Arya M. Sharma, MD

Before, I get into the promised review of the obesity papers in the January issue of the Canadian Journal of Psychiatry, I would like to set the stage by clarifying that I certainly do not consider obesity to be a mental illness.

Thus, I very much opposed the notion (proposed by some) to include obesity as a diagnosis in the the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders and was very much relieved to see this proposal being rejected.

Although the brain is the ultimate regulator of energy balance and there is a significant and relevant relationship between mental health and the propensity for weight gain (as will be discussed in forthcoming posts), obesity itself is hardly a mental illness. In fact, the vast majority of overweight and obese individuals do not have any mental health problems that would be in any form or fashion differentiate them from the non-obese population.

This situation, however, is markedly different in the ‘weight-loss-seeking’ obese population, where an increased prevalence of mental health problems has been well documented. This is why clinicians dealing with obese patients, particularly those seeking obesity treatment need to be well versed in the diagnosis and basic principles of managing mental health problems.

What is also indisputable is the fact that for patients with mental health problems, weight management can prove particularly challenging.

When we consider how difficult implementing and maintaining the often complex regimens for weight management can be for most people, it should be no surprise that adding the additional burden of mental illness can make such efforts almost impossible.

Add to this the fact that many of the psychiatric medications can further promote weight gain, and we can easily see why obesity has become such an important challenge in light of the increasing use of such medications (whether indicated or not).

Remember, that in this discussion we are talking about significant and major mental health problems like depression, bipolar disorder, psychosis, anxiety, PTSD, or addictions. We are not talking about simple ‘overeating’ associated with stress, boredom, social pressures, or other factors that have little to do with severe mental health problems and should rather be considered completely normal and natural human behaviours.

Thus, it is important that in any discussion of the clinically important relationship between obesity and mental illness, we make sure that we do not add the stigmal of the latter to the already widespread stigma of the former.

In other words, while mental health problems can undeniably contribute to or complicate obesity, let us by no means assume that everyone with excess weight must somehow have a mental health problem - the vast majority of overweight and obese individuals do not.

Nonetheless, clinicians need to be well aware of this relationship, be able to identify it where it exists, and provide or refer individual obese patients, for whom this may well be a problem, to the appropriate services.

I would certainly love to hear from any readers who have experienced that addressing their mental health issues did indeed help them better manage their weight or from readers where their mental health problems are making contributing to their weight gain.

AMS
Saskatoon, Saskatchewan

The January issue of the Canadian Journal of Psychiatry focuses on the close relationship between mental health problems and obesity.

The issue (just released online) features two review articles: One looks at the many links between obesity and chronic mental illness - as it turns out, a two-way street. The other reviews current approaches to improving obesity management in individuals with chronic mental illness.

The same issue also features an original article examining the relationship between abdominal obesity and cardiometabolic risk factors in kids with mental health problems - particularly in those who require treatment with new-generation antipsychotic medications.

In a guest editorial, I comment on the importance of understanding and addressing the links between these two co-epidemics. As regular readers are well aware, assessment for mental health problems has to be part and parcel of any assessment for obesity (the first of the 4Ms of obesity assessment).

When present, managing these mental health issues, more often than not, will be the lynchpin of successful weight management. Not addressing these issues will likely guarantee failure in weight management.

For readers, who do not have access to this journal, I will discuss these articles in more detail in upcoming posts.

AMS
Saskatoon, Saskatchewan

Dr. Sean Wharton, Burlington, Ontario

Readers may recall a recent post on a clinical trial by Wadden and colleagues on the feasibility of achieving clinically meaningful outcomes of ‘enhanced’ lifestyle counselling largely delivered by primary care practitioners with minimal training in obesity management. In that study, ‘health coaches’ (with no advanced expertise as one may expect from registered dieticians or exercise specialists), working under the guidance of a primary care physician, helped about 20-25% of patients achieve at least a 5% weight loss.

A paper by Sean Wharton and colleagues, published in the latest edition of the Canadian Family Physician, now presents ‘real-life’ data from a similar primary care approach in 2739 consenting patients attending an interdisciplinary obesity-management program in Burlington Ontario.

As described in the paper,

“The Wharton Medical Clinic (WMC) is an interdisciplinary bariatric clinic located in Hamilton and Burlington, Ont, which includes a team of physicians, behavioural therapists, dietitians, and nutritionists. The clinic operates under principles outlined in the Canadian clinical practice guidelines for the treatment of obesity, which recommend dietary, exercise, and behavioural interventions for weight loss, with meal replacement, pharmacotherapy, and surgery as adjunct therapies when indicated. Patient visits consist of services charged to the Ontario Health Insurance Plan, including physician visits, calorimetry, and diagnostic testing such as blood work and electrocardiography. Complementary services (drop-in visits in which patients weigh themselves and educational sessions) that are not charged to the Ontario Health Insurance Plan or to patients are also offered to allow for greater patient contact without increasing the cost to the health care system. As obesity is a chronic, relapsing medical condition, there is no defined program length.”

A key element of the program is the employment of ‘bariatric educators’, who have a university degree in nutrition, but no other formal training as health professionals. Under the guidance of the physicians, these bariatric educators deliver 20-minute educational sessions on nutrition and exercise to patients and monitor individualized weight-management strategies at each visit.

The paper presents the results of all 2739 patients as well as for the 1085 patients, who attended the clinic for at least 3 months, and the 389 patients, who attended for at least 6 months. The average weight loss in these groups were 2.3, 3.5, and 4.3 Kg, respectively.

Perhaps, more importantly, 17, 32, and 47% of patients achieved and maintained at least a 5% weight loss, whereas 4, 9, and 17% achieved a 10% weight loss, respectively.

Although these results may appear modest, it is important to note that these levels of adherence, retention, and ‘control’ are in fact very similar to what is seen with virtually every other chronic condition including hypertension, diabetes, or chronic respiratory disease and speaks to the general difficulties that many patients appear to have with the long-term adherence to chronic disease management programs in general, especially those requiring on-going frequent clinic visits.

Thus, as the authors note:

“As with many other chronic conditions, clinical goals and treatment outcomes for obesity management might not bring patients to “normal” levels. For example, the clinical goals for hypercholesteremia and hyperlipidemia, hypertension, and type 2 diabetes management do not return patients to levels observed in individuals without the conditions. In fact, up to two-thirds of patients are unable to meet clinical goal targets, highlighting the difficulty in managing chronic conditions. Thus, the proportion of participants achieving the targets of 5% to 10% weight loss at the WMC appears to be comparable with successes in the management of other metabolic conditions.”

This said, it is indeed notable that this ‘real-life example’ of a physician-run interdisciplinary publicly funded clinic (vs. the afore mentioned ‘clinical trial’ setting of the Wadden study) can help a substantial number of patients achieve clinically significant weight loss (almost 50% of patients who remained in the program for at least 6 months).

While this level of ’success’ may be well below what most patients normally expect (for e.g. from a commercial ‘weight-loss’ program), the health benefits of modest ‘therapeutic’ weight loss are well recognized and may perhaps be better sustainable than the much larger short-term weight-loss promised and targeted in many commercially driven ‘wehght-loss’ programs.

Obviously, as the authors note, it will be important to determine the effectiveness of this program beyond six months.

Nevertheless, this ’short-term’ real-life experience does provide some valuable insights:

For one, this paper demonstrates the potential value of bariatric educators (nutritionists), who provide education and dietary support.

As the authors note,

“The decision to engage nutritionists rather than registered dietitians in the program was based on the fact that although dietitians are highly qualified health professionals, their continuing engagement in a high-intensity program requiring ongoing follow-up visits is limited by availability and cost. In contrast, as demonstrated in this paper, bariatric educators, under the guidance of a physician, can provide an economical and effective approach to routine weight management in uncomplicated patients.”

In addition,

“Given the important relationship between frequency of follow-up visits and maintenance of weight loss, it appears prudent to offer self-directed walk-in weigh-in sessions in an unintimidating environment, which increases patient contact with the clinic and serves as a regular reinforcement of behavioural change.”

Future studies will also need to determine improvements in other relevant health outcomes including comorbidities and quality of life as well as cost-effectiveness of this approach.

Nevertheless, these initial observations certainly appear promising and may provide a model for other primary care practices considering weight-management interventions in their patients.

AMS
Toronto, Ontario

Wharton S, Vanderlelie S, Sharma AM, Sharma S, & Kuk JL (2012). Feasibility of an interdisciplinary program for obesity management in Canada. Canadian family physician Medecin de famille canadien, 58 (1) PMID: 22267637

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Regular readers will appreciate how environmental determinants can affect complex behaviours such as physical activity and eating behaviours.

New data on this topic is presented by Canadian Obesity Network Bootcamper Stephanie Prince and colleagues from the University of Ottawa in a paper just published in OBESITY.

The paper examines in considerable detail the relationships between variables from built and social environments and physical activity with excess weight across 86 Ottawa neighborhoods.

Individual-level data including self-reported leisure-time PA and other variables were analysed in a sample of 4,727 adults from four combined cycles (years 2001/03/05/07) of the Canadian Community Health Survey (CCHS) together with data on neighbourhood characteristics from the Ottawa Neighbourhood Study (ONS).

For women greater park area was associated with increased odds of leisure time physical activity as well as overweight/obesity. Also, greater neighborhood density of convenience stores and fast food outlets were associated with increased odds of females being overweight/obese.

Higher crime rates were associated with greater odds of leisure time physical activity in males, and lower odds of both male and female overweight/obesity.

Incidentally, this being Canada, it was perhaps not surprising that season was significantly associated with physical activity in men and women with the odds of leisure time physical activity in winter being half that of summer.

Based on these findings, the authors conclude that the impact of park area, crime rates, and neighborhood food outlets may has different effects on activity levels as well as the prevalence of overweight/obesity in men and women.

This may certainly be consistent with the notion that men and women interact differently with their neighbourhoods both in terms of activity as well as food choices.

AMS
Toronto, Ontario

Prince SA, Kristjansson EA, Russell K, Billette JM, Sawada MC, Ali A, Tremblay MS, & Prud’homme D (2012). Relationships Between Neighborhoods, Physical Activity, and Obesity: A Multilevel Analysis of a Large Canadian City. Obesity (Silver Spring, Md.) PMID: 22262164

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