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Journal of the Canadian Academy of Child and Adolescent Psychiatry logoLink to Journal of the Canadian Academy of Child and Adolescent Psychiatry
. 2020 Nov 1;29(4):229–240.

Association between Weight Status and Mental Health Service Utilization in Children and Adolescents

Sarah Carsley 1,2, Eliza Pope 3, Karen Tu 4,5, Patricia C Parkin 6,7, Alene Toulany 2,7, Catherine S Birken 6,7,✉, on behalf of Team ABC
PMCID: PMC7595256  PMID: 33184567

Abstract

Background

Previous literature reports inconsistent associations between obesity and mental health. The objective of this study was to determine the association between weight status and mental health service utilization in Ontario children and youth.

Methods

A cross-sectional study of children 0 to 18 years, identified using primary care electronic medical records from the EMRPC database in Ontario, Canada was conducted. Height and weight data were extracted to calculate BMI and linked to administrative data on mental health related outpatient visits, emergency department visits, and hospitalizations. Multivariable logistic regression models were performed.

Results

A total of 50,565 children were included. Overall, 2.2% were underweight, 70.4% had a normal weight, 18.3% were overweight, 6.9% had obesity and 2.2% had severe obesity. 28.2% of all children had at least one mental health visit. Multivariable analyses showed children with overweight, obesity, and severe obesity were 1.11 (95% CI 1.05–1.17), 1.18 (95% CI 1.08–1.27) and 1.39 (95% CI 1.22–1.59) times more likely to have an outpatient mental health visit compared to children with normal weight.

Conclusion

Increased weight status was associated with mental health related outpatient visits and emergency department visits. This study may inform policy makers’ planning of mental health resources for children with obesity and severe obesity.

Keywords: body mass index, severe obesity, mental health service use, electronic medical records

Introduction

As childhood obesity remains an international focus, many countries are working to understand and accommodate the unique healthcare needs of this population. In Canada, approximately one in three children are overweight or obese (Rodd & Sharma, 2016), and thus are at an increased risk of poor cardiovascular health (Skinner, Perrin, Moss, & Skelton, 2015), asthma (Gold, Damokosh, Dockery, & Berkey, 2003), impaired glucose tolerance (Sinha et al., 2002), and poor mental health outcomes (Halfon, Larson, & Slusser, 2013; Tiffin, Arnott, Moore, & Summerbell, 2011). In particular, previous literature examining the association between weight status and mental health found that children with obesity have more internalizing (Kirk, Kuhle, Ohinmaa, Colman, & Veugelers, 2012) and externalizing behaviours (Janicke, Harman, Kelleher, & Zhang, 2008) and were three times as likely to have depressive and/or anxiety disorders (Anderson, Cohen, Naumova, Jacques, & Must, 2007) and twice as likely to have attention deficit hyperactivity disorder (Erhart et al., 2012).

There may be two potential mechanisms underlying the association between obesity and mental health outcomes. Firstly, the exposure to weight bias, stigma, and bullying, particularly for school-aged children may be associated with increased risk of poor mental health outcomes (Hebebrand & Herpertz-Dahlmann, 2009; Skinner et al., 2017). Secondly, the association may be based on dysregulated stress systems such as the hypothalamic-pituitary-adrenal (HPA) axis which is a key element in the shared biology of obesity and depression (Bornstein, Schuppenies, Wong, & Licinio, 2006). This dysregulation could be exacerbated in early childhood during the critical period of rapid brain development. Some studies have found no associations between weight status and mental health problems (Hampl, Carroll, Simon, & Sharma, 2007; Morrison, Shin, Tarnopolsky, & Taylor, 2014), and findings vary by sex, age, and mental health diagnosis (Erhart et al., 2012; Griffiths, Dezateux, & Hill, 2011; Lu et al., 2012). The majority of these studies were examining children older than 7 years, with small clinical samples of youth, or had limitations in the measurement of either weight status or mental health outcomes.

Other research has shown that children with increased weight status also have higher mental health service utilization (Hering, Pritsker, Gonchar, & Pillar, 2009). These studies, however, focused on mental health specialist visits (Estabrooks & Shetterly, 2007; Trakas, Lawrence, & Shear, 1999), which represent only 27.4% and 47.9% of child and adolescent general health care visits prompted by mental health concerns, respectively. This suggests that true levels of mental health service utilization may have been previously underestimated (Olfson, Blanco, Wang, Laje, & Correll, 2014). Furthermore, this association has not been examined in younger children or children with severe obesity, the population with possibly the greatest risk of health care use given that adults with severe obesity were almost twice as likely to visit a mental health provider compared to healthy weight peers (Espallardo et al., 2017). With 70% of mental health problems beginning in childhood (Government of Ontario, 2011), there is a possibility that findings in adults reflect mental health problems beginning earlier in life.

In recent years there has been an increase in the rates of mental health service utilization in children in the province of Ontario in Canada (Gandhi et al., 2016). Examining the association between weight status and mental health service use in children will allow practitioners, and policy makers to better anticipate and support the health care needs of children with obesity, with a goal of providing appropriate timely mental health support to prevent long-term problems throughout the lifespan. The objective of this study was to determine the association between weight status and mental health service utilization in children and adolescents 0 to 18 years of age in Ontario.

Methods

Study Design and Population

This was a cross-sectional study that included children 0 to 18 years old as of March 31, 2015, identified through the Electronic Medical Records Primary Care database (EMRPC; also known as EMRALD); held at ICES. As of 2015, EMRPC was comprised of 54,964 children registered to 339 family physicians, at 41 primary care practices across Ontario. ICES is an independent, non-profit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement. This study was approved by the Research Ethics Boards at Sunnybrook Health Sciences and the Hospital for Sick Children.

Patients were included in the study population if they met the following criteria: patients had to be less than 19 years old as of March 31, 2015, have a valid height and weight measurement to calculate body mass index z-score (zBMI), be registered to an EMRPC physician who was using the EMR for a minimum of two years, and have a valid identification number to link with the administrative databases at ICES. Children <28 days old were excluded in order to avoid capturing neonatal hospitalization codes. Missing data on covariates were less than 5% so complete case analysis was performed.

Mental Health Service Utilization

Mental health service utilization was defined as any outpatient visit to a family physician, pediatrician or psychiatrist with an Ontario Health Insurance Plan (OHIP) mental health billing code, and any emergency department (ED) visit or any hospitalization for a mental health problem, defined by International Classification of Disease 10 (ICD-10) diagnostic codes. If multiple visits were listed, the most proximal visit to the date of measured height and weight was used. All diagnostic codes used to define mental health related service use are outlined in the ICES Mental Health and Addictions Scorecard Evaluative Framework (MHASEF) (MHASEF Research Team, 2017a). This outcome should be conceptualized as health care use for mental health concerns rather than health care use for children seeking mental health services. For example, children <5 years may have behavioural problems or neurodevelopmental disorders that are associated with health care use and are captured under the umbrella term ‘mental health outcomes’.

Definition of Weight Status

BMI z-scores (zBMI) were calculated by dividing weight (kg) by height squared (m2), measured on the same date, and standardizing values by age and sex to the World Health Organization (WHO) Growth Standards and Reference (WHO, 2006). Height and weight data were cleaned using a standard set of data cleaning rules (Smith et al., 2010) and zBMI values outside −5 and +5 were excluded based on WHO recommendations for biologically implausible values (WHO, 1995). The most recent valid zBMI measurement was used and categorized by WHO definitions. For children <5 years, zBMI <−2 were categorized as underweight, zBMI≥ −2 to ≤1 as normal weight, zBMI >1 to ≤2 as ‘at risk for overweight’, zBMI ≥2 to <3 as overweight and zBMI >3 as obesity. For children ≥5 years, zBMI <−2 were categorized as underweight, zBMI≥ −2 to ≤1 as normal weight, zBMI>1 to ≤2 as overweight, zBMI>2 to ≤3 as obesity and zBMI>3 as severe obesity. The z-score categories for both <5 and ≥5 years old correspond approximately to the 85th, 97th and 99.9th BMI percentiles, respectively.

Covariates

Several potential confounding factors were included in the multivariate analyses between weight status and mental health service use. These were identified a priori based on the literature, and included: age, sex, rural or urban residence, and neighbourhood income quintile (Flores & Lin, 2013; Goodman, Slap, & Huang, 2003; MHASEF Research Team, 2017b). Neighbourhood income quintile was used as a proxy for socioeconomic status, and was based on the patient’s postal code. The Ontario Registered Persons Database (RPDB) was used to acquire postal code which was linked to the 2006 Canadian Census data to obtain neighbourhood income quintile and rural/urban status (Glazier, Zagorski, & Rayner, 2012). These datasets were linked using unique encoded identifiers and analyzed at ICES.

Statistical Analysis

Descriptive statistics were performed for all outcome, exposure and covariate variables to determine variable distributions, frequencies and to assess normality. Descriptive characteristics were stratified by sex to determine any significant differences between the two groups using chi-square tests.

Univariate associations between weight status and lifetime mental health service use were examined for each mental health service outcome (outpatient visits, ED visits, and hospitalizations) stratified by age; children <5 and ≥5 years of age. BMI z-score was used both as a categorical variable. Multivariable logistic regression models were then examined for the relationship between zBMI and mental health related outpatient and ED visits, adjusted for age, rural or urban residence, and income quintile. To further investigate the association between zBMI and outpatient visits, models were stratified by sex and age group (<5, 5 to 9, 10 to 14 and 15+ years). When examining the age and sex stratified associations between weight status and ED visits, sample size restrictions made the models for categorical data unstable, and so stratification was only performed by sex for children ≥5 years. Very few patients had a hospitalization for mental health in this study sample therefore no further multivariable regression models were performed.

Sensitivity Analyses

In order to improve the precision of the estimated association between weight status and mental health service utilization, we narrowed the time frame a priori between exposure and outcome based on previous health services research (Gill et al., 2017; Omand et al., 2017). For patients with a mental health outpatient visit, the observation window to have a valid zBMI was limited to two years before or after the mental health outpatient visit. For patients with a mental health-related ED visit, the observation window was limited to five years because there were fewer ED visits. If multiple measurements were available, the measurement closest to the mental health visit date was selected. For the comparison group of children without a mental health visit, the most recent visit with a valid zBMI measurement was used. Analyses were performed using SAS Enterprise version 7.1 (SAS Institute, Cary, North Carolina).

Results

Study Population

In total, 50,565 children had a valid zBMI measurement recorded in the EMRPC database. Figure 1 shows the cohort exclusions; 201 children were less than 28 days of age (0.37%), 6.5% of children had incomplete data, and 1.6% had inaccurate data. Study sample characteristics are presented in Table 1. Overall, 2.2% were underweight (zBMI<−2), 70.4% had a normal weight (−2≤ zBMI ≤1), 18.3% were at risk of overweight/overweight (1< zBMI ≤2), 6.9% had overweight status/obesity (2< zBMI ≤3), and 2.2% had obesity/severe obesity (zBMI>3). A significantly higher proportion of boys had overweight status, obesity, and severe obesity compared to girls. There were no significant differences in rural status, or income quintile. Table 2 presents the proportion of mental health outpatient visits, ED visits, and hospitalizations by age and weight status. Overall, 14,266 (28.2%) children had at least one mental health service visit.

Figure 1.

Figure 1

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Selection of study sample from EMRPC cohort

Table 1.

Baseline demographics of selected EMRPC cohort (N=50565)

Total Females Males
N % N % N %
Age Group
 0–4 23091 45.6% 11249 45.0% 11842 46.3%
 5–9 13764 27.2% 6782 27.1% 6982 27.3%
 10–14 9173 18.1% 4518 18.1% 4655 18.2%
 15–18 4537 9.0% 2445 9.8% 2092 8.2%
Weight Status
 Underweight (−2> zBMI) 1133 2.2% 554 2.2% 599 2.3%
 Normal Weight (−2≤ zBMI ≤1) 35597 70.4% 18038 72.2% 17539 68.6%
 Overweight (1< zBMI ≤2) 9247 18.3% 4417 17.7% 4830 18.3%
 Obesity (2< zBMI ≤3) 3482 6.9% 1533 6.1% 1949 7.6%
 Severe Obesity (zBMI > 3) 1106 2.2% 452 1.8% 654 2.2%
Sex
 Female 24994 49.43%
 Male 25571 50.57%
Rural Status
 Rural 8840 17.7% 4394 17.8% 4446 17.6%
 Urban 41221 82.3% 20600 82.2% 21125 82.4%
Income Quintile
 1- Lowest 7867 15.8% 3846 15.4% 4021 15.7%
 2 8876 17.8% 4410 17.6% 4466 17.5%
 3 10770 21.6% 5362 21.5% 5408 21.1%
 4 11086 22.2% 5454 21.8% 5632 22.0%
 5- Highest 11314 22.7% 5602 22.4% 5712 22.3%
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Table 2.

Lifetime utilization of mental health-related services including outpatient visits, emergency department visits, and hospitalizations

Weight status Total Outpatient visits ED visits Hospitalizations
N % N % N % N %
All Ages 50565 14198 28.1 825 1.6 N/A
 < 5 years 23091 45.7 2552 11.1 47 0.2 N/A
  Underweight (−2 > zBMI) 608 2.6 55 9.0 <6
  Normal Weight (−2≤ zBMI ≤1) 16787 72.7 1803 10.7 34 0.2
  Risk of Overweight (1< zBMI ≤2) 4242 18.4 507 12.0 7 0.2
  Overweight (2< zBMI ≤3) 1159 5.0 137 11.8 <6
  Obesity (zBMI > 3) 295 1.3 50 16.9 <6
 ≥ 5 years 27474 54.3 11646 42.4 778 2.8 252 0.9
  Underweight (−2 > zBMI) 545 2.0 244 44.8 15 2.8 10 1.8
  Normal Weight (−2≤ zBMI ≤1) 18790 68.4 7583 40.4 477 2.5 159 0.8
  Overweight (1< zBMI ≤2) 5005 18.2 2269 45.3 166 3.3 45 0.9
  Obesity (2< zBMI ≤3) 2323 8.5 1137 48.9 89 3.8 28 1.2
  Severe Obesity (zBMI > 3) 811 3.0 413 50.9 31 3.8 10 1.2
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Mental Health Outpatient Visits

Of children and adolescents 5 to 18 years, the prevalence of severe obesity was 3.0%. Fifty-one percent of those with severe obesity had a mental health related outpatient visit compared to 40% of children at a normal weight (Table 2). In adjusted logistic regression analyses, there were significant associations between increased weight status and outpatient mental health visits (Table 3). Children with overweight, obesity, and severe obesity were 1.11 (95% CI 1.05–1.17), 1.18 (95% CI 1.08–1.27) and 1.39 (95% CI 1.22–1.59) times more likely to have an outpatient mental health visit compared to children with a normal weight.

Table 3.

AORs and 95% CIs for having a lifetime mental health outpatient or emergency department visit by weight status

Variable Outpatient visit Emergency department visit
OR (95% CI) OR (95% CI)
Weight status
 Underweight 1.12 (0.96–1.30) 1.15 (0.68–1.95)
 Overweight 1.11 (1.05–1.17) 1.20 (1.00–1.44)
Obese 1.18 (1.08–1.27) 1.28 (1.01–1.62)
Severely obese 1.39 (1.22–1.59) 1.20 (0.82–1.77)
Sex (ref=Female) 1.40 (1.34–1.46) 0.87 (0.75–1.01)
Age (years) 1.21 (1.21–1.22) 1.28 (1.25–1.31)
Rural residence 0.87 (0.82–0.92) 1.38 (1.16–1.64)
Income quintile (ref=1, lowest)
 2 0.87 (0.81–0.94) 0.90 (0.72–1.14)
 3 0.78 (0.73–0.84) 0.74 (0.59–0.93)
 4 0.79 (0.73–0.84) 0.61 (0.48–0.77)
 5 - highest 0.79 (0.74–0.85) 0.60 (0.47–0.76)
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AOR = Adjusted Odds Ratio

Table 4 presents stratified analyses by age group and sex. There were significant associations between weight status and lifetime mental health outpatient visits for boys <5 years who had overweight and obesity, 5 to 9 years who had overweight and obesity, 10 to 14 years with severe obesity, and 15 to 19 years with obesity. In girls, there were significant associations between weight status and mental health services use at age 5 to 9 years (overweight and obesity), 10 to 14 years with underweight and obesity, and girls 15 to 19 years with severe obesity. Of those children with severe obesity and a mental health outpatient visit, the main diagnostic codes were behavioural disorders (24.8%), anxiety (24.2%), habit spasms, tics, stuttering, tension headaches, anorexia nervosa, sleep disorders, enuresis (14.6%), and educational problems (11.5%).

Table 4.

AORs (95% CI) of a lifetime outpatient mental health related visit by age group and sex (reference = normal weight)

Female Male
OR* (95% CI) OR* (95% CI)
0 to 4 years
 Underweight 1.30 (0.87–1.93) 0.88 (0.58–1.33)
 At risk of overweight 1.11 (0.94–1.32) 1.09 (0.95–1.26)
 Overweight 0.82 (0.58–1.16) 1.30 (1.03–1.63)†
 Obesity 1.29 (0.72–2.30) 1.53 (1.05–2.24)†
5 to 9 years
 Underweight 1.02 (0.68–1.53) 0.78 (0.54–1.11)
 Overweight 1.22 (1.05–1.42)† 1.27 (1.11–1.45)†
 Obesity 1.29 (1.04–1.60)† 1.24 (1.02–1.51)†
 Severe obesity 1.36 (0.94–1.97) 1.06 (0.81–1.40)
10 to 14 years
 Underweight 2.17 (1.43–3.30)† 1.01 (0.66–1.55)
 Overweight 1.06 (0.92–1.23) 1.06 (0.92–1.23)
 Obesity 1.23 (1.00–1.51)† 0.99 (0.82–1.18)
 Severe obesity 1.24 (0.85–1.80) 1.51 (1.08–2.11)†
15 to 18 years
 Underweight 1.96 (0.82–4.64) 1.70 (0.87–3.33)
 Overweight 1.07 (0.86–1.33) 0.96 (0.76–1.21)
 Obesity 1.18 (0.86–1.63) 1.40 (1.03–1.90)†
 Severe obesity 1.74 (1.11–2.74)† 1.36 (0.81–2.28)
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AOR = Adjusted Odds Ratio

*

Adjusted for age, rural residence, income quintile

†

Indicates significance with p-value<0.05

Mental Health Emergency Department (ED) Visits

Overall, 3.8% of children and adolescents with severe obesity had an ED visit compared to 2.5% of normal weight children. The adjusted logistic regression analysis showed children 5 to 18 with overweight status had a 1.20 (95% CI 1.00–1.44) times higher odds and with obesity had a 1.28 (95% CI 1.01–1.62) higher odds of a mental health related ED visit compared to children at normal weight. After stratifying by sex, weight status was significantly associated with outpatient visits in girls, but had no association in boys (Table 5). The main emergency department admission ICD-10 codes included anxiety disorder (unspecified) (17.7%), acute stress reaction (13.6%), and depressive episode (unspecified) (10.1%).

Table 5.

AORs (95% CI) of a lifetime emergency department mental health related visit by sex

Emergency department visit lifetime Girls Boys
OR* (95% CI) OR* (95% CI)
Underweight 0.99 (0.43–2.29) 1.27 (0.64–2.51)
Overweight 1.41 (1.10–1.80)† 0.99 (0.75–1.31)
Obesity 1.62 (1.81–2.23)† 0.99 (0.70–1.42)
Severe obesity 1.57 (0.96–2.56) 0.86 (0.46–1.59)
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AOR = Adjusted Odds Ratio

*

Adjusted for age, rural residence, income quintile

†

Indicates significance with p-value<0.05

Mental Health Hospitalizations

Overall, 252 children ≥5 years were hospitalized with a mental health related diagnostic code. The main ICD-10 diagnostic codes were severe depressive episode without psychotic symptoms (18.5%), adjustment disorders (11.0%), anorexia nervosa (9.1%), and unspecified depressive episode (8.7%).

Sensitivity Analyses

When we examined the relationship between BMI z-score and mental health outpatient visits using a two year window of observation rather than lifetime occurrence, we found similar results. In adjusted analyses children categorized as overweight, obese, and severely obese had a 1.27 (95% CI 1.18–1.37), 1.18 (95% CI 1.05–1.33), and 1.63 (95% CI 1.33–1.99) higher odds of having a mental health outpatient visit compared to children at normal weights (Supplemental Table 1). Analyses stratified by age and sex demonstrated similar relationships to the main results, however some associations lost significance (Supplemental Table 2).

Similarly, we examined the relationship between BMI z-score and mental health ED visits using a five-year window of observation and demonstrated similar trends to the lifetime occurrence (Supplemental Table 3). Children with overweight had 1.30 (95% CI 1.07–1.57) higher odds of having a mental health ED visit and those with obesity had a 1.32 (95% CI 1.03–1.68) times higher odds. The association was no longer significant for children who were underweight or severely obese. After stratifying analyses by sex, only girls who were overweight, obese or severely obese demonstrated an association between weight status and mental health ED visits.

Discussion

This study was a preliminary exploration of the association between weight status and mental health service utilization in children and youth in Ontario. We examined mental health service use from 0 to 18 years, across all weight status categories including severe obesity. Our findings demonstrated that increased weight status was associated with increased mental health related outpatient visits and emergency department visits. However, the strength of this association varied by age, sex, and type of service utilization.

These findings corroborate work by Estabrooks and Shetterly (2007), who found that children 3 to 17 years old with class I obesity (>95th percentile of BMI-for-age compared to the CDC 2000 growth charts) were more likely to have a specialist mental health visit within 1 and 3 years of follow up compared to those with BMI between the 85th–94th percentile (overweight). Conversely, the findings are in contrast to a study by Bianchi-Hayes (2015), which concluded that children 4 to 18 years with overweight or obesity were not more likely to have a mental health visit compared to their normal weight peers (Bianchi-Hayes et al., 2015). However, that study relied on self-reported measures of specialist mental health visits over the past year, and survey-based data have been shown to underreport levels of mental health service use when compared to administrative sources (Drapeau, Boyer, & Diallo, 2011).

The present study also noted important age and sex differences in the association between weight status and mental health service utilization. Boys <5 years with overweight and obesity were more likely to incur outpatient visits for mental health concerns. At this age, boys are more predisposed to ADHD, oppositional defiant disorder, and neurodevelopmental disorders such as autism, compared to girls, which often present in outpatient settings (Baron-Cohen et al., 2011). Autism and weight status have been linked in previous literature, with elevated weight status in children with this condition noted as early as 2 to 5 years of age (Presmanes Hill, Zuckerman, & Fombonne, 2015). Our findings support these associations; boys <5 and 5–9 amassed the largest number of visits for behavioural disorders, educational problems, delays in development, and childhood psychoses including autism (Ozonoff, Heung, Byrd, Hansen, & Hertz-Picciotto, 2008). Diagnostic codes for anxiety were most common for girls 5–9 and 10–14 years old, as well as boys 10–14 years old.

Another notable sex difference occurred between ages 10–14 years in outpatient mental health visits; boys with severe obesity were significantly more likely to have a mental health outpatient visit. While girls were also more likely to incur a mental health outpatient visit, the relationship was only borderline significant. However, there was the emergence of a strong relationship between underweight status and outpatient mental health visits in girls, likely due to eating disorders (Kurz, van Dyck, Dremmel, Munsch, & Hilbert, 2015; Reinehr et al., 2017). Interestingly, girls with overweight and obesity were significantly more likely to incur a mental health related ED visit. There is an established link between mental health conditions such as anxiety and female sex (McLean, Asnaani, Litz, & Hofmann, 2011), which can present acutely in emergency settings. This is also supported by existing literature, which shows an association between increased BMI and increased levels of anxiety and depression in girls and women ages 9–40 years (Anderson, Cohen, Naumova, & Must, 2006).

The main strength of this study is the large sample of children with measured weight and height data and population-based administrative data on mental health care utilization. Previous studies used physician reported diagnosis of obesity as the measure of weight status, which likely underreports true prevalence (Walsh, Milliren, Feldman, & Taveras, 2013). We also demonstrated strong associations with the severe obesity weight status category in Canadian children and adolescents which has been previously unstudied. This population may require more intensive services to treat the mental health disorder and provide weight management simultaneously. Finally, the sensitivity analyses performed to narrow our window of observation strengthened the magnitude of the effect for outpatient visits, although lost significance in some stratified models, likely related to small sample size.

There are several limitations to this study. The data were cross-sectional and we categorized the outcome into a dichotomous variable, therefore these results cannot be used to infer causality nor assess a dose-response. We were not able to control for other comorbidities or medications, such as psychotropic medication use, which are known to be associated with weight changes and may have influenced weight measurements in our study (Hasnain & Vieweg, 2013). It is also important to note that we were not able to control for the onset of puberty in this age group. Puberty is associated with both changes in body weight (Jasik & Lustig, 2008) and mental health outcomes such as affective disorders (Ladouceur, 2012), and may have confounded the relationship between weight status and mental health service utilization; however, associations were found in pre-pubertal children as well. The inclusion of a wide age range for this association may have attenuated some effects. For example, even in the 0 to 4 age group, coding visits for mental health concerns may be different for children less than 2 years compared to preschool aged children. The outcome for this study was mental health service utilization, using a broad definition of ‘mental health’ that includes behavioural problems and neurodevelopmental disorders, and therefore findings cannot be used to draw conclusions regarding weight status and diagnosed mental health problems in the population. Further, data on non-physician mental health services such as visits to social work and psychologists were unavailable. Although, using administrative data, Steele et al. demonstrated the validity of using administrative mental health diagnostic codes to capture mental health service utilization in the adult primary care setting (Steele, Glazier, Lin, & Evans, 2004). Finally, all of the children included had access to a primary care physician, and the results may not be generalizable beyond this population.

Despite these limitations, this study suggests that children with obesity and severe obesity have increased mental health service utilization. Health care providers may consider screening for and addressing mental health concerns early on in children with overweight, obesity and severe obesity. Our study highlights the important role for primary care providers in early identification of both overweight and obesity status and mental health concerns (Gill et al., 2017). Children, particularly those at younger ages, visit their primary care providers often. This provides an excellent opportunity for pediatricians and family physicians to identify and refer, when appropriate, to further mental health interventions as well as behavioural weight management programs that directly address mental health. Moreover, another important implication may be providing ongoing education for primary care providers on sensitive and effective identification of mental health concerns in children with higher weight status, including reducing weight stigma, to enable healthful conversations between primary care providers, children, and families about their weight status (Provvidenza, Hartman, & McPherson, 2019). Supporting family physicians by having additional mental health services co-located at the clinic site has also been shown to improve uptake of these services (Kates et al., 2019). Future research should use longitudinal data to investigate the directionality of the relationship between weight status and mental health service utilization and assess causal pathways. Psychotropic medication use and costs could also be considered as other measures of mental health service utilization in future work. Examining the mechanisms of the relationship between weight status and specific mental health conditions will allow for a better understanding of how to provide care for children and adolescents with these prevalent health concerns.

Supplementary Information

Supplemental Table 1.

Sensitivity analyses for outpatient and emergency department mental health related visits within a two year window of weight status (reference = normal weight)

Variable Outpatient Visit Emergency department visit
OR (95% CI) OR (95% CI)
Weight Status (ref=normal)
 Underweight 0.86 (0.73–1.02) 1.27 (0.73–2.20)
 Overweight 1.27 (1.18–1.37) 1.30 (1.07–1.46)
 Obesity 1.18 (1.05–1.33) 1.32 (1.03–1.71)
 Severe obesity 1.63 (1.33–1.99) 1.28 (0.85–1.91)
Sex (ref=Female) 1.42 (1.34–1.50) 0.79 (0.67–0.92)
Age (years) 1.16 (1.15–1.16) 1.30 (1.27–1.33)
Rural residence 0.92 (0.85–1.00) 1.46 (1.21–1.75)
Income quintile (ref=1, lowest)
 2 0.89 (0.81–0.98) 0.91 (0.71–1.16)
 3 0.81 (0.74–0.89) 0.76 (0.59–0.97)
 4 0.79 (0.72–0.87) 0.61 (0.48–0.79)
 5 - highest 0.75 (0.69–0.82) 0.62 (0.48–0.80)
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Supplemental Table 2.

Odds Ratios (95% CI) of an outpatient mental health related visit by age group and sex within a two year window of weight status (reference = normal weight)

Outpatient visit (2 year window) Female Male
OR (95% CI) OR (95% CI)
0 to 4 years
 Underweight 1.30 (0.96–1.75) 0.87 (0.65–1.17)
 At risk of overweight 1.11 (0.92–1.34) 1.27 (1.09–1.47)†
 Overweight 1.02 (0.70–1.48) 1.19 (0.91–1.56)
 Obesity 1.55 (0.87–2.76) 1.30 (0.82–2.08)
5 to 9 years
 Underweight 1.40 (0.72–2.72) 1.17 (0.73–1.89)
 Overweight 1.49 (1.21–1.84)† 1.10 (0.92–1.31)
 Obesity 1.24 (0.90–1.70) 1.01 (0.77–1.32)
 Severe obesity 1.42 (0.82–2.47) 0.34 (0.92–1.93)
10 to 14 years
 Underweight 1.25 (0.58–2.67) 0.97 (0.48–1.95)
 Overweight 1.26 (0.98–1.61) 1.12 (0.89–1.41)
 Obesity 1.50 (1.07–2.10)† 1.14 (0.85–1.52)
 Severe obesity 1.11 (0.58–2.15) 1.26 (0.65–2.45)
15 to 18 years
 Underweight 0.65 (0.12–3.41) 1.18 (0.37–3.82)
 Overweight 1.10 (0.73–1.66) 1.06 (0.69–1.61)
 Obesity 0.80 (0.43–1.49) 1.27 (0.74–2.19)
 Severe obesity 1.34 (0.51–3.56) 1.98 (0.80–4.94)
Open in a new tab
*

Adjusted for age, rural residence, income quintile

†

Indicates significance with p-value<0.05

Supplemental Table 3.

Odds Ratios (95% CI) of an emergency department mental health related visit within five years of weight status by sex, ages 5–18 years (reference = normal weight)

Emergency department visit 5 year window Female Male
OR (95% CI) OR (95% CI)
 Underweight 1.13 (0.49–2.61) 1.40 (0.68–2.89)
 Overweight 1.50 (1.17–1.93) 1.09 (0.81–1.46)
 Obesity 1.65 (1.18–2.30) 1.04 (0.71–1.52)
 Severe obesity 1.66 (1.00–2.76) 0.87 (0.44–1.72)
Open in a new tab
*

Adjusted for age, rural residence, income quintile

Acknowledgements / Conflicts of Interest

This research was funded by a Team Grant in Bariatric Care (Team to Address Bariatric Care in Canadian Children – Team ABC3) from the Canadian Institutes of Health Research (Institute of Nutrition, Metabolism and Diabetes). Partnership funding was also provided generously by Alberta Health Services, Alberta Innovates - Health Solutions, Canadian Obesity Network, and The Ontario Ministry of Health and Long-Term Care (MOHLTC). This study was supported by ICES, which is funded by an annual grant from the Ontario MOHLTC. Parts of this material are based on data and information compiled and provided by the MOHLTC and CIHI. The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. KT is supported by a Research Scholar Award from the Department of Family and Community Medicine at the University of Toronto. This research was supported by a Team Grant in Bariatric Care (Team to Address Bariatric Care in Canadian Children – Team ABC3) from the Canadian Institutes of Health Research (Institute of Nutrition, Metabolism and Diabetes). Partnership funding was also provided generously by Alberta Health Services, Alberta Innovates - Health Solutions, Canadian Obesity Network, and The Ontario Ministry of Health and Long-Term Care. The other authors have indicated they have no financial relationships relevant to this article to disclose. The authors have indicated they have no potential conflicts of interest to disclose.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplemental Table 1.

Sensitivity analyses for outpatient and emergency department mental health related visits within a two year window of weight status (reference = normal weight)

Variable Outpatient Visit Emergency department visit
OR (95% CI) OR (95% CI)
Weight Status (ref=normal)
 Underweight 0.86 (0.73–1.02) 1.27 (0.73–2.20)
 Overweight 1.27 (1.18–1.37) 1.30 (1.07–1.46)
 Obesity 1.18 (1.05–1.33) 1.32 (1.03–1.71)
 Severe obesity 1.63 (1.33–1.99) 1.28 (0.85–1.91)
Sex (ref=Female) 1.42 (1.34–1.50) 0.79 (0.67–0.92)
Age (years) 1.16 (1.15–1.16) 1.30 (1.27–1.33)
Rural residence 0.92 (0.85–1.00) 1.46 (1.21–1.75)
Income quintile (ref=1, lowest)
 2 0.89 (0.81–0.98) 0.91 (0.71–1.16)
 3 0.81 (0.74–0.89) 0.76 (0.59–0.97)
 4 0.79 (0.72–0.87) 0.61 (0.48–0.79)
 5 - highest 0.75 (0.69–0.82) 0.62 (0.48–0.80)
Open in a new tab

Supplemental Table 2.

Odds Ratios (95% CI) of an outpatient mental health related visit by age group and sex within a two year window of weight status (reference = normal weight)

Outpatient visit (2 year window) Female Male
OR (95% CI) OR (95% CI)
0 to 4 years
 Underweight 1.30 (0.96–1.75) 0.87 (0.65–1.17)
 At risk of overweight 1.11 (0.92–1.34) 1.27 (1.09–1.47)†
 Overweight 1.02 (0.70–1.48) 1.19 (0.91–1.56)
 Obesity 1.55 (0.87–2.76) 1.30 (0.82–2.08)
5 to 9 years
 Underweight 1.40 (0.72–2.72) 1.17 (0.73–1.89)
 Overweight 1.49 (1.21–1.84)† 1.10 (0.92–1.31)
 Obesity 1.24 (0.90–1.70) 1.01 (0.77–1.32)
 Severe obesity 1.42 (0.82–2.47) 0.34 (0.92–1.93)
10 to 14 years
 Underweight 1.25 (0.58–2.67) 0.97 (0.48–1.95)
 Overweight 1.26 (0.98–1.61) 1.12 (0.89–1.41)
 Obesity 1.50 (1.07–2.10)† 1.14 (0.85–1.52)
 Severe obesity 1.11 (0.58–2.15) 1.26 (0.65–2.45)
15 to 18 years
 Underweight 0.65 (0.12–3.41) 1.18 (0.37–3.82)
 Overweight 1.10 (0.73–1.66) 1.06 (0.69–1.61)
 Obesity 0.80 (0.43–1.49) 1.27 (0.74–2.19)
 Severe obesity 1.34 (0.51–3.56) 1.98 (0.80–4.94)
Open in a new tab
*

Adjusted for age, rural residence, income quintile

†

Indicates significance with p-value<0.05

Supplemental Table 3.

Odds Ratios (95% CI) of an emergency department mental health related visit within five years of weight status by sex, ages 5–18 years (reference = normal weight)

Emergency department visit 5 year window Female Male
OR (95% CI) OR (95% CI)
 Underweight 1.13 (0.49–2.61) 1.40 (0.68–2.89)
 Overweight 1.50 (1.17–1.93) 1.09 (0.81–1.46)
 Obesity 1.65 (1.18–2.30) 1.04 (0.71–1.52)
 Severe obesity 1.66 (1.00–2.76) 0.87 (0.44–1.72)
Open in a new tab
*

Adjusted for age, rural residence, income quintile

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