Anthony N. Fabricatore

Obesity Among Those with Mental Disorders: A National Institute of Mental Health Meeting Report

The National Institute of Mental Health convened a meeting in October 2005 to review the literature on obesity, nutrition, and physical activity among those with mental disorders. The findings of this meeting and subsequent update of the literature review are summarized here. Levels of obesity are higher in those with schizophrenia and depression, as is mortality from obesity-related conditions such as coronary heart disease. Medication side effects, particularly the metabolic side effects of antipsychotic medications, contribute to the high levels of obesity in those with schizophrenia, but increased obesity and visceral adiposity have been found in some but not all samples of drug-naïve patients as well. Many of the weight-management strategies used in the general population may be applicable to those with mental disorders, but little is known about the effects of these strategies on this patient population or how these strategies may need to be adapted for the unique needs of those with mental disorders. The minimal research on weight-management programs for those with mental disorders indicates that meaningful changes in dietary intake and physical activity are possible. Physical activity is an important component of any weight-management program, particularly for those with depression, for which a substantial body of research indicates both mental and physical health benefits. Obesity among those with mental disorders has not received adequate research attention, and empirically-based interventions to address the increasing prevalence of obesity and risk of cardiovascular and metabolic diseases in this population are lacking.

Evidence for prospective associations among depression and obesity in population-based studies

Obesity may lead to depression or be one of its consequences. We reviewed population‐based studies in order to, first, identify the most commonly used research methods, and, second, to evaluate the strength of evidence for prospective associations among obesity and depression. We examined 25 studies, of which 10 tested ‘obesity‐to‐depression’ pathways, and 15 tested ‘depression‐to‐obesity’ pathways. Descriptive statistics summarized the frequency with which various measurements, designs and data analytic strategies were used. We tallied the number of studies that reported any vs. no statistically significant associations, and report on effect sizes, identified moderating variables within reports, and sought common findings across studies. Results indicated considerable methodological heterogeneity in the literature. Depression was assessed by clinical interview in 44% of studies, weight and height were directly measured in 32%, and only 12% used both. In total, 80% of the studies reported significant obesity‐to‐depression associations, with odds ratios generally in the range of 1.0 to 2.0, while only 53% of the studies reported significant depression‐to‐obesity associations. Sex was a common moderating variable. Thus, there was good evidence that obesity is prospectively associated with increased depression, with less consistent evidence that depression leads to obesity. Recommendations for future research regarding study samples, measurement and data analysis are provided.

Impact of a Weight Management Program on Health-related Quality of Life In Overweight Adults with Type 2 Diabetes

BACKGROUND Inconsistent findings have been reported regarding improved health-related quality of life (HRQOL) after weight loss. We tested the efficacy of a weight management program for improving HRQOL in overweight or obese adults diagnosed as having type 2 diabetes mellitus. METHODS We conducted a randomized multisite clinical trial at 16 outpatient research centers with 2 treatment arms and blinded measurements at baseline and the end of year 1. A total of 5145 participants (mean [SD] age, 58.7 [6.9] years; mean [SD] body mass index [calculated as weight in kilograms divided by height in meters squared], 36.0 [5.9]; 59.5% women; 63.1% white) were randomized to an intensive lifestyle intervention (ILI) or to diabetes support and education (DSE). Main outcome measures included the 36-Item Short-Form Health Survey physical component summary (PCS) and mental health component summary (MCS) scores and Beck Depression Inventory II (BDI-II) scores. Baseline mean (SD) scores were 47.9 (7.9) for PCS, 54.0 (8.1) for MCS, and 5.7 (5.0) for BDI-II. RESULTS Improved HRQOL was demonstrated by the PCS and BDI-II scores (P < .001) in the ILI arm compared with the DSE arm. The largest effect was observed for the PCS score (difference, -2.91; 99% confidence interval, -3.44 to -2.37). The greatest HRQOL improvement occurred in participants with the lowest baseline HRQOL levels. Mean (SD) changes in weight (ILI, -8.77 [8.2] kg and DSE, -0.86 [5.0] kg), improved fitness, and improved physical symptoms mediated treatment effects associated with the BDI-II and PCS. CONCLUSIONS Overweight adults diagnosed as having type 2 diabetes experienced significant improvement in HRQOL by enrolling in a weight management program that yielded significant weight loss, improved physical fitness, and reduced physical symptoms. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00017953.

Night Eating Syndrome and Binge Eating Disorder among Persons Seeking Bariatric Surgery: Prevalence and Related Features

Objective: To assess the prevalence of night eating syndrome (NES) and binge eating disorder (BED) and their related behavioral and psychological correlates in persons who sought bariatric surgery.

Comparison of Psychosocial Status in Treatment-Seeking Women with Class III vs. Class I–II Obesity

Objective: This study compared the psychosocial status and weight loss expectations of women with extreme (class III) obesity who sought bariatric surgery with those of women with class I–II obesity who enrolled in a research study on behavioral weight control.

Health-related quality of life and symptoms of depression in extremely obese persons seeking bariatric surgery

Background: Extreme obesity, defined by a body mass index (BMI) ≥40 kg/m2, is associated with increased risk of depression and with impairments in healthrelated quality of life (HRQoL). This study examined the relationships among BMI, HRQoL, and symptoms of depression in persons with extreme obesity. Method: Participants were 306 patients who sought bariatric surgery (mean ± SD age 43.8±9.4 years, BMI 52.8±9.3 kg/m2) and who completed questionnaires to assess symptoms of depression and HRQoL prior to surgery. We defined HRQoL impairment as a score ≥1 SD below national means. Results: Impairments in HRQoL were common: >40% of participants scored in the impaired ranges of physical functioning, physical role limitations, and bodily pain. Results of analyses of variance (ANOVAs) indicated that impairments in HRQoL were significantly related to symptoms of depression. Patients with impaired HRQoL scored above the cut-off point for clinically significant depression, while those without such impairment scored below that cut-off, regardless of BMI. The contribution of BMI to depression was not significant in any ANOVA. Conclusion: HRQoL is more strongly and more directly related to symptoms of depression than is BMI. These findings highlight the need to assess HRQoL in patients with extreme obesity and suggest that interdisciplinary strategies to address HRQoL impairments may be beneficial in this population.

Predictors of Attrition and Weight Loss Success: Results from a Randomized Controlled Trial

Attrition is a common problem in weight loss trials. The present analysis examined several baseline and early-treatment process variables, as predictors of attrition and outcome in a clinical trial that combined pharmacotherapy and behavior therapy for weight loss. Participants were 224 obese adults who were treated with sibutramine alone, lifestyle modification alone, combined therapy, or sibutramine plus brief lifestyle modification. Predictors included baseline characteristics (e.g., demographic, weight-related, psychological, and consumption-related variables), plus attendance, adherence, and weight loss in the early weeks of treatment. Outcomes were attrition and weight loss success (i.e., >or=5% reduction in body weight) at 1 year. Multivariable models, adjusting for other relevant variables, found that younger age and greater baseline depressive symptoms were related to increased odds of attrition (ps <or= 0.003). Greater early weight loss marginally reduced the odds of attrition (p = 0.06). Predictors of weight loss success at 1 year were Caucasian ethnicity (p = 0.04), lower baseline depressive symptoms (p = 0.04), and weight loss during the first 3 weeks of treatment (p < 0.001). Thus, depressive symptoms at baseline were a significant predictor of both attrition and weight loss success. As a process variable, early weight loss appears to have more predictive value than early attendance at treatment sessions or early adherence.

Intentional weight loss and changes in symptoms of depression: a systematic review and meta-analysis

Objective:Obesity is related to increased risk of several health complications, including depression. Many studies have reported improvements in mood with weight loss, but results have been equivocal. The present meta-analysis examined changes in symptoms of depression that were reported in trials of weight loss interventions. Between-groups comparisons of different weight loss methods (for example, lifestyle modification, diet-alone and pharmacotherapy) were examined, as were within-group changes for each treatment type.Method:MEDLINE was searched for articles published between 1950 and January 2009. Several obesity-related terms were intersected with terms related to depression. Results were filtered to return only studies of human subjects, published in English. Of 5971 articles, 394 were randomized controlled trials. Articles were excluded if they did not report mean changes in weight or symptoms of depression, included children or persons with psychiatric disorders (other than depression), or provided insufficient data for analysis. Thirty-one studies (n=7937) were included. Two authors independently extracted a description of each study treatment, sample characteristics, assessment methods and changes in weight and symptoms of depression. Treatments were categorized as lifestyle modification, non-dieting, dietary counseling, diet-alone, exercise-alone, pharmacotherapy, placebo or control interventions.Results:Random effects models found that lifestyle modification was superior to control and non-dieting interventions for reducing symptoms of depression, and marginally better than dietary counseling and exercise-alone programs. Exercise-alone programs were superior to controls. No differences were found for comparisons of pharmacologic agents and placebos. Within-group analyses found significant reductions in symptoms of depression for nearly all active interventions. A meta-regression found no relationship between changes in weight and changes in symptoms of depression in lifestyle modification interventions.Conclusions:On average, obese individuals in weight loss trials experienced reductions in symptoms of depression. Future studies should examine incidence and resolution of clinically significant depressive disorders with weight loss interventions.

Binge Eating Disorder and the Outcome of Bariatric Surgery at One Year: A Prospective, Observational Study

Previous studies have suggested that binge eating disorder (BED) impairs weight loss following bariatric surgery, leading some investigators to recommend that patients receive behavioral treatment for this condition before surgery. However, many of these investigations had significant methodological limitations. The present observational study used a modified intention‐to‐treat (ITT) population to compare 1‐year changes in weight in 59 surgically treated participants, determined preoperatively to be free of a current eating disorder, with changes in 36 individuals judged to have BED. Changes in weight and binge eating in the latter group were compared with those in 49 obese individuals with BED who sought lifestyle modification for weight loss. BED was assessed using criteria proposed for the Diagnostic and Statistical Manual (DSM) 5. At 1 year, surgically treated participants without BED lost 24.2% of initial weight, compared with 22.1% for those with BED (P > 0.309). Both groups achieved clinically significant improvements in several cardiovascular disease (CVD) risk factors. Participants with BED who received lifestyle modification lost 10.3% at 1 year, significantly (P < 0.001) less than surgically treated BED participants. The mean number of binge eating days (in the prior 28 days) fell sharply in both BED groups at 1 year. These two groups did not differ significantly in BED remission rates or in improvements in CVD risk factors. The present results, obtained in carefully studied participants, indicate that the preoperative presence of BED does not attenuate weight loss or improvements in CVD risk factors at 1 year in surgically treated patients. Longer follow‐up of participants is required.

Axis I psychopathology in bariatric surgery candidates with and without binge eating disorder: results of structured clinical interviews.

BackgroundPrior studies have reached contradictory conclusions concerning whether binge eating disorder (BED) is associated with greater psychopathology in extremely obese patients who seek bariatric surgery. This study used the Structured Clinical Interview for DSM-IV Diagnoses (SCID) to compare rates of axis I psychopathology in surgery candidates who were determined to have BED or to be currently free of eating disorders. The relationship of BED to other psychosocial functioning and weight loss goals also was examined.MethodsOne hundred ninety five bariatric surgery patients completed the Weight and Lifestyle Inventory and the Beck Depression Inventory-II (BDI-II) and were later administered the Eating Disorder Examination. Of these 195, 44 who were diagnosed with BED, and 61 who were currently free of eating pathology, completed a telephone-administered SCID.ResultsSignificantly more BED than non-BED participants had a current mood disorder (27.3% vs. 4.9%, p = 0.002) as well as a lifetime history of this condition (52.3% vs. 23.0%, p = 0.003). More BED than non-BED participants also had a current anxiety disorder (27.3% vs. 8.2%, p = 0.014) and lifetime anxiety disorder (36.4% vs. 16.4%, p = 0.019). BED also was associated with greater symptoms of depression, as measured by the BDI-II, as well as with lower self-esteem. BED and non-BED groups, however, did not differ in their desired weight loss goals following surgery.ConclusionsThe present findings indicate that the presence of BED, in patients who seek bariatric surgery, is associated with an increased prevalence of axis I psychopathology, beyond the already elevated rate observed with severe (i.e., class III) obesity.