Dr. Sharma's Obesity Notes

Yesterday, the popular media threw a hissy fit after Christina Aguilera was first reported by US Weekly to have told Billboard magazine that she is through with being a “skinny white girl” (or words to that affect), which Billboard magazine then said never happened, leading to a retraction by US Weekly and other outlets that picked up this quote.

More interesting than the ‘who-said-what-to-whom’ episode are the comments left on Billboard magazine’s website.

Here are two examples of the diametrically opposing views on this issue:

“Mac: Oh COME ON!!…she was never “skinny”…she had a PERFECT body. But now she’s just plain FAT! Face it Christina, you got lazy, stopped working out, and have just been stuffing your face with junk food. And now this is your B.S. way of justifying it.”

“Linda: She looks great. Big ups Christina!!!! I love how she is embracing her body at its natural state for her at this point in her life. We need more women in the limelight to do just that, it frees society and humans to be themselves and happy. Haters are gonna hate. Love will eventually set us all free.”

These comments pretty much sum up the public discourse on body weight.

One camp thinks it is all self-inflicted (lazy, stuffing your face), the other is in the positive body image size-acceptance (embracing her body, natural state, good for you) camp.

Like it or not, these discussions in the context of Christina Aguilera’s (or for that matter any celebrity’s) shape and size, do more to shape the public discourse and perception of what body weight may or may not be, than any academic discussions that we may be having about this issue at public health agencies or elsewhere.

Ignoring this discourse means being irrelevant – you cannot influence a discussion if you refuse to join it.

AMS
Edmonton, Alberta

Caroline Rothstein Performing 'Fat'

The following (e-mail readers will have to head to the site to see this) is a short poem called “Fat” by Caroline Rothsteiin, a 29-year old spoken-word poet and writer who lives in New York.

This raw and personal poem, in which Rothstein describes her struggles with her bulimia and body-image issues, was ‘discovered’ by Lady Gaga and has since received over 30,000 hits on YouTube.

As anyone moved by this piece will appreciate, the power of art (in this case a poem) to change heads and hearts is far greater than any scientific study that I could ever hope to publish.

Please feel free to repost this video so that others can see it – appreciate your comments.

AMS
Edmonton, Alberta

Earlier this month, the Canadian Obesity Network, in partnership with IASO and CAMH, released the Toronto Charter on Obesity and Mental Health.

Although the Charter acknowledges the importance of recognising the rather close relationship between obesity and mental health both in adults and children, the focus of this Charter (and the conference leading up to it) was largely on adults.

Now, Shelley Russel-Mayhew (U of Calgary), who spoke a the Toronto Obesity and Mental Health Conference, and colleagues, publish a comprehensive overview of mental health, wellness and childhood overweight and obesity in the Journal of Obesity.

The researchers performed a systematic literature search of peer-reviewed, English-language studies published between January 2000 and January 2011 on this issue. They identified 759 unique records, of which 345 full-text articles were retrieved and 131 articles included in their analyses.

Based on these findings, they propose a theoretical model that reflects the current state of the literature and includes psychological factors (i.e., depression and anxiety, self-esteem, body dissatisfaction, eating disordered symptoms, and emotional problems); psychosocial mediating variables (i.e., weight-based teasing and concern about weight and shape), and wellness factors (i.e., quality of life and resiliency/protective factors).

Based on their findings, they recommend a number of possible solutions to addressing the rise in childhood obesity rates without (importantly!) further marginalize overweight and obese children and youth.

These include increasing mental resilience, stopping the focus on weight, recognising that many weight-related issues are socially constructed and maintained, promoting healthy body images (regardless of size or shape), and targeting positive adult role models.

Thus, the authors conclude that,

“…intervening for the psychosocial emotional health of overweight/obese children should be a focus in and of itself and not just an “add-on” measure to a primary outcome that is targeting weight reduction or the cessation of weight gain. Public health policy in the area of childhood obesity needs to encourage healthy body image, advocate that healthy behaviours come in every shape and size, and consider weight bias and weight and shape concerns as fundamental. In terms of mental health and wellness, this type of shift in paradigm could benefit all children and youth potentially for generations to come.”

Readers will find many of these thoughts reflected in the Toronto Charter and will certainly recognise many of these principles in many of the posts throughout these pages.

AMS
Edmonton, Alberta

Russell-Mayhew S, McVey G, Bardick A, & Ireland A (2012). Mental Health, Wellness, and Childhood Overweight/Obesity. Journal of obesity, 2012 PMID: 22778915

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The 3rd and final day of the Hot Topics Conference on Obesity and Mental Health focussed on the potential obesogenic side effects of medications commonly used to manage mental health disorders.

As pointed out by Rohan Ganguli (Toronto), persons with schizophrenia, bipolar disorder, and other psychotic illnesses, have rates of obesity 2-3 times that of the general population. They also have 2-3 times the rates of diabetes, heart disease, and premature mortality, when compared to the general population. The increased prevalence of these chronic conditions are due to multiple factors, but it has become clear that certain antipsychotics, particularly some of the newer antipsychotics, mood stabilizers, and antidepressants, contribute to the increased risk of obesity. His presentation provided a succinct overview of the evidence from controlled clinical trials regarding the risk of weight gain for different psychotropic medications. He also proposed prescribing strategies, which would minimize the exposure to these risks. This presentation was nicely complemented by Tony Cohn’s (Toronto) talk on the importance of metabolic monitoring for adults prescribed antipsychotic medications

This problem, unfortunately, is also relevant in the treatment of mental health disorders in kids. In her presentation on the Canadian Guidelines on Monitoring and Management of Metabolic Side Effects of Second Generation Antipsychotic Medications in Children, Tamara Pringsheim (Calgary) discussed the considerable evidence that second generation antipsychotic medications are associated with metabolic side effects in children, including weight gain, increased waist circumference and body mass index, as well as elevations in cholesterol, triglycerides, glucose and insulin levels. These metabolic complications can have long-term adverse effects on cardiovascular health. With the more widespread use of antipsychotic medications in children, there is a need for formal guidelines on how to monitor children for adverse effects of these medications.

The Canadian Alliance for monitoring Safety and Effectiveness of Antipsychotic medications in Children (CAmESA) guidelines seek to provide health care providers with evidence based recommendations on what, when and how to monitor children started on an antipsychotic medication for metabolic and extrapyramidal side effects. Companion guidelines have also been created which provide evidence based recommendations on the management of metabolic and extrapyramidal side effects if they are detected over the course of monitoring drug safety in kids.

The considerable problem of obesity and mental health in the Aboriginal population was discussed by Piotr Wilk from London, Ontario.

The issue of first doing no harm, especially in public messaging about obesity, was addressed by Gail McVey (Toronto). She noted that in our quest to prevent childhood obesity it is imperative that we avoid the costly mistake of triggering the competing public health issues of disordered eating, weight-related bullying and associated depression, anxiety and social exclusion. Professionals need to capitalize on opportunities for greater integration by agreeing to adopt a common set of child and youth health indicators and to settle on an integrated approach to prevention across the broad spectrum of weight-related problems. nowhere is this common vision more important than in the messaging delivered to children and youth about healthy weights.

Similarly, as pointed out by Annick Buchholz (Ottawa), dialogue between researchers and clinicians from the fields of eating disorders and obesity can take advantage of evidenced-based frameworks and key treatment approaches from the field of eating disorders and discuss its applications to working with individuals and families struggling with weight management issues. Treatment approaches such as externalizing the problem, promoting positive body image, de-emphasizing weight as a goal in treatment, understanding ambivalence, and working closely with families in treatment are all important approaches to this problem.

On a slightly different note, Peter Selby (Toronto) discussed the potential learning from tobacco prevention. Given that behaviours are determined by the net effects of the current and embodied opportunities and constraints in global, macro, mezzo, and micro environments interacting with biological and psychological abilities of the individual, disorders of consumption such as smoking and excess eating share common pathways and are modifiable through policy and clinical interventions. High reach interventions focussing on policy and legislation are likely to have a bigger impact on health than only a high risk approach to obesity. However, mitigation of unintended consequences of such measures must also be considered in order to prevent disparity in the disease burden.

Thus, after 3 days of intense presentations and discussions, I believe that the participants left with a much better appreciation and understanding of the links and commonalities between obesity and mental health.

I, for one, certainly felt very pleased to see many of the concerns and approaches discussed by the participants at this conference, nicely reflected in the 5As of Obesity Management.

Presentations from this conference are available for download here.

AMS
Edmonton, Alberta

On the day 2 of the Hot Topics Conference on Obesity and Mental Health, Zul Merali and Alfonso Abizaid from the University of Ottawa (working as a tag team) discussed the importance of stress as a driver of overeating. They described a a fascinating possible role of ghrelin as an important mediator that allow organisms to meet the energetic challenges of stress (which generally does require the organism to spend more energy).

Thus, ghrelin, a hormone that increases hunger and adiposity, is not only secreted when energy stores are low, but also in response to stressors. Chronic stress leads to chronically elevated levels of this hormone in tandem with increases in appetite and weight gain. These effects are prevented by pharmacological blockade of ghrelin receptors and are absent in mice with targeted mutations to the ghrelin receptor. These ghrelin receptor deficient mice, however, are more susceptible to stress-induced depressive like behaviors. Thus, although ghrelin response to stress may induce hunger and overeating, organisms that do not (or cannot) elicit this response may be more likely to develop depression like symptoms in the face of stress.

Shelly Russell-Mayhew (U Calgary) spoke on body dissatisfaction and weight and shape concern, two components of body image that have particular relevance for obesity and mental health. Body dissatisfaction is a consistent correlate of obesity in youth. While this may well be seen as a negative consequence of obesity, it is also important to recognise that body dissatisfaction often leads to dieting/unhealthy weight control practices. In youth, dietary restraint, or the vigilant restriction of caloric intake, in turn is associated with obesity and is predictive of future weight gain. Overweight children are even more concerned about weight than their normal-weight counterparts and normal-weight children with high weight and shape concern report higher body dissatisfaction and depressive symptoms. A focus on the promotion of healthy body image for children of all weight statuses could reduce the impact of multiple negative psychological outcomes. This is particularly important because of evidence that perceived weight rather than actual weight is more predictive of psychological distress and body satisfaction predicts less weight gain over time.

Ronnie Kolotkin, the developer of the Impact of Weight on Quality of Life questionnaire (IWQoL-Lite), a widely used questionnaire that assesses quality of life in obese persons and has been translated into over 60 languages, emphasized that assessing quality of life in obesity may be just as important as, or even more important than, measuring body weight or body mass index.

Other presentations on Day 2 included talks by Nick Finer, UK, on the potential role of gut hormones for treating obesity, Teodor Grantcharov (Toronto) on surgical treatments for obesity, Valerie Taylor (Toronto) on pregnancy and the post-partum period as windows for obesity and mental illness, Michael Vallis (Halifax) on the use of motivational interviewing, Anthony Fabricatore (Pennsylvania) on predictor of weight loss response in bariatric surgery, Rohan Ganguli (Toronto) on the potential and limitations of behavioural interventions for weight loss in psychiatric patients, Fannie Dagenais (Montreal) on efforts to change social standards on weight and body image, and Mary Forhan (Hamilton) on the factors that contribute to engagement in every day life of people living with severe obesity.

Overall, a most interesting a day, that ended with a plenary engagement of the participants in drafting the Toronto Charter on Obesity and Mental Health, which will be officially released in the coming days.

AMS
Toronto, Ontario