The Connection of Cortisol, Depression, Weight Gain and Anxiety

Americans today are more stressed than ever. We face stress at work, home, in our relationships and even from lack of sleep. Unfortunately, we are finding that chronic stress is causing a serious impact on our lives and our health. We now know that chronic stress can lead to:

High blood pressure, diabetes, obesity, and metabolic syndrome
Fatigue
Insomnia
Anxiety & Depression
Low libido

There is a growing body of literature that is looking at just how our bodies respond to stress, and how we can treat the deleterious effects of stress. But what is stress exactly? And why, when you are cramming for your final exam (or like me, up against a deadline to get an article finished), are you polishing off your last Twix and not a carrot?

What is stress?

Stress is any real or perceived threat to homeostasis (or our steady state of calm). This can be emotional stress, alteration in your sleep patterns, or even fear of physical harm. Our body has two systems designed to control how our body responds: the sympathetic nervous system (fight or flight system) and parasympathetic nervous system (rest and digest system). When we are initially stressed (i.e., running from a bear), our bodies activate the sympathetic nervous system. This, in turn, switches on the Hypothalamic Pituitary Adrenal Axis, a pathway in our body where our brain tells different parts of our body how to respond to stress. One of the main components of this system is cortisol. Cortisol is a steroid hormone that, in addition to many other actions, modulates glucose metabolism. Through a variety of pathways, high cortisol levels causes adipose tissue (fat cells which store energy) to break down in order to release their energy. The energy released from these cells can be shunted to the tissues that need them most. Cortisol has been found to have several different functions:

Regulates insulin

Manages how your body uses / stores fats and proteins in times of stress
Adjusts blood pressure and glucose levels
Controls your sleep / wake cycle
Influences immune system
Affects learning and memory in times of stress

In a healthy response to stress, the body will quickly raise cortisol levels in an effort to handle the stress. Once the stressor is gone, the parasympathetic system kicks in (rest and digest system), and cortisol levels fall. However, when a person is burdened with continued stressors, the cortisol levels are unable to fall. This persistent state of high cortisol production can lead to various metabolic and psychiatric disorders.

How do high cortisol levels affect your weight?

You may think, in short periods of stress, fat is broken down to produce energy. Isn’t that a good thing? Unfortunately, you can certainly have too much of a good thing! Obesity has certainly been linked to persistently high levels of cortisol in several ways. One theory is that persistently high levels of cortisol, in response to chronic stress, actually causes a blunted response or desensitization. This, in turn, inhibits fat cell break down (lipolysis) and leads to insulin resistance.1 This is perhaps why stress, cortisol level and diabetes are significantly linked.

High cortisol levels also interact with a variety of signaling pathways involved with appetite. Leptin, the “satiety hormone,” is released from fat cells to help control weight long-term. It helps to inhibit hunger.2 When the body is functioning properly, leptin levels will rise to lower your appetite. However, when chronically stressed (in the setting of chronically high cortisol levels), leptin receptors can be desensitized and can actually increase hunger and eating. 3 When a patient is obese, this can be magnified. Because as the individual keeps eating, the fat cells produce more leptin to signal the need for satiety, leading to even higher levels of leptin.2
Ghrelin is another appetite hormone that has received more notoriety recently. Ghrelin is a hormone secreted in the stomach and works to increase food intake. In bariatric surgery, we have found that ghrelin levels are reduced in the short term. This can add to the success of surgeries like the gastric bypass and sleeve gastrectomy. However, studies have looked at the effects of cortisol and sleep deprivation (a chronic stressor) and ghrelin. Research has shown that in periods of sleep deprivation, there is an increase in nocturnal ghrelin, leading to increase in appetite. This may be why when you can’t sleep, you have the urge to reach for comfort foods, such as sweets.3

Finally, there is the behavioral component of eating and stress. Stressors work on three parts of the brain:

Prefrontal cortex – involved with “Thinking” and mindful regulation of food intake.
Hippocampus – involved with “Emotions” and the wanting, pleasurable habitual regulation of food intake
Hypothalamus – involved with “Energy balance” and body’s homeostatic regulation of food

I think of the prefrontal cortex and hippocampus as our higher brain and hypothalamus more of our primitive brain. In periods of chronic stress, cortisol is released and maintained at a high level, and this, in turn, increases our motivations for food intake and obesity. Our prefrontal cortex and hippocampus “take over” the hypothalamus in times of chronic stress. Through pleasurable eating, the body is trying to reduce the activity of the stress-response network. This dysregulated pathway reinforces the bad feeding habit. As much as our genetics and hormones play a role in our eating habits and weight, patterns of poor eating can be learned and reinforced over time. 4

In summary, the hormones that are supposed to control appetite and hunger are dysregulated. This causes the body to try to restore a normal balance through bad habits. This is why so many patients rely on food during periods of stress.

Cortisol and Anxiety / Depression

There have been several studies that show there is a positive association between depression and obesity. Obesity has been shown to cause depression and vice versa. In periods of chronic stress, the HPA is activated, cortisol is high, ultimately resulting in obesity. Additionally, studies have found that early in life if there are stressors, such as abuse, the HPA is activated and dysregulated. This leads to higher risk for anxiety, depression and addiction.5

So what can we do?

The evidence is clear that periods of high stress, through various pathways, can lead to obesity and psychological disorders such as depression and anxiety. By understanding that stress is a very real thing, and has very real consequences is the first step. For patients with depression and anxiety, it is important that they receive adequate medical and behavioral care. Since these diseases are bidirectional with obesity, one can have a significant impact on another. For instance, it is not uncommon for me to have a patient present two years out from surgery with some weight gain. After meeting with them, I often find that a major life event (such as birth, death, divorce, loss of job) has occurred. While I could just give them an appetite suppressant and cross my fingers, this is just putting a band-aid on a problem. A more comprehensive approach would be to address the anxiety / depression underlying the weight regain. In the same way, if a patient presents with issues with insomnia, it is important to tease out why they can’t sleep. Do they have untreated sleep apnea? Are they stressed or depressed? Do they work nights and have an altered sleep schedule? By addressing the underlying cause of the sleep deprivation, using a sleeping aid and enforcing good sleep hygiene, a patient can lose up to 10% of their excess body weight. So what if you aren’t depressed and sleep well at night, but you just have a crazy, hectic lifestyle. If that is the case, then if you want to lose weight, you MUST make time to take care of yourself and de-stress. I’ve always said everyone needs to know a good plumber, good lawyer and good therapist! Therapy is a wonderful way to change maladaptive behaviors that contribute to our stress. Exercise is another great way to “work out” your stress. Exercise has also been shown to release endorphins to help lower our cortisol levels.

As I complete this article, I feel better knowing why I reach for the snack foods that I do when I’m stressed. This, in turn, helps me to be more mindful about the choices I make. For you and all my patients, my hope is that you can find a better, more healthy and mindful way to control your stress….your waistline will thank you for it!

References HYPERLINK “mailto:sakairr@ucmail.uc.edu” \o “sakairr@ucmail.uc.edu” INCLUDEPICTURE “https://link.springer.com/springerlink-static/images/svg/email.svg” \* MERGEFORMATINET
Scott, Karen, Susan Melhorn, and Randall Sakai. (March 2012). Effects of Chronic Social Stress on Obesity. Current Obesity Reports, 1(1):16–25.
Hormone.org
HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Bose%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19584720” Mousumi Bose, HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Oliv%26%23x000e1%3Bn%20B%5BAuthor%5D&cauthor=true&cauthor_uid=19584720” Blanca Oliván, and HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/?term=Laferr%26%23x000e8%3Bre%20B%5BAuthor%5D&cauthor=true&cauthor_uid=19584720” Blandine Laferrère. (Oct 2009). Stress and obesity: the role of the hypothalamic–pituitary–adrenal axis in metabolic disease. Current Opinion in Endocrinology, Diabetes and Obesity. 16(5):340–346.
Dallman, MF. (Nov 2009). Stress-induced obesity and the emotional nervous system. HYPERLINK “https://www.ncbi.nlm.nih.gov/pubmed/19926299” \o “Trends in endocrinology and metabolism: TEM.” Trends Endocrinol Metab. 2010 Mar;21(3):159-65.
C.R. Elder, CM Gullion, KL Funk, LL DeVar, NM Lindberg, and VJ Stevens. (2012). Impact of sleep, screen time, depression and stress on weight change in the intensive weight loss phase of the LIFE study. International Journal of Obesity, 36:86–92.

Why Do Patients Struggle With Maintaining Weight Loss Following Weight Loss Surgery

Collins Hodges, PsyD, LP

As both a clinical psychologist and a bariatric patient, I am intimately familiar with the struggle to lose weight. We have spent hundreds of dollars on diets, only to end up right where we started. Unfortunately, we likely will wallow in the pit of self-doubt and self-criticism as we try to make sense of our perceived failures. It can be extremely frustrating and even depressing. To make matters worse, those who don’t struggle with their weight are often mean-spirited and dismissive of our efforts and quick to label us as lazy or unmotivated. However, in the vast majority of cases, the polar opposite is true. We will do almost anything to free ourselves from the self-limiting nature of being overweight.

Even more problematic than achieving significant weight loss is the ensuing challenge of maintaining it. Of course, this is certainly true for all of us who have been on fad diets only to quickly realize that the initial weight loss is only half the battle. Inevitably, we end up on a yo-yo cycle. However, those of us who have undergone bariatric surgery also struggle with weight loss maintenance. We make all of the sacrifices necessary both pre-operatively and post-operatively to help ensure our success. Yet, for many of us, long-term maintenance becomes an issue. How could it be that we still fight this battle after taking such a big step towards achieving a healthy weight?

There are a number of things to consider with respect to weight regain following bariatric surgery. Of course, as we have all heard ad nauseum, weight loss surgery is only “a tool.” Optimizing your success is often a matter of immersing yourself in the dietary, psychological, and exercise protocols for postoperative bariatric patients. However, the initial step is creating a dialogue with your physician in exploring what specifically may be contributing to the issue. For example, patients will need to determine whether the issue is anatomical, medical, or behavioral. Anatomical issues can be diagnosed with an upper GI series or an upper endoscopy. Certain medical conditions may also contribute to weight regain. Some of these may include thyroid issues, adrenal issues, or kidney and/or heart problems. More often than not, however, patients will likely need to focus their attention on the behavioral component.

Successful long-term weight loss maintenance will require patients to make permanent changes in certain behaviors, eating habits, and activity patterns. These may include any number of the following and should be carefully evaluated with both your surgeon and a bariatric psychologist:

• Regular consultation with a dietician or nutritionist
• Keep a food diary
• Drastically reduce intake of sugar, fat, calories, and carbohydrates
• Eat more fruits and vegetables
• Take in significantly more protein
• Cut out alcohol and tobacco
• Consultation with a trainer to create an individualized exercise routine

Perhaps most importantly, patients who continue to struggle with weight gain following bariatric surgery will need to work with a mental health professional in assessing their issues related to mindless eating. The following components of mindless eating will require your attention:

• Are you eating in response to physical hunger?
• Do you have a good understanding of your physical hunger cues?
• Are you aware of the extent to which you eat in response to emotional or environmental triggers?
• Do you find yourself “food-focused” for most of the day?
• Do you view exercise as a punishment for overeating?
• Do you engage in “distracted eating” (i.e., while working, watching tv, etc.)?
• Are you choosing healthy food choices?
• Do you eat quickly?
• Are the food portions large?

Managing Problems And Thoughts

By: Collins Hodges, PsyD, Licensed Clinical Psychologist

Managing problems

Fortunately, obese patients are able to work through daily decision-making processes with very little or not subjective distress. Most situations requiring a solution demand a fairly straightforward and common-sense approach to problem solving. When not overly stressed, finding ways to deal with issues unfolds in a predictable and often automatic sequence of events. After all, obese patients are not dissimilar to others in terms of their ability to cope with the mundane.
However, a high percentage of obese patients struggle to work through challenging problems without resorting to disordered eating. Over time adaptive coping mechanisms often become supplanted by more maladaptive coping skills (i.e., disordered eating) to handle difficult and stressful events. In such cases, comfort food takes on an entirely different purpose. It serves to regulate one’s mood in order to temper the stress of facing a problematic situation without a clear solution.

Formal problem solving involves several steps, to include the following:

• Define the problem in simple terms
• Brainstorm about solutions
• Evaluate the practicality and effectiveness of each solution
• Choose one or a combination of solutions
• Commit to following through with your behavior
• Evaluate the entire problem-solving method

The patient is encouraged to consult with a psychologist to practice and rehearse these steps with complicated issues that may arise during the week. Eventually, they will become second nature and serve as a template to address life’s inherent difficulties.

Managing thoughts

In addition to struggling with finding adequate solutions to complicated situations, obese patients often show evidence of distorted thinking. In other words, behavior that is unhealthy (i.e., emotional eating) is a consequence of thinking that is unhealthy. Consider, for example, the cognitive theory of depression which has substantial empirical support. It suggests that the depressed individual sees oneself as worthless and helpless, the world as a negative and hopeless place, and the future as equally hopeless. This pattern of thinking is characterized by a set of common cognitive distortions. A large percentage of obese patients struggle with depression. However, there is ample evidence to support the notion that obese patients not struggling with depression also have disordered thinking. These common cognitive distortions can be found in David Burns’ Feeling Good Handbook (1989) and are listed below:

• All or Nothing Thinking

Also known as “Black-and-White Thinking,” this distortion manifests as an inability or unwillingness to see shades of gray. In other words, you see things in terms of extremes – something is either fantastic or awful, you are either perfect or a total failure.

• Overgeneralization

This sneaky distortion takes one instance or example and generalizes it to an overall pattern. For example, a student may receive a C on one test and conclude that she is stupid and a failure. Overgeneralizing can lead to overly negative thoughts about oneself and one’s environment based on only one or two experiences.

• Mental Filter

Similar to overgeneralization, the mental filter distortion focuses on a single negative and excludes all the positive. An example of this distortion is one partner in a romantic relationship dwelling on a single negative comment made by the other partner and viewing the relationship as hopelessly lost, while ignoring the years of positive comments and experiences. The mental filter can foster a negative view of everything around you by focusing only on the negative.

• Mind Reading

This distortion manifests as the inaccurate belief that we know what another person is thinking. Of course, it is possible to have an idea of what other people are thinking, but this distortion refers to the negative interpretations that we jump to. Seeing a stranger with an unpleasant expression and jumping to the conclusion that she is thinking something negative about you is an instance of this distortion.

• Magnification or Minimization

Also known as the “Binocular Trick” for its stealthy skewing of your perspective, this distortion involves exaggerating the importance or meaning of things or minimizing the importance or meaning of things. An athlete who is generally a good player but makes a mistake may magnify the importance of that mistake and believe that he is a terrible teammate, while an athlete who wins a coveted award in her sport may minimize the importance of the award and continue believing that she is only a mediocre player.

• Emotional Reasoning

This may be one of the most surprising distortions to many readers, and it is also one of the most important to identify and address. The logic behind this distortion is not surprising to most people; rather, it is the realization that virtually all of us have bought into this distortion at one time or another. Emotional reasoning refers to the acceptance of one’s emotions as fact. It can be described as “I feel it, therefore it must be true.” Of course, we know this isn’t a reasonable belief, but it is a common one nonetheless.

• Should Statements

Another particularly damaging distortion is the tendency to make “should” statements. Should statements are statements that you make to yourself about what you “should” do, what you “ought” to do, or what you “must” do. They can also be applied to others, imposing a set of expectations that will likely not be met. When we hang on too tightly to our “should” statements about ourselves, the result is often guilt that we cannot live up to them. When he cling to our “should” statements about others, we are generally disappointed by the failure of the others to meet our expectations, leading to anger and resentment.

• Personalization

As the name implies, this distortion involves taking everything personally or assigning blame to yourself for no logical reason to believe you are to blame. This distortion covers a wide range of situations, from assuming you are the reason a friend did not enjoy the girl’s night out because of you, to the more severe examples of believing that you are the cause for every instance of moodiness or irritation in those around you.

These cognitive distortions represent a depressogenic pattern of thinking that often leads to disordered eating. The goal for obese patients will be to work with a psychologist in identifying the specific types of distortions to which he is vulnerable. Following identification is a therapeutic technique called cognitive restructuring. This entails teaching a patient to challenge these problematic thinking patterns. For example, a patient may observe that he is particularly vulnerable to using the cognitive distortion ‘Mind Reading.’ The patient will then document throughout the week all instances of when this distortion is used. In therapy, the doctor and patient will evaluate two competing columns of evidence, one called “objective evidence to support the thought” and another called “objective evidence to argue against the thought.” Evaluating the evidence will help bring about a sense of clarity to what was once an automatic, assumption-based, subjectively critical thought process. Of course, over time the patient will become more adept at following these steps at home and therefore become his own objectivity screener.

Managing Problems and Thoughts

Problem solving and cognitive restructuring may then be used in tandem to describe a problem situation that he is facing (or faced), the desired outcome that he wants (or wanted), what thoughts and behaviors he should have (or should have had) in order to achieve the desired outcome, and whether he achieved the outcome he wanted. Provided the patient achieved the outcome he wanted, he would describe the thoughts and behaviors that were most helpful. If the patient did not achieve the outcome he wanted, then he would describe the thoughts and behaviors that were most problematic in keeping him from achieving his goal.

Burns, D.D. (1989). The Feeling Good Handbook. New York, N.Y.: Plume.