Research reportAssociation of depression & health related quality of life with body composition in children and youth with obesity
Introduction
The prevalence of overweight and obesity in Canadian children and youth has risen dramatically over the last 3 decades, replicating a pattern seen throughout the Western world (Shields and Tremblay, 2010). With this rapid rise in pediatric obesity has come the recognition of associated adverse health consequences including Type 2 diabetes and fatty liver disease. Mental health comorbidities, while less vigorously studied, have also been described (Goran et al., 2003, Daniels, 2009) and obese adolescents are reported to have lower health-related quality of life (HRQOL), higher rates of depression and lower self-esteem compared to their healthy weight counterparts. Obese youth presenting to weight management programs appear particularly vulnerable and have lower scores in all HRQOL dimensions and higher rates of depression compared to obese youth in population-based studies (Schwimmer et al., 2003, Britz et al., 2000, Wardle and Cooke, 2005). This is of particular concern given the potential adverse impact of mental illness on treatment outcomes in both pediatric and adult populations (Taylor et al., 2012).
Despite a growing understanding of the importance of the obesity-mental health dyad, moderators (factors that influence the strength of the relationship) and mediators (help explain the relationship) of the obesity – mental health pathways in obese children and adolescents remain unclear (Gatineau and Dent, 2011) and the evidence that does exist is conflicting (Zeller and Modi, 2006, Pratt et al., 2012). While increased depression and lower HRQOL have been observed in children and youth with obesity, there is some controversy as to the influence of the extent of obesity on mental health measures. Extent of obesity, measured with BMI has been inversely related to HRQOL scores (Schwimmer et al., 2003, Zeller and Modi, 2006) in some studies but not in others (Janicke et al., 2007). Although BMI is used to classify obesity, it provides inadequate information on fat mass or on fat distribution, which may be important given recent evidence on potential biological links between adiposity and mental health (Taylor and Macqueen, 2010). Kesztyeus et al. identified a predictive influence of central obesity, but not BMI, on HRQOL (Kesztyüs et al., 2014). Similarly, Hillman et al. identified the relationship of body fat percentage with anxiety and depressive symptoms in adolescent girls, but no influence of BMI (Hillman et al., 2010).
Moderators of the obesity – mental health relationship in adults include gender, age and socioeconomic status, but their influence in the pediatric population is conflicting. The prevalence of depression is, in population-based studies, higher in adolescents than in children. Furthermore, gender differences emerge in early adolescence where teenage girls are more likely to develop depression than teenage boys. Similar influences of gender and age on adverse mental health amongst youth with obesity have been seen in some studies (Gray and Leyland, 2008) but not others (Richardson et al., 2006). Similar conflicts are present when examining HRQOL amongst obese youth (Schwimmer et al., 2003, Zeller and Modi, 2006, Janicke et al., 2007).
Lower socioeconomic status (SES), while an important moderator of the obesity depression relationship in adult women, has generally not been seen to influence the relationship in children and adolescents (Gatineau and Dent, 2011) with obesity. SES is described as a moderator of HRQOL in non-obese youth (von Rueden et al., 2006) and in youth with other chronic illnesses, but its influence in children and youth with obesity is inconsistent.
We sought to examine the influence of adiposity measured by body fat compared to BMI on depressive symptoms and HRQOL in children and adolescents with obesity. Further, given the importance of understanding moderators and mediators of the relationship of obesity and psychological health in children and adolescents with obesity, we evaluated the role of potential moderators age, sex, pubertal development, SES and family history of depression in a cohort of youth with obesity at the time of entry to a weight management program.
Section snippets
Ethics statement
The study was approved by the institutional review board at the Hamilton Health Sciences Corporation (Hamilton, ON, Canada). Written informed consent was provided by the legal guardian and the participants provided signed assent.
Study design
Children and adolescents between 8 and 17 years of age were enrolled in the Determinants of Change in Childhood Obesity (DECCO) study at the time of presentation to a tertiary care weight management program at McMaster Children׳s Hospital, Hamilton, ON. To be eligible
Results
Descriptive characteristics of the study population at the baseline visit (n=244) are presented in Table 1. Of the 125 girls and 119 boys with a mean age of 12.2 (2.31) years who participated in the study, 77.6% had entered puberty. The study population was markedly overweight, with a mean BMI z-score of 2.2 (0.37) and a body fat percentage of 40.9% (4.97).
Discussion
This cross-sectional study of depression and HRQOL in a large population of obese children and youth presenting for weight management confirmed a higher prevalence of depression and lower HRQOL scores then found in the general population. In population based studies, the prevalence of depression is reported in 5–8% of adolescents (Afifi et al., 2005, Fleming et al., 1989) and 2% of prepubertal children; much lower than the 36.1% in these obese youth. Body fat percentage was the most consistent
Conclusion
We identified a high prevalence of depressive symptoms in our clinical sample of obese children and youth and found that higher body fat predicted depression and lower HRQOL. In identifying children and adolescents with depression at the time of presentation to a weight management program it is important to note that the prevalence of depression was, in contrast to findings in non-obese populations, equally common in males and females and in pre-pubertal and pubertal youth. Furthermore,
Funding sources
This study was supported by the Heart and Stroke Foundation of Canada and the Canadian Institutes of Health Research (#OCO-74267). The funding sources had no role in the conduct of the study or in the presentation and interpretation of the results.
Financial disclosure
None.
Conflict of interest
None.
None of the authors have a conflict of interest related to the findings within the submitted manuscript.
Contributors׳ statement
Katherine M. Morrison: Dr. Morrison contributed to the conception and design of the study, recruitment and study visit conduct, the integrity and analysis of the data, reviewing and revising of the manuscript, and approved the final manuscript as submitted.
Sabina Shin: Ms. Shin contributed to the integrity and analysis of the data, drafted and revised the manuscript, and approved the final manuscript as submitted.
Mark Tarnopolsky: Dr. Tarnopolsky contributed to the conception and design of the
Acknowledgments
We would especially like to acknowledge our collaborator Oded Bar-Or for his founding contribution to this work prior to his death. We would also like to thank our collaborator Stephanie Atkinson, PhD for the interpretation of the DXA scans, the clinical staff at the Children׳s Exercise and Nutrition Centre for their assistance with participant recruitment and Susan Docherty-Skippen and Vivian Vaughn-Williams for their assistance in conducting the study visits.
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