Obesity and Mental Illness:Cause or EffectClaudia Fox, MD MPH
Diplomate, American Board of Obesity MedicineDirector, 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 18:49-65Puder & 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
Hebebrand, 2009, Child Adolesc Psychiatr Clin N Am 18:49-65
Prevalence of Disordered Eating in Different Weight Categories in 1,895 adolescents
Depression in Clinical Samples
Zeller et al, 2009, Obesity 17(5):985-90Hebebrand, 2009, Child Adolesc Psychiatr Clin N Am 18:49-65
• 39% of severely obese adolescents presenting for bariatric surgery have clinically significant depressive sx (BDI≥ 17)
• 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, 48:524-537Erermis 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
Adapted from Vander Wal & Mitchell, Pediatr Clin N Am. 2011; 58:1393-1401
Pediatric Obesity
Mental Illness
Demographics: age, gender, race/ethnicity, SESObesity stigma/bias
Maternal mental healthTrauma
Weight related teasing/bullying
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 Health9,374 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 depression
inflammation HPA axis
increased body dissatisfaction low self esteem
paininsufficient physical activity unhealthy eating patterns
sleep disturbancespsychotropic medications
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
Mediators Between Obesity and Depression
obesity depression
inflammation HPA axis
increased body dissatisfaction low self esteem
paininsufficient physical activity unhealthy eating patterns
sleep disturbancespsychotropic medications
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
HPA Axis
Mediators Between Obesity and Depression
obesity depression
inflammation HPA axis
increased body dissatisfaction low self esteem
paininsufficient physical activity unhealthy eating patterns
sleep disturbancespsychotropic medications
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
Mediators Between Obesity and Depression
obesity depression
inflammation HPA axis
increased body dissatisfaction low self esteem
paininsufficient physical activity unhealthy eating patterns
sleep disturbancespsychotropic medications
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
Mediators Between Obesity and Depression
obesity depression
inflammation HPA axis
increased body dissatisfaction low self esteem
paininsufficient physical activity
unhealthy eating patternssleep disturbances
psychotropic medications
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
Mediators Between Obesity and Depression
obesity depression
inflammation HPA axis
increased body dissatisfaction low self esteem
paininsufficient physical activity unhealthy eating patterns
sleep disturbancespsychotropic medications
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
Mediators Between Obesity and Depression
obesity depression
inflammation HPA axis
increased body dissatisfaction low self esteem
paininsufficient physical activity unhealthy eating patterns
sleep disturbancespsychotropic medications
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
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
depression
obesity
sleep deprivation
↓leptin↑grehlin
increased hunger
Mediators Between Obesity and Depression
obesity depression
inflammation HPA axis
increased body dissatisfaction low self esteem
paininsufficient physical activity unhealthy eating patterns
sleep disturbancespsychotropic medications
Luppino et al, 2010, Arch Gen Psychiatry, 67:220-229
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 ADHD2. 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 DisorderDSM 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