Relationship of body mass index,abdominal obesity,and metabolic parameters with depression among reproductive-age women

NilgunSeremet-Kurklu

1 Department of Nutrition and Dietetics,Faculty of Health Sciences,İzmir Katip Çelebi University,İzmir,Turkey

2 Department of Nutrition and Dietetics,Faculty of Health Sciences,Akdeniz University,Antalya,Turkey

3 Department of Nutrition and Dietetics,Gülhane Faculty of Health Sciences,University of Health Sciences Turkey,Ankara,Turkey

Abstract

Key words:abdominal obesity;blood lipids;body mass index;depression;insulin resistance;overweight;reproductive-age women

INTRODUCTION

Obesity which is the most serious health problem of 21stcentury is a disease causing hypertension,coronary heart disease and increased mortality (Dixon,2010).Obesity prevalence reached to 39.6% in the United States of America and its ratio changes between 10-30% in European Union countries (Hales et al.,2018).Needless to say,it shows a similar increase in Turkey.In 1974,obesity prevalence was 7.6% in men and 25.0% in women (Köksal,1977).However in 2010 it reached 20.5% in men and 41.0% in women according to the Turkey Nutrition and Health Survey 2010 (Pekcan et al.,2017).

Being the most common psychiatric disorder,depression is a cluster of symptoms which cause a distress or impairment in social,occupational or other important areas of functioning.The DSM-5 outlines the following criteria to make a diagnosis of major depressive disorder.The individual must be experiencing five (or more) of the following symptoms during the same 2-week period and at least one of the symptoms should be either (1) depressed mood or (2) loss of interest or pleasure.Significant weight loss or weight gain,reduction in physical movements and slowing down of thought,fatigue,feeling of worthlessness or guilt,difficulty to concentration and recurrent thoughts of death or recurrent suicidal ideation are the other symptoms of depression (American Psychiatric Association,2013).It is estimated that depression affects more than 300 million people worldwide and its prevalence was around 4.4% in the Turkish population (World Health Organization,2017).

Although obesity and depression seem like two different concepts in terms of their physical and emotional components,common pathways play a role in their pathogenesis,including the changes in neuropeptidergic and neurotransmitter systems,such as hypothalamic pituitary adrenal (HPA) axis dysregulation,changes in the plasma glucose level,insulin and leptin resistance,increase in proinflammatory cytokines and norepinephrine,neuropeptide Y,corticotropin-releasing hormone (Bornstein et al.,2006).Thus,studies show that depressive symptoms may increase parallel to body mass index (BMI) (Luppino et al.,2010;Bjørngaard et al.,2015;Opel et al.,2015).In recent years,studies suggest that body fat distribution may also play an important role in depression (Everson-Rose et al.,2009).However,the relationship between depression and abdominal obesity remains controversial (Ho et al.,2008;Vogelzangs et al.,2010;Kim et al.,2011;Xu et al.,2011;Wiltink et al.,2013).

It is stated that people with a depressive disorder have impaired glucose tolerance along with insulin resistance.They also have a higher risk of type 2 diabetes and cardiovascular diseases.Although exact mechanism behind this association is still unclear,it is thought that an increase in visceral adipose tissue plays a role in both depression and metabolic disorders.

The link between obesity and depression has been analyzed in a number of studies around the world.On the other hand,there are only a few studies on this subject in Turkey.No research particularly on abdominal obesity and its association with metabolic parameters was encountered.This research is carried out in order to analyze the relationship of depression with BMI,abdominal obesity and metabolic parameters in women of reproductive age.

SUBJECTS AND METHODS

The sample of this observational study included 271 women between the ages of 20-49 years who admitted to Endocrine and Diet Polyclinic of İzmir Bozyaka Training and Research Hospital,Turkey.Women with chronic diseases such as heart failure,rheumatoid arthritis,kidney,liver and thyroid diseases,severe psychiatric disorders and women who are pregnant,breastfeeding and taking medication were excluded from the study.

The individuals were weighed in light clothes with TANITA TBF 300 (Tanita Corp.,Tokyo,Japan) after 4-hour fasting.Body height was measured using an inflexible tape measure while patients standing without shoes,keeping their shoulders in a relaxed position,arms hanging freely and head in Frankfort horizontal plane.Weight was divided by the height square (kg/m2) to calculate BMI.Classification proposed by the World Health Organization was used to analyze the individuals’ BMI.According to their BMI values,participants were divided into two categories as normal weight (＜ 25.0 kg/m2) and overweight or obese (≥ 25.0 kg/m2) (World Health Organization,2000).

Waist circumference was measured by an inflexible measuring tape from the midpoint between the lowest rib and crista iliaca with researchers standing in front of the patients.Values exceeding 88 cm were evaluated as abdominal obesity (World Health Organization,2000;Zhang et al.,2008).

Blood samples were collected from the patients after 8-10 hours of fasting.They were analyzed in terms of fasting glucose,fasting insulin,triglyceride,low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol levels.All blood samples were analyzed in Izmir Bozyaka Training and Research Hospital Laboratory.Assessment of the biochemical parameters was based on the standards of this laboratory.

Homeostasis Model Assessment-Insulin Resistance (HOMA-IR) method [(fasting plasma glucose × fasting plasma insulin)/405] was used to evaluate insulin resistance.The cases with HOMA-IR values ≥ 2.7 were accepted as the existence of insulin resistance.

Beck Depression Inventory (BDI) was used to identify depressive symptoms of individuals (Beck et al.,1961).BDI was developed by Beck et al.in 1961 to detect depression in adolescents and adults.It has 21 questions,with 0-3 points for each of them,which leads up to a score changing between 0-63 points.The cutoff point In Hisli’s validity and reliability study was 17 (Hisli,1988).For this reason,this research classified the individuals according to their BDI scores as ＜ 17 and ≥ 17.The scores ≥ 17 were evaluated as the presence of depression.

For this research,permission from Chief Physician of Izmir Bozyaka Training and Research Hospital (No.4.35.94.02-003) and approval from Senate Ethics Committee of Hacettepe University Faculty of Medicine were obtained (Decision No.431-1305).All participants gave written informed consent to participate in the study.

Statistical analysis

Data were evaluated in Windows environment by using the SPSS 21.0 package program.Mean and standard deviation were used in the evaluation of the quantitative data.Categorical variables were presented as number and percentage.The Kolmogorov Smirnov test was used for the assessment of normality.Comparisons between groups were performed using Student’st-tests and the Mann-WhitneyUtest for continuous variables where appropriate.Chi-square test was used for categorical variables.In order to determine the risk of depressive symptoms with abdominal obesity,BMI and insulin resistance “odds ratio (OR)” was calculated.The results were evaluated at 95% confidence interval andP＜ 0.05 significance level.

RESULTS

A total of 271 women participated in the study.Their mean age was 32.1 ± 7.4 years.Mean weight,BMI,and waist circumference were 77.1 ± 15.6 kg,29.5 ± 6.1 kg/m2and 92.5 ± 11.9 cm,respectively.Mean BDI score was determined as 17.8 ± 11.8.The mean values of the biochemical parameters for fasting glucose,insulin,triglyceride,LDL-C and HDL-C were shown in Table1.

When the individuals were classified according to their BDI scores,it was clearly seen that those with 17 or more points had significantly higher values of weight,BMI and waist circumference (P＜ 0.05).It was also observed that fasting blood glucose,fasting insulin,HOMA-IR value,triglyceride and LDL cholesterol levels were higher in this group.However,only HOMA-IR value and triglyceride levels were found statistically significant (Table1).

Table2 shows the relationship of depressive symptoms with BMI,abdominal obesity and insulin.It was seen that women with high level of depressive symptoms accounted for 45.8% of all.Moreover,21.0% of the individuals with normal BMI and 56.3% of those who were overweight or obese were observed to have a high level of depressive symptoms.This study shows that being overweight or obese dramatically increases the possibility of having depressive symptoms (OR = 4.853,95% CI:2.646-8.903).

Individuals with abdominal obesity (50.3%) had a greater possibility of having high depressive symptoms than those without abdominal obesity (39.5%) (OR = 1.553,95% CI:0.953-2.532).However,the difference was not statistically significant (Table2).

Table1:Comparison of anthropometric and biochemical parameters of women according to BDI scores

Table2:Relationship of depressive symptoms with abdominal obesity,BMI,and insulin resistance

As demonstrated in Table2,individuals with high levels of depressive symptoms (46.2%) and those who are not (45.6%) have similar insulin resistance (HOMA-IR ≥ 2.7) (OR = 1.021,95% CI:0.584-1.787).

DISCUSSION

In this study,the analysis of the relationship of depressive symptoms with BMI,abdominal obesity and metabolic parameters in women of reproductive age confirmed that BMI values were related to high depressive symptoms.It was also observed that the possibility of having high depressive symptoms was 4.8 times more in overweight and obese women.These results are compatible with previous studies (Luppino et al.,2010;Ma and Xiao,2010;Gibson-Smith et al.,2016).Gibson-Smith et al.’s (2016) 6-year follow-up study shows that high BMI might increase the risk of depression.In a community-based study conducted on women in the USA showed that BMI scores was related to major and moderate/severe depression (Ma and Xiao,2010).In a meta-analysis of Luppino et al.(2010),it was concluded that obesity increases the risk of depression by 55.0%.Contrary to this,Askari et al.(2013) stated that obesity did not trigger a significant increase in depression rate.Noteworthy,the majority of the studies pointed out the fact that the relationship between BMI and depression was only observed in women or it was stronger in women than in men (Herva et al.,2006;de Wit et al.,2010;Laborde and Sáez-Santiago,2013;Karagöl et al.,2014).Therefore,it is important to evaluate the obesity and depression relationship sex-specifically.In our research,the strong relationship detected between BMI and depressive symptoms may spring from the fact that it was only conducted with women.

The results of the studies which analyze the relationship between depression and abdominal obesity are inconsistent (Ho et al.,2008;Vogelzangs et al.,2010;Kim et al.,2011;Xu et al.,2011;Wiltink et al.,2013).Zhao et al.(2011) found that waist circumference was related to major and moderate/severe depression and stated that individuals with abdominal obesity had a greater possibility of developing depression.Xu et al.(2011) reached a similar conclusion in a meta-analysis.In Wiltink et al.’s (2013) study,it was put forward that many antropometric measurements such as BMI,weight-height ratio,waist-hip ratio and waist circumference were linked to somatic symptoms of depression.A 5-year follow-up study conducted on the elderly shows that abdominal obesity was related to the risk of depressive symptoms only in men (Vogelzangs et al.,2010).On the other hand,there were also some studies which demonstrate no relationship between abdominal obesity and depression (Ho et al.,2008;Kim et al.,2011).These different results might result from the variety of tests used to detect depression,using difference methods for the evaluation of abdominal obesity (waist circumference,waist-height ratio,waist/hip ratio,computerized tomography) and various features and sizes of the samples (sex,age,and sociocultural status).This study observed that individuals with high level of depressive symptoms had higher waist circumference values than those with lower levels of such symptoms.Although participants with abdominal obesity had a greater possibility of having high level of depressive symptoms,the difference was not statistically significant.This might be associated with the sample size and including only female participants in the framework of the study.

A number of hypotheses about the relationship between depression and obesity/abdominal obesity have been put forward.One of them is that obese individuals have poorer body perception and lower self-respect,which can lead to depression.Moreover,their lifestyle and unhealthy eating habits can trigger depression.Another pathophysiological mechanism suggests that in both abdominal obesity and depression,an increase is observed in inflammatory cytokines.It is also thought that HPA axis dysregulation and an increase in steroid hormones constitute a common mechanism that plays a role in both cases (Bornstein et al.,2006).

High levels of depressive symptoms might be related to the changes in metabolic profile (Pearson et al.,2010;Baghai et al.,2011;Qiuhua et al.,2011).Baghai et al.’s (2011) study shows that individuals with depressive disorders had higher cardiovascular risk factors such as high triglyceride and high fasting blood glucose levels.Similarly,Pearson et al.(2010) detected that those individuals had stronger insulin resistance and pointed out that abdominal obesity might have a crucial role in this relationship.Qiuhua et al.(2011) reported that the relationship between depression and insulin resistance was encountered only in males and not in females.There were also some studies reporting that major depressive disorders were not linked to metabolic syndrome (Foley et al.,2010;Gelaye et al.,2015).In this study,it was detected that individuals with high levels of depressive symptoms had high mean values of triglyceride and HOMA-IR.When the participants were classified according to their HOMA-IR values and evaluated in terms of insulin resistance,no significant difference was observed.Depression period,severity,recurrence frequency and medication used for depression treatment might play an important role in the effect of depression on metabolic profile.Ljubicic et al.(2013) showed that metabolic syndrome was more prevalent in patients with recurring major depression compared to patients who were diagnosed for the first time.Another study pointed out that metabolic syndrome risk was higher in patients with major depressive disorder,especially in those using prescribed antipsychotic (Vancampfort et al.,2014).In this study,the lack of a relationship between metabolic parameters and depressive symptoms might be associated with the lack of participants having a severe psychiatric disorder or using medication for such disorders.

One of the limitations of this study is the unidirectional analysis of the relationship between depression and obesity.In a follow-up study,Luppino et al.(2010) demonstrated that the relationship between obesity and depression was bidirectional and depression could increase the risk of obesity.Similarly,it was thought that depression might cause visceral adiposity.However,it was impossible to analyze this relationship with this study because the study was planned and conducted as cross-sectional.On the other hand,including women only aged 20-49 years and therefore creating a homogenous group in terms of age and sex were the strengths of our research.

In conclusion,this study demonstrated a clinically significant relationship between high depressive symptoms and overweight/obesity.Therefore,it may be a good strategy to follow women’s risk of depression when they apply clinics for weight control.In order to have a better understanding of the relationship of depression with BMI,abdominal obesity and metabolic parameters,follow-up studies are needed in which causality can be analyzed bi-directionally.

众多研究人员针对溢流阀的性能、突变负载对直动式溢流阀的影响以及脉动流量对溢流阀的影响都已进行了深入研究，然而针对交变压力对先导式溢流阀的性能影响的文献却非常少见。为此本文针对高频交变压力工况，对先导式溢流阀数学模型进行理论分析，并对高频交变压力下先导式溢流阀的响应特性进行仿真和试验对比研究。

Author contributions

Study concept and design,manuscript drafting:GK,EBK,NSK,KTA.The authors gave final approval for publication.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Financial support

None.

Institutional review board statement

This study was performed with the permission from Chief Physician of Izmir Bozyaka Training and Research Hospital (No.4.35.94.02-003) and approval from Senate Ethics Committee of Hacettepe University Faculty of Medicine (Decision No.431-1305).

The authors certify that they have obtained all appropriate participant consent forms.In the forms the participants have given their consent for their images and other clinical information to be reported in the journal.The participants understand that their names and initials will not be published and due efforts will be made to conceal their identity.

Reporting statement

This study followed the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement.

Biostatistics statement

The statistical methods of this study were reviewed by the biostatistician of İzmir Katip Çelebi University,Turkey.

Copyright license agreement

The Copyright License Agreement has been signed by all authors before publication.

Data sharing statement

Datasets analyzed during the current study are available from the corresponding author on reasonable request.

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Peer review

Externally peer reviewed.

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