Dr. Sharma's Obesity Notes

Regular readers will recall that in the 4Ms of Obesity Assessment, the first M refers to mental health. This is because uncontrolled mental health problems can can make weight management difficult – but not impossible.

This is the finding of a paper by Daumit and colleagues published in the New England Journal of Medicine.

The investigators randomised 291 overweight or obese adults (mean BMI 36) from 10 community psychiatric rehabilitation outpatient programs to tailored group and individual weight-management and group exercise sessions or a control intervention.

Of the participants, 58% had schizophrenia or a schizoaffective disorder, 22% had bipolar disorder, and 12% had major depression.

Over the 18 months of the trial, weight loss in the intervention group increased progressively and differed significantly from the control group at each follow-up visit – the mean between-group difference was about 3 Kg at the end of the trial with almost 40% of participants in the intervention group losing 5% of their initial weight (vs. 22% in the control group).

These effects are very much in line with the expected benefits of such a behavioural intervention in previous studies in people without mental illness.

Thus, behavioural weight-loss interventions can significantly reduce weight even in people with severe mental illness. Or, as the authors put it,

“….our results show that overweight and obese adults with serious mental illness can make substantial lifestyle changes despite the myriad challenges they face. “

Given the fact that obesity and mental health problems often co-exist and people with severe mental health issues are at high risk of weight gain, mental health programs should encourage and support weight management interventions in their clients.

AMS
Edmonton, AB

Daumit GL, Dickerson FB, Wang NY, Dalcin A, Jerome GJ, Anderson CA, Young DR, Frick KD, Yu A, Gennusa JV 3rd, Oefinger M, Crum RM, Charleston J, Casagrande SS, Guallar E, Goldberg RW, Campbell LM, & Appel LJ (2013). A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness. The New England journal of medicine PMID: 23517118

Concluding this brief series on the neurobiology of resilience, based on the paper by Bart Rutten and colleagues from Maastricht University, published in Acta Psychiatrica Scandinavica, I turn my attention to the relevance of these findings for clinicians working in the area of obesity.

Regular readers of these pages, will no doubt be aware of the considerable influence that our thinking patterns and ability to deal with the stressors and adversities of life have on our eating behaviours.

The greater our susceptibility to these stressors and the more “negative” our emotional and cognitive responses, the greater our risk to reach for “comfort” food. No amount of “education” on “healthy eating” will stop this  - as I say in my talks ,  ”You don’t treat alcohol addiction by handing out a drinking plan”.

To summarize the findings from the previous posts:

There is now considerable evidence both from animal and human studies that link resilience to the stress and reward system of the brain.

Early life events, particularly in the area of attachment, trauma (emotional, physical, sexual abuse or even just emotional neglect) or social defeat can result in a sensitized stress system, that leads to an exaggerated stress response in later life. This increased susceptibility appears to be mediated by molecular (i.e. epigenetic) changes in the brain particularly in the genes of the HPA axis and the mesolimbic dopaminergic reward system.

Fortunately, these negative influences can be reduced through positive emotional experiences and finding meaning and a purpose in life. Thus, meditation and spirituality can activate the reward systems in a manner that counteracts the impact of traumatic experiences.

With regard to stress sensitivity, the authors make an important point, namely that increased stress-sensitivity does not preclude experiencing rewards or enjoyment in daily life. In fact, the ability to feel such enjoyment and increased stress-sensitivity appear to be largely independent of each other.

Not only does this speak to the fact that enjoyment and stress-response are mediated by different underlying factors, but it also implies that,

“People can be vulnerable in terms of their tendency to be stress reactive, but also protected from this vulnerability trait in the face of strong tendencies to experience positive emotions in daily life (i.e. from pleasant events or sense of meaning) which buffer stress, prevent future psychopathology and increase mental health.”

“Thus, it seems that the experience of positive emotions has a distinct and more central role in resilience defined as the successful adaptation, swift recovery and psychological growth in the face and recovery phase after exposure to severe adversities, while the stress-response systems appears to mainly mediate vulnerability to stressors.”

Based on the finding that positive emotional experiences and purpose in life are important in counteracting the negative impact of trauma and adverse experiences on resilience, practitioners can recommend and perhaps offer interventions that increase the experience of positive emotions.

These can include meditation and mindfulness techniques not unlike those of religious practices, such as praying, counting one’s blessings and finding oneness with God or humankind.

Other factors such as finding work-life balance, cultivating friendships or hobbies, volunteering for community work, and other forms of positive engagement (even just offering to help your neighbour’s kid with his homework or coaching a baseball team) can perhaps help strengthen resilience thereby reducing the susceptibility not just for mental and physical ailments but for tackling maladaptive eating behaviours – a prerequisite for successful weight management.

AMS
Zurich, Switzerland

Rutten BP, Hammels C, Geschwind N, Menne-Lothmann C, Pishva E, Schruers K, van den Hove D, Kenis G, van Os J, & Wichers M (2013). Resilience in mental health: linking psychological and neurobiological perspectives. Acta psychiatrica Scandinavica PMID: 23488807

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Following our discussion of the importance of attachments and experiencing positive emotions in the development of resilience, we now turn to the importance of having a purpose in life, the third factor discussed in the paper by Bart Rutten and colleagues from Maastricht University, published in Acta Psychiatrica Scandinavica.

As one may expect, experiencing a sense of meaning and purpose in life goes a long way in promoting resilience.

“A sense of life purpose may literally keep us alive. Victor Frankl, a concentration camp survivor and psychiatrist, developed a theory predicting the survival chances of his inmates by observing their capacity to find meaning in their current situation. Frankl proposed that any situation can be one in which people find meaning and life purpose, but that psychological problems occur when the search is not successful.”

In contrast, lack of purpose is associated with increased risk of suicidal ideation.

This sense of purpose, which overlaps conceptually with the “Sense of Coherence” measures the extent to which

i) people feel that they understand the things that happen to them,

ii) the extent to which they see solutions to problems and

iii) the extent to which their daily life is a source of personal satisfaction.

Not surprisingly, purpose in life that emanates from religious and spiritual involvement, has also been associated with greater resilience. As the authors point out,

“There is some evidence for an association between spirituality and post-traumatic growth, which can possibly be explained by a well-succeeded search for meaning following trauma in highly spiritual individuals.”

“Thus, religious beliefs may provide a sense of meaning and purpose during difficult life circumstances. The conclusion that religion serves as a ‘pervasive and potentially effective method of coping for persons with mental illness’, warrants its integration into psychiatric and psychological practice.”

On the other hand,

“The current trend of secularization may go hand in hand with decreased population resilience to difficult periods. Therefore, it becomes important to focus on additional sources of sense of meaning and life purpose. Sense of meaning and life purpose is something very person specific and therefore different from behavioural patterns, for which therapists can provide concrete pieces of advice for modification.”

“However, indirectly, prolonged meditation or mindfulness training, in which people are trained to continuously focus their attention to the present moment, may result in increased awareness of meaning and purpose experienced in daily life situations.”

In neuroimaging studies,

“A state of prayer or sense of union with God or mankind was found to be associated with the activation of several brain areas, under which the left dorsal anterior cingulate cortex, the caudate and the orbitofrontal cortex. These are areas that are also implicated in the brain reward system.”

Thus, the authors speculate that,

“Every time that people experience sense of meaning in their everyday lives they likely experience strong positive feelings. The continuous availability of internal rewards may make people less dependent on the short-lived external rewards in daily life and may thereby facilitate a healthy level of positive emotions also in the context of adversity.”

Purpose in life is of course also fostered by being in a positive social environment – family, peers, school, community – all can promote a positive outlook and nurture positive goals that will increase resilience.

Although some medical practitioners may feel that discussions with their patients about purpose in life may lie well beyond their scope of practice, we must certainly recognise that lack of purpose can significantly increase the risk for physical and mental problems in our patients.

AMS
Edmonton, AB

Rutten BP, Hammels C, Geschwind N, Menne-Lothmann C, Pishva E, Schruers K, van den Hove D, Kenis G, van Os J, & Wichers M (2013). Resilience in mental health: linking psychological and neurobiological perspectives. Acta psychiatrica Scandinavica PMID: 23488807

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Yesterday, I discussed the importance of secure attachments in early-life  for developing resilience.

The second key positive predictor of resilience according to the paper by Bart Rutten and colleagues from Maastricht University, published in Acta Psychiatrica Scandinavica, is having positive emotional experiences

Having genuinely positive emotions (rather than just fewer negative emotions) has been found to predict better mental health and recovery from depression. Moreover, positive emotions have been associated with better stress tolerance.

Although there is a fair amount of heritability (h2 = 0.60), societal influences, particularly gender socialisation can be important modulators of positive emotional experience.

“Part of the fluctuation in positive emotions comes from internal (i.e. hormonal) or diurnal influences (i.e. circadian rhythm). Another part arises from interactions in daily life. Meeting up with a friend, playing tennis, or being smiled at in the supermarket are examples of experiences, which may temporarily boost levels of positive emotion. Research has shown that the tendency to use pleasant daily life experiences to boost positive emotions (positive affect reactivity) is associated with increased resilience against depressive symptoms in the future.”

Despite these fluctuations, it is perhaps noteworthy that the overall level of positive emotions (trait) appear to be stable over age with minor decreases With minor decreases in the elderly. In contrast, emotional reactivity may be slightly higher during childhood, a critical period during which caregiver and child learn to fine-tune emotional reactivity.

This emotional response may in part be influenced by genetic factors. Thus,

“A recent study on gene–environment interactions has found that levels of positive emotions of children with the short (S-) allele of the serotonin transporter gene 5-HTT [compared with the long (L-) allele] were more reactive to differences in parenting style. When raised in a warm and supportive environment, individuals with the S-allele experienced higher levels of positive emotions than individuals with the long (L-) allele. In contrast, they experienced lower levels of positive emotions than individuals with the L-allele when raised in unsupportive environments.”

Not only do individuals often learn to identify and seek pleasant activities, it also appears that those, who manage to hold on to positive emotions longer, appear to be more resilient.

Not surprisingly,

“Dopaminergic neuronal transmission in the pathway from the VTA to the NAc has been found to be involved in the responses to both natural rewards like food and sex, as well as unnatural rewards like psychotropic drugs. The conscious subjective experience of pleasure and reward likely takes place in the orbitofrontal cortex, which has reciprocal links with the mesolimbic system. Animal studies show that the catechol-O-methyl transferase (COMT) enzyme, which breaks down dopamine, is closely involved in dopamine regulation in both subcortical and prefrontal areas, and plays a major role in the dopaminergic signalling exchange between these areas….Consistent with this proposition, a recent study found that daily life reward experience increased proportionally with the number of Met alleles on the COMT Val158Met polymorphism. The Met allele encodes for a less active COMT enzyme, resulting in lower COMT activity, and, as a result, higher levels of prefrontal dopamine.”

For clinicians, these findings may have some important implications.

For one, enhancing positive experiences can improve resilience. Thus,

“A meta-analysis established that positive psychology interventions as diverse as writing gratitude letters, practising optimistic thinking, replaying positive experiences and socializing have beneficial effects on levels of depression. Another option may be to give individuals feedback on their own daily life dynamics of emotions. Through the identification of situations associated with positive emotions, people may learn to adapt their behaviour and become more resilient.”

“In addition, meditation- or mindfulness-based approaches may be a promising venue to increase positive emotions…In a randomized controlled trial, loving-kindness meditation was associated with increased levels of positive emotion, which in turn predicted reduced depressive symptoms. Another randomized controlled trial recently showed that mindfulness-based cognitive therapy (MBCT) was associated with increases not only in positive emotions but also the ability to make use of natural, moment-to-moment rewards in the environment.”

The importance of mental training such as meditation is born out by brain imaging studies.

“..functional MRI studies have shown that loving-kindness meditation regulates neural circuitries (insula, cingulate cortices, amygdala) linked to emotion, theory of mind and empathy….grey matter volumes in certain areas of the cortex and brain stem differ between novices and experienced meditators….Recently, a randomized clinical trial compared participants before and after participation in an 8-week course of mindfulness….was associated with changes in grey matter concentration in brain regions involved in learning and memory processes, emotion regulation, self-referential processing and perspective taking.”

These findings clearly demonstrate the impact of positive emotions elicited by pleasurable activities, thoughts and mindfulness can influence brain structures thereby possibly strengthening resilience.

It is easy to recall previous conversations with recreational and occupational therapists, who told me about their work with clients to help them seek out and engage in positive social and creative activities, resulting in much improved functioning and quality of life.

I would not at all be surprised if similar efforts can promote health behaviours in my obese patients, many of who struggle to find positive experiences in a world that treats them with disdain and negativity.

AMS
Edmonton, AB

Rutten BP, Hammels C, Geschwind N, Menne-Lothmann C, Pishva E, Schruers K, van den Hove D, Kenis G, van Os J, & Wichers M (2013). Resilience in mental health: linking psychological and neurobiological perspectives. Acta psychiatrica Scandinavica PMID: 23488807

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To those, who have been to any of my “Dr. Sharma Shows“, my interest in the topic of resilience should come as no surprise.

If my work with obese clients has taught me anything, it is the simple fact that for those who use food as a coping strategy, the solution will not lie in diet or exercise plans. To them, the discussions for and against sugar-sweetend beverages and the pros or cons of resistance vs. endurance training are irrelevant to a point that makes these discussions almost funny – they seem to exist in a parallel universe.

Indeed, the solution to emotional overeating (including its most severe form namely “binge eating disorder”), can only come from recognizing the relationship between their emotions and their eating behaviours, with the goal to ultimately developing healthier, non-food coping strategies.

Not that these will necessarily lead to weight loss – as I always hasten to point out – eliminating the cause of weight gain does not translate into weight loss – it merely translates into stopping the gain and often, a far better quality of life.

But then again, stopping the gain should be the first step in any weight management program and skipping this step (or fast-forwarding through it), can only guarantee failure.

This is why I firmly believe that for all of us working in the field of obesity, understanding the complex neurobiology of resilience (the successful adaptation and swift recovery after experiencing life adversities), is as essential as understanding the physiology of energy balance.

Readers interested in a rather comprehensive overview of resilience (in the context of mental health) are referred to a paper by Bart Rutten and colleagues from Maastricht University, published in Acta Psychiatrica Scandinavica.

In their extensive and systematic review of the literature, they find that the term “resilience” is used for phenomena ranging from susceptibility to mental health disturbances to adaptation and recovery from adverse experiences.

They describe three possible trajectories that can follow a severe stressor/trauma:

“…ranging from a trajectory showing consistent decline in mental health following exposure to adversity without subsequent recovery of mental health for a prolonged period of time, to a decline in mental health following the exposure that recovers quickly to preexposure levels of mental health and continues to increase thereby surpassing preexposure levels of mental health. This latter response, known as post-traumatic growth, is a very interesting form of adaptation, in which the individual may have obtained a better understanding of his life, possibly from a new perspective, or may have learned to respond efficaciously to similar challenges in the future.”

As the authors point out,

“The neurocircuitries mediating the stress response and reward experience are thought to be crucially involved in the neurobiology of resilience. The efficiency in activating and terminating the response to stress is regulated by elaborate negative feedback systems in the brain and the rest of the body….The hypothalamus–pituitary–adrenal (HPA) axis, the sympathetic nervous system (SNS) and the dopaminergic and serotonergic neurotransmitter systems are major neural systems that govern the stress response..”

There is indeed increasing recognition that experiences profoundly effect brain plasticity:

“These experience-dependent mechanisms regulate the sensitivity and plasticity of the central nervous system and act at several biological levels (likely partly in parallel with each other): i) cellular changes such as neurogenesis, pruning and sprouting of synapses, myelination of axons and alterations to the number of dendritic spines, ii) subcellular changes, such as alterations to the cytoskeleton and the extracellular matrix and changes in the levels of intracellular signalling molecules and iii) molecular (epi) genetic changes such as DNA methylation and chromatin changes. Thus, one can envision that aberrant regulation at any of these levels may moderate risk for and resilience to the consequences of stress and that resilience thus depends on a range of environmental and genetic factors during life.”

Although adverse life experiences can occur and have effects throughout life, there are key times of developmental vulnerability – times, when adverse effects can have “permanent” effects on the individual.

The first period is in early childhood development – beginning right after birth.

In animal studies,

“…parental care during early life induces long-term changes in behaviour as well as in gene expression mediated by epigenetic changes in the hippocampus of rats. As compared with offspring of mother rats with low-nurturing behaviour, offspring of high-nurturing mother rats (displaying more licking and grooming behaviour) were less anxious, had attenuated corticosterone responses after stress exposure and expressed higher levels of the glucocorticoid receptor (GR) in the hippocampus in adulthood. Interestingly, the methylation level of the promoter region of Nr3c1, i.e. the gene encoding the GR, was elevated already the first week of life in the hippocampus of pups that received less and lower quality nurturing , an effect that persisted into adulthood…..other studies have shown that the mother–infant interaction has long-lasting effects on endocrine and behavioural responses later in life.”

“Another interesting line of research has explored the effects of maternal separation on biology and behaviour. Although most studies observed detrimental effects of maternal separation, studies where rat pups were separated from their mother for a very brief period, i.e. 15 min, indicated that these pups, compared with non-separated pups, were more stress resistant later in life. Interestingly, as compared with offspring not separated from their mother for these brief spells in very early life, animals with brief spells of maternal separation showed higher levels of glucocorticoids (GCs) directly after stress exposure in adulthood, with a fast return to basal levels. Thus, type, severity and/or duration of stressful experience early in life seem to influence differential stress reactivity later in life.”

The other vulnerable period appears to be in adolescence, particularly in response to the “social defeat paradigm”,

“In the social defeat paradigm, male test mice aged 6–10 weeks (corresponding to puberty and adolescence in humans) are placed into the territory of a larger and more aggressive resident mouse. The mice are left in this physically and socially stressful situation for approximately 10 min, which leads to subordinate behaviour of the test mouse. After these 10 min, the mice remain in sensory (but not physical contact) with each other for the rest of the day, and the procedure is repeated for 10 consecutive days. The experimental paradigm is known to induce anxiety-like behaviour, prolonged elevations in corticosterone levels and a range of other molecular and cellular changes. Mice that were subjected to chronic social defeat stress furthermore showed a prolonged reduction in orexin signalling in the hypothalamus. Orexin has been implicated in arousal and feeding behaviour, but more recently also in the mesolimbic reward pathway… Although all mice have the same genetic background, and are exposed to similar conditions of social defeat, this experimental paradigm has repeatedly been shown to elicit two distinct responses in the domain of social behaviour: one group of mice displaying social avoidance after the social defeat experience (these mice are called ‘susceptible’), whereas a second group of mice still showing social interaction rates that are comparable with the control group (and is therefore called ‘unsusceptible’ or ‘resilient’). Thus, only a distinct subpopulation (i.e. the ‘susceptible’ mice) displays social avoidance and behavioural signs of anhedonia, while all exposed animals (‘susceptible’ and ‘unsusceptible’ mice) show elevated corticosterone levels and increased anxiety-like behaviour.”

As discussed in the above quote, it is apparent that the molecular changes associated with the response to this stress paragigm are intimately related to the very neurons and areas of the brain known to be linked to eating behaviour. Thus, the impact of adverse life events, whether this is early separation from the mother or exposure to school yard bullying, on eating behaviour and weight trajectories should come as no surprise to anyone working in the field.

Based on their review of the literature, the authors identify three rather consistent predictors of resilience include secure attachment, positive emotional experiences and having a purpose in life.

I will discuss these factors individually in subsequent posts – stay tuned.

AMS
Edmonton, AB