1. Obesity and Mental Illness: Cause or Effect
Claudia Fox, MD MPH
Diplomate, American Board of Obesity Medicine
Director, Pediatric Weight Management Program

2. 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.

3. 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.”

4. 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.”

5. Objectives
Identify the prevalence of mental illness among youth with obesity
Understand the cause and effect relationship between mental illness and obesity
Identify the implications of mental illness in the treatment of obesity

6. Most Studied Psychiatric Conditions Among Obese Individuals
Depression
ADHD
Binge Eating Disorder (BED)

7. Objectives
Identify the prevalence of mental illness among youth with obesity
Understand the cause and effect relationship between mental illness and obesity
Identify the implications of mental illness in the treatment of obesity

8. Rates of Psychological Complications in People with Obesity are Uncertain

9. Rates of Psychological Complications in People with Obesity are Uncertain
Other considerations:
Age, gender
Severity of obesity
Psychiatric definitions – rating scales, interviews, questionnaires
Distinguish between population-based samples and clinical samples of children with obesity

10. 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

11. 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
In a national US survey of more than 6500 adolescents , there was a strong positive association between BMI and disordered eating. The prevalence of binge purge cycling was highest in obese and overweight girls. (Commonwealth Fund Survey)

12. 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

13. Depression in Clinical Samples
Zeller et al, 2009, Obesity 17(5): Hebebrand, 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

14. 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:
Erermis et al, 2004, Pediatr Int, 46:
Systematic review of the literature identified 4 studies conducted in clinical setting which support higher than expected prevalence of ADHD in obese subjects

15. BED in Clinical Samples
126 youth age 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:

16. Objectives
Recognize the prevalence of mental illness among youth with obesity
Understand the cause and effect relationship between mental illness and obesity
Identify the implications of mental illness in the treatment of obesity
Focus on mood disorders, adhd and bed; could also consider stress and trauma

17. 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)

18. Context Demographics: age, gender, race/ethnicity, SES
Adapted from Vander Wal & Mitchell, Pediatr Clin N Am. 2011; 58:
Demographics: age, gender, race/ethnicity, SES
Obesity stigma/bias
Maternal mental health
Trauma
Weight related teasing/bullying
Overall, the association between childhood obesity and psychological complications is not as strong as one would expect. Rather, the strength of the association depends on important mediating characteristics. For eg, self esteem decreases as children get older, girls tend to have more body dissatisfaction and low self esteem compared to boys, self esteem issues are more prevalent among white girls compared to AA or Hispanic girls.
Stigma may lead to social isolation, decreased activity and greater over consumption of food as a misguided coping strategy
Pediatric Obesity
Mental
Illness

19. Weight-related Teasing Increases Psychological Complications
Eisenberg et al, 2003, Arch Pediatr Adolesc Med, 157(8):733-8

20. Depression and Obesity
Of the psychological comorbidities associated with obesity, most research has been done on depression
Getty Images/Sean Murphy

21. 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:
Bidirectional association between depression and obesity: obese persons had a 55% increased risk of developing depression over time, whereas depressed person had a 58% increased risk of becoming obese.
The association between depression and obesity was stronger than the assoc between depression and overweight, reflecting a dose response gradient

22. 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
Even after adjusting for confounders: baseline BMI, age, race, gender, parental obesity, numbe rof parents in home , SES, somking, PA, conduct disorder, self esteems, and deqlinquent behavior, but could be another confounder???

23. 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):

24. Mediators Between Obesity and Depression
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
obesity
depression
Inflammation: obesity can be seen as an inflammatory state as weight gain has been shown to activate inflammatory pathways and inflammation in turn, has been associated with depression.
HPA axis: fairly well known that children with high stress levels have high cortisol and increased catecholamine levels. Glucocorticoids induce insulin resistance with resultant fat accumulation, and leptin resistance. There have been some small studies that also suggest that the obese state may alter the metabolism of cortisol, leading to HPA axis dysregulation which in turn is associated with depression.
Perceived overweight may contribute to obesity
In US, thinness in consdered a beauty idea, obesity may incerease body idssatifaction and decrease se with are rf ofr depressioniabetes and IR can induce alteration in the brain
Luppino et al, 2010, Arch Gen Psychiatry, 67:

25. Mediators Between Obesity and Depression
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
obesity
depression
Inflammation: obesity can be seen as an inflammatory state as weight gain has been shown to activate inflammatory pathways and inflammation in turn, has been associated with depression.
Perceived overweight may contribute to obesity
In US, thinness in consdered a beauty idea, obesity may incerease body idssatifaction and decrease se with are rf ofr depressioniabetes and IR can induce alteration in the brain
Luppino et al, 2010, Arch Gen Psychiatry, 67:

26. HPA Axis
Increased cortisol leads to increased insulin secretion which contributes to accumulation of fat.
HPA dysregulation is well known to be involved in depression
HPA axis: fairly well known that children with high stress levels have high cortisol and increased catecholamine levels. Glucocorticoids induce insulin resistance with resultant fat accumulation, and leptin resistance. There have been some small studies that also suggest that the obese state may alter the metabolism of cortisol, leading to HPA axis dysregulation which in turn is associated with depression.

27. Mediators Between Obesity and Depression
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
obesity
depression
Inflammation: obesity can be seen as an inflammatory state as weight gain has been shown to activate inflammatory pathways and inflammation in turn, has been associated with depression.
HPA axis: fairly well known that children with high stress levels have high cortisol and increased catecholamine levels. Glucocorticoids induce insulin resistance with resultant fat accumulation, and leptin resistance. There have been some small studies that also suggest that the obese state may alter the metabolism of cortisol, leading to HPA axis dysregulation which in turn is associated with depression.
Perceived overweight may contribute to obesity
In US, thinness in consdered a beauty idea, obesity may incerease body idssatifaction and decrease se with are rf ofr depressioniabetes and IR can induce alteration in the brain
Luppino et al, 2010, Arch Gen Psychiatry, 67:

28. Mediators Between Obesity and Depression
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
obesity
depression
Inflammation: obesity can be seen as an inflammatory state as weight gain has been shown to activate inflammatory pathways and inflammation in turn, has been associated with depression.
HPA axis: fairly well known that children with high stress levels have high cortisol and increased catecholamine levels. Glucocorticoids induce insulin resistance with resultant fat accumulation, and leptin resistance. There have been some small studies that also suggest that the obese state may alter the metabolism of cortisol, leading to HPA axis dysregulation which in turn is associated with depression.
Perceived overweight may contribute to obesity
In US, thinness in consdered a beauty idea, obesity may incerease body idssatifaction and decrease se with are rf ofr depressioniabetes and IR can induce alteration in the brain
Luppino et al, 2010, Arch Gen Psychiatry, 67:

29. Mediators Between Obesity and Depression
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
obesity
depression
Inflammation: obesity can be seen as an inflammatory state as weight gain has been shown to activate inflammatory pathways and inflammation in turn, has been associated with depression.
HPA axis: fairly well known that children with high stress levels have high cortisol and increased catecholamine levels. Glucocorticoids induce insulin resistance with resultant fat accumulation, and leptin resistance. There have been some small studies that also suggest that the obese state may alter the metabolism of cortisol, leading to HPA axis dysregulation which in turn is associated with depression.
Perceived overweight may contribute to obesity
In US, thinness in consdered a beauty idea, obesity may incerease body idssatifaction and decrease se with are rf ofr depressioniabetes and IR can induce alteration in the brain
Luppino et al, 2010, Arch Gen Psychiatry, 67:

30. Mediators Between Obesity and Depression
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
obesity
depression
Inflammation: obesity can be seen as an inflammatory state as weight gain has been shown to activate inflammatory pathways and inflammation in turn, has been associated with depression.
HPA axis: fairly well known that children with high stress levels have high cortisol and increased catecholamine levels. Glucocorticoids induce insulin resistance with resultant fat accumulation, and leptin resistance. There have been some small studies that also suggest that the obese state may alter the metabolism of cortisol, leading to HPA axis dysregulation which in turn is associated with depression.
Perceived overweight may contribute to obesity
In US, thinness in consdered a beauty idea, obesity may incerease body idssatifaction and decrease se with are rf ofr depressioniabetes and IR can induce alteration in the brain
Luppino et al, 2010, Arch Gen Psychiatry, 67:

31. Mediators Between Obesity and Depression
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
obesity
depression
Inflammation: obesity can be seen as an inflammatory state as weight gain has been shown to activate inflammatory pathways and inflammation in turn, has been associated with depression.
HPA axis: fairly well known that children with high stress levels have high cortisol and increased catecholamine levels. Glucocorticoids induce insulin resistance with resultant fat accumulation, and leptin resistance. There have been some small studies that also suggest that the obese state may alter the metabolism of cortisol, leading to HPA axis dysregulation which in turn is associated with depression.
Perceived overweight may contribute to obesity
In US, thinness in consdered a beauty idea, obesity may incerease body idssatifaction and decrease se with are rf ofr depressioniabetes and IR can induce alteration in the brain
Luppino et al, 2010, Arch Gen Psychiatry, 67:

32. Appetite Hormones
Leptin – primary satiety hormone; produced mainly by adipoctyes; produced in periphery and feeds back to hypothalamus to induce satiety.
Grehlin – produced by stomach, hunger hormone, feeds back to hypothalamus to increase appetite and eating

33. “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:
Leptin normally operates via a negative feedback loop in which it upregulates feedback to the brain to increase satiety and decrease its own production. In

34. Obesity-Sleep-Depression
sleep deprivation
↑grehlin
↓leptin
increased hunger
depression

35. Mediators Between Obesity and Depression
inflammation
HPA axis
increased body dissatisfaction
low self esteem
pain
insufficient physical activity
unhealthy eating patterns
sleep disturbances
psychotropic medications
obesity
depression
Inflammation: obesity can be seen as an inflammatory state as weight gain has been shown to activate inflammatory pathways and inflammation in turn, has been associated with depression.
HPA axis: fairly well known that children with high stress levels have high cortisol and increased catecholamine levels. Glucocorticoids induce insulin resistance with resultant fat accumulation, and leptin resistance. There have been some small studies that also suggest that the obese state may alter the metabolism of cortisol, leading to HPA axis dysregulation which in turn is associated with depression.
Perceived overweight may contribute to obesity
In US, thinness in consdered a beauty idea, obesity may incerease body idssatifaction and decrease se with are rf ofr depressioniabetes and IR can induce alteration in the brain
Luppino et al, 2010, Arch Gen Psychiatry, 67:

36. Weight Gain and Atypical Antipsychotic Medications
Taylor & McAskill, 2000, Acta Psychiatr Scand, 101:

37. ADHD and Obesity

38. ADHD and Obesity Obesity leads to ADHD
ADHD and obesity are expressions of a common biological dysfunction in a subset of patients with both
ADHD contributes to obesity
Cortese et al, 2008, Crit Rev Food Sci Nut, 48:
Obesity or factors associated with obesity lead to or manifest as sx of ADHD
ADHD contributes to the development of obesity

39. 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:
Cortese et al, 2007, Int J Obes, 31:
Has been reported that pt with bulimic or abnormal eating behaviors may present with repeated and impulsive interruptions of their activities in order to get food, resulting in adhd sx such as disorganization, inattention, and restlessness

40. 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:
That dysfunciton is the reward dificincy syndrome characterized by insufficinat DA related natural reward that leasd to the use of “unnatural” immediatre rewards like Substancuse use, gambing, inappropriate eatinging; associatd with alteration in the D2 receptor in prefrontal attentional areas

41. 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:
Deficint inihibitory condotl could manifest as poor planning and could lead oto over consumption when not hungery
Strong delay aversion could favor tendency to eat fast food instead of preparing a meal
Deficints in attn or executive funch such as planning migh cause difficulty in adhereing to regular eating patterns
May be inattentive to internal cues of hunger or satiety

42. Binge Eating Disorder and Obesity

43. 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
Eating an amount of food that is definitely larger than most people would eat during a similar period of time

44. 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:
self reported ingestion of largg amots of food is not associeated with with increased psychological morbidity

45. 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

46. 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:

47. Objectives
Recognize the prevalence of mental illness among youth with obesity
Understand the cause and effect relationship between mental illness and obesity
Identify the implications of mental illness in the treatment of obesity

48. Does Weight Management Cause Eating Disorders?

49. 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

50. 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:

51. 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:

52. Screening Screen children with obesity for mental illnesses
(Screen children with mental illness for obesity)

53. Address Psychosocial Factors in the Environment
May be that addressing psychosocial elements, eg peer environment, could improve outcomes of obesity treatment
Expansion of after school programs encourage engagement and may address some mediating factors between obesity and mental illness

54. Identify Context of Overeating
Emotional eating
Binge eating
Impulsive eating

55. 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:
Cortese et al, 2007, Nut Rev, Sept,
Individual therapy, CBT, mindfulness based strategies

56. 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,
Atomoxetine effective in weight reduction in obese women

57. 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

58. Address the Mind and the Body