WebMD Live Events Transcript; Event Date: Thursday, October 28, 2004
By Elissa Epel, PhD
WebMD Weight Loss Clinic - Live Events Transcript
We all know that a frazzled mind can conjure cravings for comfort food in some and kill the appetite in others. And now we hear that stress can affect the amount of fat we produce and the shape we are in. We discussed all of this, plus how to get off the food/stress carousel, with Elissa Epel, PhD, and Laurel Mellin, MA, RD, the author of The Solution: 6 Winning Ways to Permanent Weight Loss, on Oct. 28, 2004.
If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.
MODERATOR: What is it about being stressed that changes our approach to food?
EPEL: Stress causes some people to eat more, some to eat less. Stress really disrupts our homeostasis. The same neural networks that regulate appetite and satiety also regulate the stress response.
So it makes sense that when we're stressed, we're affecting the very same neural substrates that affect eating. What's complicated is that we don't exactly know how those neurotransmitters and neural networks are affected for individuals. They are probably affected differently depending on the type of stress, and how mild or severe it is.
We're mostly going to focus on stress eating, because this is the biggest clinical problem -- it can be called nonhomeostatic eating, eating when we don't need the calories. There are many reasons for this, and it is imperative we understand the triggers and how to control this eating, because nonhomeostatic eating is at the core of today's eating epidemic.
The biggest reason for overeating is simply the environment. We're surrounded by a toxic food environment, particularly high-fat, sweet food. Our brains are wired to respond to this type of food by overeating it and then craving more. There are other reasons for nonhomeostatic eating such as:
- Overly restrained dieting, which can backfire
- Eating in response to emotions, rather than hunger
MEMBER QUESTION: I eat when I am stressed. I know I am doing it when I do it, but it calms me down. Then I gain weight and it causes me more stress. It's a vicious cycle!
ELLIN: It is sad, because it is a vicious cycle. It's not that you're giving excuses for what you're doing; it's real. Eating is soothing and pleasurable, and we're apt to reach for food when we're out of homeostasis. This nonhomeostasis happens when we're in a state called "below the line."
That's when our "feeling brain" is out of emotional balance, out of relationship intimacy, disconnected spiritually, and the drives to go to excess -- including increased appetite for food -- ramp up. In contrast, when we're "above the line," when our feeling brain is in homeostasis, there are many gratifiers, we feel balanced, our relationships are more connected, and the drive to overeat and go to excess is lower, it's easier to push away from the table and stay with a diet. We eat less because we want less.
So an important answer to weight problems is not focus on forcing yourself to overly restrict food, but to notice whether you're in homeostasis, above the line, or out of homeostasis, below the line.
If you're below the line, do not focus on forcing yourself not to eat that extra cookie. Instead focus on moving above the line. In that state the desire for the cookie fades. You can use a range of tools, such as:
- Checking your feelings and needs
- Going on a walk
- Being out in nature
- Enjoying music
- Talking with a friend
The focus should not be on overrestricting your diet but on achieving homeostasis.
EPEL: You may feel the stress eating is making you feel better in the short run, but in the long run it's causing you misery because of weight gain. There is actually a biological basis to the stress reduction effect you are experiencing.
Let me tell you what we know about rats when they're stressed. Rats start preferring sweet and high-fat food, and the ones who have access to this comforting food actually experience stress reduction in terms of their hormonal responses.
Research by Dallman and Pecoraro at UCSF show that stressed rats that get comfort food have a down regulation of their stress response system. Mainly cortisol is lowered; stress responsivity is decreased in the stressed rats that get comfort food. But, unfortunately, there is a physical price to pay. These rats lose weight overall, but have more abdominal fat compared with peripheral fat.
MEMBER QUESTION: Why do we crave sweets and not a nice, big salad? Chocolate versus vegetable -- chocolate wins every time!
EPEL: Absolutely. The biological basis to this is rooted in what triggers our pleasure response in the brain.
The nucleus accumbens, which is the pleasure center of the brain, responds to most drugs by increasing dopamine and opioid activity. These make us feel good and reduce anxiety and stress. Does sugar do the same thing? Well, it turns out that one dose of sugar to a rat also stimulates the pleasure center, in the same way that drugs do. But repeated doses of sugar don't.
The brain habituates, but there are conditions when the brain doesn't habituate. And the formula for sensitizing this pleasure center so that it doesn't habituate or so that it's more responsive to sweet, high-fat food, is severely restraining the amount of food you eat, at least in rats. Cycles of dietary restraint sensitize the nucleus accumbens. This is partly the work of Bart Hoebel at Princeton.
ELLIN: This is so important, because it almost feels we have no way out of obesity if restraining our eating stimulates overeating, and overeating triggers weight gain. That's why it's so important to have a whole range of tools, to be really sensitive to ourselves, to know when we are hungry, cut back a little bit but not enough to trigger a binge. We need to be able to create a lifestyle that meets our needs for pleasure, relaxation, and satisfaction so we don't have to turn to food.
We developed a method for that at UCSF: The Solution is for adults and Shapedown Program is for children -- you can see the research at www.thepathway.org. All we did was to pump up the skills for stress resilience, to stay in homeostasis. Participants enhanced their skills in understanding how they feel, and what they need so that they can stay above the line more, in homeostasis. This does not mean weight problems are caused by one pathway, such as being depressed and then overeating. Any disruption in homeostasis has the potential to ramp up our appetites.
But we can take action by checking in with ourselves, even five times a day, to see if we're out of homeostasis, out of balance, or not. Just ask yourself: "How do I feel? And what do I need?" It's a great start in decreasing stress and creating that homeostasis, a great way to protect ourselves from deregulating our eating.
MEMBER QUESTION: Relaxation does not curb my desire for sugar. How do I break the sugar cycle?
EPEL: The rat study suggests that restraining and then binging, restraining and then binging, conditions our brain to be overly responsive to sugar. Clearly, rigid, brittle dieting can backfire.
But a moderate amount of dietary restraint is not only healthy; it's also necessary in this toxic food environment. The goal is to have a flexible amount of restraint, and there are skills that can be taught to help people maintain this healthy restraint level.
One problem with dietary restraint is that it takes a lot of energy and mental attention, and if you are putting a lot of cognitive effort into restraining, that means when something else comes up and shifts your attention, you're vulnerable to overeating.
ELLIN: Stress comes in many forms, and one of them is our food environment. There is a center in the brain, the orbitofrontal cortex, that is sensitized to the environment, in how food smells, looks, and tastes. That part of the brain actually produces hunger in response to delicious food. You can feel hungry even when your body doesn't need food, simply by being exposed to a toxic food environment.
MEMBER QUESTION: Is cortisol involved with weight gain? I see lots of commercials for things like CortiSlim and Relacore and they don't seem very trustworthy.
EPEL: You're right. Cortisol can stimulate appetite and, along with high insulin, it also promotes fat accumulation, particularly in the intra-abdominal area. That's because the fat inside of our bellies is extra sensitive to cortisol.
Belly fat has more cortisol receptors than subcutaneous fat -- the fat at our hips and thighs. Excessive cortisol levels over time promote excessive storage of abdominal fat. We have found that cortisol in response to an acute stressor stimulates appetite for comfort food and women with greater abdominal fat distribution tend to show a greater cortisol response to acute stresses.
These women also complain of more life stress. Given these relationships, it is logical to think that reducing stress might reduce cortisol exposure, which in turn might reduce stress eating and abdominal fat. But the data demonstrating this reverse pathway is simply not there. The relationships are probably far more complicated than that. For one, not everyone with high stress has high cortisol. So simply 'reducing cortisol' is not the right target for everyone. The majority of abdominal obesity is not simply explained by chronic stress and cortisol but rather lifestyle.
Antianxiety ingredients in these supplements might possibly help people who are stress eaters, if the products do, indeed, reduce anxiety, but they would likely have tiny effects compared with exercise and cognitive skills training to control eating. I feel very badly for people who have spent a lot of money on these untested products.
MEMBER QUESTION: What specific hormones are affected by food and alcohol?
EPEL: Cortisol responds to food and alcohol and pretty much any stimulant, like caffeine and smoking, but we don't know if these short-term effects have much of an effect on health. It's likely that eating when you are stressed is a risky behavior, because you may have high cortisol from the stress, which can increase insulin, then on top of that, eating increases insulin, as well. The combination of high cortisol and high insulin stimulates hunger, most likely, and reshapes body fat stores -- away from the pear shape toward the apple shape, towards storing abdominal fat. That's Dallman's work, again.
We have found, in our research, that people who identify themselves as stress eaters do, indeed, have higher cortisol and higher insulin during stressful times and tend to gain weight, more than people who identify as stress fasters, or those who eat less when they're stressed. Not only do these people gain weight, but they also increase in the bad type of cholesterol. So we're really worried about the health of stress eaters, more than their weight. Stress eating could be a risk factor for cardiovascular disease.
ELLIN: With insulin levels and cortisol levels increased, the tendency is to eat sugar, fat, and salty, crunchy foods. Unfortunately, the kinds of foods we crave when our cortisol and insulin levels are up, only add to the weight gain.
So often when we feel most like having candy or cookies because our cortisol and insulin levels are elevated, what we most need are foods high in fiber and healthy fats, and lean protein foods. In addition, we may feel like sitting when what we need is to walk the dog or go to the gym.
It's ironic and sad that those of us who are most at risk of high insulin and high cortisol levels and cravings for sugar and fat, are most at risk of that excess weight being deposited in the abdomen, where it can increase our risk of the metabolic syndrome.
EPEL: We are very concerned about metabolic syndrome, more than about excess weight itself. Half of obese people have metabolic syndrome. This is a cluster of risk factors for chronic diseases, such as heart disease.
We think that life stress and environmental stress contribute to the type of obesity that is associated with the metabolic syndrome. So we fear that stress is not only promoting excess weight, but also excess exposure to insulin, which can be pro-aging and disease promoting, and abdominal fat, which we know is contributing to disease.
So at UCSF, we have developed an interdisciplinary center for obesity research and education. We are trying to understand, from genetics up to the social and environmental level, how different stresses contribute to the malignant form of obesity -- abdominal obesity with the metabolic syndrome -- and then, what we can do about it in our clinics and from a public health perspective.
MEMBER QUESTION: So the apple shape is a more "dangerous" shape than the pear shape?
EPEL: Many of us in the field strongly believe that abdominal obesity is a much more specific or causal factor for disease than general obesity.
In fact, there are now several studies showing that peripheral fat, the fat at our hips and thighs, is not only benign, but also possibly protective of health, in terms of relating to better glucose control and lower risk of diabetes.
ELLIN: The new research on stress and metabolic syndrome is so important. It's also key to appreciate that body fat affects many systems, and that a person who, let's say, is a pear rather than an apple, has other consequences of obesity that does not have to do with diabetes or cardiovascular disease. It could relate to pulmonary function, orthopaedic problems, or other medical conditions.
As obese people age, various medical problems are apt to crop up and often they exacerbate the obesity. For example, a person carrying some extra weight may feel fine, they may be healthy in terms of blood sugars or lipids, even though heavy, but then they have knee or foot problems associated with the body size and then have a hard time exercising -- and then being inactive contributes to their stress level and their further weight gain.
MODERATOR: So how do you move from unconsciously reaching for that bag of chips when stressed, to conscious action?
EPEL: That is a great question, one that we would all like a good answer to. There is no simple cure for our impulses, cravings, and drives -- the strong evolutionary-based motivations.
But there are skills that can help. Some programs focus on overeating and some on stress reduction, but several programs marry the two, fostering a mental shift so that someone can be in the moment, tuned into their true needs. Such programs can be more effective than ones that simply promote supplements or relaxation techniques without cognitive skills training.
One such example that has been supported in pilot studies is called mindfulness-based stress reduction (MBSR), for binge eating disorder. Jean Kristeller at Indiana State University has shown that MBSR reduces binge eating for people with binge eating disorder (BED) through attentional skills training. People who have gone through this program learn to control that incredibly strong impulse to overeat when they do not need calories.
For severe anxiety, cognitive behavioral therapy is effective. A program that uses cognitive behavioral techniques is Kelly Brownell's LEARN program (800) LEARN-4-1 www.learneducation.com). Laurel Mellin's program also has pilot data showing long-term weight maintenance, and it's long-term maintenance that matters. Anyone can lose weight -- keeping it off is the challenge.
MODERATOR: And Dr. Brownell is our in-house eating disorders expert. You can post questions for him on WebMD's message boards.
ELLIN: Nonhomeostatic eating, eating when you're below the line, is such an important contributor to obesity that we have to look at its origin -- even though it's diverse and some can be genetic -- much has to do with the feeling brain.
The feeling brain is the clearinghouse of all the information in and out, and when the total stress is more than we have the skills to bring back to balance, stress eating is triggered, therefore whole-body approaches can be more effective than single approaches.
In The Solution participants master developmental skills, knowing how to nurture themselves from the inside and set limits not only with themselves, but also with others and with life.
To live above the line, where the drive to overeat, overdrink, or overspend fades, is to not only to master these tools, but to live what we call a masterful life, taking time to care for your body, to exercise, to engage in meaningful pursuits, and to relax. Decreasing stress and obesity involves taking better care of ourselves, not only mentally, but also in our lives.
MODERATOR: We have only touched the tip of the iceberg on this subject. Do you have places for folks to go who want to pursue this more?
ELLIN: We will be having UCSF's Center for Obesity Research and Education's obesity web site up sometime next month. Visit the Center for Health and Community web site, chc.medschool.ucsf.edu to be linked to it.
The programs developed at UCSF for obesity are The Solution for adults and The Shapedown Program for children. Find a local Solution program at www.thepathway.org or call the Institute for Health Solutions: (415) 457-3331. For local Shapedown programs, visit childobesity.com. Also, the books by Laurel Mellin, MD, are: The Pathway (HarperCollins 1994) and another book due out next spring, The 3-Day Solution Plan (Ballantine, 2005).
There are also resources available at: weightwatchers.com.