Childhood Obesity and Psychopathology

CLINICAL

The prevalence of overweight children in the United States has significantly increased over the past decade. Barlow and colleagues¹ report that currently more than 1 in 5 children are overweight or at risk for obesity. It is easy to blame the advancement of technology, the increase in sedentary activities, or other environmental aspects of our current society for the expanding obese population. However, there is a complex relationship between genetic, cultural, and psychological factors that researchers relate to the proliferation of obesity.²

In the United States, the continued growth of obesity in children is economically burdensome--the health care costs for obesity-related diseases such as sleep apnea and cardiovascular disease have tripled over the past 20 years.³ In addition, weight gain can often be emotionally and physically deleterious.³ The continuation of this current epidemic has major implications and consequences for future research in psychopathology.

Obesity is defined by the body mass index (BMI), which accurately reflects the excess body fat of an individual by dividing weight (kg) by height squared (m²). In addition, the BMI demonstrates a strong relationship between body fat and secondary complications of obesity and mortality.⁴ The National Center for Health Statistics, an organization designed to accumulate statistical information to be used as a resource when drafting health care policies, suggests that any child or adolescent who has a BMI greater than the 95th percentile for his or her age and sex is more prone to remain obese well into adulthood.⁵ These children are also more likely to experience obesity-related illnesses and higher rates of mortality.⁴ According to the current literature, a person with a BMI in the 95th percentile is classified as obese, and one with a BMI in the 85th percentile or above is classified as overweight.³

More than 300,000 deaths each year have been associated with obesity and obesity-related illnesses.⁶ The 1999-2000 National Health and Nutrition Examination Survey (NHANES) reported that more than 15% of children and adolescents aged 6 through 19 years were obese, as were 10% of children aged 2 through 5 years.⁷ The NHANES also reported the greatest incidence of weight gain among non-Hispanic black and Mexican American adolescents. Between 1988-1994 and 1999-2000, the prevalence of obesity in non-Hispanic black adolescents jumped from 13.4% to 23.6%, while the prevalence in Mexican American adolescents rose from 13.8% to 23.4%.⁷ In addition, compared with other ethnic groups, African American girls were more likely than any of their counterparts to be obese.⁵ Faced with the growing epidemic of obesity, psychiatrists should be familiar with certain established relationships between weight gain, obesity, and psychopathology.

A LINK BETWEEN OBESITY AND PSYCHOPATHOLOGY?

Some studies suggest psychiatric comorbidity as a contributor to weight gain and obesity, especially in those with mood, pain, and anxiety disorders.³ However, there are no definitive data at this time that demonstrate a strong relationship between the onset of psychiatric disorders and obesity. For instance, a study by Pesa and colleagues⁸ showed a significant decrease in the differences in psychopathology between obese and nonobese adolescent girls once body image dissatisfaction was controlled for.

Conversely, a longitudinal study by Pine and colleagues⁹ demonstrated a significant sex difference in psychiatric comorbidity in adolescents who became obese as adults. Ultimately, the study depicted a positive correlation between depression and obesity in females but not in males. In addition, the investigators found a positive correlation between conduct disorder in adolescence and weight gain in young adulthood. Furthermore, a study by Neumark-Sztainer and colleagues¹⁰ reported a higher incidence of suicidal thinking among severely overweight children.

Eating disorders

Eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorders, are more common in adolescents who are obese. Moreover, overweight adolescents are more likely to partake in chronic dieting behaviors that may lead to unhealthy weight loss as well as poor nutritional intake.¹⁰ In 2000, Britz and colleagues¹¹ reported a high incidence of eating disorders occurring simultaneously with mood and anxiety disorders. In several cases, patients believed that their social phobia was directly linked to their weight, while others claimed that mood and anxiety symptoms occurred during or after the onset of their eating disorders.¹¹ With such a high co-occurrence between obesity and psychiatric disorders, it is essential to look at the effects of medications on weight gain (see sidebar: "Psychiatric medications and weight gain").

Self-esteem and well-being

Weight gain also has many adverse side effects on a person's psychological well-being. For instance, a study by Rumpel and Harris¹² looked at a nonobese population of women and found that of those women who gained 11 pounds or more, a greater number were likely to have decreased feelings of well-being and higher negative affect.¹³ In addition, self-esteem and body image is a predominant struggle in obese children. Self-esteem is closely linked to weight and body image: the more severe a child's obesity, the lower his self-esteem. Two studies found that when body image was controlled for, self-reported self-esteem levels were not significantly lower in the obese population compared with healthy controls^8,14; however, that is not to say that there is no link between obesity and body image.

Often obese children are criticized and teased by their peers. This negative stigma creates lower self-esteem and is thought to be a contributor to body dissatisfaction in later life.³ In addition, self-esteem tends to vary based on gender. It has been reported that females are at greater risk for self-esteem problems since body image has more important social implications for young girls than for young boys.³ More important, constant dieting may lead to lower self-esteem in both adolescent and younger girls because of the cyclic nature of losing and regaining weight.³ In terms of treatment, the succession of gaining and losing weight is particularly problematic since the fluctuations can be emotionally draining.

TREATMENT

The most important factor for the successful treatment of obesity is a person's willingness to change his lifestyle. Family support, especially in children, tends to facilitate a successful weight loss program. Parental lack of concern that their child is overweight and parental belief that the child will never be able to shed the excess weight are clear indications that a weight-management program will be unsuccessful.⁴ Parental involvement and support are essential when treating obese children.

Current research suggests that children with active parents are 6 times more likely to be physically active themselves.¹⁵ According to the Expert Committee on Obesity Evaluation and Treatment, healthy eating and physical activity are essential for any weight-management program to be successful. It is imperative to understand that being physically active and eating wholesome foods may be learned behaviors and that eating and exercise patterns can therefore be changed. As previously stated, family influence and support, whether it is optimal motivation or the entire family changing eat-ing habits and activity levels, is critical to weight loss success.⁴ Additional behavioral treatments include goal setting, self-monitoring, and the development of skills for managing high-risk situations.³

The study by Barlow and colleagues¹ designed to recognize different types of obesity treatments used by health care providers reported a large variety of intervention methods. Most commonly reported in children was the use of a minimally restrictive intervention, in which specific foods were limited. Many of the physicians who responded to the questionnaire reported frequently referring their young patients to registered dietitians. These professionals may be useful in treating obesity in children; they provide an additional resource to primary care physicians and possess the counseling skills and time necessary to establish a unique dietary program based on the individual needs of the child.¹

An FDA-approved pharmacologic approach for sustained weight loss in children is still needed. Studies suggest that more weight is lost with pharmacologic agents than with behavioral treatments, but the weight is gained back once treatment is discontinued.³ Serotonin and norepinephrine reuptake inhibitors, as well as medicines that affect the dopamine system, are being investigated. As reported by Zametkin and colleagues,³ "topiramate, zonisamide, felbamate, and bupropion have been [found] to cause weight loss in adults," but further research on the effects of these drugs needs to be done before they can be administered to children.

Adults who underwent gastric bypass surgery for obesity have demonstrated enhanced self-esteem, improved social relationships, and more confidence in their appearance. However, many reported poor acquiescence with dietary and exercise instructions after the surgery. Although research suggests a decrease in weight, gastric bypass surgery for obesity is a risky procedure marked by a high complication rate.¹⁶

There is an abundance of literature on the treatments for pediatric obesity that goes well beyond the latitude of this article. Two additional pediatric reviews that expand on treatments for obesity are articles by Epstein and colleagues¹⁷ and Jelalian and Saelens.¹⁸

Currently there is no "cure" for obesity. It has been suggested that future trends and research goals should focus on prevention and should target minority populations that are most at risk for becoming obese. To be successful, it is essential that prevention efforts are supported by public policy. In addition, parental involvement is critical in shaping behaviors as well as the dietary and activity levels of their children. Before attempting to impose calorie-restricted diets, more research should be done on how to permanently modify activity levels and food choices.³

For now, there continues to be a long-standing debate over effective treatment that will lead to long-term success. Researchers, physicians, and parents need to take into account the potential psychosocial outcomes of treatment and the effects of failure on a child's emotional well-being.³

In conclusion, most obese children and adolescents do not have a psychiatric disorder, although some do. For those who do, an informed psychiatric evaluation and care are crucial.

Psychiatric medications and weight gain

Of all the adverse effects experienced while taking medication, the most common reason for discontinuing treatment is an increase in weight over a short period of time.¹⁹ There is strong evidence that some medications used to treat psychiatric disorders may cause weight gain in adults. Although little research has been done with children, it can only be assumed that these trends would be similar to those that have been noted in adults.³ The most common drugs associated with weight gain are the antidepressants--lithium, tricyclics, and monoamine oxidase inhibitors--and antipsychotics such as clozapine, olanzapine, and risperidone.³

A case study by Horrigan and colleagues²⁰ in 2001 focused on an adolescent boy who had attention-deficit/hyperactivity disorder and who gained weight while being treated with olanzapine. When his doctors switched him to dextroamphetamine/amphetamine mixed salts, he was able to lose weight by taking it before meals.

Gothelf and colleagues²¹ reported a significant weight increase in adolescents with schizophrenia who were taking olanzapine compared with those given haloperidol. Sachs and Guille²² reported that about 25% of their patients treated with lithium experienced such a significant weight gain that they were classified as obese. Other research findings suggest that in patients treated with lithium, weight gain was seen more frequently in those patients who were already overweight, and it was more common in women than in men.²²

As with other previously mentioned drugs, the amount of weight gained or lost is patient-dependent.²² Psychiatrists need to be alert when starting patients on medications that are known to cause weight gain. Careful weight monitoring is critical in patients who are treated with psychiatric medications.

Michelle Gilchrist is a candidate for a bachelor of arts in psychology at the University of Rochester in Rochester, New York. She reports that she has no conflicts of interest concerning the subject matter of this article.

Dr Zametkin is a senior clinical staff physician at the National Institute of Mental Health in Bethesda, Maryland. He reports that he has no conflicts of interest concerning the subject matter of this article.This article was not written as part of Dr Zametkin's official duties as a government employee, and the views expressed herein do not necessarily represent the views of the NIMH, MIH, HHS, or the United States government.

References:

1. Barlow SE, Trowbridge FL, Klish WJ, Dietz WH. Treatment of child and adolescent obesity: reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics. 2002;110:229-235.
2. Fitzgibbon M. Commentary on psychiatric aspects of child and adolescent obesity: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2004;43: 151-153.
3. Zametkin AJ, Zoon CK, Klein HW, Munson S. Psychiatric aspects of child and adolescent obesity: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 2004;43:134-150.
4. Barlow SE, Dietz WH. Obesity evaluations and treatment: expert committee recommendations: the Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics. 1998;102:E29.
5. National Center for Health Statistics. Prevalence of Overweight Among Children and Adolescents: United States, 1999. Available at: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/overwght99.htm. Accessed August 1, 2006.
6. Goodman E, Whitaker RC. A prospective study of the role of depression in the development and persistence of adolescent obesity. Pediatrics. 2002;110: 497-504.
7. Ogden CL, Flegal KM, Carroll MD, Jonson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288: 1728-1732.
8. Pesa JA, Syre TS, Jones E. Psychosocial differences associated with body weight among female adolescents: the importance of body image. J Adolesc Health. 2000;26:330-337.
9. Pine DS, Cohen P, Brook J, Coplan JD. Psychiatric symptoms in adolescence as predictors of obesity in early adulthood: a longitudinal study. Am J Public Health. 1997;87:1303-1310.
10. Neumark-Sztainer D, Story M, French SA, et al. Psychosocial concerns and health compromising behaviors among overweight and nonoverweight adolescents. Obes Res. 1997;5:237-249.
11. Britz B, Siegfried W, Ziegler A, et al. Rates of psychiatric disorders in a clinical study group of adolescents with extreme obesity and in obese adolescents ascertained via a population based study. Int J Obes Relat Metab Disord. 2000;24:1707-1714.
12. Rumpel C, Harris TB. The influence of weight on adolescent self-esteem. J Psychom Res. 1994;38: 547-556.
13. Kawachi I. Physical and psychological consequences of weight gain. J Clin Psychiatry. 1999;60(suppl 21): 5-9.
14. French SA, Story M, Perry CL. Self-esteem and obesity in children and adolescents: a literature review. Obes Res. 1995;3:479-490.
15. Moore LL, Lombardi DA, White MJ, et al. Influence of parents' physical activity levels on activity levels of young children. J Pediatr. 1991;118:215-219.
16. Rand CS, Macgregor AM. Adolescents having obesity surgery: a 6-year follow-up. South Med J. 1994;87: 1208-1213.
17. Epstein LH, Myers MD, Raynor HA, Saelens BE. Treatment of pediatric obesity. Pediatrics. 1998;101: 554-570.
18. Jelalian E, Saelens BE. Empirically supported treatments on pediatric psychology: pediatric obesity. J Pediatr Psychol. 1999;24:223-248.
19. Masand P. Weight gain with psychotropics: size does matter. J Clin Psychiatry. 1999;60(suppl 20):3-4.
20. Horrigan JP, Barnhill LJ, Kohli RR. Adderall, the atypicals, and weight gain. J Am Acad Child Adolesc Psychiatry. 2001;40:620.
21. Gothelf D, Falk B, Singer P, et al. Weight gain associated with increased food intake and low habitual activity levels in male adolescent schizophrenic inpatients treated with olanzapine. Am J Psychiatry. 2002;159: 1055-1057.
22. Sachs GS, Guille C. Weight gain associated with use of psychotropic medications. J Clin Psychiatry. 1999;60 (suppl 21):16-19.