Dr. Sharma's Obesity Notes

When it comes to changing behaviours, it is important to understand what drives motivation.

Two well known frameworks often used in this context are the transtheoretical model of ‘Stages of Change’ and ‘Motivational Interviewing’, an intervention strategy that can help reveal and deal with ambiguity, toward changing the status quo.

Another theoretical framework that may well provide a deeper foundation for both Stages of Change and Motivational Interviewing is Self-Determination theory.

A paper by Heather Patrick and Geoffrey Williams, published in a recent issue of the International Journal of Behavioral Nutrition and Physical Activity, discusses how Self-determination theory can be applied to health behaviour together with motivational interviewing.

As the authors explain:

“Self-determination theory (SDT) is a general theory of human motivation that emphasizes the extent to which behaviors are relatively autonomous (i.e., the extent to which behaviors originate from the self) versus relatively controlled (i.e., the extent to which behaviors are pressured or coerced by intrapsychic or interpersonal forces). SDT defines motivation as psychological energy directed at a particular goal.”

Traditional theories of motivation distinguish between intrinsic motivation (characterized by engaging in behaviors for their own sake) and extrinsic motivation (characterized by engaging in behaviors for some separable outcome, such as social acceptance, proving something to oneself, or maintaining consistency between one’s values and one’s behaviours).

Although most health behaviours start out as extrinsically motivated, they can become ‘internalized’ over time.

Thus,

“According to SDT, the least internalized form of regulation is external and reflects engaging in behaviors to gain some reward or avoid some negative contingency. So, for example, someone may stop smoking because his surgeon will not perform needed coronary artery bypass surgery unless he stops smoking first, or because he wants the $800 his employer is offering to smokers for stopping.

Introjected regulation involves engaging in behavior out of some sense of guilt or obligation or out of a need to prove something to oneself or others (i.e., enhance self-worth). Thus, a person may stop smoking because she would feel guilty about the emotional and financial turmoil her family would have to face if she were to have a prolonged illness and early death.

The next most internalized form of regulation (i.e., the first level of autonomous regulation) is called identified in which case a person engages in a behavior because it is important to them. For example, someone may stop smoking because he personally believes it is an important goal to accomplish.

Finally, the most internalized form of extrinsic motivation is integrated. Integrated regulations are motives for behaviors that are important to the person, and they are engaged because they are also consistent with one’s other goals and values. So, someone may stop smoking because she values her health, and quitting smoking is consistent with her other goals in life (e.g., maintaining a regular exercise routine, living longer to enjoy her family).”

But how do such extrinsic motivators become internalised?

“SDT has identified three psychological needs critical to supporting the process of internalization and the development of optimal motivation and personal well-being.

The need for autonomy reflects the need to feel choiceful and volitional, as the originator of one’s actions.

Competence involves the need to feel capable of achieving desired outcomes, conceptually similar to self-efficacy in social cognitive theory.

Finally, relatedness reflects the need to feel close to and understood by important others.

When people experience the satisfaction of these needs in a given context, they are more likely to be autonomously self-regulated around the behaviors relevant to that context.

Thus, to the extent that a patient feels his needs for autonomy, competence, and relatedness are supported in a discussion with his primary care doctor about, for example, modifying his diet to include more fruits and vegetables, the patient is likely to feel more autonomously self-regulated (i.e., more identified or integrated) around this recommended health behavior change.”

But what does this mean in practice and how can clinicians support patients in internalising health behaviours?

“…autonomy supportive behaviors include eliciting and acknowledging patients’ perspectives and emotions before making recommendations; supporting patients’ choices and initiatives; providing a rationale for advice given; providing a menu of effective (i.e., evidence-based) options for change; minimizing control and judgment; and exploring how relevant health behaviors relate to patients’ aspirations in life.”

“Competence support involves being positive that patients can succeed; reframing past failures as short successes; providing accurate effectance feedback in a non-judgmental manner; identifying barriers; skills building and problem solving; and developing a plan that is appropriately challenging to patients’ skill and experience level.”

“…relatedness support includes providing unconditional positive regard (particularly in the face of failure to achieve desired goals), being empathic with patients’ concerns, and providing a consistently warm interpersonal environment. Thus, a practitioner may support a patient’s need for relatedness by expressing understanding about how difficult making a behavior change like quitting smoking can be and reflecting the patient’s concerns about failure.”

Readers may already recognize how this model overlaps with and feeds into Motivational Interviewing. As the authors point out:

“Support for all three needs requires that clinicians are actively engaged with their clients, and that they take a client-centered approach to the interaction. For example, eliciting and acknowledging the client’s perspective starts with active listening and includes reflections (e.g., brief summaries of the thoughts, emotions, and plans the client has about the health issue being addressed).”

Interestingly, interventions based on Self-Determination theory are being explored as a means to exact behaviour change in public health interventions. Thus, for example, New Brunswick’s Wellness Strategy, is apparently using Self Determination theory as a guiding principle to address the three needs for competence, autonomy and relatedness with promising results.

Certainly, in individual counselling, this framework can be embraced by clinicians to support behaviour change in their patients.

AMS
Edmonton, Alberta

Hat Tip to Isabel Savoie for pointing me to this paper.

The Obesity and Mental Health Hot Topic Conference, June 26 – 28, 2012, Toronto, co-organised by CON and IASO, is now accepting abstracts and registration.

Patrick H, & Williams GC (2012). Self-Determination Theory: Its Application to Health Behavior and Complementarity with Motivational Interviewing. The international journal of behavioral nutrition and physical activity, 9 (1) PMID: 22385676

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Day 2 of the 2nd International School on Obesity Research and Management (ISORAM) was kicked off by Bill Colmers (Edmonton), who provided a succinct review of the neurohormonal regulation of energy homeostasis and its importance for survival. While there was no evolutionary pressure to not exceed the minimum needs, biology favoured the ability to opportunistically store excess energy and defend body weight. While the former is the job of the hedonic system (thus, promoting weight gain), the latter is the job of the homeostatic system (thus, promoting weight regain).

Andres Thalheimer (Wuerzburg, Germany) discusses how olfactory sense and taste may change following bariatric surgery. While anecdotally, patients undergoing surgery often report changes in appetite and response to food stimuli, whether or not these changes are accompanied by changes in gustation or olfaction are less clear. In their own studies, they found a slightly lower olfaction threshold in patients following sleeve gastrectomy but not following Roux-en-Y gastric bypass. However, these preliminary data are far from conclusive and there is a need for significantly more work in this area.

Christian Jurowich (Wuerzburg) presented novel findings on changes in intestinal glucose transport in animal models of bariatric surgery in diabetic rodents. His work focussed on the Na+-D-glucose Cotransporter SGLT1, a pivotal mechanism for intestinal glucose absorption and glucose-dependent incretin secretion and shows how adaptation of this transporter may affect glucose transport and incretin secretion post surgery.

Michael Lyon (Vancouver) reviewed the many biological functions of dietary fibre on a wide range of health conditions ranging from ischemic heart disease, stroke atherosclerosis, type 2 diabetes, overweight and obesity, insulin resistance, hypertension, dyslipidemia, as well as gastrointestinal disorders such as diverticulosis, irritable bowel disease, colon cancer, and cholelithiasis. The physiological effects of fiber relate to the physical properties of volume, viscosity and water holding capacity that the fiber imparts to food leading to important influences over the energy density of food. Beyond these physical properties, fiber directly impacts a complex array of microbiological, biochemical and neurohormonal effects directly through modification of the kinetics of digestion and through its metabolism into constituents such as short chain fatty acids which are both energy substrates and important enteroendocrine ligands. Of particular interest to clinicians is the important role dietary fiber plays in glucoregulation, appetite, and satiety.

Other talks on day 2 of ISORAM included a session on the psychosocial aspects of bariatric care, including a talk by Birgit Wagner (Leipzig) on the complex issue of suicidality, depression, and anxiety disorder particularly in adolescents with severe obesity, a discussion of the many psychological and social issues relevant to the management of childhood obesity and family interventions, and a talk by Almut Rudolph (Lepizig) on the need for pre and post-surgical psychosocial support and interventions in patients undergoing bariatric surgery.

Another talk deserving special mention was a presentation by Tina Ullrich (Edmonton/Leipzig) on some of the mechanisms involved in the development of endothelial dysfunction in childhood obesity - a topic of interest given the early impact that obesity can have on cardiovascular function, thus setting the stage for future complications.

AMS
Lake Louise, Alberta

To round up my posts on the obesity articles of the January issue of the Canadian Journal of Psychiatry, I would like to briefly highlight some of my comments published in an editorial I wrote for this issue.

Reader will by now be familiar of the many links between obesity and mental health problems. With regard to this relationship, I write:

“Thus, while it is not complicated to appreciate the fact that mental health is an important determinant of body weight, it is also important to recognize that this relationship is complex.

While the links between mental illness and weight gain can be as simple as the induction of ‘hedonic hyperphagia’ with the use of ‘atypical’ antipsychotics, they can be as complex as the link between early childhood trauma and binge eating disorder or the recurrence of addictions following bariatric surgery.”

I conclude with what I have said often enough:

“It is therefore of considerable importance that mental health practitioners familiarize themselves with the complexity of obesity and its management whilst, by the same notion, anyone attempting to manage obesity requires at least basic competencies in the art and science of assessing mental health.

Indeed, nowhere are mental and physical health closer related to one another than in the context of the mental health and obesity epidemics – close enough perhaps to consider them close cousins, if not siblings. While reducing the burden of mental health on Canadians may well go a long way in improving their physical health, reducing the burden of obesity on Canadians without also addressing their often underlying mental health problems will prove virtually impossible.”

I do hope that this issue of the Canadian Journal of Psychiatry, will draw more attention to this relationship and will hopefully receive feedback on this from my readers and colleagues.

AMS
Edmonton, Alberta

p.s. Readers in Edmonton may be interested in attending a CIHR Café Scientifique: Is Canada ignoring obesity in men? Wednesday, February 15, 2012, 5:00 p.m. to 7:00 p.m. Edmonton City Hall (Hosted by the CIHR Institute of Gender and Health and the Canadian Obesity Network).

Continuing my posts on the recent articles on obesity and mental health published in the January issue of the Canadian Journal of Psychiatry, I now turn my attention to a paper by Valerie Taylor and colleagues on the many links between mental health issues and obesity.

Whilst in the previous post I have focussed on the relationship between psychiatric medications and weight gain, a problem that is common knowledge to the mental health community, this article highlights many of the lesser known links between mental health problems and excess weight. These include interesting neurobiological, psychological, and sociological factors, that are now increasingly understood.

For e.g.

“‘Atypical’ depression, a type of major depressive disorder characterized by an increase in the need for sleep and food, may actually characterize the most ‘typical’ presentation of major depression For the majority of people with depression, therefore, a diagnosis of major depression is synonymous with a phenotype that increases vulnerability towards weight problems.”

In fact,

“The neurobiology of depression [also] confers increased risk of obesity. The most common biological perturbation associated with depression is an increase in cortisol. This increase, and the hypothalamic pituitary adrenal axis abnormalities that accompany it, is similar to changes seen in Cushing syndrome, an endocrinological illness caused by an increase in cortisol that is characterized phenotypically by excessive visceral weight gain. While levels of cortisol found in major depression disorders are much lower than that of Cushings, the biological impact of excess cortisol is similar; a predisposition towards increased deposition of centrally located adipose tissue.”

In addition mood disorders often affect sleeping behaviour, which in turn affects important regulators of appetite and metabolism like ghrelin, leptin, adiponectin, and other hormones. Moreover, chronic inflammation may play a role in both major depression and obesity.

In the case of schizophrenia, primary negative symptoms like amotivation, which can be observed even in the earliest stages of the illness, may lead to reduced physical capacity and altered self-perception. Hypodopaminergic activity may in part explain increased propensity for substance use, especially cannabis, which can promote hyperphagia.

There is an increasingly recognized association between obesity and attention deficit disorder, and it may well be that impulsivity may play an important role in overeating.

Also,

“Poor planning and an inability to delay reward, processes largely mediated by the pre-frontal cortex, may lead individuals with ADHD to over-consume highly palatable, fattening foods. A related hypothesis is that individuals with low intrinsic dopamine activity in brain areas mediating reward may attempt to compensate by using various reinforcing behaviors including increased food consumption. This has been termed the “reward deficiency syndrome” and has been described separately in ADHD and in obesity suggesting that ADHD and obesity may thus reflect different manifestations of a single biological change related to low dopamine activity in prefrontal attentional areas and brain reward pathways.”

The paper also discussed findings showing that ADHD is associated with more media consumption, less participation in physical activity and organized sports.

Finally, the paper examines the literature on the relationship between obesity and childhood adverse events like sexual, mental, physical abuse and emotional neglect, which can have important impacts on the hypothalamic-pituitary-adrenal axis as well as on sex hormones that may promote fat accumulation.

“The use of food as a coping strategy or a “self-soothing behavior” is seen in both trauma patients and in those with mood disorders, and it may be related to the use of food to modulate neurotransmitters involved in affect control. Most work in this area has focused on serotonin and dopamine, both of which play a critical role in both eating behavior and mood regulation. It may be that the ability of certain foods to temporarily boost mood can create a behavioral cycle where food is consumed to control feelings of sadness.”

As readers of these posts may be well aware,

“The relationship between trauma and weight is especially evident during weight loss treatment programs and in bariatric surgery programs, a past history of trauma can be a harbinger of post-operative problems. Food and weight gain in response to abuse may be related to a desire to become “bigger” to be able to defend against an abuser, it may have been a way to change appearance when an individual inaccurately felt they were somehow provoking the abuse or it may have become a surrogate comfort mechanism when appropriate supports failed.”

Thus, clinicians (and patients) must be aware of the complex relationship between obesity and mental health issues that go well beyond just the issue of weight gain with psychiatric medications (which of course further compound these issues).

All the more reason, why all health professionals called upon to manage obesity should be well versed in recognizing and helping patients address mental health problems.

AMS
Edmonton, Alberta

Following yesterday’s post on the issue of weight gain and metabolic syndrome seen in kids treated with second-generation antipsychotics (SGAs), today, I look at another paper by Silvia Alessi-Severini and colleagues from the University of Manitoba published in the same issue of the Canadian Journal of Psychiatry.

This paper examines the use of antipsychotics in children and adolescents (aged 18 years or younger) based on data collected from the administrative health databases of Manitoba Health and the Statistics Canada census between the fiscal years of 1999 and 2008.

Over these 10 years, prevalence of antipsychotic use increased with the introduction of the SGAs from 1.9 per 1000 in 1999 to 7.4 per 1000 in 2008.

The male-to-female antipsychotic usage ratio increased from 1.9 to 2.7 as the male youth population represented the fastest-growing subgroup of antipsychotic users in the entire population of Manitoba.

Notably, the paper finds that total number of prescriptions also increased significantly despite the lack of approved indications in this population.

More than 70% of antipsychotic prescriptions to children and adolescents were written by general practitioners with the most common diagnoses being attention-deficit hyperactivity disorder and conduct disorders. In fact, the use of antipsychotics in combination with methylphenidate (ritalin) increased from 13% to 43%.

Thus, it appears that there is extensive off-label use of SGAs in kids and youth in Manitoba (and likely in other provinces), a finding that is of concern not least because of the significant (30-fold increased) risk of weight gain and metabolic syndrome associated with the use of these compounds.

So, while there is no doubt that these drugs may provide important clinical benefits in kids who do need them, it is hard to imagine that this degree of off-lable prescription is indeed warranted.

Again, I would love to hear from my readers regarding experience with these medications in children and youth.

AMS
Ottawa, Ontario