The European Journal of Public Health Advance Access originally published online on September 13, 2006
The European Journal of Public Health 2007 17(3):297-305; doi:10.1093/eurpub/ckl227
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Obesity |
Obesity and the risk for mental disorders in a representative German adult sample
Isabel Hach1, Uwe E. Ruhl2, Michael Klose2, Jens Klotsche2, Wilhelm Kirch1 and Frank Jacobi2
1 Institute of Clinical Pharmacology, Medical Faculty, Technical University of Dresden Germany
2 Clinical Psychology and Psychotherapy, Technical University of Dresden Germany
Correspondence: Dr Isabel Hach, MPH, Forschungsnetz Ambulante Versorgung, Studienzentrum der LMU München, Innere Laufer Gasse 18, D-90403 Nürnberg, Germany, tel.: +49 911 5301809, fax: +49 911 5985679, e-mail: isabel.hach{at}med.uni-muenchen.de
Received August 25, 2005, accepted July 10, 2006
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Abstract |
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Background: A systematic approach to examining associations among obesity and socio-demographic determinants, psychological problems, and mental disorders in epidemiological samples is missing.
Methods: Within the representative German Health Interview and Examination Survey and its Mental Health Supplement (GHS-MHS), 4181 subjects (age 18–65 years) took part in a physical examination (including measurement of body weight and height) and a standardized psychological interview (M-CIDI). Obesity (BMI > 30 kg/m2), somatic diseases, socio-economic variables, health-related quality of life (SF-36), and mental disorders (DSM-IV) were assessed. Data were analysed by logistic regression analyses.
Results: Prevalence of obesity was 18.5%. There was a strong association between obesity and somatic conditions, as well as to low socio-economic status (SES). No psychosocial disadvantages (e.g. regarding social relationships, impairment due to mental health problems, depressed feelings) for the obese individuals were found. With the exception of a higher prevalence of anxiety disorders in obese men (12.5 versus 8.5%, OR = 1.53, CI = 1.06–2.21, disappearing when controlled for number of somatic conditions), obese persons showed no elevated rates of mental disorders.
Discussion: Obesity is associated with a low SES and some somatic disadvantages but not with other social or emotional disadvantages that have been often assumed to be very prevalent in that group. From the population-based perspective, obesity per se seems not to be associated with a higher risk for suffering from mental disorders, whereas relations between specific aspects of obesity and specific types of psychopathology still need further study.
Keywords: mental disorders, obesity, psychosocial disadvantages
It is still controversially debated whether or not obesity and mental disorders are related.1–7 Most studies are consistent in their findings that mental health problems and obesity co-occur, particularly in clinical populations. But a systematic approach to examining associations between mental health and obesity, regarding different aspects and graduation levels of psychosocial problems (e.g. low social support), mental health problems and mental disorders (e.g. low self-esteem, low vitality, depressive mood, threshold DSM-IV diagnosis) in epidemiological samples is missing.1
However, there are several assumptions that obesity, psychosocial and mental health problems are related. Most studies demonstrate a—not necessarily causal—association between obesity and low socio-economic status (SES).8–11 Moreover, it is assumed that obese persons are disadvantaged both in working life (e.g. less chances for promotion) and private life (e.g. lower social support, lack of peer relationships, and difficulties in finding a spouse). Their being confronted with discrimination and stigmatization might contribute to limitations in their mental well-being.12–16 Further, obese persons are also considered to suffer more from low self-esteem, anxious, and depressive symptoms than does the average population,5,17 and therefore might be more vulnerable for developing manifest mental disorders.
Obesity is associated with general physical problems such as shortness of breath, sweating during normal daily activities, sleeping problems, daytime sleepiness, and arthralgias.12–14,16 A BMI >30 kg/m2 is associated with a range of somatic conditions (e.g. hypertension, diabetes mellitus, dyslipidaemia, and joint problems)18,19 and with impairment of health-related quality of life by affecting mainly physical functioning,20 what might contribute to permanent discomfort and mental health problems.21
It is supposed that obesity, mood disorders, and some physical diseases share the same or a similar pathophysiological pathway. A dysregulation of the hypothalamic–pituitary–adrenocortical (HPA) axis is discussed as a common key-mechanism in, among others, depression, stress, diabetes mellitus, and obesity.22–25 Hence, there might be an overlap of genesis and symptoms and, consequently, a co-occurrence.
Finally, associations among severe and persistent mental illness, psychotropic medication, and obesity were reported. Specific categories of psychoactive medication (particularly tricyclic antidepressants, atypical antipsychotics) are known to increase the risk of weight gain, especially in men.26
Most studies that have shown a relationship between obesity and mental health problems were based on selected clinical populations (potential help-seeking bias). To investigate this relationship for the general adult population we used data from the representative German Health Interview and Examination Survey and its Mental Health Supplement (GHS-MHS; age 18–65), where obesity, somatic conditions as well as mental disorders were reliably assessed within one study. We specifically concentrated on potential risk factors and selected mental disorders (according to DSM-IV) and addressed the following questions about whether obesity is associated with:
- social disadvantages that are discussed as risk factors for mental health problems (e.g. having no partner, low social support, low social class, unemployment, and social disability due to mental or somatic problems),
- psychological disadvantages (low self-esteem, low health-related quality of life, and low life satisfaction), and
- manifest mental disorders (DSM-IV: major depression/dysthymia, anxiety disorders, somatoform, and substance use disorders).
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Methods |
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Sample
The German Health Interview and Examination Survey consisted of a core survey (GHS-CS) and several supplemental surveys including the Mental Health Supplement (GHS-MHS).27 Its sample was a stratified random sample from 113 communities throughout Germany with 130 sampling units (sampling steps: (i) selection of communities, (ii) selection of sampling units, and (iii) selection of inhabitants from population registries). Respondents of the German Health Survey older than 65 years were excluded because the psychometric properties of the CIDI, the interview used in the study, have not yet been satisfactorily established for use in older populations.28 The eligible sample size for the GHS-MHS was n = 4773. The conditional response rate of the GHS-MHS was 87.6%, resulting in a total of 4181 respondents who completed the mental health assessment. The presented results can be regarded as representative for the German non-institutionalized adult population from 18 to 65 years of age with sufficient language skills to follow the interviews. Sample characteristics are shown in the left column in table 1.
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BMI and medical conditions involved in the present analyses were assessed in the GHS-CS. In brief, the core survey assessment consisted of (i) a self-report questionnaire, (ii) a standardized computer-assisted medical interview, (iii) anthropometric (weight, height, hip circumference, and waist circumference) measurements, blood pressure measurements, and blood and urine collection. After the completion of the questionnaire, a study physician conducted a structured interview in order to reexamine and refine the data from the self-report packet. This interview was computer-assisted for the purpose of standardization and integrity. Diagnoses were then supplemented and revised by a physician on the basis of the laboratory test data (HbA1c, plasma glucose, fasting triglyceride, cholesterol, and high-density lipoprotein cholesterol), which became available 2 weeks later. The BMI was calculated as the weight (kg) divided by the square of the height (m).
Assessment of potential disadvantages and mental disorders
Psychopathological and diagnostic assessments were based on the computer-assisted version of the Munich Composite International Diagnostic Interview.29–31 The DIA-X/M-CIDI is a modified version of the World Health Organization CIDI, version 1.2, supplemented by questions to cover DSM-IV and ICD-10 criteria. The DIA-X/M-CIDI is a fully structured interview that allows for the assessment of symptoms, syndromes, as well as 4-week and lifetime diagnoses of DSM-IV mental disorders.29,30 Associations with obesity were examined for the following diagnostic groups: substance use disorders (abuse or dependence of any substance without nicotine), major depression/dysthymia, anxiety disorders (panic disorder with or without agoraphobia, social phobia, generalized anxiety disorder, and any specific phobia), and selected somatoform disorders (subthreshold somatization disorder, SSI 4,6,32 somatoform pain disorder).
Beyond threshold diagnoses we used information from this interview to identify subthreshold negative mood states as follows: (i) social anxiety (reporting at least one core symptom of social phobia asked in the respective stem questions of the interview, i.e. excessive and persistent fear of one or more social or performance situations which are avoided or else are endured with intense anxiety and distress), (ii) depressive feelings (reporting at least one core symptom of major depression or dysthymia asked in the respective stem questions of the interview, i.e. 2 weeks feeling depressed or experiencing a loss of interest or pleasure in nearly all activities), and (iii) low self-esteem/shame (‘yes’ to one of the following items taken from the social phobia and depression sections of the diagnostic interview: fear of experiencing an embarrassing or humiliating situation, fear of being judged as dumb or weak, fear of feeling ashamed, feeling worthless, inferior or guilty for more than 2 weeks, having so little self-confidence for more than 2 weeks that one would not try to make up one's mind).
Socio-demographic variables (partnership status, number of significant others to rely on in difficult situations, educational level, current job status, and income), items regarding disability (days within past 4 weeks being unable to carry out usual everyday activities; reported sickness days within past year), health-related quality of life (SF-36,33,34 physical component score, mental component score, and separate analysis of three items on impairment due to physical problems, pain, or mental health problems), and ratings on satisfaction with different life domains (work, family life, other social life, leisure activities, residential area, living conditions, financial situation, health, and an overall rating; 7-point Likert-scales) were assessed with a self-report questionnaire.
The following variables were analysed to test hypotheses assuming selected psychosocial disadvantages being more prevalent in obese compared to non-obese people:
- Having no partner (being single/separated/divorced/widowed without current partner versus being married or unmarried with current partner);
- Low social support (having only two or less significant others to rely on in difficult situations versus having three or more);
- Low SES (lower social versus middle versus higher social class according to Winkler and Stolzenberg (1999),35 a measure combining the highest educational level, current job status, and income);
- Unemployment (currently unemployed versus economically active/retired/student/homemaker; if unemployed within past 5 years: mean duration of unemployment);
- Impairment/disability in social or professional activities (self-report variables on days within past 4 weeks being unable to carry out usual everyday activities; reported sickness days within past year);
- Quality of life (health-related quality of life as measured by the physical and mental health sum scores of the SF-36;33,34 both sum scores are standardized to 50, higher values indicate higher quality of life), self report ratings on satisfaction with different life domains;
- Social anxiety (reporting at least one core symptom of social phobia in the diagnostic interview described above);
- Depressive feelings (reporting at least one core symptom of major depression or dysthymia in the diagnostic interview);
- Low self-esteem/shame (‘yes’ to a range of items mentioned above taken from the social phobia and depression sections of the diagnostic interview).
Analytic strategy
In a first step, logistic regression analyses (odds ratios with 95% confidence intervals for categorical variables, mean ratios with 95% confidence intervals for count variables) were used to determine overall bivariate associations between obesity and the nine potential disadvantages and the four groups of mental disorders mentioned above (with and without controlling for the number of somatic diagnoses assessed in the core survey). Additional analyses were stratified by the following variables: age (18–34, 35–49, and 50–65), sex, and different BMI classes (BMI < 24.9, 25 > BMI < 30, 30 
BMI <35, BMI 35).
To account for the weighting scheme as well as the stratified sampling design by screening status, we calculated confidence intervals with the Huber–White sandwich method.36–38 This was done with Stata software package, release 7.0.39
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As shown in table 1, obesity is clearly linked to somatic health status. Taking the crude indicator of number of somatic diagnoses, prevalence of obesity was 11.6% in the group with ‘good’ (no somatic diagnosis), 18.7% in the group with ‘medium’ (1–2 somatic diagnoses), and 28.7% in the group with ‘poor’ (>2 somatic diagnoses) somatic health status. Obesity was associated with the following diagnoses (not shown in tables): hypertension (OR = 3.51, 95% CI = 2.78–4.43), diabetes mellitus (OR = 1.97, 95% CI = 1.27–3.05), dyslipidaemia (OR = 1.49, 95% CI = 1.16–1.92), and joint diseases (OR = 1.49, 95% CI = 1.21–1.83).
An overview of the associations between potential psychosocial disadvantages or mental disorders and obesity is provided in table 2. In the following section we present the overall results for obese versus non-obese persons (table 3).
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Partnership and social support
Obese people were more often married or having an unmarried partner compared to non-obese. No differences were detected with regard to social support (number of significant others to rely on in difficult situations) in men; obese women showed even more often high social support compared to non-obese. Significance of these results remained after controlling for the number of somatic diagnoses.
Socio-economic status
Obese people belonged significantly more often to the lower social class and less often to the upper class than did non-obese people. Further analyses (not shown in tables) revealed that this result of the composite measure (social class index) is equally true for both educational and financial facet of SES. This effect was significant for both sexes but even more pronounced in women; it was reduced but remained significant when controlling for the number of somatic diagnoses. A trend (0.05 < P < 0.10) to be longer unemployed within past 5 years could be shown for unemployed obese compared to unemployed non-obese but this trend disappeared when controlling for the number of somatic diagnoses. Additional analyses (not shown in tables) revealed that obese people were slightly (not significantly) more often self-employed than persons with a normal BMI.
Impairment/disability in social or professional activities
Obese respondents did not report a significantly elevated number of days within past 4 weeks being disabled in carrying out usual activities due to emotional problems. With regard to disability days due to physical problems, only obese women showed more disability days compared to non-obese. Both obese men and women reported higher impairment within past 4 weeks due to pain as well. The latter two associations reflect the higher somatic morbidity in the obese and disappear when controlling for the number of somatic conditions. There were no differences with regard to the more general question on number of sickness days within the past year (either due to emotional or physical problems). When controlling for the number of somatic conditions, even a trend towards lower impairment is found in the obese (MR = 0.86, 95% CI = 0.72–1.02) (table 3).
Quality of life
Health-related quality of life as measured by the SF-36 was reduced for the physical component score in the obese; this effect was particularly pronounced in the very obese (BMI > 35) with an average score of 43.4. This reflects the higher physical morbidity (the altogether strongest correlate of obesity with an overall odds ratio to have more somatic diagnoses of OR = 2.26, 95% CI = 1.95–2.61) but remains when controlling for the number of somatic conditions.
The mental component SF-36 sum score was even slightly elevated in the obese (significance increased when controlling for number of somatic conditions). Considering satisfaction ratings for several life domains, obese men report—only slightly but significantly—higher satisfaction in the social area and living conditions, in the work area, in the area of leisure activities, as well as higher overall satisfaction. Reduced life satisfaction in the health domain was reported by obese women and men. Despite lower SES in the obese, no differences were found in satisfaction with financial status.
Social anxiety
Obese people entered the social phobia section of the M-CIDI (‘yes’ to stem questions) as often as the non-obese. An insignificant but strong trend of answering ‘yes’ to the symptom ‘fear that something embarrassing will happen’ within that section, as well as significantly more reported ‘fear of feeling ashamed’ was found only in obese men. No differences were found for the ‘fear of being judged as dumb or weak’.
Depressive feelings
No differences at all were found with regard to the M-CIDI depression items (‘feeling of worthlessness’; ‘feeling of inferiority’; ‘having too little self-confidence to make up my mind’).
Prevalence of mental disorders
Overall, no differences between obese and non-obese people from the general population can be shown for most mental disorders. Examining these associations by gender, anxiety disorders were more prevalent in obese men but significance of this association disappeared after controlling for the number of somatic conditions. Obese women with one ore more mental disorder had a higher level of comorbidity compared to diagnosed non-obese women but again the significance of this association disappeared after controlling for the number of somatic diagnoses.
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Discussion |
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The main goal of this study was to evaluate whether or not obesity is associated with an increased prevalence of mental health problems. We used a 3-stage design to discriminate among unfavourable social conditions, psychological disadvantages, and mental disorders.
Obesity, physical illness, and social disadvantages
As to the relationships between body weight and somatic diseases, the results fulfilled the expectations. Obesity was significantly associated with somatic diseases,18,19 and the prevalence of obesity increased with age.17 Beside the age-related problems, the increasing weight can cause physical discomfort.12–16
The socio-demographic data of this large representative sample, on the one hand, confirm but are also contradictory to the results of other studies, which were often evaluated in non-representative samples. There was a significant association between obesity and a low SES.8–11 However, obese persons were significantly more frequently married or living in a partnership and less frequently divorced. Being married or living in a partnership usually is regarded as a mental illness preventing factor.39 Obese people were slightly (not significantly) more often self-employed than persons with a normal BMI. Myers and Rosen (1999)40 describe self-employment as a consequence or a coping strategy in order to avoid discriminatory situations on work place.
Obesity and psychological problems
We could not confirm previous findings and assumptions, respectively, that obesity in general is associated with significant psychological disadvantages. Opposed to other studies, we could not find indicators of lower self-esteem or stigmatization in obese subjects.5,41,42
The examination of self-perceived physical health and psychosocial health using the sum scores of the SF-36 could not provide evidence that obesity is a valid indicator for low quality of life. Although obese and particularly extremely obese subjects showed a reduced physical sum score (associated with a higher physical morbidity),14 obesity was not associated with decreased emotional well-being. Katz et al. have described that even overweight (BMI 26–30 kg/m2) is associated with significant reductions of health-related quality of life.43 Co-occurrence of obesity and physical illness is regarded to result in physical difficulties with basic activities of daily living.14,42 We found even slightly elevated mental health sum scores in obese subjects and slightly higher scores of life satisfaction in obese men than in normal weighted men. This result is difficult to explain, but may be due to some positive accompanying effects, e.g. good meals and marital life.
Obesity and mental disorders
Obesity and mood disorders share several important features, such as abnormalities in appetite, eating behaviour, and physical activity. Mc Elroy et al. (2004)1 have pointed out that there is a lack of large scale psychiatric epidemiological studies assessing anthropometric measures. There are only a few studies that used operational diagnostic criteria to assess mental disorders (and weight) in community samples.2–4,43–45 The results of these studies are disparate. Most consistently, a relationship between (severe) obesity and depression is found, which may be affected by age and gender. The results of our study do not confirm this global association. Accompanying somatic diseases seemed to have an impact on mental well being in obese subjects,12–16 but not obesity per se. As a limitation of the present analyses it has to be mentioned that, opposed to some earlier studies, we did not examine subtypes of depression (e.g. atypical depression, somatic depression, melancholic features, seasonal affective disorder, and perimenstrual depression) that might be associated with particular biological abnormalities shared with obesity.1
We are not aware of studies examining the relationship of obesity and manifest mental disorders (DSM-IV) other than depression. In the present study no overall association with obesity was found in substance use, anxiety, and somatoform disorders as well. Exceptions were higher rates of anxiety problems in obese men and higher comorbidity of mental disorders in obese women; significant associations or trends disappeared when statistically controlling for the presence of somatic conditions.
Methodological strengths and limitations
The strengths and limitations of this study deserve comment. Data come from a community-based representative sample of the German population. Weight and height were measured by medical staff and used to calculate BMI (opposed to self-report BMI data that is usually regarded as having reduced reliability and validity). Mental, physical, and subjective health status were assessed using standardized instruments. We examined obesity (BMI > 30 kg/m2) as well as extreme obesity (BMI > 35 kg/m2) in order to detect a possible higher BMI threshold for mental disorders.42 Further differentiations are needed with regard to kind of obesity (e.g. abdominal obesity and unfavourable hip and waist circumferences, obesity related to binge eating) as well as to subtypes of mental disorders (e.g. atypical depressive syndromes).
This analysis is based on cross-sectional data, only 18–64 years old subjects were included. However, due to the age-related increase of physical and mental impairments, the discrimination between obesity and age-related problems is difficult in higher age. Due to the cross-sectional design we could determine the co-occurrence of mental disorders and obesity but not if obesity was related to the onset of mental problems (or vice versa). Last, we were not able to identify obesity caused by psychopharmacological treatment and could not evaluate iatrogenic associations of specific categories of psychotropic medication with obesity.26
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Conclusions |
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Our study provides evidence that from population-based perspective obesity per se does not seem to be associated with an increased risk for mental disorders. This is not necessarily contradicting to the findings of clinical studies that (especially severe) obesity is common in persons seeking treatment for certain mental health problems.1 In many clinical cases biological as well as psychosocial factors (e.g. due to manifest discrimination) that are definitively related to obesity on an individual basis might play a causal role for developing mental health problems (i.e. pathophysiologies might be overlapping or even be the same and are not co-occurring by chance). Thus, further research into the relationship between specific aspects of overweight and specific psychopathology is greatly needed. Neither we want to question the evidence that obesity is a major and growing public health problem in terms of population attributable risk for morbidity and that there is a political need to develop strategies to modify the ‘obesogenic’ aspects of our current societies' environments, in particular in younger cohorts. But in light of the overall weak or not existing associations—most of the persons with obesity do not have mental disorders as well as most of the non-obese, and most of the people diagnosed with mental disorders are not obese as well as most of the people without mental disorders—we want to point out the invalidity of global (not specific!) assumptions and stereotypes about obesity-related mental health problems.
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Acknowledgments |
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This study was supported by grant 01EH970/8 (German Federal Ministry of Research, Education and Science; BMBF). Mental disorders were assessed in the Mental Health Supplement of the GHS-MHS (Max-Planck-Institute of Psychiatry, Munich; PI: H.-U. Wittchen). Anthropometric, socio-demographic, and somatic health status variables come from the Core Survey (GHS-CS; Robert Koch Institute, Berlin; PI: B.-M. Kurth, W. Thefeld). A public use file of this dataset can be ordered from the senior author.
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