Losing weight is hard enough when you're happy, but it's even harder when you're depressed, as many Americans well know.
Rates of depression are higher in the obese and overweight than in people of normal weight, and while the numbers don't track each other precisely, the incidence of both obesity and depression is increasing in the U.S.
Women, in particular, are more likely to be both overweight and depressed, according to the Centers for Disease Control and Prevention. And an underlying mood disorder may be responsible for 1 in 4 cases of obesity, some research suggests.
The presence of two health issues — in medical lingo, comorbidity — presents a challenge for both people who are overweight and their medical providers, and recalls the old quandary of the chicken and the egg. Do weight problems cause people to become depressed, or do people become overweight because they’re depressed?
While there’s no definitive answer to that question, some obesity specialists say that depression and other mood disorders should be addressed before people do battle with the scale.
“Starting an intentional weight-loss effort in the midst of a poorly managed clinical depression is like starting a marathon with a badly sprained ankle,” Dr. Yoni Freedhoff, an obesity specialist in Canada, has written.
“My advice is straightforward. If you’re suffering with depression, before you consider a weight-loss effort, and even if your weight is playing into your low mood, you’re better off treating your mood before your weight.”
Research from the University of Alabama and elsewhere seems to support Freedhoff's position. In Alabama, researchers found that young adults who reported high levels of depression at the start of the study gained the most weight over the next 15 years. But people who started off overweight showed no dramatic changes in depression, suggesting that depression has a bigger effect on weight than weight on depression.
Meanwhile, research published in March in the Journal of the American Medical Association shows that although 7 out of 10 American adults are obese or overweight, fewer of us are trying to lose weight; we've thrown in the towel even before the bathing-suit arrives, and it may be, in part, because we're depressed.
One of the symptoms of major depressive disorder is hopelessness, the sense that nothing we do will change our circumstances for the better.
“The longer adults live with obesity, the less they may be willing to attempt weight loss, in particular if they had attempted weight loss multiple times without success,” the authors from Georgia Southern University said.
So what’s a person to do if you're both overweight and depressed? Hang on to that towel, and try elevating your mood before tackling your weight.
Start with food
Since one side effect of some antidepressants is a loss of appetite, the problem of excess weight and depression seems easily fixed with a bottle of pills. But other studies found appetite increases with prolonged use of antidepressants and weight gain is commonly associated with their use.
A report by the CDC says that more than half of adults who were taking antidepressants still reported moderate to severe depression and were obese.
One problem is that not all people with weight problems are eating because they're hungry; even without an appetite, they'll continue eating to try to satisfy emotional needs. Moreover, antidepressants don't help everyone who's depressed, said James E. Gangwisch, assistant professor of psychiatry at Columbia University in New York City.
It seems counterintuitive to treat obesity and depression with food, but that's what some of Gangwisch's research suggests. His study published in the American Journal of Clinical Nutrition in 2015 found that consuming food that rapidly raises blood-sugar levels — also known as high-glycemic foods — increased the risk of depression among women. Other studies have found similar outcomes among other demographics, Gangwisch said.
In the Columbia study, which examined the records of more than 70,000 postmenopausal women, the more sugar and processed grains that women consumed, the more likely they were to be depressed.
This might be surprising for anyone who considers a fistful of cookies comfort food, especially taken with milk. And it's true that carbohydrates can trigger a neural process that releases serotonin, a feel-good chemical in the brain.
"However, for this process to occur, the meal must be made up entirely of carbohydrate and consumed without any protein remaining in the gut," Gangwisch and his co-authors wrote.
That's why Judith Wurtman, an obesity specialist writing in Psychology Today, suggests increasing serotonin levels by eating a small amount of carbohydrates, like Cheerios without milk or a slice of whole-grain bread, on an empty stomach a couple of times a day.
Foods like ice cream, sweetened yogurt and baked goods made with eggs contain enough protein to block the release of serotonin.
But they do increase blood sugar levels, which can cause emotional highs and lows. "If you're self-medicating depression with sweets, you may get the momentary sugar rush, but ultimately sugar crashes can end up exacerbating the depression," Gangwisch said.
While the study only showed an association between high-glycemic foods and depression, and does not prove that they cause it, Gangwisch said it's likely that altering the type of food you eat, even if you're not changing the amount or actively trying to lose weight, could improve your mood, which will help when you try to lose weight.
"Make it as painless as possible," he advises, choosing low-glycemic foods that you enjoy so you won't feel deprived. This can be as simple as trading corn flakes for bran flakes, or instant oatmeal for steel-cut oats.
The exercise problem
Vigorous, regular exercise improves not just our physical but mental health as well, so much so that some doctors are now prescribing movement instead of medicine. Several studies have shown that aerobic exercise can, in some cases, be even more effective than antidepressants, and lack of exercise has been shown to increase the risk for depression.
But ironically, the easiest way to lift your mood is also the hardest when you're overweight or obese.
"When people are depressed, they become tired and lethargic. It's difficult to get people who are depressed to exercise," Gangwisch said.
Even normal-weight people have trouble motivating themselves to exercise. Fewer than half of Americans get the amount recommended by the CDC.
The overweight and obese may also fear getting hurt physically or being ridiculed when exercising in public even though most manufacturers of exercise clothes — including Nike — have acknowledged that the pursuit of fitness isn't just for the svelte.
The Mayo Clinic, however, says that it's movement that betters our mood, and you don't have to run a 5K to improve your mental state.
"Certainly running, lifting weights, playing basketball and other fitness activities that get your heart pumping can help. But so can physical activity such as gardening, washing your car, walking around the block or engaging in other less intense activities. Any physical activity that gets you off the couch and moving can help improve your mood," the Mayo Clinic says.
And it doesn't have to be for an hour. As little as five minutes of movement can have a beneficial effect on your mood, even more so if you're outdoors and exposed to nature and light, which are among other strategies recommended to improve mood.
Focus on happy
In 18th-century England, a morbidly obese Scotsman named George Cheyne became popular for books he published about how to be healthy. Cheyne, a physician who weighed as much as 450 pounds at one point, suffered from depression, drank heavily and wrote about his struggles in his book called "The English Malady."
Cheyne's depression, in part, stemmed from guilt derived from his Anglican faith, said Anita Guerrini, a professor at Oregon State University and the author of "Obesity and Depression in the Enlightenment: The Life and Times of George Cheyne."
"He felt that being fat was sinful; he felt guilt from living such a lavish lifestyle," Guerrini said.
Cheyne extrapolated that much of English society was suffering from the same collection of ills that he deemed "The English malady."
"He thought that the English had been too successful, and were eating themselves to death and living in cities that didn't make them happy," Guerrini said. The solution, he decided, involved not just changing his diet but "keeping your mind calm and serene," and one way he did this was by reading novels and the Bible.
"He thought that having a good spiritual life was important," Guerrini said.
Cheyne never got svelte, but he eventually lost half of his body weight with a prescription that today would be described as "everything in moderation."
Three hundred years later, that's a philosophy that Freedhoff, an assistant professor at the University of Ottawa, embraces.
“If you’re already struggling with depression, and in many cases, there’s guilt associated with that, not succeeding with your planned behavior changes can make matters worse,” Freedhoff said.
Rather than working toward an ideal weight or size, people should set a goal of being happy, said Freedhoff, author of the 2014 book "The Diet Fix." That doesn't mean that your weight doesn't matter — obesity causes disease and shortens life expectancy — but getting to a healthy weight, for most people, involves small, manageable changes.
For example, Freedhoff believes people should cook at home and not succumb to the ills of fast food, but while making the transition, he advises people not to obsess about preparing, say, wild-caught salmon stuffed with garlic and kale, but food that you and your family will like.
"Maybe cutting your cooking teeth on less healthy meals will encourage you to gain the skills and comfort you'll need to slowly improve your repertoire, and in so doing make the kitchen a room in which you actually enjoy spending time," Freedhoff wrote on his blog.
“As far as quality of life goes, there’s no doubt in my mind that mental health is far more important than what a person weighs,” Freedhoff said.