Psychiatrist treating obesity?

[clozareal]

Given that some of the antiobesity medications (Contrave, stimulants, even phentermine-topiramate) as well as nonpharmacological options such as therapy (lifestyle modification, behavioral activation, motivational interviewing) are within the scope of practice for psychiatry, I was wondering how common it is for psychiatrists to be treating obesity outside of antipsychotic-induced weight gain?

There are many more medications that we may not use (orlistat, GLP-1 agonists although this is being studied more in antipsychotic-induced weight gain) in addition to other approaches (surgery although I've done several psychiatric evaluations for bariatric surgery), but those who work with this population more may be more comfortable with these other treatment options. I'm wondering because this is highly prevalent in the US but I'm not sure what the market looks like and if there is a large number of patients seeking out these services.

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[ObsequiousAplomb]

Yes it's common, ABOM just requires 60 hours of CME to get the certification. It's frequently a cash practice thing, from what I've seen, since insurances are often reluctant to cover treatments for weight loss. Good thing phentermine is cheap.

 

[smalltownpsych]

The psych NP I work with was talking about treating a patient with binge eating disorder just today. That’s in a simlar ballpark, I think. However, when she told me it was for a 500 pound patient and it was an online case and the client wasn’t following through on other treatment recommendations, I advised her not to attempt to treat and refer out. She was talking about stimulants to treat the BED. Not an area of treatment I have much experience in nor does she so in my mind probably better to let someone with more expertise provide the care. As I think it through while writing this, I completely think weight and food issues can be in our wheelhouse and there is a lot of overlap with other aspects of mental health like depression, but when it is more of the primary condition and a certain threshold of severity, it would be better to have someone who specializes in that area. Maybe, I should change my handle since I’m not in the small town anymore and there are actually options for these referrals. 😊

 

[VA Hopeful Dr]

Yes it's common, ABOM just requires 60 hours of CME to get the certification. It's frequently a cash practice thing, from what I've seen, since insurances are often reluctant to cover treatments for weight loss. Good thing phentermine is cheap.

It would be a better thing if it actually worked.

 

[ObsequiousAplomb]

It would be a better thing if it actually worked.

Agreed.

 

[deleted1100659]

medications really doesnt work well for weight loss. Even though vyvanse is FDA approved for BED, the apettite suppression isnt as strong as time passes. Also towards the end of the day, people tend have binge episodes as the medication effect is lower. Most patients I have on it may have initial weight loss than eventually stabilizes.

I often given advise about myfitnesspal and will go over what the patient is eating.

Often use metformin at times as well in antipsychotics.

Have transitioned some people to lybalvi as well.

I think the best thing we can do is education and encourage long term changes

 

[Sushirolls]

Obesity medicine might be some new fellowship out there.
Seems to be the flavor of the month.
I think it takes any specialty that wants in.
I've seen non-psych folks do it and attempt to focus on it +/- but is a cash market.
Tight competition and the folks I've run into lack the solid psychological piece.
I'm not to optimistic about this. The lack of therapy the other folks integrate and the lack of interest by Psychiatrists. And ultimately the lack of engagement for behavioral change by patients. Obesity isn't going anywhere anytime soon.

 

[nexus73]

I think it makes sense for psychiatry to do this, especially given our experience managing several of the commonly used medications (bupropion, topiramate, naltrexone, stimulants though less likely phentermine). Metformin is probably the outlier, but many psychiatrists do start this with antipsychotics like Zyprexa to mitigate weight gain. Getting trained/CME for use of GLP-1 agonists is not rocket science. I think it at least makes sense for the patients we're already treating for other mental health conditions who are obese.

I also think psychiatry not getting training in the pain management realm is unfortunate given the psychological underpinnings with many chronic pain conditions.

 

[deleted1100659]

I like metformin quite a bit because most of my patients are on SGAs and most are pretty high risk for diabetes, and it doesnt cause hypoglycemia so hard to go wrong there.

I see a ton of topamax used, i personally dont think it works that great but im sure others may have a diff experience with it.

Stimulants for weight loss never work good in the long term.

In my population, treating pain seems like a potential nightmare, lol. That is one rabbit hole I dont want to go down.

This is such a complex issue though. Nutrition education needs a significant overhaul. I think EBT (food stamps) is a broken program as well. I know a good deal about WIC and EBT, if EBT transitioned to more of a WIC structure that would be highly beneficial. There are so many widely available junk foods here/fast food with high calories its so easy for people to eat over their daily limit. I have people tell me they cant afford to eat healthy foods, so sometimes ill discuss that with them, often I find that if they're a smoker/drinker they're spending sometimes nearly 20 dollars a day on cigarettes/alcohol which is $140 a week. I often do the math in front of them, and show them the yearly cost of it. A lot of them are actually surprised to see the numbers, and they end up reducing intake or are open for medications/treatment for cravings. A little motivational interviewing I suppose.

I believe the first step to treating obesity is raising awareness to the calorie content of foods. Ill have my patients download myfitnesspal to keep a food diary, because often they have no idea that mayo for example, can add >200 calories to a sandwich. Raising insight/awareness is always a great first approach. Obviously this doesn't work in some of my more higher acuity patients, but in many others its a good start.

 

[smalltownpsych]

I like metformin quite a bit because most of my patients are on SGAs and most are pretty high risk for diabetes, and it doesnt cause hypoglycemia so hard to go wrong there.

I see a ton of topamax used, i personally dont think it works that great but im sure others may have a diff experience with it.

Stimulants for weight loss never work good in the long term.

In my population, treating pain seems like a potential nightmare, lol. That is one rabbit hole I dont want to go down.

This is such a complex issue though. Nutrition education needs a significant overhaul. I think EBT (food stamps) is a broken program as well. I know a good deal about WIC and EBT, if EBT transitioned to more of a WIC structure that would be highly beneficial. There are so many widely available junk foods here/fast food with high calories its so easy for people to eat over their daily limit. I have people tell me they cant afford to eat healthy foods, so sometimes ill discuss that with them, often I find that if they're a smoker/drinker they're spending sometimes nearly 20 dollars a day on cigarettes/alcohol which is $140 a week. I often do the math in front of them, and show them the yearly cost of it. A lot of them are actually surprised to see the numbers, and they end up reducing intake or are open for medications/treatment for cravings. A little motivational interviewing I suppose.

I believe the first step to treating obesity is raising awareness to the calorie content of foods. Ill have my patients download myfitnesspal to keep a food diary, because often they have no idea that mayo for example, can add >200 calories to a sandwich. Raising insight/awareness is always a great first approach. Obviously this doesn't work in some of my more higher acuity patients, but in many others its a good start.

At the last program I worked, we had a significant focus on health and nutrition as part of our integrative holistic model of care for patients with severe mental illness with psychiatrist, psychologist, nutritionists, fitness program etc. With all of this in place, the patients would lose weight and improve in the highly structured portion of the program, but as we reintegrated them, the gains would reverse. This was the source of my employer's greatest frustrations as a psychiatrist. We had a model of care that was highly effective for treating severe mental illness, improving function, preventing hospitalizations, developing independent living, even maintaining sobriey and engagement in 12 step recovery, but couldn't counteract the weight gain. The times he would use the I'm an MD were always tied to this issue and his inability to treat effectively and the fact that our patients were going to have a decreased life expectancy.

 

[clozareal]

Great discussion everyone. Lots of valid points. I wasn't aware of ABOM certification. The antiobesity meds seem to reduce weight over placebo in the meta-analyses that I've seen (somewhere between 6-20 lbs on average, not much but something). I forgot about binge eating disorder when I made this post but I am treating it with Vyvanse or other stimulants for several of my patients with some reduction in weight although many of them have comorbid ADHD and the appetite suppression attenuates for many but not all of my patients.

Also, it's one thing to treat BMI of 30-35, and another to treat those with a BMI >45 or with many comorbidities (diabetes, hypertension, hyperlipidemia, sleep apnea), with similar parallels to those who have severe schizphrenia with frequent hospitalizations vs more mild schizophrenia where people can still work and interact with others decently well with no hospitalizations. I worked with an endocrinology surgeon who said that everyone who has a BMI>40 should be evaluated for bariatric surgery.

In addition to nutrition and caloric intake education (I really like MyFitnessPal, but it can encourage eating things with bar codes since it's easier to track), maybe referring to a nutritionist, encouraging other lifestyle modification such as exercise and maybe even recommending they get a personal trainer, I'm wondering about psychotherapies outside of motivational interviewing for issues that come up with obesity such as self esteem, cognitive distortions on their relationship with food, and if there are any therapy manuals for this that show efficacy?

 

[deleted1100659]

With all of this in place, the patients would lose weight and improve in the highly structured portion of the program, but as we reintegrated them, the gains would reverse.

That reminds me of the TV show, Biggest Loser. If i remember correctly, didnt that happen with most contestants?

I think Obesity is such a hard thing to beat, because once they go shopping for a meal they pass 15 fast food restaurants, can order fast food on their phone, and when they go into a grocery store they're surrounded by snacks high in sugar. Exercise in itself produces very little weight reduction, normally people consume more calories after the exercise than they burned, but it does have a lot of health benefits.

The 64 million dollar question is how do you get people to consistently eat healthy, whereas unlike smoking/alcohol, food is a basic requirement and convience/taste are often seductive factors that influence someone's diet. For highly motivated/intelligent people its doable, but for people with serious mental illness, it is quite difficult.

 

[clozareal]

The 64 million dollar question is how do you get people to consistently eat healthy, whereas unlike smoking/alcohol, food is a basic requirement and convience/taste are often seductive factors that influence someone's diet. For highly motivated/intelligent people its doable, but for people with serious mental illness, it is quite difficult.

You'll probably have to change the built environment for this since individual changes are often ineffective or not long lasting. Lots of interesting experiments such as the fat tax.

 

[VA Hopeful Dr]

Great discussion everyone. Lots of valid points. I wasn't aware of ABOM certification. The antiobesity meds seem to reduce weight over placebo in the meta-analyses that I've seen (somewhere between 6-20 lbs on average, not much but something). I forgot about binge eating disorder when I made this post but I am treating it with Vyvanse or other stimulants for several of my patients with some reduction in weight although many of them have comorbid ADHD and the appetite suppression attenuates for many but not all of my patients.

Also, it's one thing to treat BMI of 30-35, and another to treat those with a BMI >45 or with many comorbidities (diabetes, hypertension, hyperlipidemia, sleep apnea), with similar parallels to those who have severe schizphrenia with frequent hospitalizations vs more mild schizophrenia where people can still work and interact with others decently well with no hospitalizations. I worked with an endocrinology surgeon who said that everyone who has a BMI>40 should be evaluated for bariatric surgery.

In addition to nutrition and caloric intake education (I really like MyFitnessPal, but it can encourage eating things with bar codes since it's easier to track), maybe referring to a nutritionist, encouraging other lifestyle modification such as exercise and maybe even recommending they get a personal trainer, I'm wondering about psychotherapies outside of motivational interviewing for issues that come up with obesity such as self esteem, cognitive distortions on their relationship with food, and if there are any therapy manuals for this that show efficacy?

BMIs that high aren't likely to get much benefit out of anything except bariatric surgery.

 

[Stagg737]

Even though vyvanse is FDA approved for BED, the apettite suppression isnt as strong as time passes. Also towards the end of the day, people tend have binge episodes as the medication effect is lower. Most patients I have on it may have initial weight loss than eventually stabilizes.

I do see Vyvanse used for BED frequently and the bolded is always a concern of mind. We're all aware of the rebound hunger that occurs in kids on stimulants who don't eat much all day, and I've had a couple of BED patients express the same with bingeing at night getting worse with stimulants.

For highly motivated/intelligent people its doable, but for people with serious mental illness, it is quite difficult.

True, I've had some decent success with some patients in our clinic, but those with SMI/SPMI or intellectual disability just can't lose the weight once they put it on.

 

[smalltownpsych]

True, I've had some decent success with some patients in our clinic, but those with SMI/SPMI or intellectual disability just can't lose the weight once they put it on.

They can if they get the right support. It is just hard to provide as most people just try to tell them what they need to do as opposed to actually getting alongside them and using a relationship to help them learn new behaviors and skills. Eating is a social activity for humans and is at the heart of many of our connections and societal structures That our patients are often disconnected from. When we enlist the power of that dynamic, change can happen. Not saying that is our role as psychiatrists or psychologists, but we do need to understand what is not working in our system and why.

 

[Merovinge]

For highly motivated/intelligent people its doable, but for people with serious mental illness, it is quite difficult.

I am moderately motivated, fairly intelligent I hope, and have failed to get off 5-8 pounds to get my BMI into normal weight since I gained it in medical school a decade ago. I work w/ EDs and thus RDs on a daily basis, know calories for almost every food, have a healthy relationship with food, don't binge eat ever, and have significantly reduced my alcohol intake over this time.

All this just to say that behavioral change and weight loss is really tricky for the majority of the population, particularly with demands of jobs, parenthood/spousehood, and availability/time for truly healthy meals. I can't imagine what it's like for someone with any financial worries to consider on top of it.

 

[deleted1100659]

I am moderately motivated, fairly intelligent I hope, and have failed to get off 5-8 pounds to get my BMI into normal weight since I gained it in medical school a decade ago. I work w/ EDs and thus RDs on a daily basis, know calories for almost every food, have a healthy relationship with food, don't binge eat ever, and have significantly reduced my alcohol intake over this time.

All this just to say that behavioral change and weight loss is really tricky for the majority of the population, particularly with demands of jobs, parenthood/spousehood, and availability/time for truly healthy meals. I can't imagine what it's like for someone with any financial worries to consider on top of it.

Well, a good deal of it is genetic, and as you age it becomes significantly harder to lose weight. BMI is a flawed system in general, most people would not fall in the normal range. Body fat percent would be a more accurate measure and waist circumference among other things.

My SO is an RD though, and sometimes ill pick her brain. My weight itself has been like a rollercoaster, weightlifter during college, gained a lot of fat in med school then burned it all off in residency and at one became super skinny, and now a fairly healthy weight. So yeah, time can be a limiting factor for sure. Ive tried a variety of meal services and have now found any premade healthy meals that had good flavor. Im a bit of a chef myself, I need to really invent a healthy premade meal delivery service that actually tastes good. I would be rich, lol

 

[Merovinge]

Im a bit of a chef myself, I need to really invent a healthy premade meal delivery service that actually tastes good. I would be rich, lol

So many companies have tried and failed to do this. The logistics + cost are so difficult with fresh meals which is where the healthy + taste good combination would come from. Scaling huge quantities of healthy + taste good also seems to elude human society. We need to be able to teach robots to cook but that feels like several years out still.

 

[littlefred]

Too add to this conversation, there might be a special niche for psychiatrists in treating patients that are overweight/obese.
In particular I find it very interesting that a medication combination that we commonly prescribe now has FDA indication for the treatment of obesity (Contrave).