IN 2001, the US Surgeon General declared an obesity epidemic, reporting that approximately 300,000 US deaths a year are associated with obesity and overweight compared to more than 400,000 deaths a year from cigarette smoking. A federal study estimates the health-care costs of overweight and obesity in the US at $92.6 billion. In 1993, according to the CDC, the prevalence of obesity in most US states was less than 14 percent. In 2001, it was approaching 24 percent. Preliminary findings indicate we have broken through 30 percent, with some estimates as high as 35 percent. Fifteen percent of children are obese, with a rise in type II diabetes. In 2002 the World Health Organization reported that "[u]nhealthy diets and physical inactivity are ... the leading causes of the major noncommunicable diseases ...."
"Obesity hits every organ system in the body," endocrinologist Judith Korner MD PhD of Columbia University told a session at the 2004 American Psychiatric Association’s annual meeting. This includes the heart, sleep, diabetes, cancer, and psychosocial ills. Ten years from now, she said, obesity will exceed lung cancer in terms of death.
Piling on Weight
At the 2003 Depression and Bipolar Support Alliance conference, Diana Lipson-Burge, a nutrition consultant and co-author of "Un-Dieting", cautioned that 80 percent of the dieting information out there is inaccurate, especially the gimmick diets found in just about every magazine. Ironically, dieters are told to consult a doctor who typically has had only one nutrition class in med school. Not surprisingly, according to one 10-year study, there is only a 5.2 percent success rate with diets.
This is what it takes to form one pound of fat: The average person burns 1,300 calories a day just to stay in bed. This is called the basal metabolic weight. An additional 600 calories are burned, on an average day, for getting out of bed and moving around, resulting in 1,900 calories to maintain natural body weight. One would have to consume 3,500 calories more on top of that in one day to add a pound of fat, which is almost impossible (disregarding meds and other exceptions). Even binge eaters, said Ms Lipson-Burge, don’t eat that much.
But eating the wrong food can result in the weight piling on fairly quickly. Dr Korner cited one example: One New York City muffin, she said, contains about 600 calories, and a 20-ounce cola 250. Assuming this little snack begins as a temptation that turns into a daily habit, in addition to normal regular food intake, it takes just four days to cross the 3,500 calories/one pound threshold and one month to put on seven pounds
How easy is it to take off weight and keep it off? Unfortunately, we run into a wall when we lose 10 percent of our body weight, Dr Korner reported. Adipose tissue shrinks, which results in less leptin, which puts the hypothalamus on red alert. The body goes into survival mode, increasing hunger pangs and lowering metabolism. Within three to five years, she said, almost all dieters are back up to original body weight.
All this comes as cold comfort to those of us caught in the pincers of our illness and our meds. Depression sends many of us into the warm embrace of ice cream and chocolate while our meds can amount to hot fudge sundaes in pill form with none of the pleasures. Weight management obviously needs to be regarded as a lifetime task - eating the right foods and getting plenty of exercise, while setting realistic goals.
Setting realistic goals may mean that aiming for a Rubenesque ideal is okay. Trying to accomplish too much too soon is counterproductive and will only lead to disappointment.
Keep in mind that BMI (body mass index) - which purports to define ideal weight according to one's height, gender, and age - fails to account for body fat. Muscle is heavier than fat, which may mean that working out after a certain point could put on weight (which is good, in this context). A 5' 9" light heavyweight boxer who tips the scales at 175 pounds is only overweight in BMI Land.
The BMI is also blind to body type. Ectomorphs - with light bones, slight muscles, and long limbs (such as marathon runners) are not going to turn into mesomorphic Tarzans - with large bones, broad chest, and well-defined muscles - simply by gulping down protein drinks and going to the gym. Likewise, medical science has yet to find a way for endomorphic Santas to stretch their soft round, short-limbed bodies into a mesomorphic or ecto-meso ideal.
Basically, we have to work with what we've got, but this should not discourage you. Athletically chunky is beautiful, as is pleasingly plump. Ignore the computer-enhanced cover girls that bombard our environment and pay attention, instead, to the paintings of the old masters.
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Throw away your scale, Ms Lipson-Burge urged, and listen to your stomach. The stomach, she explained, works like a gas gauge on a car. On a one to 10 scale, two corresponds with a growling sensation in the stomach, when all that’s left of a previous meal is a thin lining on the stomach wall. X-rays have shown that fit adults and infants and toddlers (who instinctively know how to eat right) start eating when the stomach is at two.
This contrasts with the "it’s lunchtime I must be hungry" mentality.
The fit eaters always stopped eating at seven on the "stomach gauge," with no pressure on the stomach wall.
No one agrees what a best diet is, Dr Korner told her audience at the APA meeting, but whatever diet works is okay, so long as it’s healthy. Exercise is essential, such as brisk walking at three to four miles per hour at least 2.5 hours a week. Cognitive-behavioral therapy also works well. A realistic treatment goal is a five to ten percent reduction in initial body weight over six to 12 months followed by long-term maintenance of that weight.
So-called diet aids - the type that promise, "I lost 12 pounds in five days and ate everything I wanted" - are harmful in more ways than one, she went on to say. If they don’t work, it reinforces the notion that "something is wrong with me."
Watching What You Eat
Dr Korner also said that a calorie is a calorie only in the sense that if one's intake of total calories is the same, one will wind up weighing the same regardless of the fat/carb/protein ratios. But a person on a high protein diet is going to turn out physiologically different and at a much reduced risk of diabetes and other illnesses than someone eating a lot of bad fats and sugars.
The American Heart Association recommends that no more than 10 percent of one’s calories should come from saturated fat. One gram of saturated fat equals nine calories. On an adult diet of 2,000 calories a day, then, that single burger-fries-and-shake meal (with nearly 250 saturated fat-derived calories) well exceeds the daily saturated fat limit. The American Heart Association also recommends restricting cholesterol consumption to less than 300 mg a day and sodium intake to less than 2,400 mg daily.
In May 2004, the World Health Organization issued the final draft of its "Global Strategy on Diet and Health." Its main recommendations concerning diet include:
1. Achieve energy balance and a healthy weight.
2.Limit energy intake from total fats and shift fat consumption away from saturated fats to unsaturated fats and towards the elimination of trans-fatty acids.
3. Increase consumption of fruits and vegetables, and legumes, whole grains and nuts.
4. Limit the intake of free sugars.
5. Limit salt (sodium) consumption from all sources and ensure that salt is iodized.
The WHO also recommended at least 30 minutes of regular, moderate-intensity physical activity.
My Weight Gain Experience
In January 1999, when I first sought help for my bipolar disorder, I was first put on a notorious weight-gaining mood stabilizer and equally notorious antidepressant by a crisis intervention psychiatrist who only saw me twice and failed to warn me about their side effects (why is this no surprise?). Within a few weeks, I had ballooned from 156 pounds to 187, an alarming gain of 20 percent of my original body weight. Since I am six-one, the meds ironically filled out my bean pole frame and made me look better than I ever looked in my life, bald head and all. I managed to get my weight down to about 180-185 and keep it there for the next 17 years.
Had I started out at a more normal 200 pounds for my height, a 20 percent weight gain would have represented 240 pounds, well on my way to looking like the "Before" Jarred Fogel of Subway diet fame. Any temporary gain from stabilizing my mood, I am convinced, would have been lost by the long term depression from weight-induced sluggishness and the mood swings of extra sugar and other poisons in my diet. My meds would have been engaged in a losing battle with my runaway metabolism, which would have turned me into one of those cases psychiatry calls treatment-resistant, which implicitly lays the blame on the patient. I would be a prime candidate for diabetes, which runs in my family, and my heart probably certainly would have stopped beating by now. (It almost did in 2016.) As it was, with my base metabolism so skewed toward being skinny, the meds worked like a charm.
If Calvin Klein calls asking me to appear in an underwear ad, tell him I'm busy ...
Medications and Weight
Thoroughly discuss the weight implications of any new drug your psychiatrist may recommend and hold him or her fully accountable. Psychiatrists are notorious for not bringing up weight side effects. Moreover, many of them mistakenly regard the extra weight as a fair trade-off for stabilized mood, failing to consider how putting on pounds affects one's mental well-being in the long-term. Accordingly, consider switching to healthier alternatives from the very beginning of treatment on the general principle that an ounce of prevention is worth 20 of more pounds of a diet cure. Stop paying your cable bill, if you have to, and consider seeing a nutritionist.
Everyone responds differently to meds, and the weight side effects are no exception. Some patients may actually lose weight on their meds. Among the antidepressants, Effexor and Wellbutrin are considered weight-friendly while Remeron is such a notorious weight-gainer that some doctors use it for treating anorexia. Originally, SSRIs were thought to reduce weight, but that misconception was based on short-term studies, usually eight weeks or less. A 2000 Massachusetts General Hospital study of 284 patients on either Paxil, Prozac, or Zoloft found Paxil patients experienced a significant weight increase over 26 to 32 weeks compared to modest gains for Prozac and Zoloft. The older antidepressants are even greater weight-gainers.
Among the mood stabilizers, both lithium and Depakote are weight gainers. The mean weight gain for lithium over eight weeks in one small study was 13 pounds, and 8.8 to 22 pounds over seven to ten years, according to another. For Depakote, one study found that 57 percent of patients gained more than 8.8 pounds during treatment.
The other mood stabilizers are considered weight-neutral, while Topamax (not effective for mania) is often used as a diet pill.
As for the antipsychotics, a 1997 study found patients on Zyprexa gained 27 pounds over one year. Other one-year studies found weight gain leveled off in the single figures for Risperdal and Seroquel and was negligible for Geodon and Abilify. Product labeling shows nearly 30 percent of Zyprexa users added seven percent or more weight. Twenty percent of Seroquel users, more than 15 percent of Risperdal users, around 10 percent of Geodon users, and less than 10 percent of Abilify users crossed this "clinically significant" threshold.
The meds cocktails most of us find ourselves on can add up to recipes for dietary disaster. In 2003, for instance, the FDA approved Zyprexa as combination therapy with lithium or Depakote for treating initial phase mania. Zyprexa with either of these drugs, however, is simply begging for an audition as the next Macy's Santa. Adding drug number three or four virtually clinches the deal.
But as bad as these meds are together, one must always bear in mind that absolutely none of them should be taken with a Big Mac. Or a shake. Or fries. Or a Coke. Or a loaded salad. Or a pizza. We may have no choice with our meds - especially if the weight-friendly ones fail us - but we can choose to eat smart and exercise right and use every sensible weight-management technique to our full advantage.
See also: You Are What You Eat
July 30, 2004, updated Nov 4, 2011, revised Dec 5, 2016
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