Serious Mental Illness Does Not Make Weight Management ImpossibleTuesday, March 26, 2013
Regular readers will recall that in the 4Ms of Obesity Assessment, the first M refers to mental health. This is because uncontrolled mental health problems can can make weight management difficult – but not impossible.
This is the finding of a paper by Daumit and colleagues published in the New England Journal of Medicine.
The investigators randomised 291 overweight or obese adults (mean BMI 36) from 10 community psychiatric rehabilitation outpatient programs to tailored group and individual weight-management and group exercise sessions or a control intervention.
Of the participants, 58% had schizophrenia or a schizoaffective disorder, 22% had bipolar disorder, and 12% had major depression.
Over the 18 months of the trial, weight loss in the intervention group increased progressively and differed significantly from the control group at each follow-up visit – the mean between-group difference was about 3 Kg at the end of the trial with almost 40% of participants in the intervention group losing 5% of their initial weight (vs. 22% in the control group).
These effects are very much in line with the expected benefits of such a behavioural intervention in previous studies in people without mental illness.
Thus, behavioural weight-loss interventions can significantly reduce weight even in people with severe mental illness. Or, as the authors put it,
“….our results show that overweight and obese adults with serious mental illness can make substantial lifestyle changes despite the myriad challenges they face. “
Given the fact that obesity and mental health problems often co-exist and people with severe mental health issues are at high risk of weight gain, mental health programs should encourage and support weight management interventions in their clients.
Daumit GL, Dickerson FB, Wang NY, Dalcin A, Jerome GJ, Anderson CA, Young DR, Frick KD, Yu A, Gennusa JV 3rd, Oefinger M, Crum RM, Charleston J, Casagrande SS, Guallar E, Goldberg RW, Campbell LM, & Appel LJ (2013). A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness. The New England journal of medicine PMID: 23517118
Tuesday, March 26, 2013
You write: “Thus, behavioural weight-loss interventions can significantly reduce weight even in people with severe mental illness.”
I assume you are talking about statistical significance, right? Because 3kg is not clinically significant, right? And I believe even 5% weight loss has been proven useless (in the LOOK ahead trial, at least).
You also mention that the results are the same in mentally healthy people. Does that mean that behavioral interventions can only be expected to lead to statistically significant weight loss, not clinically significant?
Tuesday, March 26, 2013
3Kg can be very clinically significant (as can simply stopping to gain weight) – it can make the difference between being diabetic or just pre-diabetic. Every kilogram lost takes four kilograms off each knee at every step! Also, in LOOK Ahead, the 5% weight loss was highly effective in reducing pain, improving sleep apnea, improving diabetes control and improving quality of life – just not in reducing CV deaths (because the LOOK Ahead participants were way too healthy or too well managed). So, no, I do mean clinically significant! If you are worried about living for ever, no, losing 3Kg won’t guarantee that – if you want a better quality of life, less pain and perhaps reduce your diabetes meds – chances are it may.
Friday, March 29, 2013
Dear Dr. Sharma,
As one who has been diagnosed with adult ADHD, chronic PTSD (the latter resulting from conditions of chronic, severe trauma throughout childhood, starting as a toddler) and also diagnosed with clinical depression on several occasions, I can attest that your topic today is highly relevant for mental health patients (and for those who wish to help them.)
My comments here, today, are intended to underscore the unpredictable complexities of an individual’s “health” status, her health care “treatments” (for mental health issues and for health problems commonly associated with obesity), and her real-life “health outcomes” in light of everyday conditions of social reality. That is, I hope to highlight typical outcomes that may happen (unexpectedly) when an individual’s lived experiences take place, accumulate, and progress outside or beyond the artificial, short-term boundaries of experimental, research-controlled conditions.
In other words, the following represents one type of scenario that happens within the contexts of (uncontrolled for) health-determining social conditions over which individuals wield little or no power to transform. It may be difficult to conceptualize as “typical” for someone with socioeconomic status, privilege, and security. I assure you, though, that it is not hard to identify with, and understand, from a social position of oppression and chronic uncertainty.
First of all, as someone with mental health struggles, it verges on *the miraculous* whenever I’ve encountered (only twice in 30 years) mental health care providers who were able to see the whole HUMAN BEING, me, beyond their psych labels, beyond the presenting symptoms, beyond the shocking history, and beyond the illnesses—illnesses which (in keeping with my dependency on humor as self-medication) I prefer to lump all together as “What The F**k Disorder!!??!” aka WTFD.
One of those providers was a psychologist (who could not legally prescribe drugs but went to bat for me with a Nurse Practitioner who COULD write scripts, and who did, in collaboration with my psychologist and with me.) The second of those live-saving providers was, of course, the aforementioned Nurse Practitioner who also treated me as a valued and trusted member of our team—the Save-HopefulandFree-Team.
Together—during 4 intense years of trust, pain, and focused effort—our little team helped me to make FAR more progress than I had made in the previous 35 years.
Eventually, among other accomplishments, I attained a state of mind (clearer, more focused and determined) whereby I was able and willing to take many positive risks, professionally and personally, and to make many hopeful and helpful “lifestyle” changes.
For instance, I began a daily walking routine and included twice-weekly weight lifting sessions, benefited from regular physical therapy, became a licensed RN, lost about 130 lbs, eliminated T2D symptoms, stabilized BP, normalized blood lipid levels, and significantly reduced (and/or learned to manage) symptoms of chronic pain and suffering related to (1) Fibromyalgia, (2) shoulder instability (torn rotator cuff plus impingement syndrome resulting from chronic overuse as a house painter), (3) lower back (reoccurring pain/inflammation from old hiking injury–jammed SI joint–and sciatica), (4) osteoarthritis of CMC joints (required bilateral LRTI arthroplasty surgery) (5) cervical osteoarthritis with osteophytes, (6) idiopathic peripheral neuropathy of toes/feet.
The chronic insomnia, which began over 15 yrs ago during early peri-menopause, was never fully resolved for more than brief periods of time (but was managed well enough to allow for improved daily functioning.) Thus, I was coping rather well in spite of several stressful setbacks—involving loss of my “miracle team” (both retired), loss of income, loss of medical insurance, and progressive worsening of various kinds of economic insecurity resulting from my partner’s severe injuries and disabilities, sustained from a car wreck (caused by a negligent driver who ran a stop sign.)
Two and one-half years ago, I’m sure I would have been recorded as a glowing “success” in terms of both weight loss, reduced health risks, and mental health stability. However, my current level of functioning is (and has been for at least 2 years) worse than I have ever experienced. I am unable to find a provider who has the slightest understanding of the most basic, elementary relationships between significant adipose loss and neuro-endocrine-metabolic dysfunctions (for example, resulting from leptin insufficiency). I appear, on the surface, rather healthy and able-bodied, I suppose, because I weigh a “normal” amount and because I present as an intelligent, well-educated, attractive, articulate, compliant, well-groomed and cooperative person.
When I try to explain that I am now disabled, that I very seldom move from my recliner or my desk chair, that I cannot concentrate on complex ideas, have difficulty reading, have no motivation or energy, experience little or no hope for future improvement, etc, it’s as if I’m speaking a foreign language—after all, I LOOK so good—or else the solution is obvious: I just need a better anti-depressant, or more psychotherapy.
Now I have resigned myself to attempting to REGAIN adipose tissue that—when I was obese—was apparently helping to compensate, in part, for neurological-endocrine-metabolic deficits, which my former care-providers understood as physiological impairments requiring psychotropic interventions which are considered too controversial and/or extreme by most status quo psychiatric providers. I’m hoping that the increased availability of endogenous leptin (from increased adipose tissue) will improve dopaminergic tone and thus improve cognitive (executive) function—mandatory for “normal” functioning—and survival—in our capitalist, efficiency and goal-oriented culture.)
Obviously, I’m not looking forward to being a target, once again, of fat stigma–with its discrimination, stereotypes, disrespect, assumptions, etc. As you can perhaps imagine, this is a terrible dilemma to be facing. And my mental illnesses (WTFD) are not even considered that “severe”, since I’ve never experienced psychotic features.
hopefulandfree (aka RNegade)
Saturday, March 30, 2013
Hopefulandfree: Thank you for sharing your story on these pages – you write of all of the things that I so often address in my posts – it is certainly the side of obesity that gets forgotten when we focus on what foods to eat (or not) and how much exercise is good for you (or not). Valuable as the latter may be for improving health – they have little to do with addressing the root causes of the problem – my patients have taught me better.
Saturday, March 30, 2013
Dear Dr. Sharma,
Thank you so much for allowing me to share my struggles here, struggles which our dominant cultural discourses and beliefs do not acknowledge because of the overwhelming focus on physical, surface appearances.
It is ghastly to be viewed as healthy and “normal” simply because of my attractive external body and my ability to interact in a socially appropriate (and approved) manner. Health, however consists of so much more than surface appearances. I am grateful beyond words that you are able to understand the kinds of struggled and dilemmas encountered by people who have lost significant (large) amounts of weight (taking us from the realm of social stigma to social acceptance and, also, admiration.)
Having to regain weight (in spite of feeling no compelling appetite or hunger) simply with the remote hope of creating improved cognitive/metabolic/endocrine functions really SUCKS. Seriously.
I’m one of the lucky ones who does not experience problems with excessive hunger or appetite, but that is condition is so incidental to the other (extreme) problems that I DO experience in terms of cognitive and emotional dysregulation—and overwhelming impairment of executive functions.
It feels very gratifying to recognize that another health care professional actually understands this terrible problem—this enforced existence in a historical reality which has not yet caught up with the science of weight maintenance.