Obesity is a topic that is too often not paid attention to in psychiatry.  Some psychiatric medications can cause sizeable weight gain.  Lithium, divalproex (Depakote), olanzapine (Zypreza), and clozapine (Clozaril) can each cause very major weight gains, although not everyone is affected.  Amitriptyline, mirtazapine (Remeron), phenelzine (Nardil), quetiapine (Seroquel) and doxepin (Sinequan) are other major offenders.  While these are all valuable psychiatric medications, for patients experiencing weight gain, finding an alternative treatment is often very valuable for their health.  Fortunately, there are many alternatives to all of these medicines and there are also techniques to help patients who need these particular medicines to minimize the weight gain.

How to deal with individual medications causing weight gain will be covered under the treatment sections for each of the disorders.  This page is more oriented to the general issue of weight gain.  

My secrets to a healthy weight are lower on this page.  I used to have a weight loss group, so my information is still fairly up to date.

Obesity Kills 112,000 Americans per Year: Using a nationally respresentative sample date from NHANES 1971-5 and NHANES II (1976-80), with follow-up to 1992, and from NHANES III (1988-94), with follow-up to 2000, researchers conclude obesity (BMI over 30) was associated with 111,909 excess deaths in the year 2000 and underweight (BMI<18.5) with 33,746 excess deaths compared with people of normal weight (BMI=18.5 to 25). Overweight (BMI=25 to 30) was not associated with excess mortality. Deaths due to obesity in more recent data from NHANES II and NHANES III than in NHANES I have actually been decreasing. Compared with obese people in the first NHANES data from 1960-2, the obese group in 1999-2000 had a 21% lower prevalence of high cholesterol level (39%  v 18%), an 18% lower prevalence of high blood pressure (42% v 24%), and a 12% lower rate of smoking (32% v 20%). There was a 55% increase in total diabetes due to an increase in obesity. Excess Deaths Associated With Underweight, Overweight, and Obesity. Flegal KM, et al. JAMA. 2005;293:1861-1867. Ed: The ideal BMI was 23-25. The excess deaths among the underweight was 80% concentrated in elderly over age 70, while 2/3rds of deaths due to obesity were under age 70 and especially concentrated in the very obese (BMI>35). Smoking kills four times as many Americans per year as obesity. 

Obesity is Depressing; Weight Loss Helps: 487 subjects, the mean preoperative BDI score was 17.7. Higher scores, indicating increased symptoms of depression, were found in younger subjects, women, and those with poorer body image. These factors had independent effects. We found no association between BDI and waist circumference or insulin concentrations. High BDI scores correlated with poorer physical and mental quality-of-life measures. Weight loss was associated with a significant and sustained fall in BDI scores, with a mean score of 7.8 at 1 year and 9.6 at 4 years after surgery. Greater falls in BDI score at 1 year were seen in women, younger subjects, and those with greater excess weight loss (combined r2 = 0.10; P<.001). Fall in BDI score correlated with improvement in appearance evaluation (r = -0.31; P<.001). Depression in association with severe obesity: changes with weight loss. Dixon JB, Dixon ME, O'Brien PE. Arch Intern Med. 2003 Sep 22;163(17):2058-65

Obesity Isn't Healthy: In a 30-year+ follow-up study of 17,640 adults, average age 47, and free of diabetes and heart disease at the beginning of the Chicago Heart Association Detection Project in Industry study, overweight and obese adults were 43% more likely to die and over 300% more likely to be hospitalized because of heart disease than normal weight adults. Obese non-smoking adults with normal cholesterol and blood pressure were still 11 times more likely to die due to diabetes than those initially normal weight. JAMA 1/25/06.

Obesity

Increasing in England: Between ’80 and ’96 prevalence increased from 6% to 16% men and from 8% to 17.3% women. If diet, exercise and behavior change is not successful in 3 mo., then medications are OK says Royal College of Physicians. If the patient doesn't lose at least 5% loss on medications, then stop them. British Medical Journal 1/16/99; In 2003, 20 percent of men in Britain are obese and a further 50 percent are overweight, according to research compiled by the charity Cancer Research UK. Weight problems increased by 60% since 1993 and approaching US levels. Reuters London 6/29/03. Ed: The only medication that looks really worthwhile is metformin, an inexpensive diabetes medication.  

Increased in U.S. to 1/3^rd Obese, Another 1/3^rd Overweight:  Newest NHANES figures, based on actual measurements and not self-report which tends to under-estimate, show 31% U.S adult 20-74yo obese (BMI >30) and almost 2/3 overweight (BMI>25). Only 15% were obese in 1980 and 23% in 1994. Obesity in children up 300% since 1980: 15% seriously overweight. JAMA 10/9/02

U.S. #1... in Teen Obesity: The U.S. won the unwelcome distinction of having the fattest teenagers. In a study of 29,000 13- and 15-year-old boys and girls in Austria, the Czech Republic, Denmark, the Flemish region of Belgium, Finland, France, Germany, Greece, Lithuania, Ireland, Israel, Portugal, Slovakia, Sweden and the U.S, the U.S. led in the percentage of overweight adolescents. Among 13-year-olds in the U.S., 11.7% were overweight. For 15-year-olds, 14.5% were overweight. After the U.S., Greece and Portugal had the highest percentages. Teens in Lithuania were the least likely to be overweight, just 2% of 13- and 15-year-olds. Arch Pediatr Adolesc Med 2004;158:27-33. Ed: American youth ate out in restaurants the most often. 

Child Obesity Up 200% in Canada: obesity among 7 to 13 year olds rose from 5% in 1981 to 17% in 1996 for boys and 15% for girls. Canadian children are considerably more likely to be overweight than their English, Scottish, and Spanish peers. BMJ 6/14/02. Canada spent about 9.4% of its gross domestic product on health care in 2001. Only three countries in the Organization for Economic Cooperation and Development spent more—the United States (12.9%), Switzerland (10.4%), and Germany (10.3%).

Increased Obesity in Brazil, China, Denmark, U.S.: Between 1971 and 1997, excessive weight tripled as a percentage of all children and teens in Brazil, from 4.1 percent to 13.9 percent, and almost doubled in the U.S., from 15.4 percent to 25.6 percent, Wang said. It increased by a fifth in China from 6.4 percent to 7.7 percent between 1991 and 1997. In contrast, in Russia, it fell from 15.6 percent to 9 percent between 1992 and 1998 during tremendous economic stress and a large reduction in the energy density of the diet. U North Carolina, Youfe Wang. 5/28/02; Danish prevalence of overweight and obesity increased from 1992 (overweight, 30%; obesity, 6%) to 1998 (overweight, 35%; obesity, 8%). Obes Res 2002 Sep;10(9):911-922

Spanish Obese, Too: 39% are over-weight and 14% obese. The rate of obesity has been steadily increasing, even in children. Sociedad Española de Endocrinología y Nutrición (SEEN). Según los datos facilitados por esta entidad, diferentes estudios de ámbito nacional han demostrado que un 39% de las personas padece sobrepeso y un 14,5% obesidad. Estas cifras van en aumento y cada vez son más habituales en los niños. 11/27/01 EFE, Madrid.

Childhood Obesity Up in England: 60% rise in obesity in 3-4 year-olds between 1989 and 1998 in England. Bundred, BMJ 2000

Obesity Up for American Kids, Especially Black & Hispanic: Overweight kids increased 50% for European-American, and 120% for Afro-Am and Hispanics from 1986 to ’98. JAMA 286:2845 ’01

Obesity Up Worldwide: 50% of Egyptian women are obese, perhaps the world's record. 60% of Mexican women are overweight or obese. Overweight in men up 200% in 8 yr and 100% for women. Obesity is up even in sub-Sahara Africa. Lancet 4/20/02

English Diet Poor Like Americans: After 8 years of health messages, Brits in the 19-24 age group are worse at eating fruit and vegetables, favoring "food on the go" such as pizzas, burgers and kebabs. But Britons are eating three times more bananas than in 1987 - from an average three quarters of a banana a week to two.

Brits Don't Eat Their Vegetables & Fruits; Too Much Pop: The Department of Health first advised the nation to eat five portions of fruit and vegetables a day in 1994. On average, men eat 2.7 portions and women 2.9. Men are eating more burgers and kebabs; both sexes are eating more breakfast cereals; and the nation eats fewer chips. People of all ages buy more fizzy drinks than 15 years ago. Young people's consumption has gone up from three a week to six. The survey by the Food Standards Agency and the Department of Health said that when a similar survey was conducted in 1987, 4% of men and 12% of women were on a diet. When the new survey was conducted in 2001, the figure was 10% and 24%. Telegraph 3/31/03

Urban Sprawl Linked to Obesity: This article disappeared but not the title.

Lower Cost of Food Has Helped Increase Obesity in the U.S. and Worldwide:

Harm of Obesity

Young Obese Die Sooner: obese 20-year-old man may have his life expectancy cut by as many as 13 years compared with normal. For an obese 20-year-old woman, 8 years, study based on three decades of data from US mortality studies. The second study, published on Monday in the Annals of Internal Medicine (AIM), analysed the medical records of 3500 US adults who were middle-aged in 1950. It found that women obese at the age of 40 lost 7.1 years of life, while obese men lost 5.8 years. AIM study found that even being overweight at 40, rather than obese, shortens life expectancy by around three years. The results were even more stark for smokers, with overweight adults dying seven years before their non-smoking counterparts, and obese smokers dying 13 to 14 years earlier. JAMA 1/8/03, AIM 1/7/03

Miscellaneous

Obesity in Middle Age Dementia Risk Factor: In a 36 year follow-up of 10,136 adults ages 40-45, compared to those with a normal BMI (18.5-24.9), those obese (BMI > 30) at midlife had a 210% increase in risk of AD, and a 401% increase in risk of VaD (HR=5.01) while those overweight (BMI > 25 and <30) had a 109% increase in risk of AD and VaD (HR=2.09 for AD and HR=1.95 for VaD). Body mass index in midlife and risk of Alzheimer disease and vascular dementia. Whitmer RA, et al. Kaiser Permanente, California. . Curr Alzheimer's Res 2007 Apr;4(2):103-9.

Obese Slower to Seek GYN, Breast Testing: A survey of 6981 adult women found an increased Body Mass Index (BMI( increased MD visits but an index of 35 or above (severe obesity) delayed clinical breast exams, GYN exams, and pap smears. Arch Fam Med 98 7:381-4

Obese Like Food More: The parts of the brain responsible for sensation in the mouth, lips, and tongue are more active in obese people than in normal-weight control subjects. Obese people have fewer brain receptors for dopamine, a neurotransmitter that helps produce feelings of satisfaction and pleasure. PET scans and MRI. July 2, 2002, NeuroReport.

US Eats More Now: According to Judith Putnam of USDA, Americans are eating roughly 500 calories more food than in 1980. Added fats and oils are up from 48 g/d in early 1950s to almost 80 g/d in 2000 (288 fat calorie increase). Tallow and lard were very low in late 80s but have rebounded to 7 g/d. Shortening has gradually risen from 10 to 16 g/d. Carbohydrates are also up. Nutrition Action 11/02, The Truth about the Atkins Diet. 29(9):3-6

Pregnancy Obesity Increases Child Obesity: The greater the maternal body mass index, the bigger the baby, the higher the maternal fasting glucose concentration, and the higher the geometric mean of the umbilical cord insulin concentration (P=0.015). There was no differences in cord leptin or insulin-like growth factor-I. The authors hypothesized that increasing maternal obesity is associated with increasing maternal glycemia, thereby stimulating fetal insulin secretion and raising the potential for obesity in the offspring. Thus, controlling weight, etc. in pregnancy may prevent adult obesity. BMJ 3/16/02.

Healthy Weight Greatest Indicator of Female Sexual Attractiveness: In a study of college students, an incredible 73% variance of sex attractiveness in females was explained by the Body Mass Index (BMI) vs. just 2% by the waist/hip ratio. Maximum attractiveness occurred with BMIs between 19 and 21 although attractiveness didn’t fall off dramatically with small changes.  A BMI of 20 at 5’3 is 112 pounds, at 5’5 it is 120 pounds, at 5’7 127 pounds, 5’9 135 pounds, and 5’11 143 pounds.

Obesity Causes Many Cancers: Up to 1/3^rd of colon, breast, kidney & digestive CA due to excess wt and low exercise. Half Europeans and 61% US adults overweight WHO, London, 4/6/01 News Gazette.

Binge Drinking in Teens May Lead to Obesity: A study interviewing 800 Seattle school children were interviewed annually starting at age 13 through age 16 and again at ages 18, 21 and 24 found that people who began binge drinking (5 or more drinks) at age 13 and continued throughout adolescence were nearly four times as likely to be overweight or obese and almost 3 times as likely to have high blood pressure when they were 24 years old than were people who never or rarely drank heavily during adolescence. Adolescent binge drinking also results in a number of immediate negative consequences, including involvement in fatal or injurious automobile accidents and engaging in risky sexual behavior. Karl Hill, U Washington. 7/8/04.

Ineffective Weight Loss

Chitosan No Help: DB PC 30 pt 28 days. Randomized, double-blind trial of chitosan for body weight reduction. Pittler MH, Abbot NC, Harkness EF, Ernst E. Eur J Clin Nutr 1999 May;53(5):379-81 U Exeter

DHEA No Benefit Obesity: 10 wk DB placebo study of 13 morbidly obese Rx DHEA 40 mg BID sublingually. Found no favorable changes. MG Vogiatzi, Cornell, Metab 8/96 45:1011-5

Gacinia Cambogia No Help: Common component of wt-loss products no help in DB study. JAMA 11/11/98

Educational Groups Fail: 6-12 sessions in two different studies in reading labels, selecting fat free restaurant foods, modifying recipes, etc. no benefit in follow-up. Two more "Pounds of Prevention" studies with newsletters, follow-up sessions, and financial incentives also failed. BMJ 10/4/02.

Metabolife May be Dangerous: In a small study of healthy volunteers, a single Metabolife 356 tablet was associated with a 24 millisecond increase in QTc interval on electrocardiogram, an increase that investigators said was associated with a 3.5-fold increase in risk for torsade de pointes. Nov. 9, 2003 at the American Heart Association (AHA) Scientific Sessions, Brian F. McBride, University of Connecticut.  Moreover, a single Metabolife tablet — which is just a third of the recommended daily dose — also significantly increased both systolic and diastolic blood pressure. Metabolife 356 currently controls about 49% of the world market in diet supplements. Metabolife 356 contains ephedra as well as 17 other ingredients. Other studies have suggested an increased cardiac event risk associated with ephedra.  Ephedra has resulted in many deaths and is banned in several states.

Effective Weight Loss: 

What Works: 1) Increase Exercise, 2) Eat Whole Grain Wheat or Rye Bread, Pasta, etc., 3) Cut TV viewing time to under seven hours per week, 4) No Sugared Pop, 5) No Fast Food Restaurants, 6) Eliminate Beef and Pork Fats and ideally all Mammal Meats; 6) Eat nuts, beans, peas, lentils, and seafood for protein, 7) Eliminate Sugar, White Bread, Refined Flour, White Rice, Potatoes (The Atkins diet, the Ornish diet, the South Beach Diet, and Weight Watchers all avoid sugar and white flour), 8) Eat Vegetables, Fruits, and Avocados; 9) Eat Nuts or Peanuts daily, 10) Use Canola or Olive Oil, 11) Cut Out Salt, 12) Use Artificial Sweeteners: Aspartame  or another Sweetener, 13) Eat Breakfast every day, 14) take Calcium 500 mg. (women only) and Magnesium 250 mg supplements twice a day and eat a cup of lite or plain yogurt each day,  15) Of course, try to eat less.  16) Chart your weight each day and weigh yourself one to several times per day.  If you weigh over 300 pounds, just buy two scales, use one for each foot, and add up the weights.  17) Breast Feed any infants you have.  18) Take 6-12 mg of melatonin each night ($3-5/month). 19) Take Vitamin D 2000 units daily.

If the above diet, exercise, and lifestyle changes are not enough, try adding medication without stopping the above: 20) Metformin ($15/month) is inexpensive and can be helpful; 5-HTP ($12 per month) is inadequately researched although is available without a prescription and might be worth a try; Topamax (over $100 per month) is probably too expensive and frequent side-effects although it is sometimes quite effective; (Meridia ($240/month) is definitely too expensive for its benefits, has worrisome side-effects, and is usually less effective; Zenical ($140/month) is too expensive for its modest benefit); If all of these fail, 21) try Gastric Stimulation.  If that fails, 22) get Gastric Banding or other surgery. (Click on the buttons at the top for more detailed information on the above)

Breast-Feeding, Exercise Help Lose Pregnancy Weight: A 5-10 year follow-up study of 540 US women found women who breast-fed and women who participated in aerobic exercise also had significantly lower weight gains. Obstet Gynecol 2002 Aug;100(2):245-52

Implantable Gastric Stimulator Works: A new device in which wires are placed in the stomach and connected to a stimulator device which is worn find that the stimulator suppresses appetite and leads to weight loss in 80% of cases. The method may provide an alternative to more invasive surgical procedures for treating morbid obesity. Scott Shikora, MD, and Michael Tarnoff, MD, presented their findings on Sunday at the North American Association for the Study of Obesity (NAASO) annual meeting in Ft. Lauderdale, Florida 10/12/03. All 30 patients were successfully implanted with the device with no complications. Mean body mass index was 42 kg/m². Mean follow-up of 9.5 months. Average amount of weight loss was 18.8% of excess weight, with 60% losing more than 10% of their excess weight. There was a 15% change in appetite before meals, a 60% change in satiety between meals, and a 90% change in satiety at the end of a meal.

More Early Weight Loss Better if Follow-Up: initial weight loss is positively, not negatively, related to long-term weight maintenance. There is evidence from randomized intervention trials to support that a greater initial weight loss induced without changes in lifestyle (e.g. liquid formula diets or anorectic drugs) improves long-term weight maintenance, providing it is followed by a 1-2 years integrated weight maintenance programme consisting of lifestyle interventions involving dietary change, nutritional education, behavior therapy and increased physical activity. Obes Rev 2000 May;1(1):17-9

Surgery: Laparoscopic Gastric Banding Good for Obesity: Series of 500 consecutive averaged 50% wt loss at two years with only 3 major complications. Ann Surg 237:1-9, ’03

Gastric Banding Looks Very Good for Obesity: Five hundred very obese patients (average age 42; weight 270 pounds) underwent laparoscopic adjustable gastric banding surgery. At 36 month follow up, average body mass index (BMI) had decreased from 45.2 to 34.9 and 47% of excess weight was lost. Complications were: gastric pouch dilatation (6.8%), slippage (2.8%), and stoma obstruction (0.6%). There was no mortality. Disease improvements were: gastroesophageal reflux disease (GERD) (87%; usually immediately postsurgery), asthma (81.8%), diabetes (66%), dyslipidemia (65.5%), hypertension (48%), and sleep apnea (33%). Weight loss and improvement of obesity-related illness in 500 U.S. patients following laparoscopic adjustable gastric banding procedure. Spivak H, Hewitt MF, et al. Houston, TX. Am J Surg. 2005 Jan;189(1):27-32

Surgery: Type 2 Diabetes Cured in 80%: Laparoscopic Roux-en Y gastric bypass results in substantial weight loss and resolves more than 80% of cases of type 2 diabetes, according to the results of a study published in the October, 2003, Annals of Surgery.

More Food, Less Exercise Linked to Chinese Obesity: Age, daily intakes of energy and carbohydrate, and marital status were positively associated with overweight, while occupational and commuting physical activity, as well as smoking, were inversely associated with overweight among both genders. Daily intakes of protein, fat and alcohol were positively related to the incidence of being overweight among men. 2600 adults Tianjin 25-64yo. Br J Nutr 2002 Jul;88(1):91-7

Thomas E. Radecki, M.D., J.D.

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