INTRODUCTION
The prevalence of diabetes in Sub-Saharan Africa is
rapidly rising, with the Sub-Saharan African region expected to see the largest
percentage increase in the incidence of diabetes compared to any other region
in the world.1
This rise in prevalence is due to
the increasing rate of obesity, physical inactivity and urbanisation, which
along with advances in medical research and development resulting in production
of vaccines have changed the global disease profile with death and disabilities
from NCDs (such as hypertension, cardiovascular disease, diabetes) exceeding
those from infection and nutritional deficiency.2, 3
Diabetes
mellitus is complicated by emotional and psychological
disorders, yet the emotional dimension of this condition is often overlooked when
caring for those affected by the disease.4
Depression is
a common mental disorder characterised by sadness, loss of interest or
pleasure, feeling of guilt or low self-worth, disturbed sleep and appetite,
feeling of tiredness and poor concentration which could be long lasting or
recurrent.2
DM and
depression are highly prevalent conditions throughout the world and have
significant effect on health outcomes.5 Furthermore there is
evidence that depression is associated with a poor metabolic control in patients
with type 2 diabetes mellitus that present with other problems like obesity.5
Apart from
being an important modifiable risk factor for non-communicable diseases such as
type 2 diabetes, obesity has severe impact on physical and psychological health
as it causes several divers psychological problems or various physical
disabilities. 6, 7,8
The prevalence
of obesity and obesity related morbidities in developing countries, though
relatively low, is changing rapidly with urban and rural variations.8
The WHO
reports that prevalence of depression and obesity is very high and both are
associated with enormous individual burden and high economic cost.9
The exact
underlying cause of obesity in depression is not clear. Depression may cause
obesity, for example through changes in eating pattern or reduced physical
activity. But it is also possible that obesity may cause depression for example
through the negative body image which is the result of obesity.
Studies
concerning the association of obesity and depression are conflicting (remain
equivocal) with positive association (higher depression with increasing
obesity), negative association (higher depression is associated with lower obesity)
or no association at all. A non- linear (U shaped) trend in association between
depression and BMI (depression with
both over weight and underweight) also abounds, with studies showing a higher
risk of experiencing depressive symptoms in both extremes of BMI, either very
high or very low.10, 11 De Wit et al in a community-based study in
the Netherland, showed a U shaped relationship between depression and BMI,
demonstrating that both obesity and underweight are associated with increase.
12 The association was very significant (p</=0.001). Yu et al in a
population-based study accessing depression with the Taiwanese depression
questionnaire found out that underweight men had a higher risk of depression
than normal weight men and overweight women had a lower risk of depression than
normal weight women.13 These findings support the `jolly fat`
hypothesis among the Chinese community. 13
With the
increasing burden of diabetes mellitus and its co- morbidities in most primary care
settings, the conflicting study reports of the association of obesity and
depression among these patients, it was necessary find out the association of
depression and obesity among the type 2 diabetes patients attending the Family
Medicine Clinic so as to improve the management of these patients, taking
proactive measures to prevent depression co-morbidity, thus improving their
quality of life.
METHODOLOGY
The study was conducted in the
Family Medicine Clinic of Rivers State University Teaching Hospital, Port
Harcourt. Port Harcourt is a cosmopolitan city.
The study population consisted of patients with type 2 diabetes
attending the Family Medicine Clinic of Rivers state University Teaching Hospital,
Port Harcourt, Rivers State, Nigeria.
All consenting adult patients (aged above 18 years), with type 2
diabetes mellitus, who had been on treatment for diabetes for a minimum of
three months were eligible. Critically ill diabetic patients and those that
might require in-patient care were excluded.
The study was a hospital based cross sectional descriptive study to
determine the association of obesity with depression in type 2 diabetic
patients attending Family Medicine clinic of Rivers state University Teaching
Hospital, Port Harcourt, using a sample size of 264.
Data was collected using - A socio demographic questionnaire to
determine the socio demographic and diabetes related characteristics of
participants, The Patient Health Questionnaire
(PHQ- 9) to assess depression among participants. Anthropometric and blood
pressure measurements of participants were measured with standiometer and
Accusson mercury sphygmomanometer respectively using the standard protocol. For
this study, a diagnosis of depression was based on the criteria of a PHQ-9
score of 5 and above .14
Data analysis:
The results were coded and entered into Excel worksheet and subsequently
transferred into Statistical Package for Social Sciences (SPSS) Version 20 and
cleaned. Frequency tables and charts were constructed for the presentation of
the results using Microsoft excel. Means and standard deviation were calculated
for continuous variables and categorical variables were expressed in counts and
percentages. Chi square (x2) tests were carried out to compare
degree of association between categorical variables. The association between
depression and body mass index was determined. Statistical significance was set
at 95% confidence interval (p< 0.05).
Ethical
approval for this study was obtained from the Ethical Committee of Rivers State
Hospital Management Board. An informed written consent was obtained from each
study participant before recruitment. This was in accordance with ethical
principles for the guidance of physicians in medical research.
RESULTS
Prevalence and Severity of Depression
Table 1 shows the prevalence of depression according
to PHQ-9 among respondents. Among the participants 130 were depressed giving a
depression prevalence rate of 49.2%.
Table 1: Prevalence of depression according to PHQ-9 among the
respondents
|
Variable
Depressed
|
Frequency (n = 264)
|
Percent
|
|
Yes
|
130
|
49.2
|
|
No
|
134
|
50.8
|
|
Mean score ±SD
|
5.4 ± 4.4
|
|
Table 2 shows the
pattern of depression among the respondents. A large number of the respondents
108(40.9%) had minimal depression as against those with severe depression that
were very few 2(0.8%).
Table 2: Pattern of depression according to PHQ-9 among the respondents
|
PHQ-9 score
|
Frequency (n = 264)
|
Percent
|
|
0
|
26
|
9.8
|
|
1 – 4
|
108
|
40.9
|
|
5 – 9
|
89
|
33.7
|
|
10 – 14
|
27
|
10.2
|
|
15 – 19
|
12
|
4.5
|
|
20 – 27
|
2
|
0.9
|
|
Mean score
|
5.4 ± 4.4
|
|
Key: 0 = No depression; 1-4 = Minimal
depression; 5-9 = Mild depression; 10-14 = Moderate depression; 15-19 =
Moderately-severe depression; 20-27 = Severe depression
Body Mass Index (BMI) of the Respondents
Table 3 shows the
Body Mass Index of the respondent. About a third of the participants (34.1)
were of normal weight, a small percentage (3.8%) were underweight, while 30.3%
and 31.8% of the participants were overweight and obese respectively. The mean
Body Mass Index was 28.2 +/- 8.4
Table 3: Body Mass Index
|
Body Mass Index
(kg/m2)
|
Frequency (n = 264)
|
Percent
|
|
Underweight
|
10
|
3.8
|
|
Normal
|
90
|
34.1
|
|
Overweight
|
80
|
30.3
|
|
Obese
|
84
|
31.8
|
|
Mean BMI
|
28.2 ± 8.4
|
|
Table 4 below shows
the relationship between BMI and Depression. The prevalence of depression was
higher in the underweight (70.0%) and lowest among those who were obese.
(35.7%). The association was statistically significant (P= <0.001)
DISCUSSION
In this study 49.2%
of the respondents had significant depressive symptoms, though majority (74.6%)
were classified as having minimal and mild depression (40.9% and 33.7%
respectively). The significant prevalence of depression among the respondents
was not surprising as diabetes mellitus is a chronic medical condition and
chronic medical conditions and depressive disorders frequently occur. Several
studies have found that people with chronic physical conditions were
significantly more likely to have depression than were those without chronic
conditions. 4, 15, 16
This findings have been irrespective of the urban or rural location as
Dienye et al in a rural clinic based study in Nigeria reported a higher
prevalence of depression (61.54%) among participants with co-morbid physical
illness than a 15.38% prevalence in those without physical illness while Adiari
et al in a study in cosmopolitan Lagos found a 14.4% prevalence of depression
among patients with a chronic illness as compared to 5.5% in the general
population. 15, 17, 18
Compounding
the presence of diabetes in the respondents is the presence of socio
environmental stressors with the prevailing general economic downturn and
upsurge of insecurity issues. The prevalence of older age group among the
respondents could also explain the prevalence of depression among the
respondents. This is because prevalence of depression is higher among certain
group of older people, in particular individuals with co morbid medical
illness. 19
The mean body
mass index of the respondents was 28.2 +8.4kg/m2 with the
majority of the respondents being in the overweight and obese category. This
high rate of overweight and obesity could have been due not only to the
prevalence of elderly respondents and the geographical location of the study,
but also because the respondents were known diabetics and obesity is a known
modifiable risk factor for non-communicable diseases like diabetes. 22
Thus, the preponderance of increased BMI among the respondents was not
surprising as excess
adiposity assessed by a high BMI is the single
strongest risk factor for type 2 diabetes mellitus.
Geographically,
the study was carried out in urban Port Harcourt City where the effect of rural
to urban migration, changes in lifestyle and socioeconomic factors play a major
role in contributing to the burden of obesity. In addition to this is the
effect of insecurity which has affected the early morning jogging exercises
which was previously common among the residents. Moreover, the prevalence of
obesity has been reported to be higher in urban than in rural communities. 21 Also, the observation that urban population
being usually associated with modernization of lifestyle largely characterised
by change in dietary pattern and lower physical activity could explain the high
prevalence of overweight and obesity in the index study.21
A similar
trend of higher prevalence of overweight (31%)was reported by Okafor et al in a
cross sectional study carried out in five different urban cities from five
geographic zones of Nigeria in which age greater than 40years was found to
confer twice the risk of becoming overweight.22(160) The findings in
the index study was also similar to the 32.9% prevalence of obesity among type
2 diabetes patients in Edo state reported by Edo et al.23 Sabir et
al in various studies in northern Nigeria corroborated a higher BMI among those
with diabetes than in subjects with normoglycemia.24, 25, 26 Of
interest in these studies is that the mean BMI were lower in the studies among
the rural Fulani population than in the sub-urban and urban Fulani population
and also the prevalence of diabetes mellitus was highest among the urban
dwellers (4.61%) than among the suburban and rural Fulani (4.3% and 0.81%
respectively). The similar high prevalence of overweight/obesity in these
stated studies and the index study could be due to similar older age of
respondents, urbanization, and/or the presence of diabetes mellitus in the
respondents. Similar results were reported by other international studies.27,
28 Anselmo et al in an epidermiological study in Panama Central America
reported that the number of people in Latin America diabetes had been
increasing because of urbanization and other risk factors with an important
biological factor identified being obesity.29.
Conversely,
Iloh et al in a descriptive study carried out among adult Nigerians in a
mission hospital found a 6% prevalence of obesity using the BMI criteria. 30
The lower prevalence of obesity compared to the 31.8% in this study could
be due to the fact that that their study was carried out in a rural population
and among all adults. A similar comparatively low prevalence of obesity (13.9%)
was reported by Adamu et al and could be due to the inclusion criteria of lower
age of 15years and above in their study. 31 The result from the
index study was however lower than that of Damian et al in Tanzania who found
an 85% prevalence of overweight and obesity (44.9% and 40.1% respectively). The
high prevalence in their study could be due to the fact that the study was
carried out among patients in a diabetic clinic, urbanization, as well as
globalization of food production and marketing and limited policies on
nutrition and regulation on marketing in that country.32
In this study,
the prevalence of depression was higher in the underweight (70.0%) and lowest
among those who were obese. (35.7%) with a statistically significant
association (P= <0.001). This is similar to the findings by Yu et al in a
population-based study accessing depression with the Taiwanese depression
questionnaire found out that underweight men had a higher risk of depression
than normal weight men and overweight women had a lower risk of depression than
normal weight women.13 These findings support the `jolly fat`
hypothesis, a belief that older adults with higher BMI have a lower risk of
developing depressive symptoms in future years, This hypothesis suggests that
there is psychological protective element in having a higher weight at an older
age. 13
The finding of
an inverse relation between depression and obesity in this study could be due
to the fact that obesity is culturally and socially accepted among Nigerians
and therefore is not usually recognised as a medical problem. 30A
further factor is that a large percentage of the participants were the Ijaws and
Ogonis (Indigenous people) among whom a well-rounded figure is accepted as an
index of good health, thus obesity though a non-communicable disease, is seen
as a symbol of beauty and virility. Though in modern Western cultures, the
obese shape is widely regarded as unattractive, not all contemporary cultures
disapprove of obesity. Many African, Arabic, Indian and pacific cultures are
traditionally more approving of obesity as it is associated with physical
attractiveness, strength, fertility and prestige.33 This obesity
approving culture is seen among the Kalabari people of the Ijaw tribe in the
Niger Delta and these formed a high proportion of the respondents in this
study.34 Esang et al in a study in South Eastern Nigeria also showed
a similar culturistic trend among the Annang Indigene of Akwa Ibom. It is of
note that both the Ijaws and Annang practice the iria or the fattening room
ceremony.33
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