Lisa is a 32-year-old woman, mother of 3 children, prescribed citalopram by her primary care provider for a diagnosis of generalized anxiety disorder (GAD), who is referred to the nurse practitioner in her medical clinic, Mr. Norman, for help with weight loss . Lisa came to see her primary physician, Dr. Munn, for the first time in 3 years. Her weight, which had been 155 lb before her third pregnancy, is now 180 lb one year after the baby was born. At 5′3″, her body mass index (BMI) is 32. Lisa admits to Mr. Norman that she has had a hard time “losing the baby weight.” She describes eating many of the same foods her children eat (“it is what I have around!”), including macaroni and cheese and chicken nuggets. She is not sure what she could do to improve her diet. When asked about exercise, she says she’s “never been much of an exerciser” and also does not think she would be able to find time to do any. She lives in a small suburban community; the local gym is 30 min away in the next town. Elaborating on her history, she explains she has been “a little heavy” since adolescence, though she has progressively gained more weight that she has not been able to lose with each pregnancy. When asked about her emotional health, she explains that she tends to be “a worrier” and gets very anxious if she does not hear from her husband at least twice a day (“I know it is silly, but I worry something has happened to him—like a car accident or something!”). She describes frequent headaches and some difficulty sleeping when she is particularly stressed. She admits that she will turn to food sometimes when she feels a lot of anxiety, for example, going to the local fast food restaurant to pick up 2 burgers on her way to pick up her oldest child from school. Occasionally, when she cannot sleep, she will eat “a whole lot” of food (e.g., a box of the kids’ cereal, and half a box of cookies). This happens once or twice a month. She feels upset about it the next morning. She denies restricting calories or any efforts to compensate for her eating, such as vomiting or laxative use. She expresses a desire to lose “a few pounds,” but adds “I wouldn’t even know where to start!”

Preferred Diagnosis: Generalized Anxiety Disorder

Lisa is overweight but does not fulfill criteria for a feeding and eating disorder. With a BMI of 32, she is in the obese range [see Text Box: body mass index (BMI) for calculation and ranges]. She has gained excess weight in the past five years, going from the “overweight” range to the “obese” range. She occasionally eats more than would be considered a “usual” amount and regrets her intake, but this is not happening with the frequency or psychological features that would meet criteria for binge eating disorder (BED). She has concerns about her weight and a decline in self-confidence related to her body image, but does not engage in restriction of food or other inappropriate compensatory behaviors to lose weight. [See Chap. 3 for more discussion of clinical scenarios where weight, food, and body image are prominent without meeting criteria for a feeding and eating disorder].

With a few exceptions, weight gain occurs when there is an overall calorie surplus—essentially, ingesting more calories a day than the body is burning. This will happen when an individual begins eating more calories, or when calorie expenditure drops. Increased calorie intake is a purely behavioral issue—the person is either eating more food or eating higher density food (e.g., food with a higher percent of fat, which has double the calories per gram than the other macronutrients: carbohydrates and protein). Many things can cause a person to eat more calories, including, but not limited to, a change in available food choices (e.g., switching from one workplace where healthy food options were available for lunch to a new workplace with a cafeteria where mostly high-fat foods are served); interpersonal factors (e.g., beginning a new relationship where many activities involve going out to restaurants for meals and possibly ingesting more alcohol than usual); increased hunger or perceived hunger (e.g., due to a new medication); or other psychological factors (e.g., elevated stress due to work or social issues, leading to “stress-eating” or “emotional eating”). It is worth noting that even an increase in exercise—something that would be considered a positive change and potentially associated with weight loss —can lead some individuals to gain weight; a modest boost in calorie expenditure may lead to a compensatory increase in hunger, with the effect that the individual begins eating more additional calories than the extra exercise is burning.

Whatever the reason a person has begun eating more calories, if this is not balanced with an increase in calorie burning, the net effect will be weight gain. This process may be something the individual is conscious of, or something that will happen gradually and seemingly “mindlessly,” only to be noticed when the individual’s clothes no longer fit the same, or when he or she gets on the scale for the first time in a while and notices a difference. It has been estimated that the gain or loss of one pound of weight is equivalent to approximately 3500 kilocalories (kcal, commonly known as “calories”). An increase of even 200 kcal per day (e.g., the amount found in a typical can of soda) will lead to a calorie excess of 6000 kcal per month, with a weight gain of 20 lb over a single year.