|Year : 2015 | Volume
| Issue : 2 | Page : 48-54
Association between obesity and mental disorders among male students of King Khalid University, Abha, Saudi Arabia
Ali Abdullah AlMousa AlQahtani1, Shamssun Nahar2, Saeed Mohammed AlAhmari1, Khaled Saad AlMousa AlQahtani3
1 Ministry of Health, Joint Program of Family Medicine, Aseer Region, Saudi Arabia
2 Department of Family and Community Medicine, King Khaled University, Abha, Saudi Arabia
3 Department of Medicine, King Khaled University, Abha, Saudi Arabia
|Date of Web Publication||16-Dec-2015|
Ali Abdullah AlMousa AlQahtani
Trainer in Joint Program of Family Medicine, Aseer Region
Source of Support: None, Conflict of Interest: None
Background: Previous research suggested that obesity is associated with an increased risk of mental illness. Depression, stress, and anxiety are among the psychological problems that are commonly associated with obesity among students. However, evidence linking obesity to mental illness is inconsistent. Objectives: The objective of this study was to investigate the associations between mental disorders (in particular the depression, anxiety, and stress) and obesity in the male students of King Khalid University (KKU). Subjects and Methods: A cross-sectional study was conducted including male Saudi students enrolled in KKU at Abha City during the academic year 2013-2014. A multi-stage random sampling technique was adopted. Data were collected using the Arabic version of the depression anxiety stress scale. Results: The study included 389 university students. Their age ranged between 18 and 26 years with a mean age of 21.2 1.5 years. They were almost equally distributed between four colleges (Medicine, Pharmacy, Sciences, and Languages and translation). Overweight was reported among 22.1% of the students whereas obesity was reported among 18.3% of them. The overall prevalence of depression, anxiety, and stress were 48.1, 58.9, and 40.4%, respectively. The association of obesity with depression, anxiety, and stress was found statistically significant (P < 0.001, <0.001 and <0.003, respectively). Conclusion: The prevalence of overweight and obesity are considerably high among male University Students in Abha. These findings suggest that obesity is associated with depression, anxiety, and stress. Prospective studies will ultimately be required in order to clarify the temporal relation between obesity and common mental disorders.
Keywords: Anxiety, depression, mental health, obesity, stress, university students
|How to cite this article:|
AlQahtani AA, Nahar S, AlAhmari SM, AlQahtani KA. Association between obesity and mental disorders among male students of King Khalid University, Abha, Saudi Arabia. Saudi J Obesity 2015;3:48-54
|How to cite this URL:|
AlQahtani AA, Nahar S, AlAhmari SM, AlQahtani KA. Association between obesity and mental disorders among male students of King Khalid University, Abha, Saudi Arabia. Saudi J Obesity [serial online] 2015 [cited 2019 Jan 23];3:48-54. Available from: http://www.saudijobesity.com/text.asp?2015/3/2/48/171953
| Background|| |
Both obesity and common mental disorders account for a significant proportion of the global burden of disease and a major public health implication. Some researchers suggest that obesity has a direct impact on psychological well-being and can lead to depression, anxiety, stress, eating disorders, distorted body image, and low self-esteem, which are the common mental health disorders.  The relationship between obesity and common mental health disorders is complex. There are several theories about how the two are linked. Because of the high prevalence of both depression and obesity and the fact that they both carry an increased risk for cardiovascular disease, a potential association between depression and obesity has been presumed and repeatedly been examined.  Results from the most recent systematic review of longitudinal studies point towards bidirectional associations between depression and obesity. The authors concluded that obese persons had a 55% increased risk of developing depression over time, whereas depressed persons had a 58% increased risk of becoming obese.  Another recent systematic review and meta-analysis found a weak but positive association between obesity and anxiety disorders. 
It is generally believed that the health of students is affected by the stresses of academic life. These stressors may affect their learning ability, academic performance, and mental health. Several international studies have revealed high rates of mental health problems in undergraduate students as a result of their studies. ,,] Depression, anxiety, and stress are among the psychological problems that are common among students. Estimates of the prevalence of mental illness in college students range from a low of 12%  to a high of 50%.  Research conducted in the USA has reported a nationwide increase in stress among undergraduate college students in various fields of study.  Medical students, in particular, have been found at risk of psychological stress, mental disorders, and decreased life satisfaction. ,, El-Gilany et al. found an overall stress rate of 30.9% and 28.9% among Egyptian and Saudi medical students, respectively.  Abdulghani reported a higher prevalence of stress (57%) in medical students from King Saud University, Riyadh, Saudi Arabia.  Study in Dammam University, Saudi Arabia, also reported a higher prevalence of stress and anxiety among medical students (48.6%) compared with nonmedical students. 
Obesity is one of the most common chronic health problems in Saudi Arabia.  National studies revealed that overweight and obesity are rising.  Al-Saleem reported a high prevalence of overweight (32%) and obesity (37%) among the adult population,  whereas a recent study among male college students in Saudi Arabia also reported the prevalence of overweight (21.8%) and obesity (15.7%). 
To our knowledge, many studies have been conducted independently on obesity and mental health disorders in Saudi Arabia. Obesity is associated with an increased risk of mental illness; however, evidence linking body mass index (BMI) to mental health disorder is lacking. Therefore, the objective of this study was to examine the association of obesity with common mental disorders among male college students in Abha, Saudi Arabia.
| Subjects and methods|| |
A cross-sectional study was carried out among male Saudi students enrolled in King Khalid University (KKU) at Abha City during the academic year 2013-2014. KKU is a public university, with colleges distributed over several towns in the Aseer Province in South-West Saudi Arabia, including Abha and Al-Namas. It is a rapidly growing university with around 70,000 students. It is one of the largest centers of learning in the Middle East region.
The sample size (n) for this study has been calculated using the formula n = Z 2 × p × q/d 2 . The estimated prevalence of stress and anxiety among medical students is taken 48.6%.  The estimated sample size was 384 male students. The sample was increased to 408 male students in order to compensate for nonresponse.
A multi-stage random sampling technique was used as follows: Stage I: Out of 10 male colleges, four male colleges were selected by simple random method (Medicine, Pharmacy, Science, language, and translation). Stage II: In each randomly selected college, three levels were selected by random sampling. Therefore, three levels were selected in each college giving a total of twelve classes. Stage III: To achieve the required sample size about 34 students were recruited from each class using list of students following systematic random sampling. A total of 408 students were selected for the study.
Mental illness refers to a wide range of mental health conditions or disorders that affect an individual's mood, thinking and behavior. It includes depression, stress, anxiety disorders, schizophrenia, eating disorders, and addictive behaviors.  However, this study only measured the overall percentage of depression, stress, and anxiety syndromes and their severity using the Arabic version of the depression anxiety stress scale (DASS). The DASS is a 42-item self-report instrument designed to measure the three related negative emotional states of depression, anxiety, and stress.  This scale was psychometrically validated to the Arabic culture by Taouk et al.  This screening and outcome measure reflects the experience of the person over the previous 7 days. Each of the three scales contains 14 items. Scores of depression, anxiety, and stress are calculated by adding the scores of the relevant items.
Gamma coefficients that represent the loading of each scale on the overall factor (total score) are 0.71 for depression, 0.86 for anxiety, and 0.88 for stress. One would expect anxiety and stress to load higher than depression on the common factors as they are more highly correlated and therefore, dominate the definition of this common factor. The reliability of the test is considered adequate, and test-retest reliability is likewise considered adequate with 0.71 for depression and 0.79 for anxiety. Exploratory and confirmatory factor analyses have sustained the proposition of its factors (P < 0.05).  The [Table 1] shows the scoring and grading of the DASS.
In addition, sociodemographic data such as age, educational grade, parents' education, occupation, and income were collected for each participant.
Obesity ("total obesity") is defined as a BMI of 30 kg/m 2 or greater. Obesity is further subdivided into Class I obesity (BMI 30-34.9), Class II obesity (BMI 35-39.9) and Class III obesity (BMI ≥40). While normal is (BMI 18.5-24.9) and overweight is (BMI 25-29.9). The aim of the study was to investigate the association between overweight and obesity and mental disorder, therefore, participants with BMI <18.5 were excluded. Height and weight measurements were taken in a private room.  Height was measured using an inflexible steel meter while subjects stand with heels, back, and shoulders against a wall; with feet together and head on the Frankfort plane. The body weight measurements were taken, while subjects were wearing light clothes, using calibrated measurement devices. BMI was calculated as body weight dividing by the square of height (kg/m 2 ).
Before Interviewing, informed consent was taken from all samples and all participants had the right not to participate in the study or withdraw at any point. The researcher explained the purpose to all respondents. This premeasurement education was an important part. Confidentiality and privacy were guaranteed and maintained for each participant.
The data were collected and verified by hand then coded before computerized data entry. The Statistical Package for Social Sciences (SPSS) software version 19.0 was used for data entry and analysis. Descriptive statistics (e.g., number, percentage, mean, range, standard deviation) and for analytic statistics Chi-square test were applied. P ≤ 0.05 was considered as statistically significant.
The proposal of this study was approved by the Research Ethics Committee at KKU, Abha, Saudi Arabia.
| Results|| |
Out of 408 university students invited to participate in the study, 389 returned filled questionnaire giving a response rate of 95.3%.
As shown in [Table 2], their age ranged between 18 and 26 years with a mean age of 21.2 ± 1.5 years. The number of students was almost equally distributed among the four colleges (Medicine, Pharmacy, Sciences, and Languages and translation). Almost quarter of them (27.2%) were recruited from each of second, third and fourth academic levels. The majority of them were singles (97.9%). More than two-thirds of the respondents (69.4%) were living with their families while 12.6% and 18% were either living alone or with their friends, respectively. Majority of them (70.4%) reported an individual income <1000 SR/month, whereas only 6.7% of them reported an individual income exceeds 5000 SR/month. The family history of mental illness was reported among 23.4% of the students). Based on calculated BMI of the participants, 46.2% of them had a normal weight, and 13.4% were underweight. Prevalence of overweight and obesity was 22.1% and 18.3%, respectively. Among the obese students, 13.4% had Class I (BMI 30-34.9) obesity, 3.1% had Class II obesity (BMI 35-39.9), and 1.8% had Class III (BMI ≥40) obesity [Figure 1]. None of the background characteristics of the students was significantly associated with obesity [Table not shown].
As shown in [Table 3], overall 48.1% of the student had depression. Regarding severity, mild, moderate, and severe depressions were reported among 18.8%, 17.7%, and 6.7% of the respondents while extremely severe depression was reported among 4.9% of them. Overall, 58.9% of the students had anxiety. Mild, moderate, severe, and extremely severe anxiety were reported among 10.5%, 20.3%, 16.7%, and 11.3% of the students, respectively. Whereas 40.4% of the students had stress regardless of the severity of stress. Mild, moderate, severe, and extremely severe stress were reported among 14.4%, 17.0, 7.5%, and 1.5% of the students, respectively.
|Table 3: Distriburion of mental disorders among male students by severity|
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It is obvious from [Table 4] that obese students had higher percentages of mental disorders (depression, anxiety, and stress) than normal and overweight students. As shown in the table, 18.3% of obese students compared to 7.2% of normal and 11.6% of overweight students were severely/extremely severe depressed. On the other, 40.8% of obese students and 59.4% of normal and 50.0% of overweight students showed no depression. This association between obesity and depression was statistically significant (P < 0.001).
|Table 4: Association of obesity with depression, anxiety, and stress among students (n=337, excluding underweight)|
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It is also obvious from the same table that 38.0% of obese students compared to 20.0% of normal and 31.4% of overweight students reported severe/extremely severe anxiety. On the other, 25.4% of obese students compared to 47.2% of normal and 44.2% of overweight students did not have any anxiety, and this association was statistically significant, (P < 0.001).
Fifteen and a half percent of obese students compared to 7.8% of normal and 4.7% overweight students reported severe or extremely severe stress. On the other, 42.3% of obese students compared to 66.7% of normal and 61.6% of overweight students showed no stress. This association between obesity and stress was statistically significant, P = 0.003.
| Discussion|| |
To our knowledge, this is the first study to examine the associations between obesity with common mental health problems using the widely used and clinically validated DASS scale. In the current study, overweight and obesity were reported among 22.1% and 18.3% students, respectively. Our figure is comparable to what has been reported in other studies conducted in our region and elsewhere. At a Central University in the West Bank, overweight was reported among 31.1% of male university students whereas obesity was reported among9.4% of them.  A study in King Saud University in Riyadh, Saudi Arabia, has reported 31% overweight and 23.3% obesity among the students  while a recent study among male college students in Saudi Arabia also reported the prevalence of overweight (21.8%) and obesity (15.7%).  The overall prevalence of anxiety among the students in the present study was 59.1%. In the USA, depressive and anxiety disorders were evaluated with the patient health questionnaire (PHQ). The prevalence of any depressive or anxiety disorder was15.6%.  In Pakistan, the prevalence of anxiety and depression among medical students of a private university using anxiety and depression scale was 60%. 
Among students of King Faisal University using the PHQ, the prevalence of symptoms of any depression or anxiety was 21.9%. Symptoms of major depression were present in 9.9%, other depression in 19.4%, and any depression among 24.4%. Panic and generalized anxiety symptoms were found in 4.0% and in 14.0% whereas the prevalence of anxiety was 14%. 
Stress, regardless its severity, was identified among 40.4% of our sample. Koochaki et al. studied a random sample of medical students in Isfahan, Islamic Republic of Iran. The data were gathered using the Kessler 10-item psychological distress scale. The overall prevalence of stress among 222 students was 61.3%.  Yusoff et al. used a 12 items general health questionnaire (GHQ-12) and medical student stressor questionnaire, to evaluate stress levels and stressors among Universiti Sains, Malaysia, medical students. The prevalence of stress among the medical students was 29.6%.  The prevalence of stress among medical students in Jizan University, Saudi Arabia, using the GHQ 20 questionnaire to assess the level of stress was 71.9%, with females being more stressed (77%) than the males (64%). 
In the present study, we found a significant association of obesity with depression, anxiety, and stress. In accordance with our findings, McLaren et al.  examined the relationship between BMI and mental health in a population-based study of adults in Canada and found that subclinical anxiety and depression was higher among obese men compared to men with normal weight. Elfhag et al.  studied 120 obese patients with a mean BMI of 41 ± 6 kg/m 2 in Sweden. They found that depression was not related to body weight, in spite of findings of more depression in obesity compared to normal weights, and body concern and body-related anxiety were more common in relatively lower degrees of obesity. They suggested that the differences in body concern and anxiety in varying degrees of obesity could be related to the social and educational context, where attitudes toward obesity differ. This considerable disparity in figures on the prevalence of psychiatric disorders in young adults could be due to the diversity in methods, definitions used, or geographical locations.
Most of the previous research has focused on the association between obesity and depression, and various mechanisms have been proposed to explain this relationship. Some of those mechanisms propose a causal pathway leading from depression to obesity. Increased appetite and weight gain are common symptoms of depression and tendency to gain weight remains stable across depressive episodes.  Depression may lead to reduced physical activity, , increasing risk for obesity. Depression may increase risk of weight gain through its effect on binge eating.  Medications used to manage mood or anxiety disorders may also lead to weight gain.  Alternatively, some proposed mechanisms suggest a causal relationship leading from obesity to depression.
Results of the association between obesity and anxiety are contradicting, with some supporting the association and others providing no support. 
Since both obesity and depression are increasingly prevalent and associated with hypertension, coronary heart disease, diabetes mellitus, as well as increased risk for mortality.  A conceivable link between these two disorders has been postulated and may be a relevant consideration in public health. To date, reports of cross-sectional, longitudinal, and intervention studies using community or clinic-based samples have been inconsistent. Our current study provides support for an association between the obesity and depression.
The limitations of this study are that the findings are based on self-reported information provided by students, and thus some reporting bias may have occurred. In addition, the study took place at only one university and among the male students. Therefore, the findings of this study cannot be generalized in all universities of Saudi Arabia. However, findings can be generalized among university male students in Aseer region.
In conclusion, overweight and obesity prevalence are considerably high among male university students in Abha, KSA. Obesity is associated with a range of common mental disorders (depression, anxiety and stress). In addition, the present study confirms the relative high prevalence of depression, anxiety, and stress among Saudi male university students. The significant associations that we found between mental health problems and obesity suggest that public health interventions should address mental and physical health holistically, and integrated programs to improve university students' mental and physical health should be developed and implemented. Prospective studies will ultimately be required in order to clarify the temporal relation between obesity and mental disorders.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]
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