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Depression Preceeds Obesity, Not Vice Versa

Excerpts From 19-July-2000 Issue Of JAMA

At a recent meeting in Chicago, a speaker, Scott Goldsmith, MD, of Weill Medical College of Cornell University, revealed that one in four persons seeing a primary care physician about weight problems has an active psychiatric illness, usually depression. These people often attribute distressed moods to their excess weight, he noted, rather than recognizing that depression or anxiety may have triggered their overeating.

While obesity itself is not a psychiatric diagnosis, Goldsmith and other speakers emphasized. It is a symptom, like fever, with complicated etiologies that vary from patient to patient. Genetic, environmental, medical, behavioral, and emotional factors may contribute to obesity. However, behavioral strategies used in psychiatry, specifically those used to treat patients with eating disorders, also may benefit some patients who are obese.

Interventions Should Last A Lifetime

Current weight loss treatments seldom produce lasting results. Most people who lose weight regain half the pounds they lost within 1 year, and nearly all of them do so within 5 years (Adv Behav Res Ther. 1994;16:31-75).

Americans of all ages are fatter than ever. Some 14% of children aged 6 to 11 and 11% of adolescents aged 12 to 17 in this country are overweight, the National Center for Health Statistics reports, and obese children grow up to become obese adults. Its third National Health and Nutrition Examination Survey data show that 54% of persons aged 18 and over in the United States—97 million adults—are overweight (

It is widely accepted knowledge that obese people are more apt to develop a wide range of serious health problems, including high blood pressure, early arthritis and diabetes, gallstones, and to die prematurely from all causes.

They also often endure psychic burdens which may be the reason the obesity kills, not the other way around. Children as young as 3 years voice derogatory opinions of overweight body types. Six-year-olds see overweight peers as "lazy" and "sloppy" and rate them undesirable as friends. Obese children report lower self-esteem than their normal-weight peers. Obese adolescents have more trouble getting into college and getting a job. Obese adults are less likely to marry than people of normal weight.

Numerous societal changes have contributed to the nation's expanding waistlines, including the wide availability of calorically dense foods, portion-size inflation, more frequent consumption of high-fat prepared foods, lower consumption of fresh fruits and vegetables, and reduced physical activity.

It has been found that food is the most heavily advertised product on television. Children who watch television more than 4 hours a day have more body fat and a higher BMI than those who watch for 2 hours or less (JAMA. 1998;279:938-942). Some clinicians seek to reduce this and other sedentary activities, such as playing computer games and talking on the phone, while encouraging walking, running, and other active play. In one study, children who had to pedal a stationary bike to keep a television turned on, for instance, quickly shed pounds.

As many as 10% of obese adults—twice as many women as men—may have binge eating disorder (BED), said Denise Wilfley, PhD, of San Diego State University in California. Such persons consume unambiguously large amounts of food twice a week or more, eat rapidly, and feel "out of control" while eating. In the APA's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Washington, DC: American Psychiatric Association; 1994:731), BED is still a provisional diagnosis.

Persons with BED, Wilfley said, are three times more likely than other obese people to have major depression and impaired work and social functioning. The most commonly used interventions for BED, Wilfley said, include group psychotherapy to target the eating disorder and behavioral weight loss management to target the obesity.

A combination of the two approaches may work best, she said. She and her colleagues randomly assigned 162 persons, mostly women in their 40s with a mean BMI of 37, to 20 weekly sessions of group cognitive-behavioral therapy or group interpersonal therapy. Both approaches prove equally effective in stopping binge behavior and reducing associated psychopathology, she said, although patients lose only 2 lb on average while undergoing such therapy. About one third continue to gain weight.

As patients in this study curbed their bingeing, the researchers introduced a program of dietary management. At 1-year follow-up, 70% of participants binged less often than once a week, and 60% reported no bingeing in the previous month. Persons who stopped bingeing entirely achieved the greatest weight loss, about 8 lb on average, and sustained it. A report on this study is in preparation.

Wilfley does not recommend pharmacological interventions for binge-eaters. Users of such prescriptions may benefit initially from medications such as selective serotonin reuptake inhibitors and appetite suppressants, she said, but they typically relapse and regain lost pounds.

Mental Health Can Trim A Waistline

Physicians can help patients most, Goldsmith said in an interview, by first taking a good history. Weight usually follows the same pattern throughout life, he said; most obese people have a childhood or family history of excess weight. If people have been at a normal weight for most of their life but recently gained 30 lb, he said, that's worth exploring. Such patients should be evaluated for possible thyroid or other endocrine disorders and other medical disorders, and for mood disorders.

Most people come to a physician, he said, after having tried diets and commercial weight loss programs without success. They expect to get a prescription for medication. Unless there is a health risk and a long history of inability to lose weight, he asserted, there is no indication for medications as a first-line treatment. Medications that affect the brain and appetite center, or affect metabolism or the ability to absorb calories from food, may give some people a small boost, but, said Goldsmith, "I'm not convinced that they prove helpful, except as an adjunct to lifestyle change."

Physicians need to teach patients the realities of weight loss, he said, emphasizing the need to cut calories as well as increase physical activity. The first step for most people, he noted, is a good nutritional program.

Ads that appear in the media, he said, prompt many obese people to believe that if they lose weight, they will feel better. Physicians, he maintained, can help people understand that it's usually the other way around.

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Editor: Susan K. Boyer, RN
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