Childhood and adolescent obesity and depression: A systematic literature review

Childhood and adolescent obesity and depression: ISSN: 2394-0026 (P) A systematic literature review ISSN: 2394-0034 (O)Review ArticleChildhood and adolescent obesity anddepression: A systematic literature reviewPriyank J. Yagnik*1, 2, David P. McCormick1, Naveed Ahmad3, 4, Arnold J. Schecter2, T. Robert Harris2 1 Department of Pediatrics, University of Texas Medical Branch at Galveston, TX, USA2 University of Texas School of Public Health at Southwestern Medical Center, Dallas, TX, USA 3 University of Texas Southwestern Medical Center, Dallas, TX, USA 4 Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS, USAAbstractChildhood and adolescent obesity is a major health concern worldwide. This review summarizes thecurrent literature on the association between childhood and adolescent obesity and depression.Multiple scientific databases (PubMed, Ovid, Web of Science, CINAHL and PsycINFO; January 1990 toApril 2011) were searched for articles focusing on the association between childhood and adolescentobesity and depression. Inclusion criteria were age ≤ 19 years and studies published in English ortranslated into English. Fifty-one articles were identified including 19 prospective cohort studies, onerandomized controlled trial and one meta-analysis. Fifteen prospective cohort studies reported thatchildhood obesity is associated with depression, whereas three prospective cohort studies, onesystematic literature review, and one meta-analysis showed that childhood depression leads tofuture obesity. Some cross-sectional studies found no association between childhood obesity anddepression. Compared with boys, obese girls are more likely to be depressed. Depression isassociated with increased actual body weight, but this relation is also mediated through perceivedbody weight and dissatisfaction with body image. The majority of studies have shown that childhoodand adolescent obesity is associated with depression. Studies have also shown that childhooddepression leads to future obesity. Clinicians should be aware of this association and provide mentalhealth assessment, obesity prevention, and treatment when indicated.Key wordObesity, Overweight, Pediatric, Adolescent, Depression, Mood disorder. *Corresponding Author: Priyank J. Yagnik E mail: [email protected] on: 04-10-2014 How to cite this article: Priyank J. Yagnik, David P. McCormick, NaveedAccepted on: 09-10-2014 Ahmad, Arnold J. Schecter, T. Robert Harris. Childhood and adolescent obesity and depression: A systematic literature review. IAIM, 2014; 1(2): 23-33. Available online at www.iaimjournal.comInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 23Copy right © 2014, IAIM, All Rights Reserved.

Childhood and adolescent obesity and depression: ISSN: 2394-0026 (P)A systematic literature review ISSN: 2394-0034 (O)Background Services has targeted overweight and obesity as a major public health issue needing to beObesity has become a major public health prevented as per www.healthypeople.gov.concern throughout the world [1, 2]. Obesity is Childhood obesity has emerged as a majordefined in terms of body mass index (BMI), public health concern because of its variouswhich is calculated as body weight in kilogram health consequences in adulthood, such as highdivided by height in meter squared (kg/m2). For cholesterol levels, hypertension, type IIchildren and adolescents (age 2-19 years), diabetes, asthma, fatty liver and sleep apneaoverweight is defined as age-specific BMI [13, 14, 15, 16]. Obesity also predisposesbetween 85th and 95th percentile, and obesity as children to low self-esteem [17, 18, 19, 20],BMI ≥ 95th percentile [3]. According to World body dissatisfaction [19, 21, 22, 23] andHealth Organization data, the worldwide depression [24, 25]. Adolescence is a criticalprevalence of overweight among adults was 1.5 phase when individuals experience dramaticbillion and that of obesity was 500 million in physical and psychological growth. During2008. In 2010, about 43 million children age less adolescence, physical appearance and peerthan 5 years were overweight [4]. Over the last 2 approval become a top priority. Sociallyto 3 decades, the population prevalence of unacceptable physique predisposes adolescentsoverweight and obesity among children has to psychological consequences. Obese childrenincreased dramatically throughout the world [1, and adolescents are often stigmatized [26, 27,3]. Easy and inexpensive availability of food 28]. Failure to adapt to new physical changescontaining excessive fat and carbohydrate and dissatisfaction with physical appearancecombined with insufficient physical activities may trigger a psychological response that leadsresult in rapid weight gain among children. to depression [29].Children also tend to spend more time in ontelevision, computer, and video games, whichrestricts their exposure to outdoor play [5, 6, 7]. Approximately 15% of obese children age < 18 years manifests symptoms of depression, and 3-Pediatric obesity has overtaken under-nutrition 5% of these develop major depressive disordersas a problem [8, 9, 10]. Oniset, et al. reported [30, 31]. The incidence of obesity as well assurvey data from 144 countries showing a global depression increase markedly as childrenprevalence of overweight and obesity to be 6.7% reaches puberty. The risk of persistent childhoodin preschool children. In this age group, the depression and adult depression is two to fourprevalence in developed countries was reported times higher when obesity is also present [32,to be 11.7% and that in developing countries 33]. Fifteen percent of obese children manifestwas 6.1%. By 2020, this prevalence is estimated symptoms of depression before 18 years of age.to increase to 14.1% and 8.6%, in developed and This is a concern because suicide is the seconddeveloping countries, respectively [11]. leading cause of death in youth age 10- 24 years,According to National Health and Nutrition and major depressive disorders play a key roleExamination Survey (NHANES) 2008, 9.5% of US for suicidal behavior in youth [34, 35].infants and toddlers are obese. Among the age According to the Diagnostic and Statisticalgroup 2-19 years, 16.9% were obese and 31.7% Manual IV text, revised (DSM IV TR), thewere overweight [12]. In Healthy people 2020, definition of major depressive disorders includesthe U.S. Department of Health and Human at least depressed mood or loss of interest andInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 24Copy right © 2014, IAIM, All Rights Reserved.

Childhood and adolescent obesity and depression: ISSN: 2394-0026 (P)A systematic literature review ISSN: 2394-0034 (O)five (or more) symptoms lasting at least two adolescent age groups, a total of 163 articlesweeks. Symptoms include depressed mood, were found. Each article was reviewed accordingdiminished interest or pleasure, significant to our inclusion criteria: study subjects age ≤ 19weight loss/ weight gain, insomnia/ years, English language (or English translation)hypersomnia, psychomotor agitation/ published January 1990- April 2011, andretardation, feeling of worthlessness, diminished focusing on the relationship between childhoodability to concentrate and recurrent thoughts of or adolescent obesity and depression. A total ofdeath. Minor depressive disorders include less 51 articles met inclusion criteria. [43-93]Thesethan five of the above-mentioned symptoms included 19 prospective cohort studies, onelasting for less than two weeks. Depression in randomized controlled trial and one meta-children is diagnosed using the same criteria as analysis. The World Health Organization (WHO)in adults, with the exception that irritable mood and Center for Disease Control and Preventionin children can substitute for depressed mood in (CDC) websites were also searched for the mostadults and failure to thrive can substitute for current information and statistics. Articles wereweight loss [36]. also analyzed for gender differences. Articles stressing the effect of perceived body weightThough there is an association between obesity rather than actual body weight were alsoand mental health, the literature is inconsistent reviewed to understand the mechanism of[37, 38]. Researchers have demonstrated that association between obesity and depression.the prevalence of obesity [39, 40] anddepression [41, 42, 43] increases as the child Discussiongrows from adolescence to young adulthood.The majority of cross-sectional studies [44, 45, Forty-eight of the 51 studies critically reviewed46, 47, 48, 49, 50, 51, 52] and some prospective provide convincing evidence of an associationstudies [43, 53, 54, 55, 56, 57, 58] have shown between depression and childhood/adolescentevidence of a link between obesity and obesity, across all age groups. Bradley, et al. indepression. To date, the literature lacks a his prospective cohort study demonstrated asystematic review of studies linking childhood positive correlation among third to sixth gradeand adolescent obesity with depression. This students, but a statistically non-significantpaper aims to evaluate the association between correlation in the younger age-group (24childhood and adolescent obesity and months- five years) [55]. A similar finding wasdepression, to compare gender differences for also noted by Lawlor, et al. [59]. Xie, et al. andthis association, and to elucidate the effects of Sanchez-Villegas, et al. have describedactual body weight versus perceived body associations between childhood obesity andweight on self-esteem and depression. depression in children as young as five years [60,Methods 61]. Several studies have reported the association between childhood obesity and depression in children aged 8-15 years [44, 45,We conducted a broad search of PubMed, Ovid, 48, 51, 52, 62, 63, 64, 65, 66, 67, 68, 69, 70], andWeb of Science, CINAHL and PsycINFO using the also in the 15-19 year age group [47, 49, 71, 72].keywords “obesity” or “overweight” and “mood Depression is mediated by feelings of low self-disorder”. A total of 620 articles were retrieved. esteem in obese children, and these feelingsAfter applying a filter for the pediatric and increase during adolescence [47, 48, 62, 67, 73,International Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 25Copy right © 2014, IAIM, All Rights Reserved.

Childhood and adolescent obesity and depression: ISSN: 2394-0026 (P)A systematic literature review ISSN: 2394-0034 (O)74]. In their longitudinal study, Herva, et al. body weight concerns [45]. Similarly, weight-found that obesity at 14 years was associated related anxiety is a major consideration for girls,with depression at age 31 [75]. whereas peer group teasing mainly affects boys [52, 81]. Xie, et al. demonstrated that in theThe majority of studies suggest that girls are adolescent age group, peer isolation is directlymore susceptible to depression than boys [47, related to depression. Perceived availability of50, 52, 60, 62, 67, 68, 69, 76, 77, 78, 79]. social support is inversely related to depressiveMustillo, et al., in their prospective study, symptoms [51]. Shaming experiences, parentalshowed an increased vulnerability for employment and parental separation have alsodepression only in “chronically obese” boys, been described as mediators between childhoodwho were defined as being obese for most of obesity and depression [49].the time over the eight-year follow up. No suchvulnerability to depression was found among Various studies have reported a directgirls [58]. Some studies have reported no association between actual BMI and depressivedifference between boys and girls for the symptoms in children and adolescents, but theyassociation of obesity with depression [44, 70, have also mentioned several factors as75, 80], but the younger age of the study groups mediators for this association [44, 45, 47, 48, 49,may explain these statistically non-significant 50, 51, 52, 53, 55, 62]. For example, severalgender differences. A higher prevalence among studies have demonstrated that high BMI leadsgirls may be explained because girls tend to be to depression by creating a sense of body imagemore self-conscious about their weight [44, 45]. dissatisfaction [44, 48, 60, 70, 82]. Other studiesFor girls, thinness relates to beauty; beauty is have shown that perceived body weight, asmore important for girls than boys. On the opposed to actual body weight, is morecontrary, for the boys, being in proper shape is commonly associated with depressive symptomsfar more important than being the proper [78, 83]. Frisco, et al. found that the combinedweight. Young-Hyman, et al., in their cross- effect of actual and perceived body weightsectional study, summarized these differences predicts depressive symptoms better than actualas follows: “boys might need to experience and perceived body weight consideredsocial ostracism to feel bad about the way they independently [84]. It was also noted that alook, whereas girls may respond to a more recent increase in BMI (rather than actual BMI)internalized standard of what they should look leads to depression [85].like” [52]. This also points out the importance ofsocial pressure on girls to be thin. On the contrary, Wardle, et al. did not find an association between obesity and depression,Ozmen, et al., in a cross-sectional study, even when controlling for race, gender andsuggested that girls tend to overestimate their socio-economic status. Wardle suggested thatweight, whereas boys tend to underestimate appearance is less important during adolescence[47]. Misperception about body-weight creates a than at adulthood, and that there is lesssense of body dissatisfaction and lower self- stigmatization of obesity during adolescence,esteem which leads to depression [45, 50, 53, compared with adulthood [73]. Brewis reported62]. In a cross-sectional study by Erickson, et al., similar findings in his cross-sectional study ofoverweight girls who were unconcerned about Mexican children. Fatness is considered a sign ofbeing overweight did not have depressive health by the Mexican population; nosymptoms, as compared to overweight girls with differences in diet and activity were notedInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 26Copy right © 2014, IAIM, All Rights Reserved.

Childhood and adolescent obesity and depression: ISSN: 2394-0026 (P)A systematic literature review ISSN: 2394-0034 (O)between boys and girls [86]. Vila, et al. argued availability of social support. The currentthat obesity is not linked to depression, but medical literature is directed mostly toward thefailure to lose weight was associated with organic complications of obesity such asdepression [87]. Similarly, Pott, et al. also diabetes, sleep apnea, and asthma; but thereported that failure to lose weight while in a psychosocial effects of obesity, such as low self-weight reduction program significantly increases esteem and depression remain unnoticed ordepression [64]. A higher rate of mood disorders diagnosed late by medical professionals. Awas noted in treatment-seeking, as compared to favorable body image is important for growingtreatment non-seeking obese adolescents [88]. children. Obesity definitely leads to socialImportantly, a dose-response relationship has rejection, discrimination and negativebeen shown between the intensity of physical stereotyping. These experiences adversely affectactivity and lowered depression scores among mood, self-esteem and self-image. Emphasisadolescents [69, 89]. should be placed on childhood obesity prevention programs in order to promoteSeveral studies have demonstrated that healthy nutrition and exercise habits, reducedepression in childhood is associated with hours spent watching television, and create safesubsequent obesity [43, 56, 71, 90, 91, 92]. Pine, environments for play. Addressing obesity andet al. demonstrated that the relation between its psychosocial effects will require significantdepression and obesity remains constant across efforts by patients, parents, medicaldifferent age groups and genders [43]. professionals, and policymakers.Goodman, et al. concluded that childhoodobesity was not associated with subsequent Referencesdepression, but depression is associated withsubsequent obesity [56]. In contrast, Hesketh, et 1. Reilly JJ. Obesity in childhood andal. showed that obesity is clearly associated with adolescence: Evidence based clinical anddepression, but depression is not associated public health perspectives. Postgradwith subsequent obesity [57]. Richardson, et al. Med J, 2006; 82(969): 429-37.reported that depression in adolescence isassociated with subsequent adult obesity, 2. Chinn S, Rona RJ. Prevalence and trendsparticularly among girls [93]. Fuemmeler, et al. in overweight and obesity in three crossshowed that males with the Monoamine sectional studies of British Children,Oxidase A allele, with depressive symptoms, 1974-94. BMJ, 2001; 322(7277): 24-6.have a higher chance of being overweight orobese [71]. 3. Mei Z, Grummer-Strawn LM, Pietrobelli A, Goulding A, Goran MI, Dietz WH. Validity of body mass index comparedConclusion with other body-composition screening indexes for the assessment of body fatness in children and adolescents. AmAn extensive literature has been published J Clin Nutr, 2002; 75(6): 978-85.linking childhood obesity and depression. 4. Obesity and overweight. In: WorldSeveral biological and social-cognitive factors Health Organization, 2011. Fact sheethave been suggested linking this association N311.such as age, gender, socio-economic status, 5. Janssen I, Katzmarzyk PT, Boyce WF,perceived body weight, social ostracism and Vereecken C, Mulvihill C, Roberts C, etInternational Archives of Integrated Medicine, Vol. 1, Issue. 2, October, 2014. Page 27Copy right © 2014, IAIM, All Rights Reserved.

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