.  Participants also provided information about weight control efforts, age, gender, education level, income, household inhabitants, marital status, physical activity levels, stress awareness, alcohol consumption, depressive symptoms, perceived health, body image, and menopause status. The analysis was limited to participants aged 40 years and older who were classified as ‘overweight’ or ‘obese’ by standard BMI cut-offs for Asians (23-24.9 and >=25, respectively) and who had attempted to lose weight in the previous year. The final sample included 2439 ‘overweight’ and 4182 ‘obese’ participants. Weight change in the previous year was assessed – either weight gain, loss, or maintenance. Gain was further categorised into low (3-6kg), moderate (6-10kg), and high (over 10 kg). Weight control failure was defined as having gained weight during the year despite weight loss attempts.

What they found

Unsurprisingly, suicidal ideation was higher in poorer, unemployed individuals who were in poorer health. No significant findings appeared for engagement in moderate physical activity or whether participants believed their bodies were in the ‘slim/normal’ range or the ‘fat’ range. There was also no effect of weight control failure in ‘overweight’ men or women. In obese women, but not men, weight control failure was associated by a 70% higher risk of suicidal ideation (OR 1.7o, 95% CI 1.2-2.4) after controlling for all other collected variables. This was higher than the increased risk associated with perceived ill health (OR 1.38, 95% CI 1.0-1.9), but lower than for being low income (OR 2.12, 95% CI 1.4-3.3), highly stressed (OR 3.35, 95% CI 2.4-4.6), or depressed (OR 9.49, 95% CI 4.9-9.6). Having experienced menopause was also associated with a 65% increased risk of suicidal ideation in obese women.

In terms of raw numbers, just over 600 of the obese women in the sample had experienced failed weight control, or about 30%. 147 of these women (23.6%) reported suicidal ideation, compared with 285 (19.3%) of the women without failed weight control experiences (p=.02).

What it means

First, this study adds to the literature on factors associated with suicidal ideation in adults and is the first to link it with weight control failure. Before reading too much into this, a number of limitations should be noted. First, despite the very large original sample size, the numbers involved in the final analysis are relatively small. For example, there were 1323 women in the ‘overweight’ category, and only 310 of them experienced failed weight control. Of these, just 63 women (20.3%) reported suicidal ideation, compared with 168 (16.6%) of the non-weight control failure group. This may be one of the reasons that statistical significance was not achieved for ‘overweight’ women. The numbers were much closer for overweight men (10.8% versus 10.0% with and without weight control failure) and obese men (10.0% vs 9.3%, respectively).

Another possible limitation is the definition of ‘failed weight control’. From the reporting in the paper, it is unclear whether a distinction was, or could be, made between people who had gained weight subsequent to weight loss attempts, or if weight loss attempts had followed weight gain. There was also no information about the frequency or extent of previous weight loss attempts or weight cycling. And as always, the usual caution has to be taken when looking at cross-sectional data: it is impossible to tell from this kind of analysis whether people with weight gain became depressed and considered suicide or whether depression and suicidal ideation impacted on health behaviours and self-care and led to weight gain.

Having said all that, yet again, a disparity is evident in the relationship between weight and wellbeing in men and women. The authors correctly point out that this difference could be due to weight stigma, which is directed at women more often than at men, and is observed at lower levels of weight. Societal expectations for women to maintain a particular idealised slim physique, and negative judgments when they do not, have resulted in uneven application of punishment and suffering between the sexes.

The authors also note that in this middle-aged population, weight-gain associated with menopause may add to the psychological distress, and that ‘obesity’ rates have recently increased among women in this age group. And this brings me to the reason that I chose to write about this paper today. The proposed solution.

The authors suggest a number of potential solutions that supposedly support these women who may be at increased risk of suicidal ideation. These include supporting them into physical activity and weight management programmes, working to increase retention and adherence in the programmes, and health policy to provide hormone replacement therapy to avoid the weight gain in the first place.

This study therefore adds to my astonishingly vast collection of ‘obesity’ studies that are well conducted and provide interesting and important data, and totally miss the point in their conclusions when viewed through obesity-epipanic-tinted lenses. The solution to the harms of weight stigma should not be to get the victim to ‘fix’ themselves. Bullying, harassment, discrimination – it is not the target that is the problem.