Association between Children Living with Obesity and Mental Health Problems: a Data Analysis of the Welsh Health Survey, UK

doi:10.21203/rs.3.rs-1977698/v1

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Research Article

Association between Children Living with Obesity and Mental Health Problems: a Data Analysis of the Welsh Health Survey, UK

https://doi.org/10.21203/rs.3.rs-1977698/v1

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Journal Publication

published 23 Feb, 2023

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Background

Obesity and mental health problems in children are both significant and growing public health issues. There is mixed evidence on the relationship between obesity and mental health in children. This study examines the association between obesity and mental health problems in a nationally representative sample of children using the Welsh Health Survey for Children (n = 11,279 aged 4–15 years).

Methods

The Chi-square test assessed the difference in the proportion of children reporting abnormal mental health scores (strengths and difficulties score ≥ 20) in children living with obesity (≥ 95 centile for age and sex). Then, a multivarible logistic regression was used to assess any association after accounting for confounding.

Results

There were 1,582 children living with obesity in the study (19.6%). The Chi-square test indicated a significant difference in the proportion of children with abnormal mental health scores in children living with obesity (p = 0.001). This study found a very small but highly significant positive association between mental health and childhood obesity after accounting for confounding, Odds Ratio 1.02 (95%CI: 1.01 to 1.02, p = 0.001). However, socio-economic status was more of a driver.

Conclusion

The findings of this study show a very small but highly significant association between childhood obesity and mental health problems. The multivariable logistic regression indicates that the focus must remain on reducing health inequalities as this is a more important driver of child health and well-being. However, as a precautionary measure it may be worth considering if children living with obesity who present for weight-management services may benefit from a review of their mental health status to identify if further support is needed, if capacity allows, and this can be done in a supportive way.

Obesity

Epidemiology

Public Health

Pediatrics

Adolescent

This study considers the relationship between two considerable public health issues: childhood obesity and mental health. A recent report from the UK Chief Medical Officers¹ suggested that more research was needed to investigate this relationship. It is essential to understand any association to inform clinical evaluation and treatment plans and optimise pathways for both disorders. Both obesity and common mental health disorders account for a significant proportion of the global burden of disease.²

Childhood obesity has increased worldwide over the last 30 years.³ It is a significant and growing public health issue in the United Kingdom (UK). Childhood obesity in Wales, UK continues to rise and has now reached 12% on entry to school.⁴ Obesity has a considerable cost to the health service, economy and society.⁵ Childhood obesity often persists into adulthood where most negative health impacts are observed.⁶ A meta-analysis by Simmonds et al. (2016) found that children living with obesity were five times more likely to experience obesity in adulthood.⁷ Childhood obesity can result in substantial threats to health and well-being throughout the life course.⁸ Children living with obesity are more likely to develop non-communicable diseases like diabetes and cardiovascular diseases at a younger age and childhood obesity can profoundly affect children's physical health, social, and emotional well-being, and self-esteem.^{9, 10} Obesity is also associated with poor academic performance and a lower quality of life.¹¹ About one third of girls who are overweight and a quarter of boys who are overweight report being teased by peers at school.¹² Children living with obesity often face stigmatisation and discrimination in many areas of their lives.¹³ Obesity has been shown to reduce a child’s opportunities to meaningfully engage in desired occupations at home and in school, especially social participation and play.¹⁴ The COVID-19 pandemic has been shown to increase levels of obesity in children, with the longer the absence from school the greater the impact.¹⁵ In developed countries, obesity is regularly reported to be highest in children from the lowest socioeconomic strata.¹⁶

In the UK, one in ten children have a clinically diagnosed mental health disorder and/or emotional and behaviour problems.¹⁷ Children with poor mental health have an increased likelihood of poor social and economic outcomes, in both the short and long term.¹⁸ The number of children seeking help for mental health problems has increased in Wales.¹⁹ Poor mental health in childhood is associated with an increased risk of self-harm and suicide.²⁰ Half of lifetime mental health problems start by the age of 14.²¹ The World Health Organization report that there is a 10–25 year life expectancy reduction in patients with severe mental disorders.²² The rate of increasing requests for the treatment of mental health problems in children creates a considerable challenge for the health service: there has been a doubling of demand between 2008 and 2014 for the specialist Child and Adolescent Mental Health Service.²³ The demand for mental health services and difficulties in providing COVID-19 secure services has exacerbated this.²⁴ In 2009, the cost of mental health problems in Wales was estimated at £7.2 billion/year.²⁵ In developed countries, poor mental health is regularly found at higher rates in children of the lowest socioeconomic status.²⁶

Whether there is a relationship between obesity and mental health is still uncertain with conflicting evidence.^27,13 The original contribution of this paper is that it is uses a large, generalisable, population based study to examine the association between obesity and mental health in children: existing studies often focus on small, clinical populations.^28,29,30,31.

Whilst much research has been undertaken on the relationship between obesity and physical factors there is still a need to further investigate the relationship between obesity and mental health.³² The relationship specifically between one aspect of mental health, that of depression, and childhood obesity has been established in a recent meta-analysis.³³ However, there is limited research on the relationship between obesity and overall mental health: Russell-Mayhew et al. 2012 concluded that the direction of the relationship between obesity and mental health remains unclear.³⁴ The aim of this study was therefore to identify and quantify any cross-sectional associations between obesity in children and abnormal mental health scores (from the Strengths and Difficulties Questionnaire) in a large national dataset, after accounting for deprivation and other confounding factors. The Children’s Welsh Health Survey has not previously been used for this purpose.³⁵

The sample frame for the Children’s Welsh Health Survey is all residential homes in Wales, selected from an up-to-date list of addresses in the Post Office™ Postcode Address File.³⁶ The annual datasets for the Children’s Welsh Health Survey are held by the Welsh Government and were anonymised and shared under a formal data access agreement.

Ethics Statement

Formal ethical approval was given for the collection of data by NatCen Research Ethics Committee on behalf of Welsh Government for data collection. Ethical approval and informed consent was not required for this study as it used anonymised secondary data. A formal data sharing agreement outlining specific use of the data with the Welsh Government was agreed prior to receipt of the anonymised data.

Subjects and Design

The Children’s Welsh Health Survey collected data from 3,000 children each year between 2008 and 2012 using a stratified sampling technique to produce a nationally representative sample. The Children’s Welsh Health Survey was conducted in the child’s home, occasionally the survey is initiated in the home where all children were measured (height and weight) and then the family subsequently return the survey by post. Parents of children aged 4–12 answered the survey on behalf of their child, whilst children aged 13–15 completed the survey independently. The response rate was 79%.³⁵ Many of the survey questions were subject to cognitive testing to ensure that they are consistently understood as intended, and that respondents could recall the information needed to answer them.³⁵ To avoid seasonal variation, data were collected throughout the year.

Mental Health Questionnaire

The Strengths and Difficulties Questionnaire (SDQ) is a validated screening tool used to assess both behavioral and mental health difficulties in children, and has been used in several countries.³⁷ The SDQ contains 25 statements, five questions on each of the following five topic areas: conduct problems, hyperactivity, emotional symptoms, peer problems and pro-social behaviours. The child (or parent) considers each of the 25 statements, an example of a statement is, “Considerate of other’s feelings”. Each of the 25 statements have three possible answers: Not True, Somewhat True or Certainly True. The SDQ has high test-retest reliability and good validity.³⁸ The SDQ forms part of the Children’s Welsh Health Survey and was used to provide an overall assessment of mental health using the sum of the difficulties scores (conduct problems, emotional symptoms, hyperactivity, peer problems). A higher score indicates more mental health difficulties, a score equal or greater than 20 indicates mental health difficulties. The SDQ has been validated against semi-structured diagnostic interviews in terms of the ability to detect clinically significant behavioral or emotional disturbance in the community setting.³⁹ Full details of the SDQ tool⁴⁰ are available at http://sdqinfo.org/. The SDQ is provided in numerous languages and the norms for different populations are also provided on the website.

Obesity Measure

Trained interviewers recorded the height of each child to the nearest millimeter (Marsden HM-250P Leicester Portable Stadiometer) and the weight of each child (without shoes or outdoor clothing) in kilograms to one decimal place (Tanita THD-305 scales). Mass and height were then used to generate a Body Mass Index (BMI) score for each child. Obesity was classified using sex and age with BMI equal to or greater than the 95th centile. The 95th centile is commonly used as the definition for childhood obesity in the UK⁴¹ and is suggested as a cut point by the International Obesity Task Force (IOTF, 2000).⁴²

The data set was cleansed as follows: all subjects that had a BMI of under 13kg/m² were removed (n = 45); all children with a BMI over 35 kg/m² (n = 56) were reviewed with a paediatrician to assess feasibility and five subjects were removed. All remaining data were used in the descriptive and analytical statistics. Comparison was made between children living with obesity and all other children: this is in line with guidance from previous authors for example Griffiths et al. 2010.⁴³

Measure of Deprivation

The relationship between obesity and deprivation is well documented.⁴⁴ It was therefore important to account for deprivation at the analysis stage, this was managed using the Welsh Index of Multiple Deprivation (WIMD). The WIMD is the approved measure of deprivation in small areas in Wales (WIMD, 2014).⁴⁵ The WIMD is a composite measure which incorporates the following elements: crime; employment; income; education; housing; access to services; environment and health. WIMD is not a direct measure of deprivation, but the deprivation rank is determined by the circumstances and lifestyles of the people living in that area. The WIMD category was classified according to the postcode of the main dwelling of each child.

Statistical Analyses

The Chi-square test was used to establish if there was any difference in the proportions of children reporting clinically significant mental health scores (≥ 20) between children living with obesity and children without obesity. The results are reported with levels of significance.

Logistic regression was subsequently utilised to explore the relationship between obesity and mental health as this methodology can account for confounding factors. Complete case analysis was used: there was some missing data (BMI available for n = 8,078). However, the analysis of those with missing BMI data in comparison to those with complete data showed no significant differences in a range of other variables including SDQ scores. Univariate logistic regression was undertaken using obesity and the following variables: mental health (from the Strength and Difficulties Questionnaire scores), consuming vegetables daily, quintile of WIMD⁴⁵ and physical activity (> 1hr every day) as these are all highlighted as potential confounding factors in the existing literature.^46,26,47 The analyses were also run by age groupings for self-report participants (13–15 years) and parental report participants (4–12 years). The Odds Ratios and 95% Confidence Intervals (CI) were calculated and reported. All statistical analysis was undertaken using STATA/IC 14.2.

Characteristics of the Study Sample

The distribution of the sample by age, sex, WIMD quintile, BMI category and lifestyle variables is provided in Table 1. The distribution in the number of children by age group was similar across age groups with an average 940 children in each age group (range of 844 to 1,042). The percentage split of girls (48.5%) and boys (51.5%) is similar to the general childhood population for Wales.⁴⁸ The percentage of children in each of the quintiles of deprivation ranged from 19.4–20.8% (Table 1).

Table 1

Summary Statistics of the Sample
Variable	Data recorded	Number (percentage)
Sex recorded Male Female	11,279	5,813 (51.5) 5,466 (48.5)
Age Age 4 Age 5 Age 6 Age 7 Age 8 Age 9 Age 10 Age 11 Age 12 Age 13 Age 14 Age 15	11,279	949 (8.4) 900 (8.0) 908 (8.1) 844 (7.5) 931 (8.3) 889 (7.9) 905 (8.0) 943 (8.4) 958 (8.5) 987 (8.8) 1,023 (9.1) 1,042 (9.2)
WIMD (calculated from postcode) Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5	11,279	2,193 (19.4) 2,262 (20.1) 2,344 (20.8) 2,187 (19.4) 2,293 (20.3)
BMI recorded Normal weight Overweight Obese	8,078	5,186 (64.2) 1,310 (16.2) 1,582 (19.6)
Physical activity recorded Active for 1 hour, daily	11,014	5,822 (52.4)
Diet Eats Vegetables daily	11,126	5,747 (51.0)

Descriptive Statistics for Obesity

A total of 1,582 (19.6%) of children in this sample, were children living with obesity. There was a small difference in prevalence of obesity by sex in the sample, with boys having higher levels n = 897 (21.1%) than girls n = 685 (17.9%). The percentages of normal weight children were similar by sex with 45.9% boys compared to 46.1% girls (Table 1). The univariate logistic regression of weight classification by gender showed no statistically significant difference and therefore sub-group analysis by gender was not undertaken.

Descriptive Statistics for Strength and Difficulty Questionnaire

The differences in the SDQ by obesity classification are described in Table 2. This shows the mean score for the children living with obesity was almost one point higher at 8.5, compared to other children. When considering abnormal SDQ scores (≥ 20), the difference between the children living with obesity and children without obesity was 2.1% (Table 3). This was a statistically significant proportion in the Chi-square test (p = 0.001).

Table 2

Mean and Standard Deviation of the Strengths and Difficulty Scores (SDQ) for Children aged 4–15 by Body Mass Index Category
Body Mass Index (BMI) classification	SDQ mean	SDQ SD	Frequency
Obese	8.5	6.4	1,582
Normal weight	7.6	5.9	5,186
Overweight	7.6	5.9	1,310
No BMI data	8.0	6.4	3,201
TOTAL	7.8	6.1	11,279

Table 3

Strengths and Difficulty Scores (SDQ) Under 20 and Greater than 20 by Body Mass Index Category
	Body Mass Index (BMI) classification
	Non-obese (percentage)	Obese (percentage)
SDQ score under 20	6,151 (95.7)	1,468 (93.6)
SDQ score 20 or more	276 (4.3)	100 (6.4)
TOTAL	6,429 (100)	1,568 (100)
Chi Square Test used all available data = 0.001

Confounding Factors

Table 1 shows that total number of children in the sample who reported being physically active for more than an hour daily was n = 5,822 (52.4%). Obesity in those who were active was lower at 17.7% compared to 21.8% of children who did not report being active. The univariate logistic regression indicated this was a statistically significant difference (Table 4).

Table 4 details the univariate Odds Ratios and 95%CI. The variables that were statistically significant in the univariate logistic regression and were therefore included in the multi-variable logistic regression were: WIMD; being active and eating vegetables daily.

There was a generally increasing rate of obesity as social deprivation increased, from n = 243 (15.7%) in the least deprived group through to n = 347 (22.3%) in the high deprivation group. Deprivation was statistically significant in the univariate logistic regression (Table 4) and the multivariable logistic regression (Table 5).

Table 4

Univariate Logistic Regression of Childhood Obesity with Variables
n = 10,088	Odds Ratio	(95% CI)	p-value
Mental Health (SDQ difficulties score)	1.02	1.01–1.02	0.001*
Sex	0.99	0.93–1.08	0.94
WIMD Quintile 1	Reference
WIMD Quintile 2	1.14	1.01–1.29	0.03*
WIMD Quintile 3	1.28	1.13–1.44	0.001*
WIMD Quintile 4	1.30	1.15–1.47	0.001*
WIMD Quintile 5	1.51	1.34–1.70	0.001*
Vegetables Consumed Daily	0.94	0.91–0.96	0.001*
Physical Activity Daily	0.95	0.92–0.97	0.001*

*denotes statistically significant at p<0.05 level

Table 5

Multivariable Logistic Regression of Childhood Obesity with Mental Health Adjusted for Deprivation and Lifestyle Factors for Children 4–15 years
n = 10,934	Odds Ratio	(95% CI)	p-value
Mental Health (SDQ difficulties score)	1.02	1.01–1.02	0.001*
WIMD Quintile 1	Reference
WIMD Quintile 2	1.11	0.98–1.26	0.098
WIMD Quintile 3	1.24	1.10–1.40	0.001*
WIMD Quintile 4	1.21	1.07–1.37	0.001*
WIMD Quintile 5	1.39	1.23–1.58	0.001*
Vegetables Consumed Daily	0.86	0.80–0.93	0.001*
Physical Activity Daily	0.83	0.77–0.90	0.001*

*denotes statistically significant at p<0.05 level

Multivariable Logistic Regression

The multivariable logistic regression showed obesity was associated with poor mental health even after accounting for deprivation and lifestyle with a very small but highly statistically significant Odds Ratio, OR 1.02 (95% CI: 1.01 to 1.02, p > 0.001) see Table 5 for full details. When analysed by age, the self-report group (13–15 years) results were non-significant OR = 1.01 (95%CI 0.99–1.02, p = 0.218) whereas the results from the parental report group for younger children (4–12 years) was similar to the overall findings with OR = 1.01 (95%CI 1.01–1.02, p = 0.003).

The main findings of this study are twofold. Firstly, the results show a statistically significant difference between the proportion of children who record clinically significant SDQ scores (≥ 20) in children living with obesity when compared to children without obesity. Secondly, there is a very small but highly statistically significant association between children living with obesity and mental health after accounting for confounding in this nationally representative dataset. Whilst the Odds Ratio is small, the direction of these results indicates a positive association between obesity and poorer mental health scores (i.e. higher SDQ scores in children living with obesity).

The mean and standard deviation of the SDQ scores were similar to norms provided for UK children.⁴⁹ The mean SDQ score for the children living with obesity was almost one point higher. A score one point higher on the SDQ scale is deemed a clinically relevant difference,³⁴ (noting that this difference was observed prior to adjusting for confounding). The difference in SDQ scores between the two groups in this study is therefore both clinically and statistically significant. This is comparable to the study by Griffiths et al. 2011 who identified similar differences in total SDQ scores between children living with obesity and children without obesity in children at age five.⁵⁰

The public health implication of this finding should use the precautionary principle,⁵¹ i.e. to exercise precaution while dealing with uncertainty.⁵² This could include consideration of an assessment of mental health needs when obesity is identified in a child by a healthcare practitioner. This goes one step further than the latest public health guideline from the National Institute of Health and Care Excellence on the management of overweight and obesity in children which recommends, “if concerns about their mental wellbeing are identified refer the child or young person to their GP for assessment and treatment and, if appropriate, for onward referral to child and adolescent mental health services.”⁵³

The percentage of children living with obesity and severe obesity is rising⁵⁴ and the global pandemic has exacerbated this trend.¹⁶ Childhood obesity is a complex and persistent public health issue.⁵⁴ The Welsh Government has recently responded to this by publishing its first Obesity Strategy for Wales.⁵⁵ This outlines the strategies that will be employed in the next decade to tackle obesity, including identification and treatment of children living with obesity.

A total of 1,582 (19.6%) of children in this sample, were children living with obesity, and our study shows obesity rates increasing with age in line with national trends.⁵⁶ It is similar to the findings from the UK wide Millennium Cohort Study which includes a small sample from Wales, where they found 20% of children were living with obesity by the age of eleven.⁵⁷ In this study we compared children living with obesity to all other children (including overweight children). This was recommended by previous authors who suggest that the combination of obesity and overweight may weaken any conclusions.⁴³

The observation in this study that there is a greater risk of obesity in children from more deprived groups (OR ranging from 1.11 to 1.40) is in line with other published literature from the UK.^{1, 39} This adds credence to the results of the study, and indicates that policies that reduce inequalities remain the most important area of focus for tackling obesity in children.

The number of population based studies that review the relationship between obesity and mental health are very limited. The literature in this field shows mixed results.^34,31,58 One large cross-sectional study in America,⁵⁹ using data from 4,743 adolescents collected in 1994/5, found a statistically significant relationship between BMI and general and physical health but not psychosocial outcomes overall except in the youngest group (12–14 years). The confidence intervals reported in this American study were wide, indicating a lack of power to detect a relationship even with the relatively large sample. A cross-sectional study⁶⁰ in France where parents of 1,026 children (6–11 years) completed the SDQ reported a statistically significant difference in abnormal SDQ scores for children living with obesity, but the authors did not report Odds Ratios after adjusting for confounding. Another study⁶¹ in Norway combined data from two cross-sectional studies undertaken in 2002 and 2017 (n = 3,188) in older adolescents (15 or 16 years old) to assess the relationship between mental health and overweight and obesity in adolescents and found small but significant relationship, but when this was adjusted for confounding the results were non-significant. The studies from France and Norway used the same methodology and cut-off points to measure obesity and abnormal SDQ scores as were used in this study, and found similar results when unadjusted for deprivation but in the study from Norway results once adjusted for deprivation were non-significant. In the current study, there was a much bigger sample size (more than three times as many participants) than the largest comparable study from Norway. In the current study we identify that there is a relationship between obesity and mental health scores after accounting for deprivation but that this is very small. This indicates that most of the focus for public health activity should therefore be on interventions that reduce inequalities in society.

The relationship between obesity and mental health scores found in the current study is similar in scale and direction to that found in other studies, with the exception that in the current study the relationship is maintained after accounting for confounding. This could be due to the scale of our study or different cultures in different countries. Even across the four countries in the UK (England, Scotland, Wales and Northern Ireland) we can see that childhood obesity varies dramatically, with Wales consistently having the highest rates of obesity in children in the four countries over the last few decades.⁵⁸

From the existing literature examining the reasons why there might be a relationship between obesity and poor mental health there are numerous theories but most indicate that they appear to exist in a causal loop, with each exerting cause and effect influences on each other.^62,63 Any planned interventions should therefore be mindful of this bidirectional relationship.

The results in this study differed by age group. For the (4–12 years) the results were very similar to the results for the whole group, this is as expected as it made up the majority of the participants 72.9% (n = 8,227). However, the non-significant result for the older children (13–15 years) who self-reported scores indicated that obesity and total SDQ scores were not associated in this group, perhaps indicating that this relationship may become less important with age.

The main strength of this study is the large data set (n = 11,279) which confers an advantage over many previous studies that report outcome results based upon much smaller sample sizes. The use of stratified random sampling helps generalisability of the results to the wider population. Ideally, once enough primary studies are undertaken a meta-analysis should be conducted to combine the results and settle the controversies arising from the conflicting results presented in the existing literature. This has been undertaken recently for depression and obesity³³ but understanding obesity and its relationship to overall mental health more generally would be helpful to clinicians and those planning both obesity and mental health services.

Further strengths of the study were that the height and weight of each child was measured by the enumerator rather than relying on self-report which improves the accuracy of the BMI data.⁶⁴ The study also used multivariable logistic regression to account for confounding. The main weaknesses of this study are the cross-sectional design, and the timeframe of the data collection. Cross sectional data can identify associations, but it is not possible to ascribe any causal relationships. Whilst the data was collected between 2008 and 2012 the results are still important to report and relevant as both obesity and mental health issues have deteriorated since then in the UK and beyond. In future, longitudinal data sets should be used to explore this relationship further. However, longitudinal studies often have fewer participants and are more expensive to run. There was no more up to date data for Wales that had been collected systematically and had all of the variables needed to undertake this analysis. A recommendation has been made to the Welsh Government to add to BMI and SDQ to current surveillance surveys of children in Wales so that this can be addressed. With increasing rates of obesity and mental health problems in childhood globally, an understanding of the relationship between obesity and mental health assumes even greater importance.

This study shows a very small but highly significant association between obesity and mental health problems. Whilst the association is small, it is both clinically and statistically significant, and as a precautionary measure, consideration should be given to a psychological element to obesity services that are being planned for children. However, the main focus must remain on reducing inequalities in society.

This study explored the association between childhood obesity and mental health problems in children that exists above and beyond deprivation status. Whilst the relationship identified between obesity and mental health is very small it may be prudent to consider the review of mental health status in children entering weight management programmes as a precautionary measure to assess if further complementary mental health support is needed. However, this should only be attempted if it does not cause harm, i.e. in a non-stigmatising way. In addition, this study has demonstrated that there are statistically significant poorer health outcomes in relation to both obesity and mental health for children in lower socio-economic groups, demonstrating that policies that reduce the number of children living in poverty are crucial to reducing health inequalities and the study indicates that this should be where more effort is focused. Findings from this study will be of interest to public health professionals, policy makers and providers of obesity and mental health services for children.

Ethics approval and consent to participate: All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Formal ethical approval was given for the collection of data by NatCen Research Ethics Committee on behalf of Welsh Government for data collection. Ethical approval and informed consent was not required for this study as it used anonymised secondary data.

Consent for publication: Not applicable.

Availability of data and materials: The data that support the findings of this study are available from the Welsh Government but restrictions apply to the availability of these data, which were used under a formal data access agreement for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Welsh Government.

Competing interests: The authors declare that they have no competing interests.

Funding: None.

Authors' contributions: All persons who meet authorship criteria are listed as authors, and all authors certify that they have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the manuscript. Furthermore, each author certifies that this material or similar material has not been and will not be submitted to or published in any other publication. CB is responsible for concept/design, data acquisition, data analysis, drafting and revision of the manuscript.

Acknowledgements: With thanks to the Welsh Government for making the data available to Public Health Wales for this analysis to be undertaken.

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Association between Children Living with Obesity and Mental Health Problems: a Data Analysis of the Welsh Health Survey, UK

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Abstract

Background

Methods

Results

Conclusion

Introduction

Methods

Ethics Statement

Subjects and Design

Mental Health Questionnaire

Obesity Measure

Measure of Deprivation

Statistical Analyses

Results

Characteristics of the Study Sample

Descriptive Statistics for Obesity

Descriptive Statistics for Strength and Difficulty Questionnaire

Confounding Factors

Multivariable Logistic Regression

Discussion

Conclusion

Declarations

References

Additional Declarations

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