Systematic Review of the Impact of Exercise on Depression in Obese Adolescents

Introduction

As much of the developed world experiences an increase in obesity, with as many as 23.8% of male adolescents and 22.6% of female adolescents experiencing being either overweight or obese,¹ many unexpected issues arise such as depression.² Research suggests that in those with obesity, depression is twice as prevalent than in those with a healthy BMI.² Depression can cause several issues including fatigue, anxiety, apathy, agitation, and loss of concentration.³ One group particularly affected by depression is overweight and obese adolescents. Studies show that overweight and obese children are not only more likely to have depression but also suffer from a worse quality of life, behavioral problems, and struggles with self-worth.⁴ This systematic review will focus on the question, how does reducing weight through exercise impact depression? This adds to the field by updating this area with recent articles found to the best of the author’s knowledge dating from 2004 to 2024.

Literature Review

Depression

Depression is defined as a mental disorder that can affect the way you feel, act, think, and see the world around you.⁵ It is known to cause feelings of hopelessness, loss of interest, and suicidal intentions.⁵ Depression can be caused by genetics, trauma, substance abuse, medications, and even obesity.⁶ Neurotransmitters can have large effects on depression with the three main neurotransmitters being associated with causing depression, they include dopamine, norepinephrine, and serotonin. Changes in the levels of any of these three can cause the onset of depression and many medications are aimed at controlling these levels in those with depression.⁷

The way that neurotransmitters affect depression is based on the levels of their presence and how they move between neuron synapses. Neurons have times when they absorb neurotransmitters as well as times when there is no uptake. When the neurons are at rest, they experience reuptake where the unused neurotransmitters are gathered and will then be reused.⁸ Depression is caused by a lack of dopamine, serotonin, and/or norepinephrine. Serotonin helps mood, sleep, digestion, blood clotting, as well as others. Norepinephrine helps to reduce stress and enhance focus. Dopamine helps to drive pleasure and reward seeking. This means that the lack of these between neurons, (i.e., synapses) is not able to improve mood and can cause depressive symptoms.⁸ Antidepressant medications (i.e., SSRIs and SNRIs) work by making certain neurotransmitters more available by limiting their reuptake.⁸

Obesity

Obesity can be defined as having excess body fat and is measured as having a body mass index of 30 or higher. BMI is calculated by taking weight in pounds divided by height in inches squared and then multiplying the results by 703. While BMI has its drawbacks such as not always accounting for differences in race, sex, and culture it is still widely accepted and serves as a standard measurement worldwide.⁹ Differences in sex can account for BMI issues with women having a higher body fat percentage than men and a different distribution of fat.¹⁰ Not all cultures view obesity the same, with some cultures including but not limited to some within Africa and Asia seeing obese and overweight individuals as rich, healthy, strong, and even more fertile.¹¹ Race can also play a factor with certain genetics being more likely to be affected by obesity.¹² Body fat distribution can differ based on race leading to BMI creating differences in who is considered overweight and obese, this creates a racial divide in those who are considered obese based on the distribution of fat.¹³ One study found that black and Hispanic women had a significantly higher average BMI than white women while also having a lower body fat percentage.¹³ Obesity can cause numerous physical health issues.¹⁴ Some possible conditions include cardiovascular disease, type 2 diabetes, sleep apnea, osteoarthritis, and even some cancers.¹⁵

Adolescent Obesity

Within the adolescent population, depression caused by obesity is a large problem with many obese children experiencing much lower quality of life scores especially those who are obese in the prebuttal and early stages of puberty.¹⁶ These groups also are at a higher risk of mental health issues based on their perception of their weight. Students polled in certain schools within South Korea found that children and teens who saw themselves as overweight had mental health issues including depression and stress.¹⁷ Those suffering from obesity in adolescent communities are greatly affected by mental health issues and some issues may persist long after their younger years. These health issues later in life include diabetes, hypertension, fatty liver disease, and others.¹⁸

As previously stated, childhood obesity can cause depression and other mental health issues. Mental health issues such as changes in anxiety, mood, self-esteem, quality of life, and body image can be observed in those with depression.¹⁵ Studies have found that obesity and depression at a young age can lead to depression and mental health issues that persist throughout adulthood.¹⁹ There are several ways to treat obesity and depression all with varying levels of success.

Treating Obesity and Mental Health

Managing obesity and depression within adolescents is crucial in improving overall health and takes many forms. One such way would be the use of drugs to help manage either weight or depression. Antidepressants have been used to help try and manage mental health issues and weight in individuals who are obese.²⁰ Types of antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and atypical antidepressants such as bupropion and mirtazapine. SSRIs prevent the reuptake of serotonin making serotonin more available to nearby neurons and therefore improving mood.

SNRIs work in the same way but affect both serotonin and norepinephrine. Atypical neurotransmitters also function similarly and can impact dopamine, serotonin, or norepinephrine.²¹

Antidepressant drugs can also have negative side effects including but not limited to insomnia, anxiety, dry mouth, overweight, nausea, diarrhea, headaches, dizziness, and a tremor.²² Some studies have found that antidepressants can cause an increase in suicidal thoughts initially due to SSRIs making changes in the amount of serotonin present. These studies also show that particularly in adolescents there is an initial increase in suicidal thoughts and attempts.²³

Studies have also been performed to see how a change in diet may affect both obesity and depression. The use of certain foods, such as a traditional Brazilian diet, to directly improve depression and anxiety has been successful with trials showing improved mental health in participants.²⁴ The Brazilian diet consisted of two main meals, large meals of vegetables, rice, beans, and a small amount of low-fat meat, as well as small meals that consisted of dairy products, breads, and fruits; with both types of meals focusing on limiting processed foods.²⁴ Some diet studies focused on more specific aspects such as using lower glycemic intake to treat depression in obese individuals and found success.²⁵ One diet that saw success was a keto diet which focuses on low carbs and high fats, a study found remission of depression and anxiety with a keto diet in some participants.²⁶ Obesity can occur when eating excess of any kind of food, it is important to not only eat the right foods but also the right amounts. The common standard of the food pyramid recommends a daily intake in servings of 6-11 grains, 3-5 vegetables, 2-4 fruits, 2-3 dairy, and 2-3 meat/fish to maintain a healthy balanced diet.²⁷

Therapy has been also used in trying to help manage depression in adolescents with obesity. While the therapy does not always help with obesity, many involved in trials conducted had improvements in their mental health.²⁸ Cognitive behavioral therapy, which helps minimize and challenge negative ways of thinking to create a healthier lifestyle, has proven particularly effective at encouraging participants to understand eating disorders and obesity to better improve their mental health specifically depression.²⁹

Surgery is also used to help obese individuals lose weight. After weight loss procedures are conducted many adolescents see improvements in their mental health including depression. Some surgeries such as a Roux-en-Y gastric bypass procedure are meant to reduce the size of the upper stomach using staples making it so the patient cannot eat as much.³⁰ Liposuction can also be used to reduce weight by the direct removal of fat from certain areas of the body. Finally, there are also studies on how exercise can impact obesity and depression. This study will focus on the question, how does reducing weight through exercise impact depression in adolescents?

Methods

The literature search involved the use of PubMed to find specific articles in the systematic review based on the Cochrane Handbook for systematic reviews.³¹ The articles were selected between a period of June through July of 2024. To start the search key words obesity and depression were used. These were used as MeSH terms leading to a total of 1,314 results. Next, a range of 6-18 years old was applied narrowing the search to 412. Then the options for clinical trials and randomized control trials were selected leading to 27 results. Then the dates from 2004-2024 were chosen leading to 25 included studies. After reviewing the articles and making sure they applied to the research topic, three were selected to be used in the results. To obtain more sources of data and a more thorough review, a subsequent topical search was done through Google Scholar where a total of 15 articles were reviewed and four were selected to be used. In total, this led to seven articles being used in the results. The relevant data about changes in depression and obesity were then compiled into Table 1. After Table 1 was created, the current author assessed trends and results found across all the included studies.

Figure 1: PRISMA Flow Chart

Results

Table 1. Summary of Research Investigating Adolescent Obesity and Depression

Measures of Depression: Depression Scale in Children (CDS), Beck Depression Inventory (BDI), Short Mood and Feelings Questionnaire (SMFQ), Children’s Depression Inventory (CDI), Reynold’s Child Depression Scale (RCDS), Brunell Mood Scale (BMS), High-Intensity Group (HIG), Low-Intensity Group (LIG), Quality of Life (QoL)

Obesity Trends

Of the research gathered six of the seven saw a relationship using some form of exercise and an improvement in mental health. The remaining paper also noticed that mental health improved with exercise but focused mainly on how an intervention from the parents on diet and exercise encouragement of the child could improve mental health.³⁴ Three of the articles saw no major change in BMI with a decrease that ranged from 0.1-1.96 during each of their programs.

Even with no major change to BMI, all three recorded improvements in depression.^32,33,36 The study that focused on body fat percentage saw a decrease of 1.8% and compared to its control groups saw a statistically significant change of p = 0.04.⁴ Another study found that there was a very noticeable change in BMI after its program with a measured p-value less than 0.001.³⁵ The study that focused on 4 different categories saw significant decreases in BMI compared to the control group, specifically the resistance group (p = 0.002) and the mixed group (p = 0.01) found a significant decrease, while the aerobic group saw a non-significant change (p = 0.06) compared to the control group.³⁷

Depression Trends

While all the studies saw an improvement in depression and mental health with association to exercise, not all of them used the same measure of depression.

The two studies that used the Children’s Depression Inventory (CDI) saw a decrease in their scores, indicating an improvement in mental health and decreased depressive symptoms. The experimental group of one experiment saw a decrease in CDI of 7.68 to 4.57 (p = 0.02).⁴ The other found a decrease in its experimental population of 7.6 to 6.3, with no p-value listed.³⁶ While other studies used different tests and measurements, they still show similar results with less depressive symptoms after exercise programs.

The two studies that both used the Child’s Depression Scale (CDS) also both saw a decrease in depressive symptoms. The positive thoughts of the experimental group saw improvements which correlated with a decrease in the number of depressive thoughts; the experiment saw a change in depressive thoughts with a p-value of 0.020 meaning the changes were statistically significant.³² The other study that employed the CDS used three groups including a control, a 40-minute exercise group, and a 20-minute exercise group. The 40-minute group saw a significant change in the CDS in relation to the control group with a p-value of 0.02. The 20-minute group saw a change in relationship with the control group, but it was not considered statistically significant with a p-value of 0.07.³⁵

One study used the Beck Depression Inventory (BDI) on two exercise groups. The study used two groups with differing levels of intensity during their exercise programs. The low- intensity group had 20% less intense workouts compared to the high-intensity group. Both groups saw a decrease in depressive symptoms as the BDI shows with p ≤ .01, but little change in self-esteem.³³

The study conducted by educating parents and helping adolescents directly exercise used the Short Mood and Feelings Questionnaire (SMFQ). The adolescents participated in physical activity circuits while the parents were educated on parenting techniques, diet, and support for their children. The results found that depressive symptoms decreased throughout the study with a pre-intervention mean decrease of 1.3 (p = 0.042) followed by another mean decrease of 1.7 post-intervention (p = 0.004).³⁴

The final study used in the table used the Brunell Mood Scale (BMS) and consisted of four groups of participants. One group focused on aerobic training, another resistance training, a combination of both aerobic and resistance, and a control group. All groups besides the control saw improvements in depression, but the resistance had the most significant change with a p- value of 0.02.³⁷

Discussion

Through multiple studies conducted in different countries (i.e., the United States and Australia) and with varying methods (i.e., cross-sectional and randomized control trials), many found improvements in depressive symptoms when exercise was undertaken. Several different studies focused on varying levels of exercise either with different duration of exercise or different types of training. From the data gathered generally more intense and longer workouts had larger impacts on obesity and especially depression. Studies that continued for longer durations saw greater improvements as the study progressed over time.

One study conducted focused on a high and low-intensity workout. The study found that both groups had Beck Depression Inventory (BDI) scores decrease indicating an improvement in depressive symptoms, but the improvements were more consistent with the high-intensity group. The authors of the study³³ accredit the improvements in depression for many possible reasons including a sense of accomplishment and the increased release of neurotransmitters such as serotonin, dopamine, and norepinephrine. The reason there is a difference between the high and low-intensity exercises may be a higher more prolonged release of these neurotransmitters in the higher-intensity group.³³

Another study³⁵ focused on exercise duration with high and low dose groups of 40 and 20 minutes, respectively. Similarly to the previous study, both groups saw improvements when scored for depression on the Child Depression Scale (CDS) compared to the control group, but the higher dose group saw more improvement. This study attributes the improvements in depression to the loss of weight causing a greater sense of self-worth directly, so with increased duration of exercise, more weight was likely lost, possibly leading to more impact on depressive symptoms.³⁵

Finally, one study³⁷ focused on using aerobic and resistance training. The aerobic training included treadmills, elliptical machines, and exercise bikes while the resistance training used free weights and weight machines. Both groups had the same timing of 25-40 minutes, and once again all groups saw improvements in their scores for depression, particularly the resistance training. This study partially accredited the differences in exercise type due to resistance training leading to greater changes in the body because it is higher intensity and therefore may have a greater effect on mental health. The study suggests that it should be further inspected and researched to see what specific elements of resistance training might have greater impacts on mental health.³⁷

Studies collected in this review^4,32,36 showed that with increased length of time, many had better results the longer they had participants doing exercise. One study⁴ conducted over 8 months on participants found that those who participated for the entire duration of the study scored better on quality of life and depression scores than those who dropped out of the study earlier. This study attributed its success to the duration of the experiment and exercise as well as suggesting lifestyle changes, adult attention, and interacting with peers will improve depressive symptoms.⁴ Conversely, those who dropped out may have had more severe depression making it difficult to complete assigned tasks, possibly indicating extended exercise may not work for all individuals with depression.

Another study³² that took place over 20 weeks found that throughout the study, more participants had more positive thoughts which correlated to less depressive symptoms in children with obesity. The authors of this study found that the increased duration of the experiment compared to others helped to promote more positive thoughts and lifestyle choices over time, along with exercise, which may likely cause a decrease in depressive thoughts.³²

A study³⁶ conducted over 28 weeks measured depressive symptoms in weeks 8, 14, and 28. The results showed an increase in physical self-worth between each time interval. The study compared the exercise group with a usual care group at each time interval; after 8 weeks the p- value was 0.02, after 14 weeks the p-value was 0.03, and after 28 weeks the p-value was 0.03, showing a large difference in change of self-worth among the participants in the exercise group. This study associated its improvements with depressive symptoms with the length of the study. The increased length of the study helped to best treat depressive symptoms in participants.³⁶ This study did not explore the relationship between self-worth and depression. Other studies support a link between decreased self-worth and increased depressive symptoms and vice versa.³⁸

The final study³⁴ conducted included a post-12-month follow-up measurement. This study focused on including an exercise program and educating parents on how to best help their children. The study found that depressive symptoms lessened as time progressed within the experiment. The researchers found that exercise was helpful as a treatment for depression, but adult influences helped to create lasting improvements.³⁴ Studies have shown that increased parental intervention for their adolescent children helps to lead to decreased depressive symptoms.³⁹

In comparing results with other reviews, the current author found similar results on the impact of exercise on depression in obese adolescents. One review saw that exercise helped treat depression with the optimum timing being 6 weeks, 4 times a week, for 30 minutes.⁴⁰ Another review found that overall, the incorporation of structured physical activity led to decreases in depression, increased self-esteem, and improved body image in obese adolescents; the study also found similarly to this paper that longer interventions had a greater impact than shorter ones.⁴¹ Another review inspected the importance of the type of exercise and found (contrary to the current author's findings) that aerobic exercise was the most effective followed by group exercise and then strength training.⁴² The study accredits this to the idea that aerobic exercise can be easily included within physical education classes compared to group and strength training which would require more time and training.⁴²

The studies above show that exercise is linked with improvements in mood, stress, and depression. With exercise, those with obesity see great improvements in mental health issues using many ways to exercise.⁴³ Physical activity and exercise are heavily associated with body image, especially in younger populations.⁴⁴ Children who exercise are more likely to have improvements in their body image, motor skills, and self-esteem.⁴⁴ Studies suggest that with increased exercise more serotonin and dopamine are released, improving the mood of the individuals.⁸ When these neurotransmitters are released, exercise can feel rewarding and help to combat mental illnesses such as depression even in cases where the participants’ weight does not change drastically.⁴⁵

Future Research

Future research should focus on several aspects to improve current findings on obesity and depression in adolescents. Neurotransmitters and their impact on mental health during exercise is an important field. Research that focuses on neurotransmitters during exercise could help improve studies such as the ones above and answer more in-depth why depression can be affected by exercise. It is also important that research focuses on culture and body image. In certain cultures (i.e., United States, Australia, Canada), obese adolescents may be targets of bullying which can have severe impacts on depression and mental health.⁴⁶ Socioeconomic status can be a factor in how it relates to obesity. In higher-income countries, obesity is greater amongst those with lower socioeconomic status countries, while in lower-income countries those with higher socioeconomic status are more at risk of obesity.⁴⁷ It is important that researchers in the future take this into account as it relates to where they are performing their research. Future researchers should also focus more on the type of exercise such as resistance training vs. strength training and which might be more beneficial and why. Many research studies in this field focus on one of the factors mentioned above, but future studies should see how multiple factors interact and which ones have the largest effects on depression.

Limitations

Throughout this study, many limitations were encountered that possibly limit the effectiveness of the research. Research was only done through Google Scholar via a topical search and PubMed via a systematic search meaning it is possible that research from other databases, as well as Google Scholar, could be missed. A meta-analysis was not performed which could cause certain limitations. The results found on PubMed within the systematic review were very limited causing the need for supplemental articles to be pulled from Google Scholar.

The results from Google Scholar were not systematically reviewed because the results were too numerous for a single researcher. Many articles focused on multiple independent variables and took focus away from how exercise can directly affect depression with variables including diet, medication, therapy, and others. Isolating studies that focus on exercise or one specific variable as they relate to depression in adolescents would help better understand the impact of each variable individually.

Conclusion

The information gathered in this study shows how exercise can positively impact depression. Either by directly impacting weight or by indirectly improving mental via neurotransmitters, self-image, or self-worth. Many sources support positive changes in depression in obese adolescents through exercise, with greater improvements in higher intensity workouts and longer duration of exercise programs. While this study focused on exercise, parents and their children must promote other lifestyle changes to best impact mental health.

Therapy, diet, and medication are all important to improving depressive symptoms. Encouraging adolescents with obesity to exercise can also lead to significant improvements in mental health. Further research must address how depression and mental health change with exercise with a focus on neurotransmitters and how they can improve mood and body image with exercise, as well as the impact of exercise type.

Bibliography

1. Ng M, Fleming T, Robinson M, et al. Global, regional and national prevalence of overweight and obesity in children and adults 1980-2013: A systematic analysis. Lancet Lond Engl. 2014;384(9945):766-781. doi:10.1016/S0140-6736(14)60460-8

2. Fuller NR, Burns J, Sainsbury A, et al. Examining the association between depression and obesity during a weight management programme. Clin Obes. 2017;7(6):354-359. doi:10.1111/cob.12208

3. Kennedy SH. Core symptoms of major depressive disorder: relevance to diagnosis and treatment. Dialogues Clin Neurosci. 2008;10(3):271-277.

4. Williams CF, Bustamante EE, Waller JL, Davis CL. Exercise effects on quality of life, mood, and self-worth in overweight children: the SMART randomized controlled trial. Transl Behav Med. 2019;9(3):451-459. doi:10.1093/tbm/ibz015

5. Chand SP, Arif H. Depression. In: StatPearls. StatPearls Publishing; 2024. Accessed July 3, 2024. http://www.ncbi.nlm.nih.gov/books/NBK430847/

6. Remes O, Mendes JF, Templeton P. Biological, Psychological, and Social Determinants of Depression: A Review of Recent Literature. Brain Sci. 2021;11(12):1633. doi:10.3390/brainsci11121633

7. Nutt DJ. Relationship of neurotransmitters to the symptoms of major depressive disorder. J Clin Psychiatry. 2008;69 Suppl E1:4-7.

8. Biology Of Depression - Neurotransmitters & Depression. www.MentalHelp.net. January 30, 2024. Accessed July 31, 2024. https://www.mentalhelp.net/depression/biology-of-depression- neurotransmitters/

9. Mohajan D, Mohajan H. Body Mass Index (BMI) is a Popular Anthropometric Tool to Measure Obesity Among Adults. J Innov Med Res. 2023;2:25-33. doi:10.56397/JIMR/2023.04.06

10. Karastergiou K, Smith SR, Greenberg AS, Fried SK. Sex differences in human adipose tissues – the biology of pear shape. Biol Sex Differ. 2012;3:13. doi:10.1186/2042-6410-3-13

11. Naigaga DA, Jahanlu D, Claudius HM, Gjerlaug AK, Barikmo I, Henjum S. Body size perceptions and preferences favor overweight in adult Saharawi refugees. Nutr J. 2018;17(1):17. doi:10.1186/s12937-018-0330-5

12. Caprio S, Daniels SR, Drewnowski A, et al. Influence of Race, Ethnicity, and Culture on Childhood Obesity: Implications for Prevention and Treatment. Diabetes Care. 2008;31(11):2211-2221. doi:10.2337/dc08-9024

13. Rahman M, Temple JR, Breitkopf CR, Berenson AB. Racial differences in body fat distribution among reproductive-aged women. Metabolism. 2009;58(9):1329. doi:10.1016/j.metabol.2009.04.017

14. Lin X, Li H. Obesity: Epidemiology, Pathophysiology, and Therapeutics. Front Endocrinol. 2021;12:706978. doi:10.3389/fendo.2021.706978

15. Sarwer DB, Polonsky HM. The Psychosocial Burden of Obesity. Endocrinol Metab Clin North Am. 2016;45(3):677-688. doi:10.1016/j.ecl.2016.04.016

16. Förster LJ, Vogel M, Stein R, et al. Mental health in children and adolescents with overweight or obesity. BMC Public Health. 2023;23(1):135. doi:10.1186/s12889-023-15032-z

17. Choi Y, Hong J. Association between Weight Status and Mental Health among Korean Adolescents: A Nationwide Cross-Sectional Study. Children. 2023;10(4):620. doi:10.3390/children10040620

18. Barton M. Childhood obesity: a life-long health risk. Acta Pharmacol Sin. 2012;33(2):189-193. doi:10.1038/aps.2011.204

19. Gibson-Smith D, Halldorsson TI, Bot M, et al. Childhood overweight and obesity and the risk of depression across the lifespan. BMC Pediatr. 2020;20(1):25. doi:10.1186/s12887-020- 1930-8

20. Toups MSP, Myers AK, Wisniewski SR, et al. Relationship between obesity and depression: characteristics and treatment outcomes with antidepressant medication. Psychosom Med. 2013;75(9):863-872. doi:10.1097/PSY.0000000000000000

21. Antidepressants: Selecting one that’s right for you. Mayo Clinic. Accessed July 31, 2024. https://www.mayoclinic.org/diseases-conditions/depression/in-depth/antidepressants/art- 20046273

22. Ramic E, Prasko S, Gavran L, Spahic E. Assessment of the Antidepressant Side Effects Occurrence in Patients Treated in Primary Care. Mater Socio-Medica. 2020;32(2):131-134. doi:10.5455/msm.2020.32.131-134

23. Nischal A, Tripathi A, Nischal A, Trivedi JK. Suicide and Antidepressants: What Current Evidence Indicates. Mens Sana Monogr. 2012;10(1):33-44. doi:10.4103/0973-1229.87287

24. Canheta AB de S, Santos ASEA de C, Souza JD de, Silveira EA. Traditional Brazilian diet and extra virgin olive oil reduce symptoms of anxiety and depression in individuals with severe obesity: Randomized clinical trial. Clin Nutr Edinb Scotl. 2021;40(2):404-411. doi:10.1016/j.clnu.2020.05.046

25. Breymeyer KL, Lampe JW, McGregor BA, Neuhouser ML. Subjective mood and energy levels of healthy weight and overweight/obese healthy adults on high-and low-glycemic load experimental diets. Appetite. 2016;107:253-259. doi:10.1016/j.appet.2016.08.008

26. Calabrese L, Frase R, Ghaloo M. Complete remission of depression and anxiety using a ketogenic diet: case series. Front Nutr. 2024;11. doi:10.3389/fnut.2024.1396685

27. Sarac I, Butnariu M. Food Pyramid - The Principles of a Balanced Diet. Int J Nutr. 2020;5(2):24-31. doi:10.14302/issn.2379-7835.ijn-20-3199

28. Danielsen YS, Nordhus IH, Júlíusson PB, Mæhle M, Pallesen S. Effect of a family-based cognitive behavioural intervention on body mass index, self-esteem and symptoms of depression in children with obesity (aged 7-13): a randomised waiting list controlled trial. Obes Res Clin Pract. 2013;7(2):e116-e128. doi:10.1016/j.orcp.2012.06.003

29. Wilfley DE, Kolko RP, Kass AE. Cognitive Behavioral Therapy for Weight Management and Eating Disorders in Children and Adolescents. Child Adolesc Psychiatr Clin N Am. 2011;20(2):271-285. doi:10.1016/j.chc.2011.01.002

30. Kosatka D, Sobów T, Strzelczyk J. [Severity and rate of depression in obese patients after surgical treatment of obesity with Roux-en-Y gastric bypass procedure]. Wiadomosci Lek Wars Pol 1960. 2006;59(7-8):477-480.

31. Cochrane Handbook for Systematic Reviews of Interventions. Accessed July 31, 2024. https://training.cochrane.org/handbook/current

32. Romero-Pérez EM, González-Bernal JJ, Soto-Cámara R, et al. Influence of a Physical Exercise Program in the Anxiety and Depression in Children with Obesity. Int J Environ Res Public Health. 2020;17(13):4655. doi:10.3390/ijerph17134655

33. Fidelix Y, Lofrano-Prado MC, Fortes LS, et al. Aerobic Training Performed at Ventilatory Threshold Improves Psychological Outcomes in Adolescents With Obesity. J Phys Act Health. 2019;16(10):851-856. doi:10.1123/jpah.2018-0193

34. Fenner AA, Howie EK, Davis MC, Straker LM. Relationships between psychosocial outcomes in adolescents who are obese and their parents during a multi-disciplinary family- based healthy lifestyle intervention: One-year follow-up of a waitlist controlled trial (Curtin University’s Activity, Food and Attitudes Program). Health Qual Life Outcomes. 2016;14(1):100. doi:10.1186/s12955-016-0501-z

35. Petty KH, Davis CL, Tkacz J, Young-Hyman D, Waller JL. Exercise Effects on Depressive Symptoms and Self-Worth in Overweight Children: A Randomized Controlled Trial*. J Pediatr Psychol. 2009;34(9):929-939. doi:10.1093/jpepsy/jsp007

36. Daley AJ, Copeland RJ, Wright NP, Roalfe A, Wales JKH. Exercise Therapy as a Treatment for Psychopathologic Conditions in Obese and Morbidly Obese Adolescents: A Randomized, Controlled Trial. Pediatrics. 2006;118(5):2126-2134. doi:10.1542/peds.2006- 1285

37. Goldfield GS, Kenny GP, Alberga AS, et al. Effects of aerobic training, resistance training, or both on psychological health in adolescents with obesity: The HEARTY randomized controlled trial. J Consult Clin Psychol. 2015;83(6):1123-1135. doi:10.1037/ccp0000038

38. Orth U, Robins RW. Understanding the Link Between Low Self-Esteem and Depression. Curr Dir Psychol Sci. 2013;22(6):455-460. doi:10.1177/0963721413492763

39. Cardamone-Breen MC, Jorm AF, Lawrence KA, Mackinnon AJ, Yap MBH. The Parenting to Reduce Adolescent Depression and Anxiety Scale: Assessing parental concordance with parenting guidelines for the prevention of adolescent depression and anxiety disorders. PeerJ. 2017;5:e3825. doi:10.7717/peerj.3825

40. Wang X, Cai Z dong, Jiang W ting, Fang Y yan, Sun W xin, Wang X. Systematic review and meta-analysis of the effects of exercise on depression in adolescents. Child Adolesc Psychiatry Ment Health. 2022;16:16. doi:10.1186/s13034-022-00453-2

41. King JE, Jebeile H, Garnett SP, Baur LA, Paxton SJ, Gow ML. Physical activity based pediatric obesity treatment, depression, self-esteem and body image: A systematic review with meta-analysis. Ment Health Phys Act. 2020;19:100342. doi:10.1016/j.mhpa.2020.100342

42. Li J, Zhou X, Huang Z, Shao T. Effect of exercise intervention on depression in children and adolescents: a systematic review and network meta-analysis. BMC Public Health. 2023;23:1918. doi:10.1186/s12889-023-16824-z

43. Annesi JJ. Effects of Minimal Exercise and Cognitive Behavior Modification on Adherence, Emotion Change, Self-Image, and Physical Change in Obese Women. Percept Mot Skills. 2000;91(1):322-336. doi:10.2466/pms.2000.91.1.322

44. Foley Davelaar CM. Body Image and its Role in Physical Activity: A Systematic Review. Cureus. 13(2):e13379. doi:10.7759/cureus.13379

45. Basso JC, Suzuki WA. The Effects of Acute Exercise on Mood, Cognition, Neurophysiology, and Neurochemical Pathways: A Review. Brain Plast. 2(2):127-152. doi:10.3233/BPL-160040

46. Styrkársdóttir EÝ. The Effects of Overweight and Obesity on Depression, Anxiety and Bullying among Adolescent Females. In: ; 2014. Accessed August 14, 2024. https://www.semanticscholar.org/paper/The-Effects-of-Overweight-and-Obesity-on-Anxiety- Styrk%C3%A1rsd%C3%B3ttir/06a763e5f8f7a318b49e517415d3fa08283de340

47. Templin T, Cravo Oliveira Hashiguchi T, Thomson B, Dieleman J, Bendavid E. The overweight and obesity transition from the wealthy to the poor in low- and middle-income countries: A survey of household data from 103 countries. PLoS Med. 2019;16(11):e1002968. doi:10.1371/journal.pmed.1002968