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Incorporating stress management into weight-loss programs can help preventthe problem of weight regain, the so-called yo-yo diet syndrome, sayresearchers at the University of Kansas Medical Center in Kansas City.
Their weight-management study followed 69 low-income African-American womenwho lost weight over a 6-month period in a primary care setting. Theresearchers presented their findings at the 2005 Annual Scientific Meeting ofNAASO, The Obesity Society (formerly the North American Association for theStudy of Obesity), held in Vancouver, British Columbia, October15–19.
Throughout the clinic intervention, each woman received 12 minutes permonth of direct physician consultation. At the end of the program, averageweight loss was 2.27 kg (5 lb).
Researchers assessed the women at 9, 12, and 18 months following theweight-loss program. By the 18th month, the women had upped their intake offatty foods, were ingesting more calories, and had decreased their consumptionof fruits and vegetables. Average weight gain was 1.86 kg (4.1lb).
To assess subjects' levels of stress and depression, the investigators usedthe Weekly Stress Inventory, a validated pencil-and-paper survey of minor lifeevents, and the Center for Epidemiologic Studies Depression Scale ofdepressive symptoms. Participants reported seemingly minor stressors, such asbeing caught in traffic jams or arguing with a spouse orcoworker—simple, everyday occurrences that tend to be more highlyassociated with adverse outcomes than major life events, according to theresearchers.
Increasing levels of stress accurately predicted increased body mass index(BMI), increased weight gain, increased caloric intake, and higher dietary fatintake, concludes lead author, Paula Rhode, PhD, a clinical psychologist andprofessor of preventive medicine and public health at the University ofKansas. Stress and depression predicted 26% of the variance in weight gain and29% of the increase in BMI, results first reported last year at a meeting ofthe Society of Behavioral Medicine.
The findings suggest that in order to achieve long-term weight-loss goalsand avoid regain, psychosocial factors must be addressed in any weight-lossprogram, Rhode says.
"Stress and depression aren't typically addressed in weight-lossstudies or weight-loss interventions," she says. "We have toidentify these patients who are at high risk, who suffer the small dailystressors and feel they have no control, who then regulate or `self-medicate'their emotions through eating."
These people are not clinically depressed, so antidepressants would not beappropriate, but early intervention with cognitive behavioral therapy canhelp, Rhode says.
DON'T MISS DEPRESSION
Psychologist Patrick M. O'Neil, PhD, director of the Weight ManagementCenter at the Medical University of South Carolina in Charleston, says therole of depression in obesity is just beginning to be recognized.
"We typically think of depression as including features such as lossof appetite,1insomnia, and weight loss associated with the loss of appetite," O'Neilsays. "But some people have just the opposite features: increasedappetite and weight gain, and they sleep to an excessive degree. Theirdepression is certainly contributing to their obesity, and we do know thatsevere obesity can detract from the quality of life."
In general, clinicians should screen for depression in all of theirpatients, not just those who are obese, he says. Primary care providers canuse screening tools such as the self-reporting Beck Depression Inventory-II orthe Hamilton Depression Rating Scale to determine whether their patient is atrisk for depression.
"Depression can manifest itself in so many ways, it often getsmissed," O'Neil says. "There are the easy ones, such as adepressed mood, where the patient comes in tearful, reporting that they arefeeling blue. But the ones that get missed most often are the loss of energy,the loss of interest, the loss of ability to experience pleasure. Thesepatients aren't going to volunteer the information because they may notrecognize that they are depressed."
If the primary care clinician is targeting obesity and not seeing changes,he or she should have one eye cocked for depression, O'Neil says. "Ifyou're seeing the depression, it must be addressed. If you're seeing both,each should be addressed on its own merits. Dealing with obesity is moredifficult when depression is present. Early detection is key."
Having a plan or strategy to manage depression within the practice settingis helpful, he continues. Outside sources with this particularexpertise—psychologists, psychiatrists, or social workers—oftencan identify patterns.
"Meaningful progress is possible when depression is recognized andtreated early," O'Neil says. 
Footnotes
The Beck Depression Inventory-II is a 21-item self-reportingscreening tool in line with the depression criteria of the Diagnostic andStatistical Manual of Mental Health Disorders—Fourth Edition(DSM–IV). It's available for purchase athttp://harcourtassessment.com.
The Hamilton Depression Rating Scale (HAMD) is a 17-item scale thatevaluates depressed mood, symptoms of depression, and comorbid anxietysymptoms. HAMD and four other depression-screening instruments are availableat the Web site of the Department of Veterans Affairs Office of Quality andPerformance:http://www.oqp.med.va.gov/cpg/MDD/MDD_cpg/content/appendices/mdd_app1.htm#6.
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