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Do Anti-Depressants Promote Weight Gain?

There is no doubt that some people gain weight when started on anti-depressant medications. However, it is also true that the increased appetite and listlessness that accompanies “atypical” depression can contribute to weight gain. Finally, there is evidence that weight-gain in turn may decrease mood, which in turn may further exacerbate weight gain.

Trying to cut through all of this is a study by Rafael Gafoor and colleagues from King’s College London, in a paper published in BMJ.

They examined data from the  UK Clinical Practice Research Datalink, 2004-14, which included data on 136,762 men and 157,957 women with three or more records for body mass index (BMI).

In the year of study entry, 17,803 (13.0%) men and 35,307 (22.4%) women with a mean age of 51.5 years were prescribed anti-depressants.

While during 1, 836,452 person years of follow-up, the incidence of new episodes of ≥5 weight gain in participants not prescribed anti-depressants was 8.1 per 100 person years, it was slightly higher at 11.2 per 100 person years in those prescribed an anti-depressant.

In the second year of treatment the number of participants treated with antidepressants for one year for one additional episode of ≥5% weight gain was 27.

Thus, there appears to be a slight but discernible increased risk of weight gain associated with the prescription of anti-depressants, which may persist over time and appears highest during the second and third year of treatment.

However, as the authors caution, these associations may not be causal, and residual confounding might contribute to overestimation of associations.

Nevertheless, the notion that there may be a distinct weight-promoting pharmacological effect of some anti-depressants is supported by the finding that certain anti-depressants (e.g. mirtazapine) carry a far greater risk of weight gain than others (e.g. paroxetine).

Given the frequency with which anti-depressants are prescribed, it could be argued that the contribution of anti-depressants to the overall obesity  epidemic (particularly in adults) may be greater than previously appreciated.

If nothing else, patients prescribed anti-depressants should be carefully monitored for weight gain and preventive measures may need to be instituted early if weight gain becomes noticeable.

@DrSharma
Edmonton, AB

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The Vast Majority Of Healthy Women Will Become Unhealthy!

Most healthy women, who live long enough, will eventually become unhealthy.

So it should not at all come as a surprise to anyone, that the vast majority of women with “healthy” obesity (a misnomer, as in my view, the medical term “obesity” should only apply to people who already have health problems attributable to abnormal or excess body fat), eventually end up with “unhealthy” obesity.

This, essentially, is the gist of a paper by Nathalie Eckel and colleagues, published in The Lancet.

In their study of 90,257 participants of the Nurses Health Study, who were followed-up from 1980 to 2010 for incident cardiovascular disease (representing over 2 million person-years of follow-up), they found that around 80% of metabolically healthy women with obesity converted to metabolically unhealthy obesity over the course of follow-up.

But one might say that this was only marginally higher that the 70% of metabolically healthy “normal weight” women, who also converted to metabolically unhealthy over the 20 years of observation. In fact, the population-attributable risk of the latter group was much higher, as it consisted of almost 10 times the number of women than in the former.

While the risk of cardiovascular disease was statistically elevated (by about 40%) in the metabolically healthy women with obesity, this risk was 243% higher in metabolically unhealthy women with normal weight, 260% higher in metabolically unhealthy women with overweight and 315% higher in metabolically unhealthy women with obesity, all compared to metabolically healthy women with normal weight.

So, yes, women with metabolically “healthy obesity” have a high risk of becoming metabolically unhealty and developing cardiovascular disease, so are metabolically healthy normal-weight women.

Overall, I believe it is safe to say that the vast majority of metabolically healthy women (regardless of body weight) will eventually become metabolically unhealthy, at which time their risk for cardiovascular disease increases.

Bottom line, everyone (not just women with obesity) will benefit from efforts to stay as metabolically healthy as possible for as long as possible – fortunately, we know that healthy diets and regular physical activity (while not necessarily preventing weight gain) can help maintain metabolic health, irrespective of current body weight.

Clearly, living as healthy as possible is not just good advice for women with obesity – who would have guessed?

@DrSharma
Edmonton, AB

p.s. although this was a study in women, I have no doubt whatsoever that the findings also apply to men – most metabolically healthy men will eventually become metabolically unhealthy over the course of their lifetime.

 

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Why Weight-Loss Challenges Send the Wrong Message

I was recently, once again asked about my opinion on weight-loss challenges. So here is a repost of an article I wrote back in 2008 on this topic – apparently, it is still as relevant today, as it was almost a decade ago.

There appears to be a rather widespread notion out there that introducing a bit of competition into the affair may spurn people on to try and lose those “extra” pounds.

In fact, a quick google search on the term “weight-loss challenge” reveals an amazing array of challenges from voyeuristic and sadistic TV shows like the “Biggest Loser” to well-meant workplace wellness initiatives or fund raisers. I am sorry to admit that I recently even became aware of a weight-loss challenge within my own hospital – well intended, but useless in the fight against obesity.

So what’s wrong with this idea? Isn’t competition a great motivator?

Sure it is – and people will do anything to win a competition – including crazy stuff like starve themselves, exercise till they drop, or even (God forbid) pop diet pills, diuretics or laxatives just to win.

All of this is in direct contradiction to a fundamental principle of obesity management: you do not do things to lose weight that you are unlikely to continue doing to keep the weight off.

Most people seem to think that if only they could lose some weight, they will somehow be able maintain that lower body weight in the long-term with less effort.

The reality unfortunately is (and most dieters have experienced this over and over again) that no matter what diet or exercise routine you chose, no matter how slow or fast you lose the weight, no matter how long you keep the weight off – the minute you relax your efforts, the weight simply comes back.

As I have blogged before: obesity is a chronic disease for which we have no cure – only treatments! When you stop the treatment the weight (and any related problem) simply comes back.

By now you will already have figured out the problem with these challenges – unless you are very modest and reasonable about your weight-loss target and are carefully making changes that you can reasonably sustain forever, you are simply setting yourself up for failure.

If you are indeed modest and reasonable – you’ve already lost the competition to all the crazy folks who’ll do anything just to win.

My advise to anyone with a weight problem – the next time you see an invitation to a weight-loss challenge – simply ignore it!

If you really think you will benefit from obesity treatment – seek help from a trained and accredited health professional with experience in weight management – let’s put an end to weight cycling!

@DrSharma
Berlin, Germany

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We Need To Change The Public-Health Narrative On Obesity

While at the level of the individual, clinicians are beginning to acknowledge the vast body of research now showing that “lifestyle” approaches to managing obesity (“eat-less move more”) result in minimal outcomes (3-5% sustainable weight loss at best), public health attempts to address the obesity epidemic continue to perpetuate the myth that obesity (and its prevention) is simply about getting people to eat better and move more (with very little  evidence to show that such measures can be implemented at a population level to effect any noticeable change in obesity rates).

In an article I co-authored with Ximena Ramos-Salas, published in Current Obesity Reports, we provide an in-depth overview of current public health policies to address obesity in Canada and argue that the “narrative” underlying these policies is an important driver of weight-bias and discrimination and significantly hindering efforts to provide Canadians living with obesity better access to obesity prevention and treatment efforts.

As we state in the article (based on original research by Ramos-Salas and others),

“A critical review of Canadian obesity prevention policies and strategies revealed five prevailing narratives about obesity: “(1) childhood obesity threatens the health of future generations and must be prevented; (2) obesity can be prevented through healthy eating and physical activity; (3) obesity is an individual behavior problem; (4) achieving a healthy body weight should be a population health target; and (5) obesity is a risk factor for other chronic diseases not a disease in itself”. These narratives create the opportunity for Canadian obesity policy recommendations to focus mainly on individual-based healthy eating and physical activity interventions. By simplifying the causes of obesity as unhealthy eating and lack of physical activity, these policies may be contributing to the belief that obesity can be solely controlled through individual behaviors. This belief is a fundamental driver of weight bias.”

This “world-view” of obesity at the level of policy makers has a significant impact on the willingness and capacity of health systems to provide access to evidence-based obesity treatments to the nearly 7 million Canadian adults and children living with this chronic disease – in fact, the unwillingness to even consider obesity a chronic disease is a big part of the problem.

“..the conceptualization of obesity as a risk factor in public health policies has implications for government action, by prioritizing prevention over treatment strategies and potentially alienating Canadians who already have obesity. The review concludes that existing Canadian public health policies and strategies (a) are not sufficiently comprehensive (i.e., solely focused on prevention and mainly focused on children; exclude evidence-based management approaches; are not person-centered); (b) are based on reductionist obesity models (i.e., models that cast shame and blame on individuals by focusing on individuals’ responsibility for their weight); and (c) do not account for individual heterogeneity in body size and weight (i.e., generalize weight and health outcomes at the population level).”

In contrast we suggest that,

“Adopting a chronic disease framework for obesity would imply that both prevention and management strategies need to be implemented. Within this chronic disease context, public health should ensure that strategies do not have unintended consequences for individuals and populations, such as perpetuating weight bias. There is now sufficient evidence demonstrating that weight bias and obesity stigma are fundamental drivers of health inequalities. Public health has an opportunity to leverage existing health promotion frameworks such as the health for all policy framework and the global plan of action on social determinants of health to address weight bias and obesity stigma”.

Based on the analyses presented in this paper, we make the following recommendations:

  • Canadian provincial and territorial governments, employers, and the health insurance industry should officially adopt the position of the Canadian Medical Association and the World Health Organization that obesity is a chronic disease and orient their approach/resources accordingly.

  • Canadian provincial and territorial governments should recognize that weight bias and obesity stigma are significant barriers to helping people with obesity and enshrine rights in provincial/territorial human rights codes, workplace regulations, healthcare systems, and education policies.

  • In an era of people-centered health care, public health and health system decision makers should engage people with obesity in the development of policies and strategies. Having active participation of individuals with obesity can help change negative attitudes and beliefs about obesity and facilitate the development of compassionate and equitable health promotion strategies.

  • Employers should recognize and treat obesity as a chronic disease and provide coverage for evidence-based obesity treatments for their employees through health benefit plans.

  • Provincial and territorial governments should increase training for health professionals on obesity prevention and management.

  • Existing Canadian Clinical Practice Guidelines for the management and treatment of obesity in adults should be updated to reflect advances in obesity management and treatment in order to support the development of evidence-based programs and strategies by health systems, employers and health insurance companies.

@DrSharma
Athens, Greece

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The Heterogeneity of Obesity

In the same manner in that there is not one predisposing factor for the development of obesity, the phenotypic clinical presentation of obesity is likewise extraordinarily heterogenous. (This has some authors speaking of “obesities” rather than “obesity”).

While it is now well established that BMI is a measure of size rather than health, it is perhaps less well recognised how the different types of body fat and their storage in various fat depots and organs can contribute to cardiometabolic disease (location, location, location!).

Now, a comprehensive review by Ian Neeland from the University of Texas Southwestern Medical Center, Dallas, together with my colleagues Paul Poirier and JP Despres from Laval University in Quebec, published in Circulation discusses the cardiovascular and metabolic heterogeneity of obesity.

As the authors point out,

“Although the BMI has been a convenient and simple index to monitor the growth in obesity prevalence at the population level, many metabolic and clinical studies have revealed that obesity, when defined on the basis of the BMI alone, is a remarkably heterogeneous condition. For instance, patients with similar body weight or BMI values have been shown to display markedly different comorbidities and levels of health risk.”

Not only has BMI never emerged as a significant component in risk engines such as the Framingham risk score, there are many individuals with obesity who never develop metabolic complications or heart disease during the course of their life.

The paper offers a good review of what the author describe as adipose dysfunction or “adiposopathy” = “sick fat”. Thus, in some individuals, there is an accumulation of “unhealthy” fat (particularly visceral and ectopic fat), whereas in others, excess fat predominantly consists of “healthy” fat (predominantly in subcutaneous depots such as the hips and thighs).

The authors thus emphasise the importance of measuring fat location with methods ranging from simple anthropometric measures (e.g. waist circumference) to comprehensive imaging techniques (e.g. MRI).

The authors also provide a succinct overview of exactly how this “sick fat” contributes to cardiometabolic risk and briefly touches on the behavioural, medical, and surgical management of patients with obesity and elevated cardiometabolic risk.

I, for one, was also happy to see the inclusion of the Edmonton Obesity Staging System in their reflections on this complex issue.

This paper is certainly suggested reading for anyone interested in the link between obesity and cardiovascular disease.

@DrSharma
Edmonton, AB

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