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Obesity and Mental Illness:
Cause or Effect
Claudia Fox, MD MPH
Diplomate, American Board of Obesity Medicine
Director, Pediatric Weight Management Program
Disclosures
• I have no relevant financial relationships with the
manufacturers of any commercial products and/or
provider of commercial services discussed in this
CME activity.
• I do not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation.
What Kids Say
Claire, age 19, 5'4", 210 lb,
“I hate looking in the
mirror :( it's the
saddest part of each of
my days. I hate myself.”
What Kids Say
sad and depressed, age 16, 5'9",
320 lb
“i really am sick of being fat…ive
been a big kid ever since i can
remember and during all that time
ive been teased and made fun of.
i hate myself for being the size i
am and I pretty much have no self
esteem.”
Objectives
1. Identify the prevalence of mental illness
among youth with obesity
2. Understand the cause and effect
relationship between mental illness and
obesity
3. Identify the implications of mental illness in
the treatment of obesity
Most Studied Psychiatric Conditions
Among Obese Individuals
• Depression
• ADHD
• Binge Eating Disorder (BED)
Objectives
1. Identify the prevalence of mental illness
among youth with obesity
2. Understand the cause and effect
relationship between mental illness and
obesity
3. Identify the implications of mental illness in
the treatment of obesity
Rates of Psychological Complications in
People with Obesity are Uncertain
Rates of Psychological Complications in
People with Obesity are Uncertain
Other considerations:
– Age, gender
– Severity of obesity
– Psychiatric definitions – rating scales,
interviews, questionnaires
Population-based Samples
• No increase in
psychopathology among
obese youth, except for
eating disorders
• Maybe some increase in
“behavioral problems”
among obese school aged
children
Hebebrand, 2009, Child Adolesc Psychiatr Clin
N Am 18:49-65
Puder & Munsch, 2010, Int J of Obesity 34:
S37-S43
Eating Disorders in
Population-based Samples
• Strong positive association between BMI and disordered
eating
• Binge-purge behavior among national US survey of 6,500
students between 5th and 12th grade:
– 20% in obese girls
– 17% in overweight girls
Hebebrand, 2009, Child Adolesc Psychiatr Clin N Am 18:49-65
Eating Disorders in
Population-based Samples
Prevalence of Disordered Eating in Different Weight Categories in 1,895 adolescents
Hebebrand, 2009, Child Adolesc Psychiatr Clin N Am 18:49-65
Depression in Clinical Samples
• 39% of severely obese
adolescents presenting for
bariatric surgery have
clinically significant
depressive sx (BDI≥ 17)
Zeller et al, 2009, Obesity 17(5):985-90
Hebebrand, 2009, Child Adolesc Psychiatr Clin N Am 18:49-65
• 32% of adolescents who
participated in weight
management program had
CDI>13
ADHD in Clinical Samples
30 adolescents, aged 12-16yrs:
– 13% in clinical obese group
– 3.3% in non-clinical obese group
– 3.3% in control group
Cortese et al, 2008, Crit Rev Food Sci Nut, 48:524-537
Erermis et al, 2004, Pediatr Int, 46:296-301
BED in Clinical Samples
• 126 youth age 10-16 residential treatment for
obesity:
– 36% reported binge episodes
• 102 obesity treatment seeking adolescents:
– 17% reported moderate to severe binge eating
symptoms
Decaluwe et al. 2003, Int J of Eat Dis, 33:78-84
Isnard at al. 2003, Int J Eat Disord, 34:235-43.
Objectives
1. Recognize the prevalence of mental illness
among youth with obesity
2. Understand the cause and effect
relationship between mental illness and
obesity
3. Identify the implications of mental illness in
the treatment of obesity
Determining Causality is Difficult
• Cross sectional nature of most
studies
• Different definitions and
assessments of psychopathology
in childhood
• Lack of inclusion of potential
confounders or mediators (social
parameters, sleep deprivation, etc)
Context
Demographics: age, gender, race/ethnicity, SES
Obesity stigma/bias
Maternal mental health
Trauma
Weight related teasing/bullying
Pediatric
Obesity
Mental
Illness
Adapted from Vander Wal & Mitchell, Pediatr Clin N Am. 2011; 58:1393-1401
Weight-related Teasing Increases
Psychological Complications
Eisenberg et al, 2003, Arch Pediatr Adolesc Med, 157(8):733-8
Depression and Obesity
Getty Images/Sean Murphy
Meta-analysis of Longitudinal Studies
N=58,745
OR 1.55
obesity
depression
OR 1.58
*associations were not statistically significant for <20 yo
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
Depression and Obesity:
Cause or Effect?
Depressive symptoms in
childhood predict obesity in
later childhood, adolescence
and adulthood
Puder & Munsch, 2010, Int J of Obesity 34: S37-S43
Nat’l Longitudinal Study of Adolescent Health
9,374 teens grades 7-9
• Baseline depression was not significantly correlated with
baseline BMI
• Depressed mood at baseline predicted increased odds of
obesity (OR 2.05; 95% confidence interval: 1.18, 3.56) at 1
year follow up, controlling for baseline BMI, age, gender,
race, parental obesity, SES, smoking, and physical activity
• Obesity at baseline did not predict depressed mood at
follow-up
Goodman and Whitaker, 2002, Pediatrics, 110(3):497-504
Mediators Between
Obesity and Depression
obesity
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
depression
Mediators Between
Obesity and Depression
obesity
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
depression
HPA Axis
Mediators Between
Obesity and Depression
obesity
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
depression
Mediators Between
Obesity and Depression
obesity
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
depression
Mediators Between
Obesity and Depression
obesity
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
depression
Mediators Between
Obesity and Depression
obesity
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
depression
Mediators Between
Obesity and Depression
obesity
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
depression
Appetite Hormones
“Leptin Hypothesis”
• Low levels of leptin are associated with
depressive behaviors
• Leptin insufficiency and leptin resistance
may contribute to alterations of affective
status
Lu, Cur Opin Pharmacology, 2007, 7:648-652
Obesity-Sleep-Depression
increased
hunger
obesity
depression
↓leptin
↑grehlin
sleep
deprivation
Mediators Between
Obesity and Depression
obesity
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
depression
Weight Gain and
Atypical Antipsychotic Medications
Taylor & McAskill, 2000, Acta Psychiatr Scand, 101:416-432
ADHD and Obesity
ADHD and Obesity
1. Obesity leads to ADHD
2. ADHD and obesity are expressions of a
common biological dysfunction in a subset
of patients with both
3. ADHD contributes to obesity
Cortese et al, 2008, Crit Rev Food Sci Nut, 48: 524-537
Obesity Leads to ADHD
• Sleep disordered breathing can manifest as
ADHD symptoms during the day
• Binge eating may contribute to impulsive
behaviors
Chevrin et al, 2005, Sleep, 28: 885-890
Cortese et al, 2007, Int J Obes, 31: 340-346
Obesity and ADHD
Share Common Etiology
Reward Deficiency Syndrome
– Described independently for both ADHD and
obesity
– Low dopamine activity in attentional areas and
brain reward pathways results in an attempt to
compensate by using reinforcing behaviors such
as eating
Cortese et al, 2008, Crit Rev Food Sci Nut, 48: 524-537
ADHD Contributes to Obesity
• Poor planning and an inability to delay
reward may lead to overconsumption
• Kids with ADHD are engaged in less
physical activity and organized sports
• Kids with ADHD have lower gross
motor skills, poor physical fitness, and
delayed motor development
Davis et al, 2006, Eat Behav 7:266-274
Binge Eating Disorder and Obesity
Binge Eating Disorder
DSM V Diagnostic Criteria
Recurrent episodes of BE characterized
by BOTH:
• Eating large amounts of food in a
discrete period of time
• A sense of lack of control (LOC)
BE episodes are associated with ≥ 3 of:
• Eating more rapidly than usual
• Eating until uncomfortably full
• Eating large amounts when not
hungry
• Eating alone because of embarrassed
• Feeling disgusted or guilty
Marked distress regarding BE
BE occurs at least 2 days per week
for 6 months
Not associated with compensatory
behaviors
Binge Eating Disorder
• Those with LOC had significantly higher BMIs and
more adiposity
• After controlling for BMI, those with LOC reported
more anxiety, depressive symptoms, and body
dissatisfaction.
• No association between attempts to diet and
episodes of LOC over eating
Morgan et al 2002, Int J Eat Dis, 31:430-441
Binge Eating Disorder
• No evidence that BE is a result of dietary restraint
• Disinhibition, rather than dietary restraint, seems to
precipitate BE in many obese subjects
• Negative emotional states, social situations, time
of day, and type of meal trigger BE
de Zwaan, 2001, Int J of Obes, 25:S51-s55
ADHD and BED
Emerging evidence that binge eating occurs at
higher than expected rates in people with
ADHD
Cortese et al, 2007, Int J Obes, 31:340-346
Objectives
1. Recognize the prevalence of mental illness
among youth with obesity
2. Understand the cause and effect
relationship between mental illness and
obesity
3. Identify the implications of mental
illness in the treatment of obesity
Does Weight Management Cause
Eating Disorders?
Does Weight Management Cause
Eating Disorders?
National Task Force on the Prevention and
Treatment of Obesity 2000
– Dieting and weight loss in obese adults:
• NOT associated with development of eating disorders
• typically associated with improvements in depression,
anxiety
• associated with decrease in BE in individuals who
began weight management with this complication
In Children?
Review of 5 relevant studies:
“Professionally administered weight loss
interventions:”
1. pose minimal risks of precipitating eating
disorders in overweight children and adolescents
2. associated with significant improvement in
psychological status in several studies
Butryn and Wadden, Int J Eat Disord , 2005, 37:285-293
Psychological Difficulties are Associated With
Decreased Weight Loss Success
• Baseline depression and LOC eating are
associated with higher rates of weight loss
treatment drop out
• Presence of fewer psychological
complications predicts better long term
weight loss maintenance
Van der Wal & Mitchell, Pediatr Clin N Am. 2011; 58:1393-1401
Screening
• Screen children with
obesity for mental
illnesses
(Screen children with
mental illness for obesity)
Address Psychosocial Factors
in the Environment
May be that addressing psychosocial
elements, eg peer environment, could improve
outcomes of obesity treatment
Identify Context of Overeating
• Emotional eating
• Binge eating
• Impulsive eating
Psychotherapy
• Aid in drawing connections between triggers
and behaviors
• Improve social skills
• Improve attentional and organizational
strategies
• Develop response inhibition
Van der Wal & Mitchell, Pediatr Clin N Am. 2011; 58:1393-1401
Cortese et al, 2007, Nut Rev, Sept, 404-411
Pharmacotherapy
• Some evidence that treatment with
stimulants improve ADHD and abnormal
eating behaviors in patients with both
conditions
• SSRIs can decrease binge eating episodes
Cortese et al, 2007, Nut Rev, Sept, 404-411
Conclusions:
Obesity and Mental Illness
• Co-occur with maladaptive eating behaviors
• Involve problematic coping strategies
• Share:
– abnormal inflammatory response
– dysregulated HPA axis
– perturbations in neurotransmitter systems
– genetic vulnerabilities
Address the Mind and the Body