Dr. Sharma's Obesity Notes

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

Regular readers will recall my recent posts on the notion that the benefits of regular exercise on body weight are largely mediated by the positive impact on caloric intake rather than by the number of calories burnt.

This notion is based on the idea that exercise modulates eating behaviour by reducing stress, improving mood, and perhaps, even by reducing the ‘reward’ response of palatable foods.

The latter assumption, is supported by a recent stud by Maciej Buchowski and colleagues from Vanderbilt University, Nashville, Tennessee, published in PLoS.

The study was conducted in 12 sedentary or minimally active non-treatment seeking cannabis-dependent adults, who attended 10 supervised 30-min treadmill exercise sessions standardized using heart rate (HR) monitoring (60-70% HR reserve) over 2 weeks.

Self-reported drug use reduced from about 6 joints per day to less than 3 joints a day during the exercise intervention and remained at 4 joints per day 2 weeks after the end of the study.

Average Marijuana Craving Questionnaire factor scores for the pre- and post-exercise craving assessments were also markedly reduced for compulsivity, emotionality, expectancy, and purposefulness.

As the authors discuss:

“Consistent with the changes in cannabis use reported by participants, subjective cravings elicited by cannabis cues were also significantly reduced by exercise, suggesting the possibility that the potential therapeutic effect of exercise may be mediated via brain mechanisms responsible for cue-induced craving.

These same brain mechanisms have been invoked in behavioral addictions involving non-drug rewards, as is observed in overeating and obesity, problematic hypersexuality, and pathological gambling. Analogously, it has been reported that exercise activates some of the same reward pathways as are activated by addictive drugs. For instance, acute bouts of exercise increase central dopamine concentrations and chronic exercise leads to sustained increases in dopamine concentrations and compensatory alterations in dopamine binding proteins in brain regions relevant to reward.”

Thus, the findings from this rather small study provides the basis for conducting a much larger and longer-term study on the use of exercise as a treatment for marijuana addiction.

On the other hand, given important role of the brain’s reward circuitry for food in take, it may not be expected if such a study also demonstrates a positive effect on overconsumption of highly palatable foods.

AMS
Dushesnay, Quebec

Buchowski MS, Meade NN, Charboneau E, Park S, Dietrich MS, Cowan RL, & Martin PR (2011). Aerobic exercise training reduces cannabis craving and use in non-treatment seeking cannabis-dependent adults. PloS one, 6 (3) PMID: 21408154

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.

PSYCHOSIS

Symptoms suggestive of mania or psychosis need to be investigated and treated before initiating a weight-reduction strategy. Unfortunately, current pharmacotherapy for bipolar disorder (lithium, valproate, olanzapine) and many of the the newer antipsychotics (clozapine, olanzapine, quetiapine) can produce dramatic weight gains. This effect on body weight can exacerbate obesity-related illnesses and hinder compliance with antipsychotic treatment.

There has been some success using topiramate for bipolar and mood disorders both as an independent weight-neutral or even weight-negative mood stabilizer, and as an adjunct to other antipsychotics to decrease iatrogenic weight gain. Lamotrigine may also be considered as a mood stabilizer, and it too has been shown to be weight neutral.

Of all the novel antipsychotics, ziprasidone and aripiprazole have been reported to be nearly weight neutral.

© 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.

Perhaps the short title of today’s post should simply be “(too) Great Expectations”.

While yesterday, I discussed issues related to emotional eating, food addiction and vulnerability as possible causes for patients to fail, today I want to focus on another issue that I have seen provide a very different type of challenge in some patients - unrealistic expectations.

Indeed, unrealistic and exaggerated weight-loss expectations can often lead to dissatisfaction, disappointment, frustration, distress and hopelessness in patients undergoing bariatric surgery.

The reasons for this are simple. As noted in previous posts, media and blog posts are rife with stories on the extreme outliers - the cases where things go horribly wrong and the cases where things go amazingly well (perhaps too well?). While the former, keeps people, who may well benefit, away from surgery, the latter is perhaps as problematic but in a very different way.

As the old joke goes, “80% of people think they are above average” - as a result of the Anchoring and the Example rules, most patients are expecting that their rather bold and drastic decision to undergo surgery will produce dramatic results.

Studies show that the average ‘dieter’ is hoping to lose around 50% of their weight - the same is probably even more true for patients seeking surgery.

In reality, however, the ‘average’ medium-to-long-term weight loss with bariatric surgery is only a rather sobering 20-30% of initial weight.

Please reread this last sentence very carefully!

The term “average’, means that about half of all patients will actually lose LESS than 20-30% of their initial weight (the other half of course will lose more).

Imagine the disappointment of the ‘average’ 300 lb patient, who, after experiencing the ‘average’ success (25% weight loss), still weighs 225 lbs! Nevermind that her health has dramatically improved, she is off all their medications, and she feels better and healthier than ever before - she is still 225 lbs! From a medical and health perspective a spectacular success story - psychologically nothing but disappointment and failure.

Imagine how devastated the ‘less-than-average’ patients feel when they do not even manage to hit and sustain the 10 or 15% mark. These cases are often described as ‘failures” because, this rather small degree of weight-loss, which for many is in fact far less than they may have achieved with diet and exercise alone in the past, is sometimes not even noticeable.

The fact that they never managed to keep even 10% of their weight off in the past (3-5% is the average sustainable weight loss with diet and exercise), but can now do so because of their surgery, is hardly comforting. The fact that surgery, perhaps will only help them keep off the weight that they managed to lose before surgery or even only prevent further weight gain can only come as a disappointment.

Thus, for the vast majority of patients, as they begin experiencing their weight-loss plateau at about 18 to 24 months post surgery, the reality dawns on them that they will still be ‘obese’ and will be nowhere close to whatever they (or society) imagines their ‘ideal’ weight should be.

Imagine the sense of frustration and failure, the disappointment and despair, the anger and hopelessness as realization sets in - all of this (the time, the risk, the money, the struggle, the anticipation, the euphoria of weight loss) for what? To still be stared at and ostracized - to still be accused of being gluttonous and lazy - so what if my knees no longer hurt and my energy levels are higher than ever before - I AM STILL FAT!

This is when many patients, will begin showing maladaptive, seemingly ‘irrational’ behaviours. Those, not happy with or unable to accept their disappointing weight-loss result will begin pushing the limits - steadily increasing their exercise levels till they reach unsustainable amounts of hours spent in the gym each day - or further decreasing their food intake to try and lose more weight. (Yes, ‘yo-yo’ dieting is possible even after surgery.)

While the former can result in biomechanical problems including severe and sometimes irreparable strain injury (remember - these are still very large patients), the latter can precipitate severe malnutrition for all of the reasons discussed previously.

Other patients simply give up - fall off their diet and exercise programs - why bother if ‘everything’ just stays the same?

Thus, simply going into surgery with unrealistic expectations, only to be disappointed, can lead to ‘complications’ that, although often blamed on the surgery, have very little to do with the surgery itself.

Obviously, private surgical centres (or for that matter even some of the publicly funded surgeons) will rarely emphasise this rather modest result of bariatric surgery - modest, only if the amount of weight loss is the focus - spectacular, if improvement in health is the real goal.

This is perhaps why surgeons prefer to talk to their patients about percent Excess Weight Loss (or the amount of ‘excess weight’ you will lose) rather than weight loss in absolute terms. I have in the past criticized this common practice and have called upon surgeons to abandon this ‘misleading’ term, which is misleading for all kinds of reasons that I do not wish to get into here. (Readers may wish to refer to our recent paper published in SOARD.)

Patients (and surgeons?) also generally refuse to accept that the total amount of weight loss starts from the highest weight that the patient had before surgery - irrespective of whether or not the patient has already lost weight.

This can actually mean that the average 300 lb patient from the above example, who manages to lose 25% or 75 lbs before surgery, may experience no additional weight loss after surgery - in fact, the only reason I would advise this patient to still consider having surgery would be because surgery would make it so much easier and so much more likely to keep the 75 lbs off - that’s all!

Thus, these ‘failures’ are not really ‘failures’ in the sense of what surgery does or how it works.

But they are very much ‘failures’ from the patients’ perspective (and their friends and relatives) - ‘failures’ attributable only to overly optimistic and unrealistic expectations.

I can honestly state that most patients in our program are visibly disappointed when we explain their real chances of weight loss and many change their mind or have second thoughts.

Others, will listen, but still think that they can beat the average - only to be disappointed when they don’t.

The best outcomes and the greatest satisfaction appears to be in those patients, who are truly and honestly only concerned about their health and are perfectly and honestly happy with the substantial improvement in comorbidities and quality of life that they experience even with a modest 20-30% weight loss (or less).

These are the patients, who do not measure ’success’ on a scale - and that is exactly the way it should be for any obesity treatment.

Tomorrow, we will look at how bariatric surgery can affect relationships - another important but often unaddressed issue when considering bariatric surgery.

AMS
Edmonton, Alberta

Karmali S, Birch DW, & Sharma AM (2009). Is it time to abandon excess weight loss in reporting surgical weight loss? Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery, 5 (4), 503-6 PMID: 19632649