Arya M. Sharma, MD

The January issue of the Canadian Journal of Psychiatry focuses on the close relationship between mental health problems and obesity.

The issue (just released online) features two review articles: One looks at the many links between obesity and chronic mental illness - as it turns out, a two-way street. The other reviews current approaches to improving obesity management in individuals with chronic mental illness.

The same issue also features an original article examining the relationship between abdominal obesity and cardiometabolic risk factors in kids with mental health problems - particularly in those who require treatment with new-generation antipsychotic medications.

In a guest editorial, I comment on the importance of understanding and addressing the links between these two co-epidemics. As regular readers are well aware, assessment for mental health problems has to be part and parcel of any assessment for obesity (the first of the 4Ms of obesity assessment).

When present, managing these mental health issues, more often than not, will be the lynchpin of successful weight management. Not addressing these issues will likely guarantee failure in weight management.

For readers, who do not have access to this journal, I will discuss these articles in more detail in upcoming posts.

AMS
Saskatoon, Saskatchewan

At the 1st National Summit on Weight Bias and Discrimination organized by the Canadian Obesity Network in Toronto almost exactly a year ago, I learnt that weight-based bullying is one of the most common and pervasive forms of bullying experience by children and youth.

This topic is further examined by Obesity Network Bootcamper Atif Kukaswadia and colleagues from Queens University, Kingston, Ontario in a paper just published in OBESITY FACTS.

The researchers report on their findings in a longitudinal analysis of the Health Behaviour in School-Age Children Survey conducted in 2006 and then again in 2007, which included 1,738 youths from 17 Ontario high schools.

Based on self-reports, excess adiposity preceded bullying involvement and obese and overweight males reported 2-fold increases in both physical and relational victimization, while obese females reported 3-fold increases in perpetration of relational bullying over the observation period.

In addition, among those free of bullying at baseline (2006), significant increases in perpetration of relational bullying were reported by obese females in 2007 relative to normal-weight females (14.8 vs. 3.8% among normal-weight girls).

These findings support previous findings on the increased risk for bullying faced by overweight and obese youth and certainly suggest that this problem, if anything, is getting worse.

Given the many deleterious (and often lasting) effects of bullying on mental and physical health, this issue is certainly something that should concern us all.

Thus, it is certainly not surprising that one of the strategic priorities identified at CON’s Weight-Bias Summit was to “address weight-bias and discrimination in education settings”.

A full report of the Summit is available here.

AMS
Edmonton, Alberta

Kukaswadia A, Craig W, Janssen I, & Pickett W (2011). Obesity as a determinant of two forms of bullying in ontario youth: a short report. Obesity facts, 4 (6), 469-72 PMID: 22248998

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This week, the Canadian Obesity Network welcomed a new parter - Craving Change, a small Canadian ’start up’ that has become an almost overnight success with providers and patients.

The founders describe it on their website as follows:

“Created by dietitian Wendy Shah and clinical psychologist Dr. Colleen Cannon, Craving Change™ provides a missing piece to the puzzle of helping people change their eating habits. Craving Change™ translates behaviour modification and cognitive-behavioural theory into appealing and practical strategies that a variety of professionals can use with groups or individuals.“

What the program really does, is break down the cognitive-behavioural-theory (CBT) approach to dealing with emotional ‘overeating’ into a stepped-program that can be administered by health professionals (e.g. dieticians, nurses, etc.) with minimal prior expertise or training in psychology.

“Craving Change does not provide dietary advice, nor is it psychotherapy - rather, Craving Change focuses on the “why” of eating - it is designed to help patients who struggle with what they eat, when they eat, and how much they eat.”

As Colleen, herself a clinical psychologist is quick to point out, Craving Change does not attempt to replace psychologists or diminish their importance in an obesity program. However, it does address the reality that many health professionals called upon to manage obesity, do not have ready access to psychologists that will see their patients (indeed there are simply not enough psychologists around to help everyone who would require their help).

“If you have limited access to psychosocial resources, the stepped care approach of the Craving Change™ workshop can be invaluable for reaching more clients. Self-awareness of eating triggers can be achieved in a group setting using Craving Change™ workshop activities. Clients can then be encouraged to try a variety of strategies, based on behaviour modification and cognitive-behavioural theory, to improve their eating behaviours. Craving Change™ also helps clients learn skills that promote long-term adherence to new behaviours.“

So, far Wendy and Colleen have trained over a 1000 health professionals to administer their program - their ‘clients’ include Alberta Health Services and a growing number of providers across Canada.

Wendy and Colleen are also long-time members and enthusiastic supporters of the Canadian Obesity Network and have generously agreed to donate a proportion of their ongoing proceeds to sustain the Network.

I am sure several of my readers will either have delivered or attended Craving Change sessions, here in Alberta or elsewhere - I certainly look forward to hearing from you.

AMS
Edmonton, Alberta

In a follow up to yesterday’s post on why parents are often reluctant to seek professional help to deal with their kid’s excess weight, I want to draw my readers’ attention to an article by Jillon Vander Wal and Elisha Mitchell from Saint Louis University, MO, just published in Pediatric Clinics of North America.

The paper gives a succinct overview of the many psychological and behavioural problems that can be associated with excess weight (or weight gain) in kids and adolescents: body dissatisfaction, symptoms of depression, loss-of-control eating, unhealthy and extreme weight control behaviors, impaired social relationships, obesity stigma, and decreased health-related quality of life.

The authors note the importance of recognizing and addressing psychosocial issues in overweight kids - they point out that:

“ecological models that take into consideration individual, psychosocial, physical, and macrolevel environments are best suited for understanding the associations between child obesity and psychosocial difficulties”

They discuss how such approaches can be important determinants of successful interventions:

“Consistent with the bioecological theory, these interventions addressed the more immediate family social context, but also the broader peer environment. These findings highlight the importance of addressing these issues before the initiation of weight loss treatment or, at the very least, concurrently. The addition of social facilitation and skills building may prove to be a core improvement to lifestyle intervention programs.”

While noting that:

“The topics of weight and mental health issues must be approached with care and consideration.”

the authors also point out that:

“Physicians must objectively evaluate psychological complications among overweight youth and not assume maladjustment.”

A number of non-threatening and non-judgemental ‘conversation starters’ for assessing mental health concerns are suggested (e.g. Does your child express concerns regarding appearance?, Does your child worry a lot?).

The paper also provides practitioners with a list of standardized and validated assessment tools that can help explore a wide range of important dimensions like emotional functioning, physical functioning, teasing/marginalization, positive social attributes, mealtime challenges, and school functioning (e.g. Sizing Me Up).

As the authors point out:

“More comprehensive screenings for high-risk populations are also available and should be used by appropriately trained professionals, preferably in multidisciplinary treatment settings. These tools are most applicable for high-risk children, such as children with BMIs of 40 or greater or for youth presenting for professional weight loss services.“

Ideally, if significant psychosocial concerns are identified, the family can be referred to an experienced psychologist for further consultation and management:

“Pediatricians may consider referral to psychologists who can assess for a broad range of physical and mental health conditions and aid in their treatment, as well as associated psychosocial difficulties.Further, psychologists can intervene from a systems-level approach to promote the individual, family, and social-level change needed to promote and maintain weight loss. A psychologist intervening at a systemic level works not only with the child, but with the child’s family to promote healthy eating practices, engage in opportunities for physical activity, and establish positive peer interactions at home, with external caretakers, in the child’s school, and in the surrounding community. “

As the authors conclude:

“Addressing psychological complications associated with pediatric obesity is an important component of treatment success.”

I would certainly like to hear from any of my readers, who have had positive and helpful interactions with health professionals regarding their kids’ excess weight.

AMS
Edmonton, Alberta

Vander Wal JS, & Mitchell ER (2011). Psychological complications of pediatric obesity. Pediatric clinics of North America, 58 (6), 1393-401 PMID: 22093858

Yesterday, I posted on the recent Senate Committee call on the FDA to ease the path to approval of new obesity, which it described as “a significant unmet medical need.”

In my commentary, I suggested that one solution to better balancing risk and benefit would be to subcategorize obesity into meaningful subtypes, ideally based on an objective aetiological framework.

In a paper just published in Appetite, Caroline Davis and colleagues from Toronto’s York University provide evidence suggesting that ‘food addiction’ (FA) may be a valid clinical sub-phenotype of obesity.

The researchers examined the validity of the Yale Food Addiction Scale (YFAS) - the first tool developed to identify individuals with addictive tendencies towards food - in a sample of obese adults (aged 25-45 years) and non-obese controls.

The YFAS is available here - the instruction sheet for interpreting the test is available here.

In their analysis, the researchers focused on three domains relevant to the characterization of conventional substance-dependence disorders: clinical co-morbidities, psychological risk factors, and abnormal motivation for the addictive substance.

Not only were their results strongly supportive of the ‘food addiction’ construct demonstrated validity of the YFAS, in addition, those who met the diagnostic criteria for food addiction had a significantly greater co-morbidity with Binge Eating Disorder, depression, and attention-deficit/hyperactivity disorder compared to their age- and weight-equivalent counterparts.

Those with FA were also more impulsive and displayed greater emotional reactivity than non-FA obese controls. They also displayed greater food cravings and the tendency to ’self-soothe’ with food.

As the authors conclude:

“These findings advance the quest to identify clinically relevant subtypes of obesity that may possess different vulnerabilities to environmental risk factors, and thereby could inform more personalized treatment approaches for those who struggle with overeating and weight gain.”

From a treatment perspective, these would be the patients, who would perhaps be most responsive to behavioural and pharmacological treatments aligned with an addiction paradigm.

In contrast, non-food addicted obese individuals will likely be far less responsive to these approaches.

Thus, while it may make sense to expose individuals with food addiction to drugs like buproprion, naltrexone, or rimonabant, non-addictive obese individuals may neither respond well nor warrant the risk of these drugs for treating their obesity.

As long as we continue on the path to developing obesity treatments using an outdated and simplistic ‘let’s-get-anyone-with-a-BMI-higher-than-X-to-lose-weight’ approach, we will never get a good handle on risk benefit ratios, let alone, get any closer to ‘aetiology based’ treatments.

AMS
Lisbon, Portugal

Davis C, Curtis C, Levitan RD, Carter JC, Kaplan AS, & Kennedy JL (2011). Evidence that ‘food addiction’ is a valid phenotype of obesity. Appetite PMID: 21907742