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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


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.


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)


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


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)


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


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


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


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


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


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


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


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%


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


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.


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


7, a

The current

and lifetime rates of psychopathology

are

particularly high

in

bariatric surgery candidates.

Malik S et al, 2014

(review)


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


8, a

Psychiatric disorders may appear

after weight loss surgery

•  addiction transfer

•  post-surgical eating disorders •  body image disorders

•  …


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)


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.


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.


10, b


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