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BODY MASS INDEX AND MENTAL HEALTH STATUS 2

The Relationship between Body Mass Index and Mental Health Status

1.0 Introduction

Nowadays, in the developing countries obesity can be represented as a major public health

problem (Doll, Petersen & Steward-Brown, 2000). As reported by World Health Organization

(WHO) in 2013, the numbers of people in the state of overweight and obesity are estimated to be

1.4 billion adults with over 200 million men and 300 million women approximately. According

to Marylin, Malaysia ranked top of the obese country in Southeast Asia (Hazim, Hartini &

Shamsuddin, 2014). Based on the quality-studies, overweight and obesity levels were highest

among people in the age between 40 to 59 years old of adult (Khambalia & Seen, 2010). Higher

BMI increased vascular mortality, while lower BMI increased deaths from vascular diseases,

cancers, and, especially, respiratory diseases (Hong, Yi, & Sull, 2015). Obesity is defined as a

condition of excessive fat accumulation in adipose tissue, which may affect physical health

(Jokela, 2012). In term of Body Mass Index (BMI), obesity is defined when someone has BMI

reading 30kg/m2 and over (Lee & Yen, 2014).

Zivin et al. (2009) reported the number of cases related to mental health problems among

people are increasing every year (Che, Asbah & Rajalingam, 2013). World Health Organization

reported that up to 450 million people suffer from a mental disorder. Plus, four out of six people

suffered from neuropsychiatric disorders (WHO, 2003). It has been reported that nowadays,

Malaysian teenagers experienced a quite high rates of mental health problems and it can be seen

from the percentage of emotional problems is 49% and aggressiveness is 41% (Teoh, Woo &

Chong, n.d). A survey report by National Health and Morbidity Survey 2011 stated that, among

the adults (16 years and above) experienced 1.7% (0.3 million) have Generalised Anxiety


Disorders, 1.8% (0.3 million) have current depression, 1.7% (0.3 million) have suicidal ideation

and 1.1% (0.2 million) reported to have attempted suicide in the past (NHMS, 2011). A report

from Ministry of Health Malaysia demonstrated that about 11% of Malaysian in the age between

18 to 60 experienced mental health illness such as stress, anxiety and depression (Malaysian

Welfare Report) (Laporan Kesejahteraan Rakyat Malaysia, 2013). The example of mental health

diseases are depression, anxiety and stress (Mumford, Liu, Hair & Yu, 2013). Jokela (2012)

reported that depression and anxiety are part of the dangerous mental illnesses that can affect our

community nowadays.

Previous research shows obesity has a positive association with the level of mental health

in an individual. Mumford et al. (2013) stated that obesity can lead someone into depression. In

addition, Becker, Margraf, Turke, Soder, and Neumer (2001) reported that obesity can increase

the rates mental disorder of “unhealthy BMI” person especially in anxiety disorder. Furthermore,

Baumeister and Harter (2007) verified there is association between body weight and stress as

they found out people who were in the state of obese experienced the most frequent mental

health occurrence reported such as mood, anxiety and somatoform disorders. Nonetheless,

according to Barber, Bayer and Pietrzak, (2011), there was no relationship between obesity and

mental health.

Hence, this study plans to examine the relationship between BMI and mental health status

in term of depression, anxiety and stress. This present research is to find out whether body

weight can contribute the changes in term of mental health status within the Malaysian context.


1.1 Statement of Problem

As mentioned by Marylin, Malaysia ranked as the most obese country in Southeast Asia, and

followed by the Asia-Pacific in the sixth rank. (Hazim et al., 2014). World Health Organization

(2000) recorded among adults aged 18 to 60 years in Malaysia, 4.7% of men and 7.9% of women

were found to have BMI above 30. Indian population shows more serious overweight and

obesity problem which are 17.7%, compared to Malay which are 8.8% and Chinese, 4.3% (p.

30). A lot of researches stated that obesity can lead to several numbers of mental health problems

(Lee et al., 2014; Doll et al., 2000; Mumford, Liu, Hair & Yu, 2013). For example, psychological

status which is significant with the unhealthy weight are depression (Mumford, 2013; Lee et al.,

2014; Mukamal, Kawachi, Miller & Rimm, 2007) as well as anxiety (Lee et al., 2014; Mumford

et al., 2013; Mukamal et al., 2007; Zhao, Ford, Dhingra, Li1, Strine & Mokdad, 2009) and stress

(Lee et al., 2014; Mumford et al., 2013; Zhao et al., 2009).

According to those past researches, it is proved that obesity is among the major issues

that may risk the status of mental health. Taking care of physical health especially in term of

body weight is one of essential aspects in order to maintain individual mental well-being. Thus,

in order to sustain the status of mental health, individual should keep their body weight in the

state of “healthy weight”. However, there are limited number of studies regarding body mass

index and mental health status within the Malaysian context. In response to this problem, this

present study propose to investigate the issue of obesity in relation with the status of mental

health. Hence, this research is design to discover the association between body mass index and

mental health status within Malaysian context.


1.2 Significance of the study

The present research is important to be conducted because it can provide the information

regarding the issue of body weight and mental health status. Furthermore, as there was a few

numbers of researches has been conducted which examine the relationship between BMI and

mental health in the context of Malaysia, therefore, this study will review on this particular

relationship specifically in the population of International Islamic University Malaysia. As a

result of discovering this particular topics, solutions can be proposed to remedy this problem,

ensuring people know the importance of keeping an ideal weight in order to sustain mental

health well-being. This study would be expected to create the awareness on the importance of

taking care their physical body to avoid negative influences on mental health.

1.3 Research Objective

This study aimed to examine the following:-

1.3.1 The association between BMI and mental health status which includes depression,

anxiety and stress among IIUM students.

1.3.2 The level of mental health status of IIUM students.


1.4 Research Question

This present study aims to answer the following research question:

1. What are the level of BMI among IIUM students?

2. What are the level of mental health status among IIUM students?

3. What are the relationship between BMI and mental health status among IIUM students?

4. Is there any significant differences between the “healthy BMI group” and the “unhealthy

BMI group” in term of mental health status?

2.0 Literature Review

2.0.1 BMI and depression

According to past researches, it showed higher rates of obesity in persons with depression (Pratt

& Brody, 2014). According to Pratt and Brody (2014), in 2005–2010, 34.6% of U.S. adults aged

20 and over were obese and 7.2% had depression. A study conducted by Mumford et al. (2013)

among adults found out that, individuals who were in the state of obese may experience

depression. In addition, Lykouras & Michopoulos (2011) also stated that normally, obesity will

be accompanied with depression, low self-esteem, hard to adjust themselves with society and

interpersonal problem.

On the other hand, there are also researches that found out depression can lead to obesity

which turns the other way round. A study conducted by Needham, Epel, Adler & Kiefe (2010) in

order to see the association between depressions and the changes of body weight. Result showed

that respondents who already with higher levels of depressive symptoms, experienced a quicker

rate of raising in BMI than those who reported fewer symptoms of depression. Another research


proved depression can lead someone to obese was conducted by Maguen, Madden and

Bertenthal (2013). The study had been conducted among Iraqi and Afghanistan veterans. The

finding showed that veterans with depression were at the highest risk to either be obese without

weight loss or overweight or obese and continuing to gain weight. Moreover, people in the state

of depression may gain weight faster than people who are not in the state of depression (Ladwig,

2006).

On top of that, there were also differences of the findings between BMI and mental health

in term of gender. According to Zhao et al. (2009), men who underweight were 85% more likely

have diagnosed depression during their lives, and those who had BMI > 40 kg/m2 (severely

obese), 38% of them are more likely experience current depression, 40% more likely have

lifetime diagnosed depression and 42% more likely have lifetime diagnosed anxiety. Meanwhile,

obese women also show correlation with depression (Baumeister & Harter, 2007). A research

conducted by Zhao et al. (2009) stated those who had BMI more than 25kg/m2 (overweight and

obesity) experienced higher prevalence of depression than men. Moreover, among the women

who are either overweight or obese, 17 to 31% more likely experience current depression and

17% to 53% more likely have diagnosed depression.

The link between BMI and depression also showed differences in term of ethnic group.

According to Mumford et al. (2013), non-Hispanic whites had the lowest occurrence of current

depression yet, the highest occurrence of lifetime diagnosed depression. For non-Hispanic

blacks, it was reported that they had the lowest prevalence of lifetime diagnosed depression and

anxiety (Mumford et al., 2013).


2.0.2 BMI and anxiety

Another symptom of mental health which may have correlation with body weight is anxiety. A

longitudinal study had been conducted at Germany to investigate the prevalence rates of mental

disorder in obese people compared with physically healthy people by Baumeister and Harter in

2007. The study found out people who were in the state of obese experienced the most frequent

mental health incidence reported such as mood, anxiety and somatoform disorders. In term of

prevalence rates, overweight individuals got less rates compared to obese individuals. Moreover,

as compared to healthy probands, overweight and obese individuals were more likely display

more than one mental disorder. In short, according to this research there was a strong

relationship between obesity and mental disorder. Besides that, there was also another cross-

sectional research that examined the relationship of body mass index and anxiety by

Hatzenbuehler, Keyes and Hasin (2009). A study that had been conducted among US adults who

were in the state of overweight and obesity. The result demonstrated that obesity was

significantly associated with mental health such as anxiety and stress (Hatzenbuehler et al.,

2009). Another research that sought to ascertain the relationship of BMI and anxiety can be seen

in the research of Puhl and Heuer in 2009. The research was conducted upon US adults.

According to Puhl and Heuer (2009), when someone being discriminated for being obese, it was

significantly associated with mood and anxiety disorder and also other mental health issues such

as stress.

Other than that, the relationship of BMI and anxiety can be seen in term of gender. A

research conducted at United States of America (USA) by Zhao et al. (2009) sought to examine

the association of anxiety with body mass index with consideration of other psychosocial factors.

There was a significant relationship between anxiety and BMI in this study. The result was


varied by gender. In both male and female, anxiety is higher in both genders who were

underweight. Whereas, for overweight and obese the result showed higher only in women and

for severely obese, the rates of anxiety showed higher in men only (Zhao et al., 2009). Men tend

to experience anxiety disorder when they were in the state of underweight (Puhl & Heuer,

2010).Similarly, Puhl & Heuer (2010) also proved there was variety result in term of gender.

Puhl & Heuer (2010) stated that obese women are more socially discriminated than men which

may risk them to anxiety disorder.

Nonetheless, there was less numbers of studies conducted to scrutinize the influence of

anxiety on body weight. A future research should be conducted in order to analyze this

correlation.

2.0.3 BMI and stress

Stress is one of mental health that is going to be examine in this present research. Stress can be

seen into numbers of types and condition. As reported by Shaley (2009), there are differences

between Posttraumatic Stress Disorder (PTSD) and stress. PTSD is one of mental health illnesses

that should be treated where it had been listed in Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition (DSM-5). Whereas, Posttraumatic Stress (PTS) or stress is a common

responses when someone experiences stressful events. Stress also one of mental health

conditions that seemed to have correlations with body mass index. There are a lot of perceptions

and perspectives whether stress may influence the weight gain among people.

According to American Psychological Association (APA) survey, about one-fourth

Americans rate their stress level to the point scale of 8 to 10. As reported in the Hazard Health


Publications (2012), there is relationship between stress and appetite which may lead to obesity.

Physiologically, stress can both increase and decrease appetite of an individual. If someone

experience a temporary stress, it may shut down appetite as a hormone named corticotropin

which was released from hypothalamus, which suppresses appetite. In contrast, if stress

happened persistently, it may increase one’s appetite and arise the motivation to eat as a hormone

named cortisol was released from adrenal glands (http://www.health.harvard.edu, 2012).

Therefore, this situation might be the reason of BMI trajectory in an individual.

Numerous studies have documented associations between obesity and various forms of

psychological distress (Luppino, deWit, Bouvy, Stiinen & Cuiipers, 2010). A research conducted

by Pagoto, Schneider and Bodenlos in 2012. This research aimed to examine the relationship

between PTSD and obesity of the US population. Among 20,013 participants, the highest rate of

obesity was among people with past year PTSD (32.6%), following with people with history of

PTSD which is (25.5%) and those with no PTSD (24.1%) (Pagoto et al., 2012). Therefore, it was

proved that PTSD may lead to obesity. Additionally, as reported by Kubzansky, Bordelois and

Jun (2014), posttraumatic stress disorder (PTSD) may give a possible factor for weight gain and

also obesity. This symptom could lead the weight gain faster and may increase risk of obesity in

women. Plus, greater numbers of PTSD symptoms were associated with greater BMI increases

over time. The result was equivalent with the study conducted at Virginia among 252 male

veterans by Vieweg, Fernandez, Julius, Satterwhite and Benesek in 2006. This research was to

examine the BMI among PTSD veterans. The result demonstrated there was positive relationship

between BMI and PTSD. It showed that veterans with PTSD tend to gain weight and, to be

overweight (37%) or obese (39.7%) and severely obese (6.7%) (Vieweg et al., 2006). Therefore,

from those retrospective researches, it showed that there are high correlation between PTSD and

http://www.health.harvard.edu/


obesity in an individual. Furthermore, another study that may prove PTSD has a high correlation

with obesity is from a study by Perkonigg, Toshimi, and Stein (2009) which has been conducted

in Germany. This study aim to scrutinize the association between PTSD and obesity among

adults. The finding showed there was association adults with a lifetime PTSD with obesity.

Other than PTSD, psychosocial stress may also lead someone in gaining a high BMI. A

research by Dallman (2010) which has been conducted at San Francisco sought to examine the

relationship of stress toward obesity. In this study, Dallman (2010) stated that stress can arise

eating behaviors and this situation may lead to obesity among people. It was also reported that

stress can influence eating pattern of a person. In the other word, stress can incline the

motivation of someone to eat often. In addition, Dallman (2010) also found out that stress can

also cause the secretion of glucocorticoids, a hormone which can incline appetite hence lead one

to obese. The result demonstrated that people who are overweight at the first place tend to

experience weight gain when stress. . In contrast, those people with underweight do not

experience the same situation (Dallman, 2010). Besides that, there was a study that has been

conducted in US to see the relationship of psychosocial stress and the changes of BMI among

adults by Block, Yulei, Zaslavsky, Lin, and Ayanian in 2009. This longitudinal study assessed

from 1995 to 2004 and sought to determine the level of BMI in term of gender. This particular

study measured the changes of body weight by numerous domains which are psychosocial stress

related to work, personal relationships, life constraints, and finances. The result showed that

psychosocial stress has a high correlation with inclination of body weight for both gender.

However, women had higher level of psychological stress compared to men (Block et al., 2009).

There were differences finding on the association PTSD and obesity between male and

female. According to Perkonigg et al. in 2009, it was reported that there was a significant


association between obesity threshold lifetimes PTSD among women. Perkonigg et al. (2009)

also reported that women with PTSD tend to obese rather than men. However, men tend to

overweight rather than women.

On the other hand, there was difference result in term of relationship of BMI and mental

health status according to Barber et al. (2011). Barber et al. (2011) conducted a study on sample

of Operation Iraqi Freedom Veterans which examined the relationship between weight and

trajectory of Posttraumatic Stress Disorder (PTSD). However, the result showed there were no

relationship between obesity and mental health.

Nevertheless, there was very few research that studied the other way round which is to

see the influences of obesity toward stress. A future research need to be conducted in order to

verify this association.

2.1 Conceptual Definition

Body Mass Index (BMI)

Body Mass Index (BMI) or also known as body weight is a formula to measure the ideal body

mass by calculating weight in kilograms divided by height in meters squared (WHO, 2003).

Mental Health Status

According to WHO, mental health is defined as when someone is in a good state of well-being

and can understand the potential in himself. In addition, it is also when someone can handle his


or her stressful life and can work productively thus he can contribute his potential to the

community (WHO, 2003).

Meanwhile, mental health status is defined as the level of the mental health itself. For

example, the level of depression which has been evaluated by using DASS21 scale. The higher

the result of depression scale, the lower the level of mental health status Nurasikin, Aini, Aida, &

Ng (2010). As a result, a low level of mental health can risk someone to experience mental

health illnesses such as schizophrenia, bipolar disorder and many more (Tran, Tran & Fisher,

2013).

Depression

The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack

of interest/involvement, anhedonia, and inertia (Willemsen, Markey, Declercq & Vanheule,

2010).

Anxiety

The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and

subjective experience of anxious affect (Willemsen et al., 2010).

Stress

The stress scale is sensitive to levels of chronic non-specific arousal. It assesses difficulty

relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient.

(Willemsen et al., 2010).


2.2 Operational Definition


According to World Health Organization, BMI is categorized into four groups which are

underweight, normal weight, overweight, and obese. Underweight is defined as BMI below 18.5,

normal weight between 18.5 and 24.9, overweight between 25 and 29.9, and obesity as BMI of

30 or higher. Therefore, obesity is defined when an individual’s BMI is more than 30kg/m2.

Mental health status

Mental health status will be measured by using DASS21. This scale was made by

Lovibond and Lovibond in 1995. In this scale, mental health is being measured in term of

depression, anxiety and stress.

According to the scale, items that evaluate depression are items number 2 (dryness of my

mouth), 4 (breathing difficulty), 7 (trembling), 9 (fool myself), 15 (panic), 19 (heartbeat) and 20

(scared). Next, items 3 (permissive), 5 (difficult to initiate things), 10 (demotivated), 13 (down-

hearted), 16 (not enthusiastic), 17(feel worthless) and 21(meaningless life) are to evaluate

anxiety. Meanwhile, stress are being evaluate from the item 1 (calm down), 6 (over-react), 8

(nervous), 11 (agitated), 12 (difficult to relax), 14 (intolerant), and 18 (touchy) (Pouralkhas,

Rajabi & Pishgar, 2012).

The result of DASS21 scale will be referred in order to determine the status of mental

health. If the score of mental health in term of depression, anxiety and stress are high therefore

the worse mental health status will be considered.


2.3 Theoretical framework

This present research sought to determine whether body mass index may influence the status of

mental health in an individual among students of International Islamic University Malaysia

(IIUM). It is based on the three construct of distress of DASS by Lovibond and Lovibond (1995)

which are depression, anxiety and stress. This study will sought to see mental health changes due

to the factor of body weight. For example, BMI more than 30kg/m2 will lead to low level of

mental health status. The relationship are important in order to understand that body weight may

lead the changes of individual level of mental health. Therefore, the hypothesis for this present

study to determine if there is any relationship between BMI and mental health status would be

there is relationship between BMI and mental health status in term of depression, anxiety and

stress.

3.0 Method and Procedures

Research Design

This study will use quantitative research design and correlation design to examine the

relationship between BMI and mental health status.

Participants

The participants of this research will be enrolled from undergraduate student of International

Islamic University Malaysia (IIUM) and the participant will be recruited by using random

sampling design. There are 200 students between the ages of 20 to 26 years old.


Procedures

The study will be divided into two parts: data collection part and data analysis part. Before

collecting the data, participants will be given informed consent form. Participants also will be

informed that they have rights to decline to participate and to withdraw from the research once it

has started. Participants also will be briefed that their details and information are private and

confidential. After that, the researcher will collect the BMI data by taking self-report from the

participants itself and distributing DASS 21 to the participants afterwards. After data collection

finished, the researchers will analyze the data by using Statistical Package for Social Science

(SPSS).

Measure


The participants’ BMI will be collected by self-report during the fill-up of demographic data

process. BMI is categorized into four groups which are underweight, normal weight, overweight,

and obese. Underweight is defined as BMI below 18.5, normal weight between 18.5 and 24.9,

overweight between 25 and 29.9, and obesity as BMI of 30 or higher.

Depression Anxiety Stress Scale 21 (DASS21)

Depression Anxiety Stress Scale 21 (DASS 21) will be used in this research. This scale is

suitable to use as it has been used before and the internal consistency (Cronbach’s alpha) of each

subscale is high (DASS21-D subscale 0.72; DASS21-A subscale 0.77; and DASS21-subscale


0.70). The overall score, which includes all items, also had high consistency (Cronbach’s alpha =

0.88) (Tran, Tran & Fisher, 2013).

DASS 21 is a brief version the scale of DASS 42 which measures depression, anxiety and

stress emotional states over the past week. DASS 21 contains 21 items which used four-point

evaluation scale (0: Did not apply to me at all, 1: Applied to me to some degree, or some of the

time, 2: Applied to me to a considerable degree, or a good part of time, 3: Applied to me very

much, or most of the time) to assess the level of mental health status which focus more on

depression, anxiety and stress. In order to obtain the scores of the depression, anxiety and stress

scale, the relevant of seven items should be sum up. The higher the scores, the severe the

emotional status. The samples of the items are ‘I felt that I had nothing to look forward to’

(depression) ‘I was aware of dryness of my mouth’ (anxiety) and ‘I found it difficult to relax’

(stress) (Meredith, Strong & Feeney, 2007).

Instead of DASS42, the present study will use DASS21 as the inventory as is shorter and

may reduce the administration of time which make it convenience to be answered by the

participants. Moreover, DASS21 always being administered by psychologists or clinicians via

pencil-and-paper questionnaires or structured clinical interviews (Antony, Bieling, Cox, Enns, &

Swinson, 1998) to examine the level of mental health, specifically depression, anxiety and stress

(Lovibond & Lovibond, 1995).


Data Analysis

This research will be analyze by using SPSS according to the variables itself which are

BMI and mental health status (depression, anxiety and stress). The data analysis will be

conducted in accordance to the research questions.

Descriptive statistics will be used to identify the frequency of general information such as

gender, age, marriage status and others. Moreover, the data of mental health status as a result of

DASS21 also will be used descriptive statistics. In addition, Pearson Correlation will be used to

analysis the relationship between BMI and mental health status. Furthermore, T-Test will be

used to analyze the significant differences between the “healthy BMI group” and the “unhealthy

BMI group” in term of mental health status.


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Appendix

Please tick ( ) wherever appropriate.

GENERAL INFORMATION

1. Name :

2. Matric Number :

2. Contact Number :

4. Age :

5. Gender: Male Female

6. Marriage Status Single Married

7. Nationality: Malaysian Non-Malaysian

8. Kuliyyah

AIKOL KENMS IRKHS ICT

KAED INSTEAD ENGIN Others: _________

9. Level of Study:

1st Year 2nd Year 5th Year

3rd Year 4th Year Others: _________

10. Weight:

11. Height:

12. Physical Health Status. Chronic Illness? (Example: Asthma, Cardiovascular, Diabetic, Hypertension, etc.)

Yes No

Please State: ________________________

FOR RESEARCHER USE

Serial Number : BMI : Category :

DEMOGRAPHIC SURVEY DATA


DAS S 21 Name: Date:

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past week . There are no right or wrong answers. Do not spend too much time on any statement.

The rating scale is as follows:

0 Did not apply to me at all

1 Applied to me to some degree, or some of the time 2 Applied to me to a considerable degree, or a good part of time 3 Applied to me very much, or most of the time

1 I found it hard to wind down 0 1 2 3

2 I was aware of dryness of my mouth 0 1 2 3

3 I couldn't seem to experience any positive feeling at all 0 1 2 3

4 I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion)

0 1 2 3

5 I found it difficult to work up the initiative to do things 0 1 2 3

6 I tended to over-react to situations 0 1 2 3

7 I experienced trembling (eg, in the hands) 0 1 2 3

8 I felt that I was using a lot of nervous energy 0 1 2 3

9 I was worried about situations in which I might panic and make a fool of myself

0 1 2 3

10 I felt that I had nothing to look forward to 0 1 2 3

11 I found myself getting agitated 0 1 2 3

12 I found it difficult to relax 0 1 2 3

13 I felt down-hearted and blue 0 1 2 3

14 I was intolerant of anything that kept me from getting on with what I was doing

0 1 2 3

15 I felt I was close to panic 0 1 2 3

16 I was unable to become enthusiastic about anything 0 1 2 3

17 I felt I wasn't worth much as a person 0 1 2 3

18 I felt that I was rather touchy 0 1 2 3

19 I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat)

0 1 2 3

20 I felt scared without any good reason 0 1 2 3

21 I felt that life was meaningless 0 1 2 3

draft ugrp 5.0 (2)

Documents

mental health status1

level of mental health

national health

ministry of health malaysia

world health organization

physical health jokela

obesity levels

dangerous mental illnesses