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ANTHONY N. FABRICATORE, PhD THOMAS A. WADDEN, PhD
Abstract. Obesity is a complex condition associated with a host of medical disorders. A common assumption is that obesity must also be related to psychological and emotional complications. Research on the psychosocial aspects of obesity has grown more sophisticated over the years, from purely theoretical papers to cross-sectional comparisons of people with and without obesity to prospective investigations of the temporal sequence of obesity and mood disturbance. These studies have shown that obesity, by itself, does not appear to be systematically associated with psychopathological outcomes. Certain obese individuals, however, are at greater risk of psychiatric disorder, especially depression. The present paper reviews the research findings and presents their clinical implications. Chiefly, treatment providers should not assume that a depressed or otherwise disturbed obese person needs only to lose weight in order to return to psychological health. Significant mood disturbances should be treated equally aggressively, regardless of a patient’s weight status.
he literature on the psychosocial aspects of obesity has evolved considerably in recent years. The earliest articles were theoretical and asserted that excess weight was the manifestation of underlying psychopathology and suboptimal development. The first empirical studies of the matter attempted to find commonalities in the psychological profiles of obese persons. No “obese personality” was ever identified, however. Comparisons of overweight and averageweight individuals yielded inconsistent results that depended on the characteristics of the samples. Some studies showed that obese persons suffered greater levels of psychopathology, whereas others demonstrated an apparent protective effect of excess body weight on psychological distress. These studies, collectively, have been criticized for methodological shortcomings.1 The best evidence (from nationally representative samples of the U.S. population) suggests that obese women— but not obese men— have a slightly higher rate of depression and suicidal ideation than their normal-weight counterparts.2,3 The research on the psychosocial correlates of obesity has entered a “second generation,” in which scientists are now attempting to identify risk factors for psychopathology within the obese population.1 Female sex, as suggested by the findings cited earlier, is one such risk factor. Second-generation studies have also revealed extreme obesity and binge-eating disorder to be markers for greater psychopathology among obese persons.
From the Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. Supported in part by grants (1-U01-DK57135 and K24-DK065018) from the National Institute of Diabetes and Digestive and Kidney Diseases. Address correspondence to Anthony N. Fabricatore, PhD, Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, 3535 Market Street, Suite 3108, Philadelphia, PA 19104-3309. E-mail address: firstname.lastname@example.org © 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010
The past 2 years have seen the beginning of the third generation of research on the association between obesity and psychopathology. As has been the case with previous generations of research, the focus is largely on depression (versus other psychological disorders). These third-generation studies are designed to uncover the temporal and causal relations between body weight and psychological distress.1 This article reviews the literature on the relationship between obesity and psychopathology, particularly with respect to mood disturbance. We begin by presenting research on the prejudice and discrimination that obese persons frequently experience. We then summarize findings on psychological complications in obese individuals, both in the general population and in clinical settings. Next we explore the evidence suggesting that psychological disturbance is more common among obese women, those with extreme obesity, and those with binge-eating disorder. We also review new findings on the temporal relationships between obesity and depressive symptoms (ie, whether obesity leads to depression or vice versa). We conclude with a discussion of the clinical implications of the research findings reviewed.
Stigma and Discrimination
Prejudice and discrimination toward obese individuals persist despite worldwide increases in the prevalence of obesity and the recognition of genetic contributions to body weight. In America, negative attitudes and behaviors are likely exacerbated by our culture’s idealization of thinness. Ridicule and disparagement of obese individuals seems to remain a socially acceptable form of prejudice. The “fat is bad” stereotype begins early in life. Children as young as 3 years old have been found to rate “chubby” target figures more negatively than otherwise
0738-081X/04/$–see front matter doi:10.1016/j.clindermatol.2004.01.006
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equivalent average-weight or thin figures.4 A group of 6-year-old children characterized silhouettes of an overweight child as “lazy,” “dirty,” “stupid,” and “ugly.” These children also expressed the belief that the heavier figure “lies and cheats.”5 Obesity-related stigma persists through adolescence and adulthood. College students, for instance, rated obese individuals as less-suitable marriage partners than embezzlers, cocaine users, and shoplifters.6 Negative attitudes toward obese individuals are pervasive. Evidence of bias has been found among health care professionals (even those specializing in obesity)7 and even among obese children and adults themselves.4,8 Researchers also have found a stigma-by-association effect with regard to obesity. In one study9, male job applicants were rated less favorably if seen in the company of an obese woman than if depicted with an average-weight woman. The negative evaluation was found whether the rater was male or female and whether the rater thought the obese woman was a romantic partner of the applicant or a stranger. Several studies have demonstrated that obese persons are the targets not only of negative attitudes, but also of discriminatory behaviors.10 The unfair treatment of obese individuals, especially women, has been found in virtually all stages of employment, including selection, placement, compensation, promotion, discipline, and discharge.11 Discrimination is similarly apparent in the realm of educational attainment. Overweight children, for example, receive less financial support for college from their parents than do their average-weight peers, even when controlling for parental income, ethnicity, family size, and children’s grades.12 Prejudice and discrimination are chronic stressors. Intuitively, one might expect the experience of negative attitudes and behaviors to adversely affect the mental health of obese individuals. The hypothesis that prejudice and discrimination lead to more depression among obese persons has not yet, to our knowledge, undergone empirical scrutiny. In the next section we review the prevalence of psychopathology among obese people and the associations between body mass index (BMI) and psychological distress.
not significant enough to suggest meaningful differences in their psychosocial status. Some researchers argued that better-designed studies were needed to draw more reliable conclusions about the psychological functioning of obese versus nonobese people. They called for studies that included large, nationally representative samples; consistent definitions of overweight and obesity; clinically valid assessment tools; and appropriate control groups.1 In the first of two studies that met these requirements, Istvan et al2 examined the relationship between BMI and depression in a large, nationally representative sample of adults age 25–74. They found no relationship between BMI and depression among men, but found that women in the highest quintile of BMI (BMI 28.96 kg/m2) were 38% more likely to report clinically significant depressive symptoms than those in the lower BMI quintiles. Carpenter et al3 conducted the second study meeting the rigorous requirements outlined earlier. Similar to Istvan’s group, Carpenter’s group studied a large (more than 40,000 people), nationally representative sample and found that the relationship between obesity and depression varied by sex. Men with a BMI 30 kg/m2 were significantly less likely to report a history of major depression (see the diagnostic criteria in Table 1), suicidal ideation, or suicide attempts in the past year than average-weight men (BMI 20.8 –29.9 kg/m2). In contrast, underweight men (BMI 20.8 kg/ m2)experienced a 25% increased risk for depression, 81% increased risk for suicidal ideation, and 77% increased risk for suicide attempts compared with average-weight men. A different pattern was seen for women. The 1-year prevalence of major depression was 37% higher among obese females than in their averageweight peers. Women with a BMI 30 kg/m2 also were 20% more likely to report suicidal ideation and 23% more likely to have made a suicide attempt in the past year. There was no association with depression or suicide for underweight women.
Studies of Clinical Populations
If the prevalence of depression among women in the general population is approximately 10%,13 then the studies of Istvan et al2 and Carpenter et al3 suggest that nearly 14% of obese women in the population are depressed. Prevalence estimates of psychopathology are generally higher in treatment-seeking samples of obese people than in the population at large. Uncontrolled studies of individuals seeking weight reduction estimate the lifetime prevalence of depressive disorders (eg, major depression, dysthymia) at 9.2%– 47.5% and the lifetime prevalence of other Axis I mental disorders (ie, clinical syndromes) at 2.5%–31%.14 –16
Obesity and Psychopathology Studies of the General Population
Early studies of the psychosocial status of obese individuals in the general population yielded inconsistent results.1 Some found that obesity was related to greater emotional distress, whereas others reported that obese people displayed less psychological disturbance. Regardless of the direction of the relationships between obesity and psychopathology, these studies consistently failed to find clinically significant results. The differences between obese and nonobese individuals were
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Diagnostic criteria for major depressive episode and major depressive disorder
Criteria for Major Depressive Episode A. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure: (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad or empty) or observation made by others (eg, appears tearful). Note: In children and adolescents, can be irritable mood. (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) (3) significant weight loss when not dieting or weight gain (eg, a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. (4) insomnia or hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. B. The symptoms do not meet criteria for a Mixed Episode. C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition (eg, hypothyroidism). E. The symptoms are not better accounted for by Bereavement; ie, after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, sui cidal ideation, psychotic symptoms, or psychomotor retardation. Criteria for Major Depressive Disorder, Single Episode A. Presence of a single Major Depressive Episode. B. The Major Depressive Episode is not better accounted for by Schizoaffective Disorder and is not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified. C. There has never been a Manic Episode, a Mixed Episode, or a Hypomanic Episode. Note: This exclusion does not apply if all of the manic-like, mixed-like, or hypomanic-like episodes are substance- or treatment-induced or are due to the direct physiological effects of a general medical condition.
(Reprinted from with permission.13)
Potential Risk Factors
In recent studies, the focus of inquiry has shifted from whether obesity is related to greater psychological distress to which obese people are at increased risk for psychopathology. This new question characterizes the second-generation studies and recognizes the heterogeneity of obese persons. Discovery of risk factors is of great importance given that there is likely greater variability among obese individuals than between obese and nonobese people. In this section we review the characteristics that may be associated with increased risk of psychopathology (particularly depression) among obese individuals.
sponsible. Women are teased about their weight more than men and report higher levels of body image dissatisfaction.17 Whether distress about appearance and greater societal pressure to be thin explains the differential relationship between obesity and depression in women and men remains to be examined empirically.
Individuals who eat objectively large amounts of food two or more times per week (for at least 6 months), who experience loss of control while eating, and who are distressed by their behavior meet the criteria for bingeeating disorder (BED) (Table 2). 13 The prevalence of BED is 5% in community samples, but has been estimated to be 7%–30% in samples of obese people seeking weight-loss treatment.18 BED appears to be a reliable marker for psychopathology among obese treatment-seekers. Numerous studies found that binge eaters reported not only more symptoms of depression compared with non– binge eaters, but also lower self-esteem, more symptoms of borderline personality disorder, and greater lifetime prevalence of any Axis I mental disorder, including substance abuse or dependence.19 –22
The findings of Carpenter et al3 and Istvan et al2 are remarkably similar. These studies found that obese women in the general population are 37% and 38% more likely, respectively, to be depressed than are their average-weight peers. There was no relationship, or a negative relationship, between BMI and depression for men. The explanation for the gender difference in the obesity– depression relationship is not known. Different societal expectations about thinness may be partly re-
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Research criteria for binge eating disorder
A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: (1) eating, in a discrete period of time (eg, within any 2-hour period), an amount of food that is definitely larger than most people would eat in a similar period of time under similar circumstances (2) a sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating) B. The binge eating episodes are associated with three (or more) of the following: (1) eating much more rapidly than normal (2) eating until feeling uncomfortably full (3) eating large amounts of food when not feeling physically hungry (4) eating alone because of being embarrassed by how much one is eating (5) feeling disgusted with oneself, depressed, or very guilty after overeating C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least 2 days a week for 6 months. E. The binge eating is not associated with the regular use of inappropriate compensatory behaviors (eg, purging, fasting, excessive exercise) and does not occur exclusively during the course of Anorexia Nervosa or Bulimia Nervosa.
(Reprinted with permission.13)
Nearly 5% of U.S. adults have a BMI of at least 40 kg/m2 and are considered extremely obese (formerly termed “morbidly obese”).23 Extremely obese persons appear to be at greater risk of psychological distress than more moderately obese individuals.16 The mechanisms accounting for the higher rates of psychopathology among those with a BMI 40 kg/m2 are unknown but may include an increased risk of medical complications, a greater likelihood of experiencing prejudice and discrimination, and more significant impairments in health-related quality of life.
Temporal Sequencing of Obesity and Psychopathology
Researchers have begun to examine the question of whether obesity precedes depression or whether an existing mood disturbance predisposes to increased weight. Three studies have addressed this issue. Goodman and Whittaker24 studied a nationally representative sample of 9374 U.S. adolescents in grades 7–12. Participants reported their height and weight and completed a depression questionnaire in 1995 and again in 1996. The investigators explored the reciprocal relations between obesity and depression, while controlling for baseline BMI, age, race, gender, and other psychosocial variables. At baseline, obesity and depression were not related. Being obese in 1995 did not increase the incidence of depression in 1996. Depression at baseline, however, doubled the risk of developing obesity (among those not obese at baseline) at followup. Richardson et al25 assessed 1037 New Zealanders to determine the presence of obesity and major depression in early adolescence (ages 11, 13, and 15), late adolescence (ages 18 and 21), and adulthood (age 26). Controlling for sex, socioeconomic status, maternal obesity and depression, and baseline obesity, they found that
depression in early adolescence was associated with a slightly lower risk of adulthood obesity in both boys and girls. The relationship between late-adolescent depression and adulthood obesity differed across the sexes. Boys who were depressed at age 18 or 21 were less likely to be obese at age 26 than were boys without depression in late adolescence. Girls with late-adolescent depression, however, were twice as likely to be obese at age 26 than were girls who were not depressed at 18 or 21. Furthermore, the prevalence of obesity among girls increased linearly with the number of assessment periods at which they were depressed. Approximately 10% of girls with no episodes of depression were obese in adulthood, compared with approximately 16% and 21% of girls with one episode and two or more episodes of depression, respectively. Roberts et al26 examined the temporal and reciprocal relationships between obesity and depression among 2123 U.S. adults age 50 and older. Participants reported their height, weight, and depressive symptoms during interviews in 1994 and 1999. Those who were depressed in 1994 were 32% more likely to have become obese by 1999, but this increase was not significant after controlling for important demographic and psychosocial variables. The incident risk of depression in 1999, however, was significantly higher (79%) for obese persons versus nonobese persons in 1994. Collectively, results from these longitudinal studies suggest that depression precedes obesity in adolescents— girls, but not boys—and that obesity precedes depression in older adults. These preliminary findings hold promise for further scientific understanding of the positive relationship between BMI and depressive symptoms. Clearly, more research is needed to replicate these findings, to examine temporal and reciprocal relationships among middle-aged adults, and to discover the mechanisms that bridge the relationship between depression and obesity.
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The preceding sections have shown that obesity is related to a slight increase in the risk of mood disturbance— but only among women—and that depression appears to precede obesity in adolescence but to follow the onset of obesity in later adulthood. Clinicians are reminded, however, that the vast majority of obese people are not depressed. Careful assessment is needed. When confronted with an obese patient who is also depressed, the clinician should not assume that the patient’s depression is attributable solely to obesity or that the patient only needs to lose weight to eradicate the mood disturbance. Obese patients who have a significant mood disorder deserve and require the same care that would be provided to a depressed person of average weight. We recommend that patients with major depression be treated for their mood disturbance before they undertake a weight-loss program. The symptoms of depression (eg, poor concentration, low motivation, social withdrawal) can diminish patients’ capacity to adhere to a weight loss program, leaving them vulnerable to attrition, unsatisfactory weight loss, and exacerbation of the mood disorder. Efficacious treatments of depression include cognitive-behavioral psychotherapy, interpersonal psychotherapy, and selective serotonin-reuptake inhibitor therapy.27,28 A psychiatric consultation is recommended to aid in selecting the most appropriate treatment. Patients who report binge eating require further evaluation for mood disturbance and other psychopathology. Care must be taken to distinguish objective bingeing from subjective overeating. The episodes of overeating that many patients call “binges” may actually be subclinical in severity. Binge episodes may (but do not necessarily) have a dissociative quality. Patients may describe feeling “out of it” or outside of themselves, and state that they could not stop eating if they tried. Binge eating is often pressured, even frenzied, and done in secret so as to avoid embarrassment. Binges are typically followed by shame and disgust about the behavior or, at a minimum, an uncomfortable feeling of fullness.13 Binge eating in the absence of depression does not contraindicate participation in a weight-loss program. In a trial of standard life-style modification for obesity (ie, a program of diet, exercise, and group behavior therapy), patients with BED achieved greater average weight reduction than patients with no history of bingeing, and maintained their losses equally well.29 Health care professionals should also be alert to impaired quality of life in obese individuals, which increases in severity at higher BMI levels.30 Research suggests that difficulties in completing daily tasks may account for reports of depression among obese individ-
uals.31 Perceived impairments in self-care activities and work-related tasks, as well as the presence of significant bodily pain, may be particularly detrimental to mood.
Contrary to common stereotypes and assumptions, obesity is not strongly associated with depression or any abnormal personality characteristics. Psychological traits are more widely varied within the population of obese persons than between obese and nonobese individuals. As with people of average weight, certain factors appear to increase the risk of psychopathology among obese persons. Obese females, binge eaters, and extremely obese persons are at increased risk for emotional disturbance. Recent research has attempted to discover whether excess body weight is a risk factor for depression, or whether mood disturbances predispose to obesity. Among adolescents, it seems that depression is related to obesity later in life; in older adults, obesity precedes depression. Psychopathology in an obese person requires the same treatment that would be provided to a person of average weight. Weight loss is not an empirically supported treatment for major depression or other psychiatric conditions.
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23. Flegal KM, Carroll MD, Ogden CL, et al. Prevalence and trends in obesity among US adults. JAMA 2002;288: 1723–7. 24. 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. 25. Richardson LP, Davis R, Poulton R, et al. A longitudinal evaluation of adolescent depression and adult obesity. Arch Pediatr Adolesc Med 2003;157:739 –45. 26. Roberts RE, Deleger S, Strawbridge WJ, et al. Prospective association between obesity and depression: evidence from the Alameda County Study. Int J Obes 2003;27:514 – 21. 27. Chambless DL. Training and dissemination of empirically validated psychological treatments: report and recommendations. Clin Psychol Rev 1995;48:3–23. 28. Sampson SM. Treating depression with selective serotonin reuptake inhibitors: a practical approach. Mayo Clin Proc 2001;76:739 –44. 29. Gladis MM, Wadden TA, Foster GD, et al. A comparison of two approaches to the assessment of binge eating in obesity. Int J Eat Disord 1998;23:17–26. 30. Kolotkin RL, Crosby RD, Williams GR. Health-related quality of life varies among obese subgroups. Obes Res 2002;10:748 –56. 31. Fabricatore AN, Wadden TA, Sarwer DB. Depressive symptoms as a function of body mass index and healthrelated quality of life in treatment-seeking obese adults [abstract]. Obes Res 2003;11:A10.
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