The Journal for Nurse Practitioners
Volume 5, Issue 4 , Pages 255-261, April 2009

Depression and Obesity in Adolescents:

What Can Primary Care Providers Do?

  • Christina J. Calamaro

      Affiliations

    • Christina J. Calamaro, PhD, CRNP, and Roberta Waite, EdD, APRN, CNS-BC, are assistant professors in the College of Health and Nursing Sciences at Drexel University in Philadelphia, PA.
    • ,
  • Roberta Waite

      Affiliations

    • Christina J. Calamaro, PhD, CRNP, and Roberta Waite, EdD, APRN, CNS-BC, are assistant professors in the College of Health and Nursing Sciences at Drexel University in Philadelphia, PA.

Article Outline

Abstract 

The health effects of childhood obesity have been shown to have serious short- and long-term consequences that include a wide range of psychological and physical ailments. In particular, obesity and depression, conditions once considered only adult health problems, are increasing in adolescents. There is some early evidence suggesting that predictors of depression such as shortened sleep, sedentary behavior, and depressed mood, may overlap as predictors of obesity. Assessment, evaluation, and treatment of these predictors could lead to better strategies for the primary care provider to not only manage and treat the depression, but potentially prevent and better manage the coexisting obesity and prevent further complications.

Keywords:  adolescence , comorbidity , depression in the adolescent , pediatric obesity

 

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Introduction 

Obesity and depression, conditions once considered adult health problems, are increasing in prevalence among children and adolescents. The increased prevalence of obesity (defined as body mass index [BMI] > 95th percentile for age and-gender1) in youth is now seen as a public health crisis, and if unchecked, it is predicted that 24% of American children will be overweight or obese by 2015.2 The health effects of childhood obesity have been shown to have serious short- and long-term consequences, which include a wide range of psychological and physical ailments (eg, low self-esteem, depression, anxiety, type 2 diabetes, hypertension, hyperlipidemia, polycystic ovarian syndrome, asthma, and obstructive sleep apnea).3

Adolescence (defined as children ages 12 to 18 years)4 is a period of life wherein puberty is a primary neurohormonal determinant of physiologic and psychological changes that occur. Social and behavioral factors can also contribute to the process of puberty. During this period, weight gain and depression can become more common, indicating the likelihood of simultaneous occurrence, as well as the likelihood of a possible association.5

Primary health care providers are cognizant of the physiological implications of obesity among adolescents. However, the psychosocial issues associated with adolescent obesity are not well understood and quite often are neglected.6 Given the toll that both disorders have on adolescents' quality of life and functional status, it is important to explore the link between them and target interventions that primary care providers (PCPs) can use to mitigate adverse consequences. Considering the number of moderating and mediating variables that relate to both depression and obesity during the developmental period of adolescence, understanding the overlap of the variables, and how to address them in practice, is critical for the primary care provider.

The purposes of this paper therefore are to discuss the interface and common pathways of obesity and depression in the adolescent population and examine strategies that PCPs can incorporate into practice regarding the management of obesity and depression in this target population.

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Depression and Obesity: The Overlap 

For the most part, obesity and depression have been compartmentalized as separate health problems of a physical and emotional nature, respectively.7 However, depression and obesity have shared similar symptoms such as complaints of poor self-image, depressed mood, sleep difficulties, sedentary behavior, and dysregulated food intake.4 These symptoms are diagnostic criteria for depression and may serve as links between obesity and depression.

Self-Image 

Non-physical consequences of adolescent obesity such as: being depressed, socially isolated, or discriminated against; having poor self-esteem and body image distortions; and being less preferred as friends and more likely to be the targets of teasing or bullying are less frequently considered in the literature.8, 9, 10, 11, 12, 13 Despite the increase in prevalence of overweight and obesity, stigma, prejudice, and discrimination against individuals with obesity prevail. These individuals are described as “ugly, unhappy, less competent, socially isolated, and lacking in self-discipline, motivation and personal control” (p. 1802).14 Evidence is even emerging that both children and adults implicitly believe that obese individuals are more likely to be carrying communicable pathogens than are non-obese individuals.15, 16

Gender issues are also identified in association with weight and mental health issues. As early as age 5, children rate overweight and obese children as less likeable, particularly obese female children.17 Biases such as this appear to persist into the female's adulthood, therefore potentially influencing opportunities for developing satisfying relationships.14 Overweight youth initially free of psychopathology, particularly females, are more likely to endure significant depression and anxiety later in adulthood.17

Thoughts, mood, and behavior have been linked conceptually in the cognitive behavioral model of depression. Interventions typically targeting one of these components are expected to influence the other two.18 For adolescents who are obese, these cognitive processes regarding their self-image are often negative. The thoughts can then become internalized, and can affect motivation to address concerns related to increased weight.16, 19 Multiple studies19 also have linked childhood obesity to depressed mood. Depressed mood in childhood and adolescence was associated with a 1.90- to 3.50-fold increased risk of BMI greater than the 95% percentile for age and gender later in life.5 Low self-image has also been associated with adolescent overweight and overeating, even after controlling for body mass index.20

Depressed Mood 

Depression indicators include depressed mood, anhedonia (diminished interest or pleasure from normally pleasurable events/activities), fatigue, feelings of guilt or worthlessness, thoughts of death, as well as changes in sleep, appetite, or psychomotor activity. Problems with sleep, appetite, and psychomotor activity can occur in either direction — individuals may experience insomnia or hypersomnia, anorexia or increased appetite, psychomotor retardation or agitation. The Diagnostic and Statistical Manual IV text revised (DSM-IV-TR)20 criteria for a major depressive disorder (MDD) episode stipulate that 5 of 9 possible depression criteria must be present for most of the time over a 2-week period; one of the criteria must include either depressed mood or diminished interest or pleasure, and the symptoms must be a change from prior functioning.20 There are 2 differences in how depression is diagnosed in youth compared with adults. Mood may be irritable, instead of depressed or anhedonic, and youth may meet symptom criteria if they fail to make expected gains in growth rather than experience weight loss from decreased appetite. Subtypes of MDD often related to youth include atypical, melancholic, catatonic, or chronic depression features.20

Sleep 

Sleep problems are a known feature in adolescent depression and may be difficult to treat.21 Sleep changes in the depressed adolescent can present differently with each individual (eg, sleep change can be insomnia or hypersomnia). Symptoms of insomnia may serve as links between adolescent depression and obesity, and a possible target for intervention for both disorders. Adolescents with depression have prolonged sleep latency compared with nondepressed adolescents.21 In a cross-section study22 of 383 adolescents ages 11 to 16 years, wrist actigraphy was used to objectively measure sleep. Obese adolescents experienced less total sleep time than non-obese youths.22 While decrease in sleep is not a consistent feature in depression or obesity, sleep deprivation may contribute to a worsening of both depression and obesity.22 As sleep deprivation, or insomnia, is associated with increased hunger and decreased insulin sensitivity, obesity can likely be exacerbated.23 Additionally, sleep deprivation may also affect mood, and is associated with increased suicidality in depressed patients.4 Although sleep deprivation has not been irrefutably demonstrated as an independent risk factor for sleep and obesity, it is an intervention that the PCP can address.

Sedentary Behavior 

A central feature of depression is lack of interest and decreased physical activity with an increase in sedentary behavior. Thought processes affect mood and can significantly influence adolescents' psychosocial engagement, physical activity, and lifestyle choices (eg, obese youth are 5 times more likely to avoid participating in sports and other school activities and have lower emotional, social, and school functioning).24 Implications of sedentary behavior, depression, and obesity are multidirectional. As such, increased interaction with peers may improve mood as well as thoughts of self-esteem (“other classmates like to play with me”). Many sedentary activities are considered pleasurable by youth (eg, playing a favorite video game).25 However, exclusive pursuit of sedentary activities promotes social isolation as well as decreased physical activity. Increased sedentary behavior is also likely to sustain or worsen obesity unless there is significant reduction in food intake.25 Therefore, reduction in sedentary behavior may help improve obesity by increased energy expenditure and improve mood by increased social interaction/support.

Appetite and Food Intake 

Another symptom associated with both depression and obesity is change in appetite. Obesity arises out of an imbalance between energy intake and expenditure. Appetite changes, or desire to eat, can go either direction in the depressed adolescent (anorexia or hyperphagia). For the context of this paper, the focus will be hyperphagia. In a community sample of adolescents diagnosed with MDD, both hyperphagia and depressed mood were associated with recurrence of depression in adulthood.26 In adolescents diagnosed with seasonal depression, increased carbohydrate and subsequent weight gain was reported during depressive episodes.27 One hypothesis regarding the role in the association between depressive symptoms is that increases in food intake and overweight are due to disturbances in central serotonergic pathyways.4 Studies also suggest that depressive symptoms and weight gain could be related to dysregulation.27 Ethnic and racial differences have been identified regarding their relationship with self-esteem and eating behavior. For Caucasian and Hispanic girls, low self-esteem has been associated with being overweight to a greater degree than among African American girls.28 Thus, there is evidence that unhealthy eating behavior is associated with low self-esteem and that this may vary among ethnic and racial groups. Given the bi-directional effects of depression and obesity, primary health care providers need to be more alert regarding the presentation of depression among youth among diverse ethnic groups of adolescents.

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Clinical Implications 

Primary preventive measures (eg, universal depression screening) should take place with all adolescents and their families. Moreover, depression screening (eg, in schools, primary health care) can facilitate early identification and timely referral to prevention and treatment programs. Screening overweight and obese adolescents for mental health concerns and providing treatment is essential to enabling effective lifestyle change to occur. Many families have limited access to specialty mental health care or prefer to receive their mental health care for their adolescent in the primary care setting.29 This underscores the importance that PCPs need to understand how to approach, manage, and effectively treat depressive symptoms in the primary care setting. The following are strategies suggested for in-office approaches to management of obesity and depression, and the relevance of referring youth and families to mental health specialists for care (eg, advanced practice mental health nurses, licensed clinical social workers, psychologists, and psychiatrists).

Primary Care Approach 

One study30 conducted from 1999 to 2003 aimed to increase access of adolescents with depression to evidenced-based treatments by primary care PCPs trained in cognitive behavioral therapy. When mental health issues of adolescents were treated in the primary care setting by trained PCPs, at 6 months, those patients receiving the intervention reported significantly fewer depressive symptoms, higher mental health-related quality of life, and greater satisifcation with their mental health care than those referred for the usual standard of care.30

For the PCP, it is important therefore to focus more attention on the emotional effect of obesity and the mental health of the adolescent. This involves a comprehensive review with the obese adolesent of patterns of sleep, activity, and appetite, as well as assessment of mood and self-image. If any cues are present that suggest depressive symptoms, screening tools for depression, although they require more time, may be indicated. Few pediatric providers consistently check for signs of anxiety, depression, or related signs of distress, even though screening tools can be used as part of the assessment process.31 Although the scores derived by such instruments do not provide definitive diagnostic information, they can be used as a basis for making appropriate referrals for further assessment and possible intervention. Table 1 details specific screening tools validated for use in the primary care setting.

Table 1. Depression Screening Instruments
Age Range/YearsNo.of ItemsClinical Cut-Off
Beck Depression Inventory–2nd ed (BDI-II)4913-182120-28 (moderate depression)
29 + (severe depression)
Children's Depression Inventory (CDI)5017-1927t scores ≥65 clinically significant
Moods and Feelings Questionnaire (MFQ)8-1732 (long)≥12 for adolescents
11 (brief)≥9 for children
Kutcher Adolescent Depression Scale12-1816 (long)6 indicator for depression
6 (brief)
Reynolds Adolescent Depression Scale13-183077 indicates a clinically significant level of depression
Columbia Depression Scale (CDS)11-182216+ (high likelihood for depression)
Center for Epidemiological Studies2-182019 or higher indicating depressed mood
Depression Scale for Adolescents (CES-D)40

Adherence to current clinical practice guidelines32, 33 to prevent or treat childhood overweight or obesity is an important component to assisting the patient in weight management, and hopefully improving mood, if there are sympotms of mood disorder. Because excessive weight gain, social stigmatization, and lower self-esteem can lead to depressive symptoms, children with weight problems may need to be viewed as a high-risk group for depression. The American Academy of Pediatrics Committee on Obesity Prevention34 recommends that PCPs routinely monitor children's BMI and provide guidance to parents regarding healthy eating habits, physical activity, and emerging symptoms of depression.34 One example of a comprehensive, holistic approach to obesity management is the The Healthy Eating and Activity Together (HEAT) guideline developed by the National Association of Pediatric Nurse Practitioners. It provides culturally appropriate screening tools that include an outline for the PCP to screen for not only depression but other comorbidities as well.33

Cognitive monitoring is a useful strategy to identify irrational beliefs about eating, cognitive distortions, and the association between thoughts, feelings, and behaviors associated with diet and exercise.35 Cognitive restructuring can then correct or mitigate distorted thinking around food and weight that adolescents may have such as “I will never be able to lose weight,” “My obesity runs in the family. I can't do anything about it,” “If the food is fat-free (or low fat), the calories do not count,” or “I should always finish my plate.” Properly identifying “permission statements” and other irrational beliefs may help reframe these cognitions to be more conducive to weight loss.36 Youth with cognitive distortions are therefore at increased risk of poorer adherence to treatment recommendations for both obesity and depression.

Recognition can also be increased when PCPs more frequently ask parents, or adolescents themselves, about stress or personal emotional difficulties. The process can be enhanced by having a welcoming environment, and taking time to listen carefully, and build rapport. Obese adolescents, as per guidelines for prevention and treatment of obesity in children,37 require additional support and follow-up from PCPs to monitor weight and comorbidities, if present. If screening for depression determines that an adolescent is depressed, a referral process to a specialist or other mental health services should be instituted.

Referral Process 

The mental health specialist tends to initiate and manage psychopharmacologic agents (Table 2), side effects of psychopharmacologic agents (Table 3), and psychotherapy strategies (Table 4). Because of the fragmentation of the mental health system, a gap can potentially exist in communication between the mental health provider and PCP providers, leading to a gap in the feedback loop necessary for continuity in care.38 To prevent this, it is important to communicate the potential benefits of receiving mental health services with the adolescent and family, and explain the likely duration of therapy and, in the components of the initial mental health consultation, discuss any costs that can be incurred. Working closely with the mental health specialist, while providing weight managment strategies for the adolescent, will only increase his or her chances for success. The goal of communication with the adolescent and family is to obtain their active participation and ownership of a plan that meets the adolescent's needs and is most likely to result in optimal mental and physical health.39 Communication should occur in a manner that is developmentally and linguistically appropriate for the patients and their families. Cultural factors need to also be considered, as they can affect diagnosis and management of depression. Finally, the patient and family should be made aware of the limits of confidentiality, including the need to involve parents if there is an imminent risk of harm to the patient or others. It is a requisite that PCPs are familiar with their state laws regarding confidentiality.

Table 2. Pharmacotherapy for Adolescent Treatment of Depression*§
Drug Dose (mg/d)Increments (mg)Effective Dose (mg)Maximum Dose (mg)
Citalopram (Celexa)101020
*Fluoxetine (Prozac)1010-2020
Fluvoxamine (Luvox)5050150
Paroxetine (Paxil)101020
Sertraline (Zoloft)2512.5-2550
Escitalopram (Lexapro)5510

* Children and adolescents taking antidepressants should be monitored closely for suicidal thoughts and behavior. There is a cautionary label or “black-box warning” used to treat depression for this population.

§ The FDA has only approved Prozac (fluoxetine). All licensed health providers with prescriptive authority have the option of prescribing medications for “off-label” use based on their clinical judgment of an individual's treatment needs. Off-label use, which consists of using a medication for medical conditions that are not recognized on the FDA approved labeling for that medication, is a common practice.

Table 3. Common Adverse Effects of SSRIs
With SSRI useIf SSRI is decreased or discontinued
Akathisia or motor restlessnessDizziness
DizzinessHeadache
HeadacheImpaired concentration
Treatment-emergent agitation or hostilityLightheadedness
TremorNausea
DrowsinessDrowsiness
Gastrointestinal symptomsFatigue
Table 4. Counseling/Therapy Strategies for Treatment of Depression
TypePhilosophical Underpinning
Cognitive-behavior therapy (CBT)41, 42, 43
Depressed individuals have cognitive distortions of themselves, the world, and the future.44 CBT assists in identifying negative or dysfunctional interpretations of events and substituting these with positive thought patterns.

This technique shows promise for use in primary care in the prevention of depression in children and adolescents.45

Interpersonal psychotherapy (IPT)42, 46
Focuses on working through disturbed personal relationships that may contribute to depression.

The focus of IPT is on improving current functioning and interpersonal relationships.

IPT-A, adapted for adolescents, addresses 5 interpersonal problem areas: interpersonal role disputes, role transition, interpersonal deficits, grief, and single-parent families.

The IPT-A intervention can be learned and delivered by social workers, psychologists, and nurses who work in health clinics.46

Family therapy41, 42
Family therapy focuses on altering family interactions.

Therapists focus on improving the presenting problem and relationship patterns associated with the identified problem.47 Family therapy appears to be more effective for younger children with depression.48

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Conclusion 

Overall, to address the complex, multifactorial health-related concerns of obesity and depression among youth, a more proactive approach in prevention and early intervention is required. Collaborating across professional groups and heightening sensitivity to both physiological and psychological factors may serve to improve health outcomes for youth in the United States who are suffering from traditional “adult onset” health problems.

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 In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.

PII: S1555-4155(09)00041-5

doi:10.1016/j.nurpra.2009.01.004

The Journal for Nurse Practitioners
Volume 5, Issue 4 , Pages 255-261, April 2009

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