To enhance the prevention and intervention efforts of childhood obesity, there is a strong need for the early detection of psychological factors contributing to its development and maintenance. Rather than a stable condition, childhood obesity represents a dynamic process, in which behavior, cognition and emotional regulation interact mutually with each other. Family structure and context, that is, parental and familial attitudes, activity, nutritional patterns as well as familial stress, have an important role with respect to the onset and maintenance of overweight and obesity. Behavioral and emotional problems are found in many, though not all, obese children, with a higher prevalence in clinical, treatment-seeking samples. The interrelatedness between obesity and psychological problems seems to be twofold, in that clinically meaningful psychological distress might foster weight gain and obesity may lead to psychosocial problems. The most frequently implicated psychosocial factors are externalizing (impulsivity and attention-deficit hyperactivity disorder) and internalizing (depression and anxiety) behavioral problems and uncontrolled eating behavior. These findings strengthen the need to further explore the interrelatedness between psychological problems and childhood obesity.
The prevalence of childhood obesity is still increasing in most countries and is associated with immediate and long-term medical consequences.1 The mechanisms responsible for the etiology of overweight and obesity are complex. Besides a genetic predisposition, environmental factors act as determinants for energy intake and expenditure. To enhance prevention and intervention efforts, there is a strong need for the early detection of psychological factors contributing to the development and maintenance of overweight and obesity.2 Depending on the setting (laboratory, clinical, non-clinical general population), the measures used, the age and sex of the children and the degree of overweight, data on different psychological or biological factors are often controversial. In addition, the causal relationship between obesity and psychological factors, such as impulsivity, depression, anxiety, familial influences3 and poor social functioning,3, 4 is not clearly defined. This is further due to the cross-sectional nature of most studies, different definitions and assessment of psychopathology in childhood, as well as a lack of inclusion of potential confounders or mediators (social parameters, TV viewing, sleep deprivation and so on). Rather than a stable condition, childhood obesity represents a dynamic process, in which behavior, cognition and emotional regulation interact mutually with each other, with biological parameters, as well as with contextual factors, such as parental attitudes and familial eating, activity and nutritional patterns.1, 5
In this review, we concentrate on the role of psychological factors in the development and maintenance of childhood obesity, taking into account possible limitations of the current literature.
Psychological factors within familial context
In obese children, family structure and context, that is, familial eating behavior and its transmission, have an important role with respect to the onset and maintenance of their overweight and obesity.6, 7, 8 Children learn via observation and imitation, as well as by modeling the behaviors of their parents. In overweight and obese children, parents transmit their eating style and influence their children's eating behavior with specific instructions or reinforcements.9, 10 For example, findings from the study of Laessle et al.9 indicate that mothers’ monitoring of eating behavior decreased obese children's self-control in the laboratory. Their results suggest that the observed eating behavior in a laboratory setting of obese children might be a result of previous maternal reinforcing processes such as prompting high eating rates and large bites. Another study using a preload paradigm to investigate the effect of eating style on energy intake in overweight-to-obese 8- to 12-year-old children revealed a strong association between children's and mothers’ eating behavior. Most importantly, the results showed neither an effect of preload nor that of eating style, such as restrained eating, but solely of mother's food consumption, which was assessed independently in another room, predicting the child's energy intake. Besides genetics, influencing the rate and size of energy intake, this could be an effect of further generalization of a certain eating style learned in the familial context mostly from mothers.10
A further important psychological correlate of childhood obesity might be found in familial stress. Familial stress such as mental disorders or somatic illnesses of parents, or stress associated with low socio-economic status, might further contribute to the manifestation and maintenance of childhood overweight, partly by fostering excessive energy intake. As possible common pathogenetic pathways, both shared genetic factors as well as production and release of neuromonoamine neurotransmitters and peptides within the neuroendocrine axis in response to stress/stressors (including serotonin, norepinephrine, dopamine, neuropeptide Y and corticotropin-releasing hormone) are discussed.11, 12
In most studies relying on clinical and population-based samples of obese children between 5 to 12 years, behavioral problems were found when assessed by interviews or questionnaires (Child Behavior Checklist (CBCL13); Strength and Difficulties Questionnaire (SDQ14); Behavioral Problem Index (BPI)). These psychopathological features included internalizing problems (anxiety and depression, isolation and withdrawal) and externalizing problems such as hyperactivity, conduct problems, low self-esteem and, furthermore, peer conflicts and interaction problems.3, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 Only a few studies used standardized diagnostic interviews to assess mental disorders in obese children. Most often, affective as well as anxiety and conduct disorders, and attention-deficit hyperactivity disorders (ADHDs) were found.21, 25, 26 When studied, the degree of obesity was not automatically related to more psychological problems.16 Furthermore, associations between psychopathology and obesity were not systematically observed in all cross-sectional studies20, 27 and were not always independent of other confounders such as SES or lifestyle.3 Until recently, only a few studies compared behavioral problems of obese children seeking treatment with those of obese children from the general population and normal-weight children.17 Findings of a study by Braet et al.17 revealed significant differences only between the treatment-seeking sample and the control group. The authors suggest psychological distress to be associated with treatment-seeking status and not with BMI per se. Indeed, comparison of a clinical and a non-clinical group of obese prepubertal children revealed that the clinical group had more pronounced behavioral and emotional problems and more often suffered from mental disorders, pointing to a greater psychological vulnerability in clinical groups of obese children.17, 21 These findings stand in contrast with the results of other school-based assessments, where obese children from the general population also showed increased levels of behavioral problems.19, 26, 28, 29, 30, 31, 32
In longitudinal studies, behavioral problems have also been associated with subsequent weight gain or an increased risk of becoming overweight in previously normal-weight children.11, 19, 33 Further studies reveal the predictive value of mental disorders such as depression or conduct disorders for the development of overweight and obesity.11, 12 Evidence further exists that children with a rapid relative gain in weight had a higher prevalence of behavioral and learning problems and also psychosocial stress.34, 35 Thus, the interrelatedness between weight gain and psychological problems might be bi-directional, in that clinically meaningful psychological distress might foster weight gain and rapid weight gain may lead to psychosocial problems.24, 25
Externalizing behavioral problems: the role of impulsivity
On the basis of findings indicating that children with ADHD are characterized by heightened levels of physical activity,36 a potential increase in body weight in these children is thought to be due to an increase in energy intake. One explanation for the common pathogenetic pathway of hyperactivity and excessive food intake can be found in either increased reward sensitivity or the dysfunctional capacity of self-regulation. Central to the concept of self-regulation is the ability to override impulses, as well as to refrain from acting on undesired behavioral tendencies and to follow rules or inhibit immediate desires, and thus to delay gratification.37, 38 A neurobiological explanation was found in the existence of a dopamine dysfunction in the brain, which is associated with overweight.39, 40, 41 Dopamine has a fundamental role in mediating the rewarding effect of food, and low intrinsic dopamine activity may result in compensation by increased food consumption and by consumption of energy-dense food to activate the dopamine pathways.38
Conflicting data exist regarding the association between increased body weight and impulsivity and/or ADHDs. A recent study demonstrated that 8- to 11-year-old obese children had more problems in a behavioral task that involved waiting for a larger delayed food reward instead of taking an immediate smaller reward compared with normal-weight peers.42, 43 In addition, binge-eating obese children were more impulsive than non-binge-eating obese children. Regarding the influence of impulsivity on treatment course, data are contradictory.43, 44 Other data pointing to the role of impulsivity demonstrated that overweight children reached higher scores in delinquent problems and were evaluated by peers as being more aggressive and disruptive than non-overweight children.45, 46 Not only poor inhibitory control, but also reward sensitivity, another aspect of impulsive behavior, has been linked to childhood obesity or overeating.4 The overeating is especially pronounced in the presence of food that varies in color, form, taste and texture.47 Agranat-Meged et al.48 obtained a prevalence of 58% for ADHD in school-aged inpatient obese hospitalized children compared with 10% in the general population, thus pointing to high comorbidity between childhood overweight and ADHD. Similarly, in a clinical setting of 100 consecutive boys with ADHD, the mean BMI-SDS and the prevalence of overweight and obesity were significantly higher compared with age-adapted reference values of German boys, with 19.6% and 7.2% being overweight and obese, respectively.49
In contrast to the clinical data, behavioral problems associated with ADHD were not related to overweight in a nonclinical sample of 1000 French schoolchildren.3 This relationship has been more clearly defined in a national representative sample of US children and adolescents (National Survey of Children's Health), where 62 887, 5- to 17-year-old, children were analyzed: non-medicated children with ADHD had an independent odds ratio of 1.5 for being overweight, whereas children receiving stimulants had no increased risk for overweight, but rather for underweight.50 The latter results can be contributed to the well-known effect of methylphenidate on impulsivity as well as on appetite. Not only can ADHD lead to obesity, but diet or nutritional deficits (for example, in omega-3 polyunsaturated fatty acids) or maternal obesity during pregnancy by themselves can also be associated with or exacerbate ADHD symptoms.51, 52, 53, 54, 55
Internalizing behavior problems: emotional regulation
Besides impulse regulation deficits, obese children often exhibit a deficit in emotional regulation. These internalizing behavior problems encompass depression, anxiety, somatoform problems and social withdrawal as well as isolation.12, 56, 57 Existing data point to an association between depressive symptoms and anxiety and childhood obesity.3, 20, 25, 27, 58, 59 However, longitudinal studies investigating the specific interrelatedness of depressiveness, and onset and course of obesity are rare. Pine et al. analyzed 6- to 17-year-old (mean age 11 years) children with major depression, comparing them with a healthy control group of similar BMI until 10–15 years later. Suffering from major depression in childhood independently predicted adult BMI and was associated with a twofold increased risk to become overweight. Duration of depression between childhood and adulthood also emerged as a predictor of adult BMI.58 Similarly, in a large, national representative sample of adolescents, baseline depressed mood independently predicted obesity 1 year later. The twofold increased risk for the development of obesity was the same among those not obese at baseline. Among the initially obese adolescents, depressed mood was associated with worsening obesity over the year, though this latter association was probably mediated through low self-esteem.11, 12 A further population-based study with young adults found a strong interrelatedness between depressiveness and weight gain especially in girls, even when controlled for familial overweight, SES and baseline body weight.11 Thus, existing data point to the predictive value of depressiveness with respect to the onset and increasing risk of overweight and obesity. A pathological explanation for this comorbidity could lie in the inability to regulate affect (affect-regulation model).11, 60, 61 This model postulates that emotional eating works as a coping strategy to regulate and reduce negative emotions. Accordingly, a positive relationship between anxiety or depression and excessive food intake in children and adolescents has been confirmed by recent research.60 It is assumed that depression and body fat regulation share genetic factors and have common monoamines and peptides (including serotonin, norepinephrine, dopamine, neuropeptide Y and corticotropin-releasing hormone), and it is proposed that chronic stress can increase overweight and its related adverse metabolic consequences.11 Stress leads in turn to changes in the brain morphology and in the neuroendocrine axis.12 Thus, repeated activation of the hypothalamic–pituitary–adrenal axis mediates stress responses, with the accompanying increase in cortisol secretion.62 In turn, high cortisol levels or cortisol reactivity are associated with (abdominal) obesity. In 8- to 13-year-old healthy children, the association between symptoms of depression (child behavior checklist) and BMI was mediated by cortisol reactivity in girls, but not in boys. Thereby, cortisol reactivity was measured as a change in salivary cortisol in response to a cognitive and social evaluative challenge (Trier Social Stress Test for Children).62 In a similar experiment, changes in perceived stress and heart rate reactivity were independently related to body fat and the latter was also related to central obesity in both boys and girls.63
Excessive body weight not only represents a persistent medical condition, but also influences important development tasks of overweight to obese children and adolescents, such as interaction and integration into age-relevant peer activities. Several studies thus indicate the link between obesity and social and peer problems such as social stigma and poorer self-perception.3, 17, 20 These correlates of obesity might represent risk factors for future depression, especially in more vulnerable individuals. In a large Spanish study, body shape at age 5 predicted a 50% increased risk for adult self-reported physician-diagnosed depression (‘have you ever been diagnosed’), though they did not adjust for a possible previous pre-existing psychopathology.64 Adolescent obesity has been associated with an increased risk of adult depression symptoms or major depression 20 years later.65, 66 However, another study failed to find an association between obesity at age 10 and adults’ psychological disorders.67
Although the above-mentioned studies indicate an association between obesity and severe psychological problems, it is important to take into account that psychopathology might not solely be due to the experience of teasing and impaired quality of life often associated with obesity,21, 68 but might also be transmitted in families. Epstein et al.16, 22 investigated maternal psychopathology, socio-economic status (SES) and child's percent overweight in a hierarchical regression model to test the influence of these factors on the child's psychological functioning. Positive associations between maternal psychopathology and SES and the child's emotional and behavior problems were found.16, 22, 25, 26 Another study investigating 8- to 12-years-old overweight-to-obese treatment-seeking children from the general population confirmed mother's psychopathology to be a predictor for the child's psychological problems.69 According to their findings, the mother's anxiety predicted the child's internalizing problems and the child's self-reported depression and anxiety symptoms, whereas the mother's depressive symptoms and eating-disorder pathology did not make an additional contribution.
Uncontrolled eating behavior
Apart from internalizing and externalizing behavioral problems, there is increasing evidence that, similarly to obese adults suffering from binge-eating disorder (BED), uncontrolled eating behavior seems to be prevalent in obese children and adolescents.70
Whereas loss of control over eating appears also in children and is associated with increased general and eating disorder psychopathology, there are several important differences in the phenomenology of binge eating in children compared with adults.30, 70, 71, 72, 73, 74, 75, 76 Subjectively uncontrollable binge eating is further associated with substantial increase in body fat mass of 15%, as indicated by a prospective longitudinal study over 4 years.77 Children experience eating binges also during regular meals or special eating occasions such as parties or during offered snacks.30 As in adults, the amount of energy intake seems to be less important for the identification of binge-eating episodes than the subjective feeling of loss of control.30, 73 As only very few children seem to fulfill the adults research criteria of BED and thus are diagnosed with EDNOS (eating disorder not otherwise specified), Marcus and Kalarchian72 developed specific criteria to assess binge eating in children, which led to substantial efforts in defining and assessing binge eating in childhood. Based on current data, Tanofsky-Kraff et al.70 adapted the original criteria and suggest rather to assess the experience of ‘loss of control eating, LOC’, defined as the experience of loss of control independent of the amount of energy intake than the full-blown picture of adult BED.
Cross-sectional studies examining binge and LOC eating in different non-clinical samples using different questionnaire methods have found prevalence rates varying from 2 to 10% (for an overview, see Tanofsky-Kraff et al.70). Another study from Tanofsky-Kraff et al.32 investigated 162 non-treatment-seeking overweight children using a specialized interview methodology (Child Eating Disorder Inventory, Ch-EDE),78 delivering a prevalence rate of about 9% for LOC eating. Whereas LOC eating is more frequent in obese treatment-seeking groups with prevalence rates rising from 15 up to 36%,79 none of the assessed children suffered from BED.
A recent study investigated the natural course of binge eating during one year in 259 (8–13 years old) children from the general population, as well as from a clinical setting using the Eating Disorder Examination for Children, Ch-EDE,80 thereby assessing predictors for manifestation and development of binge-eating episodes.81 Overall 4.2 and 5% of all children suffered from binge-eating episodes with subjectively or objectively large amount of food intake. After 1 year, most of these children ceased to binge eat. Whereas for manifestation of binge eating, eating concerns revealed a predictive value, the course of binge eating was significantly influenced by both restrictive and emotional eating. During the 1-year follow-up period, 13 children developed binge-eating behavior (subjective or objective binge eating), obese children thereby being more likely to report binge-eating episodes when compared with normal and overweight children.81
The findings of the latter study support cognitive–behavioral accounts of binge eating, and suggest that binge eating might be driven from a deficit in affect-regulation emotional eating as a response to an adverse arousal state82 in combination with engaging in strict dietary restraint. According to Westenhöfer et al.,83 dietary restraint is not a homogenous construct, but includes rigid and flexible control. Rigid control is characterized by an ‘all or nothing’ cognitive style with respect to, for instance, forbidden food. Flexible control includes strategies such as the ‘allowance’ of limited amounts of forbidden food without feelings of guilt or planned compensations. With overweight children, studies report elevated scores of external and emotional eating, as well as engagement in restrained eating in an attempt to restrict energy intake to achieve society's beauty ideal of thinness.84
Although many studies point to a strong mutual association of obesity in childhood and psychological factors such as behavioral problems, the generalizability of the findings remains limited. Limitations include diversity of study samples, and assessment methods such as different questionnaires and interviews. Especially for children, it seems to be important to include both parental and children's perspective of psychological distress to prevent the documented effect that internalizing behavior problems often tend to be neglected by parents.85, 86 Furthermore, as parents of obese children are often not well aware of their children's health problems, this situation might underestimate not only children's excessive body weight, but also the associated psychological impairments.86
These findings strengthen the need to further explore the interrelatedness between psychological problems during onset and maintenance of overweight and obesity, and to further clarify the causality of this association. For clinical purposes, it will turn out to be very important to assess psychological problems and to account for them within treatment procedures.
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The authors declare no conflict of interest.
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Puder, J., Munsch, S. Psychological correlates of childhood obesity. Int J Obes 34, S37–S43 (2010). https://doi.org/10.1038/ijo.2010.238
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