Depression Is Common in Children with Obesity Who Attend Weight Management Programs

Overweight young boy upset and standing on a scaleApproximately one-quarter to one-third of all children who have obesity and enter weight management programs are depressed, according to 2 recent studies. The studies found a variety of predictors of depression in these children, including screen time, socioeconomic status, father’s involvement, and percent body fat.  

“It is important to screen for depression in children and teenagers because they are not readily going to admit their feelings,” said Ronald J. Williams, MD, lead author of one of the studies. “You can quickly get past the façade and look for depression if you ask questions,” said Dr. Williams, who is Director of the Pediatric Multidisciplinary Weight Loss Program at Penn State Hershey Children’s Hospital at Penn State Hershey Medical Center. For clinicians who choose to formally screen for depression, Dr. Williams recommended using the Children’s Depression Index (CDI), a self-administered inventory of depressive symptoms in children.

One-Quarter of Children Who are Obese Have Depression in Penn State Study
In a study by Dr. Williams and colleagues published in the 2013 in Clinical Pediatrics, the researchers examined data from 117 children with obesity ages 7 to 17 years who began treatment at the Penn State Pediatric Multidisciplinary Weight Loss Program.

A clinical diagnosis of depression (ie, CDI score ≥13) was found in 31 of the 117 participants (26.5%). In a multivariate analysis that controlled for allergies, asthma, divorce, and family structure, lack of father’s involvement (P=0.04) and daily TV/computer/video game time (P=0.002) were significantly correlated with depression. BMI was not correlated with depression in this analysis.

Tips for Reducing Screen Time
“We’ve been fairly successful at getting screen time down to the 2 hours a day that is recommended by the American Academy of Pediatrics,” Dr. Williams said. “I tell parents that screens are a privilege and not a right. Sometimes children have to earn that privilege, meaning that they have to do 1 hour of physical activity in order to earn 2 hours of screen time as a form of positive reinforcement. If they choose not to do things that they need to like eating properly and exercising, then they can choose to not have their screen time, but that is their choice.”

“If a child currently has 8 or 9 hours of screen time, we slowly cut it back by being mindful of the shows that they really want to watch. It is hard to go cold turkey, so we stage it in whatever time period you feel will work for the patient, but you have to have their buy in,” Dr. Williams said.

“With iPhones and texting, I tell patients to wait 45 minutes and then answer 4 or 5 texts in a row instead of constantly being on the screen. I say, "we are not taking screen time away, but are re-proportioning screen time like we do with food. You can still watch TV and eat different foods, but keeping everything in moderation is key,” Dr. Williams said.

One-Third of Children with Obesity Have Symptoms of Depression in Canadian Study
A study by Morrison et al showed a slightly higher incidence of depression, with 36.4% of 244 youth aged 8 to 17 years entering a weight management program being categorized as depressed using the Center for Epidemiological Studies Depression Scale for Children questionnaire. Multivariate analysis showed that percent body fat (measured by dual energy X-ray absorptiometry [DEXA]) and family socioeconomic status were both significant predictors of depression (odds ratios: 1.1 and 0.79, respectively, for those with household income > $50,000.

“It is very important for clinicians to realize the high prevalence of symptoms of depression in kids or families who are presenting with their child for weight management. In our study, it was 36% and it has been notably elevated in other studies using other methodologies,” said Katherine Morrison, MD, Associate Professor in the Department of Pediatrics, Co-chair of the Metabolism and Childhood (MAC) Obesity Research Program, at McMaster University, Hamilton, ON, Canada. She is also Medical Director of the Children’s Metabolism and Obesity Program at McMaster’s Hospital.

Factors that are typically predictive of depression in population-based studies—including pubertal status, female gender, family history of depression—were not predictive of depression in this group of children with obesity. Thus, in the pediatric population, it may not be the “typical patient” who has symptoms of depression, Dr. Morrison said.  

A Family Approach To Change
“The key for pediatric obesity programs is that it is not just 1 person who needs to change; it is the whole family. If the parents don’t change, the success rate is going to be low,” Dr. Williams said.

“If you are a primary care physician, your focus in terms of obesity prevention really ought to be on lifestyle behaviors and not on that number on the scale per se,” Dr. Morrison said. “It is important to focus on nutrition, physical activity, screen time as is shown in the study by Dr. Williams and colleagues, and sleep, which is emerging as a very important predictor of obesity in children,” she said. She noted that her research into the early origins of obesity has shown that poor sleep at 3 years of age is a predictor of having overweight at 7 years of age.

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