Depression and Obesity in

Adolescents
What Can Primary Care
Providers Do?
Christina J. Calamaro
and Roberta Waite

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 consid-
ered only adult health problems, are increasing in
adolescents.There is some early evidence sug-
gesting 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 man-
age and treat the depression, but potentially pre-
vent and better manage the coexisting obesity
and prevent further complications.

Keywords: adolescence, comorbidity, depression

in the adolescent, pediatric obesity

INTRODUCTION chological and physical ailments (eg, low self-esteem,

Obesity and depression, conditions once considered
adult health problems, are increasing in prevalence
among children and adolescents.The increased preva-
lence 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 pre-
dicted that 24% of American children will be overweight
or obese by 2015.2 The health effects of childhood obe-
sity have been shown to have serious short- and long-
term consequences, which include a wide range of psy-
depression, anxiety, type 2 diabetes, hypertension, hyper-
lipidemia, 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 psy-
chological 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

www.npjournal.org The Journal for Nurse Practitioners - JNP 255

simultaneous occurrence, as well as the likelihood of a and discrimination against individuals with obesity pre-
possible association.5 vail.These individuals are described as “ugly, unhappy,
Primary health care providers are cognizant of the less competent, socially isolated, and lacking in self-dis-
physiological implications of obesity among adolescents. cipline, motivation and personal control” (p. 1802).14
However, the psychosocial issues associated with adoles- Evidence is even emerging that both children and
cent obesity are not well understood and quite often are adults implicitly believe that obese individuals are more
neglected.6 Given the toll that both disorders have on likely to be carrying communicable pathogens than are
adolescents’ quality of life and functional status, it is non-obese individuals.15,16
important to explore the link between them and target Gender issues are also identified in association with
interventions that primary care providers (PCPs) can use weight and mental health issues. As early as age 5, chil-
to mitigate adverse consequences. Considering the num- dren rate overweight and obese children as less likeable,
ber of moderating and mediating particularly obese female chil-
variables that relate to both dren.17 Biases such as this
depression and obesity during appear to persist into the
the developmental period of Depression and obesity have female’s adulthood, therefore
adolescence, understanding the potentially influencing oppor-
shared similar symptoms,
overlap of the variables, and how tunities for developing satisfy-
to address them in practice, is such as complaints of poor ing relationships.14 Overweight
critical for the primary care self-image, depressed mood, youth initially free of psy-
provider. sleep difficulties, sedentary chopathology, particularly
The purposes of this paper females, are more likely to
behavior, and unregulated
therefore are to discuss the endure significant depression
interface and common pathways food intake. and anxiety later in
of obesity and depression in the adulthood.17
adolescent population and Thoughts, mood, and
examine strategies that PCPs can incorporate into behavior have been linked conceptually in the cognitive
practice regarding the management of obesity and behavioral model of depression. Interventions typically
depression in this target population. targeting one of these components are expected to influ-
ence the other two.18 For adolescents who are obese,
DEPRESSION AND OBESITY: THE OVERLAP these cognitive processes regarding their self-image are
For the most part, obesity and depression have been often negative.The thoughts can then become internal-
compartmentalized as separate health problems of a ized, and can affect motivation to address concerns relat-
physical and emotional nature, respectively. However,
7
ed to increased weight.16,19 Multiple studies19 also have
depression and obesity have shared similar symptoms linked childhood obesity to depressed mood. Depressed
such as complaints of poor self-image, depressed mood, mood in childhood and adolescence was associated with
sleep difficulties, sedentary behavior, and dysregulated a 1.90- to 3.50-fold increased risk of BMI greater than
food intake.4 These symptoms are diagnostic criteria for the 95% percentile for age and gender later in life.5 Low
depression and may serve as links between obesity and self-image has also been associated with adolescent over-
depression. weight and overeating, even after controlling for body
mass index.20
Self-Image
Non-physical consequences of adolescent obesity such Depressed Mood
as: being depressed, socially isolated, or discriminated Depression indicators include depressed mood, anhedo-
against; having poor self-esteem and body image distor- nia (diminished interest or pleasure from normally pleas-
tions; and being less preferred as friends and more likely urable events/activities), fatigue, feelings of guilt or
to be the targets of teasing or bullying are less frequent- worthlessness, thoughts of death, as well as changes in
ly considered in the literature.8-13 Despite the increase in sleep, appetite, or psychomotor activity. Problems with
prevalence of overweight and obesity, stigma, prejudice, sleep, appetite, and psychomotor activity can occur in

256 The Journal for Nurse Practitioners - JNP April 2009

either direction — individuals may experience insomnia Sedentary Behavior
or hypersomnia, anorexia or increased appetite, psy- A central feature of depression is lack of interest and
chomotor retardation or agitation.The Diagnostic and decreased physical activity with an increase in sedentary
Statistical Manual IV text revised (DSM-IV-TR)20 crite- behavior.Thought processes affect mood and can signifi-
ria for a major depressive disorder (MDD) episode stipu- cantly influence adolescents’ psychosocial engagement,
late that 5 of 9 possible depression criteria must be pres- physical activity, and lifestyle choices (eg, obese youth are
ent for most of the time over a 5 times more likely to avoid
2-week period; one of the crite- participating in sports and
ria must include either depressed other school activities and have
mood or diminished interest or Although sleep deprivation lower emotional, social, and
pleasure, and the symptoms must has not been irrefutably school functioning).24
be a change from prior function- demonstrated as an Implications of sedentary
ing.20 There are 2 differences in behavior, depression, and obesi-
how depression is diagnosed in
independent risk factor ty are multidirectional. As such,
youth compared with adults. for depression and obesity, increased interaction with
Mood may be irritable, instead it is an intervention that the peers may improve mood as
of depressed or anhedonic, and well as thoughts of self-esteem
PCP can address.
youth may meet symptom crite- (“other classmates like to play
ria if they fail to make expected with me”). Many sedentary
gains in growth rather than activities are considered pleas-
experience weight loss from decreased appetite. Subtypes urable by youth (eg, playing a favorite video game).25
of MDD often related to youth include atypical, melan- However, exclusive pursuit of sedentary activities pro-
cholic, catatonic, or chronic depression features.20 motes social isolation as well as decreased physical activi-
ty. Increased sedentary behavior is also likely to sustain or
Sleep worsen obesity unless there is significant reduction in
Sleep problems are a known feature in adolescent food intake.25 Therefore, reduction in sedentary behavior
depression and may be difficult to treat.21 Sleep changes may help improve obesity by increased energy expendi-
in the depressed adolescent can present differently with ture and improve mood by increased social
each individual (eg, sleep change can be insomnia or interaction/support.
hypersomnia). Symptoms of insomnia may serve as links
between adolescent depression and obesity, and a possible Appetite and Food Intake
target for intervention for both disorders. Adolescents Another symptom associated with both depression and
with depression have prolonged sleep latency compared obesity is change in appetite. Obesity arises out of an
with nondepressed adolescents.21 In a cross-section imbalance between energy intake and expenditure.
study of 383 adolescents ages 11 to 16 years, wrist
22
Appetite changes, or desire to eat, can go either direction
actigraphy was used to objectively measure sleep. Obese in the depressed adolescent (anorexia or hyperphagia).
adolescents experienced less total sleep time than non- For the context of this paper, the focus will be hyper-
obese youths. While decrease in sleep is not a consistent
22
phagia. In a community sample of adolescents diagnosed
feature in depression or obesity, sleep deprivation may with MDD, both hyperphagia and depressed mood were
contribute to a worsening of both depression and obesi- associated with recurrence of depression in adulthood.26
ty. As sleep deprivation, or insomnia, is associated with
22
In adolescents diagnosed with seasonal depression,
increased hunger and decreased insulin sensitivity, obesity increased carbohydrate and subsequent weight gain was
can likely be exacerbated. Additionally, sleep depriva-
23
reported during depressive episodes.27 One hypothesis
tion may also affect mood, and is associated with regarding the role in the association between depressive
increased suicidality in depressed patients.4 Although symptoms is that increases in food intake and overweight
sleep deprivation has not been irrefutably demonstrated are due to disturbances in central serotonergic pathy-
as an independent risk factor for sleep and obesity, it is ways.4 Studies also suggest that depressive symptoms and
an intervention that the PCP can address. weight gain could be related to dysregulation.27 Ethnic

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and racial differences have been identified regarding their toms, higher mental health-related quality of life, and
relationship with self-esteem and eating behavior. For greater satisifcation with their mental health care than
Caucasian and Hispanic girls, low self-esteem has been those referred for the usual standard of care.30
associated with being overweight to a greater degree than For the PCP, it is important therefore to focus more
among African American girls.28 Thus, there is evidence attention on the emotional effect of obesity and the men-
that unhealthy eating behavior is associated with low self- tal health of the adolescent.This involves a comprehensive
esteem and that this may vary among ethnic and racial review with the obese adolesent of patterns of sleep,
groups. Given the bi-directional effects of depression and activity, and appetite, as well as assessment of mood and
obesity, primary health care providers need to be more self-image. If any cues are present that suggest depressive
alert regarding the presentation of depression among symptoms, screening tools for depression, although they
youth among diverse ethnic groups of adolescents. require more time, may be indicated. Few pediatric
providers consistently check for signs of anxiety, depres-
CLINICAL IMPLICATIONS sion, or related signs of distress, even though screening
Primary preventive measures (eg, universal depression tools can be used as part of the assessment process.31
screening) should take place with all adolescents and Although the scores derived by such instruments do not
their families. Moreover, depression screening (eg, in provide definitive diagnostic information, they can be
schools, primary health care) can facilitate early identifi- used as a basis for making appropriate referrals for further
cation and timely referral to assessment and possible inter-
prevention and treatment pro- vention.Table 1 details specific
grams. Screening overweight screening tools validated for
and obese adolescents for men- use in the primary care setting.
tal health concerns and provid- Screening overweight and Adherence to current clini-
ing treatment is essential to obese adolescents for mental cal practice guidelines32,33 to
enabling effective lifestyle prevent or treat childhood
health concerns and provid-
change to occur. Many families overweight or obesity is an
have limited access to specialty ing treatment is essential to important component to assist-
mental health care or prefer to enabling effective lifestyle ing the patient in weight man-
receive their mental health care change to occur. agement, and hopefully
for their adolescent in the pri- improving mood, if there are
mary care setting. This under-
29
sympotms of mood disorder.
scores the importance that Because excessive weight gain,
PCPs need to understand how to approach, manage, and social stigmatization, and lower self-esteem can lead to
effectively treat depressive symptoms in the primary care depressive symptoms, children with weight problems may
setting. The following are strategies suggested for in- need to be viewed as a high-risk group for depression.
office approaches to management of obesity and depres- The American Academy of Pediatrics Committee on
sion, and the relevance of referring youth and families Obesity Prevention34 recommends that PCPs routinely
to mental health specialists for care (eg, advanced prac- monitor children’s BMI and provide guidance to parents
tice mental health nurses, licensed clinical social work- regarding healthy eating habits, physical activity, and
ers, psychologists, and psychiatrists). emerging symptoms of depression.34 One example of a
comprehensive, holistic approach to obesity management
Primary Care Approach is the The Healthy Eating and Activity Together (HEAT)
One study30 conducted from 1999 to 2003 aimed to guideline developed by the National Association of
increase access of adolescents with depression to evi- Pediatric Nurse Practitioners. It provides culturally appro-
denced-based treatments by primary care PCPs trained in priate screening tools that include an outline for the PCP
cognitive behavioral therapy.When mental health issues of to screen for not only depression but other comorbidities
adolescents were treated in the primary care setting by as well.33
trained PCPs, at 6 months, those patients receiving the Cognitive monitoring is a useful strategy to identify
intervention reported significantly fewer depressive symp- irrational beliefs about eating, cognitive distortions, and

258 The Journal for Nurse Practitioners - JNP April 2009

Table 1. Depression Screening Instruments
Age Range/Years No. of Items Clinical Cut-Off
Beck Depression Inventory–2nd ed 13-18 21 20-28 (moderate depression)
(BDI-II)49 29 + (severe depression)
Children’s Depression Inventory (CDI) 50
17-19 27 t scores ⱖ 65 clinically significant
Moods and Feelings Questionnaire (MFQ) 8-17 32 (long) ⱖ 12 for adolescents
11 (brief) ⱖ 9 for children
Kutcher Adolescent Depression Scale 12-18 16 (long) 6 indicator for depression
6 (brief)
Reynolds Adolescent Depression Scale 13-18 30 77 indicates a clinically significant
level of depression
Columbia Depression Scale (CDS) 11-18 22 16+ (high likelihood for depression)
Center for Epidemiological Studies 2-18 20 19 or higher indicating depressed
Depression Scale for Adolescents mood
(CES-D)40

Table 2. Pharmacotherapy for Adolescent Treatment of Depression*§

Drug Dose (mg/d) Increments (mg) Effective Dose (mg) Maximum Dose (mg)
Citalopram (Celexa) 10 10 20
*Fluoxetine (Prozac) 10 10-20 20
Fluvoxamine (Luvox) 50 50 150
Paroxetine (Paxil) 10 10 20
Sertraline (Zoloft) 25 12.5-25 50
Escitalopram (Lexapro) 5 5 10

*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.

the association between thoughts, feelings, and behaviors
associated with diet and exercise.35 Cognitive restructur-
ing 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 “per-
mission 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 recom-
mendations 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 adoles-
cents, as per guidelines for prevention and treatment of
obesity in children,37 require additional support and fol-
low-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 man-
age psychopharmacologic agents (Table 2), side effects
of psychopharmacologic agents (Table 3), and psy-
chotherapy strategies (Table 4). Because of the fragmen-

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Table 3. Common Adverse Effects of SSRIs Table 4. Counseling/Therapy Strategies for Treatment of
With SSRI use If SSRI is decreased Depression
or discontinued Type Philosophical Underpinning
Akathisia or motor Dizziness Cognitive-behavior Depressed individuals have
restlessness therapy (CBT)41-43 cognitive distortions of
Dizziness Headache themselves, the world, and
the future.44 CBT assists in
Headache Impaired concentration
identifying negative or
Treatment-emergent Lightheadedness dysfunctional
agitation or hostility interpretations of events
and substituting these with
Tremor Nausea
positive thought patterns.
Drowsiness Drowsiness This technique shows
Gastrointestinal promise for use in primary
symptoms Fatigue care in the prevention of
depression in children and
adolescents.45
Interpersonal Focuses on working
tation of the mental health system, a gap can potentially psychotherapy (IPT)42,46 through disturbed personal
relationships that may
exist in communication between the mental health contribute to depression.
provider and PCP providers, leading to a gap in the The focus of IPT is on
feedback loop necessary for continuity in care.38 To pre- improving current
vent this, it is important to communicate the potential functioning and
interpersonal relationships.
benefits of receiving mental health services with the
IPT-A, adapted for
adolescent and family, and explain the likely duration of adolescents, addresses 5
therapy and, in the components of the initial mental interpersonal problem
health consultation, discuss any costs that can be areas: interpersonal role
disputes, role transition,
incurred. Working closely with the mental health spe-
interpersonal deficits, grief,
cialist, while providing weight managment strategies for and single-parent families.
the adolescent, will only increase his or her chances for The IPT-A intervention can
success. The goal of communication with the adoles- be learned and delivered by
cent and family is to obtain their active participation social workers,
psychologists, and nurses
and ownership of a plan that meets the adolescent’s
who work in health
needs and is most likely to result in optimal mental and clinics.46
physical health.39 Communication should occur in a Family therapy41,42 Family therapy focuses on
manner that is developmentally and linguistically altering family interactions.
appropriate for the patients and their families. Cultural Therapists focus on
factors need to also be considered, as they can affect improving the presenting
problem and relationship
diagnosis and management of depression. Finally, the
patterns associated with
patient and family should be made aware of the limits the identified problem.47
of confidentiality, including the need to involve parents Family therapy appears to
if there is an imminent risk of harm to the patient or be more effective for
younger children with
others. It is a requisite that PCPs are familiar with their
depression.48
state laws regarding confidentiality.

CONCLUSION
Overall, to address the complex, multifactorial health-
related concerns of obesity and depression among youth,
a more proactive approach in prevention and early inter-
vention 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 suffer-
ing from traditional “adult onset” health problems.

260 The Journal for Nurse Practitioners - JNP April 2009

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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. Calamaro can be reached at
cjc72@drexel.edu. In compliance with national ethical
guidelines, the authors report no relationships with business
or industry that would pose a conflict of interest.
1555-4155/09/$ see front matter
© 2009 American College of Nurse Practitioners
doi:10.1016/j.nurpra.2009.01.004
The Journal for Nurse Practitioners - JNP 261