Depression is a common finding in overweight and obese patients trying to lose weight. So is obstructive sleep apnea.

Unfortunately, the symptoms of sleep apnea can mirror those of major depressive disorder: tiredness and low energy levels, lack of interest and motivation to pursue your favourite activities, trouble with concentration, memory or decision making, and weight gain.

A paper by Mitsunari Habukawa and colleagues from the Kurume University School of Medicine, Fukuoka, Japan, just published online in Sleep Medicine, reminds us to screen overweight patients who do not respond adequately to antidepressant therapy for sleep apnea.

The authors describe 17 patients, who, despite pharmacotherapy for depression, continued having signs of major depressive disorder and were diagnosed with sleep apnea.

After two months of CPAP treatment for sleep apnea, their depression scores significantly improved.

Improvement in depression scores paralleled the reduction in sleepiness.

The results illustrate that patients with depression, who despite adequate pharmacotherapy continue having residual symptoms, should be screened for sleep apnea and treated if found positive.

An important corollary to this is that overweight and obese patients presenting with sleep apnea, should perhaps also be screened for signs of major depression.

Given the close association between excess weight, depression and sleep apnea, it is probably wise to regularly screen all patients presenting for obesity treatments for both conditions.

While simply treating depression and/or sleep apnea in people with excess weight is unlikely to result in significant weight loss, when present, both conditions can pose important barriers to successful weight management and must therefore be adequately addressed.

AMS
Edmonton, Alberta

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Habukawa M, Uchimura N, Kakuma T, Yamamoto K, Ogi K, Hiejima H, Tomimatsu K, & Matsuyama S (2010). Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms. Sleep medicine PMID: 20488748

Chocolate, prepared from the seed of the tropical Theobroma cacao tree, contain alkaloids such as theobromine and phenethylamine, which have physiological effects on the body that include elevating serotonin levels in the brain.

Low levels of serotonin are linked to mood disorders and one of the primary action of antidepressants is to raise brain serotonin levels, thereby alleviating the signs and symptoms of depression.

It is therefore not unreasonable to ask the question whether some people who like to eat chocolate are really using it to self-medicate their depression.

This question was now addressed by Natalie Rose and colleagues from the University of California in a paper just published in the Archives of Internal Medicine.

In this paper, the researchers examined the relationship between chocolate consumption and depressed mood in 1018 adults (694 men and 324 women).

Participants who screened positive for possible depression had significantly more chocolate consumption (8.4 servings per month) than those not screening positive (5.4 servings per month) for depression.

In fact, those with the highest depression scores reported even higher chocolate consumption (11.8 servings per month).

Although the authors are very careful in pointing out that this correlation by no means implies causality, it is clearly consistent with the hypothesis that people with mood disorders are more likely to consume chocolate than those with no signs of depression.

This finding certainly corroborates my own, albeit anecdotal, experience that proper management of mood disorders often alleviates chocolate cravings in many of my patients.

As chocolates are one of the densest forms of energy commonly consumed (a single ounce of milk chocolate can contain 150 KCal), using chocolate to treat your depression is certainly a bad idea if you happen to also have a weight problem.

Tip to all clinicians: it may not be a bad idea to screen all patients reporting a particular liking for or excessive consumption of chocolate for an underlying mood disorder.

AMS
Edmonton, Alberta

p.s. Join my new Facebook page for more posts and links on obesity prevention and management

Rose N, Koperski S, & Golomb BA (2010). Mood food: chocolate and depressive symptoms in a cross-sectional analysis. Archives of internal medicine, 170 (8), 699-703 PMID: 20421555

Psychological and psychiatric assessment prior to bariatric surgery is an essential part of our current management model and is recommended by all current obesity guidelines. Indeed, there is little doubt that psychiatric diagnoses are relatively common in weight loss-seeking obese individuals. Specifically, the prevalence of binge eating disorder (BED) has been reported to be in the range of 25-40% of all individuals seeking bariatric surgery.

The general notion is that patients with significant BED should undergo cognitive behavioural intervention prior to surgery and that severe BED may be a contraindication to proceeding with any form of weight-loss.

However, contrary to this widely held notion, hard data confirming that the presence of BED is indeed a predictor of poor surgical outcomes is sparse. In fact, most published studies, suggest that weight loss results in BED patients may be as good (or in some cases even better) than in patients without BED!

Nevertheless, there appear to be some important caveats. Thus, in a new study by Sharon Alger-Mayer and colleagues from Albany Medical College, NY, published in this months edition of Obesity Surgery, weight loss outcomes in patients with severe BED (37 out of 157 patients), who managed to lose 10% of body weight prior to surgery and attended all follow-up consultations during the first 12 months following surgery, were similar to the outcomes in patients without BED over 6 years of follow-up.

Note: the two caveats are:

1) losing 10% of their weight prior to surgery and

2) attending all follow-up appointments.

The study of course did not include patients with BED, who did not lose 10% body weight prior to surgery or who failed to attend their follow-up appointments.

Incidentally, depression (Beck’s Depression Inventory) and poor quality of life (SF-36) likewise did not predict weight loss outcomes.

Overall, this study is consistent with previous shorter-term studies that did not find BED to be a negative predictor of surgical outcomes. Nevertheless, the authors still regard psychological and psychiatric assessment an essential part of patient work-up prior to surgery.

Thus, BED should not generally be seen as a contraindication to proceeding with gastric bypass surgery. Does the same apply to other types of surgery such as the gastric sleeve or gastric banding? We’ll have to wait for the appropriate studies.

In the meantime, at our centre, we continue to insist on regular attendance and demonstration of significant lifestyle changes that include diligent food journaling, regular planned exercise, strict attendance of all clinic appointments, and a minimum of 5-10% weight loss in all pateints prior to consideration for surgery (in addition, we insist on smoking cessation, elimination of all pop, juices and carbonated beverages, elimination of all junk foods and high-caloric snacks, and a sound understanding of the risks and benefits of the planned procedure) .

I guess it may be time for a randomized trial to determine if assessment and treatment for BED will help improve surgical outcomes or prove a waste of resources and an unwarranted barrier to sugery.

Till then, I believe it is advisable to err on the side of caution.

AMS
Edmonton, Alberta

Yesterday, I hosted another of my Bariatric Lunch Forums that can be viewed via the TeleHealth Network in Alberta.

My guest on the forum was Geoff Ball, Director of the Pediatric Centre for Weight and Health (PCWH) here in Edmonton. While the program focuses on family interventions, Geoff emphasized the importance of psychological issues (both in the kids and their parents) that often prove important promoters of weight gain and/or barriers to weight management.

Indeed, I have previously blogged about studies showing that mental health issues are common in overweight and obese kids and can be important predictors of obesity in adulthood.

Now a new obesity study by Rhonda BeLue and colleagues from Penn State University, PA, published in the latest issue of Pediatrics, examines the relationship between mental health problems and overweight in a nationally representative sample of US youth aged 12 to 17 years.

The study specifically focuses on whether the association between mental health problems and weight is moderated by race and ethnicity in the 2003 National Survey on Children’s Health data.

Compared with their nonoverweight counterparts, both white and Hispanic youth who were overweight were significantly more likely to report depression or anxiety, feelings of worthlessness or inferiority, behavior problems, and bullying of others. In black subjects, only the physician diagnosis of depression was more frequent in overweight kids.

The results of this study not only emphasizes the important need for assessing mental health problems when addressing overweight and obesity in kids, but also that this relationship may differ between ethnic groups.

As in the adult population, it appears more and more evident that the obesity epidemic is not just a matter of individuals and families making poor choices and not moving enough - clearly, the obesity epidemic is part of a much bigger mental health issue that is affecting vast proportions of society.

If I had to bet on what comes first (the chicken or egg question), I’d be placing my money on mental health issues.

I believe it is safe to predict that any approach to solving the obesity crisis without due attention to the much broader mental health problem is doomed to failure.

While clearly not all overweight and obese kids or adults have mental health problems; but for the ones that do, addressing these issues is key to managing their weight.

AMS
Edmonton, Alberta

Yes, we all know someone, who has lost a significant amount of weight and is keeping it off - all without drugs or surgery.

While these people definitely exist, they are rare indeed and always interesting people to study. This is exactly what the National Weight Control Registry (NWCR) has been doing for years - anyone, who has maintained at least a 30 pound weight loss for one year or longer can join the study. Currently over 5000 individuals are being followed, many of whom have lost considerable amounts of weight and are continuing to keep it off.

Although this registry is good evidence that long-term weight loss maintenance is indeed possible with lifestyle change alone, in reality, the vast majority of patients attempting lifestyle change will rarely keep the weight off. This is why, an increasing number of patients with severe obesity turn to surgery for help. Despite its risks and limitations, the likelihood for the average patient to substantially reduce their weight and keep it off with surgery is substantially higher than the success rate of lifestyle interventions alone.

So how are patients who manage to lose weight and keep it off different from those who need surgery to do the same?

This question was now studied by Bond and colleagues from Brown University, Providence, RI, USA, in a study just published in the International Journal of Obesity.

This study compared the amount of weight regain, behaviors and psychological characteristics in NWCR participants who were equally successful in losing and maintaining large amounts of weight through either bariatric surgery or non-surgical methods.

A total of 105 surgical participants were matched with two non-surgical participants (n=210) for gender, entry weight, maximum weight loss and weight-maintenance duration, and compared prospectively over 1 year.

Both the surgical participants and the matched non-surgical participants reported having initially lost around 56 kg and hving keept off at least 13.5 Kg over the last 5.5 years.

Over the year of the study, both groups (re-)gained a similar amount of weight (1.8 vs. 1.7 Kg). However, surgical participants reported less physical activity, more fast food and fat consumption, less dietary restraint, and higher depression and stress at entry and 1 year than the non-surgical group. In both groups, higher weight regain was observed in individuals with higher levels of disinhibition.

These findings suggest that weight-loss maintenance comparable with that after bariatric surgery can be accomplished through non-surgical methods with more intensive behavioral efforts.

In other words, obesity surgery appears to be more “forgiving” than lifestyle management alone, when it comes to weight maintenance. Thus, although the surgical participants exercised less, ate more fat and fast food, showed less dietary restraint and were more depressed and stressed, they were still able to maintain the same degree of weight loss as the succesful non-surgical NWCR group. I have little doubt that these same surgical patients would likely have done a lot worse had they relied on lifestyle change alone. This does not deny the fact that success with surgery also requires substantial and consistent changes in lifestyle.

My conclusion from this study is: Yes, some people can indeed lose significant amounts of weight and keep it off, but they need to exercise more, avoid fast food, display high dietary restraint and better not be depressed or stressed out (even then, there is some weight regain). For others, surgery may very well be a more realistic option.

AMS
Edmonton, Alberta