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Caught in the weeds: The impact of cannabis on mental health

Christine Collins, MD, Lindner Center of Hope

By: Christine Collins, MD, Lindner Center of HOPE Addiction Psychiatrist

 

 

 

Legalization of cannabis is rapidly expanding across the world. To date, 17 states (and DC) in the US have legalized marijuana for all uses, and another 19 states have legalized it for medical purposes only. The media tends to portray cannabis and its constituents, as safe, natural items that have potential to provide benefit. As medical marijuana dispensaries and CBD stores seem to be popping up all over, it is important for us to recognize the impact of cannabis on mental health and how it may affect vulnerable populations, such as young people. Clinicians and patients alike should be aware of the current state of scientific evidence and possible risks posed by cannabis use.

Cannabis is a complex plant composed of hundreds of compounds including THC (9delta-tetrahydrocannabinol, the main psychoactive component) and CBD (cannabidiol, purported to offer many health benefits). There are currently several medications approved by the FDA that are cannabis-related: dronabinol and nabilone (synthetic THC containing meds used for chemotherapy-related nausea and for appetite/weight gain in HIV patients), and recently-approved Epidolex (cannabis derived which contains CBD used for the treatment of rare childhood seizure disorders, Dravet syndrome and Lennox-Gastaut syndrome). These were extensively studied and underwent the typical FDA process for approval as effective and safe medications for these purposes. Other uses of cannabis are largely unregulated.

Using “medical” marijuana varies by state and is a much different process from taking an FDA approved medication which has been rigorously studied. Since it is designated DEA schedule I by the federal government, large scale studies on cannabis have been limited in the US. The current scientific evidence on cannabis remains mostly observational data and animal studies, rather than the gold-standard randomized controlled trials in humans. There is an ongoing need for well-designed research in this area to better understand the possible therapeutic benefits and safety profile of cannabis and to differentiate the effects of its constituents. Current evidence suggests that cannabis may help chronic pain, nerve pain, and spasticity in certain patients. There is limited and inconsistent evidence that CBD in particular may have benefit in treatment-resistant anxiety, social anxiety, and insomnia. However, other studies show that whole-plant cannabis worsens existing anxiety and mood. Notably, there IS consistent evidence that cannabis increases the risk for developing a psychotic disorder in vulnerable individuals and exacerbates psychotic symptoms. Cannabis use in anyone with a history of an addictive disorder may trigger another cross addiction or contribute to someone falling back to an old addiction.

Safety considerations must be taken into account regarding cannabis. Today’s whole-plant cannabis is generally more potent (higher levels of THC) than it was historically. How it is consumed also plays an important role—vaping allows for a higher percentage of THC to be absorbed quicker and therefore may be more likely to trigger adverse mental health reactions such as anxiety and paranoia. Edibles can cause problems for users who expect a quicker onset of action leading to higher levels of consumption to achieve a desired effect. Interactions with other medications do occur. For instance, certain psychiatric meds may alter the breakdown and elimination of THC and CBD, and vice versa.

What may be the area of greatest concern is the impact of increasing cannabis acceptance and legalization on young people. A recent study demonstrated that earlier use of all substances including cannabis was associated with increased risk for developing a substance use disorder later in life.  Cannabis use has been shown to have adverse effects on IQ and executive functioning. Moreover, younger onset of marijuana use is associated with lower overall neurocognitive functioning. Youth who engage in marijuana use, also report taking part in other risky behaviors such as using other substances like nicotine and alcohol, and driving after marijuana use. As such, there is grave concern that cannabis use in this age group could lead to significant problems.

While ongoing high-quality research is needed in this area, current available evidence does NOT show consistent benefit for cannabis (including CBD products) on mental health symptoms and it may instead exacerbate symptoms. Patients should be encouraged to use caution and to have open conversations with their mental health and medical providers about cannabis use in order to understand how this may impact their mental health. Clinicians should be aware of the risks of cannabis use particularly for adolescents and should help prevent use in this specific population.

Sources:

Dharmapuri, S, Miller, K, & Klein, JD. Marijuana and the pediatric population. Pediatrics. 2020; 146(2)279-289

Hill, K. Medical marijuana for treatment of chronic pain and other medical and psychiatric problems, a clinical review. JAMA. 2015; 313(24) 2474-2482

Levinsohn, E & Hill, K. Clinical uses of cannabis and cannabinoids in the United States. Journal of the Neurological Sciences. 2020; 116717

Whiting et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015; 313(24) 2456-2473

 

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Transitioning to Young (and not quite) “Adult”hood

Jennifer L. Farley, PsyD
Lindner Center of HOPE, Associate Chief of Psychological Services

Congratulations! Your child graduated from high school!  And now…   what?

Many are busy selecting their fall semester college courses and buying necessities for their dorm room. Others have chosen to delay college and work instead, using time to consider their future. Some opted to focus on a career trade and are doing apprenticeship work. No matter their course, these newly-minted adults can now do 3 main things in America: vote, go to jail for their own actions, and enter into contracts on their own accord.  Yet, there are some contracts for which 18-year-olds are too young, and many lack the financial independence many contracts require. Bottom line: young adults still need support. But things are different, they’re high school graduates now. And most still live at home, at least for a little while.

The length of time it takes for one’s emancipation from home is entirely dependent on the path they’ve chosen and their success with it. For college students, the biggest first leap is when they move into their college dorm. It’s their first space outside of home to call their own.  Yet, the college dorm is still a contained bubble, where rules still dictate what’s expected and complete freedom is not given. Even dorms typically shut down during extended or holiday breaks. Freshman year represents the first of a graduated series of “bubble” expansions, when by their 3rd or 4th year, students have learned how to cook some of their own meals (instead of relying on cafeteria meal plans), they have to navigate roommate tensions without the aid of a dorm resident advisor, and they’ve (hopefully) learned to be self-disciplined and self-accountable. Most college students aren’t fully emancipated from their parents until they function completely independently on their own – when they get a job and make enough money to support themselves. That stage doesn’t mean “without support” of parents, it’s just that the adult child no longer requires parents’ resources to live on their own. For any young adult, this takes time:  time to get a job, time invested in working, and time spent saving money.

Even among the healthiest of families, any young adult’s process of emancipating from home comes with tension. This is par for the course… it’s how young adults develop self-confidence and gumption.  Without “tests” involving interactions with family, without the development of gumption, young adults risk a poor transition into their independent years. Imagine going away to college, working a full-time job, or moving out feeling insecure about yourself, not being able to trust that you can assert yourself or make good decisions. Without gumption, one may be so comfortable at home that they don’t seek more independence. Gumption fuels self-decision-making and serves as a foundation towards independence. Gumption often brings tension, and tension is experienced before big changes or transitions. The changes involved with emancipation are experienced by young adults and their families, alike.

During the months leading up to one’s emancipation from home, tension is often experienced in waves. Parents, realizing the borrowed time they have with their child, may seek more time to spend together with their child. Other times, parents may engage in more activities without their child to prepare themselves for their child to leave home. Adult children do a similar dance; sometimes they may seek their parents in anticipation of being away from them, while much of the time they want to spend time with friends. You can imagine the conflicts that arise when an adult child wants freedom with friends during a time when parents seek quality time with their child. This is all natural, it’s just a matter of recognizing and understanding it. Time spent together can involve some creativity with lessons in laundry, basic cooking, and how to manage money – while times of tension make it easier for everyone to prepare to say “goodbye” and to face the changes ahead.

No matter the transition ahead, practice the cycle of a “submarine parent” – stay offshore, come up for air sometimes to check in with your young adult child, and retreat back down in the water when you see your child is doing just fine.

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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

Bibliography

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),
604-611.

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.

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Can the COVID-19 Vaccine Improve Your Mental Health?

Thirteen months ago, the world was experiencing the onset of a shared trauma … a pandemic was sweeping over the globe. The actions that were taken to keep people safe included community shut downs, stay at home orders and mandated isolation. Lindner Center of HOPE, like mental health providers around the world, began to see spikes in mental illness and addiction. Individuals who were already struggling with mental illness or a pre-disposition, saw exacerbated symptoms and an increase in severity of illness. People who were managing, saw new onset at higher levels of acuity. As time has passed since the beginning of the pandemic, the trauma has been sustained with higher percentages of people still struggling with mental illnesses and addictions. Additionally, data shows people who have experienced COVID-19 infection are also suffering with co-occurring psychiatric symptoms.

Dr. Paul Crosby, Lindner Center of HOPE

Fortunately, vaccines have been released to protect the population from the physical health threats of COVID-19. However, Lindner Center of HOPE’s President and Chief Operating Officer, Paul R. Crosby, MD, states the vaccine also offers mental health benefits as well.

“The first mental health benefit of the vaccine is simple,” Dr. Crosby said, “since the risk of COVID-19 infection diminishes significantly with vaccination, receiving the vaccine would also protect individuals from co-occurring mental illness that has proven to manifest with COVID-19 infection.”

“The second mental health benefit of the vaccine is the reduction in overall anxiety and stress, as risk and fear of infection is reduced. Vaccinated individuals can lift their isolation from other vaccinated individuals, can begin to see a return to other activities that improve mental health, like more exercise, improved sleep, new experiences through travel and more. A return to these healthier activities can hopefully also lead to a reduction in substance use, overeating or lack of participation in other things that bring joy.”

“The COVID-19 vaccine has significant potential in improving your mental health.”

For individuals experiencing symptoms of mental illness, it is critical to access help. Mental illnesses are common and treatable and no one should struggle alone.

Lindner Center of HOPE in Mason is a comprehensive mental health center providing excellent, patient-centered, scientifically-advanced care for individuals suffering with mental illness. A state-of-the-science, mental health center and charter member of the National Network of Depression Centers, the Center provides psychiatric hospitalization and partial hospitalization for individuals age 12-years-old and older, outpatient services for all ages, diagnostic services for all ages and short-term residential services for adults, and research. The Center is enhanced by its partnership with UC Health as its clinicians are ranked among the best providers locally, nationally and internationally. Together Lindner Center of HOPE and UC Health offer a true system of mental health care in the Greater Cincinnati area and across the country. The Center is also affiliated with the University of Cincinnati (UC) College of Medicine.

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Mental Health and the Environment of Connection

By Chris J. Tuell, EdD, LPCC-S, LICDC-CS
Lindner Center of HOPE, Clinical Director of Addiction Services; Assistant Professor, Department of Psychiatry & Behavioral Neuroscience
University of Cincinnati College of Medicine

At the end of the Vietnam War in 1975, 1 out of 5 soldiers (20%), returning to the United States from Southeast Asia, was addicted to heroin. It was estimated that approximately 100,000 American soldiers would be returning home, addicted to this destructive drug. Experts projected a drug epidemic, which would destroy countless lives and communities. It never happened.

Once soldiers returned home to families, friends and communities, the destructive nature of a hardcore drug, like heroin, failed to materialize. In fact, 95% of the soldiers who were once addicted to heroin, stopped using the drug almost immediately once they returned home.

For many years, our understanding of addiction was based on early research conducted in the first half of the 20th century. These studies involved rats and consisted of placing a rat in a solitary cage, providing the rat with a choice of water: plain water or water laced with cocaine or heroin. The study found that all the rats preferred the drug-laced water to the plain water. All the rats overdosed on the drug. The majority of the rats died in the study. This became our model of addiction for many years. The accepted belief became, if you are exposed to a drug, you will become addicted, and you may overdose and die.

Several years later, this original study was replicated, but with a significant difference. Researcher Bruce Alexander from the University of Vancouver, created, what was referred to as: a “rat park.” This park consisted of tunnels, multiple levels, toys, and other rat companions. Similar to the original study, all rats were given the same choice of water: plain water or water laced with heroin or cocaine. In Alexander’s study, rats preferred the plain water. Rates of overdose and death to the rats were significantly lower when compared to the initial study. How do we explain this difference in results? Perhaps, it is about the cage. Perhaps, it is about the environment.

Upon their return home, the soldiers from Vietnam who were struggling with a heroin addiction were able to re-connect with loved ones and community. A change in environment allowed for a change in connection, resulting in health, wellness and sobriety. Likewise, the environment of the rat in a solitary cage, as compared to the environment of the rat park, provided the rat with a “connection” with other rats, an environment which allowed the rat…to be a rat.

Individuals, who experience issues of mental illness and/or substance use disorders, have a natural tendency to withdraw and isolate from others. Depression, anxiety and addiction, greatly affect an individual’s ability to connect with others, let alone with one’s environment. This past year we have seen the devastating impact of COVID-19. We know that in order to maintain health and wellness, we need to maintain social distance and disconnect from one another. For now, this has and continues to be, what we need to do. It remains challenging for many of us to continue to avoid contact with loved ones and friends. We are separated from the very individuals who love us, support us, and are our sources of connection.

We have seen the rise of mental health issues during the past year. Nearly 20 percent of COVID-19 patients have developed a mental health issue (i.e., depression, anxiety) within three months of their diagnosis. During the past year, 4 in 10 adults in the U.S. have reported symptoms of anxiety or depression. Within the general population, rates of mental health issues and substance use have significantly increased across the board. In addition, the disconnection that we have witnessed has fragmented our society in general by harboring increased levels of fear, anger and animosity towards one another.

Hope on the horizon

Once “herd immunity” is achieved, the importance of re-connecting with one another becomes vital and essential to our health and mental wellness. We are social beings and need connection with one another. History has shown that the mental health impact of disasters outlasts the physical impact, suggesting today’s elevated mental health needs will continue well beyond the coronavirus outbreak.  Like the moth that needs to struggle out of the cocoon in order to develop the strength that it needs to survive in the world, we too are developing the strength that we need from the struggles we have endured.  Re-connecting with one another is an answer.  It gives us strength and it gives us hope.

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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.

  1. 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.
  2. 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.
  3. 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).
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.

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“This above all: to thine own self be true…” – Shakespeare

By Tracy Suzanne Cummings, MD 

Chief of Child and Adolescent Psychiatry 

If you have ever been a passenger on an airplane, you have heard the directive to don your own oxygen mask first before attempting to help someone else with theirs. Perhaps as February’s decorative hearts and cupids fill our visual fields, we can consider how this is true for our actual hearts and self-worth, particularly for the younger members of our population. After all, adolescence is a time of self-discovery and identification. Let us encourage teens to build and strengthen a relationship with themselves, thereby preparing them for the challenges of the complex tapestry that we call love. Building up the 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.

Self-esteem can be defined as the confidence in one’s own worth or  abilities. It often includes self-respect  and compassion. Once we are able to believe in our worth (which is vast and unique, and exists for everyone), we can better accept and give respect and compassion to those with whom  we have relationships, from friendships to romance. Without it, a person might sacrifice themselves to gain the approval of others, only to find later the disappointment in that superficial, unhealthy pattern. Unfortunately, most health classes will not cover relationships in their curriculum, and, naturally, teens will get their information from observing others and asking peers. They might seek social media likes and attention, rather than true connection, keeping face instead of keeping true to one’s essence. While they may long for roses, candy hearts, and chocolates, we need instead to attempt to instill the desire for an arrow pointing them to their own passions and skills. Recent data suggests that over 90% of thirteen to seventeen year-olds go online daily, with over 70% using more than one social media site (American Academy of Child and Adolescent Psychiatry). If only we could have confidence that those sites and online interactions would lead to affirmation!

So, here is where trusted adults can step in and make an impact, by modeling caring relationships and self-compassion. By doing so, we highlight their strengths and capabilities without social comparisons, teaching them to value their personal gifts now so they may be able to share them with a partner later. Helping a teen find their path to success might involve trial and error (it’s ok to not know right away what you want in life), adjusting expectations (self-imposed or otherwise), and creating the context in which wins can happen. While self-esteem and worth begin to be formed in childhood, improvements can be attained at all stages of life by working on the following:

* Insisting on equality and mutual respect in a relationships

* Setting appropriate boundaries

* Verbalizing needs

* Accepting feedback (perhaps even in the form of conflict)

* Acknowledging the possibility of failure, while trying to seek success

* Maintaining assertiveness

* Releasing the pressure of achieving the unattainable goal of perfection (in yourself and others)

If Cupid was really in the business of creating fulfilling and lasting relationships, we would see his arrows pointing towards boosting self-esteem. Besides, who needs a special day to have chocolate anyway?

 

 

 

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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.

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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
  1. LaChance LR, Ramsey D. Antidepressant foods: an evidence-based nutrient profiling system for depression. World J Psychiatry. 2018;8:97-104.
  2. 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.
  3. 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
  4. Ruixue HuangKe WangJianan Hu  Effect of Probiotics on Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials, Nutrients 2016 Aug 6;8(8):483
  1. Richard T LiuRachel F L WalshAna 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.
  2. Marit K ZinöckerInge A LindsethThe Western Diet-Microbiome-Host Interaction and Its Role in Metabolic Disease Nutrients   2018 Mar 17;10(3):365.

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Grief During the Holidays

By Danielle J. Johnson, MD, FAPA

Lindner Center of HOPE, Chief Medical Officer

Many people have experienced loss of several types during the COVID-19 pandemic – employment, financial security, social connections, a sense of safety, and loved ones.  The way we grieve has changed because we cannot rely on our support systems to be physically there for us due to restrictions with social distancing.  With the increasing number of COVID-19 cases, the holiday season will be different this year – no holiday parties, large family gatherings, or other traditions.  It is difficult to be physically separated from loved ones, but even more difficult for those who may be experiencing their first holiday season after the loss of a loved one.

 

What are some ways that we can manage grief during this unprecedented holiday season?

  • Take charge of your holiday season: Anticipating anxiety about the holiday, especially if it is the first one without a loved one, can be worse than the actual holiday. Taking control of your plans and deciding how you will spend your time can relieve anxiety.  Do not spend time where you do not feel emotionally safe or comfortable.
  • Find nourishment for the soul: Your faith community may offer resources. Look for a support group for people who have suffered a similar loss or for those who are alone.  Due to the pandemic, many support groups are online.
  • Give yourself permission to change your holiday traditions: Some traditions may be a comfort, while others may be painful. Some traditions will have to change due to the pandemic.  It is ok to start new traditions.  Many families are finding ways to celebrate virtually.
  • Change how you give: Give a gift on behalf of your loved one to someone else or donate to a charity in memory of your loved one.  If you are spending less due to not spending the holidays with loved ones, consider giving more to charitable organizations.
  • Do not let guilt overtake you: You can enjoy the holiday without your loved one.  Celebrating does not mean you do not miss or have forgotten about your loved one.
  • Be gentle with yourself: Realize that familiar traditions, sights, smells and even tastes, may be comforting, or may trigger strong emotions. Be careful with your emotions and listen to yourself.
  • Do not pretend you have not experienced a loss: Imagining that nothing has happened does not make the pain of losing a loved one go away or make the holidays easier to withstand. It is ok to talk with others about what you have lost and what the holidays mean to you.
  • Pay attention to your health: It is often difficult for people who have experienced a recent loss to sleep. Make sure you get regular rest.  If you feel overwhelmed, talk with your health care provider.
  • Experience both joy and sadness: Give yourself permission to feel happiness and pain. Do not feel like you must be a certain way because of your loss or because it is the holidays.
  • Express your feelings: Suppressing your feelings may add to distress. To express your feelings, talk with a supportive friend or journal.
  • How can support persons help those who are grieving during this holidays season if we cannot physically be there? Be available to listen. Send cards, gift cards for meals, offer to help shop, or decorate the outside of the home.  If you are concerned about their mental wellbeing, offer to help them find a support group or encourage them to reach out to their health care provider for help.

Resources

https://www.griefshare.org/holidays

https://whatsyourgrief.com/alone-together-14-ideas-for-a-virtual-holiday/

https://coronavirus.ohio.gov/wps/portal/gov/covid-19/families-and-individuals/resources-for-parents-and-families/holiday-celebrations

Crisis Text Line, text CONNECT to 741741 for 24/7 help from a crisis counselor.

Ohio Care Line, call 1-800-720-9616 for 24/7 support from behavioral health professionals.