O B E S I T Y
psychiatr ic aspects
02/06/14 massimo cuzzolaro 1
B o l o g n a , 3 1 m a g g i o 2 0 1 4
Why should psychiatrists and clinical psychologists play an important role in
obesity assessment, treatment and prevention?
Obesity is not classified as a mental disorder per se and there is no a place for obesity in the DSM-5
02/06/14 massimo cuzzolaro 2
H o w e v e r , i t i s a s s o c i a t e d w i t h a n u m b e r o f b e h a v i o r a l s y m p t o m s t h a t a r e l i k e l y n e u r o - p s y c h o l o g i c a l i n o r i g i n
a n d w e h a v e t o t a k e i n t o a c c o u n t a t l e a s t t e n p o i n t s .
Obesity is still clinically diagnosed by a simple formula based on the weight and height of a subject.
02/06/14 massimo cuzzolaro 3
1, a
Lifestyle education is a form of
psychological intervention for the reason that it involves
emotional, cognitive, and behavioral processes,
family habits,
and social relationships.
Electronically delivered programs (web, telephone) are less effective than face-to-face interventions.
They have a significant public health impact; however, drop-out rates were high and effect sizes were modest.
Schulz DN et al, 2014
(R, C)
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1, b
Comprehensive lifestyle intervention alone
is likely to be more successful in people whose BMI
is not too far from the
desirable range (< 35 kg/m2).
However,
“it is foundational to weight loss, regardless of augmentation
by medications or bariatric surgery” .
AHA/ACC/TOS Guideline, 2013
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1, c
An intensive lifestyle intervention
on body weight and
cardiovascular disease risk factors
among severely obese individuals
(BMI ≥ 40 kg/m2)
can obtain important results in a significant proportion of
patients.
Unick JL iet al, 2013
(R, C)
Health coaching
may be effective in people who suffer from
major psychiatric disorders as well
Bonfioli E et al, 2012
(meta-analysis)
but results are controversial
Usher K et al, 2013
(R, C)
02/06/14 massimo cuzzolaro 6
1, d
Lifestyle education
is ordinarily helpful and often needed after obesity surgery
because
a considerable proportion of patients
are unable
to benefit optimally from bariatric surgery
in terms of weight loss
Mechanick JI et al, 2013
(Guidelines)
Providing information
about necessary postoperative lifestyle changes
can somewhat reduce
the stigma of bariatric surgery
Vartanian LR et al, 2014
02/06/14 massimo cuzzolaro 7
2, a
Difficulties in the area of
affect regulation and
stress response
may trigger emotional eating.
In the treatment of pediatric obesity
the emotional bond between caregiver and child
should be explored as well.
Vandewalle J, 2014
02/06/14 massimo cuzzolaro 8
2, b
The orexigenic hormone
ghrelin might play a key role
in the relationship between
acute and chronic stress
and food intake.
Its plasma levels are enhanced
under conditions of
physiological stress
The ghrelinergic system
seems to be a critical factor at the interface
of homeostatic control of appetite
and reward circuitries,
modulating
the hedonic aspects of food intake
Schellekens H et al, 2012
02/06/14 massimo cuzzolaro 9
3, a
A number of
individuals with obesity suffer from
a definite eating disorder
and others from
a specified or
a not specified eating disorder.
• Binge Eating Disorder
• Night Eating Syndrome
• Grazing
02/06/14 massimo cuzzolaro 10
4, a
As a minimum
in a subgroup of people, non-homeostatic eating
appears to be some kind of addiction
(food addiction)
The strong reinforcing effects
of both food and drugs are mediated by
rapid dopamine increases
in the brain reward centres
that,
in vulnerable individuals, can override the brain’s
homeostatic control mechanisms.
Krashes MJ et al., 2014
02/06/14 massimo cuzzolaro 11
4, b
Elevated (YFAS) scores
were associated with similar patterns of neural activation
as substance dependence:
elevated activation
in reward circuitry
in response to food cues (anticipated receipt)
and reduced activation
of inhibitory regions
(lateral orbitofrontal cortex)
in response to food intake (receipt)
anticipated receipt > receipt
Gearhardt AN et al., 2011
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4, c
A subset of
41.5% of BED patients met
the YFAS food-addiction cutoff.
Gearhardt AN et al., 2013
The food-addiction model
of obesity does not increase
weight bias
Latner JD et al., 2014
02/06/14 massimo cuzzolaro 13
5, a
Anxiety and depression often go together with
obesity.
Carey M et al, 2014
Data obtained
in a cross-sectional survey from 3361 general practice patients
demonstrated
a U-shaped relationship
between weight and depression.
prevalence of depressive symptoms • underweight 24%
• obese 23%
• normalweight 11%
• overweight 12%
02/06/14 massimo cuzzolaro 14
5, b
Which came first,
obesity or
depression?
A number of studies suggest
a bidirectional relation between obesity and depression
• in adults
Pan A et al, 2012
• n adolescents
Marmorstein NR et al, 2014
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6, a
Negative body image and
social stigma are important issues
Gender, age, degree of obesity,
onset age of overweight, ethnicity, social class, history of sexual abuse,
teasing and
parental criticism about weight,
history of weight cycling,
and presence of binge eating all show important
modulating effects on
body uneasiness.
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6, b
A circular relationship links together
obesity, social stigma,
internalized stigma
and negative self image
Obesity social stigma is
pervasive in contemporary societies
De Brun A et al, 2014
02/06/14 massimo cuzzolaro 17
7, a
The current
and lifetime rates of psychopathology
are
particularly high
in
bariatric surgery candidates.
Malik S et al, 2014
(review)
02/06/14 massimo cuzzolaro 18
7, b
The prevalence of BED
among bariatric surgery candidates
is particularly high,
about 10%
Mitchell JE et al, 2012
An additional 3.43%
of candidates met the diagnostic threshold for
BED
when using DSM-5 criteria.
Marek RJ et al, 2014
02/06/14 massimo cuzzolaro 19
8, a
Psychiatric disorders may appear
after weight loss surgery
• addiction transfer
• post-surgical eating disorders • body image disorders
• …
02/06/14 massimo cuzzolaro 20
8, b
The underlying causes
leading to weight regain are patient- and procedure-specific,
multifactorial and overlapping:
• psychiatric disorders
• psychological features • unhealthy lifestyle (physical
inactivity and/or dietary non-compliance)
• endocrino-metabolic diseases
• problems related to surgical procedure
Addressing
post-surgical weight regain requires
a systematic
multidisciplinary approach.
Karmali S et al, 2013 (review)
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9
The prevalence of obesity in
people diagnosed as having a mental illness
is very high.
The interaction of
• genetic factors
• socioeconomic status
• lifestyle
• medications
likely accounts for the high risk of
overweight, metabolic syndrome, and premature mortality
in people with serious mental illness.
02/06/14 massimo cuzzolaro 22
10,a
Psychometric instruments may be helpful to
reliably and validly assess specific constructs
relevant to
eating and
weight-related disorders.
From a clinical perspective,
an evaluation of single items
may offer precious information.
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10, b
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