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. Author manuscript; available in PMC: 2012 Nov 1.
Published in final edited form as: J Clin Psychiatry. 2011 Mar 8;72(11):1494–1502. doi: 10.4088/JCP.10m06077gry

Temporal Relationships between Overweight and Obesity and DSM-IV Substance Use, Mood, and Anxiety Disorders: Results from a Prospective Study

Roger P Pickering 1, Risë B Goldstein 1, Deborah S Hasin 2,3,4, Carlos Blanco 2,4, Sharon M Smith 1, Boji Huang 1, Attila J Pulay 1, W June Ruan 1, Tulshi D Saha 1, Frederick S Stinson 1, Deborah A Dawson 1, Bridget F Grant 1
PMCID: PMC3227748  NIHMSID: NIHMS329098  PMID: 21457678

Abstract

Background

Associations between overweight and obesity and medical conditions have been extensively studied, but little is known about their relationships to psychiatric disorders.

Objective

To present nationally representative findings on the prospective relationships between overweight and obesity and DSM-IV substance use, mood and anxiety disorders.

Design, Setting and Participants

Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions, a nationally representative sample of 34,653 U.S. adults.

Main Outcome Measures

Incidence of DSM-IV substance use, mood and anxiety disorders and changes in BMI status during the 3-year follow-up.

Results

Regression analyses that controlled for a wide array of covariates showed that overweight and obese women were at increased risk for incident major depressive disorder (MDD) during the follow-up period. Overweight men and obese men were at decreased risk of incident drug abuse and alcohol dependence, respectively. Obese women had a decreased risk of incident alcohol abuse and drug dependence. Men with drug dependence and women with specific phobia had a decreased risk of becoming overweight or obese during the follow-up.

Limitations

The NESARC excluded adolescents and the homeless and weight was self-reported, but highly correlated with external validating data.

Conclusions

Increased risk of MDD among overweight and obese women could be attributed to stigma and greater body dissatisfaction among women in Western cultures. Overweight and obesity may serve as protective factors against developing incident substance use disorders possibly due to shared neural functions in the brain underlying addictions to numerous substances. Results are discussed in terms of their clinical implications including the need to update treatment guidelines for the management of overweight, obesity and MDD.

Introduction

From 1976–1980 to 2003–2004, the prevalence of obesity in the United States (body mass index (BMI) ≥ 30.0) doubled from 15.1% to 32.2% (1). During the same period, the prevalence of overweight and obesity (BMI ≥ 25.0) markedly increased from 45.0% to 66.3% (2, 3). Although associations between overweight and obesity and major medical conditions (4, 5) and their associated disabilities (6) and excess and premature mortality (7), including diabetes mellitus, cardiovascular diseases, and degenerative joint disease have been extensively studied, evidence concerning their relationships to psychiatric disorders is limited.

To date, sixteen cross-sectional and nine prospective surveys using standardized psychiatric assessment interviews, have examined relationships between BMI status and psychopathology. Most cross-sectional studies (8–24) found modest associations (8, 10, 11, 14–23) between overweight and/or obesity and any mood disorder or major depressive disorder (MDD), with some finding the relationship only among women (8, 11, 14–17, 19, 20). Six studies also found associations between overweight and/or obesity and any anxiety disorder (9, 21, 23), including panic disorder (15, 19, 20, 23), specific phobia (8, 19, 20, 22), generalized anxiety disorder (GAD) (15, 19), and social phobia (8, 15, 22).

Most prospective studies (25–33) on obesity and psychopathology have focused on MDD. Longitudinal surveys among cohorts of children or adolescents spanning about 20 years have consistently shown that MDD is associated with an increased risk of later obesity (25–27), though only among women in one study (30). In contrast, one long-term longitudinal survey of women of average age 27 years at baseline (8) found that baseline obesity predicted major depressive disorder 30 years later (28). Prospective studies of much shorter durations (2-to-5 years) conducted among adults aged 50 years and older found the same result (31–33).

Studies examining relationships between substance use disorders and overweight and/or obesity have been mixed. Except for two studies (19,24), no associations were observed between alcohol abuse, dependence, or any alcohol use disorder and overweight and obesity (10, 15, 20–22). Most studies also found no associations with drug abuse (19, 20), drug dependence (15, 19), any drug use disorder (22), or overall substance use disorders (9, 12, 13). One study found an inverse relationship between drug dependence and obesity among men (20), while another found a positive association between substance use disorders and obesity among men (17).

Although much has been learned about relationships between overweight and obesity and psychopathology from prior epidemiologic work, none of these studies were without limitations. For example, some previous studies were restricted by age and/or geography, failed to exclude pregnant women and underweight individuals, did not analyze data by sex or present data on specific psychiatric disorders, failed to differentiate between overweight and obesity and between MDD and bipolar disorder and, by definition, could not discern temporal relationships between BMI status and psychopathology. Prospective studies have also been limited by long follow-up periods with sporadic measurement of BMI and psychopathology, an exclusive focus on child or adolescent cohorts or individuals over the age of 50 years, and failure to measure a broad range of specific psychiatric disorders that are highly comorbid with one another. The latter limitation, also shared by most cross-sectional studies, is important, as psychiatric comorbidity, a potentially critical confounder of BMI-psychopathology associations, could not be controlled. Other critical factors, e.g., substance use, medical conditions, stress and psychotropic medication use, have also not been controlled.

The absence of a large national prospective survey of U.S. adults on the temporal relationships between BMI status and psychiatric disorders represents a gap in our knowledge in terms of etiology, prevention, intervention and economic costs of each of these conditions. The present study was the first to examine temporal relationships between overweight and obesity and Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) (34) specific substance use, mood and anxiety disorders within a 3-year national prospective survey of the U.S. population, the Waves 1 and 2 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (35,36). The analyses importantly controlled for comorbidity at Wave 1 and concurrent comorbidity during the follow-up period, in addition to a battery of sociodemograhic and clinical covariates shown to influence BMI-psychopathology associations, including sex.

Methods

Sample

The 2001–2002 Wave 1 of the NESARC is described in detail elsewhere (35, 36). The Wave 1 NESARC surveyed a representative sample of the adult U.S. population 18 years and older, oversampling Blacks, Hispanics and young adults aged 18–24 years. The target population was the civilian population residing in households and group quarters. Face-to-face interviews were conducted with 43,093 respondents, with a response rate of 81.0%.

The 2004–2005 Wave 2 NESARC attempted face-to-face reinterviews with all Wave 1 participants (37). Excluding respondents ineligible for the Wave 2 interview, the Wave 2 response rate was 86.7%, reflecting 34,653 completed interviews. The cumulative response rate at Wave 2 was 70.2%. The mean interval between the two interviews was 36.6 months. Wave 2 NESARC data were weighted to reflect design characteristics of the NESARC and account for oversampling. Wave 2 NESARC weights included a component that adjusted for nonresponse, sociodemographic factors and psychiatric diagnosis, to ensure that the sample Wave 2 approximated the target population, that is, the original sample minus attrition between the two waves. There were no significant differences between the Wave 2 respondents and the target population on sociodemographic characteristics, BMI status or the presence of any lifetime psychiatric disorder (34). Weighted data were then adjusted to be representative of the civilian population of the United States based on the 2000 decennial census.

The research protocol, including informed consent procedures, received ethical review and approval from the U.S. Census Bureau and U.S. Office of Management and Budget.

Body mass index

Body mass index was defined using standards developed by the National Heart, Lung and Blood Institute: healthy weight, BMI of 18.5–24.9 kg/m2; overweight, BMI of 25.0-29-9 kg/m2; and obesity, BMI ≥ 30.0 kg/m2. Similar to previous studies, height and weight were self-reported in the NESARC. Self-reported weight correlates highly with measured weight (r = 0.86), and is largely independent of height (r ≈ −0.03) (38). Validation studies suggest that any bias in self-reported BMI is unlikely to affect conclusions about associations in epidemiologic studies, especially those conducted over time (39–42). In ancillary analyses, correlation coefficients were computed to examine associations between the Wave 1 NESARC BMI data and comparable data from the combined 1999–2002 National Health and Nutrition Examination Survey (43) that measured actual height and weight, by sex, five race-ethnic groups, and four age groups. Correlations of BMI were 0.76 for healthy weight, 0.85 for overweight, 0.84 for obesity.

Psychiatric disorders

The diagnostic interview was the Alcohol Use Disorder and Associated Disabilities Interview Schedule—DSM-IV Version (AUDADIS-IV) (44, 45). Axis I disorders were assessed identically in the Wave 1 and Wave 2 versions of the AUDADIS-IV except for the time frames. In Wave 1, these time frames were: (1) the year preceding the interview; and (2) the past, including all but the year preceding the interview. In Wave 2, the time frames were: (1) the year preceding the Wave 2 interview; and (2) the intervening period, about 2 years, between the Wave 1 interview and the year preceding the Wave 2 interview. Thus, in the Wave 2 interview, the entire time between Waves 1 and 2 was covered for each respondent.

In Waves 1 and 2, DSM-IV specific drug abuse and dependence diagnoses were aggregated to yield diagnoses of any drug abuse and any drug dependence. Mood disorders included DSM-IV major depressive disorder (MDD) and bipolar I disorder. Anxiety disorders included DSM-IV panic disorder (with and without agoraphobia), social and specific phobias and GAD. AUDADIS-IV methods to diagnose these disorders are described in detail elsewhere (46–51). All AUDADIS-IV mood and anxiety disorder diagnoses excluded disorders that were substance-induced or due to general medical conditions.

Past-year and prior-to-past-year diagnoses of attention-deficit/hyperactivity disorder (ADHD) and post-traumatic stress disorder were assessed in Wave 2 and served only as control variables in the analyses. DSM-IV lifetime personality disorders (PDs) also served as control variables. PDs measured at Wave 1 (described in detail elsewhere (52)) included avoidant, dependent, obsessive-compulsive, paranoid, schizoid, histrionic and antisocial. Borderline, schizotypal and narcissistic PDs were measured at Wave 2.

The good to excellent test-retest reliability and validity of AUDADIS-IV substance use disorders, mood, anxiety, PD and ADHD diagnoses are documented in clinical and general population samples (47–63).

Other covariates

Sociodemographic variables included sex, age, race-ethnicity, marital status, education, income, urbanicity, and region of the country. Fourteen stressful life events occurring during the year prior to the Wave 1 interview were summed to produce a scale of 0, 1 and 2+ events. Respondents were asked whether a doctor or other health care professional had told them that they had any of eleven medical conditions in the year preceding the Wave 1 interview. The number of medical conditions was summed into a scale of 0, 1 or 2+ conditions.

When substance use and substance use disorders served as covariates, three-level mutually exclusive variables were constructed for respondents’ lifetimes, and for the year, preceding the Wave 1 interview: (1) no alcohol use/disorder, alcohol use/no alcohol use disorder and alcohol use disorder; (2) no drug use/disorder, drug use/no drug use disorder, and drug use disorder; and (3) no nicotine use/dependence, nicotine use/no nicotine dependence, and nicotine dependence. For the period between Wave 1 and 2, we used any alcohol use, any other drug use, and any nicotine use as covariates. Whether the respondents were prescribed medication for the target mood or anxiety disorder of interest and for any other mood or anxiety disorder during the follow-up period were also covariates in the multivariable analyses.

Statistical analyses

In order to determine the temporal relationship between BMI status and psychopathology, three sets of multivariable analyses were conducted. In the first set of multivariable linear logistic regression analyses, BMI status (normal weight, overweight or obese) was the major exposure variable predicting each incident specific psychiatric disorder occurring during follow-up, controlling for Wave 1 sociodemographic characteristics, lifetime mood, anxiety and PD comorbidity and alcohol, drug, and nicotine use and disorders at Wave 1, and Wave 1 past-year medical conditions and stressful life events. Incidence rates were also calculated for each psychiatric disorder developing for the first time during the 3-year follow-up. Each of these analyses was restricted to individuals at risk for each incident target disorder.

Multinomial logistic regression analyses were also conducted in which each Wave 1 past-year psychiatric disorder served as the major exposure variable with transitions in BMI status over follow-up as the outcome, controlling for wave 1 sociodemographic characteristics and wave 1 past-year mood, anxiety, alcohol and drug use and disorders, medical conditions, and stressful life events, in addition to alcohol and drug use, anxiety, and mood comorbidity, use of alcohol or drugs, prescribed medications for the target anxiety or mood disorder, and prescribed medications for other mood and anxiety disorders during the follow-up period, as well as lifetime PDs. The categorical outcome variable, transition in BMI status, was categorized as: (1) remaining in the same BMI category from Wave 1 to Wave 2; (2) moving into a lower BMI category; and (3) moving into a higher BMI category. These analyses were also repeated, substituting a continuous BMI change variable for the categorical ones, that is, BMI at Wave 2 minus BMI at Wave 1, and conducting multivariable linear regression analyses.

Analyses were conducted on weighted data and standard errors and 95% confidence intervals were estimated using SUDAAN (64)a software package that adjusted for the design characteristics of the NESARC. All analyses excluded respondents who were pregnant at either Wave 1 or Wave 2, and those underweight at Wave 1.

Results

Table 1 shows the numbers of respondents at risk at Wave 1 for each psychiatric disorder during the follow-up and the 3-year incidence of each disorder by Wave 1 BMI status. Incidence rates mirror their prevalence rate counterparts, with substance use disorder incidence being greater among men and mood and anxiety disorders incidences being much greater among women, regardless of BMI status. Table 2 shows prediction of incident substance use, mood and anxiety disorders during the follow-up period by Wave 1 BMI status, controlling for all covariates. Among men, obesity at baseline decreased the risk of incident alcohol dependence and overweight at baseline decreased the risk of incident drug abuse over follow-up. Overweight men at baseline were at increased risk of incident alcohol abuse. Women obese at baseline were at decreased risk of incident alcohol abuse and drug dependence. In contrast, overweight or obesity at baseline increased the risk of incident MDD during the follow-up among women.

Table 1.

Number of Respondents at Risk at Wave 1 and 3-Year Incidence of BMI Status During the Follow-Up Period by Sex

Disorder Number of Respondents at Risk Incidence During Follow-up Period
Healthy Weight % (SE) Overweight % (SE) Obese % (SE)
Men
Substance use disorder
 Alcohol abuse 8391 8. 7 (0.67) 9.0 (0.62) 3.1 (0.20)
 Alcohol dependence 11853 6.1 (0.46) 3.9 (0.30) 3.7 (0.44)
 Drug abuse 12275 3.5 (0.36) 1.6 (0.24) 1.8 (0.35)
 Drug dependence 13777 1.8 (0.29) 0.9 (0.15) 0.8 (0.20)
Mood disorder
 Major depressive disorder 12893 3.5 (0.30) 2.7 (0.29) 3.5 (0.44)
 Bipolar I 13792 2.0 (0.29) 1.7 (0.22) 1.8 (0.27)
Anxiety disorders
 Panic disorder 13760 1.4 (0.21) 1.0 (0.16) 1.4 (0.23)
 Social phobia 13631 1.5 (0.22) 1.1 (0.14) 1.5 (0.22)
 Specific phobia 13312 2.2 (0.29) 1.6 (0.20) 1.7 (0.24)
 Generalized anxiety 13836 2.2 (0.26) 1.7 (0.18) 2.5 (0.34)
Women
Substance use disorder
 Alcohol abuse 15020 3.9 (0.32) 2.8 (0.32) 2.0 (0.24)
 Alcohol dependence 16772 2.6 (0.25) 1.6 (0.23) 1.8 (0.26)
 Drug abuse 16922 1.4 (0.15) 1.2 (0.19) 1.0 (0.20)
 Drug dependence 17840 0.7 (0.14) 0.6 (0.15) 0.3 (0.11)
Mood disorder
 Major depressive disorder 15028 5.8 (0.33) 7.0 (0.55) 7.5 (0.50)
 Bipolar I 17535 2.0 (0.20) 1.8 (0.23) 2.8 (0.29)
Anxiety disorders
 Panic disorder 16991 2.6 (0.26) 2.1 (0.26) 3.0 (0.31)
 Social phobia 17166 1.9 (0.18) 1.6 (0.22) 2.2 (0.28)
 Specific phobia 15951 3.1 (0.30) 3.0 (0.31) 3.1 (0.37)
 Generalized anxiety 17181 4.3 (0.31) 4.1 (0.37) 5.6 (0.48)
Total
Substance use disorder
 Alcohol abuse 23411 5.6 (0.33) 6.0 (0.37) 3.9 (0.31)
 Alcohol dependence 28625 4.0 (0.24) 3.0 (0.20) 2.7 (0.25)
 Drug abuse 29197 2.2 (0.18) 1.4 (0.16) 1.4 (0.20)
 Drug dependence 31617 1.1 (0.14) 0.8 (0.11) 0.6 (0.11)
Mood disorder
 Major depressive disorder 27921 4.8 (0.23) 4.3 (0.27) 5.4 (0.33)
 Bipolar I 31327 2.0 (0.17) 1.7 (0.15) 2.3 (0.20)
Anxiety disorders
 Panic disorder 30751 2.1 (0.19) 1.4 (0.14) 2.2 (0.19)
 Social phobia 30797 1.7 (0.12) 1.3 (0.13) 1.8 (0.19)
 Specific phobia 29263 2.7 (0.19) 2.2 (0.18) 2.4 (0.21)
 Generalized anxiety 31017 3.4 (0.22) 2.6 (0.19) 4.0 (0.29)
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Table 2.

Adjusted Odds Ratios (AORs)* of BMI Status at Wave 1 Predicting Incident DSM-IV Substance Use, Mood, and Anxiety Disorders During the Follow-Up Period by Sex

Disorder Men Women Total
Overweight vs. Healthy Weight AORa (95% CI) Obese vs. Healthy Weight AOR (95% CI) Overweight vs. Healthy Weight AOR (95% CI) Obese vs. Healthy Weight AOR (95% CI) Overweight vs. Healthy Weight AOR (95% CI) Obese vs. Healthy Weight AOR (95% CI)
Substance use disorder†
 Alcohol abuse 1.3 (1.04–1.64) 0.9 (0.63–1.14) 0.9 (0.72–1.23) 0.6 (0.45–0.88) 1.2 (1.00–1.39) 0.8 (0.61–0.93)
 Alcohol dependence 0.9 (0.70–1.10) 0.7 (0.52–0.97) 0.7 (0.50–1.02) 0.7 (0.49–1.06) 0.8 (0.68–1.00) 0.7 (0.55–0.91)
 Drug abuse 0.7 (0.44–0.96) 0.7 (0.41–1.03) 1.1 (0.76–1.63) 0.8 (0.51–1.35) 0.8 (0.59–1.03) 0.7 (0.51–0.96)
 Drug dependence 0.8 (0.48–1.20) 0.6 (0.30–1.03) 1.2 (0.64–2.07) 0.4 (0.21–0.91) 0.8 (0.58–1.22) 0.5 (0.30–0.80)
Mood disorder
 Major depressive disorder 0.8 (0.58–1.08) 1.0 (0.69–1.39) 1.3 (1.02–1.56) 1.2 (1.02–1.51) 1.1 (0.90–1.24) 1.1 (0.95–1.33)
 Bipolar I 1.0 (0.66–1.68) 0.9 (0.59–1.40) 0.9 (0.63–1.25) 1.0 (0.71–1.37) 0.9 (0.73–1.23) 0.9 (0.72–1.20)
Anxiety disorder
 Panic disorder 0.8 (0.52–1.26) 1.0 (0.64–1.52) 0.8 (0.60–1.13) 1.0 (0.72–1.37) 0.8 (0.63–1.07) 1.0 (0.75–1.30)
 Social phobia 0.8 (0.51–1.32) 1.0 (0.62–1.63) 0.9 (0.67–1.30) 1.0 (0.69–1.38) 0.9 (0.66–1.15) 1.0 (0.72–1.27)
 Specific phobia 0.8 (0.55–1.25) 0.8 (0.53–1.29) 1.1 (0.84–1.42) 1.1 (0.79–1.49) 1.0 (0.79–1.17) 1.0 (0.74–1.24)
 Generalized anxiety 0.9 (0.65–1.32) 1.9 (0.80–1.80) 0.9 (0.75–1.20) 1.1 (0.83–1.39) 0.9 (0.74–1.13) 1.1 (0.88–1.33)
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Note: Bolded figures are significant.

*

AOR = Odds ratios adjusted for: Wave 1 sociodemographic characteristics; other lifetime psychiatric disorders; alcohol, drug, and nicotine use and disorders; past-year, health care provider-diagnosed medical conditions; past-year stressful life events: moving or acquiring a new roommate; fired/laid off from a job; unemployed and looking for a job for more than a month; trouble with a boss/coworker; changing jobs; separated, divorced or breaking off a serious relationship; serious problems with neighbor/friend/relative; major financial crisis including bankruptcy; serious trouble with police or the law; something stolen or property intentionally damaged; death of a close friend/family member; physical attack on family member/close friend; and any family member’s/close friend’s serious trouble with the police or law.

†

For substance use disorders, Wave 1 lifetime use of the specific target substance is not included as a covariate (e.g., lifetime alcohol consumption for incident alcohol abuse and dependence).

Table 3 shows sample sizes and percentages of respondents moving into each BMI category during the follow-up. Table 4 shows prediction of BMI categorical transitions over follow-up by Wave 1 past-year DSM-IV substance use, mood and anxiety disorders, controlling for all covariates. Drug dependence at baseline decreased the risk of overweight and obesity among men, whereas specific phobia at baseline decreased the risk of overweight and obesity among women. When the continuous BMI change variables were substituted for the categorical transition variables, drug dependence at baseline predicted a decrease in BMI among men, consistent with the categorical results. However, the association between specific phobia at baseline and decreased risk of overweight and obesity among women at follow-up was not confirmed.

Table 3.

Prevalences and Unadjusted Odds Ratios of Wave 1 Past-Year DSM-IV Substance Use, Mood, and Anxiety Disorders Predicting BMI Transition During the Follow-Up Period by Sex

Disorder Percentages of Respondents With and Without Each Disorder Who:
Remained in Same BMI Category % (SE) Moved into Lower BMI Category * % (SE) Moved into Higher BMI Category † % (SE)
With Disorder Without Disorder With Disorder Without Disorder With Disorder Without Disorder
Men (n=10,724) (n=1,287) (n=2,179)
Substance use disorder
 Alcohol abuse 76.5 (1.66) 75.8 (0.51) 7.7 (0.96) 8.6 (0.32) 15.8 (1.50) 15.6 (0.40)
 Alcohol dependence 72.9 (1.78) 76.0 (0.52) 10.0 (1.26) 8.4 (0.32) 17.1 (1.51) 15.6 (0.41)
 Drug abuse 72.9 (3.44) 75.9 (0.51) 10.8 (2.14) 8.4 (0.31) 16.3 (2.85) 15.6 (0.40)
 Drug dependence 77.8 (4.79) 75.9 (0.49) 13.9 (4.13) 8.4 (0.30) 8.4 (3.00) 15.7 (0.39)
Mood disorder
 Major depressive disorder 74.4 (2.50) 75.9 (0.51) 7.4 (1.20) 8.5 (0.31) 18.2 (2.23) 15.6 (0.40)
 Bipolar I 75.9 (3.31) 75.9 (0.50) 9.4 (2.38) 8.5 (0.31) 14.7 (2.69) 15.7 (0.39)
Anxiety disorders
 Panic disorder 70.6 (3.62) 75.9 (0.50) 8.2 (2.55) 8.5 (0.31) 21.2 (3.45) 15.6 (0.40)
 Social phobia 77.8 (2.57) 75.8 (0.50) 8.4 (1.63) 8.5 (0.31) 13.8 (1.99) 15.7 (0.40)
 Specific phobia 77.1 (1.95) 75.8 (0.50) 8.3 (1.35) 8.5 (0.31) 14.6 (1.53) 15.7 (0.40)
 Generalized anxiety 74.8 (3.59) 75.9 (0.50) 10.7 (2.39) 8.5 (0.31) 14.5 (2.97) 15.7 (0.40)
Women (n=13,269) (n=1,694) (n=3,045)
Substance use disorder
 Alcohol abuse 78.1 (2.08) 74.9 (0.43) 7.2 (1.52) 9.4 (0.28) 14.8 (1.64) 16.7 (0.40)
 Alcohol dependence 73.1 (2.84) 74.0 (0.43) 9.0 (1.65) 9.4 (0.28) 17.9 (2.50) 16.6 (0.39)
 Drug abuse 75.8 (5.19) 74.0 (0.42) 10.8 (4.78) 9.4 (0.27) 13.5 (3.47) 16.7 (0.39)
 Drug dependence 81.5 (5.08) 74.0 (0.42) 5.2 (2.85) 9.4 (0.28) 13.4 (4.35) 16.6 (0.39)
Mood disorder
 Major depressive disorder 75.7 (1.51) 73.9 (0.45) 9.5 (0.96) 9.4 (0.30) 14.8 (1.33) 16.8 (0.41)
 Bipolar I 76.4 (2.47) 73.9 (0.43) 10.2 (1.68) 9.4 (0.28) 13.5 (2.07) 16.7 (0.40)
Anxiety disorder
 Panic disorder 73.7 (2.28) 74.0 (0.43) 9.9 (1.61) 9.4 (0.28) 16.5 (1.97) 16.6 (0.40)
 Social phobia 77.0 (2.14) 73.9 (0.43) 9.6 (1.41) 9.4 (0.28) 13.4 (1.60) 16.7 (0.41)
 Specific phobia 77.5 (1.16) 73.6 (0.45) 8.9 (0.85) 9.4 (0.29) 13.7 (0.99) 16.9 (0.41)
 Generalized anxiety 75.1 (2.50) 74.0 (0.43) 9.5 (1.62) 9.4 (0.29) 15.4 (2.22) 16.7 (0.39)
Total (n=23,993) (n=2,981) (n=5,224)
Substance use disorder
 Alcohol abuse 76.9 (1.31) 74.8 (0.37) 7.5 (0.79) 9.0 (0.23) 15.6 (1.17) 16.2 (0.29)
 Alcohol dependence 73.0 (1.43) 75.0 (0.36) 9.7 (0.98) 8.9 (0.23) 17.3 (1.36) 16.1 (0.29)
 Drug abuse 73.8 (2.68) 75.0 (0.36) 10.8 (1.95) 8.9 (0.23) 15.4 (2.21) 16.2 (0.28)
 Drug dependence 78.8 (3.66) 74.9 (0.35) 11.3 (3.04) 8.9 (0.22) 9.8 (2.49) 16.2 (0.28)
Mood disorder
 Major depressive disorder 75.3 (1.25) 74.9 (0.38) 8.8 (0.76) 8.9 (0.23) 16.0 (1.13) 16.2 (0.29)
 Bipolar I 76.2 (2.08) 74.9 (0.36) 9.8 (1.45) 8.9 (0.23) 14.0 (1.76) 16.2 (0.29)
Anxiety disorders
 Panic disorder 72.7 (1.91) 75.0 (0.36) 9.3 (1.31) 8.9 (0.22) 18.0 (1.72) 16.1 (0.29)
 Social phobia 77.3 (1.59) 74.9 (0.36) 9.1 (1.07) 8.9 (0.22) 13.5 (1.20) 16.2 (0.29)
 Specific phobia 77.3 (1.03) 74.8 (0.37) 8.7 (0.70) 9.0 (0.24) 14.0 (0.88) 16.3 (0.29)
 Generalized anxiety 75.0 (2.02) 74.9 (0.36) 9.9 (1.26) 8.9 (0.23) 15.2 (1.79) 16.7 (0.28)
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Note: Bolded figures are significant.

*

Moving between Wave 1 and Wave 2 from healthy weight to underweight; overweight to healthy weight or underweight; or obese to overweight, healthy weight, or underweight.

†

Moving between Wave 1 and Wave 2 from healthy weight to overweight or obese, or from overweight to obese.

Table 4.

Adjusted Odds Ratios (AOR)* of Wave 1 Past-Year DSM-IV Specific Substance Use, Mood, and Anxiety Disorders Predicting BMI Transition during the Follow-Up Period by Sex

Disorder Men Women Total
Moved into Lower BMI Category† vs. Remained in Same Category AORc (95% CI) Moved into Higher Category‡ vs. Remained in Same Categoryb AOR (95% CI) Moved into Lower BMI Category vs. Remained in Same Categorya AOR (95% CI) Moved into Higher Category vs. Remained in Same Categoryb AOR (95% CI) Moved into Lower BMI Category vs. Remained in Same Categorya AOR (95% CI) Moved into Higher Category vs. Remained in Same Categoryb AOR (95% CI)
Substance use disorder§
 Alcohol abuse 1.0 (0.74–1.34) 0.9 (0.75–1.20) 0.8 (0.51–1.35) 0.8 (0.59–1.03) 0.9 (0.74–1.21) 0.9 (0.73–1.07)
 Alcohol dependence 1.4 (0.99–1.95) 1.0 (0.78–1.25) 1.1 (0.72–1.69) 1.0 (0.72–1.50) 1.3 (0.98–1.63) 1.0 (0.83–1.26)
 Drug abuse 1.4 (0.83–2.22) 0.9 (0.57–1.46) 1.3 (0.47–3.77) 0.7 (0.38–1.25) 1.4 (0.87–2.10) 0.9 (0.59–1.23)
 Drug dependence 1.6 (0.78–3.28) 0.4 (0.19–0.99) 0.5 (0.16–1.80) 0.8 (0.34–1.69) 1.2 (0.67–2.25) 0.5 (0.30–0.97)
Mood disorder
 Major depressive disorder 0.9 (0.60–1.24) 1.1 (0.81–1.57) 1.0 (0.79–1.34) 0.9 (0.68–1.09) 1.0 (0.79–1.21) 0.9 (0.79–1.13)
 Bipolar I 1.0 (0.57–1.82) 0.9 (0.58–1.42) 1.1 (0.75–1.71) 0.8 (0.54–1.14) 1.1 (0.76–1.52) 0.8 (0.62–1.14)
Anxiety disorder
 Panic disorder 1.0 (0.48–2.22) 1.4 (0.88–2.12) 1.1 (0.72–1.55) 1.0 (0.77–1.41) 1.0 (0.74–1.45) 1.2 (0.89–1.48)
 Social phobia 1.0 (0.63–1.54) 0.8 (0.56–1.16) 1.0 (0.73–1.45) 0.9 (0.64–1.20) 1.0 (0.76–1.30) 0.8 (0.67–1.06)
 Specific phobia 1.0 (0.67–1.39) 0.9 (0.69–1.15) 0.9 (0.73–1.16) 0.8 (0.66–0.95) 0.9 (0.77–1.14) 0.8 (0.70–0.96)
 Generalized anxiety 1.3 (0.76–2.23) 1.0 (0.57–1.60) 1.0 (0.67–1.53) 1.0 (0.70–1.47) 1.1 (0.79–1.49) 1.0 (0.73–1.32)
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Note: Results derived from multinomial logistic regression analyses.

†

Moving between Waves 1 and 2 from healthy weight to underweight; overweight to healthy weight or underweight; or obese to overweight, healthy weight, or underweight.

‡

Moving between Waves 1 and 2 from healthy weight to overweight or obese, or from overweight to obese.

*

AOR = Odds ratios adjusted for: Wave 1 sociodemographic characteristics; other Wave 1 past-year psychiatric disorders; Wave 1 past-year alcohol, drug, and nicotine use and disorders; Wave 1 past-year, health care provider-diagnosed medical conditions and stressful life events; and any other psychiatric disorder, any alcohol use, any nicotine use, any drug use, and any prescribed medication for the target mood or anxiety disorder or other mood or anxiety disorders during the intervening period between Waves 1 and 2.

§

For analyses of substance use disorders, Wave 2 past-year use of the substance of interest is not included as a covariate (e.g., past-year alcohol consumption for prediction of change in BMI status by past-year alcohol abuse and dependence).

Discussion

The major finding of this prospective study was that overweight and obesity at baseline predicted an increased risk of incident MDD among women, after controlling for a wide array of covariates. These results are consistent with prior shorter-term prospective studies (31–33) but at variance with longer-term longitudinal studies (25–27, 30). Two psychosocial models have been posited to explain the temporal relationship from overweight and obesity to subsequent MDD. The self-appraisal perspective posits that stigma towards overweight and obese individuals (especially women) promotes low self-esteem and negative self-image leading to MDD (65). Alternatively, the fitting norms of appearance perspective argues that fitting the norm for weight is stressful among the obese because dieting is often unsuccessful, resulting in MDD. Women in Western cultures are generally under more pressure to be thin than men and experience greater body dissatisfaction; factors that may increase their vulnerability to MDD (66, 67). Other factors explaining the observed directionality of the relationship among women could also, in part, reflect gender differences in access to health care and treatment preferences (68), differential reporting of atypical features (e.g., increased appetite, weight gain) of MDD and biological factors, including genetic variation in susceptibility to both overweight and obesity and MDD(69).

Although this study’s results on BMI status and MDD are not conclusive regarding mechanisms underlying the relationships, these findings do suggest a unidirectional relationship between overweight and obesity and subsequent MDD among women. However, the disparity in results between prospective studies of child and adolescent samples that found unidirectional relationships between MDD and overweight and obesity, and short-term studies of older samples where baseline obesity predicted later MDD, is intriguing in suggesting that the directionality of the relationship may vary over the life course. In many respects both overweight and obesity and psychiatric disorders are results of life-long interactions between biological and psychological risk and protective factors and long-term studies beginning in childhood are warranted.

With respect to substance use disorders, overweight men had a decreased risk of drug abuse and obese men had a decreased risk of alcohol dependence at follow-up, whereas obese women had a decreased risk of alcohol abuse and drug dependence during the follow-up. That overweight and obesity at baseline generally appear protective, decreasing the risk of later substance use disorders, has been observed in several cross-sectional studies (21, 22). These findings are consistent with research suggesting that neural circuits in the brain serving the functions of desiring, seeking, procuring, and consuming food, ethanol, and other psychoactive substances may overlap (70). Overeating may compete with substances of abuse for brain reward sites, resulting in reduced substance intake and lower probabilities of developing substance use disorders among the overweight and obese (71, 72).

In this study, drug dependence at baseline lowered the risk of overweight and obesity during follow-up among men. Drug-dependent individuals may neglect their physical health, including appropriate caloric intake, while procuring, using and recovering from the adverse effects of substances (73). Drug dependence may disrupt eating habits, nutrient absorption and metabolism through associated physical morbidities including gastritis, pancreatitis and hepatitis (74, 75). Why this relationship was observed only among men may reflect the much greater prevalences of drug dependence among men relative to women in the general population.

With one exception, anxiety disorders did not predict later overweight or obesity and baseline overweight and obesity did not predict any anxiety disorders during follow-up, results at variance with the few cross-sectional epidemiological surveys (8, 14, 18–22) that examined anxiety disorders. Also inconsistent with prior research (19, 20, 22) was the puzzling relationship observed among women between specific phobia at baseline and decreased risk of overweight or obesity during follow-up, a result not replicated when continuous BMI change served as the outcome measure. Nonetheless, the extraordinary fear, anxiety and avoidance of phobic stimuli among individuals with specific phobia can significantly interfere with social and occupational functioning and eating habits, including undereating (34). However, the cardinal feature of excessive anxiety is common to most anxiety disorders, all of which were not shown to reduce the risk of overweight or obesity during the follow-up. Future research is warranted to determine what if any characteristics of specific phobia confer protection against subsequent overweight or obesity among women.

This study has limitations common to most large-scale surveys. First, because NESARC samples only households and group quarters and those 18 years and older, information on adolescents and the homeless was unavailable. Second, the BMI measure was self-reported. However, self-reported BMI has been shown to yield valid results in epidemiological surveys, and correlations between the NESARC and NHANES BMI data were strong.

Despite these limitations, the observed temporal relationships between overweight and obesity and MDD among women and between drug dependence and overweight and obesity among men have strong clinical and public health implications. The temporal relationship between overweight and obesity and MDD may presage increases in MDD among women, given that the epidemics of overweight and obesity are predicted to increase in the United States. Accordingly, overweight and obese women should be monitored for MDD by primary care physicians and other health professionals and targeted for weight reduction interventions to prevent incident MDD. Given the lack of effective treatments for obesity, however, more research is needed to test specific interventions targeting overweight and obesity among women, especially those with MDD. Foremost there is an urgent need to update treatment guidelines for MDD to address the management of overweight and obesity. Similarly, nutritional counseling may be warranted for men with drug dependence.

With regard to research implications, this study revealed important gender differences in the temporal relationships between overweight and obesity and specific psychiatric disorders. Identification of additional psychosocial and biological factors impacting on these relationships within a long-term longitudinal study commencing in early childhood is urgently needed.

Table 5.

Adjusted Associations of Wave 1 Past-Year DSM-IV Specific Substance Use, Mood, and Anxiety Disorders with Change in BMI during the Follow-Up, by Sex

Disorder Men Women Total
Adjusted* Change in BMI β (95% CI) Adjusted Change in BMI β (95% CI) Adjusted Change in BMI β (95% CI)
Substance use disorder†
 Alcohol abuse −0.03 (−0.25 – 0.18) −0.09 (−0.41 – 0.24) −0.07 (−0.24 – 0.11)
 Alcohol dependence −0.29 (−0.57 – 0.02) 0.31 (−0.07 – 0.70) −0.09 (−0.31 – 0.13)
 Drug abuse −0.32 (−0.81 – 0.17) −0.07 (−0.75 – 0.60) −0.22 (−0.61 – 0.16)
 Drug dependence −0.62 (−1.18 – −0.06) −0.32 (−1.45 – 0.81) −0.50 (−1.02 – 0.01)
Mood disorder
 Major depressive disorder 0.19 (−0.09 – 0.48) −0.10 (−0.36 – 0.17) 0.01 (−0.19 – 0.21)
 Bipolar I −0.09 (−0.52 – 0.34) −0.21 (−0.63 – 0.21) −0.15 (−0.47 – 0.17)
Anxiety disorder
 Panic disorder 0.34 (−0.16 – 0.84) −0.15 (−0.53 – 0.22) 0.01 (−0.29 – 0.30)
 Social phobia −0.08 (−0.35 – 0.18) −0.23 (−0.55 – 0.09) −0.17 (−0.39 – 0.06)
 Specific phobia −0.10 (−0.32 – 0.13) −0.04 (−0.22 – 0.14) −0.06 (−0.21 – 0.08)
 Generalized anxiety −0.16 (−0.56 – 0.25) −0.23 (−0.61 – 0.15) −0.20 (−0.49 – 0.08)
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Note: Results derived from multiple linear regression analyses.

*

Mean change in BMI between Waves 1 and 2 associated with Wave 1 past-year prevalence of index disorder, adjusted for Wave 1 sociodemographic characteristics; other Wave 1 past-year psychiatric disorders; Wave 1 past-year alcohol, drug, and nicotine use and disorders; Wave 1 past-year, health care provider-diagnosed medical conditions and stressful life events; and any other psychiatric disorder, any alcohol use, any nicotine use, any drug use, and any prescribed medication for the target mood or anxiety disorder or other mood or anxiety disorders during the intervening period between Waves 1 and 2.

†

For analyses of substance use disorders, Wave 2 past-year use of the substance of interest is not included as a covariate (e.g., past-year alcohol consumption for prediction of change in BMI status by past-year alcohol abuse and dependence). In addition, analyses of alcohol dependence are not adjusted for alcohol abuse, nor vice versa; similarly, for drug dependence and drug abuse.

Acknowledgments

Financial Support: The National Alcohol Epidemiologic Survey on Alcohol and Related Conditions (NESARC) is funded by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) with supplemental support from the National Institute on Drug Abuse (NIDA). This research was supported in part by the Intramural Program of the National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. The study is also supported by NIH grants DA019606, DA020783, DA023200, l DA023973, MH076051 and MH082773 (Dr. Blalnco), AA08159, AA018111 and AA00161 (Dr. Hasin), the American Foundation for Suicide Prevention (Dr. Blanco), and the New York Stat Psychiatric Institute (Drs. Blanco, Hasin).

Footnotes

Disclaimer: The Views and opinions expressed in this report are those of the authors and should not be construed to represent the views of sponsoring organizations, agencies, or the UA.S. government.

Corresponding Author Statement: Dr. Bridget Grant attests that all authors had access to the study data, take responsibility for the accuracy of the analyses, and had authority over manuscript preparation and the decision to submit the manuscript for publication.

Conflict of Interest: The authors have no conflicts of interest to report. The funding sources had no role or involvement in this study.

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