Hormonal & Psychological Management of Stress in Obesity Treatment

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Hi, everyone, thank you very much for joining. I'll just get started in the interest of time and I'll go through the house rules and then I'll hand over to our speakers. So welcome.

As I said, this is the first EASLcom's network webinar of 2024. My name is Lisa and on behalf of the European Association for the Study of Obesity, I'd like to welcome you to today's session. So today's session is going to focus on hormonal and psychological management of stress in obesity treatment.

And our session chair today will be Dr. Andrea Curin, who is the co-chair of the Obesity Management Working Group of EASL. So today's webinar is being recorded and the webinar recording and relevant links and resources will be available after the event. To remind everyone, the EASLcom's webinars are free to attend.

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So it'd be great to hear what kind of themes you would like to see. That's it for me. For now, I'm going to hand over to our session chair, Andrea Curin, but thanks again for joining today's webinar.

Thank you. Thank you very much, Lisa, for this introduction, and I would like to welcome you, everyone, and wish you actually a happy new year. We are still in January, so this is the first webinar of the year.

And I think that the topic is very, very interesting. Hormonal and psychological management of stress in obesity treatment. And I think it's interesting not from the perspective of obesity, but for all of us, maybe we can take notes and some good tips of the management of stress now that we are starting a new year with a lot of activities.

We have here today two excellent speakers that will give us an overview of hormones and stress related to obesity from two different perspectives. One more biological and medical that will be presented in about 20 minutes by Professor Elisabeth van Rossum. She's a professor in the field of obesity and stress hormones.

She's an internist endocrinologist and works at Erasmus University Medical Center in Rotterdam, Netherlands. And she will speak about stress, glucocorticoids and obesity. And then we'll have about another 20 minutes of talk given by Professor Andrew Hill, which is professor of medical psychology at the University of Leeds in UK about stress management from a psychological perspective.

So welcome you all. And Professor van Rossum, the floor is yours. Well, thank you so much for this great introduction and for the invitation to talk here.

I will start with sharing my slides. I would love to hear whether they are visible for every one of you. Right now.

Yes. Yes. Thank you so much.

Thank you. Yeah, indeed. I'm very happy to see there's so many attendants right now for this topic.

And I will indeed address the first part with more biological perspective. What is stress doing to your body? What is stress and how does it relate to obesity? And next, Andrew will take you through the stress management and a more psychological perspective. First, my disclosures.

I'm a speaker at many congresses, also on the topic of obesity, sometimes about stress or the combination. And I do also have some board functions as for the Partnership Overweight Netherlands. So we give advice to the Ministry of Health in the Netherlands.

I chaired the Dutch Guideline on Obesity for Adults. And I co-authored a book about but it's not only stress and obesity is more general as obesity as a endocrine organ, but also stress is involved there. And I'm leading the domain of obesity and diabetes for the European Society of Endocrinology.

I don't have any commercial interest here. So let's get into stress. Like many people, if you would ask to be jumping out of a plane to make a parachute jump, skydiving, then this will definitely generate an acute mental stress reaction, which is very good sometimes because you can think faster and it prepares the body, which can be very beneficial.

For example, if you have acute stress to run a 100 metre finals and you need high blood pressure and good energy for your muscles. So it can be very functional. So what happens in the body when there is stress? Well, we know that there is a hypothalamus pituitary adrenal axis and in the hypothalamus, CRH can be produced, the corticotropin releasing hormone, and that stimulates the pituitary to produce ACTH, and that stimulates in its turn the adrenals to produce cortisol.

Now, cortisol is one of the stress hormones that is always present in the body, but in stress, it's more elevated. And we know that cortisol can prepare the body for acute danger. And at that point, it's very helpful.

For example, if you do an exam or like this 100 metre finals, you mobilise energy, glucose and also you have a better memory, so it's really suitable. But at the same time, many processes are shut down or suppressed, like the immune function or reproduction or growth. So it really prepares for acute danger.

But sometimes you can have chronic stress and that can be mental, like work life balance is not not OK, or there are many mental stressors in the environment or noise or whatever, but also physical stressors like somatic disease or chronic pain. Chronic pain also stimulates the HPA axis to be hyperactivated. Or, for example, night shift.

If you change your biological clock, your day night rhythm, that also can affect your stress hormone system. And what happens if you have chronic stress? Well, then you have also chronic mobilisation of energy like elevated glucose and cholesterol, but also your blood pressure will be high chronically. It affects the bones, the menstrual cycle is affected.

Your mood can be affected. For example, depression can be induced. But also you can have an increase of your abdominal fat mass and a decrease of muscle mass.

Now, talking about fat mass, it's important to realise that this fat mass, that is an endocrine organ, has an important role in the production of many fat hormones and also very important for the immune system. Too little fat is not good, but too much fat, we all know, that's also not healthy. And why? Because then all these hormones which are being produced, the Oedipal kinds in the fat mass, which normally really very well communicate to the brain and also to other organs, they get in a state of disturbance of hormones, but also in a pro-inflammatory state, a low, low grade inflammatory state.

And that is not a disease only by itself, but it is also a gateway disease to many other diseases. And we all know the cardiovascular diseases and type 2 diabetes, but also 13 forms of cancer, also mechanical problems, which is also due partly to the inflammation like osteoarthritis. But importantly, also at the level of the amygdala, for example, these disturbances in insulin and leptin, but also it is chronic inflammation, can affect your mood at the amygdala level and other brain areas.

So that can also lead to depression and anxiety, which are obesity related diseases. Now, it's important to realize that within your fat mass, there is an enzyme, the 11-hydroxysteroid dihydrogenase type 1, HSD1, can activate the inactive pro-hormone cortisone to the active cortisol. So actually, if you have a lot of fat mass, you can better produce locally also your cortisol levels.

And in this context, I will show you in this talk today that stress and obesity are very much interconnected and that there is a whole vicious circle on obesity, chronic stress and the increased action of glucocorticoids. Now, we know chronic stress, I will show you later, how it can lead to obesity, but also obesity can lead to chronic stress, like the stigma of obesity, but also by increased production of cortisol in the body. And we also know that obesity can lead to increased action of corticosteroids.

Like I, for example, just showed that you have increased cortisol production and it occurs in quite some proportion of the people with obesity. But also this increased action of glucocorticoids can also increase obesity. Now, how is that related? I will show you how these connections are established.

Well, first of all, this relationship, stress, but like dessert, is not a coincidence. This is really a biological finding, because what will happen if you have chronic stress, physical or mental stress, as I showed you, is increasing your cortisol. At first, in the first minutes, you also have increased adrenaline and other things.

It's much too simplified to say it's only cortisol, but I will focus today on cortisol. And we know that cortisol can increase your abdominal fat mass by increasing your central fat mass and decreasing your peripheral fat through different mechanisms and redistribution of your fat mass. And at the same time, it also induces extra appetite and in particular your appetite in high caloric food.

So when you are stressed, you may much more prefer a donut or a bar of chocolate rather than the healthy salad, although you know it's so healthy. And if you eat this high caloric foods, in particular when it's very sugar rich, for example, it can even further increase your cortisol. There are even some indications that in animals, for example, that if you eat this high caloric food when you're stressed, that it's more even affecting your weight in a negative way.

So this is a large connection between cortisol and appetite. And very recent findings by our PhD candidate, Suzanne Kukuk, she found that there's also for the long term, the stress hormone levels are associated with increased food cravings. And you see here a trend for hair cortisol.

I'll come back to the measurement later. We see a slight trend, but in particular for the long term, cortisone as measured in hair, we saw a significant increase with more food craving, the higher your hair cortisone is. Now, if we look back to obesity, we know there are many causes of obesity.

And of course, lifestyle is one of the major causes, unhealthy eating, too little exercise, but it's only part of the story. There are many other causes like intoxications, but also mental causes. And Andrew will come to that later.

And medication can have also weight inducing side effects. There are hormonal causes and also some more rare causes like hypothalamic or genetic obesity. Well, it's sometimes time consuming to disentangle which causes that is playing a role in your patient, because it's most of the time necessary also to have to get the proper treatment to determine the treatment.

And we are currently in the Netherlands. We have a Dutch site for to check cause obesity. It's the way of the Dutch side, which is already launched.

But we are well in the near future. We also launched an English version and other languages where people can people living with obesity can fill out their own sites and symptoms in a questionnaire and algorithm calculate what might be one of your causes and discuss it with your health care provider. But interestingly, if you look at this table, that many of these factors are related somehow to either stress or to high cortisol or increased glucocorticoid exposure.

And in the lifestyle, we know that, for example, chronic lack of sleep, sleep apnea syndrome, shift work can all increase your cortisol levels. Also, intoxications can can increase it. Of course, mental causes can increase cortisol levels, which will be increased.

Also in the third category medication, we know that, for example, pain is increasing cortisol, but also there are many people using from exogenous sources, corticosteroids, for example, for for asthma or for joint complaints, or there are many reasons to to use it. And it's actually artificial stress. And then you have hormonal factors which can raise your cortisol.

And one of the things people screen a lot on, but it's very, very rare, is, for example, Cushing's disease or Cushing's syndrome. And then you have a tumor either in the adrenal or in the pituitary, leading at the end to increased chronic, chronically increased cortisol levels. So looking at this schedule, we see that increased action of corticosteroids can lead to chronic stress, but also to obesity.

And you would say, actually, maybe it's not so it's quite simple. Just measure cortisol. Then you have a good stress measure, right? Well, that is that that is actually too simple.

Why? We know that cortisol is a stressful one, but it's everyday present in the body and it has a very strong diurnal rhythm high in the morning, lowering during the day. But it's also very variable from day to day, but also within the day. There's a pulsatile secretion and it's a stress hormone.

So if you draw blood in a person, you can elevate, easily elevate to the cortisol levels. So just drawing blood to determine stress levels by cortisol is not so easy. But in the past decades, a new method has been developed because we know that cortisol is also built in, incorporated in hair through the bloodstream.

It's incorporated in the hair and every hair is growing about one centimeter a month. And there you can buy every centimeter can provide a long term measure of your cortisol levels. It's not so hard.

I mean, it's non-invasive. You just cut a sample of hair. You can extract the cortisol from it and either measured by an ELISA or an LCMS.

And the other method is the most commonly used right now. And if you compare, we see that if you, for example, measure cortisol in serum or saliva, you have only an impression of seconds to minutes. So for acute stress, it might be relevant, although it's very, very variable as you see.

If you take urine samples, you can measure for hours or maybe days. So you have a larger window. You can see, you can assess the cortisol exposure.

But when you compare to hair with one haircut, you can look back for one month or a couple of months or depending on the hair, even for years. How is the average stress hormone level in hair? Now, if you look at Cushing's syndrome, we know there's a lot of cortisol present in the body. And interestingly, we know and I see these patients also in my clinic.

Well, they all develop metabolic syndrome, including the abdominal obesity, but also about 80 percent is developing depressive symptoms. So it's also affecting our mood. So we know cortisol can induce obesity and depression when it's pathologically elevated.

But what about the normal population? Is that because this is very rare and this hair cortisol measurement provided us the opportunity to study that in the normal population. And we compared or in 10 years ago, how people with normal weight, their long term cortisol levels were as measured in hair. They were rather normal.

And when you look in people living with obesity, we saw in average severely elevated cortisol levels. Not all of them, interestingly, about half of them had elevated and the other half had normal levels. So there's also high variation.

And these were adults. But interestingly, we also found at the age of six years old that even children who had the highest cortisol levels, the highest quintile of cortisol levels, they had about tenfold increased risk of the presence of obesity. Now, this was all cross-sectional and this was one study long term ago.

But more recently, we did a systematic review and in many studies, more than 30,000 individuals. And again, we found a correlation between higher hair cortisol associated with higher BMI. And more interesting, actually, the cortisol levels were particularly associated with an increased waist circumference.

And the waist is exactly what you would expect from high stress hormone levels. And interestingly, also, these hair cortisol levels recently, we showed that also not only in cross-sectional analysis, they are correlated, but also over time, there are increases. If you have high cortisol baseline, there are increases in BMI and waist over time.

And we know we are always afraid if you have obesity, do you develop cardiovascular disease? Well, actually, what we found with these cortisol levels, these stress levels, indeed, they were associated with cardiovascular disease. And actually, we reached the world press with this message, although I must say this was only a cross-sectional study. And this was the original study more than 10 years ago when we showed that the highest in the elderly population, that the people with the highest cortisol levels, they had 2.5 increased risk of having cardiovascular disease.

And this was cross-sectional. And now we did a new study on that also high cortisol is over time. When we followed up a large cohort, about five to seven years, we followed them in time.

And the people who had a baseline is particularly high cortisol levels. They also have a higher chance of incident cardiovascular disease. And in particular for the young population, the younger ones, you had an odds ratio of 3.7. And on average for the whole group, the odds ratio of or developing cardiovascular disease was 2.2. So what you see here is now, nowadays, as a doctor, you've often if people have obesity, you look for risk factors for, for example, cardiovascular disease.

And we check cholesterol and diabetes and smoking. We never check stress because it's so hard to measure. But this hair cortisol is one of the ways to measure long term stress.

And actually, in a cross-sectional study, we found also that the increased risk on cardiovascular disease is similar to smoking or type 2 diabetes if you measure stress in hair. Now, the way stress can affect the system is very variable between persons. And we know that cortisol needs a receptor to exert its effects.

And in every cell of the body, in the brain and the whole body, there's a glucocorticoid receptor and cortisol binds to the receptor. It's an essential step to have an effort to exert an effect. And after dissociation of a whole protein complex, it moves to the nucleus of the cell.

And there you have different ways of acting. It can either bind to the DNA and it stimulates all kinds of metabolic and hormonal effects. But it can also, through direct protein-protein interaction, go to other DNA of other genes and thereby also, for example, inhibit transcription.

And that mechanism is very important for the anti-inflammatory effects, for example. We now have developed with Robin Langton and Anant Iyer and also Jordi Renes, we're working on a bioassay. And this is very well measuring how sensitive is an individual for their own stress hormone cortisol.

So you can imagine if you're more sensitive, then the effects are greater than where you're resistant. And you can measure the sensitivity on different levels, for example, with a bioassay. And another way to know whether a person is sensitive or not is looking at the genes, because we know there's a genetic variance in the glucocorticoid receptor.

What we found is that some make, are associated with a more hypersensitive and hypersensitivity of the receptor. So we found associations with, for example, more fat mass, less lean mass and a higher risk of type 2 diabetes, but also higher risk of depression. So distress related disease.

And at the other side, there are also sort of gene variants which are related with maybe more protective effects. They are, they have decreased action of glucocorticoids. And what we found in young men that they have, on average, more muscle mass.

They were also stronger. They were taller. And also in women, we found, so there was sex differential effects.

In women, we found smaller waist circumferences. I depicted here with a Barbie in purpose, but just smaller waist. So the opposite of too much cortisol.

So some people might be a little bit protected with metabolic side effects. And we have to see maybe some of these people are more or less vulnerable also to develop stress related diseases, but also to obesity. Maybe also one very other way.

I want to share one very new other way to look at stress. And that is more like artificial stress, which is very common in the population right now. So this is a case, Mrs. B. And she was referred to my outpatient clinic because she had obesity.

And there was a question that she has a hormonal cause of obesity. And this was her history. And as you can see, like I often see, there's a whole list of obesity related comorbidities like asthma, sleep apnea syndrome, joint complaints.

But she had obesity and it increased in the past years. She couldn't exercise anymore because she had a scooter accident. She was in a. So she couldn't walk anymore.

This was her list of medication. And because she had indeed some symptoms of Cushing's disease, some muscle atrophy, some buffalo hump, she had also diabetes de novo. I also checked her urine and saliva cortisol and a dex suppression test.

And they were all normal. So there was no Cushing's disease or Cushing's syndrome. But if you look at her medication, it struck me that so many medications she was using had a weight inducing side effect and or a potential weight inducing side effect.

And many of these medications were also related, contained corticosteroids. And if you ask her, there was also a time relation with using of this medic, use of this medication. So I started to, together with her and her symptoms, I started to taper down this medication.

And actually, first, her diagnosis was not a Cushing's, but her diagnosis was actually the normal multifactorial obesity was type 2 diabetes with weight gain through medication and a lack of exercise. And she told me that this was her daily breakfast. So she had so many medications and she also wanted to get rid of it.

So I referred her to a lifestyle intervention. We are lucky to have that in the Netherlands, reimbursed from the basic insurance and at the same time tapered down her medication. And after we did this, this was she presented in July of 2023.

And this was in December 23, a couple of months later that she said, well, I'm feeling better again. I can walk again. I really have an improved quality of life.

And she told me her big dream was to to go cycle again. And she bought a bike like everyone in the Netherlands is having a bike. And two weeks ago, she sent me this picture that she could bike again.

And this was just by tapering off most of the corticosteroid medication and and replacing it by a healthy lifestyle. Now, corticosteroids are very common in the normal population. Many people use it, not only on pills, who everybody knows, but also inhalation spray, nose spray injections.

And in normal population, about 10 of percent is using it. And people with obesity have found that more than twice are using any type of corticoids. And when we looked in large population based studies, so these are associations, there's no causality, of course.

But we found association with more corticosteroid use and increased BMI. And interestingly, also an increased waist circumference. And in women, also all components of the metabolic syndrome.

But also we found that in also large epidemiological studies in the Lifeline cohort, that this nose spray, for example, was associated with anxiety disorders and the inhalation medication with corticosteroids and the oral versions were related to depression and anxiety and decreased cognitive functioning. So now this brings us to the end to look at the Fisher circle. Then now you can see that all the lines are there.

So the chronic stress can induce obesity, but obesity can also induce chronic stress. And they are both also very much interrelated. How at the tissue level is a person sensitive to their own cortisol? How is a person exposed to exogenous cortisol or to stress or environmental or psychological or physiological stress, which we heard a lot more about in the next talk and also how to address it? We know in general that if you decrease your weight, that also cortisol levels can decrease because also inflammation is going lower.

So I want to get to my conclusions that stress can be either mental or physical. And also next to many other stress hormones, cortisol is one of the main drivers of the stress effects, especially also the chronic stress effects. And we know it can lead to obesity, but it's much more complicated.

The relation stress and obesity is very much bi-directional. And what we've showed today is that long term cortisol and which can be measured in hair. It's associated with prevalent and incident obesity and cardiovascular diseases.

It can also induce changes in appetite and food cravings. And the sensitivity of a person is very much individually determined. It can be variable.

The genes play a role. And it also makes some people more sensitive to stress and develop obesity from it than others. You can nowadays measure it.

It's rather complicated, though. But there are some ways to to to measure that right now. And don't forget the artificial stress from a pill, from injection, from an inhalation puffs or which can also be a driver of obesity.

Because then the needs in some case to be established. But there are more and more indications that there are some causal relationships as well next to the associations you found in the large studies. And also it cannot only it's not only associated with obesity, but also with stress related outcomes like depression and anxiety.

So these are my conclusions. I want to thank also my research group who did a lot of work in glucocorticoid and or stress and or obesity research. There are many people involved.

So I really like to thank them very much. And if you are more interested in the whole topic of obesity, about fat as an organ, how the biological clock works, but also about this whole chapter about relations, stress and obesity. You're very much welcome to read this book, which is now in many languages available.

It's also for our health care professionals, but also for interested people. I read together with my colleague Mariette Bone. So thank you so much for your interest.

I like to hand over the words to the next speaker. Thank you very much for this excellent presentation on a clinical and mechanistic perspective of the stress hormones. Let's move to the next session.

Professor Hill, the floor is yours. We'll take the questions in the end of the webinar. Thank you.

I clearly can't talk while I'm loading up my slides, but hopefully you everybody can see you can see those. So what I'm going to do is to give you a complementary, I hope, perspective on stress from my from my point of view as a psychologist. So I'm going to do five things.

I'm going to give you a little bit of what I taught my undergraduate medical students about, and that is how do we understand stress? You need a conceptual framework for stress. I'll talk about what you might think is typical stress management. I'll show you some of the evidence in terms of whether bolting on a stress management component to a weight management program is effective.

I'll also give you some perspectives on alternative ways of managing stress, which, again, sort of complements some of the things that Elizabeth thought about. And I'll end up by just planting some seeds into your head. Those of you who work clinically thinking about whether we can use that information to create a stress sensitive clinical team.

In other words, take home some of some of this perspective and and incorporate it into your working practice. So this is a really nice perspective. This is a model based.

It comes from a review, a fairly recent review by Janet Tomiyama. And I again recommend if you want an overview of the field from the perspective of a psychologist, then please have a please have a look at please have a look at this. I like it because what it does is it also talks about some of the the physiological and biochemistry, the mechanism of biological mechanisms that Lizbeth talks about.

I am not going to talk about those. What I will do is I will talk about the way that we can break down these interactions and look at them in terms of cognitive perspectives and behavioral perspectives, but also to to link obesity to stigma and the way that stigma works on stress, too. So what I have is, again, this is the perspective.

This is the trans transactional perspective on stress, which is the sort of the the most modern approach to stress, most modern. It's it's now what is 40 years old Lazarus and Foltman. It's a sort of classic perspective, and it moved the field on from just looking at stress as a response.

Some of the responses that Lizbeth talked about or some of the things that happen, you know, life events that happen in people's lives to thinking more about where the person is. And it's nice because it places the person central to the model and also says that stress appraisal is dynamic. In other words, it's continually being reappraised or reevaluated.

So if I take you from top down, then we have all sorts of stuff goes goes on in our lives, in our environments, some of which is stressful. Again, we have a sort of an individual perception filter. Some people are much more sensitive to to events going on in their environment.

Other people seem to be a little bit more resilient, don't even notice them. The person comes in because they interpret what's going on and make an interpretation as to whether this stress is. Irrelevant, it doesn't matter whether actually some of these things that are happening in our lives and we need stresses in lives, you know, gives us mobility, gives us action, gives a threat, gives us enjoyment.

Life, life without stress would be very, very dull. So some things that happen in our lives that we can interpret as positive. However, other things that happen offer a threat.

They are a challenge. They're perceived as potentially dangerous, but they're only dangerous if we don't have insufficient resources. So in other words, it's what we take to that situation, how we appraise it.

If we have a history of managing that and we think we have sufficient resources around us, particularly social support, then we can take it in our stride and it is not perceived as particularly stressful. However, if it overcomes the resources that we feel, then we have to find some ways of coping with it. And I'll talk about the distinction between problem focus and emotional focus, coping in a minute.

But stress doesn't just happen like that. It's it's a dynamic. OK, so we're continually going back to this appraisal.

Is it is it continuing? Is it still a threat? What are my resources in relation to it? And it may be that the things you do in terms of coping help you in your secondary appraisal to mobilize other resources. OK. So if we look at the type of coping strategies, the way that they are categorized, then the distinction between what tend to be strategies would have a positive outcome, that's problem focused strategies in which we look at particularly what we do now.

We look at what we've done in the past and we cast our eyes forward in terms of focusing on on changing the situation. So what we can do to modify the situation so it reduces the current stress and we avoid future situations which are much more similar. We rarely are in those types of circumstance.

More likely, we have to focus on the way it's making us feel. And these are emotion focused strategies, which, again, you will recognize in your own daily lives. We book holidays.

We use leisure. We use ways of relaxing as coping with stress. We compartmentalize.

We deny that this is important. OK, denial is a very common strategy. Or we distract ourselves with other tasks.

We talk about these things with others or we overtalk them and overthink them. And that's called rumination. Or we're more active.

So exercises, again, is a good way of managing stress, managing our time and using, again, different cognitive strategies. So I'm going to come back to our model and I'm going to talk. I'm going to show you some ways in which we can look at changing our thinking and looking at changing our behavior in relation to stress.

And what when you go back to the coping strategies, again, I've highlighted a few of these, which are the basis for most of the approaches that traditionally uses stress management. So focusing on relaxation, in particular, building an imagery and mindfulness, focusing on talking about how how we're feeling, using exercise. And again, some of the cognitive strategies looking at the way we prioritize what we do.

So if you look at the types of psychological interventions that people use, then what you'll find is they're broadly grouped into these four categories. There's one group which uses mindfulness and meditation techniques. One group that uses relaxation, in particular, things like guided imagery, you know, thinking, think, cast your mind into an an image in which you are sitting on a beach, for example, and really enjoying the walk along the beach, the warm sand beneath your beneath your toes, the cold water that spills.

So again, it's it's a sort of distraction, but it's also taking you off into a nice, safe, enjoyable space. And CBT and other talking therapies are another broad grouping of psychological interventions. And the last one is what's referred to as mind body training, things like using via feedback that things that strategies like using yoga.

You will see that most stress management interventions use a map. They may max on one of these approaches, but they will typically use two or three. Now, I've used that grouping in part because this is a grouping used by some colleagues of mine in the School of Psychology here at Leeds, who have just published a systematic review of meta analysis using cortisol as the outcome and looking at the which of these strategies is most effective in reducing stress.

So it's a large number of studies, a very good overall sample size. No difference, no differences by the type of intervention or how long it was used, the age of the participants or gender. But what's clear was the largest effects were seen in those stress management techniques that used mindfulness, meditation and relaxation.

Those that use talking therapies and mind body training did reduce cortisol, but to a much smaller degree, in fact, in a non-significant degree. So if you wanted the evidence and this is not this is nothing to do with obesity, this is just a general population. If you wanted to build a program based on what we have currently in terms of what we know on the impacts of cortisol, then you'd certainly build it, build it around techniques of mindfulness, meditation and relaxation.

So let me show you a little bit of evidence. What I'm going to do is to contrast two different strategies. I've just picked out two examples.

There's a very limited evidence base using stress management within a weight management setting. And so I just picked out two of the much more recent ones. There's a group from Athens in Greece who have used a an eight week program, which is one hour a week plus homework, again, which is built around things like relaxation, guided imagery and some strategies for making cognitive change and built.

And this this is a second study following an earlier study that they published. What they found was in comparison to the standards and lifestyle advice relating to food choices and exercise, then the people who went through this program both felt more positive in terms of their weight well-being and actually lost significantly more weight, not huge amounts of weight, but significantly more weight than those in the standard arm of the trial. Another group from Adelaide in Australia have combined a cognitive behavioral stress management program to online weight weight watchers and use the sort of standard weight watchers program as the comparison arm.

What they found was that the the program produced positive outcomes in terms of the psychological measures and in terms of its reduction in cortisol. They didn't find a weight difference. And I wonder whether that is because actually the standard online weight watchers program produced a reasonable amount of weight loss.

Just a couple of other studies to to mention, because they're published protocols, French group de Thiel et al. 21 day spa residency. This is a this is a thermal spa residency program from the most intensive of all the interventions.

I do wonder whether because I've seen no outcome of this, whether this is a victim of Covid actually to run a quite an intensive intervention over a period of Covid seems seems relatively ambitious. And then an American group, which is looking at the the effect of a program which is specifically relevant to to black American women. So those are in progress.

There is another literature, which is so those are all adults. The knowledge that's looked at children, young people. Again, it's the Athens group who put this a systematic review together.

Most of these interventions have, again, built their built their practice around mindfulness. There are these authors identify six programs. And in four out of the six, there was a difference in BMI, BMI percentage or waste hit hit ratio.

So, again, reasonable, reasonable evidence that these can be effective. However, it just sort of plants into your minds. What is the key outcome in these? Are we putting in stress management programs simply to get better weight loss within these programs? Are we looking for physiological markers of their effectiveness? Or are we content with participant patient improvements in reported well-being? So I'm a psychologist.

I know in the interventions that I've been involved with and fairly short term interventions. And when the the Adelaide study, for example, was it's ten weeks of interventions over three weeks. Three months group sessions for one and a half hours with a bit of homework associated with that.

It's in terms of hours, it's quite a substantial intervention. But stress happens on a daily basis, on a sort of hourly basis for some people. So maybe these interventions are relatively light touch.

Should we expect these interventions to have quite profound impacts on weight or are we content with an impact on well-being as an as an interim? I'd also plants in your head. Should we be focusing almost exclusively on clients or should we thinking about stress management programs for the practitioners, those who are part of weight management teams, not just to manage their own stress, but to make them more stress competent? Last couple of points I want to make. So let me go back to the model here.

So let's talk again about another way of looking at intervening on behavior and then thinking about weight stigma. So the whole range of other interventions that are focused on helping people to manage the emotional aspects, which which are common in people with obesity. So problems people have with emotional eating or problems people have with binge eating.

So a whole set of other interventions which are specifically targeting emotionally driven eating. OK, so I've been involved for many years in guided self-help interventions, which are added to other interventions to manage either weight or type two diabetes. More than happy to talk about guided self-help as an approach.

There are also a new brand of third wave cognitive based cognitive behavior therapies, such as ACT acceptance and commitment therapy, which is again about helping people to manage the emotions and the thoughts associated with those emotions. Evidence of success for those approaches within weight loss and weight loss meant maintenance is increasing. And we're becoming much more trauma informed in terms of looking at stigma and weight bias within obesity.

So there's a there's a nice position paper published by World Obesity, which is well worth looking at. And trauma informed approaches are a more general. They're generic.

They're about the language that we use and our approach broadly on behalf of obesity, which are excellent. However, there's another perspective, which I think I just want to get you to remind you, I'm sure you're aware of it, and that is a life course approach to to life events and so-called adverse childhood experiences. Early obesity is a well recognized ace.

OK, so again, the perspective here is things that happen in people's past then have implications for the rest of their future. So a traumatic event that happens during childhood knocks people in a particular direction during adolescence and adulthood. Again, one of the areas we've worked in in the past is looking at school experience and school streaming.

So children with with obesity, particularly profound obesity, they are treated differently within schools, and that experience can then jeopardize what happens to them in secondary schools and the subjects they choose, the schools that they get transferred to. And again, poor academic performance during adolescence knocks one's ability to get into university. So again, early life experiences have implications for later work space and qualifications.

So again, thinking about early obesity as potential traumatic events or things that happen to young people with obesity leads us to this idea of thinking about trauma specific interventions. So there are some types of CBT, EMDR, eye movement desensitization and reprocessing is a particular technique used by psychologists, and it's evidence based for trauma interventions is excellent these days. And again, there's no reason why it shouldn't be used within with people with obesity.

So my final thoughts are these, and it's thinking about being stress sensitive as a as a as a practical clinical scene. So in terms of what you do, if you work clinically, then, yes, you can think about delivering interventions as part of or alongside weight managements so they can be complementary to a traditional weight management program, or you can embed them within a weight management program. OK, that requires some expertise that requires psychological inputs in in doing it.

And it's a major investment, as I said. Look back on some of the interventions that have already been done. There's quite a lot of hours of intervention there.

We can think about training staff in terms of improving their psychological awareness and the approaches that they use. Lots of techniques like motivational interviewing, again, are ways not stress directed specifically, but just differently directive ways of working with patients. We should certainly be aware of what external resources there are locally and available to patient groups.

And that's signposting by clinical scenes is absolutely key. And I think likewise, again, with my guided self-help hat on to then we should be engaging with our clients, our patients, looking at what they're doing themselves in terms of their stress management strategies and procedures, supporting them troubleshooting if necessary. And again, walking along them, along with them on the weight management journey, but also being very attentive to the ways they are dealing with stress.

OK, thanks very much. Thank you very much for this nice talk, how to manage stress for the interest of time, we have time for two short, very short questions for each of the speakers. Is everybody from the audience, anybody would like to ask a question? Otherwise, I will read from the chat one for each of our speakers and the rest will try to answer them after the session.

Lisa will collect them and will try to answer. If there are no live questions, I would like to ask Elizabeth. One of the questions was in the case of the... Sorry.

Yes. I have a question. OK, so do you think one person in a team that works on obesity is the major role psychologist or physician or nutritionist? Who would like to answer first? The three of us, maybe.

I would say it depends on the cause. Like I showed, there are many categories of obesity and many factors can induce it. And yes, it can be very psychological, like a binge eating disorder, psychotrauma, just like Andrew just showed.

But it can also be medication induced or lifestyle or specific medical diseases. So I think first look at the cause and then, you know, and in most cases, multidisciplinary teams is very beneficial for obesity care. OK, it's important that the people have trust or show to one part of the team, for example, maybe they are easy for physicians and they don't pay attention to the psychology advice.

How do I do in this situation? Well, I think it's I think it's really, really tricky. I think this was sort of picked out on what would be the ideal. And that's what we have, multidisciplinary teams.

In other words, you have a team of three or four people who bring different skills. You know, we've got we've got exercise specialists. We've got dietitians, physicians, psychologists in an ideal team.

The important thing is that one one person can't be everybody. You have you have your particular background, your specialty, and that's what you're really good at. I think the important thing is also to give patients patients come up with their own solutions to problems and to work to work with some of those.

They're their own experts sometimes in their own lifestyle and the things that they can do and things that they can't do. And part of me mentioning motivational interviewing is, again, a way of helping people solve their own problems, identify what's happened, what's worked well for them in the past and helping them to overcome difficulties in using that. Thank you.

I fully agree that multidisciplinary it is very important in the management of obesity during the lifespan. Are there any other questions from the audience? If not, one interesting question written in the chat is for Andrew and says, are you aware of some self-management of stress strategies based on digital tools, on digital approach? Do you think if they are effective or any idea on this? Yeah, we're in a digital age and I think it's important to recognize that as a way of delivering and what it does is increases reach. But all that is is a vehicle for actually communicating with individuals and providing them with resources.

So the bottom line is it's the approach which which is most important. I'm most familiar with working with guided self-help and we do guide yourself out in person with written manuals, but we also do guide yourself out remotely. So in the sense with Zoom communications or by phone and using materials that we provide, I provide over the web.

So I think those platforms are are good. It's connectivity, which is really important. So much of the obesity literature says that social support or therapeutic support in weight management is really, really important.

And I think what that does also is provide opportunities for stress management. Again, the stress literature says discussion, talking about things, feeling supported is a really way is a really good, important way of managing one's own personal stresses. Feeling connected with others is key to this.

And so I don't see why that doesn't apply to a supportive clinical team. Feeling connected with that clinical team, again, keeps you on board with managing your own emotions, but also following the advice of that team. Thank you.

A short question for Elisabeth. Valeria Stockholm, she's a dietitian and she asked in the chat, could you give some more details on the mechanisms of weight regain related to antidepressants? I think that all of us have some examples and we'd like to have this explanation. In a practical way.

Yes, well, there are many different antidepressants with it through different mechanisms that can lead to weight gain. So there are some categories who are more known for it, like Mirtosapine is very known for weight gain or tricyclic antidepressants. In general, the SSRIs are less weight inducing, although some are more or less, so Cetralin, for example, less than Paroxetine, for example.

What we did in the Dutch guideline, we have a table with the most weight inducing medication and also the weight neutral or rate decreasing medication like Biproprion, for example, which is also part of a medication for obesity. But when you combine the Naltrexone, but it's also an antidepressant. So you can look at a patient to to make a choice which fits not only the depression, but also the obesity.

And we know in general in the mechanism are multiple. They can affect appetite hormones like Guilin and Leptin. They can influence cytokines, the MPK is signaling.

So many different ways it can affect your weight gain. But in general, we know that there's a beautiful meta analysis and review done that showing that, for example, exercise it can be an average as a vector for certain types of depression as antidepressants with the extra benefit is that it's good for the rest of the body. Also, mathematically to exercise, for example.

So there's a new way to go to to look at different at the combination of depression and weight that you should treat both of it, because also treating obesity is good for depression. So we should look at more at the whole person, not only at depression or obesity, but look at the whole person and treat both and choose the right therapies. So, yes, there are there.

There's literature on how to replace that. And I think in the check causes obesity, we also look at depression, but also have no new websites for health care professionals, how you can see how to replace which medication. So that will be developed, hopefully also in English.

Thank you. Thank you very much for the interest of time. We'll have to finish here the Q&A session.

There are a couple of unanswered questions in the chat. So at least I will collect them and our speakers will try to to answer them. So thank you, everybody, for being here.

Thank you very much, Elisabeth and Andrew, for these excellent talks and this very practical overview and see you at the next webinar. Thank you. Bye.

Thank you. Thank you. Bye bye.