Arya M. Sharma, MD

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

Dr. Sean Wharton, Burlington, Ontario

Readers may recall a recent post on a clinical trial by Wadden and colleagues on the feasibility of achieving clinically meaningful outcomes of ‘enhanced’ lifestyle counselling largely delivered by primary care practitioners with minimal training in obesity management. In that study, ‘health coaches’ (with no advanced expertise as one may expect from registered dieticians or exercise specialists), working under the guidance of a primary care physician, helped about 20-25% of patients achieve at least a 5% weight loss.

A paper by Sean Wharton and colleagues, published in the latest edition of the Canadian Family Physician, now presents ‘real-life’ data from a similar primary care approach in 2739 consenting patients attending an interdisciplinary obesity-management program in Burlington Ontario.

As described in the paper,

“The Wharton Medical Clinic (WMC) is an interdisciplinary bariatric clinic located in Hamilton and Burlington, Ont, which includes a team of physicians, behavioural therapists, dietitians, and nutritionists. The clinic operates under principles outlined in the Canadian clinical practice guidelines for the treatment of obesity, which recommend dietary, exercise, and behavioural interventions for weight loss, with meal replacement, pharmacotherapy, and surgery as adjunct therapies when indicated. Patient visits consist of services charged to the Ontario Health Insurance Plan, including physician visits, calorimetry, and diagnostic testing such as blood work and electrocardiography. Complementary services (drop-in visits in which patients weigh themselves and educational sessions) that are not charged to the Ontario Health Insurance Plan or to patients are also offered to allow for greater patient contact without increasing the cost to the health care system. As obesity is a chronic, relapsing medical condition, there is no defined program length.”

A key element of the program is the employment of ‘bariatric educators’, who have a university degree in nutrition, but no other formal training as health professionals. Under the guidance of the physicians, these bariatric educators deliver 20-minute educational sessions on nutrition and exercise to patients and monitor individualized weight-management strategies at each visit.

The paper presents the results of all 2739 patients as well as for the 1085 patients, who attended the clinic for at least 3 months, and the 389 patients, who attended for at least 6 months. The average weight loss in these groups were 2.3, 3.5, and 4.3 Kg, respectively.

Perhaps, more importantly, 17, 32, and 47% of patients achieved and maintained at least a 5% weight loss, whereas 4, 9, and 17% achieved a 10% weight loss, respectively.

Although these results may appear modest, it is important to note that these levels of adherence, retention, and ‘control’ are in fact very similar to what is seen with virtually every other chronic condition including hypertension, diabetes, or chronic respiratory disease and speaks to the general difficulties that many patients appear to have with the long-term adherence to chronic disease management programs in general, especially those requiring on-going frequent clinic visits.

Thus, as the authors note:

“As with many other chronic conditions, clinical goals and treatment outcomes for obesity management might not bring patients to “normal” levels. For example, the clinical goals for hypercholesteremia and hyperlipidemia, hypertension, and type 2 diabetes management do not return patients to levels observed in individuals without the conditions. In fact, up to two-thirds of patients are unable to meet clinical goal targets, highlighting the difficulty in managing chronic conditions. Thus, the proportion of participants achieving the targets of 5% to 10% weight loss at the WMC appears to be comparable with successes in the management of other metabolic conditions.”

This said, it is indeed notable that this ‘real-life example’ of a physician-run interdisciplinary publicly funded clinic (vs. the afore mentioned ‘clinical trial’ setting of the Wadden study) can help a substantial number of patients achieve clinically significant weight loss (almost 50% of patients who remained in the program for at least 6 months).

While this level of ’success’ may be well below what most patients normally expect (for e.g. from a commercial ‘weight-loss’ program), the health benefits of modest ‘therapeutic’ weight loss are well recognized and may perhaps be better sustainable than the much larger short-term weight-loss promised and targeted in many commercially driven ‘wehght-loss’ programs.

Obviously, as the authors note, it will be important to determine the effectiveness of this program beyond six months.

Nevertheless, this ’short-term’ real-life experience does provide some valuable insights:

For one, this paper demonstrates the potential value of bariatric educators (nutritionists), who provide education and dietary support.

As the authors note,

“The decision to engage nutritionists rather than registered dietitians in the program was based on the fact that although dietitians are highly qualified health professionals, their continuing engagement in a high-intensity program requiring ongoing follow-up visits is limited by availability and cost. In contrast, as demonstrated in this paper, bariatric educators, under the guidance of a physician, can provide an economical and effective approach to routine weight management in uncomplicated patients.”

In addition,

“Given the important relationship between frequency of follow-up visits and maintenance of weight loss, it appears prudent to offer self-directed walk-in weigh-in sessions in an unintimidating environment, which increases patient contact with the clinic and serves as a regular reinforcement of behavioural change.”

Future studies will also need to determine improvements in other relevant health outcomes including comorbidities and quality of life as well as cost-effectiveness of this approach.

Nevertheless, these initial observations certainly appear promising and may provide a model for other primary care practices considering weight-management interventions in their patients.

AMS
Toronto, Ontario

Wharton S, Vanderlelie S, Sharma AM, Sharma S, & Kuk JL (2012). Feasibility of an interdisciplinary program for obesity management in Canada. Canadian family physician Medecin de famille canadien, 58 (1) PMID: 22267637

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This week I am attending the World Congress on Obesity, organized by the International Diabetes Federation.

As one would imagine, the program here is chock-full of talks on obesity - everything from the impact of excess weight on insulin resistance and diabetes risk to basic science talks on energy and appetite regulation.

This morning I will be presenting a 60 min course on obesity management in diabetes and later this week, I will be co-chairing a session on bariatric surgery.

At this moment I am sitting in a session on obesity in ethnic populations listening to talks on why, for e.g., the very concept of weight loss goes against many traditional cultures and indeed, losing weight or being skinny is neither socially desirable nor a sign of good health.

This of course, proves a challenge as type 2 diabetes becomes more rampant in these populations (like India, South America, Australian Aboriginals, etc.) where there is little interest in weight management as an important principle in diabetes prevention and management.

I certainly look forward to a most interesting week here in Dubai and learning more about diabetes and its management from my colleagues around the world.

AMS
Dubai, UAE

Regular readers of these pages will by now be quite familiar with the ‘obesity paradox’ - the rather consistent finding that people with chronic disease (e.g. heart failure, chronic obstructive lung disease, end-stage kidney failure, etc.) tend to have lower mortality rates that skinny people with these conditions.

This raises the question whether or not obesity may generally be ‘protective’ in the elderly, who often have such conditions.

This question was now addressed by Jiska Cohen Mansfield and Rotem Perach from Tel Aviv University, in a paper just published in the Journal of Aging Research.

The authors looked at data from 1369 participants aged 75-94 from the Longitudinal Aging Study (CALAS), a national survey of a random sample of older Jewish persons in Israel conducted during 1989–1992.

Based on the mortality data at 20-year follow up, extracted from the Israeli National Population Registry, obesity was a significant predictor of higher mortality in persons aged 75 to 84 compared to ‘non-obese’ individuals.

Past the age of 85, however, obesity was no longer a predictor of mortality and, if anything, appeared to have a (non-significant) ‘protective’ effect.

In contrast, being underweight was consistently predictive of mortality.

These findings certainly support the notion that obesity (at least when measured by BMI) may be less of a health concern in the very elderly and may indeed signal better health than being skinny.

The authors provide several possible explanations for their findings:

“Lower rates of osteoporosis in heavier persons, possibly due to greater weight-bearing bone formation, may reduce their risk of falls and subsequent potential trauma. Obesity may also provide energy reserves in times of stress, illness, and trauma. In addition, obesity may prolong the period of predeath weight loss, as aging is associated with decreased food intake.”

Thus, as the authors discuss:

“..with the increasing numbers of old-old persons and of their life expectancy, extra attention is often given to avoiding obesity. Current findings suggest that such an emphasis may not apply to those advancing towards old-old age, at least as far as mortality is concerned.”

Sounds like it may be time to tell your Grandma to go off her diet?

AMS
Toronto, Ontario

p.s. Hat tip to Morgan Downey for alerting me to this article

Cohen-Mansfield J, & Perach R (2011). Is there a reversal in the effect of obesity on mortality in old age? Journal of aging research, 2011 PMID: 21966593

As i have often noted before, the ultimate burden of delivering obesity management will fall on primary care practitioners (PCPs).

However, many PCPs shy away from providing these services due to lack of knowledge, lack of reimbursement or widely held beliefs about the modest outcomes of such services. In addition, practitioners (and patients) often cite the lack of access to specialized professionals (e.g. registered dietitians, psychologists, exercise specialists, etc.) as a limiting step in providing weight management in primary care.

Now, a paper by Tom Wadden and colleagues, just published in the New England Journal of Medicine, shows that clinically meaningful weight management can be provided in primary care settings by staff that has minimal training in obesity interventions.

For this study (Practice-based Opportunities for Weight Reduction Trial at the University of Pennsylvania or ‘POWER-UP’), a total of 390 obese adults in six primary care practices were randomized to one of three types of intervention:

1) Usual care, consisting of quarterly PCP visits that included education about weight management;

2) Brief lifestyle counseling, consisting of quarterly PCP visits combined with brief monthly sessions with lifestyle coaches who instructed participants about behavioral weight control;

3) Enhanced brief lifestyle counseling, which provided the same care as described for the previous intervention but included meal replacements (SlimFast) or weight-loss medication (sibutramine or orlistat).

Over 85% of participants completed the 2-year trial, at which time, the mean weight loss with usual care, brief lifestyle counseling, and enhanced brief lifestyle counseling was 1.7, 2.9, and 4.6 kg, respectively.

Initial weight decreased at least 5% in 21.5%, 26.0%, and 34.9% of the participants in the three groups, respectively.

While these reductions in body weight, are certainly modest, the key point of interest to me is that the brief lifestyle counselling interventions were delivered in 10 to 15 minutes of monthly encounters with an auxiliary health care provider (medical assistant), referred to as a ‘lifestyle coach, who was trained and certified to deliver assessment and advise based on a review of participants’ recording of food intake, physical activity, and other goals.

Importantly, none of these PCPs or ‘lifestyle’ coaches had any prior training or experience in weight management. In fact, their only qualification for providing weight counselling consisted of study staff provided 6 to 8 hours of training to PCPs and lifestyle coaches. Recertification was provided every 6 months and throughout the trial, study staff met with PCPs and coaches for 30 to 60 mins to review protocol implementation.

Thus, these results were achieved by PCP staff that underwent minimal training in weight management and certainly had no ‘advanced’ professional expertise (e.g. that of a registered dietitian or certified exercise physiologist).

As the authors point out, this study certainly shows that even the most minimal intervention provided in this study by PCPs and ‘health coaches’ could achieve a clinically meaningful 5% weight loss in about 20-25% of their patients, certainly not a number to be lightly dismissed given the evidence that a 5% weight loss may be enough to decrease the risk of type 2 diabetes by 60% (indeed, such ‘control’ rates are not too different from those of many other chronic conditions in primary care settings).

While the paper does not discuss actual costs of this interventions (or its long-term cost-effectiveness), the results certainly suggest that weight management in primary care could be delivered at a reasonable and sustainable cost, even with very limited resources or training.

On the other hand, I would be tempted to suggest that any ‘lifestyle’ intervention that is largely based on a ‘behavioural’ rather than an ‘etiological’ paradigm is always likely to produce modest outcomes (that most patients are unlikely to sustain).

While simple advise and reinforcement can certainly be delivered with some basic training in ‘coaching’ techniques, I would presume that interventions that specifically address the ‘whys’ underlying the relevant behaviours may well require greater diagnostic competencies and expertise (and possibly different management strategies).

Thus, I continue to be wary of obesity studies that recruit ‘all comers’ irrespective of potential differences in aetiology - after all, eating too much is a ’symptom’ not a ‘diagnosis’.

AMS
Toronto, Ontario

Wadden TA, Volger S, Sarwer DB, Vetter ML, Tsai AG, Berkowitz RI, Kumanyika S, Schmitz KH, Diewald LK, Barg R, Chittams J, & Moore RH (2011). A Two-Year Randomized Trial of Obesity Treatment in Primary Care Practice. The New England journal of medicine PMID: 22082239