A Clinical Guide to Pediatric Weight Management and Obesity, 1st Edition
Mental Health Issues
There is a complex relationship between obesity and psychological morbidity.
Psychological conditions can (a) predict later obesity, (b) be consequences of obesity (c) be associated with obesity, and (d) affect obesity treatment. This is not surprising, considering the intricacies of energy regulation, which depends on the ability to regulate eating behavior, hunger, affective states, and interactions with the nutritional environment as well as maintain a balance between physical activity and inactivity, all factors that are vulnerable when mental and social health is impaired (Fig. 13.1).
In childhood, factors such as poverty, social stress, and parental neglect have been found to predict adult body mass index (BMI) (1). These social factors also correlate
with child psychopathology. In a longitudinal study, childhood depression was correlated with an increased adult BMI even though there was no difference in childhood BMI between those children who were depressed and nondepressed controls (2). Lissau and Sorensen (2) suggest that parental neglect may cause a psychological state that affects energy balance by either altering behavior that causes overeating and physical inactivity or altering hormonal balance that influences fat storage. It is known that the physiologic reaction to stress is to increase cortisol production, which alters glucose homeostasis, and this may affect eating behavior at the level of the central nervous system in an attempt to reverse stress-induced effects (3).
FIG. 13.1. The complex relationship between obesity and psychosocial morbidity.
Depression has clearly been shown to precede the development of obesity.
In a longitudinal study of adolescents in New Zealand, depression in girls in late adolescence conferred a twofold risk of obesity at age 26 years. The risk of adult obesity was also related to the number of episodes of depression these girls experienced. These relationships were not found in boys or in girls in early adolescence (4). In another study of 7th- to 12th-grade adolescents, depressed mood predicted follow-up obesity 1 year later. In contrast, baseline obesity did not predict follow-up depression (5).
Dysregulated eating behavior may also be a risk factor for obesity. In a study of adolescent girls surveyed yearly over 4 years, self-reported dietary restraint, radical weight control behaviors, depressive symptoms, and perceived parental obesity predicated obesity onset. Of interest in this study is that the consumption of high-fat food, binge eating, and exercise frequency were not predictive of later obesity (6). Dysregulated eating may also be a symptom of family stress and/or parental physical or psychological illness.
A negative or low self-concept may predispose children and adolescents to obesity.
In a Canadian population study of adolescents, girls and young adolescents who had a weak self-concept had an increased incidence of depression when studied longitudinally. Low self-concept also predicted physical inactivity among boys and obesity among both boys and girls. Self-esteem was lower among girls than boys (7).
Obese children and adolescents can develop psychosocial morbidity, which includes the following:
- Low self-esteem
- Poor school and social functioning
- Social isolation
In a study of 7th- to 12th-grade adolescents, younger but not older, overweight and obese adolescents ages 12 to 14 had an increased rate of depression, low self-esteem, and poor school and social functioning. Overweight and obese adolescents of all ages had worse self-reported health and functional limitations (8). Overweight adolescents were more likely to be socially isolated than normal weight peers and to have fewer friends. Behaviors not uncommonly seen in obese adolescents, such as increased television viewing and lower sports and club participation, were found to contribute to social isolation in both overweight and normal weight teens (9). One third of obese children and adolescents who sought treatment at an obesity clinic self-reported difficulties with social function and low self-esteem as well as with internalizing symptoms (10).
Overweight and obesity carry social consequences, which are often linked to psychological morbidity.
Women who had been overweight at ages 16 to 24 in follow-up 7 years later had completed fewer years of school, were less likely to be married, had lower household incomes, and had higher rates of household poverty than the women who had not been overweight, independent of their baseline socioeconomic status and aptitude test scores. Men who had been overweight were less likely to be married (11).
Obesity is also a risk factor for bullying from peers. Associations have been found between BMI and peer victimization, such as withdrawing friendship, spreading rumors or lies, name-calling, teasing, and peer aggression—hitting, kicking or pushing in girls, and verbal bullying in boys. In contrast, obese boys and girls in the older age groups (15 to 16 years) were more likely to perpetrate bullying than normal weight peers (12).
Overall quality of life is often compromised in children and adolescents who are obese.
The likelihood of having impaired health-related quality of life is 5.5 times greater in obese children and adolescents than in normal weight peers.
Obese children reported lower health-related quality of life scores in all domains—physical, psychosocial, emotional, social, and school functioning—than normal weight children and adolescents. Parents of obese children scored them even lower in these domains (13).
Children diagnosed with depression, bipolar disease, and anxiety disorders may be at increased risk for developing obesity. (14). A review of the literature to determine
the association of mood disorders and obesity found that children and adolescents with major depression are at risk for developing overweight. Patients with bipolar disease may have higher than average rates of overweight, obesity, and abdominal obesity (14).
In consequence, an increased incidence of psychological comorbidity may be found in children and families who seek treatment for obesity.
In a study from Turkey of children and adolescents in obesity clinic, about 40% of patients were found to have an anxiety disorder. There was no correlation between the degree of obesity in the child or parents and the frequency of psychiatric disorders. When compared with children with type 1 diabetes, obese children had higher internalized and externalized score and poorer social skills (15).
Patterns of obesity are also associated with specific mental health problems and point to the importance of a longitudinal understanding of the weight gain trajectory. In a longitudinal study of children and adolescents in Appalachia, four weight gain trajectories were identified: normal weight following the standard growth curves, obesity developing in childhood that resolved in adolescence, obesity developing in adolescence, and obesity that developed in childhood and continued through adolescence (chronic obesity). These obesity trajectories were associated with the risk of psychological morbidity. Children who were chronically obese, comprising 15% of the study population, had a greater incidence of oppositional defiant disorder in both girls and boys and a significantly greater rate of depression in boys compared with normal weight boys. Interestingly, there was no difference among the children with various obesity trajectories in gender, family structure, parenting style, family history of mental illness, drug abuse, crime, or traumatic events. Both chronic obesity and childhood obesity were associated with having less educated parents and low family income (16).
Obese children and adolescents are a heterogeneous population with respect to psychological morbidity.
In a study of an obesity clinic population, children who were depressed had a lower self-esteem than children who were not depressed. As depression increased, self-esteem decreased. Depressed children had increased anxiety and had more perceived behavior problems, such as increased frequency of punishment and difficulty in obeying orders, than nondepressed obese patients. Children in the depressed group also had fewer interests in school and thought their physical appearance was not acceptable. Depression in this group of obese patients did not correlate with age, race, sex, Tanner stage, socioeconomic status, or BMI (17).
Specific eating behaviors may be associated with psychological morbidity. Binge eating is not uncommon in patients with obesity. Adolescents in an obesity treatment program with binge eating had higher levels of depression and anxiety than did adolescents with no binge eating symptoms, as well as lower levels of self-esteem and body-esteem (18). In a group of overweight children (6–10 years) who were not in treatment, one third experienced episodes of loss of control over eating. These children weighed more and had greater body fat than children who did not experience loss of control. They were more likely to be depressed and anxious and had increased body dissatisfaction than children without loss of control. Among these children 5.3% met the criteria for binge eating disorder. These episodes were sporadic and contextual and involved usual foods (19).
Attention deficit disorder (ADD) has been identified as an obesity-related comorbidity. In obese adults in a weight treatment program, the prevalence of ADD was 27.4% and increased to 42.6% in patients with a BMI greater than 40 (20).
In a hospital-based obesity treatment program, more than one half (57.7%) of the obese patients suffered from comorbid attention deficit hyperactivity disorder (ADHD), and the authors speculate that “the characteristic difficulty in regulation found in ADHD may be a risk factor for the development of abnormal eating behaviors leading to obesity” and the authors suggested that “obese children should be screened routinely for ADHD” (21).
Impact on Therapy
Coexisting psychological conditions, such as stress and depression, can affect food choices and may interfere with behavior change toward a healthier diet. Sweet, energy-dense, high-fat foods can improve mood and mitigate some of the effects of stress and in vulnerable individuals can be self-reinforcing choices (22).
Intervention and therapy for obesity focuses on family-based lifestyle intervention, and children and parents who suffer from depression, anxiety, bipolar illness, and ADD have additional obstacles to overcome in implementing treatment. In a study of children and adolescents in an obesity treatment program, 55% of patients withdrew from treatment. They were more likely to be Medicaid recipients, black, older, and self-report greater depressive symptomatology and lower self-concept (23). In adults, mean weight loss in obese patients with ADD was about one half of those who did not have ADD. Obese adult patients with ADD had more clinic visits and longer treatment duration (20).
Family function can affect treatment, and attention should be paid not only to the child's and adolescent's psychosocial difficulties but also to those of the family. In a study of obese children and adolescents, 41% of children's mothers and 56% of
adolescents' mothers reported clinically significant psychological distress. The child's and adolescent's reports of psychological difficulties were strongly associated with the mother's level of psychological distress and/or family socioeconomic status (24).
Family Factors Can also be Somewhat Protective
Family connectedness, parental expectations, and moderate levels of parental monitoring seemed to reduce unhealthy behavior and psychosocial distress (25). Psychosocial factors in obese children and families are common and can be predictive, associated, and/or consequences of obesity. It is important to identify both psychosocial risks and resilience in children, adolescents, and their families so that treatment can be instituted and implementation of lifestyle change can be successful.
GR is a 15-year-old African American boy who comes for a “check-up” because his parents are worried about his decreased energy. Two months ago, his parents had taken him to a psychiatrist, and he was diagnosed with depression and was prescribed fluoxetine (Prozac). His mother is overweight and has recently been diagnosed with diabetes; she has begun insulin therapy, and she says this has really upset GR. His weight at this examination is 106.2 kg (>95th percentile) and his height is 174.8 cm (75th percentile), with a BMI of 35.6 (>95th percentile). Blood pressure is 125/70 mm Hg (<90th percentile). His mother and father are both obese, as are his two older brothers, whose BMIs range from 28 to 35. His family history is positive for diabetes in a paternal grandmother as well as in his mother. Hypertension is a problem for all the great aunts and uncles on his father's side of the family, and his maternal grandfather has cardiovascular disease. One of his brothers has been diagnosed with attention deficit disorder; his maternal grandmother has obsessive-compulsive disorder and depression.
You review his diet history and discover that he is skipping breakfast (no time to eat), buying a school lunch, and eating one to two portions of dinner. He is drinking “a lot” of soda and juice between meals and is snacking at night. He is busy with extracurricular activities, which include the school newspaper and yearbook but is not playing any sports and is watching the television or using the computer “all the time” when he is at home. His parents are concerned about his behavior and report that GR frequently argues with them, daydreams, and demands a lot of attention. He seems to be jealous of his brothers, has low self-esteem, and can be very stubborn. His school performance is declining, and he has recently been put on academic probation. When you ask about homework, GR says he is “not doing any.”
He has been getting headaches, and his parents have taken him to a neurologist. His headaches are stress headaches, but his parents are wondering if he has visual integration problems. He has asthma and uses an inhaler as needed. Physical examination
reveals that he is a Tanner 5 and has abdominal striae. You acknowledge the parents' concerns about GR's behavior and fatigue and raise the issue of his weight. You decide to order laboratory tests, and you work out a time to see the family in 2 weeks to discuss the results and begin working on a plan for GR.
Two Weeks Later
Two weeks later GR and his mother return, and you review his laboratory studies, which show an elevated fasting total cholesterol of 195 mg/dL. His fasting glucose was normal at 86 mg/dL and his insulin was normal at 14 µU/mL. His thyroid studies and liver enzymes were also within normal limits. You discuss the fact that medically GR is at risk for cardiovascular disease and diabetes based on the family history and that his weight has a direct impact on his risk. This worries GR, especially because his mother already has diabetes. His risk for cardiovascular disease is very much on his mother's mind because his maternal grandfather was just diagnosed with heart failure.
You review the multiple factors that may be influencing GR's weight gain, which include a positive family history of obesity. His parents clearly feel that his inactivity is a major factor in his weight gain, and they are concerned about his lack of energy. They do not really see diet as a problem; GR notes that the fluoxetine has helped him feel less hungry and decrease his night-time eating. You note that depression can be associated with weight gain but also discuss that his decline in school performance, trouble finishing homework, and difficulty with concentration may mean that he also has ADD, especially in light of the positive family history. You suggest that ongoing counseling would be helpful. GR's mother agrees to discuss this with his psychiatrist.
You point out that lack of timed meals and snacks and dysregulated eating work against weight loss. Time management becomes an issue as it relates to the balance between homework, inactivity, and activity and the need for a schedule. As you, GR, and his mother begin to discuss structure and planning meal times, menus, and physical activity, his mother says she thinks she has trouble providing structure because she may have ADD herself; you encourage her to explore this diagnosis.
You work with GR and his mother to set the first goal as weight stabilization using family-based change to institute small changes in nutrition, activity, and inactivity and to remove obstacles to behavior change. The family will set standard meal times and GR will try to have three meals and one after school snack daily. GR agrees, as long as he can still order a school lunch. They will also eliminate calorie-containing juice and soda from the home (an additional benefit for the mother, who has diabetes). He will try to work with a study schedule to finish homework and create opportunities for activity and agrees to begin walking 15 minutes daily. Neither he nor his mother could see any way to limit television or computer time.
You are also continuing to address his other medical follow-up by having him keep diet records to track fat intake to monitor his elevated cholesterol. You arrange a follow-up appointment in 1 month.
One Month Later
One month later the family has canceled the appointment because of the death of the maternal grandfather. On the phone, mom reports that GR initially followed his diet changes and walking program, but this was disrupted by the loss of his grandfather and his family's distress. She notes that GR did see his psychiatrist for evaluation of possible ADD; the diagnosis was made, and he was started on Adderall XR and was still taking his fluoxetine.
Two Months Later
GR returns 1 month later. His weight is 100.4 kg, a decrease of 5.8 kg, and his BMI is 33.4, a decrease of 2.2. His waist measurement is down by 2 in. He reports that he has cut back “drastically” on regular soda consumption; he is trying to make better choices when he eats at restaurants and is trying to find a safe place to walk (his mother is concerned about the neighborhood). He reports that his mood is stable and he is still in counseling. You congratulate GR on his progress and ask if he can continue the changes he has made. You also give him some information on increasing the fiber in his diet and encourage him to try to limit his television/computer time by 1 hour per day. You also spend some time discussing his grief at his grandfather's death.
GR misses his next appointment because of the school's concerns about his missed days, but his mother calls and reports that his medications have been changed to methylphenidate (Concerta), dexmethylphenidate (Focalin), and bupropion (Wellbutrin). She reports that school continues to be stressful, but his mood has improved and his interest in school and activities has increased.
Sixteen weeks after his initial visit, GR returns to the office. He has lost a total of 17.8 lb, and his BMI is 32.3, a decrease of 3.3. His cholesterol is now 184 mg/dL. He plans to increase his walking and continue the changes he has made in his eating schedule and food choices.
You have him check in with a nutritionist to continue support for his nutritional decision making and arrange to see him in 2 months.
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