- Obesity and Depression — Obesity Action Coalition
- Obesity Defined
- What is Depression?
- How to Measure Depression
- What Could the Connection Be?
- Depression after Weight-Loss
- What Happens after Bariatric Surgery?
- Tips for Avoiding Depression after Treatment
- The relationship between mental health and obesity
- Why is this so important?
- The relationship between mental health and obesity is complex
- Signs and symptoms of poor nutrition, and how it is linked to mental health recovery
- What can be done in a GP consultation?
- Educating patients on good nutrition and mental wellbeing
- B vitamins
- IBS, probiotics and FODMAP
- The influence of cognitive behavioural therapy (CBT)
- Does Being Overweight Make Depression More ly, Even if It Doesn’t Negatively Impact Metabolic Health?
- Researchers Examine Genetic Factors to Learn What Causes Depression in People With Obesity
- Social and Environmental Factors May Contribute to Having Obesity
Obesity and Depression — Obesity Action Coalition
by David Engstrom, PhD
What researchers know, and most people assume, is that individuals with excess weight often suffer from depression. What is less clear is which comes first.
Could the effects of being seriously overweight directly lead to depression, or does depression itself cause excess weight gain in the first place? Probably, the answers are “yes” and “yes,” and it may not matter in any practical sense. Depression and weight gain go hand-in-hand.
Certainly, increased appetite, reduced activity and weight gain can be symptoms of depression, and people with depression are more ly to binge eat and less ly to exercise regularly.
Both depression and obesity have strong genetic links, so children of people with either or both problems are more predisposed to have them as well.
In addition, many prescribed antidepressant medications cause weight gain as side effects.
One recent study found that overall, individuals affected by obesity have a 20 percent elevated risk of depression, and specifically for Caucasian college-educated people with obesity, the depression risk rises to as high as 44 percent. Although females with obesity have previously been found to suffer more depression, this study showed that there were no differences between sexes.
One standard measure of obesity is weighing more than 20 percent greater than the ideal body weight for a given height. Another definition is having a body mass index (BMI) of more than 30. According to recent findings, approximately one third of the U.S. population is affected by obesity.
What is Depression?
Defining depression has always been a puzzle. Many people are depressed but don’t know it. Others may seem depressed to friends but really aren’t. It seems that we all have stereotypes of what depression is, but they aren’t always accurate in reality.
One way to understand depression is to see it as consisting of two factors, or primary components. They are the psychological or “cognitive” component which affects mood, and the physical or “somatic” component which influences areas such as sleep and appetite. Viewing depression in this way sometimes helps to determine the primary cause of the problem.
A recent World Health Organization (WHO) report identified depression as “the number one cause of disability in the United States and the third largest, behind heart disease and stroke, in Europe.”
How to Measure Depression
One of the most commonly-used and respected instruments to measure depression is the Beck Depression Inventory (BDI).
The cognitive subscale contains eight items:
- Past failures
- Guilty feelings
- Punishment feelings
- Suicidal thoughts or wishes
The somatic subscale has 13 items:
- Loss of pleasure
- Loss of interest
- Loss of energy
- Change in sleep patterns
- Change in appetite
- Concentration difficulties
- Tiredness and/or fatigue
- Loss of interest in sex
What Could the Connection Be?
Stop and think about all the possibilities for depression to accompany obesity. To begin with, childhood obesity frequently leads to painful ridicule and exclusion from peer activities.
Problems with body image, social isolation and self-esteem might easily follow. Being seriously overweight at any age is a major source of dissatisfaction, sadness and frustration.
Extra pounds often cause chronic joint and extremity pain, making individuals less able to get around, enjoy life or exercise.
Serious illness such as diabetes, hypertension and sleep apnea can threaten or shorten life. People with excess weight are often stereotyped and discriminated against by airlines, department stores, insurance companies and even doctors.
Depression after Weight-Loss
Several recent studies have found significant improvements in depression following major weight-loss. This finding has been reported in a large group of patients after gastric restrictive procedures. Younger patients, women and those with greater excess body weight loss after surgery had the greatest improvement on their BDIscores.
What Happens after Bariatric Surgery?
In a study of depression in our own bariatric surgical population at Scottsdale Bariatric Center, approximately 2,005 consecutive patients were evaluated for depression before and after surgery, as well as post-surgical weight loss. We defined improvement of depression in three areas:
- Cognitive (reduced thoughts of worthlessness, hopelessness and personal failure)
- Affective (reduced feelings of sadness, frequent crying and mood swings)
- Physiological (increased energy level and better sleep habits)
It was found that 24 percent of those patients were diagnosed with depression prior to surgery, a finding very consistent with national norms. Six months after surgery, there was a 62.
5 percent decrease in excess body weight, accompanied by a 13 percent reduction of depressive symptoms, while at 12 months after surgery, there was a 76.9 percent loss of excess body weight, as well as an 18 percent resolution of depression.
It may be surmised from our data that loss of excess body weight following bariatric surgery is accompanied by a reduction of depressive symptoms.
Tips for Avoiding Depression after Treatment
Exercise – There is no doubt that regular physical exercise and activity is the cheapest and most efficient way to control your mood. Not only does exercise release brain chemicals which fight depression, it also gives a person a greater sense of control over his or her life.
Get rid of anger – Remember, an old definition of depression is “anger turned inward.” Unresolved resentment can damage both your relationships and health. Chronic anger and hostility can be your worst enemies. If anger is a problem, try taking an anger or stress management class to learn techniques to ward off long-standing angry feelings.
Keep a positive attitude – There is an entire field called “positive psychology,” which has grown from research that indicates the people with positive attitudes fight disease better and live healthier lives.
I know it’s easier said than done, but remember the famous saying of Abraham Lincoln… “Most folks are about as happy as they make up their minds to be.”
Don’t take yourself too seriously – This is a tip that I’ve learned both from my own life and many of my patients. Humor is an important part of life.
Some people have the ability to laugh at themselves, while others don’t. And each day, everything changes anyway. Laughing is good for all of us. Seeing the silly parts of life may give you a fresh point of view and change your mood.
Stay motivated – Try to set a goal for yourself, and then develop a plan of simple, small steps to get to the goal. Perhaps exercise is a good place to start. The keys to motivation are to not get overwhelmed with a goal that is too big or unrealistic, and to write things down to keep track of progress.
Talk to someone – If you were seeing a mental health professional before treating your obesity, keep in touch with them after as well. Remember, treating your obesity has a major emotional impact, and your life will change.
Although these changes are mostly for the better, it is a good idea to have someone other than family or friends to talk to as you adjust to your new life.
Use medications if prescribed – If you were taking prescribed antidepressant medication before treating your obesity, check with your doctor to see if you can remain on it. It may give you that “boost” you need during your recovery. Many of our patients have found that they can reduce or eliminate these medications after they see changes in their weight and quality of life.
David Engstrom, PhD, is a clinical health psychologist, board certified in Clinical Psychology. He practices in Scottsdale, Arizona and is a psychologist at Scottsdale Bariatric Center. Dr.
Engstrom is an active member of the American Society for Bariatric Surgery and is a specialist in applying mindfulness techniques to long-term weight management. Dr. Engstrom currently serves on the OAC Advisory Board.
The relationship between mental health and obesity
This month we spoke to Arti Dhokia, Advanced Mental Health and Gastroenterology Dietitian at Priory Hospital Woodbourne, about the relationship between mental health and obesity. Arti specialises in eating disorders, spotting the early signs of disordered eating, weight gain/loss management, and has a particular interest in obesity management.
We explore the links between ‘food and mood’, what the signs and symptoms of poor nutrition are and how it is linked to mental health recovery, the effects that mental health medication can have on weight, and what particular foods can help to improve wellbeing.
Why is this so important?
Despite there being a number of demographic variables that could affect the direction and/or strength of this link, including socioeconomic status, level of education, age, gender and ethnicity, a 2010 systematic review highlighted a two-way association between depression and obesity. The review found that people who were obese had a 55% increased risk of developing depression over time, whereas people experiencing depression had a 58% increased risk of becoming obese.
It is estimated that the NHS spent £6.1 billion on overweight and obesity-related ill-health from 2014 to 2015.
Failing to address the challenge posed by the obesity epidemic will place an even greater burden on NHS resources.
This emphasises the importance of spotting the early signs of disordered eating as well as carefully considering the influence of mental health on obesity.
The relationship between mental health and obesity is complex
It has become increasingly clear that obesity may also be a side effect of medications used to manage mental health issues. Increased appetite or overwhelming lethargy can both contribute to undesired weight gain and the associated long-term consequences.
Moreover, the development of co-morbid conditions such as diabetes or joint pain can significantly reduce quality of life. As medication is often an essential element of treatment, diet and lifestyle changes should be first-line interventions for managing weight.
General healthy eating guidelines, although indispensable, may alone not be effective in precipitating change in this patient group. Additional education is often required, to enable patients to develop a greater understanding of the relationship between food and mood, in order to make small but meaningful changes.
For example, serotonin is made from the amino acid tryptophan, which is better absorbed with carbohydrate-rich foods, which goes some way to explain ‘carbohydrate cravings’ and the excessive consumption of sweet and comforting carbohydrate foods, to boost mood.
However, evidence to show that an increase in carbohydrate consumption can improve mood in the long-term, is currently lacking.
The short-term reward associated with these foods can contribute to excess weight gain, and consolidate habitual behaviours that patients may struggle to change if no intervention is offered.
Improvements in both dietary intake and one’s relationship with food will ly result in reduced weight gain and improved mental health, which in turn is ly to improve compliance with medication.
Signs and symptoms of poor nutrition, and how it is linked to mental health recovery
The association between poor nutrition and anxiety disorders is well documented and there are many signs and symptoms a GP can look out for when making as assessment as to whether a patient may have disordered eating:
- Loose or tight clothes, belts, jewellery
- Being tired and less energetic
- Not being as capable at performing activities of daily living
- Being less physically active e.g. not being able to walk as far or as quickly as before
- Changes in mood, such as becoming depressed and lethargic
- Getting ill often, and taking a long time to recover
- Delayed wound healing
- Poor concentration
It is important to remember that weight loss or weight gain can be due to many different reasons – weight monitoring in patients is very important, and unintended weight loss should be a red flag.
What can be done in a GP consultation?
- Weight monitoring in patients taking mental health medication is essential – intervention should ideally begin as soon as weight increases are noted
- Ask questions around changes in appetite
- Have discussions around the relationship between food consumption and mood. This can help to start discussions around food choices and comfort eating
- Attempt to gain input from family and carers, if they are attending the GP consultation with the patient. This is invaluable as it is well documented that patients ‘under-report’, when asked what they are eating
Educating patients on good nutrition and mental wellbeing
Diet is a low risk, cost-effective and modifiable risk factor when considering mental health recovery. GPs should be encouraged and supported to test people fornutritional deficiencies if they suspect that their mental health problems could be linked to poor diet, and to prescribe supplements if there is a deficiency.
The ability to concentrate comes from the adequate supply of energy to the brain; up to 25% of our total glucose intake is used by the brain. It is thought that a low carbohydrate diet can lead to low mood.
With the rise in popularity of ketogenic diets (high protein/high fat), it is important that patients suffering or recovering from mental health issues are aware of the role of carbohydrates in brain function and absorption of tryptophan for serotonin production.
These patients may be particularly susceptible to the enticement of fad dieting, as they may have gained weight from mental health medication and have reduced self-esteem as a result.
Low levels of iron and the resulting reduction in oxyhaemoglobin can lead to patients feeling tired, weak and lethargic. This is ly to significantly impact on an individual’s self-efficacy and mood. The risk of anaemia is reduced with adequate intakes of iron, particularly from red meat, poultry and fish. Vegetarian sources are found in beans, pulses and fortified breakfast cereals.
It may be helpful to ask about an anaemic patient’s consumption of tea, as tannin in tea reduces iron absorption. Avoiding tea with meals can be helpful, and drinking orange juice with iron containing foods even more so, as this will help to increase absorption.
Deficiencies in B vitamins can increase the feeling of tiredness, and cause patients to feel depressed and irritable. Fortified foods include wholegrain cereals and animal protein foods such as meat, fish, eggs and dairy.
B vitamin deficiency is common amongst vegans.
The Vegan Society states that the ‘Veganuary’ campaign, where people eat vegan for the month of January, grew by 183% in 2018, with a whopping 168,500 participants.
With veganism becoming a rising trend, it is imperative that the risk of B vitamin deficiency and supplementation is discussed for those with at risk or with a history of mental health disorders.
IBS, probiotics and FODMAP
Irritable bowel syndrome (IBS) is associated with higher levels of mood disorders, anxiety, and other psychiatric conditions.
IBS reportedly affects up to 23% of people around the world, and although IBS is not fully understood, symptoms appear to result from a disturbance in the brain-gut axis—the line of communication that exists between the brain and the gastrointestinal tract—and may be underpinned by disruptions in the microbiome-immune interface.
The current state of the gut microbiome can be preserved by improving dietary fibre and diversity of foods to promote microbial diversity.
The gold standard for IBS management is the Low FODMAP diet for IBS, which reduces fermentation in the bowel, and allows the gut respite from ongoing fermentation by omitting long chain carbohydrates from the diet, delivered under the supervision of a specialist dietitian. With a 71% success rate of satisfactory symptom reduction at one year (as reported by Kings College London), the FODMAP diet has provided a much needed framework for IBS treatment in primary care.
The influence of cognitive behavioural therapy (CBT)
Dietary management of IBS can improve symptoms significantly, however this is most effective when placed alongside psychological therapies such as CBT. This treatment allows the patient to understand root causes of disordered eating and teaches them how to cope better with anxiety and depression, which may lead to over-eating.
The British Society of Gastroenterology recommends psychological therapy alongside FODMAP diet as first-line treatment when the patient has a history of anxiety, panic attacks, or depression.
Does Being Overweight Make Depression More ly, Even if It Doesn’t Negatively Impact Metabolic Health?
Being overweight or obese can increase the risk for several chronic health conditions, such as type 2 diabetes and heart disease, and a growing body of evidence suggests it can take toll on mental health as well.
A recent study, published July 16 in Human Molecular Genetics, found that having a higher body mass index (BMI) increased the lihood of depression, even in the absence of poor metabolic health and increased risk for weight-related diseases, including type 2 diabetes or heart disease.
Obesity and depression have a bidirectional relationship — that is, having obesity does appear to cause depression, and depression does cause obesity, says Roger S.
McIntyre, MD, a professor of psychiatry and pharmacology at the University of Toronto, who was not involved in the research.
“This has been evaluated in both cross-sectional as well as longitudinal studies in both clinics and in the general population; it’s a robust and statistically significant association that goes in both directions,” says Dr. McIntyre.
Obesity is a growing health crisis, both in the United States and around the world. According to the World Health Organization (WHO), worldwide obesity has nearly tripled since 1975; in the United States, it’s estimated that 39.6 percent of adults are considered obese, according to the most recent National Health and Nutrition Examination Survey (NHANES) data.
Researchers Examine Genetic Factors to Learn What Causes Depression in People With Obesity
Using data from a mental health questionnaire in 145,668 people with European ancestry in the U.K.
Biobank, the study set out to determine if obesity related depression was made more ly do to due to health conditions associated with a higher BMI, such as heart disease, high blood pressure, or type 2 diabetes.
The Biobank is a major international health resource, where over a half-million people ages 40 to 69 agreed to provide blood, urine, and saliva samples, as well as a detailed history for the purposes of research.
This information allowed investigators to explore genetic causal factors using a method called Mendelian randomization, named after Gregor Mendel, the scientist who is considered the founder of the science of genetics.
This method uses genetic variants to determine whether an observational association between a risk factor and an outcome is actually a cause and effect relationship, according to an article published in November 2017 the JAMA Guide to Statistics and Methods.
Researchers used the genetic data from participants to look at two sets of previously discovered genetic variants.
One set of the genes causes people to have more fat, yet better metabolic health, meaning that they were less ly to develop obesity-related diseases hypertension and type 2 diabetes.
The second set of genes made people heavier and metabolically unhealthy, making those individuals more prone to those conditions.
Investigators found little difference in the rates of depression between the two groups, which suggests that even without adverse metabolic effects, having a higher BMI causes depression and lowers well-being.
“This suggests that both physical health and social factors, such as social stigma, both play a role in the relationship between obesity and depression,” said lead author Jess O’Loughlin, a PhD student at the University of Exeter Medical School in England, in a release.
“These findings align with what I see in clinic. When patients have obesity, a lot of their value and self-worth is determined by their weight status.
This can start really early in life — as young as 3 years old,” says Fatima Cody Stanford, MD, MPH, assistant professor of medicine at Harvard Medical School and an obesity medicine doctor and researcher at Massachusetts General Hospital in Boston. Dr. Stanford was not involved in this research.
“This depression is often present in patients who don’t have any of the metabolic issues that can be associated with having obesity,” she says.
Social and Environmental Factors May Contribute to Having Obesity
Depression and obesity are both multifactorial — there’s not just one cause for either condition, says McIntyre.
“When one looks at how obesity causes depression, immediately what jumps out is social and environmental determinants.
For example, if a person has insufficient access to healthy food due to economic insecurity, that would be a factor related to both obesity and depression,” he says.
Childhood trauma in the form of abuse or neglect is another factor that predisposes someone to obesity, depression, or both, says McIntyre.
Having obesity can also change the biology of the person with obesity, he explains. “For example, having obesity increases the lihood of having insulin-resistance and prediabetes. There is actually evidence that shows that insulin resistance could lead to depression in some people,” says McIntyre.
Inflammation may also contribute to mood disorders, he says. McIntyre explains, “Many people with obesity have an elevated state of inflammation, and that may impact the brain’s process in a way that puts a person at higher risk of depression.”
This research highlights the complexity of the relationship between obesity and depression, he says. “Clearly there are factors influencing depression in people with obesity other than metabolic health. Further research is need to identify what those factors are,” says McIntyre.