Weight, Weight Perception and Psychiatric Distress in Freshmen at a National University in Hualien County

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1 ORIGINAL ARTICLE Weight, Weight Perception and Psychiatric Distress in Freshmen at a National University in Hualien County Yin-Ming Li, Chen-Chung Fu 1 Departments of Family Medicine, Internal Medicine 1, Buddhist Tzu Chi General Hospital, Hualien, Taiwan ABSTRACT Objectives: To investigate the prevalence of abnormal weight, weight perception and psychiatric distress in university freshmen. Materials and Methods: A physical checkup of freshmen at a national University was conducted in Well-trained staff measured students height and weight. Self-perceptions of weight status, health, distress about physical development, difficulty in making friends, personality scale, and Brief Symptoms Rating Scale (BSRS) were measured by a structured questionnaire. Results: Of 825 subjects, the overall prevalence of overweight students (at risk of obesity) was 12.7%, 14.8% in the men and 9.7% in the women. A further 15.4% of men and 10.6% of women were obese. The overall prevalence of high depressive symptoms, anxiety and psychiatric morbidity were 16.0%, 20.0% and 25.1%, respectively. High anxiety symptoms were more likely to be positive among those who were overweight (men 26.3%, women 25.9%) but were not significantly different from gender. Women who actually had a normal weight had the highest rate of psychiatric morbidity (28.6%). One out of ten subjects was underweight or overweight and had psychiatric morbidity. Among subjects with normal weights, 14.7% had psychiatric morbidity. Compared with the objective body weight status defined by the International Obesity Task Force, women were more likely to misperceive themselves as overweight whereas relatively more men missclassified their weight status as underweight. Subjects who perceived their health as worse than their peers, and those who had high neurotic traits and low self-acceptance were more likely to have psychiatric morbidity (p<0.05). Conclusions: Abnormal weight and distortion of weight, and psychiatric morbidity were prevalent among young adults. There was no significant association between abnormal weight and psychiatric morbidity. High neurotic traits and low self-acceptance were significant factors predicting psychiatric morbidity. These findings may have significant implications for both public health and clinical interventions directed at young adults with abnormal weights. (Tzu Chi Med J 2005; 17: ) Key words: weight perception, psychiatric morbidity, personality trait, freshmen, Hualien County INTRODUCTION The prevalence of obesity among children and adolescents has increased gradually and is a major global public health problem because of its health consequences and the greater risk of obesity in adulthood [1-5]. The growing epidemic of child and adolescent obesity deserves attention because of its immediate mental health and long-term medical complications. Adolescent overweight/obesity is associated with poor physical and psychosocial health in clinical samples [5,6]. However, there is little information on the health status of overweight and obese young adults. Studies have found high rates of psychological disorders in obese young adults, especially in women [6-8]. Depressed mood at baseline predicts obesity among those who are not obese at baseline. Women are at greater risk of self-esteem problems. Stunkard et al (2001) found a positive relationship between neuroticism and body mass index (BMI) in women but not in men [9]. More studies on the relationship between obesity and mental Received: August 26, 2004, Revised: September 24, 2004, Accepted: November 24, 2004 Address reprint requests and correspondence to: Dr. Yin-Ming Li, Department of Family Medicine, Buddhist Tzu Chi General Hospital, 707, Section 3, Chung Yang Road, Hualien, Taiwan NSV

2 Y. M. Li, C. C. Fu health are needed to aid in prevention and treatment strategies. The aims of this study were to study the prevalence of obesity and psychiatric distress among university freshmen and to evaluate their association. MATERIALS AND METHODS In September 2001, a physical checkup of freshmen at a national University was conducted. The height and weight of each student were measured by well-trained staff. Height was recorded using a measuring tape, with the individual standing straight next to a wall, with the heels, buttocks, shoulders and occipitals touching the wall. Weight was measured using normal scales with the individual wearing light clothes and shoes. The weight was recorded to the nearest 100 g and the height to the nearest 0.1 cm. Overweight classification Body mass index (BMI) was based on weight in kilograms divided by height in square meters. Subjects were classified by the International Obesity Task Force (World Health Organization guidelines for the Asian Pacific population) into five BMI categories [10]: underweight (BMI less than 18.5 kg/m 2 ), normal weight ( kg/m 2 ), at risk of obesity (BMI between kg/m 2 ), obesity I (BMI kg/m 2 ), and obesity II (equal to or more than 30.0 kg/m 2 ). Since only 3.7% of men and 3.8% of women were in the obesity II category, a combined obesity category (25.0 kg/m 2 or over) was used. A self-administered questionnaire was used. It included: (1) demographic characteristics: age, sex, school performance; (2) personality: neurotic traits and self acceptance; (3) self perceived psychiatric symptoms; (4) self-rated health compared to peers in similar age groups (better, normal or worse); (5) self-perception of weight status (in terms of the following response options: relatively thin, normal, overweight and obese); and (6) distress about his/her development and difficulty making friends with the opposite sex. The scale of neurotic traits [11] consisted of 10 items, with yes or no responses. Yes answers were summed to yield a total score ranging from 0-10 (low to high level for neurotic traits). The internal consistency coefficient of the neurotic scale was 0.64 [12]. The scale of self-acceptance included 7 questions with answers rated as follows: 0= not agree, 1= not sure and 2= agree. Scores of the scale ranged from 0-14 and its Cronbach s α coefficient was 0.79 [12]. We defined scores equal or over the mean plus one standard deviation as high self-acceptance for the self-acceptance scale and positive neurotic traits on the neurotic scale. The Short form of the Brief Symptoms Rating Scale (BSRS-5) was employed to assess psychiatric morbidity. The BSRS-5 consists of 5 psychopathology items, anxiety, hostility, depression, inferiority and sleep disturbance, selected from its parental form, the BSRS- 50. Scales were self-rated by students on a 5 point scale of symptoms of severe distress experienced during the previous week (0 for none and 4 for very severe). Scores of the scale ranged from Internal consistency (Cronbach α) coefficients of the BSRS-5 ranged from The BSRS-5 has been tested and may be used to identify psychiatric morbidity in both medical practice and the community. Choosing 6+ as the cut-off score for psychiatric morbidity, the rate of accurate classification of the BSRS-5 was 76.3% (78.9 % sensitivity, 74.3% specificity, 69.9% positive predictive value)[13]. The standardized Cronbach α coefficient was 0.79 in this study. Depressive and anxiety symptoms Items of depressive mood and anxiety were also selected from the parental form (BSRS) to evaluate more specific symptoms of depression and anxiety. Subjects were asked to rate the frequency of each symptom during the past week on a 5-point Likert scale of symptoms of severe distress (0 for none and 4 for very severe). The short form depressive items were: (1) feeling lonely, (2) feeling blue, (3) feeling hopeless about the future, (4) feeling of worthlessness, and (5) feeling no interest; The internal consistency as reflected by the Cronbach α coefficient of depressive symptoms in the current sample was Five items of anxiety symptoms were: (1) feeling fearful, (2) feeling tense or keyed up, (3) spells of terror or panic, (4) feeling something bad is going to happen to him/her and (5) thoughts and images of a frightening nature. The Cronbach α coefficient of anxiety symptoms in our sample was Statistical analysis Subjects were grouped into three weight categories, underweight, normal and overweight at analysis. Descriptive statistics (mean, standard deviation, and percentage) were calculated to reflect the background characteristics of subjects. Chi-square tests and independent Student s t tests were used to compare the frequencies and continuous data. Multivariable logistic regression was used to assess covariates of psychiatric morbidity. The significance level was set at Statistical analyses were carried out using SAS (version 8.2); NTM

3 SAS Institute, Cary, NC, USA. RESULTS Of 908 freshmen, 825 (91.0%) subjects completed the questionnaire and physical check up. Among the subjects, 486 (58.8%) were men and 339 (41.2%) were women. The mean (±standard deviation) ages for men and women were 18.6(±1.2) and 18.4(±1.0), respectively (Table 1). The overall prevalence of those at risk of obesity (BMI ) was 12.7%, 14.8% in men and 9.7% in women. A further 15.4% of men and 10.6% of women were obese (BMI 25 or over). The rates of men and women who were underweight (BMI less than 18.5) were 13.4% and 21.8%, respectively (χ 2 =5.78, p=0.01). The gender difference in the rates of those underweight and overweight was significant (overweight: χ 2 = 5.94, p <0.01). Perceived weight, self-rated health status and personality traits were assessed by BMI category (Tables 2, 3). About 30.2% of the men and 45.8% of the women reported he/she was overweight. Comparing perceived weight categories to actual weight categories, 35.1% (289/824) of subjects misclassified their body weight status with 19.2% (n=158) overestimating and 15.9% (n=131) underestimating his/her weight. Women who were actually normal weight or underweight were more likely than men to describe themselves as relatively overweight (26.3% vs 7.0%, χ 2 = 58.69, p < 0.01). Men who were actually normal weight or overweight were more likely than women to see themselves as underweight (18.5% vs 2.7%, χ 2 =47.41, p< 0.01). Totally, 17.7% subjects self-rated their health as worse than their peers. One-fourth of subjects who were actually underweight (women 25.7%, men 24.5%) and 30% of subjects who were actually overweight or obese rated their health as worse than their peers. The percentages of those who reported distress about physical development and difficulty in making friends with the opposite sex were not significantly different among weight categories stratified by gender. Table 1. Characteristics of University Freshmen by Gender Male Female Total N=486 (%) N=339 (%) P N=825 (%) Age (years, mean, SD) 18.6 ( 1.2) 18.4 ( 1.0) ( 1.2) BMI (kg/m 2, mean, SD) 22.0 ( 3.6) 20.9 ( 3.9) < ( 3.7) BMI category+ < 0.01 <18.5 (under weight) 65 (13.4) 74 (21.8) 139 (16.9) (normal weight) 274 (56.4) 196 (57.8) 470 (57.0) (at risk of obesity) 72 (14.8) 33 ( 9.7) 105 (12.7) 25 or over (obesity) 75 (15.4) 36 (10.6) 111 (13.5) Self acceptance (0-14) Mean Score (SD) 9.9 ( 3.1) 10.1 ( 2.9) ( 3.0) High self acceptance ( 13, %) 113 (23.2) 74 (21.8) (22.7) Neurotic trait (0-10) Mean Score (SD) 4.6 ( 2.3) 4.8 ( 2.1) ( 2.2) Positive Neurotic trait ( 6.9,%) 108 (22.2) 87 (25.7) (23.6) Depressive symptoms Mean score (SD) 4.1 ( 3.4) 3.8 ( 3.1) ( 3.3) High depressive symptoms ( 7.2,%) 74 (17.6) 41 (13.8) (16.0) Anxiety symptoms Mean score (SD) 2.8 ( 3.0) 2.7 ( 2.7) ( 2.9) High anxiety symptoms ( 5.7,%) 78 (22.4) 45 (16.9) (20.0) Psychiatric morbidity BSRS-5,Mean score (SD) 4.7 ( 3.4) 4.8 ( 3.1) ( 3.3) Yes (> 6) 118 (24.5) 89 (26.3) (25.1) No ( 6) 368 (75.5) 250 (73.7) 618 (74.9) BMI and psychiatric morbidity 0.63 Normal weight and no psychiatric morbidity 209 (43.0) 140 (41.3) 346 (41.9) Abnormal weight and no psychiatric morbidity 159 (32.7) 110 (32.5) 269 (32.6) Normal weight but with psychiatric morbidity 65 (13.4) 56 (16.5) 121 (14.7) Abnormal weight and with psychiatric morbidity 53 (10.9) 33 ( 9.7) 86 (10.4) BMI: body mass index; +: Classification of weight by BMI in adult Asia (WHO 2000) NTN

4 Y. M. Li, C. C. Fu Personality traits in terms of self-acceptance and neurotic traits were not significantly different between women and men (self-acceptance: t= p=0.33; neurotic trait: t= -1.69, p=0.09). The mean score of selfacceptance for all subjects was 10.0 (SD 3.0). One of five had high self-acceptance (score 13 and above). Men had higher self-acceptance than women (23.2% vs 21.8%, χ 2 =0.23, p=0.631). Of all subjects, one of four had high neurotic traits (score 6.9 and above). Women were more likely to have high neurotic traits (25.7% vs 22.2%, χ 2 =1.31, p=0.25). The mean scores and the proportions of high scores were not significantly different between genders. The mean score of depressive symptoms for all subjects was 3.9 (SD 3.3); 16.0% had positive depressive symptoms (score 7.2 and above). Men were more likely than women to have high depressive symptoms (17.6% vs 13.8%, χ 2 =1.89, p=0.17). One of five subjects had high anxiety symptoms (score 5.7 and above). Men were also more likely than women to have high anxiety symptoms (22.4% vs 16.9%, χ 2 =2.86, p=0.09). High anxiety symptoms were more common among those who were overweight (male 26.3%, female 25.9%) but the difference was not significant. Women experienced higher depressive and anxiety symptoms with increasing weight but the result was not significantly different. The prevalence of high depressive and anxiety symptoms among the three weight categories was not significantly different between sexes. No significant differences were found in depressive symptoms, anxiety symptoms and psychiatric distress for either men or women who perceived themselves as underweight, normal weight or overweight (data not shown). Women had a higher mean BSRS-5 score (4.8, SD 3.1) than men (4.7, SD 3.5) (t=0.66, P=0.51). Based on the cut-off of the BSRS-5, women were more likely than men to have psychiatric morbidity (BSRS-5 >6) (26.4% vs 24.5%, χ 2 =0.40, p=0.52) but the difference was not significant. Women who were actually normal weight had the highest rate of psychiatric morbidity (28.6%). The prevalence of positive psychiatric morbidity was proportionally higher among men with increasing weight Table 2. Self-Rated Health and Personality Trait among Male Freshmen by Weight Actual Weight Category Under weight Normal Over weight χ 2 p N=65 (%) N=274 (%) N=147(%) Self perceived weight <0.01 Overweight 1 ( 1.5) 32 (11.7) 114 (67.5) Normal 4 ( 6.2) 155 (56.7) 29 (19.3) underweight 60 (93.3) 86 (31.3) 4 ( 2.7) Self rate health Better 7 (10.8) 36 (13.9) 29 (19.7) Normal 42 (64.6) 192 (70.3) 95 (28.9) Worse 16 (24.5) 45 (16.5) 23 (15.7) Distress about physical development No 22 (34.9) 115 (42.3) 57 (39.0) Yes 41 (65.1) 41 (57.7) 89 (61.0) Making friends with opposite sex No difficulty 31 (48.4) 125 (45.8) 75 (51.0) With difficulty 33 (51.7) 148 (54.2) 72 (49.0) High Self acceptance Yes ( 13) 52 (82.5) 211 (77.3) 50 (72.4) No (<13) 11 (17.5) 62 (22.7) 40 (27.6) High Neurotic trait Yes ( 6.9) 13 (20.6) 62 (22.8) 33 (23.4) No (< 6.9) 52 (79.4) 210 (77.2) 108 (77.6) High Depressive symptoms Yes ( 7.2) 7 (12.1) 43 (17.9) 24 (19.7) No (< 7.2) 51 (87.9) 197 (82.1) 98 (80.3) High Anxiety symptoms Yes ( 5.7) 12 (23.5) 40 ( 20.1) 26 (26.3) No (< 5.7) 39 (76.5) 159 (80.0) 73 (73.3) Psychiatric morbidity (BSRS-5) Yes (> 6) 15 (23.1) 65 (23.7) 38 (25.9) No ( 6) 50 (76.9) 209 (76.3) 109 (74.2) NTO

5 but it was not significantly different. Six of the 30 severely obese (BMI 30) subjects had psychiatric morbidity. Being overweight or underweight was not a significant factor associated with psychiatric distress. Psychiatric morbidity was positively correlated with neurotic traits (r=0.59, p <0.01), depressive symptoms (r=0.80, p<0.01) and anxiety symptoms (r= 0.74, p<0.01). The correlations of body mass index to psychiatric morbidity and depressive or anxiety symptoms were not significant (data not shown). To assess the multivariate analysis of covariates of psychiatric morbidity (BSRS-5 >6), logistic regression analysis was performed. In the logistic model of the 205 subjects with psychiatric morbidity, the chi-square = , DF=3, and p < This showed that neurotic traits was the most important factor predicting psychiatric morbidity (OR 6.82, 95% CI 4.73, 9.80). Low selfacceptance was the second most important factor (OR 2.27, 95% CI 1.36, 3.80). Health self-rated as worse than peers (OR 2.43, 95% CI 1.59, 3.72) was also an important factor associated with psychiatric morbidity. The coincidence of abnormal weight and psychiatric morbidity is shown in Table 1. Totally, one out of ten subjects was underweight or overweight and had psychiatric morbidity. One third of the subjects were underweight or overweight and had no psychiatric morbidity. For those with normal weight, 14.7% had psychiatric morbidity. DISCUSSION In our study, 13.5% of subjects were obese and 12.7% were overweight. Men were more prone to be overweight or obese than women (overweight 14.8% vs 9.7%, obesity 15.4% vs 10.6%), while women were more prone to be underweight than men (21.8% vs 13.4%). This difference between genders was also noted in other studies [1,2,4,14-16] and may reflect present ideas and Table 3. Self-Rated Health and Personality Trait among Female Freshmen by Weight Actual Weight Category Under weight Normal N=74 (%) N=196 (%) Over weight N=69 (%) χ 2 p Self perceived weight <0.01 Overweight 1 ( 1.4) 88 (45.2) 66 (95.7) Normal 31 (41.9) 98 (50.3) 3 ( 4.3) Thin 42 (56.8) 9 ( 4.6) 0 ( 0.0) Self rate health Better 5 ( 6.8) 18 ( 9.3) 7 (10.2) Normal 50 (67.6) 144 (74.2) 51 (73.9) Worse 19 (25.7) 32 (16.5) 11 (15.9) Distress about physical Development No 22 (30.0) 65 (33.5) 18 (26.5) Yes 51 (69.9) 129 (66.5) 50 (73.5) Making friends with opposite sex No difficulty 37 (50.0) 98 (50.0) 38 (56.7) With difficulty 37 (50.0) 98 (50.0) 29 (43.3) High Self acceptance Yes ( 13) 19 (25.7) 40 (20.5) 15 (22.1) No (<13) 55 (74.3) 156 (79.5) 23 (77.9) High Neurotic trait Yes ( 6.9) 16 (21.6) 55 (28.2) 16 (23.5) No (<6.9) 58 (78.4) 140 (71.8) 52 (76.5) High Depressive symptoms Yes ( 7.2) 6 ( 9.2) 25 (14.6) 10 (16.4) No (< 7.2) 59 (90.8) 146 (85.4) 51 (83.6) High Anxiety symptoms Yes ( 5.7) 5 ( 8.8) 26 (16.6) 14 (25.9) No (< 5.7) 52 (91.2) 130 (83.3) 40 (74.1) Psychiatric morbidity (BSRS-5) Yes (> 6) 15 (20.3) 56 (28.6) 18 (26.1) No ( 6) 59 (79.8) 140 (71.4) 51 (73.9) NTP

6 Y. M. Li, C. C. Fu wishes among women in most of countries to be slim. Young adults have become increasingly overweight during the past decades [1,2,4]. Our results also showed that the burden of being overweight is high. Obesity in early adulthood is more strongly associated with increased risks of all-cause and cardiovascular disease mortality [17-19]. The growing epidemic of young adults who are overweight deserves attention because of its immediate mental health and long-term medical complications. We need to reduce the number of overweight young adults to reduce the burden of future chronic disease. Also, underweight young adults should not be neglected. We should counsel them on how to keep a healthy weight to prevent anemia or poor bone density. Jan et al conducted a similar study at a national university at Taipei. The prevalences of underweight, overweight and obesity among men were 9.6%, 16.5% and 16.4% respectively; among women the prevalences were 24.0%, 8.5% and 6.2% respectively [14]. The prevalence of underweight among women was similar in two studies but more men were underweight in our study (13.4%) [14]. Striking differences in obesity prevalence were found among females in two studies [14]. Further studies are needed to investigate the differences. The comparison of the subjects self-perceived weight status with actual BMI revealed that many misperceived themselves as being either underweight or overweight. In our study, 30.9% of men described themselves as underweight, among which 40% of them were actually underweight, 57.3% were actually normal weight, and only four were overweight. In other words, 60.0% of the men misclassified themselves as underweight. In our study, of the 155 (45.7%) women who described themselves as overweight, 56.7% were actually normal weight and one was even underweight. Women were more likely to misperceive themselves as overweight, whereas relatively more males misclassified themselves as underweight. The results were consistent with previous findings about self-perception of body weight status in United States [20-22] and Chinese adolescents [8,23]. Self-perception of body weight may be influenced by many factors. Sociocultural factors including pressure from peers, parents and the media may affect young adults weight norms. Standards of muscularity for males and sliminess for females seem to play an important role for adolescents in setting their own body image standards, even if these standards are unhealthy or unrealistic [21-23]. Although the self-perceived health status was a reflection of personal thought, surprisingly, 84.3% of the overweight subjects did not believe they had a health problem, categorizing their health as normal or better than their peers in this survey. Wrongly perceived health status in overweight young adults deserves attention since the wrong perception could lessen motivation to reduce weight. Health education is necessary to enforce young adults understanding of obesity and its risks. In our study, we found no significant, positive relationships between abnormal body weight, perceived weight, and psychiatric morbidity. Overweight women were not more likely to suffer psychiatric symptoms than those who were normal weight or underweight. Several cross-sectional and prospective studies have shown an increased risk for psychiatric morbidity among overweight women [7-9]. However, studies have also reported depression mainly among persons with severe obesity and a weak relationship between relative body weight and psychiatric distress among women but not men [6,24]. A prospective study showed an association between obesity and depression but not a significant risk factor for depression in multivariate analyses [25]. Our findings suggested that a neurotic personality and low self-acceptance are predictors of detrimental psychological effects. Negative emotional states predict poor weight control treatment outcomes, particularly for obese women [26]. We suggest promotion of mood management and self-efficacy should be considered in weight control program design. Further studies should address associations among eating behaviors, physical activity, weight concerns and a person s actual body. This study had several limitations. First, this was a cross-sectional study; a temporal relationship between being overweight and psychiatric morbidity could not be inferred. Second, we had data only on youths between 17 and 21 years old from one university. Thus, the study was limited to that age group and may not be generalized to other populations; and third, psychiatric morbidity was not a clinical diagnosis. However, to our knowledge, this is the only study that has assessed the psychiatric distress of young adults with abnormal weights in Taiwan. We stratified the analysis by gender, which allowed us to identify gender-specific prevalence of abnormal weight and patterns of association. CONCLUSIONS Abnormal weight is common in young adults. High neurotic traits and low self-acceptance were important factors associated with psychiatric morbidity. Obesity deserves attention because of its immediate mental health and long-term medical complications. Health and weight NTQ

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