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Prevalence of anxiety and depression in patients with overweight and obesity

Sayedeh Elham Sharafi, Gholamreza Garmaroudi, Mohammad Ghafouri, Shabnam

Akhoundzadeh Bafghi, Mojtaba Ghafouri, Mastaneh Rajabian Tabesh, Zahra
Alizadeh

PII: S2451-8476(19)30089-2
DOI: https://doi.org/10.1016/j.obmed.2019.100169
Reference: OBMED 100169

To appear in: Obesity Medicine

Received Date: 13 October 2019

Revised Date: 17 December 2019
Accepted Date: 17 December 2019

Please cite this article as: Sharafi, S.E., Garmaroudi, G., Ghafouri, M., Bafghi, S.A., Ghafouri, M.,
Tabesh, M.R., Alizadeh, Z., Prevalence of anxiety and depression in patients with overweight and
obesity, Obesity Medicine, https://doi.org/10.1016/j.obmed.2019.100169.

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Credit author statement:

Zahra Alizadeh: Conceptualization, Methodology, Software Mohammad ghafouri: Data curation,

Writing- Original draft preparation. Mastaneh Rajabian Tabesh: Visualization, Investigation.
Gholamreza Garmaroudi and Sayedeh Elham Sharafi: Supervision. Shabnam akhoundzadeh bafghi:
Software, Validation. Zahra Alizadeh and Mojtaba ghafouri: Writing- Reviewing and Editing.
 1

Prevalence of anxiety and depression in patients with overweight and obesity

Sayedeh Elham Sharafi, Psychosomatic research center, Imam Khomeini Hospital, Tehran University of
Medical Science, Tehran, Iran
esharafi@yahoo.com, Tell: +98(21)88630227-8, Fax: +98(21)88003539

Gholamreza Garmaroudi, School of Public Health, Tehran University of Medical Sciences, Tehran,
Iran.
garmaroudi@tums.ac.ir, Tell: +98(21)88630227-8, Fax: +98(21)88003539

Mohammad ghafouri, School of medicine, Tehran University of Medical Sciences, Tehran, Iran
Mohammadghafouri1372@gmail.com, Tell: +98(21)88630227-8, Fax: +98(21)88003539

Shabnam akhoundzadeh bafghi, School of Medicine, Shahid Sadoughi university of Medical Sciences,
Yazd, Iran.
Shabnam21219@yahoo.com, Tell: +98(21)88630227-8, Fax: +98(21)88003539

Mojtaba ghafouri, School of Medicine and Public Health, Tehran University of Medical Sciences,
Tehran, Iran
Ghafouri_mojtaba@yahoo.com, Tell: +98(21)88630227-8, Fax: +98(21)88003539

Mastaneh Rajabian Tabesh, Sports Medicine Research Center, Tehran university of Medical Sciences,
Tehran, Iran.
mastaneh.tabesh@ut.ac.ir, Tell: +98(21)88630227-8, Fax: +98(21)88003539

Zahra Alizadeh (Corresponding Author),

1. Sports Medicine Research Center, Tehran university of Medical Sciences, Tehran, Iran.

2. Department of Sports and Exercise Medicine, Tehran University of Medical Sciences, Tehran,
Iran.

Address: No7, Ale-ahmad Highway, Opposite of the Shariati Hospital, 14395-578, Tehran, Iran

E-mail: z_alizadeh@tums.ac.ir, Tell: +98(21)88630227-8, Fax: +98(21)88003539

 2

Abstract:

Aim: Depression and anxiety are the most common psychological disorders among obese

patients. Therefore, understanding the risk factors for this relationship is essential. This study

was carried out aiming to assess the association of anxiety and depression with BMI and to

evaluate the related risk factors.

Methods: This cross-sectional study was conducted on a large sample of 732 overweight and

obese patients. Hospital Anxiety and Depression Scale (HADS) questionnaire was used for

measuring depression and anxiety. Additionally, for all subjects, body mass index (BMI),

percentage of body fat (PBF) and total soft lean mass (SLM) were measured using AVIS 33

body composition analyzer.

Results: We found that BMI and PBF were significantly higher among overweight/obese

patients who had anxiety or depression. Depression and anxiety were more frequent among

housekeepers. Anxiety (p<0.001) and depression (P<0.001) scores were also positively

correlated with BMI but not with PBF and SLM in different groups of BMI. Female subjects had

a higher prevalence of anxiety (p=0.010). In addition, sleep hours did not have correlated with

weight status or development of anxiety or depression.

Conclusions: Obesity/overweight associated with the development of anxiety and depressive

symptoms irrespective of sleep behavior. On the other hand, depression and anxiety were found

to be the potential risk factors for developing obesity. These results indicate a direct association

between psychosocial state and obesity.

Key words: Anxiety, Depression, Overweight, Obesity

 3

Introduction

The prevalence of obesity and overweight is increasing rapidly and reaching an alarming rate

worldwide (Sturm 2007). In Iran, 61.6% of the adult population were overweight and 25.8%

were obese in 2016 (World Health Organisation 2019). It is evident that overweight and obesity

are associated with several comorbidities including diabetes, cardiovascular disease, some type

of cancer, and psychiatric disorders which negatively influence the quality of life (Onyike et al.

2003; Flegal et al. 2005). Depression and anxiety are two of the most common psychiatric

disorders, highly associated with obesity. (Preiss et al. 2013).

There are numerous data that link obesity to depressive and anxiety symptoms (Preiss et al.

2013; Luppino et al. 2010; Kalarchian and Marcus 2012; Pan et al. 2012); however, there are

some controversies surrounding this association. Some previous studies suggest that body fat

distribution and sleep behavior were a stronger risk factors for this correlation (Moreira et al.

2007; Labad et al. 2010; Whitaker et al. 2018). Additionally, it has been shown that total lean

mass was strongly associated with fewer anxiety/depressive symptoms. Thus, body composition

comprising fat and lean tissue might be related to psychiatric comorbidity in overweight

individuals (Guedes et al. 2013). There were also recognized racial-ethnic differences in body

composition (Sun et al. 2003) which could influence the mentioned association. While to our

knowledge, there has not been a study investigating the association of body composition with the

psychologic burden of obesity among Iranians. Moreover, Obesity is usually accompanied by

several physical illnesses which may influence measuring depression and anxiety. Hence, using

suitable evaluation method such as HADS1 questionnaire with the emphasis on reducing the

impact of physical illness on the total score is more competent (Edelstein et al. 2010). Therefore,

1
Hospital Anxiety and Depression Scale
 4

the aim of this study was to evaluate the prevalence of anxiety and depression using HADS in

overweight/obese Iranians and evaluating the related factors.

Methods and Materials

Study design and target group

This cross-sectional study was conducted on patients with overweight and obesity BMI 2≥ 25,

who referred to the Obesity Clinic in Imam Khomeini Hospital, Tehran, Iran; from April 2016 to

January 2016. Inclusion criteria consisted of all age groups of patients with overweight and

obesity, who referred to the clinic, signed a consent form to participate in the study, and had the

ability of reading and writing. Exclusion criteria consisted of young children and the elderly who

have difficulty understanding the questionnaire, people who did not have the ability to read and

write (according to the self-report questionnaire), and patient's dissatisfaction to enter the study.

We also excluded individuals with incomplete data.

Participants

Seven hundred fifty patients with BMI≥25, based on inclusion criteria were included. Eighteen

patients excluded due to incomplete data (ten patients), disability to read and write (six patients),

and have difficulty to understand the questionnaire (two patients). Finally, 732 patients

completed the study. The study received ethics approval from the Ethics Committee of Tehran

University of Medical Sciences (IR.TUMS.IKHC.REC.1396.4740), and all participants

completed informed consent. A demographic questionnaire including age, sex, occupation, sleep

hours and HADS questionnaire for depression and anxiety were completed. For all subjects,

2
Body mass index
 5

BMI, PBF3 and total SLM4 were measured using AVIS 33 body composition analyzer and all of

these information were attached to the patient records.

Instrument

AVIS 33 body composition analyzer: The AVIS 33 body composition analyzer was used to

measure body composition. Using this device through the BIA5 method, all body composition

were measured including BMI, PBF, and SLM. The accuracy of the BIA method for measuring

body composition has been confirmed in various studies (Beshyah et al. 1995; Earthman et al.

2000; Ul-Haq et al. 2014).

Hospital Anxiety Depression Scale (HADS): This 14 items questionnaire is a short form

questionnaire which evaluates the anxiety and depression by removing the physical symptoms

and focusing on psychological signs and symptoms. This questionnaire evaluates two subscales

including anxiety and depression. Scores for each subscale (anxiety and depression) range from 0

to 21 with scores categorized as follows: normal 0-7, suspicious 8-10, and the presence of a

depressive or anxiety disorder 11-21. The HADS has been found to be a reliable questionnaire in

psychiatric, non-psychiatric and well populations (Bjelland et al. 2002). The psychometric

properties of the Persian version of the scale was examined. In a study of Iranian patients,

Cronbach's alpha coefficient for depression and anxiety subscales were 0.78 and 0.86,

respectively (Nejat et al. 2006). Obesity is usually accompanied by several physical illnesses

which may influence measuring depression and anxiety. While using the HADS which emphasis

3
percentage body fat
4
soft lean mass
5
bioelectrical impedance analysis
 6

on reducing the impact of physical illness on the total score, rises the validity of the current study

(Edelstein et al. 2010).

Data analysis

Data were analyzed and reported only for patients with completed information. Statistical

analysis of data was performed using SPSS version 18 software. Chi-square test was used to

compare qualitative variables between groups. Kolmogorov-Smirnov test was used in order to

evaluate the normal distribution of all quantitative studied parameters. Student t-test was used for

variables with normal distribution, on the other hand, Mann-Whitney and Wilcoxon tests were

used for variables without normal distribution. The two-tailed p-value less than 0.05 was

considered significant.

Results

The mean depression score in the studied population was 6.78 ±3.9 (0-21) and the anxiety score

was 7.79 ±4.9 (0-21). The prevalence of depression among all the study population was 17.5 %

(n= 128; 3% in overweight and 14.3% in obese patients) and 23.8% (n=178; 5.9% in overweight

and 17.9% in obese patients) were suspicious to have depression. Moreover, the prevalence of

anxiety was 26.5 % (n= 194; 7.4% in overweight and 19.1% in obese patients) while 22%

(n=161; 5.9% in overweight and 16.1% in obese patients) were suspected to have anxiety.

As obtained, age in obese patients with anxiety was significantly higher than other patients

(P=0.045). Interestingly, the anxiety score was significantly higher in women compared to men

(28.4 % vs 17.5%; P=0.04) (Table 1). While there was no significant difference in depression

score between two sex (P>0.05) (Table 2). Moreover, we found that BMI and PBF were

significantly higher in patients with anxiety and depression as compared to normal and
 7

suspicious patients and the SLM was higher among depressed cases as well as suspicious to

anxiety (P<0.05). Furthermore, we found that anxiety was significantly higher in housekeeper

patients (P=0.002). This difference was obtained in patients with depression that depression was

significantly higher in housekeeper patients (P<0.001) (Table 1 and 2).

As shown in table 3 neither anxiety nor depression have any significant correlation with sleep

hours (P= 0.37 and 0.49, respectively). Logistic regression analyses were used for comparative

and moderator analyses of age, BMI, PBF, and SLM on HADS scores. We found that only BMI

was positively correlated with depression (P<0.001, Exp (B) = 0.169) and anxiety (P=0.001, Exp

(B) = 0.126) development among the study groups. Thus, the positive correlation of PBF (r=

0.194, P<0.001) and SLM (r=0.096, P=0.01) with depression score and PBF (r= 0.175, P<0.001)

with anxiety shown in table 3 is due to their relationship with BMI.

Regarding the non-normality of the data distribution, the Mann-Whitney U test was used to

compare males and females. In this regard, the result shows that there was a significant

difference in the anxiety scores (Z= -2.565, p=0.001) between males and females, but this

difference was not significant in depression scores (Z= -0.538, p=0.590). The Kruskal Wallis

test was used to compare the anxiety and depression scores for occupation and BMI and Tables 5

and 6 show these results.

In table 5, The finding indicates that there was a significant difference in the anxiety (χ²= 16.564,

df=3, p=0.001) and depression (χ²=35.574, df=3, 0.001) scores between occupations. Mean and

mean rank showed that housekeepers had a higher rate of anxiety and depression.
 8

Our result in BMI (table 6) showed that there was a significant difference in the anxiety (χ²=

16.904, df=3, p=0.001) and depression (χ²=45.447, df=3, 0.001) scores between BMI categories.

Mean and mean rank showed that 40 ≤ categories had a higher rate of anxiety and depression.

Discussion

Association between Overweight/ obesity and anxiety/ depression: Our results showed that

the average BMI and PBF were significantly higher in patients suffering from anxiety or

depression. On the other hand, the results from logistic regression analysis demonstrated that

BMI was positively correlated with anxiety and depression, as the BMI rises the HADS score

increases. It has been estimated that in Iran, about 61.6% of the adult population suffers from

overweight/obesity thus a significant number of people could be affected in regard to our

findings (Emamian et al. 2017; World Health Organisation 2019). Mental and behavioral

disorders affecting more than 25% of all people during their life (Organization 2001). The last

mental health survey of the Iranian adult population by AA Noorbala et al. revealed that 10.39%

of cases were suspected of severe depression (Noorbala et al. 2017). In the present survey, the

prevalence of definite and suspected depression was 17.5% (3% in overweight and 14.3% in

obese patients) and 18.6% (5.9% in overweight and 17.9% in obese patients), respectively, which

is more than that of reported by AA Noorbala (Noorbala et al. 2017). Furthermore, they

demonstrated that about 29.5% of the Iranian population are suspected of anxiety (Noorbala et al.

2017). Based on our results, the prevalence of definite and suspected anxiety was 26.5% (7.4%

in overweight and 19.1% in obese patients) and 22% (5.9% in overweight and 16.1% in obese

patients), respectively. Overall, about 48.5% of the overweight/obese population suffered from

varying degrees of anxiety which is approximately 1.6 times greater than Noorbala et al.’s

estimation (Noorbala et al. 2017). In addition, our data revealed that overweight/obese patients
 9

are at greater risk of having a clinical diagnosis of anxiety (r= 0.16, P<0.001) and depressive (r=

0.25, P<0.001).

On the other hand, there is a significant difference in the prevalence of depression between

overweight and obese patients which highlights the tight association of weight status with

depression. While there was not enough evidence to suggest that the prevalence of anxiety

increases in obese patients compared to those who are overweight. It is evident that adults with

current depression or a lifetime diagnosis of depression or anxiety are more likely to be obese

(Strine et al. 2008). Consistently, current data show that the average BMI and PBF were

significantly higher in patients with anxiety and depression. It has been revealed that depression

and anxiety cause obesity as a side-effect of the drugs used to treat them. Additionally, unhealthy

lifestyle, such as insufficient physical exercise and unhealthy diet or increased carbohydrate- and

fat-rich food known as “carbohydrate craving” as a response to enhance brain serotonin synthesis

and alleviating dysphoria possibly leading to obesity (Wurtman and Wurtman 2018).

Neuroendocrine and cortisol disturbances in depressed and anxious patients may be also

involved in weight gain. (Björntorp 1996).

Sex differences: In the present study, anxiety but not depression was associated with the female

gender specially housekeepers. It may be caused by more social pressures for being thin on

women rather than men in Iranian people. Some studies have also shown inconsistency regarding

the association between symptoms of anxiety and depression and sex in obese patients (Roberts

and Steele 2010). A community survey in 2003 also indicated that obese women were suffered

more from anxiety than obese men, as well as depressive symptoms which were aligned with

Carpenter et al, and. Palinkas et al, experiences (Jorm et al. 2003; Carpenter et al. 2000). Such

differences could be explainable by less willingness of women for participating in vigorous

 10

exercise and low familial and social support. However, there were some investigations that have

been also shown no sex differences in obese patients who develop depressive symptoms [20].

Sleep hours: In the present study, sleep hours did not have any significant association with

weight status or HADS scores. Some investigations claimed that sleep disturbances due to

obesity play an important role in psychological function (Whitaker et al. 2018; Koinis-Mitchell

et al. 2017). Current study results were consistent with the existing literature indicating that

obesity; irrespective of changing in sleep hours and gender, positively correlated to anxiety and

depression.

Limitations

The various confounding factors have not been adjusted in this study. Based on a cross-sectional

type of our study, we could not find a transposition correlation between the effects of anxiety and

depression on obesity or obesity on anxiety and depression.

The existing evidence supported the results are insufficient. Therefore, a longitudinal study with

higher sample size is needed in order to find possible correlation.

Conclusions

Findings support the hypothesis that the overweight/obese population are more suspected of

depression and anxiety disorders regardless of sleep status. These findings highlight the

importance of treatment, although further research is needed to elucidate the possible

mechanisms involved in this association. Acknowledgment

This study was supported by the Trauma Research Center, Tehran Medical Sciences University,

Tehran, Iran. We gratefully acknowledge the dedicated efforts of the investigators, the
 11

coordinators, the volunteer patients who participated in this study, and the Clinical Research

Development Units (CRDU) of Tehran Imam Khomeini.

Funding

This research received no specific grant from any funding agency in the public, commercial, or
not-for-profit sectors.

Declarations of interest: non

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 13

Table 1. Studied variables in patients based on anxiety level

Anxiety Anxious Suspicious Normal (n=377) P-value

(n=194) (n=161)
Variables

Age (year) 40.03 ±13.12 36.73 ±13.24 39.43 ±13.38 0.045

Sex Male 22 (17.5%) 32 (25.4%) 72 (57.1%) 0.04

Female 172 (28.4%) 129 (21.3%) 305 (50.3%)

Job Student 24 (23.8%) 33 (32.7%) 44 (43.6%) 0.002

Employed 71 (22.8%) 61 (19.6%) 179 (57.6%)

Housekeeper 89 (32%) 62 (22.3%) 127 (45.7%)

Retired 10 (25%) 4 (10%) 26 (65%)

Sleep (hour) 7.67 ±1.89 7.69 ±1.53 7.5 ±1.53 0.374

BMI (kg/m2) 34.92 ±6.59 34.69 ±6.59 32.74 ±5.94 <0.001

PBF (%) 39.68 ±4.95 38.78 ±4.89 37.74 ±5.14 <0.001

SLM (kg) 49.48 ±9.94 50.98 ±10.62 48.51 ±10.67 0.045

 14

* BMI: Body Mass Index, PBF: Percentage body fat, SLM: Soft lean mass

Table 2. Studied variables in patients based on depression level

Depression Depress (n=128) Suspicious Normal (n=430) P-value

(n=174)
Variables

Age (year) 40.67 ±12.87 39.77 ±13.25 38.18 ±13.44 0.123

Sex Male 23 (18.3%) 29 (23.0%) 74 (58.7%) 0.957

Female 105 (17.3%) 145 (23.9%) 356 (58.7%)

Job Student 12 (11.9%) 15 (14.9%) 74 (73.3%) <0.001

Employed 41 (13.2%) 78 (25.1%) 192 (61.7%)

Housekeeper 73 (26.3%) 73 (26.3%) 132 (47.5%)

Retired 2 (5.0%) 8 (20.0%) 30 (75.0%)

Sleep (hour) 7.73 ±2 7.62 ±1.62 7.53 ±1.51 0.495

BMI (kg/m2) 36.14 ±6.48 35.01 ±7 32.52 ±5.7 <0.001

PBF (%) 39.98 ±5.23 39.28 ±4.82 37.74 ±5.03 <0.001

 15

SLM (kg) 51.26 ±10.91 50.17 ±10.89 48.4 ±10.14 0.013

* BMI: Body Mass Index, PBF: Percentage body fat, SLM: Soft lean mass

Table 3. Pearson correlation between studied variables

Age BMI PBF SLM Sleep Anxiet Depressio

y n

Age Coefficient 1

Sig.

BMI Coefficient .018 1

Sig. .619

PBF Coefficient .242** .612** 1

Sig. .000 .000

SLM Coefficient - .542** - 1

.260** .203**

Sig. .000 .000 .000

Sleep Coefficient - .010 -.003 -.005 1

.116**

Sig. .003 .793 .938 .892

Anxiety Coefficient .020 .166** .175** .041 .015 1

Sig. .598 .000 .000 .275 .705

 16

Depression Coefficient .071 .251** .194** .096** .061 .612** 1

Sig. .055 .000 .000 .010 .117 .000

**. P< 0.01 level

Table 4. Mann-Whitney U test for the sex difference in anxiety and depression

variable sex Mean SD Mean Rank Mann-Whitney U Z sig

Anxiety female 6.9127 4.38547 322.64 32651.500 -2.565 0.010

male 6.6508 4.12663 375.62

Depression female 7.9802 4.38626 357.30 37018.500 -0.538 0.590

male 6.8119 3.86605 368.41

 17

Table 5. Kruskal Wallis Test for occupation difference in anxiety and depression

Variable Job Mean SD Mean Rank χ² df sig

Anxiety Student (n=102) 7.7941 3.87768 377.43 16.564 3 0.001

Employed (n=311) 7.3215 4.14178 342.61

Housekeeper (n=278) 8.5791 4.78557 400.27

Retired (n=41) 6.0976 3.94845 291.55

Depression Student (n=102) 5.9216 3.49451 319.03 35.574 3 0.001

Employed (n=311) 6.3441 3.74949 343.96

Housekeeper (n=278) 7.8417 4.07291 422.31

Retired (n=41) 5.0976 3.25427 277.13

 18

Table 6. Kruskal Wallis Test for BMI categories difference in anxiety and depression

Variable BMI Mean SD Mean Rank χ² df sig

Anxiety 25-29.9 (n=231) 7.2294 4.03509 340.39 16.904 3 0.001

30-34.5 (n=233) 7.4635 4.49518 349.79

35-39.9 (n=157) 8.0892 4.37999 382.88

40 ≤ (n=111) 9.2613 4.65679 432.77

Depression 25-29.9 (n=231) 5.7316 3.70274 306.77 45.447 3 0.001

30-34.5 (n=233) 6.6052 3.92476 355.96

35-39.9 (n=157) 7.3758 3.58310 405.06

40 ≤ (n=111) 8.5135 4.03815 458.37

Highlights

• Body mass index and Percentage body fat were significantly higher among
overweight/obese patients who had anxiety or depression.

• Depression and anxiety were more frequent among overweight/obese housekeepers

and anxiety was more frequent among overweight/obese women
 Prevalence of anxiety and depression in patients with overweight and obesity

Disclosures:

The manuscript has not been and will not be published or submitted elsewhere. The manuscript

has not been published previously (partly or in full), unless the new work concerns an expansion

of previous work. A single study is not split up into several parts to increase the number of

submissions and submitted to various journals or to one journal over time. No data have been

fabricated or manipulated (including images) to support our conclusions.

No conflicts of interest have been reported by the authors. Authors whose names appear on the

submission have contributed sufficiently to the scientific work and therefore share collective

responsibility and accountability for the results. All authors have approved the final article

Authorship.

Zahra Alizadeh*

Sports Medicine Research Center, Department of Sports and Exercise Medicine, Tehran

university of Medical Sciences, Tehran, Iran

Address: No7, Ale-Ahmad Highway, Opposite of the Shariati Hospital,14395-578, Tehran, Iran

E-mail: z_alizadeh@tums.ac.ir, Tell: 00982188630227-8, Fax: 00982188003539