Depression and body image disturbances among females seeking treatment for obesity in Saudi ArabiaMoataz M. Abdel-FattahPhD, Epidemiology and Research Unit, Department of Preventive Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi ArabiaAbdel-Rahman A. AsalMD, Department of Psychiatry, Al-Hada Armed Forces Hospital, Taif, Saudi ArabiaTamer HifnawyPhD, Epidemiology and Research Unit, Department of Preventive Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi ArabiaMohamed M. MakhloufPhD, Department of Family Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi ArabiaAbstractHypothesis: Obesity is an increasingly prevalent disease around the world and is becoming one of the main public health problems in developed countries. The relationship between obesity and psychological distress continued to be debated by researchers and clinicians. This study aimed to assess depression and body image disturbances in obese patients seeking treatment for obesity.Method: A case-control design was adopted in the study. Total of (236) obese women, self-referred to a residential weight-loss facility for weight control, were invited to participate in this study. Obese women were compared with (296) of an age-matched control group. All participants completed the Beck Depression Inventory for depressive symptoms, Multidimensional Body-Self Relations Questionnaire for body-image satisfaction and The Body Image Avoidance Questionnaire.Results: revealed that obesity were more common among older than younger females, among married than single females, and among those with lower level of education than those with higher level. Obese women as compared with non-obese reported significantly more symptoms of depression and significantly more negative body image.Conclusions and significance: Our results indicate a high frequency of depressive symptoms, and concern with body image among obese patients. Therefore, obese women who seek treatment should be screened for depression and body image dissatisfaction.Keywords: Depression, Obesity, Body image, Saudi ArabiaIntroductionObesity is an increasingly prevalent disease around the world and is becoming one of the main public health problems in developed countries. (1) The rate of obesity has doubled since 1900 (2) In the United States, obesity reached epidemic proportions, affecting approximately one-quarter of the American population (3). The same trend was also found in developing countries. (4)Obesity rates are consistently higher in urban compared with rural areas in many countries, including China (5) In countries of the Eastern Mediterranean Region (EMR), health professionals similarly caution against a major surge in obesity rates. (6) The prevalence of obesity among women in Kuwait was found to be 40% in 1999, which placed the country among the highest rates in the world (7). A higher figure was found Among Saudi Arabian females, where 26.8% were overweight, 41.9% were moderately obese and 5.1% were morbidly obese (8)Emotional factors contribute incisively for the development of obesity, and may be originated from it, aggravating the condition of the affected subject and making the treatment more difficult. (9)Studies of non-clinical samples of obese persons have been consistently showing that obese individuals do not differ from their non-obese counterparts in psychological symptoms, psychopathology, or overall personality. (10) On the other hand, individuals seeking treatment for weight loss have consistently demonstrated a higher prevalence of distress than their counterparts who are not seeking treatment. For instance, it has been found that obese treatment- seekers show elevated levels of depression (11), and body image distress. (12) It was also found that high levels of body dissatisfaction in treatment-seeking obese individuals are associated with elevated depression and decreased levels of self-esteem. (13)To our knowledge, no studies have been reported to investigate depressive symptoms and body image disturbance in Saudi Arabia patients who undergo several treatments to lose weight. So the aim of this study is to assess the prevalence of depressive symptoms and problems associated to body image, among obese Saudi females who sought a dieting service for treating their obesity.SubjectsStudy designA case-control strategy was adopted for this study.Target populationFemales aged 15 to 49 years, attending spontaneously the dietitian clinic at Prince Sultan Hospital, KSA for weight control were treated as cases. Females attending the same hospital as visitors were considered as controls; provided that they were in the same age range (15-49 years) and their body mass index was normal (18.5 to 24.9 kg/m2).SamplingAll females fulfilling the above-mentioned criteria for cases, and attended the specified clinic during the study period (from 1st May to 31st October 2005) were included. A comparable number of females considered, as controls were also included in the study.Females with chronic diseases (e.g., diabetes, hypothyroidism, and asthma) and those taking medications regularly (except for oral contraceptives; amounted 27 obese and 33 control subjects) were excluded.The protocol of this study was approved by the Research and Ethics Committee of Al-Hada Armed Forces Hospitals program, Taif, Saudi Arabia and all participants provided written consent to participate in this study.MethodsAll females (cases and controls) were subjected to the following:1-Interviewing questionnaire including sociodemographic data as age,educational level and marital status.2-Multidimensional Body Self Relations Questionnaire (MBSRQ) (14)This scale has 69 items and assesses self-evaluation and orientation toward appearance, health, and fitness. This scale is a well-validated self-report inventory for the assessment of body image. The MBSRQ is intended for use with adults and adolescents (15 years or older).MBSRQ SubscalesThe Factor Subscales:Appearance evaluation:Feelings of physical attractiveness or unattractiveness; satisfaction or dissatisfaction with ones looks. High scorers feel mostly positive and satisfied with their appearance; low scorers have a general unhappiness with their physical appearance.Appearance orientation:Extent of investment in ones appearance.High scorers place more importance on how they look, pay attention to their appearance, and engage in extensive grooming behaviors.Low scorers are apathetic about their appearance; their looks are not especially important and they do not expend much effort to look good.Fitness evaluation:Feelings of being physically fit or unfit.High scorers regard themselves as physically fit, in shape, or athletically active and competent. Low scorers feel physically unfit, out of shape, or athletically unskilled.Fitness orientation:Extent of investment in being physically fit or athletically competent.High scorers value fitness and are actively involved in activities to enhance or maintain their fitness.Low scorers do not value physical fitness and do not regularly incorporate exercise activities into their lifestyle.Health evaluation:Feelings of physical health and/or the freedom from physical illness.High scorers feel their bodies are in good health. Low scorers feel unhealthy and experience bodily symptoms of illness or vulnerability to illness.Health orientation:Extent of investment in a physically healthy lifestyle.High scorers are health conscious and try to lead a healthy lifestyle. Low scorers are more apathetic about their health.Illness orientation:Extent of reactivity to being or becoming ill.High scorers are alert to personal symptoms of physical illness and are apt to seek medical attention. Low scorers are not especially alert or reactive to the physical symptoms of illness.Overweight preoccupation:This scale assesses a construct reflecting fat anxiety, weight vigilance, dieting, and eating restraint.MBSRQ scale also assesses other areas as persons satisfaction about different parts of his body and how he perceives and labels his own weight (not included in the analysis).3- The Body Image Avoidance Questionnaire (BIAQ) (15) It is 19-item self-report questionnaire on avoidance of situations that provoke concern about physical appearance, such avoidance of tight-fitting clothes, social outings, and physical intimacy. In particular the questionnaire measures the avoidance behaviors and grooming habits associated with negative body image The questionnaire uses a 6-point scale to rate frequency of behavior: never, rarely, sometimes, often, usually, and always. Total score and four subscales are computed for: clothing, social activities, eating restraint and grooming/weighing; the authors reported it to have adequate psychometric properties.4- Beck Depression Inventory (BDI) (16)It is a structured instrument composed of 21 categories of symptoms and attitudes, and describes behavioral manifestations of depression. It assesses the intensity of depressive symptoms. Scores range from 0 to 63, and intensity categories vary from absent or normal (0 to 9), mild (10 to 15), mild to moderate (16 to 19), moderate to severe (20 to 29), and severe (30 to 63). The cutoff point used in this instrument to consider the patient as having depressive symptoms and, therefore, with greater probability of having clinical depression, was 20 points.5- Anthropometric measurements: A registered nurse measured participants height on a standard wall height-measuring device and weight on a digital computerized scale. Body mass index (BMI) was calculated by dividing the weight in kg by the square of the length in meter. Participants were categorized, based on their BMI values into four subgroups; normal (BMI from 18.5 to 24.9 kg/m2), overweight (BMI from 25 to 29.9 kg/m2), Obese (BMI from 30 to 39.9 kg/m2), and extremely obese (BMI ? 40 kg/m2).Statistical analysis (17, 18)Data were analyzed using SPSS; version 13 (Chicago, IL).The associations between the body mass index and sociodemographic characteristics (age, educational level and marital status) was assessed by using chi-squared test. Comparison of studied psychological scales between normal and abnormal subjects based on their BMI was done using non-parametric statistical tests: the Mann-Whitney test for comparing scores of two sub-groups. The correlation between Beck Depression Inventory and Body Image Avoidance Questionnaire with subscales of Multidimensional Body-Self Relations Questionnaire in obese group was performed using non-parametric Spearman correlation coefficient. In non-parametric tests, the ranks of the data rather than their raw values were used to calculate the statistic. Data were ranked by ordering them from lowest to highest and assigning them, in order, the integer values from 1 to the sample size. Ties were resolved by assigning tied values the mean of the ranks they would have received if there were no ties. Accordingly, the mean rank score was calculated for each group by dividing the sum of the ranks by the sample size of that group.ResultsThe present study included 532 women; 236 cases and 296 controls.Table 1 revealed that the majority of obese and extremely obese (61.3 and 83.3 % respectively) were older in age (? 36 years) while the majority of controls (76.4%) were younger in age (?35 years), and this was statistically significant (x2 =155.7, p< 0.001). Regarding educational level, there was a statistical significant association between educational level and body mass index (x2 =71.1, p< 0.001) as high educational level (university) was more prevalent among controls (33.8%) compared to obese and extremely obese females (16.9% and 16.7% respectively).Table 1: Distribution of the participants in the study according to their body mass index and sociodemographic data (n=532).*illiterate or read and writeIt was also shown that more single females (36.1%) were found among control group (with normal weight) than among overweight, obese or extremely obese (15.4, 21.3, 16.7% respectively) and this was statistically significant (x2 =43.6, p< 0.001).Table 2 shows a comparison between cases subgroups and normal control group using different psychological scales. The table revealed that, overweight, obese and extremely obese had statistically significant higher Beck Depression Inventory scores as compared to normal (Z value= 6.78. 5.92 and 6.63 respectively; p