Differential Associations Between Excess Body Weight and Psychiatric Disorders in Men and Women

Abstract

Background:

The current investigation is the first large-scale population-based study from France that documents the association between excess body weight and common psychiatric disorders, and examines the influence of gender on the association between excess body weight and these disorders. A recent plan has been implemented in France to treat the rising rate of those who are overweight or obese, and we seek to demonstrate whether integrated treatment of excess weight and psychiatric conditions appears as indicated.

Materials and Methods:

Data were drawn from a cross-sectional general population survey of 17,237 adults. Past-year psychiatric disorders were assessed using the Composite International Diagnostic Interview-Short Form. Body mass index was used to determine excess weight status.

Results:

Overall, 3.7% of the sample were underweight, 57% were normal weight, 28% were overweight (35% of men, 22% of women), and 11% were obese (11% of men, 11% of women). Being overweight was more common in men than women, although obesity did not differ by gender. Sociodemographic variables significantly associated with weight status included, age, marital status, education, employment status, income level, and population density. Adjusting for these variables, being overweight was associated with major depression and other disorders among women and inversely associated with drug abuse and dependence among men. Obesity was associated with major depression, panic disorder, agoraphobia, social phobia, specific phobia, and obsessive–compulsive disorder among women. Only generalized anxiety was associated with obesity among men.

Conclusion:

Past year, mental disorders were more likely associated with being overweight or obese among women as compared with men. The prevalence of these co-occurring psychiatric disorders in the context of the rising rate of obesity in France indicates a clear need for psychiatric assessment and treatment in caring for those with excess weight, especially women. Preliminary reports suggest this need is unmet within the otherwise progressive move in France to assist those struggling with excess weight.

Introduction

The increasing prevalence of excess body weight is a significant public health concern around the world.¹ For example, in the United States, 71% of men and 62% of women have excess body weight, and approximately one-third of men and women are obese.^1
–3 In contrast to the United States and to a representative sample of 16 European countries, France is among those countries with the lowest rates of obesity (12.2%).⁴ However, the prevalence of obesity is increasing in France,⁵ and the French Ministry of Health has developed a plan to curtail this trend.⁶ The plan establishes “specialized obesity centers” to promote screening and ameliorate lack of access to care for excess body weight and co-occurring disorders that may contribute to being overweight or obese, and “integrated obesity centers” to increase research and education with a particular focus on socioeconomically vulnerable populations.

Among the health conditions associated with excess body weight are psychiatric disorders.^7
–9 In particular, U.S. data indicate that being overweight or obese increases the associated risk of mood disorders,^10

–14 anxiety disorders, including generalized anxiety disorder, panic disorder, social phobia, agoraphobia, and specific phobia,^10,12,15,16 and binge eating disorder.^17,18 Moreover, gender differences have been observed in the association between psychiatric disorders and excess weight.¹⁶ Specifically, obesity has been positively associated with depression among women, with a negative association in men.¹⁴ In addition, being overweight or obese is associated with increased risk for lifetime alcohol abuse and dependence in men but not in women.¹¹ While obesity has been found to be associated with increased odds of any anxiety disorder and specific phobia in men and women, women were additionally at increased risk for social phobia.¹⁵

The current investigation is the first large-scale population-based study documenting the association between excess body weight and these mental health disorders in France, and examining the influence of gender on the association between excess body weight and psychiatric disorders. The prevalence of serious weight problems remains relatively low in France, despite a culture largely built around fine food and wine. Yet, increasing rates of excess weight in the population establishes the need to document “baseline” relationships between excess body weight and psychiatric disorders with population-based empirical data, and determine the influence of gender on the association of weight problems and psychiatric disorders. These data also are designed to inform the need for integrated care in the assessment and treatment of excess weight and psychiatric disorders.

Materials and Methods

Study design and sample

A cross-sectional survey designed to characterize mental healthcare needs in the general population of France included 22,138 participants and was conducted across four regions: Ile de France, Upper Normandy, Lorraine, and Rhone-Alpes. Data were collected between April and June 2005 by trained interviewers using a computer-assisted telephone interviewing system. Interviews lasted 20 minutes on average for those who did not endorse any of the screening questions, and ∼40 minutes on average for those who met criteria for at least one disorder. In each region, participants were selected using a two-stage procedure. First, 59,836 households with landline numbers were randomly contacted. Second, one person was randomly selected within each household according to a method proposed by Kish.¹⁹ Landline telephone numbers listed in the directory for each region were randomly chosen. The last digit of each number was then replaced with a randomly chosen number so as to include both listed and unlisted numbers.

Exclusion criteria for participants included being a non-French speaker, being under 18 years of age, unable to answer the phone or complete the interview (i.e., the person was unable to hear, did not answer the questions, or answered inconsistently). Participants were provided with a description of the study and informed consent was obtained over the telephone. The overall response rate was 62.7%. Recruitment and consent procedures were approved by the Ethics Committees of the National Data Protection Authority (CNIL).

In the present study, the sample was limited to respondents who provided their weight and height to allow for the calculation of body mass index (BMI). Women who were pregnant at the time of the survey were excluded from the sample. The final sample included a total of 17,237 respondents, 10,262 women and 6,975 men.

Survey variables

Sociodemographic variables

Sociodemographic information included gender, age, marital status, education level, employment status, household monthly income, and population density in the region of residence.

Overweight and obesity

Respondents reported their weight and height, and BMI was computed for each participant. Population-based studies in the United States [e.g., National Comorbidity Survey-Replication (NCS-R)⁸ and National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)^11,15] and Europe [e.g., European Study of the Epidemiology of Mental Disorders (ESEMeD)⁷] compute BMI based on self-report. Declaration biases have been studied in France, and findings show that, on average, weight is underestimated by 0.54 kg among men and by 0.85 kg among women, and height is overestimated by 0.38 cm among men and by 0.40 cm among women.²⁰ Such estimates suggest minimal under-reporting of BMI estimated at 0.29 for men and 0.44 kg/m² for women. Persons were considered underweight if their BMI was 18.49 or below, normal weight BMI was 18.5 to 24.9, overweight was a BMI of 25 to 29.9, and obese was a BMI ≥30.

Past-year DSM-IV psychiatric disorders

Twelve-month Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) axis I mental disorders were assessed with the short form of the Composite International Diagnostic Interview (CIDI-SF).^21,22 The CIDI-SF is designed to identify DSM-IV disorders based both on the presence of diagnostic criteria and on functional impairment. The CIDI-SF was used in the current study to assess the probable presence of a major depressive episode, anxiety disorders, including generalized anxiety disorder, panic disorder, agoraphobia, social phobia, specific phobia, obsessive–compulsive disorder (OCD), post-traumatic stress disorder, and alcohol or drug abuse and dependence. Due to the need to ensure a relatively brief assessment (20–40 minutes), other disorders, including personality disorders, were not assessed. Interviews were performed by trained staff and were recorded and monitored at random for quality control.

Statistical analyses

We first examined the weighted frequency of underweight, normal weight, overweight, and obesity status by sociodemographic characteristics and performed chi square tests to determine between-group differences. Second, cross-tabulations were used to determine the percentage of persons who meet criteria for a psychiatric disorder among persons who are underweight, normal weight, overweight, or obese in samples stratified by gender. We then determined the odds of presenting with a DSM-IV psychiatric disorder in persons who are overweight, using normal-weight individuals (18.5 < BMI >24.9) as a reference, thus excluding underweight individuals from the analysis. The same procedure was used to determine the odds of presenting with a psychiatric disorder in persons who are obese. Third, adjusted odds ratios were calculated using multivariate logistic regressions to determine whether the univariate associations between weight problems and psychiatric disorders were maintained when adjusting for sociodemographic variables. Specifically, age, education, marital status, employment status, household income, and population density were associated with weight status in univariate analyses. Finally, additional logistic regressions were used to include the gender by overweight, and gender by obesity interaction terms. All analyses were performed using SPSS v. 20.

Results

Distribution of BMI by sociodemographic characteristics among women and men

The prevalence of being underweight, normal weight, overweight, or obese by sociodemographic characteristics among women and men are presented in Table 1. Overall, 3.7% of the sample was underweight (1.4% of men, 5.5% of women), 57% were normal weight (52.5% of men, 60.8% of women), 28.2% were overweight (35.3% of men, 22.4% of women), and 11.1% were obese (10.8% of men, 11.3% of women). This distribution showed significant gender differences (χ² = 504.40, df = 3, p < 0.0001), in which women were more likely to be underweight or normal weight as compared with men, and less likely to be overweight, although the prevalence of obesity was similar in men and women. Morbid obesity (BMI ≥40) was identified in only 0.7% of the overall sample thus was not considered separately from the obesity group (BMI ≥30).

Table 1.

Prevalence of Underweight, Normal Weight, Overweight, and Obesity by Sociodemographic Characteristic Among Women and Men

	Women (n = 10,262)					Men (n = 6,975)
	Underweight BMI >18.49 (n = 555), %	Normal weight 18.5 < BMI > 24.9 (n = 6,158), %	Overweight 25.0 < BMI > 29.9 (n = 2,395), %	Obese BMI ≥30 (n = 1,154), %	p	Underweight BMI >18.49 (n = 91), %	Normal weight 18.5 < BMI > 24.9 (n = 3,650), %	Overweight 25.0 < BMI > 29.9 (n = 2,475), %	Obese BMI ≥30 (n = 759), %	p
Total	5.5	60.8	22.4	11.3		1.4	52.5	35.3	10.8
Age
18–29	10.3	73.2	11.6	4.9	0.0001	3.1	76.4	17.0	3.5	0.0001
30–39	5.8	63.4	20.7	10.1		0.8	56.2	34.3	8.7
40–49	4.4	63.6	20.7	11.3		0.9	48.7	38.8	11.5
50–59	3.0	53.1	28.5	15.4		0.9	38.4	44.0	16.6
60–69	2.2	47.4	32.4	17.9		0.1	30.3	51.2	18.4
70–99	3.4	47.0	34.0	15.6		1.2	37.1	46.1	15.6
Marital status
Married or in a relationship	3.9	60.2	24.5	11.4	0.0001	0.6	44.9	41.5	13.0	0.0001
Divorced or separated	7.1	59.9	20.2	12.7		1.4	52.2	35.3	11.1
Widowed	3.1	45.3	32.6	18.9		1.2	37.6	44.2	17.0
Single	11.2	69.9	12.0	7.0		3.4	74.4	17.7	4.6
Highest degree
None	3.8	48.8	27.3	20.1	0.0001	2.8	46.4	35.6	15.2	0.0001
Professional degree	4.7	53.7	27.2	14.3		1.0	47.8	38.2	13.0
High school diploma	7.2	69.4	16.2	7.1		2.2	60.1	30.8	6.9
2-Year college graduate	6.1	69.7	18.3	5.9		1.0	58.9	32.5	7.7
4-year college graduate or more	6.9	75.5	13.9	3.8		0.9	58.8	32.8	7.6
Employment status
Employed or working	5.3	64.7	20.8	9.2	0.0001	1.0	54.0	35.4	9.6	0.0001
Unemployed	8.0	61.5	18.4	12.1		2.3	62.7	24.9	10.1
Retired	2.5	48.3	33.3	15.9		0.6	33.0	48.4	17.9
Student	13.3	78.8	6.4	1.6		3.6	83.9	10.4	2.2
Home maker	3.8	53.8	25.7	16.7			—	—	—
Other inactive	9.0	50.9	21.4	18.8		5.3	44.1	37.2	13.4
Monthly household income
<1,200 euros	6.6	52.5	25.0	16.0	0.0001	2.0	54.4	31.1	12.6	0.0001
1,200 to 1,500 euros	5.8	58.7	21.8	13.7		1.2	50.6	36.9	11.3
1,500 to 2,000 euros	4.7	59.7	23.2	12.5		1.9	50.2	36.0	11.9
2,000 to 3,000 euros	4.6	62.8	23.6	9.0		1.0	51.3	36.7	11.0
>3,000 euros	6.2	70.4	17.8	5.6		1.0	53.9	36.3	8.8
Undisclosed	5.4	58.5	22.0	14.1		1.9	59.6	27.1	11.5
Population density
Rural	4.4	57.4	26.8	11.3	0.0001	1.3	46.8	39.8	12.2	0.0001
<20,000	5.6	58.2	23.7	12.5		1.7	48.7	38.1	11.6
20,000 to 100,000	5.2	59.5	25.4	9.9		1.2	51.3	37.3	10.2
>100,000	6.0	63.1	19.5	11.4		1.4	56.3	32.1	10.3

Weighted percentages of persons who are underweight, normal weight, overweight, or obese in the overall sample.

p < 0.05.

p < 0.01.

p < 0.0001.

BMI, body mass index.

Sociodemographic factors associated with weight status

These data are also presented in Table 1. Weight status was significantly associated with age in that obesity was least likely and being underweight was most likely in women and men who were 18 to 29 years of age. The distribution of weight status categories varied by marital status with a greater proportion of underweight or normal-weight persons among those who were single. Those with higher levels of education had lower rates of being overweight or obese. Employment status and income were also associated with weight status in that those who are in the higher income brackets or are employed have lower rates of obesity than those who are unemployed or earn minimum wage.

Prevalence of psychiatric disorders by weight status

The prevalence of psychiatric disorders by weight status is presented in Table 2. Among both women and men, the prevalence of depression and any anxiety disorder varied as a function of weight status. While there were limited gender differences in the frequency of depression and anxiety disorders associated with being underweight, there were significant differences in the prevalence of these disorders between women and men who were normal weight, overweight, or obese.

Table 2.

Prevalence of Psychiatric Disorders by Weight Status Among Women and Men

	Women (n = 10,262)					Men (n = 6,975)					Gender differences
	Underweight BMI ≥18.49 (n = 555), %	Normal weight 18.5 < BMI > 24.9 (n = 6,158), %	Overweight 25.0 < BMI > 29.9 (n = 2,395), %	Obese BMI ≥30 (n = 1,154), %	p	Underweight BMI ≥18.49 (n = 91), %	Normal weight 18.5 < BMI > 24.9 (n = 3,650), %	Overweight 25.0 < BMI > 29.9 (n = 2,475), %	Obese BMI ≥30 (n = 759), %	p	Underweight BMI ≥18.49 (n = 646), % p	Normal weight 18.5 < BMI > 24.9 (n = 9,808), % p	Overweight 25.0 < BMI > 29.9 (n = 4,870), % p	Obese BMI ≥30 (n = 1,913), % p
Major depressive disorder	15.0	13.6		17.3	16.8	0.0001	14.2	9.7	7.6	8.7	0.005	0.817	0.0001	0.0001	0.0001
Anxiety disorders	25.7	25.1		26.6	29.7	0.017	23.6	16.3	15.5	18.5	0.039	0.653	0.0001	0.0001	0.0001
Panic disorder	3.3	3.9	3.5	6.0	0.006	1.9	2.3	1.8	1.6	0.382	0.467	0.0001	0.0001	0.0001
Agoraphobia	6.0	4.9	5.2	8.3	0.0001	3.8	2.3	2.2	2.4	0.746	0.377	0.0001	0.0001	0.0001
Generalized anxiety disorder	5.3	5.9	6.2	7.8	0.089	3.8	3.1	3.4	6.8	0.0001	0.532	0.0001	0.0001	0.399
Social phobia	7.9	7.8	8.2	10.9	0.011	6.6	5.5	5.4	6.3	0.787	0.637	0.0001	0.0001	0.0001
Specific phobia	13.0	12.3	13.5	17.3	0.0001	6.8	5.9	5.9	5.9	0.984	0.078	0.0001	0.0001	0.0001
OCD	4.3	3.8	4.5	5.4	0.091	4.8	3.9	3.1	2.5	0.091	0.920	0.792	0.012	0.0001
PTSD	9.9	7.8	8.6	10.2	0.034	4.7	4.0	3.3	3.6	0.506	.807	0.0001	0.0001	0.0001
Substance use disorders	5.7	4.1	3.2	2.6	0.006	26.7	14.6	7.3	6.4	0.0001	0.0001	0.0001	0.0001	0.0001
Alcohol abuse	0.8	0.6	0.7	0.5	.837	4.7	4.2	2.9	2.7	0.021	0.002	0.0001	0.0001	0.0001
Alcohol dependence	1.0	1.3	0.9	0.7	.292	11.5	4.6	3.1	2.7	0.0001	0.0001	0.0001	0.0001	0.001
Drug abuse	1.7	1.3	0.9	0.4	0.034	5.7	4.8	1.3	1.2	0.0001	0.014	0.0001	0.229	0.038
Drug dependence	2.5	1.3	0.8	1.2	0.019	9.5	3.7	0.6	0.1	0.0001	0.0001	0.0001	0.453	0.0001
Number of comorbid disorders
Two or more	17.7	16.2	18.9	21.1	0.0001	17.5	13.0	9.9	10.6	0.0001	0.960	0.0001	0.0001	0.0001

Weighted percentages of persons who are underweight, overweight, or obese and present with a psychiatric disorder in the overall sample.

Bold indicates statistically significant results.

OCD, obsessive–compulsive disorder; PTSD, post-traumatic stress disorder.

Associations between psychiatric disorders and overweight

Table 3 presents the odds of a psychiatric disorder among women and men who are overweight, using normal weight as a reference. Adjusting for age, education, income, employment status, and population density, most of the observed unadjusted associations were maintained. However, using the adjusted model, major depression (adjusted odds ratio [AOR] = 1.30) and having at least any two psychiatric disorders (AOR = 1.24) were associated with being overweight in women. Among men, none of the psychiatric disorders was more likely in those who were overweight as compared with normal weight. In fact, drug use disorders were significantly less likely to be associated with being overweight, and being overweight was inversely associated with substance use disorders (AOR = 0.77), including drug abuse (AOR = 0.56) and dependence (AOR = 0.37). The overweight by gender interaction term was significant for major depression (p < 0.001), drug abuse (p < 0.05), and dependence (p < 0.001) and the presence of two or more disorders (p < 0.001).

Table 3.

Associations Between Psychiatric Disorders and Overweight in Women and Men

	Overweight 25.0 < BMI > 29.9
	Women (n = 8,553)				Men (n = 6,125)
	OR	95% CI	AOR	95% CI	OR	95% CI	AOR	95% CI	Gender × overweight interaction p
Major depressive disorder	1.17	1.03–1.33	1.30	1.13–1.49	0.77	0.64–0.92	0.90	0.74–1.10	0.003
Anxiety disorders	1.04	0.94–1.16	1.11	0.99–1.24	0.92	0.80–1.05	1.04	0.89–1.21	0.651
Panic disorder	0.89	0.69–1.14	1.04	0.80–1.35	0.70	0.49–1.00	0.82	0.57–1.20	0.353
Agoraphobia	1.11	0.90–1.37	1.06	0.85–1.32	0.93	0.65–1.33	1.02	0.70–1.48	0.802
Generalized anxiety disorder	0.99	0.82–1.20	0.95	0.77–1.16	1.01	0.77–1.34	1.01	0.75–1.35	0.703
Social phobia	1.03	0.86–1.23	1.03	0.85–1.24	0.96	0.76–1.21	1.13	0.88–1.45	0.787
Specific phobia	1.15	1.00–1.33	1.14	0.98–1.33	0.98	0.78–1.22	0.98	0.78–1.22	0.646
OCD	1.11	0.87–1.43	1.25	0.97–1.63	0.79	0.59–1.05	0.97	0.71–1.32	0.332
PTSD	1.01	0.85–1.20	1.05	0.88–1.26	0.85	0.65–1.11	0.91	0.69–1.21	0.902
Substance use disorders	0.67	0.51–0.87	0.90	0.68–1.19	0.49	0.41–0.59	0.77	0.64–0.93	0.226
Alcohol abuse	0.96	0.53–1.75	1.31	0.70–2.42	0.88	0.67–1.15	1.07	0.80–1.43	0.795
Alcohol dependence	0.52	0.32–0.86	0.66	0.40–1.10	0.62	0.47–0.82	0.84	0.62–1.13	0.361
Drug abuse	0.64	0.38–1.07	0.82	0.48–1.41	0.26	0.18–0.37	0.56	0.38–0.84	0.017
Drug dependence	0.70	0.44–1.13	1.12	0.68–1.84	0.18	0.11–0.31	0.37	0.22–0.64	0.001
Number of comorbid disorders
Two or more	1.14	1.00–1.29	1.24	1.09–1.42	0.70	0.59–0.82	0.90	0.76–1.08	0.001

OR of presenting with a psychiatric condition based on overweight status using normal-weight individuals as a reference (18.5 < BMI >24.9). AOR are adjusted for age, education, income, marital status, employment status, and population density. Obese and underweight individuals are not included in the analyses.

Bold indicates statistically significant results.

AOR, adjusted odds ratio; CI, confidence interval; OR, odds ratio.

Associations between psychiatric disorders and obesity

Table 4 presents the odds of a psychiatric disorder among women and men who are obese using normal weight as a reference. Among women, obesity was associated with increased odds of mental disorders. The association between obesity and mental disorders among women was maintained when adjusting for sociodemographic and socioeconomic factors. Among men, obesity was only associated with increased adjusted odds of anxiety disorders (AOR = 1.34), and generalized anxiety disorder in particular (AOR = 1.83). Only drug dependence yielded lower odds (AOR = 0.08) in those with obesity. Obesity by gender interactions revealed significant differences for generalized anxiety disorder (p < 0.01) and drug dependence (p < 0.05), but no significant differences regarding the remaining disorders.

Table 4.

Associations Between Psychiatric Disorders and Obesity Among Women and Men

	Obese BMI ≥30
	Women (n = 7,312)				Men (n = 4,409)
	OR	95% CI	AOR	95% CI	OR	95% CI	AOR	95% CI	Gender × obesity interaction p
Major depressive disorder	1.30	1.10–1.53	1.33	1.12–1.59	0.89	0.67–1.12	1.02	0.76–1.36	0.207
Anxiety disorders	1.25	1.08–1.43	1.22	1.05–1.41	1.22	0.99–1.49	1.34	1.08–1.66	0.290
Panic disorder	1.41	1.06–1.86	1.53	1.13–2.06	0.70	0.40–1.23	0.85	0.47–1.52	0.085
Agoraphobia	1.70	1.33–2.17	1.39	1.07–1.79	1.10	0.66–1.85	1.04	0.61–1.80	0.424
Generalized anxiety disorder	1.24	0.98–1.58	1.05	0.81–1.35	1.94	1.38–2.72	1.83	1.28–2.61	0.007
Social phobia	1.45	1.17–1.79	1.28	1.02–1.60	1.18	0.85–1.65	1.32	0.93–1.87	0.886
Specific phobia	1.53	1.28–1.82	1.39	1.15–1.67	1.03	0.74–1.44	1.03	0.74–1.44	0.246
OCD	1.51	1.12–2.02	1.41	1.03–1.93	0.76	0.48–1.21	0.89	0.55–1.44	0.145
PTSD	1.37	1.11–1.69	1.24	0.99–1.54	0.99	0.66–1.46	1.00	0.66–1.52	0.755
Substance use disorders	0.56	0.40–0.83	0.66	0.44–0.99	0.48	0.36–0.64	0.80	0.59–1.09	0.745
Alcohol abuse	0.66	0.26–1.69	0.86	0.33–2.24	0.78	0.50–1.22	0.99	0.62–1.57	0.661
Alcohol dependence	0.45	0.22–0.94	0.48	0.23–1.02	0.74	0.49–1.13	1.00	0.64–1.55	0.086
Drug abuse	0.44	0.19–1.02	0.52	0.22–1.23	0.23	0.12–0.45	0.65	0.32–1.31	0.477
Drug dependence	0.73	0.39–1.38	1.03	0.53–2.00	0.04	0.00–0.26	0.08	0.01–0.64	0.013
Number of comorbid disorders
Two or more	1.38	1.18–1.62	1.33	1.12–1.58	0.81	0.63–1.03	1.03	0.79–1.34	0.050

OR of presenting with a psychiatric condition based on obese status using normal-weight individuals as a reference (18.5 < BMI >24.9). AOR are adjusted for age, education, income, marital status, employment status, and population density. Overweight and underweight individuals are not included in the analyses.

Bold indicates statistically significant results.

Discussion

The present study assessed the prevalence of weight problems in a large population-based survey in France, a country with a relatively low occurrence of obesity as compared with a number of western countries, including the United States, the United Kingdom, Spain, and Belgium.^1,4,7 We documented the rates of psychiatric disorders by weight status, and examined the relationship of gender in the co-occurrence of excess weight and psychiatric disorders in this large sample.

Several noteworthy findings were obtained: (1) significant differences between age groups, marital status, highest educational level, employment status, monthly household income, and population density were found for both women and men across weight status, (2) among women, when adjusting for the sociodemographic variables associated with excess weight, being overweight was associated with major depression, and with having two or more psychiatric disorders, (3) among women, obesity was associated with increased odds of depression, panic disorder, agoraphobia, social phobia, specific phobia, and OCD, and (4) for men, only obesity was associated with increased odds of a disorder, specifically generalized anxiety disorder.

One in 3 men and 1 in 5 women were overweight, whereas 1 in 10 respondents were obese, which was similar for women and men. These rates are similar to those obtained in a 2006 national survey indicating that 31.0% of the population was overweight and 13.1% was obese.²³ A more recent 2012 survey estimated being overweight at 32.3% of adults and obesity at 15%.⁵ In terms of gender differences, the present study did not replicate the increased prevalence of obesity among women as compared with men that has been reported in developed countries,¹ including France.⁵ Importantly, the differences in the prevalence of obesity by gender may in part be explained by the fact that while obesity rates in France have risen for both genders between 1997 and 2012, the increase is more prominent among women than among men.⁵

The present results were consistent with prior findings regarding the relationship of age, low household income, population density,^1,5 lower education and unemployment,²⁴ and being single²⁵ to the prevalence of being overweight or obese. For example, the latter finding is consistent with existing research showing that while married persons are healthier for most measures of health and are less likely to engage in risky health behaviors, BMI constitutes an exception, where never-married men and women are less likely than adults in any other group to be overweight or obese regardless of race, ethnicity, education, poverty status, or nativity status.²⁵

Among women, being overweight and obese were both associated with greater likelihood of major depression in the previous 12 months, as compared with what is found in normal-weight women. This association has been consistently found in previous research in both men and women in the United States.¹⁵ However, among men, being overweight or obese was not associated with increased odds of major depression, a difference that was highly significant for being overweight and did not reach significance for obesity. This finding contrasts with prior findings^9,15 from the NESARC data in the United States, and from New Zealand. However, it has also been shown that the association between major depression and obesity exists among women and not men.^14,16 These findings highlight the importance of investigating psychological problems, and specifically major depression in women treated for obesity, and may contribute to our understanding of lower health-related quality of life and greater mortality found in obese women aged 45 and above.²⁶ The latter study suggests that the results may be due to a potential confounding effect of muscle mass in the estimation of BMI among men, to delayed mortality among women, or to psychological morbidity associated with obesity-related stigma.²⁵ The present study also showed greater association between mental disorders and being overweight or obese in women than men in the relatively low prevalence of obesity in France as compared with what is reported in the United States.

Fewer psychiatric disorders were associated with obesity among men, consistent with prior research.¹⁶ Significant gender by obesity status interactions were found only for generalized anxiety and drug dependence. In fact, the present study indicated that drug abuse and dependence were inversely associated with being overweight among men, and only drug dependence was inversely associated with being obese. These associations were not found in the NESARC data in the United States,¹¹ but have been reported in a nationally representative sample in Canada.¹⁶

Limitations

The limitations of this study should be considered when interpreting the findings. First, the cross-sectional nature of the study did not allow us to determine whether excess weight preceded or followed the development of psychiatric disorders. Longitudinal studies are needed to provide an understanding of the temporal relationship between weight problems and psychiatric disorders. However, the present study focused on identifying the co-occurrence of psychiatric disorders among men and women to determine the existing treatment needed for those with excess weight. The cross-sectional nature of the survey allowed us to examine this issue. Second, self-reported height and weight have been shown to be somewhat biased.²⁵ However, declaration biases have been studied in France and indicate that, on average, BMI can be underestimated at 0.29 kg/m² for men and 0.44 for women.²⁰ Consequently, the probability of false positive results in the associations reported in this study is decreased rather than increased.

Conclusions

The present study identifies those sociodemographic factors associated with excess weight in France, and the gender-specific associations between being overweight or obese and psychiatric disorders. Importantly, in examining associations between excess weight and psychiatric disorders, our findings control for the influence of sociodemographics associated with increased probability of excess weight in France. The French National Authority for Health has recognized the need for psychological intervention for those struggling with excess weight,²⁷ and the current results confirm the need for integrated services in addressing co-occurring psychiatric conditions. Despite the existing public health policy and demonstrated need for services, Lamore et al.²⁸ have shown that such support referable specifically to bariatric surgery is lacking within the specialized obesity centers created by the French Ministry of Health. In summary, our findings indicate that psychological services are needed in the progressive plan to ensure “specialized obesity centers” for the assessment and treatment of excess weight, and further research and education on comorbid psychiatric disorders in France's “integrated obesity centers” is necessary with a particular focus on socioeconomically vulnerable populations.

Footnotes

Acknowledgments

The authors thank the Direction Générale de l'Offre de Soins, the Direction Générale des Services, and the four regions, Upper-Normandy, Ile-de-France, Lorraine, and Rhone-Alpes, which funded this study.

Role of the Funding Bodies

The funding bodies did not participate in the study design and analysis.

Author Disclosure Statement

No competing financial interests exist.

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