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Running head: A NEW APPROACH TO TREATING OBESITY

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Treating obesity with the PERMA model of wellbeing, strengths, gratitude, and hope: A new approach

Swinburne University of Technology

Submitted as PSY30011 Major Project Unit Convenor: Toby Mizzi Due Date: 10 February 2020 Word Count: 5302

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Abstract Obesity, defined as an excessive accumulation of fat, affects over a third of the Australian population. It is associated with a number of high-risk diseases such as cardiovascular disease, musculoskeletal disorders and some types of cancers. Treatments such as diets, pharmaceuticals, and psychological interventions only seem to manage short term weight loss and fail to help patients maintain weight over the long term. Positive psychology may be a field that can assist with obesity, but to date has received little attention. Positive psychology is the scientist study of wellbeing and optimal functioning which focuses on positive emotions, human strengths, and enabling institutions. The aim of positive psychological interventions (PPIs) is to increased wellbeing by cultivating positive feelings, behaviours and cognitions. PPIs such as signature strengths, gratitude, and hope have shown to be beneficial in increasing life appreciation, confidence, personal resilience, and goal achievement – all areas considered to be lacking in obese people. This report outlines a proposed positive psychology intervention with the goal to build the psychological deficits found in obese people and increase their wellbeing. The intervention incorporates strengths, gratitude, hope, and elements of Wellbeing Theory: positive emotions, engagement, relationships, meaning, and accomplishment. The proposed intervention is 6month program that uses face-to-face and online delivery approaches to teach the positive psychology concepts and assign PPI exercises to participants.

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Contents Section 1: Introduction............................................................................................................4 Section 2 – Obesity...................................................................................................................6 What is Obesity......................................................................................................................6 Obesity Impacts......................................................................................................................6 Factors Contributing to Obesity.............................................................................................7 Obesity Treatments and Interventions....................................................................................8 Where to Next.......................................................................................................................10 Section 3 - Positive Psychology..............................................................................................11 What is Positive Psychology................................................................................................11 What is Wellbeing.................................................................................................................12 Positive emotions..............................................................................................................12 Engagement......................................................................................................................12 Relationships.....................................................................................................................13 Meaning............................................................................................................................13 Accomplishment...............................................................................................................13 How can Wellbeing be Increased?........................................................................................14 Signature Strengths...........................................................................................................14 Gratitude...........................................................................................................................15 Hope..................................................................................................................................15 Section 4 – Intervention.........................................................................................................16

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Intervention Rational............................................................................................................16 Participants...........................................................................................................................17 Recruitment..........................................................................................................................18 Delivery and Structure..........................................................................................................18 The Intervention...................................................................................................................19 Week 1 - Initial consultation.............................................................................................19 Week 2 – Positive Emotions and Gratitude......................................................................20 Week 3 – Engagement and Signature Strengths...............................................................20 Week 4 – Relationships.....................................................................................................21 Week 5 – Follow up consultation......................................................................................21 Week 6 – Meaning and Hope (Pathways Thinking).........................................................21 Week 7 – Accomplishment and Hope (agentic thinking).................................................21 Week 8 – PERMA & PPI Summary..................................................................................21 Week 9 – Follow up Consultation / summary of online classes.......................................21 Weeks 10 to 22 – Monthly consultations..........................................................................22 Week 26 – Final Evaluation..............................................................................................22 Measuring Success...............................................................................................................22 Intervention Exercises..........................................................................................................22 Intervention Measures:.........................................................................................................23 Conclusion...............................................................................................................................24 References...............................................................................................................................26

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Section 1: Introduction Obesity is defined as a condition in which an individual has an excessive or abnormal amount of fat. In 2017/18, 31% of the Australian adult population had a Body Mass Index of 30 or greater and were classified as obese. A drastic rise from 18.7% found in 1995. Obesity is associated with a number of noncommunicable diseases including cardiovascular disease, musculoskeletal disorder, some types of cancers, and Type 2 diabetes. Additionally, obese people are often discriminated leading to increase in mood disorders, anxiety, and reduced self-esteem. The impacts of obesity further extend to the Australian economy costing billions each year. Obesity is complex issue with a number of factors including environmental, biological, sociocultural, and psychology factors interact in varying degrees to promote the development of obesity, however, it is primarily a result of overconsumption of calories and reduced physical activity. Technological advances have led to a decrease in physical activity, and changes to food supply systems have led to the promotion of calorie-dense foods. Treatment for obesity include various diets, pharmaceuticals, bariatric surgery, as well as psychological interventions. Most interventions achieve initial weight loss, however, a common theme amongst many is that they fail to achieve long-term weight loss. A number of psychological assets required for long-term weight management are often lacking in obese individuals. These assets may be improved by using positive psychological techniques. Positive psychology is a field of psychology that looks at what is going well in life and how to build on it. While traditional forms of psychology have focused on fixing what wrong with a person, positive psychology aims to build on the positive aspects of human experience.

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Wellbeing is a central theme of positive psychology, and flourishing is considered the gold standard for measuring wellbeing. Wellbeing Theory proposes five elements that are required in order for people to flourish: positive emotions, engagement, relationships, meaning, and accomplishment (known as the PERMA model). A number of issues have been identified in obese individuals, including lower positive emotions and psychosocial functioning, impaired self-confidence and goal achievement. These findings suggest that they may be suffering from reduced wellbeing. A number of positive psychology interventions have been identified as having the ability to increase certain positive psychological assets, these include signature strengths, gratitude and hope. Using strengths has been linked to increases in wellbeing, personal resilience, self-confidence, and goal achievement. Individuals higher in gratitude tend to have a greater appreciation of life, able to utilize effective coping strategies, and have greater body image satisfaction. Hope has also been linked in effective coping strategies, goal achievement, as well as greater information seeking to manage conditions. Taken together, these findings suggest that obese individuals may be lacking in a few of the key areas described by Wellbeing Theory and using positive psychology interventions may help to increase assets in these areas. Based on these findings this reported proposes and positive psychology intervention for obesity. It incorporates the PERMA model of wellbeing and uses signature strengths, gratitude, and hope based techniques to help participates build and cultivate key areas. The goal of the intervention is to increase overall wellbeing which will in turn be reflected in more positive lifestyle decisions that will guide weight management. The interventions involves a combination of face-to-face consultations and online presentations focusing on the elements of PERMA incorporating strengths, gratitude, and hope over a 6-month period. Base line measures such as weight, wellbeing and lift satisfaction will be measured before, during

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and at the end of the intervention. Success will be measured by improvement in wellbeing, with a secondary goal being reduction in weight and healthier lifestyle choices. Section 2 – Obesity What is Obesity Obesity is defined as an individual who has an excessive or abnormal accumulation of fat which poses major health risks (World Health Organization [WHO], 2018). In the Australia adult population obesity has risen from 18.7% in 1995 to 31% in 2017/18 (Australian Bureau of Statistics [ABS], 2019). Obesity is commonly measured using the Body Mass Index (BMI), a BMI of 30 or greater is considered obese (National Health & Medical Research Centre [NHMRC], 2013). Obesity Impacts Being obese increases the risks associated with a number of noncommunicable diseases such as cardiovascular disease (heart attack and stroke), musculoskeletal disorders (osteoarthritis), some types of cancers (breast, prostate, and colon; NHMRC, 2013; WHO, 2018); type 2 diabetes, asthma, as well as problems with reproductive health (including miscarriage and infertility; NHMRC, 2015). In addition, society often hold negative views of obese people and they are often discriminated against, leading to increases in mood disorders, anxiety, and reduced self-esteem (Collins & Bentz, 2009). Studies have shown that, compared to normal weight populations, obese individuals report higher body dissatisfaction (Weinberger, Kersting, Reidel-Heller, & Luck-Sikorski, 2016), lower autonomy, and poorer environmental mastery (Mehar, Srivastava, & Tiwari, 2017). Due to the high association between obesity and a number of high-risk chronic illnesses it is linked to additional healthcare costs. In 2008, the impacts of obesity were estimated to have cost $58.2 billion to the Australian economy (Commonwealth of Australia,

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2009). This figure included direct costs relating to the treatment of obesity, as well as indirect costs associated with reduced productivity. Compared with normal weight populations obese individuals have lower overall wellbeing, higher sickness rates, higher unemployment benefits, lower workplace participation, and higher absenteeism (Commonwealth of Australia, 2009). Factors Contributing to Obesity Obesity is primarily caused from an imbalance between energy taken in (food eaten) and the energy expended (physical activity; WHO, 2018). Traditionally, obesity has been considered a consequence of bad food choices and behaviours relating to reduced physical activity (Brennan, Bray, Frühbeck, Ryan, & Wilding, 2016). However, environmental, biological, sociocultural, and psychological factors interact in varying degrees to promote the development of obesity (Brennan et al., 2016; Wright and Aronne, 2012). Technological advances, such as automobiles, escalators and other labour-saving devices (remote controls, automatic door openers) has reduced physical activity levels (Meldrum, Morris, & Gambone, 2017). Increased options in television viewing, video games, and the online world of socialization, entertainment and shopping, means that many people can meet all their needs within the confines of their homes and further reduces physical activity physical (Meldrum et al. 2017; Albuquerque, Nobrega, Manco, & Padez, 2017). Changes to food supply systems has increased the availability of cheap, processed foods high in saturated fats, salt, and sugar (NHMRC, 2013; Wright & Aronne, 2012), and humans are biologically engineered to seek out these types of foods (Dobbs & Manyika, 2015). Following centuries of food insecurity, humans have evolved to have a biological ability to cope with food scarcity, hormones encourage the body to seek out energy-dense foods and conserve energy as fat for when food is scarce. With a rapidly changing world,

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food is in abundance in Western society and this biological process has not had the chance to evolve and people continue to seek out these readily available calorie-dense foods (Dobbs & Manyika, 2015). The relationship people have with food goes beyond basic sustenance. Evidence suggests that food intake increases when in the presence of others (Faith & Kral, 2006). de Castro and de Castro (1989) suggests that physiological signals relating to appetite and portion sizes are hindered by social interactions. Further, individuals who are suffering from a psychological factor may find it harder to control their food intake. When a person is feeling sad, stressed, lonely, or frustrated food is often used as a coping mechanism (Collins & Bentz, 2009). Obesity Treatments and Interventions Most obesity interventions typically focus on physical factors such as reducing weight and increasing physical activity with success usually measured by the amount of weight lost (Peckmezian & Hay, 2017). Diet-based interventions typically involve low calorie (energy deficit) diets and are one of the most common weight loss methods used (Dayan, Sforzo, Boisseau, PereiraLancha, & Lancha, 2019). Dayan et al. reported that these types of interventions may help with initial weight loss, however, 90% to 95% regain all, if not more, weight in the long term. Food restriction tends to trigger changes to certain bodily functions that promote weight gain and should be avoided (Dayan et al., 2019). Further, research shows that diets are hard to maintain over the long term and rely on continued motivation from the dieter (Peckmezian & Hay, 2017). Certain pharmaceutical medications can also assist with weight loss, however, they are not recommended to be used long-term and studies show that once medication ceases so

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does weight loss (Peckmezian & Hay, 2017). Long term weight loss is reliant on continued lifestyle changes. Bariatric surgery, such as gastric sleeve, and gastric by-pass has become increasingly popular choice for high risk obesity patients. The surgery involves making changes to the stomach to reduce food intake and calorie absorption. It is considered to be one of the most effective weight loss treatments available to extremely obese patients (NHMRC, 2013). However, like most interventions, the success of bariatric surgery is dependent on the patient adhering to lifestyle changes, in addition, it is high invasive and expenses (NHMRC, 2013; Peckmezian & Hay, 2017). Behavioural therapy (BT) and cognitive behavioural therapy (CBT) are two common psychological techniques used to treat obesity. BT aims to change maladaptive eating patterns and exercise habits by teaching new behaviours (Wing, 2002). CBT is similar to BT, but also incorporates cognitive techniques. There is substantial evidence supporting the use of BT in obesity treatment (Wing, 1998). However, individuals who initially succeed at losing weight while using BT ultimately succumb to environmental factors of obesity once treatment ends (Drewnowski & Rolls, 2005). Studies have shown that cognitive strategies were not effective as stand-alone treatments, with most individuals regaining the weight lost within a year of the treatment ending (Shaw, O’Rourke, Del Mar, and Kenardy, 2015). Motivational interviewing (MI) is a client-centred counselling approach which aims to address client’s ambivalence in order to strengthen motivation and behaviour change (Miller & Rollnick, 2013). A systematic review by Barnes and Ivezaj (2015) showed that MI was successful in assisting patients to lose weight, with over a third of the 24 random control studies reviewed showing improvements in weight of about 5%. However, more than half the studies showed no improvements in weight loss compared to control groups.

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Where to Next Despite a number of treatments available for obesity, many fail to achieve long-term weight loss. Long-term results are reliant on the individual adhering to continued lifestyle changes. Lack of motivation and poor adherence to lifestyle changes are two of the main reasons people fail to achieve long term weight maintenance (Teixeira, Silva, Mata, Palmeira, & Markland, 2012). Currently, weight loss surgery, and weight-loss medications are the most commonly recommended treatments for highly obese people. While these treatments may be effective with weight loss, they are associated adverse effects and can be costly (NHMRC, 2013). Less invasive effective long-term strategies need to be found. A possible consideration for why most treatments are effective for long-term weight maintenance because they are often generic and fail to recognise that each individual is unique with their own barriers that may prevent them from achieving long-term weight goals. Given the range psychological deficits found in obese individuals...