At a glance
- Rather than focus on the end result of obesity, look at the patient’s underlying emotional health.
- Studies have found depression to correlate with the onset of obesity and obesity to predict the onset of depression.
- If you suspect an overweight patient is struggling with a mental health issue, approach the possibility directly.
- Obesity prevention is a public health issue because of the costs it creates for an already overburdened system.
Seventy-three million Americans are obese —a startling statistic that becomes more than a number in our day-to-day clinical lives as we treat patients suffering from the sequelae of this epidemic: gastroesophageal reflux disorder, diabetes, hypertension, polycystic ovary syndrome, infertility, gallbladder disease, osteoarthritis, and hyperlipidemia. Primary-care practitioners should be aware of a potential underlying cause of obesity: mental illness.
Recent studies have shown that many cases of obesity are the result of such mental illnesses as depression, anxiety, post-traumatic stress disorder (PTSD), binge eating disorder, and night eating syndrome. In a busy clinic it’s difficult even to begin to unearth and address these factors when the purpose of the patient’s appointment is chronic illness management. However, instead of focusing on the end result of obesity, we may be of greater assistance to our patients by looking at their underlying emotional health and intervening as appropriate.
Understanding the mental health/obesity relationship
What part does mental health play in the rise in obesity seen over the past 20 years? “We have more emotional issues than ever to deal with,” explains Phillip Ballard, MD, a family practice physician and psychiatrist with Colorado Springs Health Partners (CSHP) in Colorado Springs, Colorado. “We have more than any other society has and we feel guilty that we’re not happy.” According to Dr. Ballard, these negative feelings fuel depression, and people often use food to self-medicate their emotions. Food is seen as nurturing; consider how we frequently turn to our “comfort foods” that remind us of feeling happy or cared for.
People are living longer than ever before, and paradoxically, that brings more problems. For example, Dr. Ballard points out, older, retired individuals who are prone to anxiety and depression have lost a tool for relieving these conditions. “Work has always been used to control anxiety and depression,” he notes.
Family dynamics and stress play an integral role in mental health. Extended families are not as geographically close today as in the past. Adult children are leaving home later, and their greater dependence on their parents contributes to more problems for everybody involved.
Lisa M. Schab, MSW, LCSW, a Chicago-based licensed clinical social worker and author of several books on teen depression and anxiety, observes that in her practice, these two illnesses are the most common emotional health issues connected with obesity. Anxious patients can be compulsive, and eating compulsively and excessively contributes to obesity—making the behavior very destructive. In major depressive disorder, a common symptom is appetite change: A depressed person’s appetite can increase or decrease, although an increase is more typical. Depression can lead to reduced physical activity, which has “always proved to work as well as psychotropics to control depression,” states CSHP’s Dr. Ballard.
Studies have found depression to correlate with the onset of obesity and obesity to predict the onset of depression. Depression predicts poorer success with weight loss, but successful weight loss is associated with a reduction in depression.
In addition to anxiety and depression, a recent study by indicated a strong relationship between PTSD and obesity, with a 32.6% rate of obesity found among PTSD patients (Obesity. 2009;17:539-544).
Women with less-than-positive emotional health are reported to have a significantly greater risk of weight gain (Obesity. 2008;16[Suppl 1]:s95). Michele Bartels, MSW, LCSW, a psychotherapist in private practice in Colorado Springs, says that many of her severely obese female patients have a history of sexual trauma in childhood. “They believe their weight protects them as a shield or a defense against others.”
Interestingly, no heightened risk of obesity has been reported in persons with substance abuse disorders, perhaps because these individuals use agents other than food in their self-medicating behavior.
An elevation of cortisol levels reflects the clinical impression that night eating occurs during times of stress. Some obese patients describe having little to no hunger for breakfast. This may be a sign that they’re overeating at night, as night eating syndrome is characterized by an unusual circadian pattern: minimal eating in the morning with hyperphagia (consumption of at least 25% of daily calories after supper) both during the evening and at night, along with insomnia. These patients often consume half their daily calories during these nocturnal eating episodes. Night eating syndrome was found to be unique in that it represents the coexistence of an eating disorder, a sleep disorder, and a mood disorder (Int J Obes Relat Metab Disord. 2003;27:1-12). The syndrome has been associated with an increased risk of dental caries, which can be assessed on an oral exam.
Binge eating disorder generally appears to be more common than the well-established eating disorders bulimia nervosa and anorexia nervosa. It is likely a chronic, albeit stable, disorder rather than a transient abnormal eating pattern.
In one study, participants with a current Axis I disorder as categorized in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition had a significantly higher BMI than those without such a diagnosis (Am J Psychiatry. 2007;164:328-334). In addition, even those study participants who had a history of any Axis I disorder had a higher BMI.
Weight and hedonics
In hedonism, the principle object is pleasure. The pleasure derived from eating is regulated by opioid neurotransmission. A high intake of carbohydrates stimulates the production of insulin, which forces sugar into the cells, raises body temperature, and ends in somnolence. Ketones from a high-fat diet were long used before psychotropic medications became available to minimize the impact of dopamine, diminishing psychotic behaviors and acting biochemically to reduce anxiety by causing sedation.
Wanting also influences food intake. However, the wanting and liking of food are not necessarily correlated. Overweight women were found to be particularly sensitive to the rewarding aspects of food. Deprivation did not increase the pleasure derived from food but did increase motivation to eat (Physiol Behav. 2003;78:221-227). Obese people have a higher motivation to eat but not increased pleasure from food. This correlation seems to be more pronounced in women than men.
How to approach emotional issues
Many mental-health screening tools are available to help clinicians quickly assess the many overweight patients they see in a day. One such instrument, the Burns Anxiety and Depression Screening Tool, can be administered by a medical assistant to patients who are waiting to see the practitioner.
Another useful device is a food diary. People aren’t particularly fond of keeping food diaries, but these journals can be extremely eye-opening for not only the provider but the patient. If participants are honest and write down everything they eat, they will often identify not only their problem foods but the circumstances under which they tend to overeat and the emotions associated with eating. Consider having patients jot down a word or two to describe their frame of mind with each food entry to help identify emotional eating.
Most clinicians would agree that encouraging patients to lose weight by warning them about health issues doesn’t have much of an impact. Using scare tactics to pressure people into losing weight often has the opposite effect. Conversely, developing a caring, empathetic approach can open the door for patients to discuss their emotional health with you. One of the hallmarks of major depression is a change in appetite; asking a patient if his or her appetite has changed in the last few months can be a non-threatening way to broach the subject.
To identify binge eating, ask the patient if he or she feels unable to control the volume or type of food consumed or if he or she often eats what most people would regard as an unusually large amount of food in any given two-hour period. If the answer to both questions is yes, ask whether such episodes have occurred twice weekly on average for the past three months.
If so, binge eating disorder is the likely diagnosis (Table 1).
If you suspect that an overweight patient is struggling with a mental health issue, approaching the possibility directly is often the best strategy. Have a referral base of counselors well-versed in obesity at the ready and recommend exercise to the patient, explaining that even a few minutes a day will help until the person can build endurance.
Appropriate medication management for the underlying mental health diagnosis can be a key component in your armamentarium, but may prove to be a double-edged sword in that many psychotropics increase appetite. Serotonin selective reuptake inhibitors are not designed to stimulate the appetite, but they can have that effect nonetheless. The atypical antipsychotics as a class stimulate the appetite, causing weight gain. They can also trigger the onset of diabetes irrespective of weight gain.
Just as the causes of obesity are multifactorial, treatment needs to be multifactorial as well. Medications and psychotherapeutic counseling work well together. Follow-up clinic visits also have been shown to be effective. To monitor the patient’s progress and ensure appropriate medication management, evaluate possible side effects and screen for the onset of chronic illness.
Success requires self-motivation and support
Behavior change has been shown to be most successful if a person is self-motivated to make those changes. The person needs to feel personally driven to correct harmful behaviors rather than feel pressured by a health-care provider, spouse, other individuals, or society at large to make such changes. An increase in autonomous motivation is a predictor of weight-loss success.
You can help your patients by being supportive and even by sharing your personal struggles with weight loss and/or weight maintenance. Personalize your advice by relaying tips that have worked for you. Refer patients to specific programs you have found to be effective, such as Weight Watchers or dietary counseling. Unfortunately, most insurers do not cover dietary counseling, and this service can be costly for people paying out of pocket. You can give the patient some basic information for free in a one-page nutrition sheet as an easy reference (Table 2). Posting the information on a small bulletin board in your exam rooms can lead to conversations about weight loss.
Reviewing patients’ food diaries with helpful suggestions for improvement rather than judgments about their choices will encourage them to be honest with their entries. “Hammering on [the patients] or trying to extinguish compulsive behavior makes it worse,” affirms CSHP’s Dr. Ballard. Being supportive, offering alternatives, explaining BMI, and discussing diet and exercise is more therapeutic than being critical. Reviewing the person’s cardiovascular risk factors in a matter-of-fact manner can also be helpful.
Bariatric surgery is becoming more popular as a treatment option. People seeking bariatric intervention are more likely to have a history of depression and anxiety (J Behav Med. 1997;20:391-405). Clinicians should make an effort to identify underlying mental health issues in candidates for bariatric surgery. If the Axis I diagnosis isn’t treated, these patients will have a difficult time achieving successful outcomes.
Clinicians will be better able to treat obesity by pinpointing the underlying mental health causes. Psychological counseling plays an integral role in weight-loss success and improved overall health. Carving out time to delve into our patients’ psychological issues is a difficult task in today’s primary-care setting, but we don’t seem to be making any great strides in curtailing the obesity epidemic through current practices.
We’ve gotten very good at treating the sequelae of obesity. Perhaps we’d have an even greater impact if we screened our overweight patients for emotional health issues before they become obese. In this fast-paced, frenetic society in which stress is inevitable, everyone is at risk for weight problems. Educating all of our patients in stress management and the prevention of obesity—even those individuals who don’t currently have weight problems—should become part of our health maintenance system. Obesity prevention is a public health issue not only because of the associated morbidity and mortality but also because of the costs it creates for an already overburdened system.
Approaching the delicate health topics of obesity and mental illness with empathy and a genuine caring attitude will go far in getting patients to trust and open up to us so that we in turn can help manage the problem. Given that this is a multifactorial issue, responding with a multidisciplinary team approach will most likely yield the best results for patients.