Arya M. Sharma, MD

A few weeks ago, I read Lori Lansens’ bestselling book “the wife’s tale“.

The book tells the story of Mary Gooch, a 43 year-old woman with severe obesity, who lives her life in defensive, deflective blame, segregating herself in the small farming town of Leaford, Ontario.

When her husband dissapears on the eve of their 25th wedding anniversary, Mary abandons her comfortable position to take the next flight to look for him in California. Soon after arriving she loses her wallet and passport, which further complicates her situation.

With the help of some unlikely friendships that she makes along the way, Mary undertakes a journey of self discovery resulting in an amazing transformation. The deeply insightful story touchingly depicts the heart-wrenching daily reality of someone living with severe disabling obesity.

In an opening sequence, Mary describes how, as a nine year old, she heard her doctor whisper the word “obese” to her mother. Never having heard the word before, little Mary imagined that she was under the power of an “obeast”, a creature that had taken over her body and was manifesting itself in her starving gut.

As Lori Lansens, who hails from Chatham, Ontario, a rural community near the border to Detroit, notes in her self-penned author profile,

“I drove the curving roads of the Santa Monica Mountains thinking of the thousands of conversations I’ve had with women about loneliness, self acceptance, marriage, husbands, body image, food, denial, betrayal and more recently, encroaching middle-age. I thought about what it means to be a stranger, and how one can be transformed by circumstance, and as I found my own tribe of friends and settled into the new rhythm of a different life, the story of Mary Gooch unfolded.”

Although her biography makes no mention of any weight issues that Lansens herself may have experienced, she tells the story of many patients that I see in my clinic everyday.

Anyone who still believes that we will solve the obesity epidemic by simply telling people to eat less and move more should take the time to read this book - but my guess is that if you believe that the solution to obesity is as simple as eating less, then you may have little interest in a book which reveals uncomfortable layers of complexity to a problem for which there are no easy solutions.

If any of my readers have read “The Wife’s Tale”, I’d love to hear from you.

AMS
Edmonton, Alberta

Anyone who has ever taken high doses of cortisone is well aware of the profound effect of glucocorticoids on appearance and body weight.

Not only do patients on high doses of cortisone regularly develop a typical Cushingoid phenotype (with abdominal obesity, moon face and buffalo hump) but patients also develop a ravenous hunger and appetite with an often dramatic increase in food intake.

Given this impact of the glucocorticoid system on ingestive behaviour, it may be reasonable to ask whether genetic differences in this system can perhaps also play a role in eating disorders?

This question was now addressed by Cellini and colleagues from the University of Florence, Italy, in a paper just published online in Psychiatric Genetics.

The authors studied the distribution of various variants of the glucocorticoid receptor gene in 572 Italian patients: 118 patients with anorexia nervosa, 108 patients with bulimia nervosa, 62 patient with binge eating disorder, 177 obese non-binge eating disorder patients, and 107 unrelated, normal, age-matched controls.

While there were no significant relationships between any of the receptor polymorphisms and other eating disorders, there was a significant association between one variant (rs6198) and binge eating disorder.

In addition, irrespective of eating behaviour, individuals with another genetic variant of this receptor (N363S) tended to have higher a BMI.

While it is always wise to treat such findings, especially when they come from a single, relatively small study, with caution, these results are certainly compatible with the notion that the glucocorticoid system (perhaps not unexpectedly) may well play a role in the development of obesity and binge eating disorder (at least in a subset of patients).

Although it is highly unlikely that finding these genetic variants will lead to a genetic diagnostic test anytime soon, people with this problem may find some comfort in the idea that their genetic makeup may well be a factor that determines their susceptibility to this disorder.

Fortunately, binge-eating disorder is highly responsive to treatment, and professional psychological counseling (sometimes in combination with pharmacotherapy) can lead to the resolution of binge-eating behaviours in the vast majority of patients.

AMS
Montreal, Quebec

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Cellini E, Castellini G, Ricca V, Bagnoli S, Tedde A, Rotella CM, Faravelli C, Sorbi S, & Nacmias B (2010). Glucocorticoid receptor gene polymorphisms in Italian patients with eating disorders and obesity. Psychiatric genetics PMID: 20440229

Yesterday, the draft version of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released for public comment until April 20.

The book, which serves mental health professionals, is also used by insurance companies making decisions on treatment coverage and in courtrooms and schools. It was last revised in 1994.

From what I’ve been able to garner from the news wires, the new Manual now clearly lists and identifies binge eating but not obesity as a mental health disorder.

This is probably a good thing.

While there is no doubt that binge eating disorder is a syndrome that requires specific mental health intervention, the same cannot necessarily be said for all of obesity.

This is not to say that a large proportion of overweight and obese individuals may also have mental health problems ranging from poor body image to major depression, addictions or attention deficit disorder - I have often blogged about this before.

But clearly, not everyone with excess weight also has a mental health diagnosis and certainly not all overweight patients need to be seen by a mental health professional.

Indeed, as previously noted, obesity is really only the clinical manifestation of caloric excess, and is as such more a clinical sign than a discrete entity in itself. It would therefore make no sense to list obesity as a mental illness or to expect that all obese individuals must now seek help from a mental health professional.

Nevertheless, given the importance of mental health problems either as promoters and/or consequences of weight gain or as important barriers to weight management, having mental health expertise in a weight management program is absolutely essential.

I am sure that the DSM-5 will prompt a wide range of debates and discussions and I will certainly take a closer look at the relevant segments of this intimidating document.

The final version of the manual is due to be published in 2013.

Certainly appreciate comments from any of my readers who work in mental health.

AMS

Vienna, Austria

As blogged before, binge eating disorder (BED) can be diagnosed in as many as in one in four patients presenting in bariatric centres for weight loss.

Typical BED is characterized by frequent and persistent episodes of binge eating accompanied by feelings of loss of control and marked distress in the absence of regular compensatory behaviors. The disorder is associated with specific psychopathology (eg. dysfunctional body shape and weight concerns), psychiatric comorbidity (depression and anxiety disorders), and significant health and psychosocial impairments.

In my experience, the vast majority of patients with BED present with impressive histories of weight cycling, sometimes losing substantial amount of weight, only to soon gain it back. As do many obese patients, including those without BED, they fully believe that losing weight is the only solution to their often complex problems.

Just how futile weight loss attempts can be for patients with BED without primarily addressing the underlying psychopathology is nicely illustrated by Terence Wilson and colleagues from Rutgers University, New Jersey, just published in the Archives of General Psychiatry.

In this study, 205 women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED were randomised to twenty sessions of behavioural weight loss with moderate caloric restriction and exercise (BWL) or interpersonal psychotherapy (IPT) or 10 sessions of guided self-help cognitive behavioural therapy (CBTgsh) during 6 months.

At the end of the 6 month intervention, a substantially greater number of BWL patients achieved a 5% reduction in body weight (41%) than with IPT (15%) or CBTgsh (15%). At this time, all patients reported a similar reduction in binge-eating episodes.

However, two years later the picture looked quite different: while there were no longer significant weight differences between the groups (which means that the BWL patients regained virtually all the weight they lost), both IPT and CBTgsh were more likely to remain in remission from binge eating than BWL patients. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT.

Although there was no significant association between sustained remission from binge eating and percent change in weight, a significantly greater proportion (31%) of patients with sustained remission from binge eating during follow-up lost a minimum of 5% of their baseline weight compared with patients who were never in remission (10%).

Not only does this study clearly show that behavioural weight loss is substantially less effective in long-term control of BED than psychological treatments, it also shows that simply losing weight is not a solution. Indeed, because conventional behavioural lifestyle treatments generally focus on dietary restraint, they are far more likely to ultimately promote binge eating than reduce it.

Not surprisingly, the authors conclude that guided self-help based on cognitive behavior therapy should be a first-line treatment option for most patients with BED, with IPT (or full cognitive behavior therapy) used for patients with low self-esteem and high eating disorder psychopathology.

Clearly, simply joining the next weight-loss challenge is not the solution.

AMS
Edmonton, Alberta

Binge Eating Disorder (BED) can be diagnosed in around 20-40% of patients presenting with severe obesity in obesity programs.

This disorder is characterized by uncontrolled episodic consumption of large quantities of food, generally associated with psychological symptoms of guilt and despair.

Whether or not BED is also associated with physical symptoms is less well studied.

This question was recently examined by Cremonini and colleagues from the Mayo Clinic, Rochester, MN, USA published in last month’s issue of the International Journal of Obesity.

In a population-based survey of community residents through a mailed questionnaire measuring GI symptoms, frequency of binge eating episodes and physical activity level in 4096 subjects, 6.1% of whom reported BED symptoms, BED was independently associated with acid regurgitation, heartburn, dysphagia, bloating, upper abdominal pain, diarrhea, urgency, constipation and feeling of anal blockage.

From this study it appears that BED is significantly associated with both upper and lower GI symptoms in the general population, independent of the level of obesity.

This work has two important implications: firstly, patients presenting with GI symptoms should be questioned regarding BED; secondly, patients presenting with BED should be screened for GI symptoms.

AMS
Edmonton, Alberta