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Obesity and Mental Illness: Addressing a Double Epidemic

From CONDUIT Magazine, Fall 2012 

In recent years, health experts have had an epiphany: successful long-term weight management isn’t simply a matter of fewer calories in than out; it’s about permanent behavioural changes. Making such changes, however, relies on things like intention, willpower and coping skills, all of which reside in the mind. But what if mental illness taxes the brain’s ability to plan, execute and sustain the efforts required for weight management?

One of the most vital lessons the scientific and health care communities have learned is that obesity and mental illness are related. And identifying and exposing the complex interplay between the two kinds of diseases is a solid start to developing more comprehensive and effective solutions than currently available in the arsenal. This is why, according to the 4Ms of obesity assessment outlined in the Canadian Obesity Network's 5As of Obesity Management program (see CONDUIT, Fall 2012 story here; ordering information can be found here), assessment of mental health status should be an essential part of any examination for excess weight (along with the evaluation of mechanical, metabolic and financial health).

Hatching New Strategies

Underlining the need for policy changes, better education and involvement of various health care professionals, the Toronto Charter on Obesity & Mental Health hopes to deepen our understanding of the links between these two major health issues with a view to addressing their consequences.

The Charter is a call to action for policy makers and health care professionals to recognize the relationship between obesity and mental illness, and to galvanize their efforts to address the complexity of this double epidemic. The Canadian Obesity Network (CON-RCO), in partnership with the International Association for the Study of Obesity (IASO) and the Centre for Addiction and Mental Health (CAMH), ratified the Charter at a hot topic Conference of Obesity and Mental Health in Toronto in June, 2012.

“Our main purpose is to raise awareness and to get across to both policy makers and health professionals that an association between mental health and obesity is a real issue that must be addressed or we will never be successful in getting the obesity epidemic under control,” says Dr. Valerie Taylor, psychiatrist-in-chief in the department of medicine at Women’s College Hospital, and obesity chair in mental health for the Canadian Obesity Network.

“In both the bariatric field and in psychiatry, there has been very little recognition and research on the relationship between mental illness and obesity, or on the way in which mental disorders might influence the outcome of obesity treatments,” says Dr. Rohan Ganguli, professor of psychiatry and Canada Research Chair (Tier 1, Chronic Disease Management), University of Toronto. “The Charter, and the conference out of which it grew, highlights these facts and helps to justify an organized effort to set this inequitable situation right. We hope that it will result in increased resources for treatment, and research into both treatment and understanding the mechanisms underlying the relationship between obesity and mental health.”

According to the Charter, public health policies should prioritize prevention of mental illness and weight-related disorders, and recognize the links of both conditions to socioeconomic, cultural, gender and other health determinants. Breeding a cultural shift will require training and support for all health practitioners, focused on prevention and interventions, as well as collaboration with relevant specialties across disciplines, services and sectors.

A Double-Edged Sword

What health care professionals need to be aware of is that anyone with one of these health problems is much more susceptible to developing the other one. Statistics offer a clue: people with mental health issues have a two- to three-times higher risk of obesity, and people with obesity have a 30% higher risk of mental health issues. Also, for someone with a diagnosis of major mental illness, the risk of dying from an obesity-related illness can increase by up to 38%, which means that life expectancy declines by 15 to 20 years. “You only have to peer into the waiting room of a psychiatrist to see that many mentally ill patients have significant weight issues,” says Taylor. 

A range of mental illnesses, including schizophrenia, bipolar disorder and depression, have all been shown to be associated with increased risk of overweight and obesity, and also increased risk of obesity-related illnesses, such as diabetes and coronary heart disease, explains Ganguli. Diabetes, for example, is two to three times more prevalent in people with schizophrenia than in the general population. “There’s also a correlation between the severity of diabetes and depression,” adds Ganguli.

Such comorbidities aren’t surprising, since obesity and mental illness share a number of underlying risk factors and causes, including biology, says Taylor. “Individuals with depression have higher levels of cortisol; in people with obesity, fat tissue is linked to producing higher levels of cortisol. So you have a chemical introduced by fat tissue that, in high amounts, is linked to depression,” she says. “People need to understand that if someone is vulnerable and they start putting on weight, basic biology is going to increase their risk of mental illness.”

Not everyone with a mental health issue will have a weight problem or vice-versa. But for many who do have both, mental illness seems to affect the outcome of obesity treatment. “You cannot expect anyone to engage in a successful weight-management program while they have an untreated major mental illness,” says Taylor. 

In fact, mental illness may actually set in motion a vicious cycle: For example, depression often is linked with weight gain, which can sabotage a person’s self-esteem and may, in turn, worsen depression. While most clinicians focus first on relieving depressive symptoms, Ganguli cautions against waiting too long to start discussing the person's general health, including weight issues. 

“The fact that some medications used to treat mental illness can increase the risk of weight gain makes it even more important that the clinician address weight management as part of the overall approach to helping the patient feel better,” he explains.

Ganguli laments, however, that despite available guidelines for monitoring adverse health effects of medication, study findings to date suggest that very few patients receive monitoring. “For those who develop obesity, diabetes and other health problems, access to sound evidence-based interventions to reverse weight gain and mitigate its harmful effects is also severely limited,” he says

Putting Our Heads Together

Obesity is a complex problem that requires a multifaceted team approach, given its downstream health effects and the complicit role that mental health may play in the management of many chronic diseases. 

“What’s killing individuals with depression or bipolar isn’t just suicide, but diabetes and heart attack,” says Taylor. “Because psychiatrists look after depression, endocrinologists deal with diabetes and cardiologists treat heart attack, there’s been a real paucity of communication, and it has taken a while for people to realize that this is something we need to work on together, acting on informed policy.”

Yet, there’s often a missed opportunity in primary care to screen for mental health issues or to open a discussion about weight-related issues. “Part of the problem is that primary care practitioners feel they may not have the time or the expertise to provide treatment if they did start addressing these issues,” explains Ganguli.

Providing doctors with proper education, training and resources are key to ensuring primary care practitioners don’t get discouraged, says Ganguli. “Training in both the assessment and treatment of weight-related problems should be provided, and practitioners—not just physicians, but also nurses, physicians' assistants, pharmacists, etcetera—should be required to take such training and demonstrate their competence in providing treatment,” he says. 

Ultimately, some issues will be beyond the scope of primary care. Access to specialist services becomes imperative to address complex cases involving either or both obesity and mental illness, says Ganguli.

Primary care physicians can’t be expected to do it all, agrees Taylor:

“Expectations are high for family doctors to screen for, diagnose and manage chronic diseases.” Taylor insists that we should let them do what they do well—coordinating care. “We need a team approach with primary care physicians leading the way. They’re the ones who know the patient best. They’re the ones who are going to see the patient and family on a regular basis. They’re the key coordinating hub, and the other specialities need to be willing to be involved and help them out,” she says. 

Prevention Pays Off

The key to helping primary care physicians so they can in turn help their patients is creating awareness among them about the links between obesity and mental illness. The focus for these physicians shouldn’t necessarily be on tackling either problem, but on preventative efforts, suggests Ganguli.

“Our primary care system is designed to emphasize prevention of disease and ill health as much as the treatment of established disease,” says Ganguli. “In such a system, primary care services would have a natural advantage in identifying weight-related health problems and mental illnesses and other psychological distress, while being able to address them in an integrated and comprehensive manner.”

Recognizing the association in and of itself can be preventative, suggests Taylor. “You can actually prevent the development of another chronic disease if people are aware that this relationship exists,” says Taylor. “Treatment of depression can be considered as preventative for the development of obesity, and adequate management of obesity as preventative for the development of mental illness.”

Given that the link between obesity and mental health is a fairly recent concept that requires more exploration, a cultural shift and policy changes that would address these links will take time to come to fruition. 

“This sort of a lag is, however, common in medicine, and should not discourage us, but rather stimulate us to educate and persuade practitioners and policy makers more aggressively and reduce the ‘lag’ as much as possible,” says Ganguli.