Arya M. Sharma, MD

Today’s post is another excerpt from “Best Weight: A Practical Guide to Office-Based Weight Management“, recently published by the Canadian Obesity Network.

This guide is meant for health professionals dealing with obese clients and is NOT a self-management tool or weight-loss program. However, I assume that even general readers may find some of this material of interest.

SEASONAL AFFECTIVE DISORDER

Seasonal affective disorder (SAD) is a recurring depression with seasonal onset and remission. SAD primarily occurs in the winter months and it is postulated that the decrease in daylight hours alters circadian rhythms and affects melatonin and serotonin levels.

A number of factors distinguish SAD from major depressive disorder. Especially important here is that SAD is often associated with increased rather than decreased appetite.

There are two primary treatment modalities for SAD. Light therapy involves exposure to visible light that produces a minimum of 2,500 lux at eye level. Daily treatment duration depends on the intensity of the light: two hours a day are needed with a light emitting 2,500 lux, while 30 minutes a day is sufficient with 10,000 lux. Light therapy devices are readily available in specialty health-care stores and on the Internet. SAD can also be treated with pharmacotherapy using antidepressants in the same way one would treat non-seasonal depression.

To date, no study has demonstrated additional benefit from combining light therapy and pharmacotherapy.

© Copyright 2010 by Dr. Arya M. Sharma and Dr. Yoni Freedhoff. All rights reserved.

The opinions in this book are those of the authors and do not represent those of the Canadian Obesity Network.

Members of the Canadian Obesity Network can download Best Weight for free.

Best Weight is also available at Amazon and Barnes & Nobles (part of the proceeds from all sales go to support the Canadian Obesity Network)

If you have already read Best Weight, please take a few minutes to leave a review on the Amazon or Barnes & Nobles website.

Regular readers will appreciate the importance of mood as a driver of ingestive behaviour. While typically depression is associated with a loss of appetite, atypical depression can lead to increased cravings for “comfort” foods, especially those high in sugar and fat.

Depression is also well recognized as a major barrier to weight loss in that individuals with depression will appear less motivated, report lower energy levels, and have poor sleep patterns, all of which can in turn affect diet and physical activity.

So while depression can clearly drive weight gain and make weight management more challenging, a question often asked is whether weight loss will actually improve mood.

This question was now addressed by Anthony Fabricatore and colleagues from the University of Pennsylvania in a paper just published in the International Journal of Obesity.

The authors conducted a comprehensive meta-analyses of over 5971 articles, including 394 randomized controlled trials, regarding the relationship between weight loss and depression.

Thirty-one studies, in almost 8000 participants were included in the final analysis.

Comprehensive lifestyle modification was found to be superior for reducing symptoms of depression than control and non-dieting interventions.

Lifestyle modification was also marginally better in improving mood than dietary counseling or exercise-alone programs.

Of particular note (given my recent post on the nutritive benefits of exercise), exercise-alone programs were superior to control interventsions in reducing symptoms of depression.

Nearly all active interventions improved depression but there was no relationship between the amount of weight lost and the reduction in depression symptoms.

Health at every size (HAES) enthusiasts will likely argue that the improvement in mood has more to do with the active interventions (which include eating healthier and increasing physical activity) than with the actual weight lost - something that would be hard to argue with given that the amount of weight lost appears to have little impact on the actual improvement in mood.

Thus, rather than concluding that weight loss leads to an improvement in mood, it would perhaps be more accurate to conclude that lifestyle modifications AIMED at weight loss ALSO, on average, tend to improve mood.

This of course would not be hard to believe given the evidence that both dietary intake of certain (unhealthy) nutrients as well as increased physical activity can significantly decrease symptoms of depression.

Certainly, this study does not change my opinion that in many patients mood disorders need to be identified and addressed as a “root cause” of weight gain and that weight loss, without lifestyle change, is unlikely to improve mood.

Clearly the notion held by many of my patients, that they would be so much less depressed if only they could lose some weight, is not borne out by this data - rather I would suggest to them that a healthier lifestyle will probably improve their mood irrespective of whether or not they actually lose weight.

But of course, as always, I defer the last word on this to my readers…

AMS
Edmonton, Alberta

Fabricatore AN, Wadden TA, Higginbotham AJ, Faulconbridge LF, Nguyen AM, Heymsfield SB, & Faith MS (2011). Intentional weight loss and changes in symptoms of depression: a systematic review and meta-analysis. International journal of obesity (2005) PMID: 21343903

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