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Obesity & Depression

Our guest expert in May 2011 was Dr. Valerie Taylor, MD, PhD, psychiatrist-in-chief at Women’s College Hospital. Dr. Taylor is also national director of the bariatric surgery psychiatry program, and mental health chair for the Canadian Obesity Network, and an associate professor at the University of Toronto. Her academic focus is on obesity and mental health in both adults and children. She is interested in the origins and overlap between obesity, diabetes and depression, the concept of food addiction and the impact of psychiatric medications on weight and behaviour.

Here are the responses to your questions on Obesity & Depression.

Q: I am a 31-year-old mother of five and I have tried to lose weight over and over again. I find myself severely depressed from time to time. What are some ways to stop feeling sorry and disgusted with myself and get some weight off before it’s too late? Are there any support groups available to me?

A: You are not alone in your struggles with weight. Currently, in Canada, over 50 per cent of the population is overweight or obese. Getting weight off is difficult, and for most people diets do not work because they require people to do things that are difficult to maintain over time. There are also a number of links between weight concerns and problems with depression and self-esteem. You first need to ensure you are not suffering from clinical depression, as dealing with your weight concerns will be impossible if you have an untreated mental illness. Going to see your family doctor, and, if needed, a psychiatrist or psychologist, is the first step to ensuring that if you have depression the condition is diagnosed and treated. The resources available to provide support during weight struggles vary from region to region, but most places have groups such as Overeaters Anonymous that may be of help. In the Toronto area, Danielle’s Place, which is located in Burlington, Ontario, is also a good resource. I would also search the Internet, as there are a number of excellent support groups online.

To help my patients, my colleagues and I wrote a treatment workbook called the Cognitive Behavioral Workbook for Weight Management that is designed to help serve as a tool to help with weight changes and self-esteem. It is one of a number of books on the topic that you may find helpful.

You are not alone in this struggle and I think your plan to seek support is a good one. It is difficult to do alone.

 


Q: I am overweight and have been for most of my life. I am larger now than ever. I have also suffered from some form of depression most of my life. When exploring the possibility of bariatric surgery, I was told that I was not eligible for the surgery because after a one-hour visit, a psychiatrist diagnosed me as having borderline personality disorder. My question is, why that is a factor in rejection of the surgery, and how can a one-hour session determine that this is the ‘disorder’ that I have, and how does this make me an unsuitable candidate for gastric bypass? I am otherwise healthy. I don’t have diabetes, high blood pressure, high cholesterol or anything. What is the connection between the two that makes me unsuitable for surgery?

A: There is a link between mental illness and weight problems, and a number of studies have shown that individuals with weight problems are at higher risk of also having a psychiatric diagnosis. That is also true of people seeking bariatric surgery, and over half of those that receive surgery have a mental illness. So, having a diagnosis of depression or borderline personality disorder or schizophrenia does not mean you cannot have surgery. The things people are concerned about when they assess for suitability for bariatric surgery are how well a person is functioning and if there are psychiatric disorders present that are not being properly treated or are not stable. If people are unwell with a psychiatric disorder, the chances of the surgery not working as it should or causing other problems increases.

If you have received a diagnosis of borderline personality, go back to your family doctor and find out what can be done to help you gain control of that illness. Simply getting this illness treated should help you feel better, and will ensure you are able to deal with the challenges associated with bariatric surgery. Then request another referral for surgery. If you are doing well you will be a suitable surgical candidate. The screening is in place to ensure the procedure helps people become healthier. If it does not appear that surgery will make your psychological health worse, having a psychiatric diagnosis is not a reason for you to not have surgery.

 


Q: I feel like I am in a vicious cycle: being overweight is one of the things that makes me feel hopeless and feel bad about myself. But when I feel hopeless and bad about myself, I overeat. How can I get past this cycle? I do not ‘purge’ but I understand why some people resort to that.

A: The link between mental illness and weight is complicated. You cannot focus on weight issues while you have an unstable psychiatric illness, but sometimes the treatments of psychiatric disorders can cause weight gain. It is a vicious cycle. It is important that you share your weight concerns with the people responsible for treating your depression, and indicate that the symptoms are impacting your mood. There are a number of medications available and the side-effects are often different, so changing medications may be helpful.

It is also important to recognize the links between food and mood. Certain foods actually do impact mood and are called comfort foods for a reason: we actually do feel better for a short time when we eat them. This would be great if they were foods like carrots, but usually the foods that give us “comfort” are carbohydrates that are high in fat. You need to break the cycle of turning to food when stressed, which can be a challenge. There are groups like Overeaters Anonymous or support groups online that may be of help. It is also important to be seen by a psychiatrist to find out if you have binge eating disorder, which is an illness in which people binge on huge amounts of food, feel quite out of control with respect to their ability to control eating, and have a lot of negative feelings after. This disorder often has its own specific treatment and could be contributing to your difficulties.

Any decision to change your medications should only be made after consultation with your doctor and after speaking with a naturopath. Some herbal preparations can make psychiatric disorders worse and you need to get advice on what works best for you. For some, naturopathic treatments can help in combination with prescription medications – but get advice from your treating team before making medication changes.

 


Q: When looking at the link between obesity and depression in women, what is known (from the research or your clinical practice) regarding pregnancy and preconception health? As obesity may affect fertility, what is the influence of obesity on depression among women of childbearing age? What other mental health issues emerge, including antenatal and post-partum mood disorders, in obese women? What is the incidence of mental illnesses in the pregnant obese population? What are the options regarding treatment?

A: A few years ago the Institute of Medicine released guidelines on safe weight gain during pregnancy.

Pre-pregnancy BMI

Recommendations for total pregnancy weight gain in kg (pounds)

Underweight (BMI <18.5 kg/m2)

12.5-18 kg  (28-40 lbs)

Normal weight (BMI 18.5-24.9 kg/m2)

11.5-16 kg (25-35 lbs)

Overweight (BMI 25-29.9 kg/m2)

7-11.5 kg (15-25 lbs)

Obese (BMI > 30 kg/m2)

5-9 kg (11-20 lbs)

To figure out where you are, use the Internet to search for a BMI calculator, and input your own weight and height.

Despite the fact that we now have these guidelines, over half the population we surveyed had gained, or was planning to gain, more weight than was recommended during pregnancy. This is a concern since being overweight or obese during pregnancy is associated with a number of health risks such as preeclampsia (a type of high blood pressure during pregnancy that can impact the health of both mom and baby), gestational diabetes and increased rates of C-sections. Excess weight gain is also being linked to mental health outcomes as well.

According to The American Congress of Obstetricians and Gynecologists (ACOG), between 14 to 23 per cent of women will struggle with some symptoms of depression during pregnancy. Weight can add to this, and there is emerging work to show that excess weight gain during pregnancy can impact self-esteem and mood after delivery, increasing risk of post-partum depression. The treatments for mood problems during pregnancy depend on the severity of the illness; some people require medication while for others supportive counselling or psychotherapy is enough. It is important to discuss any changes in mood during your pregnancy with your health-care provider.

The treatment of weight problems during pregnancy has received less attention, but people are slowly starting to become aware of the seriousness of this issue. Pregnancy is often considered to be a “teachable moment” with respect to health behaviours because people often take health more seriously when they are pregnant – just look at the number of smokers that quit when pregnant. There are safe ways to eat and start exercising during pregnancy, but you should definitely get advice from experts before you start any type of behaviour change during pregnancy.

Weight gain can also impact fertility, and women in a recent study who were severely obese were 43 per cent less likely to achieve pregnancy than were normal-weight women or women who were considered overweight but not obese. Even if it does not cause infertility, weight can cause ovulation problems and make cycles irregular, making it difficult to conceive. Problems with weight and fertility are not only associated with females, however, and if the male partner is overweight, fertility is decreased as well. We do not yet know the reasons for the association between weight and infertility, but we do know that weight loss can help. It will improve fertility and help decrease a lot of the stress associated with fertility problems.

 


Q: I have been experiencing depressive episodes since I was 13 (now 30), mostly from October through April/May, but sometimes in the summer months as well. I also gain weight easily, but have noticed that this has been particularly true when I started using birth control pills, and then later followed a naturopathic routine (alternating two weeks on one tablespoon of sun flower seeds, and two weeks on one tablespoon of flax seed – one acting as progesterone and the other estrogen) while still using the pill.
As a result, I am wondering if these hormones are a contributing factor for some people in not only gaining weight, but depression as well. (I had gained 20 pounds in three months when I started on the pill, gained another 15-20 in one to two months when I added the seed routine years later).

A: No medication is without side-effects, and for a few women the pill may cause some weight gain. This weight gain is often due to fluid retention, however, and is not usually more than a few pounds. There are a number of urban myths about the pill causing significant weight gain but this is related to stories from the 1960s when the birth control pills had much higher levels of hormones than they do now. More recently, a review of 44 studies showed no evidence that birth control pills caused weight gain in most users. And, as with other possible side-effects of the pill, the minimal weight gain is generally temporary, going away within two to three months.

Not all pills are the same, however, and if you do find you are having weight problems, speak to your doctor. Birth control pills come in two forms: combination pills, which contain estrogen and progestin, and progestin-only pills. Both the estrogen and progestin in the pills can cause fluid retention, a temporary and usually cyclic effect that often begins in the first month as a result of an increase in sodium. Reducing your salt intake moderately can help control this type of water retention. The estrogen in the pill can also cause weight gain due to increased breast, hip or thigh tissue, usually after several months on the pill. This causes swollen ankles, breast tenderness, discomfort with contact lenses, or a weight gain of up to five pounds. Some progestin-dominant pills can cause appetite increase and permanent weight gain.

You mentioned in your question that you experience depression. Depression itself can cause weight gain, as it impacts appetite and motivation for things like exercise. It is also associated with hormone changes that impact weight via ways we do not yet understand. Some people are also at risk of experiencing mood changes with the use of birth control pills that may also lead to increased appetite and weight gain. If you feel that your mood changes with birth control use, speak to your doctor about another type of birth control pill or another birth control method.

 



Q: I have read that exercise can help manage depression. Obviously it would also help improve my fitness level and my weight problem, too. Do you recommend exercise for people who have weight problems as well as depression? What sort of exercise program might be feasible for someone who is both out-of-shape and not very motivated (because of depression)?

A: Enough good cannot be said about exercise, and for many of us, we do not get enough. The most recent association between exercise and improved health is related to its effect on mood, particularly depression. A number of studies have shown that for mild to moderate depression, exercise can have a significant impact on depression symptoms and can also prevent the reoccurrence of a depressive episode. We do not know exactly how exercise improves mood, but it is thought to alter brain chemistry in much the same way that antidepressant drugs do — regulating the key brain chemicals such as the neurotransmitters serotonin and norepinephrine. Exercise also causes the release of endorphins, the feel-good proteins that give some individuals a “runner’s high” when they work out, and has been associated with the release of brain-derived neurotrophic factor, a protein involved in neuron growth in the brain. Exercise also forces people to be more social and to interact with others, something that also improves mood and helps boost self-esteem.

We do not know yet exactly how much exercise is the right amount, but we do have some guidelines. In their recent book for therapists, Exercise for Mood and Anxiety Disorders (Oxford University Press, 2009), Jasper Smits and co-author Michael Otto at Boston University recommend 30 minutes of moderate-intensity aerobic exercise, like walking, five times per week, or 30 minutes of high-intensity aerobic exercise three times a week. These doses, which are regularly recommended for physical fitness, are the only ones that have been well tested for depression. Aerobic exercise is the type of exercise that increases heart rate and breathing rate, so a leisurely stroll is not enough. It is also important that if you are going to start this type of exercise program you do it slowly, as most people that try to move from no exercise to exercise five times a week injure themselves or get discouraged and quit. Start slow and find a partner.

Exercise is difficult to start when a person is quite depressed, however, so most people require another form of treatment such as medication or talk therapy to get them well enough to start to exercise. Once you are able to exercise regularly, changes to treatment should occur gradually, under a doctor’s supervision. Even if other treatments are required, exercise can help those treatments be more successful.

 


Q: What is mindful eating?  

A: Mindful eating is a term used to talk about a style of eating where people take time to reflect about what they are eating and why. This is in contrast to what many see as the traditional type of eating many of us engage in – mindless eating. Mindless eating is the type of consumption we do in front of the TV or rushing through a drive-through or consuming a meal or snack in five minutes. Mindful eating does not focus on what a person eats, but aims to try to teach them to be aware of why and how they are eating, assuming that if we become aware of the links between what is going on in our minds when we eat, we will be able to gradually change our eating behaviour. It promotes taking a compassionate and non-judgmental approach to understanding our eating behaviours and really trying to understand the underlying causes and links we have made with food.

A number of excellent books are available on the topic (Mindful Eating 101: A Guide to Healthy Eating in College and Beyond by Susan Alders is one) if you are interested in finding out more on the topic.

 

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