The increasing prevalence of obesity across the world is well documented as is the rise in psychopathological conditions. The association between obesity and psychopathology holds important implications for practitioners, academics, and policy-makers. Of interest is the influence of weight stigma on the development of psychopathological conditions. Thus, this article explores the link between psychopathology and obesity, in particular, the role of weight stigma in the development of psychopathology. This review also highlights the implications for assessment, treatment, and research.
Obesity is considered a major health concern in many countries across the world. Evidence has accumulated demonstrating it is multifaceted in its development and impact. The complexity of obesity is conceptualised within the Foresight Report1 which recognises the interplay between an array of factors, including biology, activity environment, physical activity, societal influences, food environment, and food consumption, of which psychopathology is entwined throughout. Indeed, there are more than 100 direct and indirect variables that have been reported to influence obesity.
Obese people who have psychopathological concerns are at an increased risk of associated morbidity and premature mortality.2,3 Research demonstrating the link between obesity and psychopathology has increased, where, for example, a higher ratio of psychopathology has been reported in obese people compared with non-obese people.4,5 Evidence suggests that obesity increases the risk of sub-clinical and clinical psychopathology.5-9 This association and therefore the potential for health care professionals, researchers, and policy-makers in this area to work with obese patients who have a psychopathological condition are high and are increasing as the prevalence of both obesity and psychopathology concomitantly rises.
In recent years, weight stigma and discrimination has been highlighted as a factor influencing the relationship between obesity and psychopathology. Given the extent of weight stigma reported in the previous literature,10,11 it is likely to increase the prevalence of obese people with a psychopathological concern and, thus, needs to be considered in future assessment, treatment, and research.
Stigma
A plethora of research has independently highlighted that both weight and mental health are stigmatised2,10 and that experiences of stigma occur in a variety of settings.12–14 The importance of stigma and associated discrimination cannot be overestimated given reports that weight and mental health stigma may lead to poorer body image, low self-esteem, marginalisation leading to social exclusion, reduced quality of life, substance abuse, and, in some cases, self-harming and suicide.2,15-17 For instance, Puhl and Luedicke18 reported that weight-based victimisation in boys predicted negative affect when teasing experiences occurred in the classroom or other private locations, such as the school campus. They reported that both boys and girls who reported negative affect due to weight-based victimisation were more likely to use avoidance coping strategies, such as skipping gym class, as well as increased food consumption and binge eating. Puhl and Luedicke18 also reported that boys were less likely than girls to respond to weight-based victimisation by engaging in healthy behaviours. There were some sex differences based on the setting where weight-based victimisation occurred. For example, there was a greater likelihood of increased food consumption and binge eating in boys who experienced weight-based victimisation in intimate settings, such as the locker rooms and bathrooms. It was also reported that girls experienced a negative emotional response when weight-based victimisation occurred in the classroom and gym class.
Although research has demonstrated that there is a bidirectional relationship between obesity and psychopathology,19 recently, weight stigma has been reported as an influential factor in the development of psychopathological concerns. For instance, when stigma is internalised, it can lead to stress and lowered self-worth. Moreover, when exposed to repeated experiences of weight stigma, this can become a chronic stressor leading to the development of psychopathological conditions.9,18 Weight stigma refers to the ‘social devaluation and denigration of people perceived to carry excess weight and leads to prejudice, negative stereotyping and discrimination toward those people’.20 Schafer and Kenneth9 suggested that the link between obesity and psychopathology is due to perceived weight status and the associated internalisation of weight stigma, rather than actual weight status. Pickering et al21 reported associations between overweight and/or obese weight status and the development of severe mental health concerns, including panic disorder, specific phobia, generalised anxiety disorder, and social phobia.
Obesity and Mood
Much research has highlighted clinical depression and depressive symptoms in obese children and adults, many of which have cited the potential links to poor body image, anxiety, substance abuse, and self-harming.22 Often cited as the primary determinants of obesity, eating behaviour and physical inactivity have been associated with depression and mood state. Research has reported a bidirectional relationship between weight and mood, and associative research has demonstrated that mood state affects food choice and consumption. This was reflected in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) which identifies overweight with weight gain and undereating with weight loss as diagnostic criteria for depression.23 However, more recently, obesity has been removed from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), which is suggested to be due to the incomplete understanding of the cause of obesity.24 Thus, continued work to establish the impact of mental health phenotypes on the development of obesity is warranted.
The importance of early experiences cannot be overstated in the development of psychopathology in later life. Research has highlighted that early experiences increase the likelihood of developing depression later in life. For instance, Harris25 noted that there was an increasing amount of literature that associates adversities in early childhood with long-term development of depression. Similarly, and more recently, research has reported weight discrimination among children as early as 3 years of age26 and body dissatisfaction in children as young as 6 years old.27
In the instance of successful weight loss, it should be noted that the enduring effects on well-being, the likely self-stigmatisation due to internalisation of weight stigma, previous stigmatising experiences, and associated psychopathology can remain and are likely to continue to have an impact on an individual. For example, Levy and Pilver28 found that formerly overweight adult men and women continued to be at risk of any anxiety disorder, any depressive disorder, and suicide attempts even after weight loss.
Although the mechanisms that explain the development of anxiety and depression due to stigma are still to be identified,26 perceptions of the controllability of obesity may elucidate the underlying aspects of this process. The relationship between beliefs about the controllability of obesity and weight stigma has been reported,10 and when these beliefs are internalised leading to self-stigmatisation, this is likely to have a psychological impact. It is also likely that when individuals internalise societal attitudes, they may blame themselves for weight stigma experiences rather than other people’s unfair treatment.12 By absorbing this perceived mistreatment into their own self-concept, individuals may experience weight-based identity threat.9,29,30 This situational threat can be triggered by environmental cues and stems from a person’s belief that others see them as belonging to the social category ‘overweight’. As this category is attached to negative stereotypes and devaluation, experiences of social identity threat may result in increased anxiety and physiological stress reactivity.29
Obesity and Stress
There is also a bidirectional relationship between depression and stress, both of which may influence obesity. For instance, individuals who are depressed are likely to experience increased stress leading to weight gain. Stress is known to influence engagement in lifestyle behaviours, including healthiness of food and drink consumption and physical activity level. Similarly, stress can lead to depression resulting from major life events, such as job loss, divorce, and bereavement. It has also been reported that weight stigma and discrimination can contribute to the development of obesity, for example, weight discrimination has been associated with a 2.5-fold increased risk of becoming obese within 4 years.31
Physiologically, stress leading to the action of the hypothalamic-pituitary-adrenal (HPA) axis may lead to the development of obesity and depression.22 Elevated levels of cortisol indicating activation of the HPA axis have been reported in obese people, as well as associations between depression and abdominal body fatness.32,33 For example, Tomiyama et al33 reported that weight discrimination was associated with an increased risk of obesity and a significant relationship between weight stigma and markers of activation of the HPA axis and oxidative stress. They reported that weight stigma frequency was positively related to morning cortisol indices and that consciousness of weight stigma was positively related to oxidative stress and morning cortisol levels.
When individuals are concerned about being devalued, for example, because of their weight, cardiovascular stress responses increase, as well as the activation of negative emotions related to stress.34 Increased stress undermines physical health, for example, by activating the cardiovascular, metabolic, and immune systems. It also affects executive resources such as decreases in working memory and poor performances on tasks that require executive control.29 In addition, situational cues that make concerns about weight stigma salient can lead to the disruption of the self-regulatory processes important for self-control.34 Thus, individuals often respond to weight-based victimisation in ways that may be harmful to their emotional and physical health.18
Perceived Weight Discrimination
It is important to note that perceived weight discrimination has also been linked to the negative outcomes identified above.35 For example, Schafer and Kenneth9 found that class I obese adults (body mass index [BMI], 30-34.9 kg/m2) who perceived discrimination fared worse than severely obese adults (BMI, 35+ kg/m2) who did not perceive discrimination. These findings elucidate 2 important issues: (a) that social processes of perceived weight discrimination, and not just weight alone, are responsible for the deleterious effects of obesity on mental health and emotional distress,35 and (b) that the internalisation of perceived discrimination also occurs and affects the mental health of individuals who are not objectively overweight or obese.9,11,29
Exercise and Healthy Consumption as Medicine
The links discussed in this article highlight not only the likely development of obesity with psychopathology but also the associative treatment that can be beneficial for people presenting with both health concerns. Although there is an array of treatments suggested for obesity and psychopathology independently that vary in terms of their invasiveness (eg, surgery, pharmacological interventions), there is now a strong foundation to promote exercise and healthy food and drink consumption as medicine, with previous evidence highlighting the benefits of engaging in healthy behaviours. Consequently, there are calls for physicians to promote and, where appropriate, prescribe exercise to patients to treat physical and mental health concerns.
Research examining the use of exercise and healthy food and drink consumption as medicine is ongoing. The importance of identifying the benefits on obesity and psychopathology, given their prevalence and impact globally, cannot be overestimated. What has become abundantly evident is the need for holistic interventions that consider a wide range of factors across a range of disciplines. For instance, the delivery of interventions needs to be considered given that stigma has the potential to reduce the effectiveness of interventions at all levels. The importance of supportive health care delivery with obese patients has been highlighted very recently, particularly with respect to motivation and adherence to primary care interventions.36
Conclusions
There is a vital link between obesity and psychopathology that should be considered in the assessment, treatment, and prevention of obesity. The complexity of obesity means that interventions that are discipline specific are redundant and are unlikely to lead to long-term weight loss. Instead, a whole systems approach that is holistic in nature and considers the factors identified as contributing to obesity may lead to improved effectiveness. As indicated in this article and although this is only a snapshot of the link between obesity and psychopathology, this association is clearly a key factor relating to weight status that requires consideration and should be reflected within weight loss interventions. Finally, as highlighted in the article, there is increasing evidence to suggest that stigma is a key element in the development of psychopathology and that delivering non-stigmatising, supportive health care is of paramount importance.
Three peer reviewers contributed to the peer review report. Reviewers’ reports totalled 389 words, excluding any confidential comments to the academic editor.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
SWF conceived and designed the paper, wrote the first draft of the manuscript, jointly developed the structure and arguments for the paper, and made critical revisions and approved the final version. SWF and LL-S contributed to the writing of the manuscript and agree with manuscript conclusions. All authors reviewed and approved the final manuscript.
As a requirement of publication author(s) have provided to the publisher signed confirmation of compliance with legal and ethical obligations including, but not limited to, the following: authorship and contributorship, conflicts of interest, privacy and confidentiality and (where applicable) protection of human and animal research subjects. The authors have read and confirmed their agreement with the ICMJE authorship and conflict of interest criteria. The authors have also confirmed that this article is unique and not under consideration or published in any other publication, and that they have permission from rights holders to reproduce any copyrighted material. Any disclosures are made in this section. The external blind peer reviewers report no conflicts of interest.
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