Obesity and Depression

obesity depression

inflammationHPA axis

increased body dissatisfactionlow self esteem

paininsufficient physical activityunhealthy eating patterns

sleep disturbancespsychotropic medications

Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229

1. Obesity leads to ADHD2. ADHD and obesity are expressions

of a common biological dysfunction in a subset of patients with both

3. ADHD contributes to obesity

Cortese et al, 2008

Binge Eating DisorderDSM V Diagnostic Criteria

Recurrent episodes of BE characterized by BOTH:

Eating large amounts of food in a discrete period of time

A sense of lack of control (LOC)

BE episodes are associated with ≥ 3 of:

Eating more rapidly than usual

Eating until uncomfortably full

Eating large amounts when not hungry

Eating alone because of embarrassed

Feeling disgusted or guilty

Marked distress regarding BE

BE occurs at least 2 days per week for 6 months

Not associated with compensatory behaviors

• Differences between a client’s

behavior and desired goals.

• Difference between “resistance” and the lack of motivation.

•MI requires the helper to be reflective vs. directive.DiLillo, V (2003). Siegfried, N.J., & West, D.S. (2003). Incorporating motivational interviewing into behavioral obesity treatment. Cognitive and Behavioral Practice, 10, 120-130

Motivational ScaleHow important is it for you right now to

change your behaviors?On a scale of 0-10 what number would you give yourself?

0…………………………………………………….10Not at all important Important

What would need to happen for you to go from x to y?

Motivational Scale

How confident are you that you could do it?

On a scale of 0-10 what number would you give yourself?

0……………………………………………………10Not at all confident confident

What would need to happen for you to go from x to y?

Prochaska, Norcross & DiClemente (1994)

Maintenance Relapse

ContemplationAction

Preparation

Termination

Precontemplation

Transtheoretical Stages of Change

If a client answers either question between 1-4, assume they are in pre-contemplation and consider the following steps:

•Acknowledge the client’s control of decision•Give your opinion on the medical benefits of weight loss.•Explore concerns from the client’s view•Acknowledge possible feelings of being pressured to change•Validate that they are not ready and that it is solely their decision•State that, at this time they are not ready, but that it is possible they may feel differently at a future time.

Answers between 5-7 indicate some continued ambivalence, assume clients are in contemplation.•Validate client’s experience•Restate that the decision to change is still completely their own•Clarify pros and cons of changing behavior•Leave opportunity for continued movement toward change

If answers are between 8-10, assume they are ready to take action and help prepare them for behavior change.•Praise decision to change behavior•Identify and assist in problem solving regarding obstacles•Encourage small initial steps•Help identify social supports•Provide future follow-up appointments to assist with adherence

• Based on dysfunctional cognitions and beliefs• Modify behaviors by changing

antecedents and

consequences

15

Behavior is controlled by its Antecedents and Consequences

Face-to-face session Session description1

Behavioral therapy strategies

Session 1 Psychoeducation, goal setting, and monitoring

Session 2 Eating habits and family change

Session 3 Increasing daily activity and time management

Session 4 Food choices, shopping, and cooking

Session 5 Increasing exercise, problem solving, motivation

Cognitive behavioral therapy strategiesSession 6 Coping strategies and using helpful thoughts

Session 7 Body image

Session 8 Barriers and high-risk situations

Session 9 Maintaining change

Session 10 Maintenance and relapse prevention

Behavioral Treatment sessions

•Self-monitoring•Stress management•Stimulus control•Problem-solving•Contingency management•Cognitive restructuring•Social support

•Records of place and time of food intake

•Accompanying thoughts and feelings

• Identify the physical and emotional settings in which eating occurs

• Puts responsibility on the patient

• Defining the eating or weight

problem.

•Generating possible solutions;

-Evaluating the solutions -Choosing the best one.

•Trialing the new behavior;

-Evaluating outcome.-Generating alternatives.

Modification of

• Chain of events preceding eating.

• Kinds of foods .

•Consumed of satiety cues.

•Teaches patients to

identify, challenge, and correct negative thoughts

•Positive self-talk

•Understand that drug therapy is adjunctive to lifestyle intervention•BMI of 30 kg/m² or more •Have realistic expectations about weight loss goals and outcomes •Are unable to lose/maintain weight with lifestyle change alone •Have no medical or psychiatric contraindications

NHLBI Obesity Education Initiative, Expert Panel on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults

•Drugs should never be used without

continued concomitant lifestyle modifications

•Continual assessment of drug therapy for

efficacy and safety is necessary.

•If the drug is efficacious in helping the

patient to lose and/or maintain weight loss

and there are no serious adverse effects, it

can be continued.

•If not, it should be discontinued.

Treatment of Obesity

Name Dose Action Side Effects

•Orlistat/Xenical

•Sibutramine/Meridia

•Phentermine/ Adipex, Fastin

120 mg with each meal

5-15 mg/d

15-37.5 mg per day as a single or split dose

Peripheral: Blocks absorption of about 30% of consumed fat

Central: Inhibits synaptic reuptake of norepinephrine and serotonin

Central: Stimulates release of norepinephrine

GI symptoms (oily

spotting, flatus with discharge, fecal urgency, oily stools, incontinence)

Dry mouth, constipation, headache, insomnia, increased blood pressure, tachycardia

CNS stimulation, tachycardia, dry mouth, insomnia, palpitations

Thomas Repas D.O et al .2013

Treatment of Obesity( NOT FDA approved)

Name Usual Dose Action Side Effects

•ephedrine+/-caffeine "Elsinore"pill

•Bupropion/Wellbutrin

Topiramate/Topamax

Thomas Repas D.O et al

.2013

Varies: usually 75-150 mg ephedrine and 100-150 mg caffeine

100-300 mg/d

96-192 mg/d

Stimulates adrenergic receptors

Inhibits reuptake of dopamine norepinephrineand serotonin

Central ?

CNS stimulation, tachycardia, dry mouth, insomnia, palpitations

CNS stimulation, dry mouth, headache, GI effects

Paresthesia, fatigue, dizziness, memory difficulty, concentration difficulty, and depression