Coincidence cannot be held accountable for the national mental health crisis and obesity epidemic ripening side-by-side among Canada’s children and youth. That’s why researchers, clinicians and policy makers have been examining how the two may go hand in hand.
Merely acknowledging a relationship between obesity and mental health issues in children has been a major step towards progress, says Dr. Dina Panagiotopoulos, clinician scientist at the Child & Family Research Institute, pediatric endocrinologist at BC Children’s Hospital and assistant professor of endocrinology in UBC’s department of pediatrics. “We now assess for the presence of psychological/psychiatric concerns at the initial assessment and try to provide a multidisciplinary treatment plan that focuses on both the child’s physical and mental well-being.”
The perspectives on these comorbid conditions are many, and a growing understanding of the correlation between mental health and weight issues is enabling experts to tackle the problem from different sides of the equation. One question is, if weight trouble starts in childhood, what are the long-term repercussions for physical and mental health? Obesity leads to increased risk for various chronic diseases leading to reduced life expectancy and quality of life, but it’s less clear to what extent childhood obesity affects mental health.
Research led by Paul Veugelers at the University of Alberta’s School of Public Health has found that body weight and self-esteem are inversely related in children. His national findings in Health Reports/Statistics Canadareported that for each BMI unit increase, self-esteem scores decreased by 4.8%. The study concluded that rising childhood obesity rates, through their deleterious effects on self-esteem and cognitive development, could shape an upward trend of “mental health problems and less educational attainment adding to the health burden in adulthood and that of future generations.”
Poor self-esteem in childhood is an established marker of poor mental health later in life, says Veugelers. In a University of Manitoba study published in the Journal of Psychosomatic Research (April 2009), researcher Amber Mather and colleagues found that obesity was associated with a 25% to 50% increased risk of lifetime psychiatric disorders, mood or anxiety disorder and suicidality.
Studies also show that mental health issues can contribute to overweight and obesity. “When kids present with obesity at our clinic, a high proportion present with concurrent mental health conditions, such as ADHD, symptoms of depression (even if not clinical), social anxiety or Asperger’s,” says Dr. Rachel Keaschuk, a psychologist at the Pediatric Centre for Weight and Health in Edmonton. Literature shows that one-third of children presenting for tertiary care obesity treatment report some level of psychological concern, says Keaschuk.
Mental health issues play a role in obesity by adversely affecting eating and lifestyle habits. “If depression already exists, it can cause an increase or decrease in appetite. It can also lead to loss of energy and motivation,” says Keaschuk. “ADHD, because it involves impulsivity, can lead to overeating — these kids are like cars without brakes. And a large number of kids with Asperger’s will have a weight issue because they’re typically picky eaters and not physically active.” Weight management can be particularly challenging among children with mental health issues, says Panagiotopoulos: “These children frequently struggle with complex physical and emotional issues that impact motivation, self-esteem and self-efficacy. Many of them may also be socially isolated and marginalized from physical activity, and are at high risk for unhealthy eating habits.”
Another hurdle with mental health issues is that some drug therapies can precipitate weight gain. “Medications used to treat mental health concerns sometimes increase appetite to such an extreme level that it becomes very difficult for families to implement lifestyle changes,” explains Panagiotopoulos.
Panagiotopoulos has been conducting research on the metabolic effects of atypical (second-generation) antipsychotic drugs in youth. Treated youth had three times the risk of developing pre-diabetes or type 2 diabetes and twice the risk of becoming overweight or obese. While the researchers are still studying the exact time sequence, it seems that obesity and central adiposity tend to develop fairly quickly, particularly with olanzapine, says Panagiotopoulos. “Increases in body weight have been noted as early as four weeks and are well established by three months post-treatment. Preliminary data suggest that changes in blood sugar and development of full-blown diabetes is quite variable and can either appear within one to three months of starting treatment or one to two years later,” she explains. As is often the case, if stopping drug treatment isn’t an option, Panagiotopoulos says they work on lifestyle changes to address weight concerns.
The Provincial Mental Health Metabolic Program at BC Children’s Hospital, which was created in response to these findings, uses a multidisciplinary approach and focuses on promoting a healthy lifestyle rather than on weight management. “We assess readiness for change and try to help children and families set attainable goals,” says Panagiotopoulos. “Even a simple goal of eating five servings of fruits and vegetables per day is important, rather than focusing on a number on a scale.”
However, research also shows that the relationship between childhood obesity and mental health isn’t unequivocal. A large US study led by Rhonda BeLue, assistant professor in the Department of Health Policy and Administration at Pennsylvania State University, suggests that the links may be unclear and that race and ethnicity could be confounding influences.
BeLue’s paper in the journal Pediatrics (Feb 2009) on the effects of race and ethnicity in a nationally representative sample of US youth aged 12 to 17 found no direct correlation indicating that a weight problem precipitated a mental health issue in black youth. Despite a higher incidence of overweight and obesity among black youth compared to white and Hispanic kids, black youth seem to be less bothered by weight psychologically. “Although mental health and weight status appear to be unrelated in black adolescents, it doesn’t mean the comorbidities should be ignored,” explains BeLue.
“Given the possibility of differing interpretations and expressions of mental health problems among different cultures, addressing emotional and psychological issues when they’re comorbid with obesity is essential for all adolescents.”
One obvious question arising from the findings is what other factors shape mental health in black youth or other ethnoracial groups? “Mental health problems and obesity are the result of multiple factors,” says BeLue. “Among black children (and all children for that matter) some of the factors that lead to mental health problems may also lead to obesity. Addressing the biopsychosocial determinants of energy balance and mental health is important to ameliorating and preventing mental health problems and obesity, whether they occur as correlated or uncorrelated comorbidities.”
Such findings also suggest that treatment alone isn’t enough. Prevention and health promotion may reign in the number of children and youth who will develop a weight or mental health issue, or both. Public education will put these issues on the radar, which ideally will translate into prevention, early detection and screening, as well as willingness to seek help. “In terms of mental health, earlier screening can help — pediatricians are doing more screening, more emotional check-ups. We’re also getting the stigma off mental health,” reports Keaschuk.
Veugelers, who has researched and implemented school- and community based initiatives to promote healthy diet and lifestyle, advocates societal change. “We need to make healthy eating and physical activity the norm, but it’s not right now — if you want to be nice to a child, you give them junk food. If you want to give them a treat on a special evening, you put them in front of the TV. This has to change.”
Regardless of the chicken-or-egg question, it’s clear that obesity and mental health issues in childhood coincide. By unraveling the connections between them and making certain not to underestimate the impact of one on the other, experts are making headway that promises to translate into effective interventions. .