Depression and body image disturbances among females seeking treatment for obesity in Saudi Arabia

Moataz M. Abdel-Fattah
PhD, Epidemiology and Research Unit, Department of Preventive Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
Abdel-Rahman A. Asal
MD, Department of Psychiatry, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
Tamer Hifnawy
PhD, Epidemiology and Research Unit, Department of Preventive Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia
Mohamed M. Makhlouf
PhD, Department of Family Medicine, Al-Hada Armed Forces Hospital, Taif, Saudi Arabia

Abstract
Hypothesis: 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 Arabia



Introduction
Obesity 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.

Subjects
Study design
A case-control strategy was adopted for this study.
Target population
Females 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).
Sampling
All 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 Ethic’s Committee of Al-Hada Armed Forces Hospitals program, Taif, Saudi Arabia and all participants provided written consent to participate in this study.

Methods
All 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 Subscales
The Factor Subscales:

    Appearance evaluation:
    Feelings of physical attractiveness or unattractiveness; satisfaction or dissatisfaction with one’s 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 one’s 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 person’s 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 participant’s 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.

Results
The 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).
depressionobez1.JPG
*illiterate or read and write

It 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<0.001).

Table 2: Comparison of studied psychological scales between normal (n=296), overweight and obese subjects based on their BMI (using Mann-Whitney test).
depressionobez2.JPG

The three subgroups also showed statistically significant higher scores in the appearance orientation (z= 5.68, 4.72, 4.29; p < 0.001) fitness orientation (4.77, 10.67, 2.72; p<0.001, p < 006) and illness orientation (z= 6.58, 3.57, 3.51; p<0.001) compared to normal.
Moreover, obese and extremely obese had higher scores than normal in Body Image Avoidance Questionnaire, and this was statistically significant (z=8.62, 3.22 respectively; p<0.001).They had also statistically significant higher scores in the health evaluation subscale (z=4.27, 3.44 respectively; p<0.001). On the other hand, overweight and obese females showed lower but statistically insignificant score (z=0.94, 0.87, p=0.343, 0.383 respectively) ,while extremely obese female showed higher statistically significant score compared to normal group in the Appearance evaluation Subscale (z= 5.04; P values< 0.001).
Overweight and obese subgroups showed statistically significant higher scores in the Fitness evaluation subscale (z= 2.29, 9.44; p <0.001) and in the Overweight preoccupation subscale (z= 3.37, 7.24; p <0.001) compared to normal. On the other hand, obese subgroup were found to have a statistically significant higher score (z= 4.56; P<0.001) in comparison to controls in the Health Orientation subscale.
From table (3), it was obvious that Beck Depression Inventory BDI, had positive significant correlation with The Body Image Avoidance Questionnaire (r=0.385, p<0.0001) and significant negative correlation with Appearance evaluation, Fitness evaluation and Illness orientation (r=-0.266 p<0.000; r=-0.211 p<0.004; r=-0.216 p<0.003) respectively.

Table 3: Correlation between Beck Depression Inventory and Body Image Avoidance Questionnaire with subscales of Multidimensional Body-Self Relations Questionnaire in obese group* using Spearman correlation coefficient “r (P)” (n=184).
depressionobesity3.JPG

It was also obvious that the Body Image Avoidance score is negatively correlated with Appearance evaluation, Appearance orientation, Fitness evaluation, Health orientation, Illness orientation, Overweight preoccupation and (r=0.241, p<0.000; r=0.275, p<0.000; r=0.186, p<0.011; r=0.385, p<0.000 r=0.269, p<0.000 r=0.610, p<0.000 respectively ).

Discussion
Obesity has become an epidemic problem worldwide, and in the Eastern Mediterranean Region the status of overweight has reached an alarming level. (19)
In agreement with others (20, 21), our study proved that obesity rate among females is higher with increasing age.This was also previously found in KSA. (22) Physical inactivity may partially explain increasing obesity with increasing age. Another study In Saudi Arabia (23) revealed that physically inactivity was higher among middle aged, less educated and married Saudi males. One fourth of this sample was inactive because of lack of space and facility. The problem may be higher for females due to cultural and environmental factors. In addition, the present study also demonstrated that obesity is more prevalent among married than non-married females.
This result is also congruent with other studies. (8, 20) One of the explanations of increasing obesity among married females is related to pregnancy and multiparity. The fertility rate of the women in the gulf region is very high and the spacing between pregnancies is short, resulting in accumulation of fat in the body. (8) Also our study proved that obesity rate is increasing among females with lower education. This finding is congruent with the study of Musaiger, 2003 (21) who related this observation to physical inactivity. Another explanation may be related to less information about healthy diet.
The relationship between obesity and depression continues to be debated by researchers and clinicians. Some studies did not find any association between BMI and psychological disturbances. (24, 25)
However, more recent studies (26, 27) have shown an association between obesity and depression. In a study (28) conducted on a large, nationally representative sample of more than 40,000 people in USA , it was found that obese females were 37% more likely than their average-weight peers to have experienced major depression in the past year. Obese women were also 20% more likely to report suicidal ideation and 23% more likely to have made a suicide attempt in the past year.
The relationship between obesity and depression is even more obvious in studies underwent with obese patients seeking weight reduction. Obese patients who sought weight reduction reported significantly greater psychological distress than did comparably obese individuals who did not seek treatment. (29) In their meta-analytic review, Friedman and Brownell; (30) 1995 concluded that obesity was moderately and consistently related to depression in studies that compared obese individuals who sought treatment with people in the general population. These findings are consistent with the results of the present study, which revealed that, overweight, obese, and extremely obese individuals presenting for clinical weight reduction treatment had statistically significant higher Beck inventory score as compared to normal.
Depression is more prominent in those who seek treatment because their weight is at least partially motivated by negative evaluations of their body. The severely obese person certainly suffers stigmatization and discrimination that may cause or aggravate a depressive illness. (31, 32) Symptoms of depression correlate significantly with reported body image dissatisfaction. (13, 33) It was also revealed that body dissatisfaction increased vulnerability to depression. (34, 35) Another study (36) demonstrated that symptoms of depression were affecting severely obese subjects and those with a poor body image.
The problems associated with negative body image have received substantial attention in the research literature. Recent research has suggested a multidimensional structure to body image. It was reported that body image includes at least two components: perceptual body image (i.e., estimation of one’s body size) and attitudinal body image (i.e., affective, cognitive, and behavioral concerns with one’s body size). (37)
In our study body image, satisfaction was measured with the Multidimensional Body-Self Relations Questionnaire. This scale assesses evaluation and orientation toward appearance, health, and fitness. It is obvious in our results (table2) that that overweight, obese and extremely obese had higher statistically significant scores than normal in most of the subscales of MBSRQ. This means that, with variable degree according to their BMI, they place more importance on how they look, pay attention to their appearance, and engage in extensive grooming behaviors .They value fitness, are actively involved in activities to enhance or maintain their fitness and regard themselves as physically fit. They are health conscious, and feel that their bodies are in good health. They are alert to personal symptoms of physical illness and are apt to seek medical attention. Despite of that, most of them, with the exception of the extremely obese, are unsatisfied with their body image as appears from the appearance evaluation subscale. They are trying to lose weight and seek medical advice for that reason. This may make them frustrated and had significantly higher symptoms of depression as appears from BDI (table 2). Failure of repeated attempts to lose weight may be accompanied by thoughts of guilt, hopelessness, and poor self-esteem. (38) These findings are congruent with many studies underwent with obese patients seeking weight reduction. For instance, it has been found that obese treatment seekers show body-image distress. (12) Moreover, it was revealed that 68% of obese individuals who sought weight reduction (BMI =35.6 ± 4.3 kg/m2) and 33% of non-obese controls (BMI = 23.8 ± 3.2kg/m2) reported moderate to extreme dissatisfaction with their overall appearance. (13) Body-image dissatisfaction was also found to be a potential mediator of the relationship between dysphoric psychological states (e.g., depression and low self-esteem) and obesity in a treatment seeking population. (30) Obese individuals overestimate or distort the size of their body more, are more dissatisfied and preoccupied with their appearance, and tend to avoid more social interactions because of their appearance than normal weight individuals (39) The present study revealed that obese and extremely obese had higher scores than normal in the BIAQ which were statistically significant . This finding is consistent with the findings of others. (39, 40) The present study also revealed that BDI had a significantly positive correlation with BIAQ (table 3). Obese individuals tend to avoid more social interactions because of their appearance than normal weight individuals. This avoidance may lead to social isolation and make them vulnerable to depression. Obesity may affect health not only through physiological changes in blood pressure, lipids, and the like, but also through body image, which itself is important because it affects quality of life. Body image is one area where distress occurs, and therefore deserves attention in the field.

Limitations of this study
1- This study utilized obese individuals who presented for treatment at a residential center for weight reduction. As noted previously, obese persons seeking weight-loss treatment may differ from obese individuals in the community. For instance, it would be informative to comparatively study obese individuals in the community who are not seeking treatment as well as individuals who are seeking different modalities of treatment.
2- The sample did not include males.
3- The sample was composed primarily of certain age group (15-49). Thus, the study was limited to that age group.
4- The current study focused on body image and depression. Also the relationship between BMI and many psychological aspects should be taken in consideration (e.g., anxiety, self-esteem, and binge eating…).
5- Finally, The design of our study was cross-sectional; a temporal relation between obesity and depression and body image distortion could not be inferred.

Conclusion
The results of our study show significance statistical symptoms of depression and a high degree of preoccupation with body image in obese individuals presenting for clinical weight-loss in comparing to normal weight persons.
The researchers propose that depression and body-image dissatisfaction may be a factor that should be evaluated with obese patients seeking residential weight-loss treatment, and when evident, should become one target of intervention efforts. One could readily imagine that ability to lose weight would be improved by relief of depression, anxiety, poor self-esteem, or body image distress.

Recommendations
1- It is recommended in the next researches to examine:
(a) The interaction of predictor variables (e.g., age of onset of obesity, teasing, and stigma experiences); (b) Factors that explain how important body image is to health and well-being of individuals; (c) How body image problems in obese individuals are best remedied; and (d) How body image problems can be prevented.
2- An approach that included education about the biological and psychological determinants of body weight, weight loss, and weight regain in highly indicated.
3- It is important to evaluate and treat depression in persons who seek medical treatment for severe obesity, and it may be that routine screening for depression should be formulated as the standard of care for these patients.
4- Body-image treatment programs designed for obese clients are highly indicated that overweight individuals can develop more positive feelings and beliefs about their appearance, regardless of weight loss. Directly addressing body-image dissatisfaction may decrease psychological distress and facilitate weight reduction and improved eating behaviors.
5- Further studies on community basis, including both male and females are highly required to examine depression and body image dissatisfaction of obese individuals.

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Correspondence Address
Dr. Moataz Abdel-Fattah, PhD
Head and Consultant of Preventive Medicine department
Al-Hada Armed Forces Hospital
Taif, Saudi Arabia
e-Mail: mezo106@yahoo.com, mezo106@gmail.com
Tel: 00966508741383
Fax: 00966027541238