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DSM-5: Binge Eating in, Obesity Out

Yesterday, the draft version of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released for public comment until April 20. The book, which serves mental health professionals, is also used by insurance companies making decisions on treatment coverage and in courtrooms and schools. It was last revised in 1994. From what I’ve been able to garner from the news wires, the new Manual now clearly lists and identifies binge eating but not obesity as a mental health disorder. This is probably a good thing. While there is no doubt that binge eating disorder is a syndrome that requires specific mental health intervention, the same cannot necessarily be said for all of obesity. This is not to say that a large proportion of overweight and obese individuals may also have mental health problems ranging from poor body image to major depression, addictions or attention deficit disorder – I have often blogged about this before. But clearly, not everyone with excess weight also has a mental health diagnosis and certainly not all overweight patients need to be seen by a mental health professional. Indeed, as previously noted, obesity is really only the clinical manifestation of caloric excess, and is as such more a clinical sign than a discrete entity in itself. It would therefore make no sense to list obesity as a mental illness or to expect that all obese individuals must now seek help from a mental health professional. Nevertheless, given the importance of mental health problems either as promoters and/or consequences of weight gain or as important barriers to weight management, having mental health expertise in a weight management program is absolutely essential. I am sure that the DSM-5 will prompt a wide range of debates and discussions and I will certainly take a closer look at the relevant segments of this intimidating document. The final version of the manual is due to be published in 2013. Certainly appreciate comments from any of my readers who work in mental health. AMS
 Vienna, Austria

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Weight Loss is Not Effective Treatment for Obese Binge Eaters

As blogged before, binge eating disorder (BED) can be diagnosed in as many as in one in four patients presenting in bariatric centres for weight loss. Typical BED is characterized by frequent and persistent episodes of binge eating accompanied by feelings of loss of control and marked distress in the absence of regular compensatory behaviors. The disorder is associated with specific psychopathology (eg. dysfunctional body shape and weight concerns), psychiatric comorbidity (depression and anxiety disorders), and significant health and psychosocial impairments. In my experience, the vast majority of patients with BED present with impressive histories of weight cycling, sometimes losing substantial amount of weight, only to soon gain it back. As do many obese patients, including those without BED, they fully believe that losing weight is the only solution to their often complex problems. Just how futile weight loss attempts can be for patients with BED without primarily addressing the underlying psychopathology is nicely illustrated by Terence Wilson and colleagues from Rutgers University, New Jersey, just published in the Archives of General Psychiatry. In this study, 205 women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED were randomised to twenty sessions of behavioural weight loss with moderate caloric restriction and exercise (BWL) or interpersonal psychotherapy (IPT) or 10 sessions of guided self-help cognitive behavioural therapy (CBTgsh) during 6 months. At the end of the 6 month intervention, a substantially greater number of BWL patients achieved a 5% reduction in body weight (41%) than with IPT (15%) or CBTgsh (15%). At this time, all patients reported a similar reduction in binge-eating episodes. However, two years later the picture looked quite different: while there were no longer significant weight differences between the groups (which means that the BWL patients regained virtually all the weight they lost), both IPT and CBTgsh were more likely to remain in remission from binge eating than BWL patients. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT. Although there was no significant association between sustained remission from binge eating and percent change in weight, a significantly greater proportion (31%) of patients with sustained remission from binge eating during follow-up lost a minimum of 5% of their baseline weight compared with patients who were never in remission (10%). Not only does this study clearly show… Read More »

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Gastrointestinal Symptoms of Binge Eating Disorder

Binge Eating Disorder (BED) can be diagnosed in around 20-40% of patients presenting with severe obesity in obesity programs. This disorder is characterized by uncontrolled episodic consumption of large quantities of food, generally associated with psychological symptoms of guilt and despair. Whether or not BED is also associated with physical symptoms is less well studied. This question was recently examined by Cremonini and colleagues from the Mayo Clinic, Rochester, MN, USA published in last month’s issue of the International Journal of Obesity. In a population-based survey of community residents through a mailed questionnaire measuring GI symptoms, frequency of binge eating episodes and physical activity level in 4096 subjects, 6.1% of whom reported BED symptoms, BED was independently associated with acid regurgitation, heartburn, dysphagia, bloating, upper abdominal pain, diarrhea, urgency, constipation and feeling of anal blockage. From this study it appears that BED is significantly associated with both upper and lower GI symptoms in the general population, independent of the level of obesity. This work has two important implications: firstly, patients presenting with GI symptoms should be questioned regarding BED; secondly, patients presenting with BED should be screened for GI symptoms. AMS Edmonton, Alberta

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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 »

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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

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