By Dr. Micaela Wexler
Last month (June 2013) the American Medical Association voted to classify obesity as a disease, a decision which will hopefully lead to a more comprehensive view of this public health issue which affects one third of all Americans, instead of our current narrow focus. As a psychiatrist, it is difficult for me to stand by while the link between obesity and depression is ignored. In recent years, solutions have been focused almost exclusively on diet. Our simplistic view of obesity is evidenced by the widespread support for Michelle Obama’s “Let’s Move” campaign. This campaign, and others like it are, at best, short sighted, and at worst, cruel and harmful, especially with regards to children and adolescents. While there is nothing wrong with promoting exercise and healthy eating, especially among young people, focusing solely on diet and exercise ignores other issues which need to be addressed in order to successfully treat this growing health crisis.
The most harmful aspect of these campaign is that it adds to the view that obesity is a moral failing, which contributes to an unhealthy treatment of people with weight issues. At the Building a Healthier Future Summit, this past March, Obama charmed her audience with the following, “We can’t lie around on the couch eating French fries and candy bars, and expect our kids to eat carrots and run around the block. But, too often, that’s exactly what we’re doing.”
This view of people with obesity is not only demeaning, but flies in the face of research which shows obesity has many causes: genetics, hormonal influences, mental health status in addition to poor diet and exercise. Multiple studies have shown a correlation between maternal obesity and obesity in offspring. Children born to obese mothers start to have weight problems as early as toddlerhood. Once obesity has set in, hormonal and metabolic conditions in the body make weight loss challenging. Limiting focus to diet and exercise doesn’t take into account the many people who are getting up and moving, like families whose children are involved in sports, but who still find themselves battling obesity. Ignoring these various causes leads to ignoring potential solutions.
As a rural psychiatrist, I am confronted with the challenge of obesity, which is more widespread. A study done by Christie Befort, PhD, published in the fall 2012 issue of the Journal of Rural Health, shows that obesity is significantly higher for adults from rural areas of the United States. The study compared 7,325 urban adults with 1,490 rural adults, and found that after controlling for factors such as demographic, diet and physical activity variables, the obesity prevalence among rural adults was 39.6% versus 33.4% among urban adults.
Studies have established that obesity tends to cluster in families, in part due to genetics. For example, in 1990, a study published in the NEJM comparing the body mass index of identical and fraternal twins reared apart and reared together showed that genetic influences on body mass index are substantial. Although no single gene can account for obesity, as many as 50 genes have been found that are associated with obesity, affecting things such as metabolism, food cravings, fat accumulation and fat storage, to name a few.
The link between depression and obesity is well known in psychiatry. Ignoring this link is especially dangerous when it comes to children and adolescents. A meta analysis study published in JAMA in March 2010 shows a reciprocal link between obesity and depression, ie, depression can lead to obesity and vice versa. (1) A study of Dutch teenagers, published in Obesity in March 2010, showed a clear association between weight status and suicidal behavior in obese adolescents. (2) The same link was found in a later study done on Korean teenagers. (3)
A person who is depressed undergoes physiological changes which affect interest, sleep, appetite sexual drive and thought process. They most likely do not possess the motivation to “get up and move.” Changes in eating patterns, along with a disconnect between food intake and hunger are common in people with depression. Depression itself has been shown to cause weight gain and fatigue; metabolic changes that occur during depression make the body less responsive to diet and exercise. People with depression tend to lose their perspective when dealing with problems in their life. They tend to carry a great deal of shame, as do people with obesity.
As with obesity, the incidence of depression is significantly higher among rural residents than among urban residents. (4). This difference becomes more pronounced with regards to suicide, especially teen suicide. (5) Currently, in the rural setting, the stigma for mental illness is a major challenge in addressing the issue of depression. The same is true for obesity, with many obese people having internalized society’s view that people are that way because they are lazy. Perhaps with the AMA classification, people with obesity will feel more empowered to reach out for help. As the veil of shame is lifted on obesity, so may it also lift when it comes to depression. Addressing the link between depression and obesity will go a long way in decreasing morbidity and mortality among our youth. Then maybe it won’t be so hard for people to get up and move.
1) Overweight, Obesity, and Depression
A Systematic Review and Meta-analysis of Longitudinal Studies FREE
Floriana S. Luppino, MD; Leonore M. de Wit, MS; Paul F. Bouvy, MD, PhD; Theo Stijnen, PhD; Pim Cuijpers, PhD; Brenda W. J. H. Penninx, PhD; Frans G. Zitman, MD, PhD
2) Weight status, psychological health, suicidal thoughts, and suicide attempts in Dutch adolescents: results from the 2003 E-MOVO project.
van Wijnen LG, Boluijt PR, Hoeven-Mulder HB, Bemelmans WJ, Wendel-Vos GC.
3) The relationship of weight-related attitudes with suicidal behaviors in Korean adolescents. Kim JS, Lee K. Department of Family Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, South Korea.
4) Rural-urban differences in depression prevalence: implications for family medicine.
Probst JC, Laditka SB, Moore CG, Harun N, Powell MP, Baxley EG.
South Carolina Rural Health Research Center, University of South Carolina, 220 Stoneridge Drive, Columbia, SC 29210, USA. firstname.lastname@example.org
Fam Med. 2006 Oct;38(9):653-60.