Obesity and psychiatric disorders finale

Obesity and
Psychiatric
Disorders
Umi Adzlin Silim,
Consultation-Liaison Psychiatrist
HOSPITAL KUALA LUMPUR 2018
IMAGE CREDIT: JASON GREENBERG

The Story of Ana
• 29 years old lady, married for 5 years with no
child
• Depressive symptoms
• Marital issues – partly related to infertility,
issues of body image, low self-esteem,
insecurity
• Psychosocial issues
• Financial difficulties

Longstanding
depression
• Depressive symptoms – since
childhood
• ‘Unwanted child’ for reason she
couldn’t understand
• Mothers favoured her sisters

Her bedroom was a
maid room, next to the
kitchen
• Find comfort in the kitchen – Food
• Binging when she was sad and
distressed

Being teased and bullied at the school
https://www.mghclaycenter.org/parenting-concerns/the-emotional-toll-of-childhood-obesity/

More obese and more depressed..
More depressed and more
obese…
https://khn.org/news/obesity-and-depression-are-entwined-yet-scientists-dont-know-why/

Bidirectional
Mind-Body Interaction
Dangerously link!

Obesity  Mental Illnesses
Mental Illnesses  Obesity
Connection with Childhood Obesity
Depression-Obesity Cycle

Obesity as a
cause of
mental health
disorders
Behavioural: dieting and binge eating
Biological: increased rates of chronic disease, body
pain, reduced physical activity, sleep problems,
medication side effects and abnormal hormonal
concentrations
Psychological: poorer perceived health, low self-
esteem and body image concern
Social: weight-related stigma and weight bias
Gatineau, M. and Dent, M. (2011) Obesity and Mental Health. National Obesity Observatory, Oxford.

Mental health
disorders as a
cause of
obesity
Behavioural: adoption of unhealthy
lifestyles, use of food as a coping strategy,
attrition from weight loss programs
Biological: medication side effects
Psychological: low expectations of weight
loss attempts
Social: reduced support from family and
friends

Childhood Obesity
Connection
• Connection between childhood obesity
and depression continues into
adulthood.
• Depression that develops during the
early-adolescent years increases the
likelihood of a person developing obesity
later in life.
• Late adolescent-onset obesity increases
the chances of a person developing
depressive disorders later in adulthood.
https://mypositiveparenting.org/2016/11/23/fighting-childhood-obesity-a-clarion-call/

The
Psychological
Causeway
Between
Depression
And Obesity
Peer victimization,
bullying, teasing and
taunting, and social
alienation make
obese children and
adolescents
depressed.
Depressive disorders
in magnify rapidly
due to poor coping
skills eg choosing to
be moody, angry, and
pessimistic, which in
turn, invite more
bullying.

The Physiological
Causeway Between
Depression And Obesity
A sedentary
lifestyle is a
major triggers
of obesity.
1
Obesity brings
on fatigue and
reduced
physical
activity.
2
Depression/
social alienation
drive to more
time with
gagdets
3
Social
alienation
magnify
depression, less
physical activity
& obesity.
4

The Physiological Causeway Between
Depression And Obesity
• Binge eating increases the
likelihood of a person becoming
obese
• Depression has been found to
trigger compulsive eating
episodes.
• Negative moods drive many to
seek comfort in food.
• "Comfort food" is usually rich in
carbohydrates. So individuals
actually experience a temporary
high after binging on their
comfort foods and become
addicted to these

Vicious
depression-obesity cycle

Physiological,
behavioral, and
emotional factors
can work together
in complicated
ways to perpetrate
the depression-
obesity cycle.

Not something new
•The first reports regarding the increased risk of
obesity in patients with mental diseases were
documented in 1946 when Nicholson reported
emotional tension and psychoneurosis factors to
be associated with obesity
Nicholson WM. Emotional factors in obesity. Am J Med Sci. 1946;211:443–7.

The Risk
Individuals with a mental
illness have a 2- to 3-fold
increased risk of obesity,
Individuals with obesity has
been documented to have
increased risk of mental illness
in range between 30 and 70 %.
De Hert M, Correll CU, Bobes J, et al. Physical illness in patients with severe mental
disorders. I. Prevalence, impact of medications and disparities in health care. World
Psychiatry. 2011;10(1):52–77.

Obesity and
Psychiatric
Disorders
Mood disorders
Anxiety
Personality disorders
Attention deficit hyperactivity disorder (ADHD)
Binge eating disorder
Post traumatic stress disorders

ADHD
• One of the most common childhood psychiatric disorders, 5–10 % of school-
aged children.
• Non-medicated children diagnosed with ADHD have a 1.5-fold increased risk
of becoming overweight relative to control subjects.
• High rates of ADHD in patients seeking weight loss treatment (26– 61 %),
suggesting an association between ADHD and obesity and the association
between the illness and obesity increases in prevalence with age, due in
part to issues with organization and impulsivity.
Avila C, Holloway AC, Hahn MK, Morrison KM, Restivo M, Anglin R, et al. An Overview of Links Between Obesity and Mental
Health. Curr Obes Rep. 2015;4:303–10. pmid:26627487

ADHD
• Hypothesis is that ADHD (predominantly with
deficit of attention), and obesity may reflect
different manifestations of a single and
hypofunctional dopamine gene variant
• People with low intrinsic dopamine activity in the
areas of the brain that mediate reward may
attempt to compensate by using various
reinforcing behaviors, including increased food
consumption.

ADHD
• Barrier to the treatment of obesity in patients with ADHD as they impact
the basic tenets of obesity management (i.e., eating in a thoughtful
organized manner and engaging in regular physical activity).
• Evidence uggests that subjects participating in weight loss programs who
received treatment for their ADHD diagnosis typically lost 12 % of their
initial weight as compared to controls (either on stimulant treatment or
non-stimulant pharmacotherapy).

Post traumatic stress disorder
• 60 % of women and 33 % of men with obesity identified PTSD as a contributing factor.
• From a behavioral perspective, trauma may be linked to the use of food as a coping
strategy and as a method of self-soothing.
• Eating can therefore result in a temporarily elevated mood and can create a behavioral
cycle where food is consumed to control feelings of sadness, as is evidenced by work
focused on the role of serotonin and dopamine playing a critical role in eating behavior and
mood regulation.

Post Traumatic Stress Disorder
• Recent studies have also suggested PTSD is associated with
physical inactivity, increased consumption of unhealthy foods
and beverages, or generally dysregulated food intake related to
dependence on activation of the brain reward system

Post Traumatic Stress Disorder
• Dysregulated neuroendocrine function, including enhanced negative feedback sensitivity of
glucocorticoid receptors, blunted cortisol levels, and exaggerated catecholamine
• Responses to trauma-related stimuli have all been found in adults diagnosed with PTSD.
• An elevated waist circumference is also linked to increased cortisol, a stress hormone that
is elevated in both acute and chronic stress.

Mood disorders
• Major depressive disorders (MDD) and bipolar disorder (BD) are illnesses
characterized by a symptom profile that can impact appetite, energy, sleep,
and motivation.
• The prevalence of obesity was almost 2-fold higher in patients with MDD
and BD versus the general population.
• ‘Obese persons had a 55% increased risk of developing depression over
time, whereas depressed persons had a 58% increased risk of becoming
obese

Mood disorders
• Obesity is one of the most prevalent somatic
comorbidities of MDD, and both conditions rank among
the leading challenges in public health.

Mood disorders
• Aspects of the neurobiology of depression also
confer an increased risk of obesity.
• The changes of hypothalamic pituitary adrenal
(HPA) axis seen in depression are similar,
although less extreme, to those seen in Cushing
syndrome, an endocrine illness characterized
phenotypically by excessive visceral weight gain,
indicating that dysregulated cortisol is a player
in both mood and weight regulation

Schizophrenia
• Before the diagnosis, patients with schizophrenia often have a lower BMI
than control subjects, but over time, the reported prevalence of overweight
and obesity in patients with psychotic spectrum disorders has been found to
range from 40 to 62 %
• Factors commonly implicated in the development of obesity in persons with
schizophrenia include medications, sedentary lifestyle, lack of exercise, and
poor dietary choices.

Pharmacotherapy
• An important mediator of the association between
mental illness and obesity is pharmacotherapy, which
can often lead to sedation and increased appetite
affecting both physical health and treatment adherence.

Binge Eating Disorder
• BED characterized by recurrent
episodes of eating large quantities
of food (often very quickly and to
the point of discomfort); a feeling of
a loss of control during the binge;
experiencing shame, distress or guilt
afterwards; and not regularly using
unhealthy compensatory measures.
• BED is one of the newest eating disorders
formally recognized in the DSM-5.

Binge eating
disorder
• Approximately 30 % of patients seeking
treatment for obesity will meet the
diagnostic criteria for BED whereas the
prevalence of BED in general
population is approximately 2.5 % [92].

Binge eating
disorder
• BED has been associated with reduced
activity in the orbitofrontal and
prefrontal cortex areas, as well as
dysfunctional dopaminergic and opioid
pathways, changes that have been
linked with behavioral impulsivity [96].

Night Eating Disorder
• “Recurrent episodes of night eating; eating
after awakening from sleep; or by excessive
food consumption after the evening meal.”
• NES is included in the Diagnostic and
Statistical Manual of Mental Disorders (DSM-
5) and classified under Other Specified
Feeding or Eating Disorder (OSFED).

The bidirectional link
• Mediating factors (i.e. factors which help explain the relationship
between two conditions) for obesity causing mental health disorders
in adults include
• low self-esteem, stigma
• dieting and weight cycling
• Medication
• Hormonal
• functional impairment.

The bidirectional link
• Mediating factors for mental health disorders causing obesity in
adults include
• unhealthy lifestyles
• medication
• reduced support.

The Moderating Factors
• Moderating factors (i.e. factors that might influence the strength of a
relationship between two conditions) for obesity and mental health
disorders in adults include:
• severe obesity
• female gender
• socioeconomic status
• stigma

Assessment
4 M's that should always be
considered when assessing
obesity:
• Mental
• Mechanical (such as excess body size
or musculoskeletal disorders),
• Metabolic
• Monetary problems.
Dr Arya Sharma, Professor of Medicine and currently holds the Alberta Health
Services Chair in Obesity Research and Management at the University of Alberta and
Medical Director of the Alberta Health Services Obesity Program.

"Any of these could be barriers to
treatment, but the very first one
is mental health. It is often
virtually impossible for a person
with mental illness to properly
manage their weight because it
involves a lot of factors that they
cannot control"
"I don't think we'll find a solution
to the obesity epidemic without
facing the mental health
epidemic. "

Multidisciplinary
• Clinicians;
endocrinologists,
psychiatrists, family
physicians, dietician,
physiotherapist,
nurses and all need to
work as a team

Psychotherapy
• Cognitive-behavioral therapy, especially for depressive disorders and
binge eating disorder;
• Mindfulness-based stress reduction;
• Dialectical behavioral therapy, which focuses on introducing affect
recognition and regulation skills;
• Interpersonal psychotherapy, which addresses social deficits; and
• Motivational interviewing, which focuses on resolving ambivalence
• Self management intervention.

Psychotherapy
•Empathetic and validating
•Aim to increase self efficacy
•Coaching and motivational interviewing
approach

Example in childhood obesity
•Mindful of the sensitivity of obese children and
adolescents to teasing and derogatory remarks
and treatment programmes should include
elements designed to enhance and protect their
self-esteem

Focus on psychosocial factors rather than
weight loss
•It has been argued that psychosocial factors in
childhood obesity are more important than
functional limitations, and that we might better
help the obese child by providing social support
rather than to focus on the child’s obesity.

Focus on psychosocial factors rather than
weight loss
• For an obese child who is exhibiting either low levels of self-
esteem or depressive symptoms, merely encouraging healthy
eating and physical activity is likely to prove ineffective in
attaining weight reduction.
• The clinical treatment of obesity should take psychosocial
aspects of the condition into account.
• Treating obesity may not just be a matter of diet and exercise
but also of dealing with issues of shame and social isolation.

Stigma
"We need to be aware that the
only illness perhaps more
stigmatizing than mental illness
is obesity. So when you have a
population that has both,
realize that that's a group that
is going to be really vulnerable
and at risk.“

Rejection and Guilt
"We also need to be aware of the role
of weight bias, as this population is
often subject to prejudice and
discrimination, and treatment of any
type may need to incorporate tools to
alleviate feelings of rejection and
guilt.”

Take Home
Message
Mental illness must be considered as a
possible etiological factor in anyone
presenting with weight gain attributable
to overeating and under-moving,"
“Complex interplay" of neurobiological,
psychological, and socioeconomic factors
contribute to the dangerous association
between obesity and mental illness
Patient-centered care, empathetic and
validating therapeutic relationship and
multidisciplinary approach is the
foundation of obesity management

Obesity and psychiatric disorders finale

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