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• W1528741311 abstract "Helping patients to successfully change thoughts and behaviours that contribute to weight gain, obesity and ill health is difficult, particularly when depression is added to the mix. While dietitians who specialise in weight management are well placed to facilitate behaviour change, they need to be well versed in identifying and taking appropriate steps to assist patients with co-morbid depression. There is recognised evidence that increased body mass index (BMI) and waist circumference are independent predictors of depressive symptoms including anxiety.1-3 Furthermore, the increasingly common antidepressant exposure in many patients is a covert and enduring risk factor for obesity, even after discontinuation of antidepressant treatment.4 In epidemiological studies that use validated diagnostic tools to screen for depression and anxiety, the prevalence ranges from 15% to 35% in obese people, compared with approximately 6% in a healthy weight population. These rates are influenced by gender and severity of obesity, with more frequent diagnosis in obese women compared with obese men and increasing prevalence of depressive symptoms with increasing grades of obesity irrespective of gender.3, 5 The prevalence of depression increases in a step-wise fashion as the number of obesity-related co-morbidities increase. There is a 6.5% age-standardised prevalence of depressive episodes in people with no co-morbidities, increasing up to 30.3% to 37.9% in people with 3 and 4–5 co-morbidities, respectively.3 People with the metabolic syndrome, a condition defined by central obesity and multiple metabolic co-morbidities, have a 50% greater risk of depression than people without the metabolic syndrome.6 Emerging evidence suggests that metabolic dysfunction itself may play a direct role in the increased prevalence of depressive symptoms in obesity.6 Observational data show that the risk of developing future depression is lower in metabolically healthy obesity compared with obesity with metabolic complications such as hypertension, systemic inflammation, impaired glycaemic control or adverse lipid profiles.7 Dietetic practice is likely to encounter obese individuals with multiple co-morbid conditions such as diabetes, cardiovascular disease, hypertension, hyperlipidaemia and fatty liver disease and so it is crucial that dietitians are well equipped to identify an increased risk of depressive symptoms in their patients. The presence of depressive symptoms may be associated with a greater dropout from dietetic services and dropout at an earlier stage of intervention compared with those without depressive symptoms.8 Current dietetic practice for weight management relies heavily on patient adherence to goal setting, attendance to counselling sessions, self-monitoring behaviours and maintaining a focus on the positive outcomes being achieved, all extremely challenging for the depressed patient.8, 9 In our own tertiary hospital setting, despite a commitment to evidence-based practice for weight management, an audit of our practice showed that outpatient attendance was often poor and attrition was common, resulting in our traditional dietetic service capturing less than 15% of referred patients (unpublished data). The remainder received no dietetic service and their outcomes, including their state of mental health, were essentially unknown. As an attempt to identify and tackle barriers to dietetic care for obesity and provide alternatives to traditional service delivery, we piloted a trial of a telephone-based lifestyle intervention programme10 modified to meet the dietary and physical activity needs of tertiary hospital outpatients with acute and chronic co-morbidities. In addition, the self-reported presence or absence of depressive symptoms and/or anxiety was identified. Patients entering our telephone-based programme had all previously refused participation in the hospital-based group weight loss programme. This alternative service option resulted in a further 21% of referred patients engaging with the dietetic service for weight management. Participants were 45% female, mean age was 49 ± 13 years and mean BMI was 37 ± 7 kg/m2. Depressive symptoms and/or anxiety were self-reported by 55% of participants—staggeringly higher than first anticipated. This may reflect the high rate of acute and chronic medical illnesses influencing depressive symptoms in a tertiary hospital patient population or also a selection bias of those who were unable or unwilling to attend face-to-face appointments when first referred. It is tempting to speculate that dietetic interventions for weight loss might indirectly benefit depressive symptoms, but the available evidence does not strongly support this hypothesis.11, 12 A sub-analysis of the Finnish Diabetes Prevention Study demonstrated a correlation between significant weight loss and an improvement in depressive symptoms assessed by the Beck Depression Inventory, but similar effects in both intervention and control groups suggested no direct link to dietetic exposure.11 In a study of obese women undertaking a diet and exercise programme, a decrease in depression score at six months was more likely in those who were exercising and who had lost >5 kg, but the relationship with weight loss was not sustained by 12 and 24 months; and at no time was there a link between change in depressive symptoms and dietary intake.12 It is unlikely that depression will resolve through dietary change alone and so appropriate identification and referral for psychological assessment and treatment as an adjunct therapy to dietetic service for weight management are important. The diagnosis of depression and anxiety in the medically ill is complicated and confounded by many clinical variables that may be present in a tertiary hospital patient population. However, a brief screening tool designed for use in medically ill patients, such as the validated DMI-10 questionnaire13 (also available for health professionals on the Black Dog Institute website) or the widely used Beck Depression Inventory14 could add value to the initial dietetic assessment by allowing the initiation of appropriate psychological referral at an early stage of care and act as a platform for discussing the impact of mental health and help tailor the motivational interviewing during therapy. Dietitians need to be conscious that greater co-morbidities signal greater risk of depressive symptoms and clear referral procedures are paramount to high quality care. A greater flexibility (such as innovative service delivery models) and extra time may be necessary to achieve lifestyle-related goals when mental health concerns are identified." @default.
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• W1528741311 date "2012-12-01" @default.
• W1528741311 modified "2023-09-26" @default.
• W1528741311 title "Depressive symptoms and obesity: Assessing and addressing the black dog in the room" @default.
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