The Missing Piece in Weight Care: Integrating Mental Health and Medicine

Written by: Guest Contributor, Julie Kim, MD, a board-certified physician in Internal Medicine and Obesity Medicine.

Date Posted: April 27, 2026 10:20 am

The Missing Piece in Weight Care: Integrating Mental Health and Medicine

The Four Pillars of Obesity Medicine

The Obesity Medicine Association (OMA) emphasizes that comprehensive treatment to improve an individual’s health through weight loss involves the application of four essential pillars: nutritional counseling, physical activity, medication(s), and behavioral modification. These fundamental principles work in tandem and are of equal importance to a patient’s success. Three of the pillars are routinely addressed in a typical clinic visit; the fourth pillar, behavioral health, is not, and it may be the most important of them all.

The latest GLP-1 receptor agonists have altered the landscape of nutritional counseling due to the powerful effects on the reward center of the brain. Patients often describe a reprieve from the cacophony of “food noise,” which gives them the opportunity to undo long-standing eating habits that contribute to poorer health, and focus on fueling their bodies with nutrient-dense foods.

Once a patient reaches the weight maintenance phase, participating in physical activity becomes easier for many. Patients often become more active of their own volition once they experience relief from the physical forces, as well as the resistance of satiety hormone signaling. For those who are able-bodied, what was once an emotional, psychological, and physical barrier becomes a source of newfound pleasure, as the body reverts back to effectively regulating energy expenditure. The real benefits go far beyond weight loss; increased strength, greater endurance, and most of all, joy in being an active participant in their own lives and the lives of their loved ones, such as the ability to play with grandchildren or hike while on vacation.

A critical first step in the patient’s journey starts with the ability to recognize and address maladaptive behaviors. Yet, out of the four pillars, behavioral modification is the least objectively quantifiable discipline, which is less rewarding in the short term for patients, who often rely on numbers and figures to measure their progress. Additionally, it is a sensitive genre for many, who have to bravely face longstanding fear, trauma, self-blame, and shame so prevalent in those who struggle with weight. Compounding this issue is the reality of modern-day clinicians who must juggle time constraints and professional obligations while simultaneously delivering patient care.

While the popularity of weight loss medications has created a spotlight on this important and often overlooked health condition, those of us who treat patients struggling with disordered eating have increasingly recognized the need for a mental health provider to unpack the complex psychological barriers that contribute to a patient’s struggle with weight. The current setup in a traditional healthcare environment is not structured to tackle this need in its entirety. Therefore, it is not surprising that out of the four pillars, healthcare providers least successfully execute behavioral modification in their patients despite good intentions and universal acknowledgment that behavioral modification is fundamental to a patient’s progress.

Behavioral counseling requires consent and active participation from patients regarding deeply personal reasons why they struggle with disordered eating. This requires not only trust and rapport in order to succeed, but also the appropriate set of behavioral health tools applied at the right time. Weight is a complex, multifactorial chronic medical condition and a unique struggle for the human race, as our biology was primarily designed for survival in a scarcity environment. The mechanisms that helped us survive in the primitive days are maladaptive to modern-day society, where nutrition is plentiful and requires minimal energy expenditure to obtain. This mismatch creates a psychological struggle for many who battle their biological drive for survival at all costs, in a plentiful environment, without realizing it has nothing to do with willpower. Additional factors such as societal expectations, self-perception, and life experience add dimensions too nuanced to undertake in a standard medical visit.

A patient needs both traditional medical care for medications, referrals, and accountability, as well as recurring behavioral counseling to discover the underlying etiology of his or her disordered eating. This holistic approach maximizes the chance of long-term success.

Addiction, Fear and Trauma

In modern-day society, it goes without saying that one’s relationship with nutrition is much more than a means for nourishment. The act of eating or sharing food can elicit strong associations and memories, such as a loved one’s primary love language, family traditions, show of care or affection, socialization, celebrations (including religious ceremonies), and much more. The chemical alterations of ultra-processed foods are considered novel from an evolutionary perspective and exert a supraphysiologic response in the hedonic centers via neurotransmitters such as dopamine. Once this system is triggered, a positive feedback loop occurs between the reward and the learning and memory system. In the hunting and gathering days, this was beneficial as it reinforced behaviors that promoted survival. In modern-day society, it has become maladaptive.

A frequent comment from a patient during the initial consultation is, “I love food.” Other patients express the importance of breaking bread with their loved ones. Once, a former elite athlete now in her 60’s confessed that it was still hard to justify eating at every single meal, in the absence of strenuous physical activity at a level she was no longer capable of performing. These comments offer insight into the patient’s formative associations with food intake, and through behavioral counseling, can help identify the multifaceted layers that make up an individual’s eating habits. A patient-centered weight loss service should inform patients that their journey is expected to have ebbs and flows through trial and error, which can sometimes span many years. Patients must be reassured that eating habits are one of the toughest habits to break, as, since birth, they have been eating multiple times per day, and eating for reasons other than as a means for survival, with foods designed to trigger addiction and overconsumption. Due to the complex relationships that modern-day humans have with nutritional intake, it is not surprising that addiction and trauma can go hand in hand with disordered eating.

Trauma is a deeply human experience that can alter the trajectory of those who struggle with weight. In the book “What Happened to You?” by Dr. Bruce Perry, MD, PhD, a neuroscientist and child psychiatrist, he aptly illustrates how trauma is processed in the brain and how it can manifest in a patient who is triggered.

One example is that of a child named Jesse who experienced trauma early in life by his biological father, and again as a young child in foster care. Jesse’s coping mechanisms differed in these two scenarios, in order to help him survive, depending on the circumstances. As a baby and toddler, abuse by his biological father elicited dissociation, as he was too young and helpless to resist or defend himself. As a foster child abused by his foster parents, Jesse displayed a fight-or-flight reflex, as he was now old enough to push back or run away. When Jesse was thrown down the stairs by his foster father and ended up in a coma, the scent of the biological father’s t-shirt plummeted his heart rate to below 60 bpm, consistent with a dissociative response. The scent of his foster father’s t-shirt soared his heart rate up to 162 bpm, consistent with a fight-or-flight response.

This story illuminates an essential aspect of trauma: significant life experiences influence the neuronal circuits developing in the brain, creating strong, subconscious associations that initially act as a survival mechanism but become maladaptive later on. When a patient is triggered, the lowest part of the brain, the brainstem, reflexively goes into survival mode. This does not require participation from the higher functions of the brain, the cortex, where executive thinking, as well as the concept of time, occurs. This means that a patient will respond as if they are experiencing the trauma in that moment, even if it occurred decades ago. A trauma response, just like disordered eating, is a survival mechanism that has now become maladaptive. The similarities cannot be ignored.

Dr. Janet Tomiyama, PhD, an associate professor in the Department of Psychology at UCLA, and her colleagues illustrated why weight stigma drives the obesity epidemic and harms health. She hypothesized that patients experiencing weight discrimination would increase their cortisol levels. Her team conducted an experiment in which test subjects were invited to a shopping excursion, only to be told that their shape and size were not ideal for the chosen clothing, and that the items must be returned in good condition. Therefore, the study was “full,” and their participation was no longer necessary. Salivary cortisol was collected pre “manipulation” and 30 minutes after “stigmatization.” Results confirmed her hypothesis: the stigmatized group had an increase in cortisol levels, and the levels were incrementally higher in those harboring internal weight bias within themselves. It is well known that excessive cortisol levels secreted out of sync with the body’s natural hormonal cycle have deleterious effects on one’s weight and metabolic health. This study highlights the interaction between trauma and physiology, and shows the detrimental health consequences that a patient with disordered eating can experience due to weight stigma, leading to adverse metabolic effects.

Integrated Weight Care

            What would integrated care actually look like in practice? A medical clinician who manages medications, labs, and referrals. A behavioral health service that addresses underlying trauma, addiction, and disordered eating. Regular, recurring visits that incorporate behavioral counseling as a core aspect of treatment rather than a supplemental service. A collective group that understands weight as a chronic, multifactorial health condition shaped by biology, experience, and environment, and not as a failure of willpower. This model is not the standard of care today, although it should be. This is precisely the model that SpringSource Center hopes to convey, not just to patients, but to the medical providers caring for such patients.

As a co-founder and the child of Holocaust survivors, Dr. Susan McClanahan, PhD, applies both decades of clinical practice, as well as a personal understanding of generational and epigenetic components of trauma, in order to get to the heart of the matter and offer comprehensive support in a safe space, using the right behavioral tools. Patients deserve all of the resources available and a healthcare team that works in tandem to make this happen. A collaboration of the medical team and behavioral counselors of this magnitude is long overdue. If done well, it can make a monumental difference in a patient’s life in more ways than one, and increase the chance of long-lasting success.