Is our biological clock leading us to gain weight?
The role of the circadian system in obesity and disordered eating
By Nicole Mori Psychiatric Mental Health Nurse Practitioner
The circadian system is the body’s endogenous timekeeper, a network of hierarchically-organized structures (“clocks” or “oscillators”) in nucleated cells, which regulates a variety of biological processes (including the cell cycle, metabolism, growth, development and sleep/activity cycles) by generating outputs in a rhythmical manner. The suprachiasmatic nucleus (SCN) in the hypothalamus acts as the “master” pacemaker by generating periodic outputs targeting clocks in peripheral cells. The endogenous SCN period is greater than 24 hours, but it resets every day in response to environmental signals. The main synchronizer for the SCN is the periodical light/dark signal over the course of 24 hours. Additional environmental synchronizers include feeding and social activity. The circadian system enables organisms to adapt to environmental changes and optimize function, playing a central role in the maintenance of health and illness. Research has linked circadian dysregulation to a variety of disorders including cancer, cardiovascular disease, metabolic abnormalities and obesity in humans and animals.
Recent studies support the role of circadian dysfunction in the development and maintenance of obesity. Circadian misalignment can manifest as metabolic abnormalities, sleep disturbances, delayed sleep phase (evening preference), abnormalities in daily rest/activity rhythms and disordered eating patterns. Both endogenous (e.g., genetic) and exogenous factors are involved in circadian dysfunction. External factors include decreased sleep duration, jet lag, frequent snacking and nighttime eating and exposure to bright light. Epidemiological data show shift work is an independent risk factor for obesity and increased metabolic risk. Decreased sleep duration is associated with increased risk for obesity and metabolic disease. Among children, sleep loss is associated with the development of obesity and is a predictor of lifelong obesity. The increasing prevalence of obesity in recent decades has coincided with trends such as shortened sleep duration, light pollution, increased nighttime exposure to bright light and increasing shift work.
Sleep pattern changes affect appetite and eating behaviors and vice versa. Sleep restriction has been associated with changes in circadian hormonal patterns, which result in increased appetite, hunger and food choices such as increased preference for sweets. In turn, alterations in eating patterns have a dysregulating effect on the circadian system. For instance, overeating has been associated with decreased sleep duration, high dietary fat and carbohydrate intake with decreased short wave sleep and high increased nighttime arousal respectively.
The timing of food consumption plays an important role in metabolism and body weight. Nighttime eating leads to increased insulin resistance and worsened glucose tolerance and lipid levels than meals consumed during the daytime. Among bariatric patients, eating late in the day has been associated with less post-operative weight loss. In addition, irregular eating patterns are associated with abnormal weight gain, increased binge eating and greater eating disorder severity. Conversely, appropriate timing of eating and regularization of meal times appear to have a beneficial effect. Animal studies show that time restricted feeding (limiting feedings to a timeframe appropriate to the species’ diurnal/nocturnal pattern) is associated with decreased obesity. Among humans, an app study showed an association between time-restricted feeding and sustained weight loss.
As we have seen, the regulation of metabolism and body weight appear to depend on the optimal function of the circadian system, which requires appropriately timed exposure to synchronizing stimuli. Interventional studies suggest that manipulation of synchronizers may be beneficial in treating disordered eating behaviors, metabolic abnormalities and obesity. Potential interventions for circadian dysfunction would optimize the timing of synchronizers (such as bright light therapy, timing of food intake and time-restricting feeding), regularize rest/activity circadian rhythms (by increasing regular exercise, maintain a consistent waking up schedule), or the administration of medications according to circadian phase. The treatment of circadian dysfunction promises improved outcomes in the prevention and treatment of obesity, but further research is needed. New technologies and methods will enable a thorough characterization of circadian function is obesity and eating disorders and determine whether the circadian system is a potential target for chronotherapeutic interventions.
The Lindner Center of HOPE is conducting a comprehensive study of circadian function in adults with obesity with and without binge eating disorder. For more information, contact Brian or George at (513) 536-0707 or visit http://www.lcoh.info
Broussard, J. L., & Van Cauter, E. (2016). Disturbances of sleep and circadian rhythms: novel risk factors for obesity. Current opinion in endocrinology, diabetes, and obesity, 23(5), 353-359.
Garaulet, M., Gómez-Abellán, P., Alburquerque-Béjar, J. J., Lee, Y. C., Ordovás, J. M., & Scheer, F. A. (2013). Timing of food intake predicts weight loss effectiveness. International journal of obesity, 37(4),
self-esteem and self-worth in our youth will bring about numerous long-lasting, positive changes that Cupid’s arrow could only dream of creating.
Promoting Positive Food Habits in Children
|By Elizabeth Mariutto, PsyD, CEDS, Clinical Director of Eating Disorder Services|
“How do I encourage mindful eating for my kids?” I often have patients come in with histories of well-intended parents who promoted diets or restrictive eating in the attempts to help their kids become “healthy.” When they come to me to rewire their brains against the diet culture so prevalent in our society, they feel like they don’t know where to start in promoting more beneficial attitudes towards food in their own kids. Here are ten tips for promoting positive food habits in kids.
- Set up your home to promote balanced nutrition. Buy a variety of produce, serve meals with a balance of proteins, fats, and carbohydrates, and while you can definitely have some sweets and packaged snack foods, having too many of these options can lead to turning to these items often. Serve unfamiliar foods with familiar foods, and introduce new foods multiple times. Encourage family mealtimes at the table without electronics.
- Allow them to trust their bodies. Think about how we feed babies and small children. Every 3 to 4 hours, they cry and tell us they are hungry. We feed them until they stop eating. If children tell you they are full after a meal, don’t force them to finish their plate. This only teaches them that it’s pointless to follow hunger and fullness cues.
- Avoid labeling foods as “good” or “bad” or “healthy” or “unhealthy.” Avoid overtly controlling food messages, such as putting pressure on kids to eat fruits and vegetables or telling them they can’t have sweets, as these practices lead to unhealthy eating habits for kids (Scaglioni, Arrizza, Vecchni, & Tedeschmi, 2011).
- Serve items for meals that you would like kids to eat at regular times, making sure there is something you know they like on the table. Don’t worry about what they end up choosing to eat.
- Avoid rewarding, bribing, or soothing kids with food. Yes, that includes bribing kids for eating their veggies with dessert! Research has found kids consume less of a food and rate them as less tasty if they were presented as instrumental to a goal (Maimaran & Fishback, 2014), and rewarding with food is associated with emotional eating later in childhood (Farrow, Haycraft, & Blisset, 2015). Additionally, teach kids to learn to cope with their emotions in other ways.
- Promote body acceptance. Some kids are naturally smaller, some kids are naturally bigger. And that is ok! Weight-related comments are really not necessary at all, and often harmful. Additionally, avoid holding different standards for children of different sizes. Encourage a balanced, “everything in moderation” approach to eating for all children.
- Practice what we preach! Be a good role model for body acceptance and positive attitudes towards food. Those little ears are listening! Sure, go out for ice cream sometimes. And avoid criticizing your body or telling yourself you have to work out to get rid of the calories from eating that ice cream. Prioritize sitting down to eat and having regular, balanced meals and snacks.
- Encourage healthy activity without tying this to food or weight. Help kids find activities that they truly enjoy, and focus on the value of exercise to help our bodies become stronger, improve our mood, and nourish.
- Teach kids to savor food. Help them be selective in choosing which dessert sounds the best, and demonstrate taking slow bites to truly relish them.
- If they, or you, mess up, treat this with compassion. No one is perfect, and we don’t need to beat ourselves, or others, up about our mistakes.
Farrow, C. V., Haycraft, E., & Blissett, J. M. (2015). Teaching our children when to eat: How parental feeding practices inform the development of emotional eating—a longitudinal experiential design. American Journal of Clinical Nutrition, 101, 908-13.
Jacobsen, M. (2016). How to Raise a Mindful Eater. Middletown, DE: First Printing.
Maimaran, M., & Fishbach, A. (2014). If it’s useful and you know it, do you eat? Preschoolers refrain from instrumental food. Journal of Consumer Research, 41, doi:10.1086/677224
Scaglioni, S., Arrizza, C., Vecchni, F., & Tedeschmi, S. (2011). Determinants of children’s eating behaviors. American Journal of Clinical Nutrition, 94, 6. doi: 10.3945/ajcn.110.001685
Tribole, E. & Resch, E. (2012). Intuitive eating: A revolutionary program that works. New York: St. Martin’s Griffin.
A Look at Binge Eating Disorder: What it is and How to Treat
Byline: Anna I. Guerdjikova, PhD, LISW
Binge eating disorder (BED) is the most common eating disorder in adults. The lifetime prevalence of BED has been estimated to be 2.0% for men and 3.5% for women, higher than that of the commonly recognized eating disorders anorexia nervosa and bulimia nervosa. Of note, BED is found in all cultures and ethnicities and spans from childhood to old age.
What is a Binge Eating Disorder
Binge eating disorder is an eating disorder characterized by binge eating without subsequent purging episodes. Individuals with BED consume large amounts of food in a short period of time while feeling out of control and powerless to stop the overeating. BED patients often struggle with feelings of guilt, disgust, and depression related to their abnormal eating behavior.
Since May 2014, the updated version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) formally recognized binge eating disorder as a distinct eating disorder, separate from the general Eating Disorder, Not Otherwise Specified category where BED was categorized. In order to receive the diagnosis of BED, an individual must meet the DSM-5diagnostic criteria listed below: experiencing recurring episodes of binge eating (consuming an abnormally large amount of food in a short period of time) and experiencing a lack of control over eating during the episode. Binge eating episodes must also exhibit at least 3 of the following characteristics: consuming food faster than normal; consuming food until uncomfortably full; consuming large amounts of food when not hungry; consuming food alone due to embarrassment; and feeling disgusted, depressed, or guilty after binging. A binging episode needs to occur at least once weekly for 3 months for formal diagnosis.
Examples of Binge Eating Episodes
An example of a binge episode might be: an individual would eat a bowl of cereal with milk, 2 scoops of ice cream, ½ bag of chips and a sleeve of cookies in a two hour period, shortly after a full size dinner; or a person driving through a fast food restaurant after work, consuming a whole meal there, and then going home to eat a regular dinner with family. Of note, the binge eating episode must be accompanied by sense of lack of control and distress in order to meet DSM-5 diagnostic criteria for BED.
While etiology of binge eating disorder is not fully understood, it is believed that dysregulation in dopamine, serotonin and glutamate neurotransmitter systems might contribute to BED development. Furthermore, there may be a genetic inheritance factor involved in BED. Risk factors for BED development may also include repetitive yo-yo dieting, childhood obesity, critical comments about weight, low self-esteem, depression, and physical or sexual abuse in childhood.
Individuals with binge eating disorder commonly have other psychiatric comorbidities such as mood disorders (major depressive disorder or bipolar disorder) and anxiety disorders. Binge eating is also a core symptom of bulimia nervosa. Unlike in bulimia, however, individuals with BED do not exhibit compensatory behaviors such as purging, fasting or engaging in compensatory excessive exercise after binge eating episodes.
Individuals suffering from binge eating disorder often have a lower overall quality of life and commonly experience social difficulties. BED is often associated with increased medical morbidity. Up to 80% of individuals with BED are overweight or obese and are at risk of suffering from obesity related complications like metabolic syndrome, increased risk for cardiovascular diseases, gastrointestinal problems and cancer.
Treatment of Binge Eating Disorder
Successful treatment of binge eating disorder begins with proper and thorough diagnosis. Binge eating is a shameful behavior and most of the time patients do not disclose it readily. Focusing their attention on specific examples like excessive, repetitive snacking or sneaking food or eating way beyond the point of comfort regularly might help with self-disclosure.
If binge eating disorder is diagnosed, a plethora of psychological and pharmacological options for its treatment are available. BED care is best implemented by a professional team consisting of a psychiatrist, a psychologist and a dietician. Cognitive behavior therapy (CBT) is currently considered the gold standard in the treatment for BED. Dialectical Behavior therapy techniques as well as guided self-help might also be helpful. While no medication is currently approved in the treatment of BED, certain antidepressants, antiepileptic and Attention Deficit Hyperactivity Disorder (ADHD) drugs hold promise in controlling BED. For example, Vyvanse (lisdexamfetamine dimesylatelate; approved for ADHD in the US) was recently announced to be effective in significantly decreasing binge days per week as compared to placebo in two pivotal Phase 3, multi-center, randomized studies.
Binge eating disorder is a biological illness and an important public health problem that is under-recognized. Timely diagnosis and comprehensive treatment are important in BED management, possibly decreasing long term consequences of dysregulated eating behavior and associated weight gain.
Learn more about Lindner Center of HOPE’s treatment for binge eating disorder.
Learn more about skills building options for binge eating disorder.
Dangers of Dieting: Why Dieting Can Be Harmful
BY: Anna Guerdjikova, PhD, LISW, CCRC, Lindner Center of HOPE, Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program University of Cincinnati, Department of Psychiatry, Research Assistant Professor
An estimated 45 million Americans diet each year and spend $33 billion annually on weight loss products. WebMD lists over 100 different diets, starting with the African Mango diet, moving on to the South Beach and Mediterranean diets and ending up with the Zone. Most diets, regardless of their particular nature, result in short-term weight loss that is not sustainable. Weight cycling or recurrent weight loss through dieting and subsequent weight gain (yo-yo effect) can be harmful for mental and physical health for both healthy weight and overweight individuals. Furthermore, weight fluctuations have been related to increased risk of development of cardiovascular disease, Type 2 diabetes, and high blood pressure.
What is Dieting
The word “diet” originates from the Greek word “diaita”, literally meaning “manner of living”. In the contemporary language, dieting is synonymous with a quick fix solution for an overwhelming obesity epidemic. Dieting implies restriction, limitation of pleasurable foods and drinks, and despite of having no benefits, the omnipresent dieting mentality remains to be the norm.
Most diets fail most of the time. Repeated diet failure is a negative predictor for successful long term weight loss. Chronic dieters consistently report guilt and self-blame, irritability, anxiety and depression, difficulty concentrating and fatigue. Their self-esteem is decreased by continuous feelings of failure related to “messing my diet up again”, leading to feelings of lack of control over one’s food choices and further … life in general. Dieting can be particularly problematic in adolescents and it remains a major precursor to disordered eating, with moderate dieters being five times more likely to develop an eating disorder than those who do not diet at all.
Diets imply restriction. Psychologically, dietary restraint can lead to greater reactivity to food cues, increased cravings and disinhibition, and overeating and binge eating. Biologically, dieting can lead to unhealthy changes in body composition, hormonal changes, reduced bone density, menstrual disturbances, and lower resting energy expenditure.
The Potential Harmful Effects of Dieting
Aggressive dieting lowers the base metabolic rate, meaning one burns less energy when resting, resulting in significantly lower daily needs in order to sustain achieved weight after the diet is over. Returning to normalized eating habits at this lower base metabolic rate results in commonly seen post dieting weight gain. Biologically, dieting is perceived as harmful and physiology readjusts trying to get back to initial weight even after years since the initial rapid weight loss. Recent data examining 14 participants in the “Biggest Loser” contest showed they lost on average 128 pounds and their baseline resting metabolic rates dropped from 2,607 +/-649 kilocalories/ day to 1,996 +/- 358 kcal/day at the end of the 30 weeks contest. Those that lost the most weight saw the biggest drops in their metabolic rate. Six years after the show, only one of the 14 contestants weighed less than they did after the competition; five contestants regained almost all of or more than the weight they lost, but despite the weight gain, their metabolic rates stayed low, with a mean of 1,903 +/- 466 kcal/day. Proportional to their individual weights the contestants were burning a mean of ~500 fewer kilocalories a day than would be expected of people their sizes leading to steady weight gain over the years. Metabolic adaptation related to rapid weight loss thus persisted over time suggesting a proportional, but incomplete, response to contemporaneous efforts to reduce body weight from its defined “set point”.
Dieting emphasizes food as “good” or “bad”, as a reward or punishment, and increases food obsessions. It does not teach healthy eating habits and rarely focuses on the nutritional value of foods and the benefit of regulated eating. Unsatisfied hunger increases mood swings and risk of overeating. Restricting food, despite drinking enough fluids, can leads to dehydration and further complications, like constipation. Dieting and chronic hunger tend to exacerbate dysfunctional behaviors like smoking cigarettes or drinking alcohol.
Complex entities like health and wellness cannot be reduced to the one isolated number of what we weigh or to what body mass index (BMI) is. Purpose and worth cannot be measured in weight. Dieting mentality tempts us into “If I am thin- I will be happy” or “If I am not thin-I am a failure” way of thinking but only provides a short term fictitious solution with long term harmful physical and mental consequences. Focusing on sustainable long term strategies for implementing regulated eating habits with a variety of food choices without unnecessary restrictions will make a comprehensive diet and maintaining healthy weight a true part of our “manner of living”.
Reference: Obesity (Silver Spring). 2016 May ;Persistent metabolic adaptation 6 years after “The Biggest Loser” competition.; Fothergill E, Guo J, Howard L, Kerns JC, Knuth ND, Brychta R, Chen KY, Skarulis MC, Walter M, Walter PJ, Hall KD.
Good Food for Great Mood
Nutritional Psychiatry and Wellness
By Anna I. Guerdjikova, PhD, LISW, CCRC
Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program
The connection between health in general and the foods we consume has been known since the dawn of human kind, and Hippocrates is credited with the “Let food be thy medicine” saying. The narrower connection between overall diet quality and common mental disorders, in particular depression and anxiety, is a much newer field and the term “nutritional psychiatry” was not coined until the most recent decade. Initially, the focus of this discipline was on researching single foods or nutrients and their role in mental health. Gradually, it has been recognized that proper nutrition for good mental health is a very complex landscape. What we consume and how it affects us cannot be researched in isolation and what we eat in excess can be as important as what we do not eat enough of.
The growing data in the field of nutritional psychiatry is encouraging. A recent systematic literature review derived a list of antidepressant nutrients linked to the treatment and prevention of depression1. The twelve identified antidepressant nutrients included: folate, iron, long-chain omega-3 fatty acids, magnesium, potassium, selenium, thiamine, vitamin A, vitamin B6, vitamin B12, vitamin C, and zinc. The most nutrient-dense individual animal foods to fight depression were oysters, mussels and seafood, all rich in DHA which helps form strong membranes that easily transport nutrients into brain cells, lowers inflammation and raises serotonin levels. From plant-based foods leafy greens, lettuces, peppers, and cruciferous vegetables received the highest score, suggesting that regularly incorporating those veggies in one’s diet might improve mood dysregulation.
Another study followed up with patients for 12 weeks in a randomized controlled design study to examine efficacy of adjunctive dietary intervention in the treatment of moderate to severe depression2. The intervention consisted of seven individual nutritional sessions to support adherence to the recommended diet, encouraging consumption of the following key food groups: whole grains (5–8 servings per day); vegetables (6 per day); fruit (3 per day), legumes (3–4 per week); low-fat and unsweetened dairy foods (2–3 per day); raw and unsalted nuts (1 per day); fish (at least 2 per week); lean red meats (3–4 per week),chicken (2–3 per week); eggs (up to 6 per week); and olive oil (3 tablespoons per day), while reducing sweets, refined cereals, fried food, fast-food, processed meats and sugary drinks (no more than 3 per week). The group receiving dietary support along with therapy or medication, showed significantly greater improvement in depressive symptoms suggesting dietary improvement may provide an efficacious and accessible treatment strategy for the management of depression.
A recent review summarized data from 20 longitudinal and 21 cross-sectional studies and concluded that adhering to a healthy diet, in particular a traditional Mediterranean diet (meals built around plant-based foods like vegetables, fruits, herbs, nuts, beans and whole grains with moderate amounts of dairy, poultry, eggs and seafood), or avoiding a pro-inflammatory diet (deficient in fruits and vegetables and containing excessive amounts of meat, refined grain products, and dessert foods) might confer some protection against depression in observational studies3.
A healthy gut environment (microbiome) supports production of vitamins, helps train the immune system, supports cleansing of the body and helps modulate the nervous system. The microbiome can be influenced by our diet, providing the direct link between the brain and the gut, as 90% of our serotonin receptors are located in the gut. Consuming a diet rich in both prebiotics (the fiber that feeds the probiotics in our gut found in onions, leeks, asparagus, bananas and garlic) and probiotics (good bacteria that are found in fermented foods like sauerkraut, yogurt with active cultures, pickles, kefir, kimchi, kombucha) is recommended for keeping the microbiome well balanced. Probiotics are associated with a significant reduction in depression and anxiety in two recent analyses, reviewing over 30 individual studies4,5. Moreover, overconsumption on ultra-processed food leads to inflammation in the gut and might dysregulate the microbiome, possibly contributing to a plethora of diseases6.
While the field is still working through challenges to identify a clear set of biological pathways and targets that mediate the brain-gut connection, the following few simple recommendations might be helpful as complementary interventions benefiting mild to moderate depression and anxiety:
- Regulated eating habits (3 meals and 1-2 snacks/day) decrease blood sugar variations and helps stabilize moods
- Follow a diet comprising mostly of real foods (Mediterranean diet)
- Probiotic-rich foods and limiting processed food (shopping the “perimeter of the store” preferentially )supports the health of the gut-brain axis and can be beneficial for mood regulation
- LaChance LR, Ramsey D. Antidepressant foods: an evidence-based nutrient profiling system for depression. World J Psychiatry. 2018;8:97-104.
- Jacka F, O’Neil A, Opie R, et al. A randomized controlled trial of dietary improvement for adults with major depression. BMC Med. 2017;15:23.
- Lassale C, Batty GD, Baghdadli A, et al. Healthy dietary indices and risk of depression outcomes; a systematic review and meta-analysis of observational studies. Mol Psychiatry. September 26, 2018
- Ruixue Huang, Ke Wang, Jianan Hu Effect of Probiotics on Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Nutrients 2016 Aug 6;8(8):483
- Richard T Liu, Rachel F L Walsh, Ana E Sheehan Prebiotics and probiotics for depression and anxiety: A systematic review and meta-analysis of controlled clinical trials Neurosci Biobehav Rev, 2019 Jul;102:13-23.
- Marit K Zinöcker, Inge A LindsethThe Western Diet-Microbiome-Host Interaction and Its Role in Metabolic Disease Nutrients 2018 Mar 17;10(3):365.
Can you blueberry your way out of depression? The evidence on dietary supplements
By Nicole Mori, RN, MSN, APRN-BC
Research Advanced Practice Nurse, Lindner Center of HOPE
Depression is a common mental health complaint. Although there are effective treatments available, many patients fail to experience satisfactory improvement. There has been increased interest in nutritional supplements as an adjunct or alternative to medications in the treatment of depression. This has contributed to the growth of the dietary supplement industry (projected to reach 230 billion by 2026). Let’s examine the evidence for the dietary supplements that have generated interest in recent years.
Omega-3 fatty acids (EPA/DHA)
A systematic review shows mild-moderate improvement in depressive symptoms, with the best outcomes in studies where omega-3 supplementation is concomitant to standard antidepressant therapy. There is a great deal of heterogeneity in dosing, duration of treatment and EPA/DHA content. Products with a high EPA content appear to be more efficacious than other omega-3 supplements. However, quality of evidence is low due to methodological flaws. Differences in study design and methodology makes it difficult to analyze data across studies. Omega-3 supplements have a favorable safety profile and are well tolerated.
B group vitamins
Folate- Possible dose dependent response in depression but level of evidence is low. Although folate is well tolerated, it has been associated with risk for proliferation of carcinogenic cells in the colon.
L-methylfolate-Available as pharmaceutical product FDA approved for depression. Data shows efficacy at 15mg/d. Some studies show efficacy as augmentation strategy for depression as comparable to lithium and atypical antipsychotics. Usually well tolerated with lower risk for proliferation of cancerous cells than folate.
A 2019 systematic review of clinical trials showed improvement in depression ratings associated with supplementation. Findings remain tentative due to paucity of studies and methodologic bias. Vitamin D is a fat-soluble vitamin commonly found in multivitamins and other commercially available products. In the absence of a deficiency, the recommended dose is not to exceed 600IU/day.
SAM-E (S-Adenosyl methionine)
Clinical trials show mixed results. A 2016 systematic review suggested SAM-E was no better than placebo. The low quality of evidence makes it difficult to draw conclusions about efficacy. There is a need for randomized clinical trials with antidepressant comparators. SAM-E usually well tolerated but there is a possible risk for inducing mania in patients with bipolar depression.
There are few high quality studies of 5-HTP. Two depression studies suggest 5-HTP is superior to placebo. Overall, level of evidence is low. Possible risk for serotonin syndrome when administered concurrently with SSRI antidepressants. Maximum recommended dose is 50mg/kg/day.
Magnesium and Zinc
There is some positive data from animal studies but evidence for efficacy in humans is low quality. There is no conclusive data on the efficacy of magnesium and zinc as coadjutant therapy in depression. Zinc and magnesium are common micronutrients and usually well tolerated.
Depression has been associated with poor diet and altered intestinal flora. Research has shown a relationship between gut health and mental health. A 2016 metaanalysis of probiotics showed an effect in reducing risk of depression in normal subjects and reduced symptoms in subjects with depression. The effect was limited to subjects under age 60. Clinical studies vary greatly in terms of bacterial species, dose, duration of treatment as well as the method of measuring of depressive symptoms. Probiotic supplements are vastly heterogeneous in terms of species composition and dosage.
There is a need for further research to determine optimal composition, dosage, duration of treatment for efficacy. Furthermore, it is important to remember that quality of diet is a major determinant in the composition of gut flora.
In conclusion, evidence for the efficacy of dietary supplements in depression remains limited. Commercially available dietary supplements vary significantly in terms of composition and bioavailability. Although supplements are well tolerated, it is important to be aware of increased risks for adverse events in some patients. Supplementation with omega-3 fatty acids as an adjunct to standard antidepressant therapy seems to hold the most promise. Further research in the area of dietary supplements is needed to determine their role in the management of depression.
For more information about Depression research studies at the Lindner Center of HOPE
call 513-536-0707 or visit https://lindnercenterofhope.org/research/
Firth J, Teasdale SB, Allott K, et al. The efficacy and safety of nutrient supplements in the treatment of mental disorders: a meta-review of meta-analyses of randomized controlled trials. World Psychiatry. 2019;18(3):308-324. doi:10.1002/wps.20672
Martínez-Cengotitabengoa M, González-Pinto A. Nutritional supplements in depressive disorders. Actas Esp Psiquiatr. 2017;45(Supplement):8-15.
Binge eating disorder in primary care: Why should I screen my patients?
Binge eating disorder (BED) is the most common eating disorder, with an estimated prevalence of 3% in the US population. It is also the most common eating disorder among men. BED is characterized by regularly recurrent episodes of eating unusual amounts of food within a discrete time frame (usually <2hrs), which are associated with loss of control and significant psychological distress. Unlike people with Bulimia nervosa, those with BED do not engage in purging behaviors (such as fasting, driven exercise or self-induced vomiting). Untreated BED is a risk factor for obesity, metabolic disorders, mental health problems and poor quality of life. Although psychotherapy and medications have demonstrated effectiveness in treating BED symptoms, the vast majority of patients with BED remain undiagnosed and untreated.
Patients with BED face significant barriers to evaluation and treatment. First, there are patient-related barriers such as lack of awareness of BED as a medical condition, where the patient may attribute their loss of control to having no willpower. Moreover, patients may be reluctant to discuss their eating behavior and weight out of shame or fear of being judged. Finally, past experience may lead patients to assume that their primary care provider is unwilling or unable to address their disordered eating. Providers also face challenges in identifying BED in the primary care setting: Some patients with BED may have a normal BMI, which makes providers assume that they do not have an eating disorder. In addition, BED often co-occurs with psychiatric disorders such as depression and anxiety, which can lead to attributing the BED symptoms to the patient’s mental health diagnosis or the effects of psychotropic medications. Finally, lack of knowledge about treatment options and underestimation of the impact of BED on medical conditions, leads many primary care providers to overlook BED as a target for evaluation and treatment.
The reality is that primary care providers have much to offer patients with BED. Screening, education, self-management tools and in some cases, referrals to specialty care or medication. Screening for and treating BED can be advantageous when managing patients with diabetes, where decreasing the frequency of binges can lead to significant improvement in metabolic parameters. A BED diagnosis is useful when selecting psychotropic medications with lesser potential to aggravate binge eating. Finally, diagnosing a patient with BED can alleviate the patient’s distress and stigma. Patients who struggle with BED are often relieved and thankful that they have a treatable medical condition rather than attributing their bingeing to a character flaw and feel empowered and thankful for any help in managing their disorder. Since untreated BED poses a challenge in treating conditions such as diabetes and dyslipidemia, diagnosing and managing BED can benefit all areas of patient health.
Although there are still significant barriers to screening, diagnosis and treatment, primary care providers have the means to improve health outcomes among their patients with binge eating. Primary care is the ideal setting for raising awareness of the problem of binge eating among the general population, to address patient’s disorder eating concerns and start patients on their journey to recovery. First of all, routine procedures such as weighing patients, offer opportunities to ask patients whether they have any concerns about their weight or eating patterns. These questions can also be added to the medical history updates hat patients complete prior to office visits. Routine screening of special populations such as patients with diabetes, those attempting weight loss or receiving psychotropic medication is of great help in managing those comorbidities. The SCOFF questionnaire is a brief screen for eating disorders suitable for primary care*. Providers interested in providing medication management for BED should also screen for psychiatric comorbidities and substance use disorders to guide their medication choices.
In summary, patients with BED are largely undiagnosed and untreated, which complicates the management of their medical and mental health issues. Although access to specialty continues to be a challenge, primary care providers have the means to start patients on their road to recovery and improve overall health outcomes and quality of life.
The Research Institute at the Lindner Center of HOPE is a world leader in Binge eating disorder research. For more information about our current studies, call 513-536-0710.
*The SCOFF questionnaire is available at:
Chao AM, Rajagopalan AV, Tronieri JS, Walsh O, Wadden TA.
Nurs Scholarsh. 2019 Jul;51(4):399-407. doi: 10.1111/jnu.12468. Epub 2019 Mar 1.
Javaras KN, Pope HG, Lalonde JK, et al. Co-occurrence of binge eating disorder with psychiatric and medical disorders. J Clin Psychiatry. 2008;69(2):266-273. doi:10.4088/jcp.v69n021
Nicole Mori RN, MSN, APRN-BC
Nurse Practitioner, Lindner Center of HOPE Disorder Services
Elizabeth Mariutto, PsyD
Clinical Director of Partial Hospitalization and Intensive Outpatient Adult Eating Disorder Services and Staff Psychologist, Harold C. Schott Foundation Eating Disorders Program, Lindner Center of HOPE
“Every time I try a diet, I do okay for a while, and then I go back to my usual eating.” According to the National Eating Disorders Association, this is an incredibly common phenomenon, as 95% of those who diet regain any weight lost within one to five years. Despite the ineffectiveness of dieting, those that fall under the overweight category on BMI charts are often encouraged to do so by the medical community. Not only is this ineffective, but dieting has been found to be associated with increased binge eating and greater weight gain.
So what is the alternative? Mindful eating. Research has found that those who struggle with binge eating, diabetes, and/or obesity may benefit from mindful eating. Keep in mind, mindful eating is not recommended for patients in the process of weight restoration or food exposure, specifically for those with Anorexia Nervosa, or those with gastrointestinal symptoms that may complicate hunger and fullness cues.
Author and psychologist Susan Albers defines mindful eating as awareness of the physical aspects of eating, the process of eating, and triggers for mindless eating. Individuals who eat mindfully slow down and take pause in their busy schedules to pay attention to their bodies and cues of hunger and fullness. The emptiness of one’s stomach, irritability, low energy, and difficulty concentrating can all be signs of hunger. When one eats, one should feel full but not stuffed, satisfied yet comfortable. Many who struggle with unhealthy eating have been so disconnected from their bodies that either they do not have awareness of these cues, or they wait until they are famished before eating and eat until they feel as if their stomachs could explode. They may focus on external cues to start and stop eating, such as if others around them are eating, rather than the internal cues of their body. To start the practice of mindful eating, it can be helpful to focus awareness on how long it has been since one has eaten and the content of what one ate at that time. Regular eating should take place within one hour of waking up in the morning, then at three to four hour increments throughout the day. Meals should balance carbohydrates with lipids and protein sources. Starting with these guidelines can help one’s body self-regulate so that the hunger and fullness cues can kick in.
Mindful eating also distinguishes physical from emotional hunger. Food has become tied to emotions in our society. People celebrate birthdays by baking a cake, revel in a promotion by going out to dinner, and calm themselves down after a stressful day by getting ice cream. While all of these can still occur within mindful eating, a mindful eater will be intentional about this, as well as develop other self-soothing strategies. A mindful eater will tune in to the qualities of the foods he or she is choosing and ask him or herself, “Does this taste good? Does this food energize me or make me sluggish? Does my body thrive when I eat this?” A mindful eater will balance cravings with nutrition, allowing oneself to have all foods in moderation. This does not always mean choosing the “healthy” choice, but rather having self-compassion and flexibility around food. Mindless eaters may overeat sweets, chips, or fast food, tell themselves that they are a failure for consuming these items, and fall into hopelessness and despair, only to lead them back towards these foods repeatedly. In fact, many comment that they do not even enjoy what they are eating. In contrast, a mindful eater may pick up fast food on a road trip, have a handful of chips with a sandwich, or try a coworker’s chocolate chip cookies; however, he or she will savor these items and consume them as part of a well-balanced diet. If one is full, one will stop eating, even if there is food left on the plate.
Lastly, mindful eaters set up an environment for success. They sit down at a table for meals rather than eating in front of the TV or grazing in the pantry. They do a lap at buffets prior to plating their food. They fill their house with diverse foods and ingredients and avoid buying trigger foods in bulk. While it takes work, many learn to gain control over their eating with the principles of mindful eating.
Albers, S. (2008). Eat, Drink and Be Mindful. Oakland, CA: New Harbinger Publications, Inc.
National Eating Disorders Association (2018). Statistics & Research on Eating Disorders. Retrieved from https://www.nationaleatingdisorders.org/statistics-research-eating-disorders.
Love the medication but hate the weight gain?
Nicole Mori RN, MSN, APRN-BC
Lindner Center of HOPE
Obesity is an important comorbidity among psychiatric patients and is associated with increased morbidity and a complicated clinical course. Many frequently used psychotropic medications can contribute to weight gain, which commonly accompanies adverse metabolic outcomes. Weight gain is distressing to patients and leads to decreased quality of life and lower adherence. Psychotropic-mediated weight gain is particularly problematic for patients with bipolar disorder who, regardless of treatment status, experience higher rates of overweight and metabolic abnormalities than the general population. Patients with bipolar disorder face additional risks for weight gain because the mainstay treatments for bipolar disorder such as mood stabilizers (e.g., Lithium and Valproate) and atypical antipsychotics carry a risk for accelerated weight gain and metabolic disturbances. The effect of many psychotropic medications on histamine, alpha-1 and serotonin 5HT 2A and 5HT 2C receptors has been associated with higher weight gain potential. In addition, many psychotropic medications can interfere with the activity of leptin, which regulates food intake. The effects of antipsychotics and mood stabilizers can also lead to dysregulation in lipid biosynthesis, insulin resistance and increased risk for type 2 diabetes.
Strategies for managing weight changes include lifestyle interventions aimed at improving diet and increasing physical activity, selecting medications with a lower weight gain liability and prescribing medications aimed at promoting weight loss or mitigating the weight gain effects of psychotropics. Selecting medications with lower risk for weight gain or switching medications can be helpful but this may not always be possible due to efficacy considerations. Studies show that lifestyle modifications can be modestly helpful in mitigating the effects of psychotropic medications on weight, but weight loss is often insufficient and difficult to maintain.
Some medications have been studied and used off label for their potential to attenuate the effects of antipsychotics and mood stabilizers on weight. Metformin has the most data for efficacy and safety, especially when used in combination with lifestyle modification. In addition, metformin has shown significant benefits in improving glycemic control and dyslipidemia. Metformin requires monitoring of renal function and carries a risk for metabolic acidosis (rare) and hypoglycemia. Gastrointestinal adverse effects associated with metformin (flatulence and diarrhea) can be a barrier to dose escalation and tolerability. There is some evidence supporting the use of topiramate for mitigating the weight gain effect of psychotropics. However, rates of discontinuation are high due to adverse events such as dizziness, paresthesia and cognitive impairment. Norepinephrine reuptake inhibitors have shown a marginal effect on weight gain, and carry a potential for adverse effects on heart rate, blood pressure and psychiatric symptoms, which limits their use.
Although the FDA has approved a handful of new antiobesity medications in the past decade (lorcaserin (Belviq), topiramate/phentermine (Qsymia), bupropion/naltrexone (Contrave) and liraglutide (Saxenda)) there is little research on the efficacy and safety of anti-obesity medications in patients for bipolar disorder. Orlistat is one of the few FDA-approved medications with clinical trial data for use in psychiatric patients but study results were mixed and the subject population was limited to patients with schizophrenia. Although orlistat carries a relatively low risk for mood destabilization, it can decrease the absorption of certain medications (including antiepileptics, warfarin and levothyroxine) and is associated with intolerable gastrointestinal side effects (flatulence and incontinence) that lead to discontinuation. There is no published data on the use of the new antiobesity medications for patients with bipolar disorder. Most antiobesity medications are combinations of drugs that target the central nervous system and modulate neurotransmitters, raising concerns for risk of destabilization and drug-drug interactions for patients with bipolar disorder. Liraglutide is the only recently approved medication that primarily targets the gastrointestinal system, and in theory, carries a lower potential for effects on the central nervous system.
There is a need for safe and effective treatments to prevent psychotropic-induced weight gain or enhance weight loss in overweight patients with bipolar disorder. Until research brings new treatments to market, timely detection and management of weight gain and metabolic abnormalities remains the most important intervention to reverse or attenuate these undesirable effects from psychotropic medications.
Dent, R., Blackmore, A., Peterson, J., Habib, R., Kay, G. P., Gervais, A., … & Wells, G. (2012). Changes in body weight and psychotropic drugs: a systematic synthesis of the literature. PLoS One, 7(6), e36889.
G Fiedorowicz, J., D Miller, D., R Bishop, J., A Calarge, C., L Ellingrod, V., & G Haynes, W. (2012). Systematic review and meta-analysis of pharmacological interventions for weight gain from antipsychotics and mood stabilizers. Current psychiatry reviews, 8(1), 25-36.
Saunders, K. H., Umashanker, D., Igel, L. I., Kumar, R. B., & Aronne, L. J. (2018). Obesity pharmacotherapy. Medical Clinics, 102(1), 135-148.
The Lindner Center of HOPE is conducting a randomized, placebo-controlled study of Liraglutide in overweight patients with Bipolar disorder. For information, please call 513-0704 or visit https://is.gd/weightlossbipolar
Sleep Hygiene and The Need For Zzzzzz’s
Director of Administrative Services, Harold C. Schott Foundation Eating Disorders Program
University of Cincinnati, Department of Psychiatry, Research Assistant Professor
We spend about one third of our lives sleeping, yet more than one third of Americans do not get enough sleep. Adults, ages 18-60, are recommended to get between seven to nine hours of sleep each night. The need for sleep varies in children and teenagers, with 13-17 years olds needing eight to ten hours per night for optimal wellness. Getting adequate sleep each night is mandatory for maintaining one’s overall mental and physical health and insufficient sleep is associated with a number of chronic diseases and conditions including diabetes, cardiovascular disease, decreased sex drive, obesity, depression and even increased thoughts of suicide and death. While its exact biological purpose remains unclear, sleep is found to be crucial for proper nerve cell communication and possibly plays a housekeeping role in removing toxins that build up in the brain when awake.
Insomnia is a sleep disorder that can make it hard to fall or to stay asleep, or causes early awakenings and inability to get back to sleep. Insomnia is common (6-10% of population struggles regularly with at least a few insomnia symptoms) but it remains under recognized and under treated. According to recently published guidelines from the American Academy of Sleep Medicine (1), psychological and behavioral interventions are effective and recommended in the treatment of chronic primary and comorbid (secondary) insomnia and should be utilized as an initial intervention when appropriate and when conditions permit. Cognitive behavioral therapy for insomnia (CBT-I), for example, is a structured program and an effective, non-medication treatment for chronic sleep problems. CBT-I teaches identification of thoughts and behaviors that cause or worsen sleep problems and encourages habits that promote healthy sleep. Some basic techniques used in CBT-I reinforce good sleep hygiene that can be easily implemented if one struggles with poor sleep are described below:
- “Yes” to fixed bedtime and an awakening time through the week- establishing a consistent sleep routine and allowing for no more than 30min variation, including on weekends, will reteach the body to “get used” to falling asleep at a certain time.
- “Yes” to sleep rituals -from relaxing stretches or breathing exercises, reading something light, meditating, or taking a hot bath to sitting calmly with a cup of caffeine-free tea, pre-sleep rituals can vary, but are needed to break the connection between all the intensive daily activities and bedtime. The sleep rituals might be equally important for enhancing healthy sleeping in both children and adults.
- “Yes” to using a sleep diary. Tracking amount and quality of sleep can be a very helpful tool in establishing realistic goals and following progress when working on improving sleep.
- “Yes” to comfortable bedding, moderate room temperature, limited excess noise and a well ventilated room.
- “No” to naps: avoiding activities/ taking naps because of tiredness or poor sleep the previous night perpetuates the insomnia issues. If a nap is needed, limiting it to no longer than 30 minutes, before 3pm, is recommended.
- “No” to caffeine 4-6 hours before bedtime, including caffeinated beverages like tea, many sodas and chocolate. Avoid heavy, spicy, or sugary foods 4-6 hours before bedtime.
- “No” to exercise before bed. Regular exercise no less than 3h before bedtime promotes better sleep, but exercising shortly before going to bed can increase insomnia issues.
- “No” to clock-watching and no electronics in the bedroom. Using a cell phone at night can increase depression and lower self-esteem, especially in teenagers.
On note, various smart phone apps that promote sleep hygiene via calming music (ex. Pzizz app), enhance circadian rhythm regulation (ex. Sleep Cycle app), teach meditation (ex. Long deep breathing” app), help with tracking sleep and can be used as a sleep diary (Sleep diary pro app) or even deliver mobile CBT-I support (ex. CBT-i Coach App.) can be helpful in insomnia management.
It takes up to one month before the body will naturally respond to some of the behavioral changes consistent with healthy sleep, thus patience and persistence while “relearning” sound sleep related habits are the key factors in psychological management of insomnia. Occasional restlessness at night can be normal, however if you have tried and failed to improve your sleep using some of the above mentioned strategies, you may like to consider professional help. Besides psychological interventions, an armamentarium of medications approved for insomnia is available and timely diagnosis and proper management of insomnia can significantly improve everyday wellness. Overall quality of life and life satisfaction should not be postponed, especially if symptoms are affecting daily functioning.