Obesity and depression, an analytical study among adults attending primary care clinics in Bahrain

INTRODUCTION

Both depression and obesity are widely spread problems with major public health implications.^1,2 Obesity is a major risk factor for a number of chronic diseases.³ However, its consequences on mental health is less certain. A crude population measure of obesity is the body mass index (BMI).³

The BMI is defined as a person’s weight in kilograms divided by the square of the persons’ height in meters (kg/m2). Obesity is defined as BMI>30 kg/m.⁴ According to the survey done by ministry of Health in Bahrain in 2007, the prevalence of obesity in Bahraini adults was 36.3% and was higher in females than males (40.3% and 32.3%) respectively.⁵ This explain why Bahrain is considered the third country with highest rates of overweight and obesity in WHO Eastern Mediterranean Region with 33% of adults aged more than 20 to be overweight of whom 36% are obese. This is higher than the global average of obesity in 2008 reaching 12%.⁶ Depression is the leading cause of disability worldwide.⁷

Chronic medical problems increase the prevalence of depression.⁸

In Bahrain, the prevalence of depression in people with many chronic diseases was studied. A study done in 2009 showed the prevalence of depression among diabetes patients attending diabetic clinics at primary care was 33.3%.⁹ another study conducted in 2011 revealed that the prevalence of mild to severe depression among sickle cell disease patients was 58.5%.¹⁰

Worldwide, many studies tried to relate the association between obesity and depression, in which some approve, and others reject the association. In China, being overweight and having abdominal obesity by wide waist circumference is linked with a high risk of depression.¹¹ However, a study conducted in Yazd health centers in Iran in 2013 did not confirm any relationship between weigh and depression.¹² The association was studied in Australian General practice in 2014, but surprisingly weight and depression demonstrated a U shaped relationship with high prevalence of depression among underweight and obese patients.¹³

This is the first study to estimate the prevalence of depression in obese adults and address any association between obesity and depression in Bahrain.

METHODS

The study period was from February 2019 to January 2020. Sample size was calculated based on the expected prevalence of depression in obese patients in Bahrain that is 30% and the expected prevalence of depression in non-obese is 20%, using the power of 80% and significant level of 0.05 the sample size will be 586 (around 550-600).

A cross sectional study was conducted in four primary health care centers. One health center was selected randomly from each of the four governorates in the kingdom of Bahrain. Halat Bu Maher health Centre from Muharraq governorate, Naim Health Centre from the Capital governorate, Jidhafs Health Centre from the Northern governorate and Engineer health Centre from the Southern governorate. The aim was to get around 150 participant from each health center.

Adults aged ≥18 years presenting for general practice care at the above-mentioned health centers were approached. Verbal and written consent was taken from those who agreed to participate in the study. Non-Arabic-English readers and pregnant ladies were excluded.

Arabic and English versions of self-filled questionnaires were distributed to Arabic and English readers, respectively, who agreed to participate in the study. The questionnaire consists of three main sections: demographic data, clinical and behavioral characteristics and the Beck Depression Inventory Scale. Demographic characteristics include: age, gender, marital status, educational level, financial level and employment. Clinical and behavioral characteristics include smoking status, alcohol, and history of chronic illness, history of psychiatric illness, use of medications and family history of depression.

Beck depression Scale (BDI-2) consists of 21 questions, each with four options with a score from 0 to 3. The sum of the answers gives a final score ranging from 0-63. Score of 16 was considered a cutoff point of depression as the same score was recommended to screen for depression in diabetes and in Parkinson disease, and post Myocardial infarction.^9,14-17

After receiving the questionnaire from the candidate, the height and weight were checked by the physician or the nurse. Weight was measured in Kilograms and height in Centimeters while wearing light clothes and no shoes using health center instrument. Body Mass Index (BMI) was calculated using weight/height/height formula and recorded in the questionnaire. A total sample of 550 were enrolled, 57 has been excluded from the study as the questionnaire were incompletely filled.

Data were analyzed using the SPSS program. Chi- Square test and logistic regression analysis were used to identify the significance of the association between depression and other factors including obesity. P-value was considered significant if ≤0.05.

RESULTS

In this study 493 patients were evaluated. The ages of patients range from 18-91 years and 54% are within the age range of 18-35. Female constitute 61% of the sample. The majority were Bahraini (86.3%). Almost three quarter of the sample were married (75.5%), the other quarter were either single, divorced or widowed. Employees are around 57% and university graduates are 56% (Table 1).

The behavioral and medical characteristics of participants are shown in (Table 2). Smokers accounts for only 15% of the participants. The majority (99%) claims that they don’t drink alcohol. While 29% of the sample had history of chronic disease, only 25% are on regular medication. When asking patients if they have ever been told by their physician to have a psychiatric disease including anxiety, depression, OCD or schizophrenia, only 12% answered yes.

In this study sample, the prevalence of obesity is 42%, while over weight is 26.9%. On the other hand, the prevalence of people with normal BMI is 27.5% and underweight is 3.4% (Table 3). Among the 493 adults who answered the Beck Scale Questionnaire, 81 (16%) only scored more than 16 which is the cutoff point for clinical depression. beck scale mean was 8.6 (Figure 1).

On assessing the relationship between depression and demographic characteristics, we found that married people and those who have a job are less likely to have depression which was significant statistically, whereas all other parameters have not. (p-value.0.009, 0.003 respectively) (Table 4).

Likewise, among clinical and behavioral characteristics, only family history of depression (p-value.0.043) and history of psychiatric illness (p-value.0.000) were strongly associated with depression (Table 5).

The prevalence of depression among underweight, normal weight, overweight and obese adults are almost the same (around 16%) with a p-value of 0.95. although the percentage of depressed people are little higher in obese compared to normal adults (17.4% to 16.5%) this difference is not statistically significant (Table 6).

Crude and adjusted odd ratio were calculated for the association between depression and other factors. We found that marital status and positive history of psychiatric illness had a statistically significant association with depression both in univariate and multivariate analysis, while positive history of chronic disease is significant if the odd ratio is adjusted only. Moreover, the adjusted odd ratio for BMI is 0.86 CI (0.43-1.76) that confirms no significant association between obesity and depression (Table 7).

In summary, using both Chi Square test and regression analysis test, no significant association between obesity and depression was documented.

* P value of Chi-Square test

P value of chi-square test.

DISCUSSION

This study is the first study in the Gulf region to assess the association between two common conditions in primary care, obesity and depression.

The study results show that more than two-third of adults are either obese or overweight. The exact prevalence of obesity is 42.2%, overweight 26.9%, normal BMI 27.5% and underweight is 3.4%. The prevalence of depression is 16%. The prevalence of depression among underweight, normal weight, overweight and obese adults are almost the same around 16% (p-value.0.95).

The study results indicated that obesity is not related to depression. This is similar to a survey conducted by Askari et al. in adults attending health centers in Iran, in which depression rate among obese and normal weight individuals showed no significant differences.¹² It might be due to the similarity of the population characteristics between the two populations.

Our results differ from others which suggest a significant relationship between obesity and depression. This difference is mainly due to the complexity of cofactors affecting both depression and obesity as well as the cultural, social and genetic variability in different population. Most of these surveys confirm the relationship among certain group characteristics. In instance, many of studies suggest an association between obesity and depression among women rather than men.^18-20

One descriptive analytical study in Ahvaz city confirms the relationship among female adolescents.²¹ Therefore, including the age group of less than 18 years in our study may change our findings. Furthermore, an association was identified in women with class 3 obesity and large waist circumference.¹⁹ That’s why we think that if assessing abdominal obesity was used in our study by measuring waist circumference and/or waist hip ratio, an association might be documented. We found studies that suggest a strong association between obesity and depression only among those with higher socioeconomic status.^20,22

In this study, an association was significant between depression and marital status, unemployment, presence of other psychiatric illness and family history of depression. The same result was found in a study in United State in 2004 in which greater odds of depression were found in unmarried and those with positive family history of depression.²³ However, in a study conducted in Kazakhstan, they found a relationship between depressive symptoms and history of chronic diseases but not with marital status or employment.²⁴ A health survey in Canada reveled that lower education and lower income were significantly related to increase risk of depression which was not positive in our study.²⁵

There are some limitations of the current study. First, the diagnosis of clinical depression is not objective, it relies on the patients themselves on determining the presence of depression through answering the Beck Scale personally. Second, categorizing depression into mild-moderate and sever was not done, this might have an association with degrees of obesity (class 1, class 2 and class 3) as seen in other studies.

Because the study is cross sectional, no causation can be tested. Hence, a longitudinal observational study might be needed to assess such relationship between obesity and depression. Putting in mind to assess obesity using scales other than BMI like waits circumference.

CONCLUSION

Awareness of the above results by all family physicians working at primary health care in Bahrain, leads to better screening for depression among all adults attending primary care clinics regardless of their weight (body mass index) in order not to miss depression among normal and underweight adults.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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