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Department of Nutrition Research, National Nutrition and Food Technology Research Institute and Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Department of Clinical Nutrition, National Nutrition and Food Technology Research Institute and Faculty of Nutrition Sciences and Food Technology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
Depression and obesity are two serious health problems influencing both physical and mental health. Regarding the high prevalence of these two conditions and their high morbidity and mortality rates associated to both, investigation the association between them seems necessary.
Method
This cross sectional study was conducted on 174 women with BMI ≥ 25 kg/m2 who referred to the obesity clinic of Sina hospital, through convenience sampling. Data from anthropometric measurements, Beck Depression inventory-II and body composition were collected and SPSS was used to statistical analysis.
Results
Mean age of participants was 36.6 ± 8.8 year. The prevalence of dysthymic disorders in obese women was higher than in those with overweight. In women with obesity, the prevalence of severe depression, was higher than mild and moderate depression (P < 0.001). According to the linear regression analysis, increasing each score in depression score, increases the fat mass by 0.44 kg, significantly (P < 0.001).
Conclusion
Depression and obesity follows a dose response association. According to the association between depression and obesity, focusing on interdisciplinary studies is suggested for the future researches.
]. Furthermore, depression is accompanied with some chronic diseases such as diabetes, coronary vascular diseases and arthritis and obesity. Depression may worsen outcomes of these diseases [
]. It has recently found that depression as a chronic psychological distress, plays an important role in the increasing trend of obesity around the world [
]. This is important because according to the report of WHO, overweight and obesity are responsible for 44%, 23% and 7–41% of diabetes, ischemic heart diseases and cancers, respectively [
]. According to “metabolic-mood syndrome” suggested by R.B. Mansour et al., it seems that there is a bidirectional association between depression and obesity [
]. On the other hand, it has been suggested that certain genes such as genes encoded glucocorticoids, leptin and dopamine receptors, are involved in pathology of these both disorders. The role of environmental factors especially chronic stress, should also be considered in common etiology of obesity and depression. Inflammatory pathways are of the mechanisms involved in obesity. The effects of inflammatory cytokines on the central nervous system, change the synaptic plasticity and neurogenesis. It is similar to what occurs in depression [
]. The pro-inflammatory cascade generated as a result of the above mechanisms, influences on peripheral resistance to the glucocorticoids, bacterial translocation, releasing of catecholamines and the secretion of TNF-α and IL-6. All of these processes lead to increase in the production of leptin and decrease in production of adiponectin in adipocytes and finally, lead to inflammation and accumulation of fatty tissue [
In addition to depression, dysthymic disorder, is another psychological disorder that is characterized by fluctuating dysphoria which is far less dramatic than major depression, symptomatically [
]. Despite clinical outcomes of obesity which have been well studied, its psychological outcomes like depression and dysthymic disorder, are not well understood. On the other hand, most of those studies, have focused on obesity, while the association between psychological disorders and body composition has not been properly investigated. Furthermore, the results of a meta-analysis showed that depression has a stronger association with obesity than with overweight [
]. So, the association between weight and depression may follow a dose-response pattern. We should also note that the risk of depression in some races is higher than others [
Associations of body mass index and anthropometric indicators of fat mass and fat free mass with all-cause mortality among women in the first and second National Health and Nutrition Examination Surveys follow-up studies.
]. So, the association between depression and FM may not be similar in different races. Therefore, determining the association between overweight, obesity and depression, needs some more regional investigations. Considering the high prevalence of depression in Iranian people and that there is not enough information on the association between FM and depression in Iranian people, the current study investigated the prevalence of depression in women with overweight comparing with women with obesity and also investigated the association of depression with FM in Iranian women with overweight and obesity, for the first time.
Method
This cross sectional study was conducted on 174 women with overweight and obesity who referred to the obesity clinic of Sina hospital. The study protocol was approved by the Ethics Committee of Tehran University of Medical Sciences. A consent form was obtained from all participants after being informed of the study objectives and benefits. They also signed an agreement regarding personal information confidentiality. Inclusion criteria were included women 18–51 years old, BMI between 25 and 39.9 kg/m2, who had no history of major psychotic disorders like schizophrenia and delusional disorder, taking any drugs related to these major disorders and also hormone therapy in the last 6 months. They should not have a history of electroconvulsive therapy, too.
Anthropometric measurements
Body weight was measured to the nearest 0.1 kg and height was measured to the nearest 0.1 cm using a standard stadiometer. Weight was measured with light clothing and height was measured without shoes. BMI was then calculated as weight divided by height squared (kg/m2). The classification of obesity status was established according to overweight (30 > BMI ≥ 25 kg/m2) and obesity (BMI ≥ 30 kg/m2). Waist circumference was taken at the maximal narrowing of the waist from anterior view. Hip circumference was measured at the point of maximal gluteal protuberance from the lateral view. The body composition indices including total fat percentage, total fat mass and total fat-free mass were measured using body composition analyzer BC-418 MA (TANITA, Tokyo, Japan).
Beck Depression inventory-II (BDI-II)
To assess depression disorder, BDI questionnaire was used. The BDI-II was found to have high internal consistency, high content validity, validity in differentiating between depressed and nondepressed individuals, and good sensitivity to change. The Persian version of this questionnaire was used in the study conducted by Hamidi et al. It showed a suitable validity (alpha = 0.92) and reliability (r = 0.64) [
]. Participants completed this 21-item self-report inventory. Items are scored on a scale from 0–3, with higher scores reflecting more severe symptoms. Total score of this questionnaire are categorized as below [
The BDI-II includes 5 somatic items: loss of energy, changes in sleeping patterns, changes in appetite, loss of interest in sex and tiredness or fatigue.
Dietary intake assessment
To assess nutritional intake information of participants, 3-day food recalls were completed by trained dietitian. Participants were asked about all the meals and snacks eating during three previous days. Calorie and macronutrients intake were calculated by Nutritionist IV software. The database was modified with reference to the existing national Iranian food composition table, developed by the Iranian National Institute of Nutrition and Food Technology.
Assessment of physical activity (PA)
To assess physical activity, International Physical Activity Questionnaire (IPAQ) was used. The Persian version of this questionnaire was validated by Vasheghani-Farahani et al. According to their study, this questionnaire has acceptable validity and reliability (0.33, 0.7, respectively) [
]. The IPAQ used in the present study is the long interview-administered version (27 items) which covers 4 domains of physical activity including: occupational (7 items), transportation (6 items), household/gardening (6 items) and leisure-time activities (6 items). The questionnaire also includes 2 questions about the time spent on sitting as indicators of sedentary behavior. After multiplying the time dedicated to each activity class by the specific MET score for that activity, physical activity was calculated and reported as MET/min/week [
Kolmogorov–Smirnov test determines if variables showed a normal distribution. Parametric and nonparametric descriptive tests were used for data analysis, depend on their normal or abnormal distribution. For descriptive analysis of quantitative data, the Mean and Standard deviation were used. For qualitative data, frequency percentage was reported. To compare more than two continuous variables, Anova test was used with Tukey HSD as posthoc test. Correlates of depression and obesity were evaluated by using regression models. We tabulated adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for correlates of depression and obesity. Considering BDI score as dependent variable and fat mass and BMI as independent variables. Statistical package for the Social Sciences, version 17.0(SPSS, Chicago, IL, USA) was used to analyze the data and P value <0.05 was considered as significant.
Results
A total of 174 women participated in this study with mean age of 36.6 ± 8.8 year. As Table 1 shows, frequency of women who reported history of psychiatric disorders and dysthymic disorder was significantly higher in women with obesity than in women with overweight (P < 0.001). Pharmacotherapy and major depressive episode have not any significant difference between overweight and obese women.
Table 2 shows mean ± SD of anthropometric measurements, FM, total calorie, calorie percentage of each macronutrients and physical activity level among different levels of depression severity. The results of ANOVA test and post hoc Tukey HSD showed that mean of FM, weight, BMI, WC and HC in women with moderate and severe depression is higher than in those with no depression (P < 0.001).
Table 2Mean of anthropometric measurements, fat mass, dietary intake and MET among different categories of depression severity.
Distribution of women with overweight and obesity among different levels of depression severity has been shown in Fig. 1. As this figure shows, in women with overweight, no depression was the most prevalent among different level of depression severity; while in women with obesity, the prevalence of severe depression, was the highest (P < 0.001).
Fig. 1Percentage of different categories of depression severity in women with overweight and obesity. ∗Significant difference with other levels of depression in women with overweight. ∗∗Significant difference with other levels of depression in women with obesity.
Table 3 shows the association of depression score with FM and BMI. According to the linear regression analysis, increasing each score in depression score, increases the FM by 0.44 kg, significantly. This association remained significant after adjusting for total calorie intake and MET (P < 0.001).
Table 3The association of depression score with fat mass and BMI according to linear regression.
In the current study the prevalence of dysthymic disorder was significantly higher in women suffered from obesity than in women with overweight. Moreover, our results showed that mean of FM, weight, BMI, WC and HC has significant difference among levels of depression severity such that the prevalence of severe and moderate depression was higher than mild and no depression. Our results were in accordance with the study of Polanka et al. in an American sample. They assessed the association of dysthymic disorder and atypical major depressive disorder (MDD) with weight using the data of National Epidemiologic Survey on Alcohol and Related Conditions waves 1 (2001–2002) and 2 (2004–2005). According to their findings, atypical MDD was a stronger predictor of increases in body mass index and incidence of obesity than were non-atypical MDD, no history of depressive disorder, and dysthymic disorder. Atypical MDD was a stronger predictor of obesity in/Latinos/Hispanics than in non-Hispanic blacks and whites. US adults with atypical MDD are at high risk of obesity and weight gain, and Latinos/Hispanics might be vulnerable to the obesogenic consequences of depressive disorders [
]. Results of our study revealed that the same relationship between obesity and dysthymic disorder in Iranian population. Also in agreement to our results, McLean et al. assessed the link between obesity and anxiety/depression using the Hospital Anxiety and Depression Scale (HADS) in a Scottish population. They reported that the prevalence of obesity was higher among patients with depression and anxiety with a significant direct relationship between HADS scores and body mass index [
Attrition and weight loss outcomes for patients with complex obesity, anxiety and depression attending a weight management programme with targeted psychological treatment.
Actigraphy measurement of physical activity and energy expenditure in narcolepsy type 1, narcolepsy type 2 and idiopathic hypersomnia: A Sensewear Armband study.
] which could cause higher energy intake. Third, adults with atypical major depressive disorder experienced higher rates of restricted-activity days and disability-days which could reduce energy expenditure [
]. Therefore, individuals with atypical MDD have greater exposure to depression and its consequent polyphagia. Fifth, weight gain is one of the side effects of some of antidepressants [
]. Our results showed that, one score elevation in depression score increases the FM by 0.44 kg. This association remained significant after adjusting for total calorie intake and MET. These findings were in agree with the results of an study by Lasserre et al. in Swiss sample [
]. They reported that atypical MDD is a risk factor for higher BMI, fat mass, and waist circumference over 5.5 years. In the current study, we extended their findings to the Iranian population. However, in contrast to our results, Lamers et al. showed that BMI fluctuation over the 6 year follow-up had no difference between adults with and without atypical depressive disorder [
]. The observed difference could be because in Lamers et al. study, unlike to our study, MDD patients were compared with controls.
Sixth reason for the link between obesity and depression is the rise in systemic inflammation and metabolic dysregulation which have been reported in individuals with depressive disorders [
], Although, it is not yet well defined whether these changes are consequences or causes of obesity. Finally, shared genetic factors could contribute to both future atypical MDD and obesity. As we know by far, obesity is considered as a low grade inflammation [
]. The expression of pro-inflammatory cytokines like TNF-α and Interlukin-6 (IL-6) was reported to be elevated in adipose tissue of obese individuals which resulted in higher circulating TNF-α and IL-6 [
]. Finally, genetic factors could partially explain the link between obesity and depression. For example, a fat mass and obesity-associated protein (FTO) gene variant was found to be related to greater odds of having atypical MDD [
Depression and obesity, both are conditions with serious impact on health, especially considering their high prevalence. Severe depression is more prevalent in women with obesity than in those with overweight. On the other hand, Fat mass increases with the severity of depression. Although there is a relationship between depression and obesity, there is no consistency about the nature and the related mechanisms for their association. According to bidirectional association between depression and obesity, focusing on interdisciplinary studies is suggested for the future researches.
Limitation
Due to the cross-sectional nature of current study, we were not able to assess the causality link between depression and obesity. Also we included only female. Although when considering depressive disorders, there is a sex differentiation between male and female with higher prevalence in female, further studies in both sexes are warranted. Energy and macronutrient intake were recorded based on participants memory, however by using 24-hours recalls for three days we tried to reduce the effect of unwanted under/over reporting.
Key points
•
The prevalence of dysthymic disorders in obese women is higher than in those with overweight.
•
The prevalence of severe depression in obese women, is higher than mild and moderate depression.
•
Fat mass increases with the severity of depression.
Ethics approval
This project was approved by ethics committee of Tehran University of Medical Sciences (IR.TUMS.VCR.REC.1398.140).
Funding
This work was financially supported by Cardiac primary prevention research center, Cardiovascular Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Authors' contributions
SR conducted statistical analysis and wrote the manuscript. MRT and MA designed the study. SRJ wrote the manuscript.
Consent to participate
A signed hand-written informed consent was obtained from each individual before data collection.
Consent for publication
Not applicable.
Data availability statement
All data were delivered and archived in the Cardiac primary prevention research center, Cardiovascular Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.
Code availability
Not applicable.
Declaration of competing interest
The authors report there are no competing interests to declare.
Acknowledgments
The authors thank the personnel of obesity clinic of Sina hospital and all women who participated in this study.
References
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A systematic review of prevalence of Depression in Iranian patients.
Associations of body mass index and anthropometric indicators of fat mass and fat free mass with all-cause mortality among women in the first and second National Health and Nutrition Examination Surveys follow-up studies.
Attrition and weight loss outcomes for patients with complex obesity, anxiety and depression attending a weight management programme with targeted psychological treatment.
Actigraphy measurement of physical activity and energy expenditure in narcolepsy type 1, narcolepsy type 2 and idiopathic hypersomnia: A Sensewear Armband study.
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