Depression , Anxiety and Stress among Obese Patients with Chronic Illnesses : Prevalence and Associated Factors in North East Malaysia

Introduction: Concomitant obesity and chronic medical illness is a significant health problem in Malaysia and worldwide. The comorbid psychological impact in obese patients is associated with a social stigma and low self-esteem. The aim of this study was to determine the prevalence and the factors associated with depression, anxiety and stress in obese patients with chronic medical illnesses attending an outpatient clinic. Methods: This was a cross-sectional study among obese patients with chronic medical illnesses presenting at the Universiti Sains Malaysia Hospital outpatient clinic. A total of 274 patients were involved. The 21-item Depression, Anxiety and Stress Scale questionnaire was used, and the results were evaluated using single and multiple logistic regression analyses. Results: The prevalences of depression, anxiety and stress among the obese patients with chronic medical illnesses were 13.9%, 23.4% and 10.9%, respectively. Younger age [p=0.003, adjusted odds ratio (AOR),1.0; 95%confidence interval (CI),0.91–0.98], unemployed employment(p=0.013, AOR,3.7;95% CI,1.32–10.09) and smoking (p=0.022, AOR,3.2; 95% CI,1.18–8.55) were associated with depression. No formal education (p=0.011, AOR,5.7; 95%CI,1.49–21.89), high body mass index (p=0.029, AOR,1.1;95% CI,1.01–1.13) and family history of psychiatric illness (p=0.018, AOR,5.1; 95% CI,1.33–19.56) were associated with anxiety. Stress was strongly associated with females (p=0.004, AOR,5.0; 95% CI,1.70–15.13) and smoking(p=0.002, AOR,6.5; 95% CI,2.03–20.7). Conclusion: Interestingly, younger age group was associated with depression. Current smokers, no education, family history of psychiatric illness and female sex were significantly associated with anxiety and stress. This notifies new emerging knowledge on factors associated with obese patients that would empower the development of effective preventive strategies for it.


Introduction
Obesity increases the risks of cardiovascular disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of preventable death 1 .More than one-third of US adults are obese, with a prevalence of 36.5% (crude estimate) from 2011-2014 1 .Overall, the prevalence of obesity among middle-aged adults (40-59 years old, 40.2%) and older adults (60 years and older, 37.0%) was higher than among younger adults (20-39 years old, 32.3%) 1 .According to the Malaysian National Health and Morbidity Survey in 2015, the prevalence of obese adults greater than 18 years of age had increased to 30.6% when compared to the data from 2011(27.4%) 2 .Depression is a major contributor to the overall global burden of disease, and it has been estimated that about 300 million people are affected by depression 3 .In Malaysia, the overall prevalence of depression among patients in primary care centres, clinical settings, and the general community ranged from 6.7% to 14.4% 4 .Previous articles have linked depression, anxiety and stress in the obese population; for example, a study from New Zealand found that obesity was significantly associated with major depressive disorders(OR=1.27),anxiety disorders (OR=1.46)and post-traumatic stress disorders(OR=2.64) 5.There were a lack of studies assessing the prevalence of depression, anxiety and stress among obese patients with chronic illnesses worldwide.The objective of this study was to determine the prevalence and associated factors for depression, anxiety and stress among obese patients with chronic medical illnesses presenting at the Universiti Sains Malaysia (USM) Hospital outpatient clinic.

Methods
This was a cross-sectional study conducted from February 2015 to December 2015 at the USM Hospital outpatient clinic.The inclusion criteria were patients with body mass indexes (BMIs) ≥ 27.5kg/m 2 and chronic medical illnesses, such as hypertension, diabetes mellitus, stroke, ischemic heart disease or hyperlipidaemia, aged 18 years old or older and who were able to read as well as understand Malay.We excluded pregnancy, less than 6 weeks postpartum, illiteracy and a known history of psychiatric illness.All the eligible participants were identified and selected using systematic random sampling with a ratio of 1:2.Informed consent was taken and selfadministered the 21-item Depression, Anxiety and Stress Scale (DASS-21) questionnaire was given.The DASS-21 is designed to measure depression, anxiety and stress, and it uses a three-scale rating system to measure the severity of a range of related symptoms.The DASS-21 has been translated to many languages, including a Malay version presented by Ramli et al. in 2007 6 .The internal consistency reliability coefficients for the DASS-21 subscales were found to be high, with Cronbach's alphas of 0.88 for depression, 0.82 for anxiety, 0.90 for stress and 0.93 for the total score 7 .For the validated Malay version, the Cronbach's alphas were 0.84, 0.74 and 0.79 for depression, anxiety and stress, respectively 6 .The participants were asked to rate their experience of each symptom over the past week based on 4-point severity scale 8 .The scores for each scale were summed and further categorized into normal, mild, moderate, severe and extremely severe 8   Overall, the prevalences of depression, anxiety and stress symptoms were lower when compared to those individuals with no depression, anxiety and stress, respectively.OR: odds ratio, CI: confidence interval, BMI: body mass index a Backward likelihood ratio Depression was found to be significantly associated with younger age, unemployment and a current smoking status (Table 3).Each increase in age yearly resulted in a 4% lesser chance of developing depression.The unemployed obese patients with chronic medical illnesses had 3.6 times the risk of depression.The current smokers had 3.1 times the risk of depression.OR: odds ratio, CI: confidence interval, BMI: body mass index In the final model, three variables (p<0.05) were found to be significant predictors for anxiety.The strongest predictor was no formal education, with an adjusted OR (AOR) of 5.7 times, followed by a family history of psychiatric illness (AOR=5.1)and high BMI (AOR=1.0)(Table4).

OR: odds ratio, CI: confidence interval, BMI: body mass index
In terms of stress, the females and current smokers remained significant in the final model, with females having 5.0 times the risk of stress and current smokers having 6.4 times the risk of stress (Table 5).

Discussion
To the best of our knowledge, thisis the first local study looking specifically for the prevalence of depression, anxiety and stress in an obese group of patients with underlying medical illnesses using our new obesity definition, which is a BMI > 27.5 kg/ m 2 .The prevalence of depression, anxiety and stress were evaluated locally in two previous studies 9,10 ; however,they were determined among type 2 diabetes mellitus patients.The findings of this study revealing the prevalence of depression, anxiety and stress among obese patients differed when compared to the two previous local studies.This shows that the psychological impact of obesity is under-detected in primary care 11 .The prevalence of depression among the obese patients in this study was lower than in a study done in Australia, which reported a 23% prevalence 12 .Past research sheds some light on the possible reasons for the high prevalence of depression among obese people, such as stigmatisation, discrimination in health care, education and employment, low selfesteem and body dissatisfaction can contribute to or exacerbate depressive illness in an obese person 13 .The prevalence of anxiety in this study was similar to that described by Svenningsson et al. in 2012 14 .The prevalence of stress among obese patients with chronic medical illnesses in this study was lower when compared to a study in Canada using telephone interviews to assess the self-perceived lifetime stress in obese patients 15 .They found that the lifetime stress was associated with an increased risk of obesity, especially in women (OR=1.44) 15.Obesity and metabolic syndrome also have close relationships with stress, and stress influences obesity via both psychological and physiological mechanisms 16 .Individuals who eat in response to stress were shown to have an increased preference for high fat and/or sweet food, which may lead to an increase in body weight 17 .The lower prevalence of depression and stress in this study could be attributed to the different tools used for assessing depression and stress and the different populations.Interestingly we found younger age, unemployed and smoking were to be significantly associated with depression among obese patients with chronic medical illnesses.Age is significantly associated, and this finding concurs with the results of a study done in China, which showed a dwindling number of depressive symptoms in theelderly 18 .This could be supported by the cultural and religious coping mechanisms among the older age group 19 .One previous study of depression found that almost 90% of older adults reported that religion was "very important" to them, 49% attended church or read the Bible (47%) at least once a week, and 95% said they prayed; 77% of those who prayed said they did so "to ask for help, guidance or strength" 19 .Religious beliefs are acceptable and useful for preventing or alleviating the cognitive symptoms of depression 19 .Unemployed was associated with depression in a similar study done in Croatia 20 .The relationship between unemployment and depression is explained by the increased financial constraints and family problems 20 .A higher rate of depression was found in the smokers (23.7%) in a study conducted in Austria 21 .The underlying mechanisms proposed that this linkage may arise from the effects of nicotine on the neurotransmitter activity in the brain, causing changes in the neurotransmitter activity, which leads to an increased risk of depression 22 .The high BMI, no formal education and a family history of psychiatric illness were found to be significantly associated with anxiety among the obese patients with chronic medical illnesses.In 2008, Scott et al. found that having no qualifications was associated with anxiety in an obese group 23 .However, this finding was contrary to the Kader et al. study, which found that a lower education level was not significantly associated with anxiety 24 .In our study, we found that every BMI unit increase was equal to1.1 times the odds of having anxiety in the obese patients with medical illnesses.An increasing BMI has been associated with anxiety, as explained by Lykouras et al. in their review article, suggesting that social discrimination leads to psychological stress, social avoidance and anxiety 25 .Finally, a family history of psychiatric illness was associated with anxiety in this study.This finding was similar to that of the Kaur et al. study in 2011, which found that patients with a family history of psychiatric illness had 2.4 times the chance of having anxiety 10 .The presence of psychopathology, especially anxiety, in obese youngsters is highly associated with parental psychopathology and psychosocial problems 26 .In this study, the factors associated with stress were the female sex and currently smoking.These findings were consistent with those of other studies, which found that obese females 18 and females with type 2 diabetes mellitus were strongly associated with stress 10 .In their study of type 2 diabetes patients, Kaur et al. found an association between females and stress with an AOR of 1.4 10 .One theory explaining stress in obese females is via the activation of the hypothalamic-pituitaryaxis 27 .Parrott et al. explained how smoking is related to stress 28 .The nicotine dependency in smokers can cause stress because regular smokers need nicotine to maintain a normal mood, not smoking creates tension when the plasma nicotine levels begin to fall 28 .In a clinical review, Moylan et al. summarized the literature and discussed the link between stress and smoking in view of the potential derangement in the neurotransmitter system in the brain, inflammation, oxidative and mitochondrial dysfunction and neurogenes is that usually occur after exposure to cigarette smoke components, especially nicotine and free radicals 29 .There were some limitations in this cross-sectional study.Recall bias might have occurred because some of the questions asked the participants to state whether the condition had been present for the past two weeks.Nevertheless, the participants were asked to think carefully before answering the questions.In addition, most of the patients were Malays; therefore, the results do not show the prevalence in other races.For future research, we recommended a communitybased study involving various ethnicities and participants from multiple centres so that the heterogeneity of the sample can be improved, ensuring generalizability.In addition, the total number of chronic medical illnesses should be included in the questionnaire in order to assess therelationships between them and depression, anxiety and stress.

Conclusion
The prevalence of depression, anxiety and stress symptoms in obese patients with chronic medical illnesses were 13.9%, 23.4% and 10.9%, respectively.Interestingly, younger age group was associated with depression.Current smokers, no education, family history of psychiatric illness and female sex were the significantly associated with anxiety and stress.This notifies new emerging knowledge on factors associated with obese patents and empowers the development of effective preventive strategies for it.

Declarations Acknowledgement
The authors would like to thank to Dr Ramli Musa for givingus permission to use the validated Malay version of the DASS-21 questionnaire.In addition, we would like to thank all the patients from the outpatient clinic who participated in this study.Authors' Contributions RH, IA, SSY and MMZ designed the study.RH and IA wrote the manuscript and guided the data collection, analysis and interpretation.SSY and MMZ assisted with writing the manuscript, analysis and interpretation.SSY and IA critically reviewed the manuscript and provided input for additional analyses and interpretations.All the authors have read and approved the final manuscript.

Competing Interest
The authors declare that they have no financial orpersonal relationships with other people or organizations that could inappropriately influence this research.

Ethics Approval and Consent to Participate
.

Table 1 :
Sociodemographic characteristics of the participants.
BMI: body mass indexa SD: standard deviation b Median (interquartile range)

Table 2 :
Prevalence of depression, anxiety and stress in obese patients with chronic illnesses.

Table 3 .
Factors associated with depression among obese patients with chronic medical illnesses.

Table 4 .
Factors associated with anxiety among obese patients with chronic medical illnesses.

Table 5 .
Factors associated with stress among obese patients with chronic medical illnesses.