Does mental health have an impact on people living with obesity?
Dr. Sharma: There is an intimate link between eating and your mental state. We often think of eating as just something that we do every day, but in fact eating is a very complex behaviour that involves different parts of the brain and uses conscious and unconscious decision making. That decision making is very much affected by your mental health status, so that is why it is common to hear people say, ‘when I am stressed out, I eat more’ or ‘when I am stressed out, I lose my appetite’.
Your mental health status has an impact on your eating habits, even if you do not have a specific or diagnosed mental health condition. Your relationship with your spouse, your job or any life stress can impact your mental health and this in turn can affect your overall health. Trying to eat healthily, be active and sleep well are essential to health, but our ability to undertake those activities is affected by our mental health status. This is an even bigger issue if you are a patient living with a mental health disorder such as anxiety or depression. The patient may understand at a cognitive level and recognise what they need to do, but struggle to perform the right behaviours. As a medic, it is virtually impossible to manage anyone’s obesity if there are significant mental health issues that are not being addressed, as all the behaviours that can contribute to obesity are linked to our mental state. The good news is there are specialists, treatments, and strategies that can make a real difference.
Do people who live with obesity experience more mental health issues than most people?
Dr. Sharma: It is important to distinguish between people who attend an obesity clinic because they are actively trying to lose weight, and those people who may be living with obesity who are not attempting to change their weight or size. Research shows that there is a higher incidence of mental health issues amongst people who are seeking weight loss, so it is unsurprising that when you work in an obesity clinic you are more likely to encounter patients who have a mental health issue. However, this can sometimes lead to the false assumption that anyone with a weight issue has a mental health issue, that is not true. Many people who perhaps carry more weight than they should, are not bothered by it, and their mental health is unaffected.
Do doctors find it difficult to discuss mental health with their patients?
Dr. Sharma: The challenge is not the difficulty of discussing mental health issues, as every medic no matter how specialised has undertaken mental health training while in medical school. Doctors know the signs and symptoms of mental health disorders; the issue is making the link between these issues and excess weight. When seeing a patient with a weight concern, doctors can often forget that the patient may also be presenting with depression or another mental health condition. So, the issue is not that doctors do not understand or are uncomfortable, rather it is recognising that mental health may also be a factor that needs to be considered.
Even a relatively minor mental health concern can have a huge impact on a patient’s ability to manage their weight. As doctors, we often focus on what the patient may be eating, or their level of physical activity but not on why they are eating or perhaps not moving enough. If a patient is eating as a coping mechanism in response to negative or anxious thoughts, no amount of education about healthy food choices will change that behaviour. Instead, the patient needs to understand why they are eating and create healthier coping mechanisms. So, a doctor can help by encouraging the patient to recognise the connection between their eating and mental health state. The need for the food will disappear if you address the underlying issue, that is why it is vital to make that connection.
How can doctors approach the issue of mental health with patients who are living with obesity?
Dr. Sharma: It is important to fully understand your patient’s life, therefore mental health must be part of the conversation. To find out the necessary information we advocate that medics use the 4 M approach which is included in the Canadian Adult Obesity Clinical Practice Guidelines. The 4Ms refer to – mental health, mechanic health (i.e. - arthritis, sleep apnoea & chronic pain), metabolic disease, and the social milieu. Social milieu refers to the patient’s physical and social setting. By going through all four categories, it is possible to develop a good understanding of the patient’s life and the challenges they are facing, I find that mental health and the social milieu tend to be the biggest issues.
Mental health is number one because it is one of the most important drivers of weight gain in the population and one of the most significant barriers to obesity management. However social milieu is also pivotal, does a patient have access to healthcare to pursue the treatment I have prescribed? Do they have an income or a stable home environment? It is important to appreciate how these social determinants can help or hinder a patient.
Without working through these four key areas, healthcare professionals may miss out on key drivers and barriers for the patient. Inexperienced doctors or those that have not had training in obesity management tend to focus on diet and physical activity, but what we try to teach people is that why people eat is just as important as what they eat.
"It is important to appreciate how these social determinants can help or hinder a patient. " Dr Arya M. Sharma Professor Emeritus of Medicine, University of Alberta, Canada
What are your top tips for healthcare professionals to help them address mental health issues with patients?
Dr. Sharma: There are three points I would like to highlight. Foremost, healthcare professionals must recognise the key importance that mental health plays in a patient’s ability to maintain their health. Secondly, mental health issues are not to be feared, instead, we must normalise those conversations and be cognisant of how highly prevalent mental health disorders are. Finally, we must destigmatise mental health so that patients feel able to share their experiences. There is a balance to observe because stigma does exist and we must be careful of the labels and language we use, but that should not dissuade us. To make sure conversations with patients are as constructive as possible it is essential that patients understand why you are posing certain questions. If a patient turns up for an appointment expecting to discuss a diet or exercise plan and they are met with questions about their sleeping habits or trauma history they may become confused. But if you explain that lack of sleep or past trauma can be related to weight gain, they may be more open to exploring these topics. Patients must understand the connections between your questions and managing their weight.
It has been suggested that lockdown has exacerbated unhealthy eating habits, do you think the pandemic has changed our relationship with food?
Dr. Sharma: I think some good things have come out of the pandemic. At one point yeast was sold out in shops because many people suddenly started baking bread, so clearly, people started cooking in a way they were not previously. Also, families have been at home together so there have been more opportunities for planned mealtimes. Cooking and planned mealtimes are both conducive to healthy eating. In terms of the bad eating habits that have developed, I think they will fade as we revert to our normal lifestyles. People who missed out on exercise due to gym closures will resume their previous levels of physical activity, while people who started consuming high-calorie junk food out of boredom will hopefully find other activities to pursue as things normalise. Of course, there are some people who will have experienced more significant issues, and they will need extra support to help them change unhealthy eating habits developed during the pandemic. Ultimately, I am very hopeful that we will all bounce back.