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