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The M & Ms of Obesity Assessment
Most textbooks on obesity will tell you that assessing someone for obesity should start with a careful exploration of weight history, eating habits and lifestyle. I disagree! For reasons that I will outline below, I believe that the proper assessment of patients presenting with excess weight should first focus on the four “M”s or the mnemonic “M”, “M”, “M”, & “M”. As I presented yesterday in a talk on obesity assessment at the American Heart Association Meeting in Orlando, obesity is not only a remarkably heterogeneous condition resulting from a wide range of environmental, psychosocial and biomedical causes, successful weight management is also remarkably difficult and tenuous even in the most motivated and determined of patients. The primary goal of assessment therefore should first strive to identify the possible causes and circumstances leading to excess weight gain, determine to what extent that excess weight is affecting health and systematically look for barriers that will make weight management difficult, if not impossible. Each of the four “M”s explores a domain that is potentially relevant to all of the above questions. The first “M” stands for “Mental Health”. Not only can common mental health problems often lead to weight gain (e.g. depression, addictions, attention deficit, abuse, PTSD, sleep disorders, emotional eating, etc.), but when present (as is often the case), they can make weight management most challenging. In addition, excess weight can directly affect mental health by promoting poor self-esteem, depression and social anxiety disorder. Thus, devising a weight management plan always requires a good understanding of a patient’s mental health status, if only to determine that there are indeed no major mental health causes or consequences of weight gain nor significant mental health barriers that will make weight management difficult, if not impossible. The second “M” is a reminder to look for the many “Mechanical” causes or complications of excess weight. These can present in the form of back pain or osteoarthritis, sleep apnea, reflux disease, urinary incontinence, and many other problems associated with excess weight. When present, these issues can not only promote or exacerbate weight gain but can also pose important barriers to weight management – clearly someone with plantar fasciitis is unlikely to walk the recommended 10,000 steps. The third “M” should prompt us to look for the wide range of “Metabolic” complications of excess weight. These not only include diabetes, dyslipidemia or gout, but also hypertension (a… Read More »
Obesity: Lifestyle Choice or Lifestyle Chance?
Readers of these pages should by now recognize that obesity is an extraordinarily heterogeneous and complex condition. While energy balance is simply a matter of energy in and energy out, the determinants of energy in and energy out are anything but simple. Indeed, the sociopsychobiology of ingestive behaviour is perhaps the most complex of all human behaviours (not surprising given its importance for survival of the species) and the physiological, neuroendocrine and biochemical pathways that determine energy metabolism and activity thermogenesis are clearly no simpler. It is perhaps, therefore, not all that unexpected when study after study (let alone your own experience) shows that the simplistic formula: “eat less – move more” is so disappointingly ineffective in either preventing or treating excess weight. Yet, health professionals, decision makers and the general public continue to believe that obesity is simply a matter of “choice”, or in other words, people struggling with excess weight are simply making the wrong choices. Were they only to smarten up and chose differently, their fat would simply melt away – hopefully forever. The fact that this “simple” formula for maintaining a healthy weight is about as realistic and effective as the “simple” formula for getting rich on the stock market by simply buying low and selling high, apparently does not deter the “healthy living missionaries” from preaching to the uninitiated, who are simply too stupid to understand that weight management is really just a matter of choosing to do the right thing! Let us for a minute assume that “lifestyle” truly is a major determinant of weight gain (and let us simply ignore the vast body of research on genetics, imprinting, fetal programming, environmental toxins, gut bugs, adipogenic adenoviruses, activated hypothalamic-pituitary adrenal axes, mood and anxiety disorders, addictions, attention deficit, abuse, emotional neglect, poor body image, obesogenic medications and the many other well-documented causes of obesity), then the question remains how much of lifestyle is truly simply a matter of “choice”. How many of us simply chose sedentary jobs that keep us in front of a computer all day, simply chose to live in neighbourhoods with no sidewalks, simply chose to work in jobs where we earn so little that the only food we can afford to feed our family is crap, simply chose to live so far from work that we face daily hour-long commutes that leave little time for recreational activity (let alone enough… Read More »
Lifestyle Patterns Among Obese Adults – Chicken or Egg?
Weight gain is the result of positive energy balance and the only way you can get into positive balance is if energy input exceeds output. As all calories enter the body as food or drink, ingestive behaviour is obviously an important determinant of energy balance. Although physical activity accounts for only around one-third of total energy expenditure (two-thirds of energy is burnt just to keep your body alive), it is still an important component of energy balance. It is therefore not surprising when studies find that “eating too much” or “not moving enough” is often (but not always!) associated with weight gain. This is in fact exactly what was found in a new study by Robert Kushner and SW Choi from the Northwestern University, Chicago, IL, just published in OBESITY. This study looked at responses to a 53-item lifestyle pattern questionnaire posted on a commercial weight loss program Web site (2004- 2008) in 446,608 adults with an average BMI of 30.5. Categorically, 25.5% were healthy weight, 29.0% were overweight, 33.7% were class I-II obesity, and 11.8% class III obesity. A stratified random sample was used to estimate the prevalence of 21 lifestyle patterns (7 eating, 7 exercise, and 7 coping: figure) and the odds ratio of the pattern prevalence for each BMI category. “Unhealthy” lifestyle patterns in diet, exercise, and coping were highly prevalent among the entire population, whereby, the prevalence of these patterns rose with increasing BMI and advancing age. Gender differences were seen with many of the patterns, most noticeably among the coping patterns. Thus, prevalence of five coping patterns was noticeably higher among women compared to men: emotional eater (41% vs. 29%), self-scrutinizer (negative self-talk) (52% vs. 27%), persistent procrastinator (73% vs. 61%), people pleaser (low self-care) (54% vs. 40%), and doubtful dieter (pessimistic thinking) (41% vs. 29%). Overall, the lifestyle patterns and terminology used in this study is reminiscent of the “personality types” that Dr. Kushner has described before (see previous blog entry on this). Based on the current study, the authors conclude that “unhealthy” behavioural patterns are associated with obesity and that behavioural pattern recognition could help identify patients at risk. For me the paper raises more questions than it answers: Firstly, I was surprised that despite the significant associations, the effect sizes of individual patterns was actually quite low: this means that a lot of people in the “healthy weight” range apparently also engage… Read More »
Still More on ADHD and Obesity
In response to yesterday’s post on ADHD and obesity, I was made aware of two recent studies, both relevant to this topic. In the first, A psycho-genetic study by Caroline Davis and colleagues from York University, Toronto, Ontario, Canada, published in the Journal of Psychiatric Research, the researchers examined whether ADHD symptoms were more pronounced in adults with symptoms of binge eating disorder (BE) than in their non-binging obese counterparts, and whether the links were stronger with inattentive vs impulsive/hyperactive symptoms. They also assessed the role of the dopamine D3 receptor in ADHD symptoms since the DRD3 gene has been associated with impulsivity and drug addiction – both relevant features of ADHD. In the study that involved 60 cases and 120 controls (60 obese and 60 normal weight), childhood and adults ADHD symptoms were assessed and genotying was performed. While all of the four ADHD symptom scales were significantly elevated in the BE and obese groups compared to the normal weight group, bearers of three DRD3 genotypes had significantly elevated scores on the hyperactive/impulsive symptom scale. These results suggest that symptoms of ADHD are more common in obese individuals (irrespective of BED status) and that the D3 receptor may play a role in the manifestation of the hyperactive/impulsive symptoms of ADHD. In another study, published in this month’s issue of OBESITY by Lance Levy and colleagues from the Nutritional Disorders Clinic, also in Toronto, Ontario, Canada, they describe their success in treating refractory obesity in severely obese adults following the management of newly diagnosed attention deficit hyperactivity disorder. 78 subjects out of 242 consecutively referred severely obese, weight loss refractory individuals were diagnosed as having ADHD, of which 65 received ADHD treatment and 13 remained as controls. After an average of 466 days of continuous ADHD pharmacotherapy, weight change in treated subjects was -12% of initial weight versus a 3% weight gain in controls. This study not only confirms that ADHD is a highly prevalent condition in severely obese patients, but that the treatment of ADHD is associated with significant long-term weight loss in individuals with a lengthy history of weight loss failure. Levy suggests, as I did in earlier postings on this topic, that ADHD should be considered as a primary cause of weight loss failure in obese patients. As he points out, this finding may also be important for patients seeking obesity surgery, as surgical patients with unmanaged… Read More »
ADHD, BED and Obesity in US Adults
In my clinical practice I remain impressed by the surprisingly high incidence of attention deficit hyperactivity disorder (ADHD) in my obese patients. Many have had symptoms all their lives, many have kids diagnosed and treated for ADHD, but have never considered that they may have this condition themselves. Long-time readers of this blog will recall several previous postings on this issue – there is little doubt that ADHD is a major handicap in dealing with a weight problem. Lack of impulse control, difficulty planning and following through on lifestyle changes, compliance problems – all make it difficult for someone with ADHD to tackle their weight problem. But how close is the relationship between ADHD and obesity in the general population? Based on previous observations that while ADHD affects ~2.9-4.7% of US adults, this condition is reported to be present in 26-61% of patients seeking weight loss treatment, Sherry Pagoto and colleagues from the University of Massachusetts, MA, USA, revisited this issue in a paper published in this month’s issue of OBESITY. Using cross-sectional data from the Collaborative Psychiatric Epidemiology Surveys, which includes data from 6,735 US residents (63.9% white; 51.6% female) aged 18-44 years, a retrospective assessment of childhood ADHD and a self-report assessment of adult ADHD were administered. The prevalence of overweight and obesity was 33.9 and 29.4%, respectively, among adults with ADHD, and 28.8 and 21.6%, respectively, among persons with no history of ADHD. Thus, adult ADHD was associated with a 58% greater likelihood of overweight and 81% greater likelihood of obesity. Further analyses suggested that binge eating disorder (BED), but not depression, partially mediates the associations between ADHD and excess weight. This is not surprising, given that poor impulse control is likely to affect binge-eating behaviour. The study underlines what I have long proposed: assessment for ADHD should be part of routine work up for obesity and weight-related health problems. When present, ADHD can pose a major barrier to obesity management and should be addressed by CBT and/or medications. AMS Edmonton, Alberta
