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/m 2 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
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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
BODY MASS INDEX AND MENTAL HEALTH STATUS 3
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.
BODY MASS INDEX AND MENTAL HEALTH STATUS 4
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.
BODY MASS INDEX AND MENTAL HEALTH STATUS 5
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.
BODY MASS INDEX AND MENTAL HEALTH STATUS 6
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
BODY MASS INDEX AND MENTAL HEALTH STATUS 7
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).
BODY MASS INDEX AND MENTAL HEALTH STATUS 8
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
BODY MASS INDEX AND MENTAL HEALTH STATUS 9
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
BODY MASS INDEX AND MENTAL HEALTH STATUS 10
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
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)