From Psych Congress 2015:
SAN DIEGO—Richard Shelton, MD, explained the science behind the obesity/depression connection and offered practical tips for changing patients' diets. After his presentation, he took the time to answer a few questions.
If you could have everyone in the audience do one thing differently when they get back to their clinical practice, what would that be?
It would be to go to their patients and ask them to reduce one high-glycemic-index food. You can build progressively from there, but you’ve got to start somewhere. Trying to get rid of all the carbohydrates at once just doesn’t work that well for people, but progressively doing it over time really helps.
I create a hierarchy with patients from the most problematic to the least problematic high-glycemic-index food and start focusing on the highest one on that list and start working up.
Do clinicians have any misconceptions about the relationship between obesity and depression that you’d want to correct?
I think the most common misconception is that the treatments are causing most of the problem. For example, people have the idea that antidepressant medications are causing the majority of weight gain over time.
I think the evidence indicates that depression itself is driving most of the weight gain as time goes by, and it’s one of the reasons you can see a wide range of antidepressant medications being used and progressively over time you’ll still get the weight gain issue. Even bupropion, which itself seems to be weight neutral, unfortunately does not cause weight loss. Therefore, you will eventually have patients catching up and continuing to gain weight.
Is a low carbohydrate diet a better strategy than exercise?
Adherence to the low-carb diet is much higher. We go from not dramatically decreasing the total calories that people have but simply converting them from higher- to lower-glycemic-index food, and hopefully eliminating carbs progressively over time.
Adherence rates tend to be quite high, even in populations that we know are otherwise resistant to lifestyle intervention effects, including people who don’t have easy access to whole, intact foods.
I think the reason why the low-carb diet works better is that people will simply do it, whereas with most other sorts of interventions—very low calorie diets, dramatic reduction in fat, exercise interventions—people just don’t adhere over time.
Does the gluten-free or paleo diet work through mechanisms that are independent of the effect of low-carbohydrate diets?
Probably no. If people want to go to one of those diets, as long as they’re reducing carbs and as long as they’ll do the diet, then it doesn’t make any difference. I certainly don’t think that there are any strong data that suggest there are anything different or special about those diets. They work by converting the patient from higher carbs to lower carbs.
If patients come in and say “I want to do the paleo diet,” I say “Fine. As long as you adhere to the diet it doesn’t make any difference. At the end of the day, I want you to have something that’s going to reduce total carbohydrates.”
Do those diets have any harmful effects?
As far as I’m aware, no. People are often confused about the health benefits of reducing gluten though. A lot of folks will attempt to explain the health benefits by focusing on the gluten itself, but the problem is that gluten is tied to wheat and comes along with a lot of carbohydrates. By eliminating gluten, you eliminate carbohydrate intake.
Any tips for negotiating with patients in terms of reducing carbs?
It’s really about doing exchanges. It’s getting people to set up a hierarchy with me and figure out one thing they’re able to do, similar to the approach we take with phobias. You have a behavioral hierarchy and you start from the least and go to the greatest.
I try to get an agreement from the patient to eliminate anything, because that makes a difference. As soon as we get a toehold, we start getting benefits, and patients more willing to take the next step.
Sugared soft drinks seem to be the easiest thing for patients to tackle first. People can go from sugared soft drinks to artificially sweetened soft drinks, which I don’t prefer them to have. Nonetheless, at the end of the day if I can get them to drop that down they’re going to start feeling better and we’ll tend to get improvements after that. Everyone has their thing they’re not willing to give up, but that doesn’t matter. We’ll just choose something else on the list.
SAN DIEGO—Richard Shelton, MD, explained the science behind the obesity/depression connection and offered practical tips for changing patients' diets. After his presentation, he took the time to answer a few questions.
If you could have everyone in the audience do one thing differently when they get back to their clinical practice, what would that be?
It would be to go to their patients and ask them to reduce one high-glycemic-index food. You can build progressively from there, but you’ve got to start somewhere. Trying to get rid of all the carbohydrates at once just doesn’t work that well for people, but progressively doing it over time really helps.
I create a hierarchy with patients from the most problematic to the least problematic high-glycemic-index food and start focusing on the highest one on that list and start working up.
Do clinicians have any misconceptions about the relationship between obesity and depression that you’d want to correct?
I think the most common misconception is that the treatments are causing most of the problem. For example, people have the idea that antidepressant medications are causing the majority of weight gain over time.
I think the evidence indicates that depression itself is driving most of the weight gain as time goes by, and it’s one of the reasons you can see a wide range of antidepressant medications being used and progressively over time you’ll still get the weight gain issue. Even bupropion, which itself seems to be weight neutral, unfortunately does not cause weight loss. Therefore, you will eventually have patients catching up and continuing to gain weight.
Is a low carbohydrate diet a better strategy than exercise?
Adherence to the low-carb diet is much higher. We go from not dramatically decreasing the total calories that people have but simply converting them from higher- to lower-glycemic-index food, and hopefully eliminating carbs progressively over time.
Adherence rates tend to be quite high, even in populations that we know are otherwise resistant to lifestyle intervention effects, including people who don’t have easy access to whole, intact foods.
I think the reason why the low-carb diet works better is that people will simply do it, whereas with most other sorts of interventions—very low calorie diets, dramatic reduction in fat, exercise interventions—people just don’t adhere over time.
Does the gluten-free or paleo diet work through mechanisms that are independent of the effect of low-carbohydrate diets?
Probably no. If people want to go to one of those diets, as long as they’re reducing carbs and as long as they’ll do the diet, then it doesn’t make any difference. I certainly don’t think that there are any strong data that suggest there are anything different or special about those diets. They work by converting the patient from higher carbs to lower carbs.
If patients come in and say “I want to do the paleo diet,” I say “Fine. As long as you adhere to the diet it doesn’t make any difference. At the end of the day, I want you to have something that’s going to reduce total carbohydrates.”
Do those diets have any harmful effects?
As far as I’m aware, no. People are often confused about the health benefits of reducing gluten though. A lot of folks will attempt to explain the health benefits by focusing on the gluten itself, but the problem is that gluten is tied to wheat and comes along with a lot of carbohydrates. By eliminating gluten, you eliminate carbohydrate intake.
Any tips for negotiating with patients in terms of reducing carbs?
It’s really about doing exchanges. It’s getting people to set up a hierarchy with me and figure out one thing they’re able to do, similar to the approach we take with phobias. You have a behavioral hierarchy and you start from the least and go to the greatest.
I try to get an agreement from the patient to eliminate anything, because that makes a difference. As soon as we get a toehold, we start getting benefits, and patients more willing to take the next step.
Sugared soft drinks seem to be the easiest thing for patients to tackle first. People can go from sugared soft drinks to artificially sweetened soft drinks, which I don’t prefer them to have. Nonetheless, at the end of the day if I can get them to drop that down they’re going to start feeling better and we’ll tend to get improvements after that. Everyone has their thing they’re not willing to give up, but that doesn’t matter. We’ll just choose something else on the list.