Introduction:
Overweight and obesity prevalence has increased markedly in recent years. As per the World Health Organization (WHO) global estimates in the year 2016, more than 1.9 billion adults, 18 years and above (i.e 39% of the adult population), are overweight (having body mass index (BMI) ≥25 kg/m2). Of these over 650 million (13%) are obese (BMI ≥30 kg/m2). (1) The problem of obesity has been particularly increasing in Kerala. A recent study conducted among adults of a rural community reports a prevalence of overweight and obesity as 24% and 40.7% respectively, as per WHO BMI guidelines for Asians. (2) Another study done among adolescent school children to find the lifestyle related risk factors for cardiovascular diseases showed that nearly 30% has overweight and obesity. (3)
Persons with severe mental illness have high risk of overweight, obesity and abdominal obesity both from the illness itself and from its treatment. (4) There is association between obesity and psychiatric disorders. A study done in Chinese seeking treatment for reducing obesity revealed that 42% having any one of the psychiatric disorders and the common psychiatric illness identified were mood disorders, anxiety disorders and eating disorders. (5)
Obesity is a major problem for persons with severe mental illness. A study done among fifty-one patients with severe mental illness who were long term inmates of regional New Zealand forensic and rehabilitation services found overweight or obesity in 94% of the study subjects, the mean BMI was 35.3, ± 8.1. (6) A national community survey conducted in Canada (n= 36,984), reports that persons having history of mood disorders are of high risk for obesity (19%) than those who are not having such a history (15%, p<0.05). (7) The prevalence of obesity is high among individuals with lifetime bipolar disorder and there are evidences for its association with illness severity also. (8) Mansur RB, Brietzke E, McIntyre RS report that mood disorders and obesity are inherently linked and share certain clinical, neurobiological, genetic and environmental factors and the relationship between mood disorders and obesity is described as concurrent and reciprocal. (9) Associations have been reported between obesity and depression (10) in the literature A prospective study done in a cohort of 66 000 US women aged between 54–79 years give evidence for a bidirectional association between these two conditions. (11) This bidirectional link between depression and obesity has also been reported in a systematic review of association studies of psychiatric disorders. (12)
Higher prevalence of obesity and diabetes were identified in patients with schizophrenia treated at Connecticut Community Mental Health Centre (USA) than the controls drawn from the same metropolitan area. The risk for obesity and diabetes were high (OR = 3.25, p= 0.000) and (OR = 2.42, p= 0.000 respectively) even after controlling for age, gender, race and presence of schizophrenia. (13) Overweight, metabolic syndrome and dyslipidemia are invariably seen in patients with schizophrenia because of several factors related to the disease related behavioural and habitual changes like irregularity of food intake, emotional intake, high sugar and fat consumption, and low energy usage because of sedentary life style resulting from variations in social and work routines. Additionally, the psychotropic medications contribute to gain in weight and metabolic changes in schizophrenia. (14) In patients with other psychotic illnesses usual symptoms like inactivity, psychomotor retardation, hypersomnia, increased appetite, and hyperphagia are believed to contribute to gain in weight. Literature suggests that individuals with severe mental illness have increased morbidity and mortality when compared to the general population and obesity has been identified as an important contributor to this problem. (15)
Eating habits of individuals may be interrupted on three levels: cognitive (e.g. awareness and understanding associated with eating food), emotional (e.g. feelings during eating) and behavioral (e.g. preferences of food and food preparation) and disordered eating practices are found to be connected with specific tendencies such as cognitive restraint, uncontrolled eating and emotional eating. (16,17) 'Cognitive restraint' applies to putting cutbacks on food, not becoming sensitive to hunger and satiation and its objective is body weight control. Researchers have found associations between cognitive restraint, overweight and obesity. Uncontrolled eating is related to consumption of surplus quantity of food (more than usual). The notion of emotional eating means that eating food in response to different negative emotions. Psychiatric illnesses are health conditions implying changes in thinking, emotion, or behavior (or a mixing of these) and persons with psychiatric illness may develop abnormal eating behavior that leads to overweight. Higher probability of weight gain is noted in individuals with schizophrenia and bipolar disorder who have less cognitive restraint, more hunger, and more of overeating. (18) In a study done among individuals with bipolar disorders found that uncontrolled eating (Hunger) as the most significant predictor of BMI. (19) The current study was conducted with the purpose of examining the eating behaviour and Body Mass Index (BMI) of clients with severe mental illness and to correlate these two variables. Less research has been carried out on these variables in this particular patient group especially in the developing countries. To the researchers’ knowledge, this is the first study of this kind from India.
Material and Methods
Study design, sample and setting
This study used a descriptive (20) cross sectional survey design to collect the data from individuals with severe mental illness, i.e., with mood disorders/schizophrenia/delusional disorders/other psychoses, for more than two years’ duration. Hundred stable patients who came for follow up at the psychiatry outpatient department of Amrita Institute of Medical Science and Research Center, Kochi, from March to May 2020 were recruited by purposive sampling. The participants were briefed regarding the study and signed informed consent was received from them prior to data collection.
Measurements
Personal Information schedule: This included sociodemographic data as well as illness related data and questions like presence of parental overweight and obesity.
Three Factor Eating Questionnaire R-18 (Karlsson et. Al. 2000):
The TFEQ-R18 contains 18 items and it measures three various features of eating behavior: restrained eating or cognitive restraint (purposeful limiting of taking food for controlling body weight or to help weight loss- six items), uncontrolled eating (urge to eat large amount of food because of loss of control in eating along with subjective feelings of hunger- nine items), and emotional eating (eating in response to negative emotions- three items). Items are scored on a 4-point response scale (definitely true/mostly true/mostly false/definitely false) and the scores are added into scale scores for cognitive restraint (score ranges from 6 to 24), uncontrolled eating (from 9 to 36), and emotional eating (from 3 to 12). The total scores range between 18 and 72 points. As the score increases in each subscale, that particular type of eating behavior also increases. The reliability estimates for each scale were excellent (Chrobach’s α for Cognitive Restraint = 0.78, Uncontrolled Eating = 0.84, and Emotional Eating = 0.86). (21) The questionnaire was translated to Malayalam and the Malayalam version was back translated to English by bilingual language experts and seemed to be similar. The participants were administered with the Malayalam version of the questionnaire.
Data collection procedure
Investigators obtained personal data from each subject individually in face-to- face interview. The items of the Three Factor Eating Questionnaire R-18 with the response options were read out to them and the responses were marked by the investigators. Body weight (in kilograms, using electronic weighing machine) and standing height of each subject was measured by the investigators, using the same scales for all patients. The BMI was estimated from person’s weight and height, that is, weight in kilograms divided by height in meter squared. Illness related data of each patient like psychiatric diagnosis, duration of illness, presence of comorbidities, and medications (psychotropic and other medications) were collected from patients’ medical record.
Ethical Consideration
The investigators received ethical approval for this study from the institutional ethics committee and permission was sought from the head of psychiatry department. Prior to data collection, the study participants and significant others were explained about the purpose and scope of the study and after receiving signed written informed consent, interview was conducted with each subject and tools were filled up.
Data Analysis
SPSS Statistics 20.0 package program was applied for analyzing the data. Quantitative data were reported using mean and standard deviation, mean percentage etc. Correlation between study variables were analyzed using Pearson Correlation Coefficient. Association of personal variables with eating behaviour and BMI were analyzed by independent t test. Multiple regression analysis was performed to find out the effect of eating behaviours and certain personal variables on Body Mass Index. All analyses used an alpha level of 0.05 (two-tailed) for statistical significance.
Results
This study intended to examine the eating behaviour and BMI and to correlate between these two variables of patients with severe mental illness who visited the psychiatric outpatient department for follow up.
Sample characteristics:
The sample characteristics are shown in Table: 1. Of the 100 patients evaluated, 54% was females and 46% were males, 38% of them were middle aged (41-60 years), and 62% were from rural area. Majority of the subjects were having mood disorders (67%), 52% had comorbidities, and 42% of the subjects were on antipsychotics only. Thirteen percentage reported obesity in their parents.
| Table 1: Sample distribution based on socio-demographic characteristics n=100 |
| Subject characteristics |
Frequency |
Percentage |
Age in years |
18-40 |
32 |
32.0 |
41-60 |
38 |
38.0 |
>60 |
30 |
30.0 |
Gender |
Male |
46 |
46.0 |
Female |
54 |
54.0 |
Education |
Up to Secondary |
30 |
30.0 |
Higher secondary |
22 |
22.0 |
Diploma/Degree/PG |
48 |
48.0 |
Marital status |
Single |
20 |
20.0 |
Married |
73 |
73.0 |
Divorced/Widowed |
7 |
7.0 |
Occupational status |
Employed |
27 |
27.0 |
Unemployed |
55 |
55.0 |
Left job due to illness |
18 |
18.0 |
Monthly family income (₹) |
<5000 |
35 |
35.0 |
5000-10000 |
48 |
48.0 |
>10000 |
17 |
17.0 |
Domicile |
Urban/Semi urban |
38 |
38.0 |
Rural |
62 |
62.0 |
Diagnosis |
Schizophrenia and other psychosis |
33 |
33 |
Mood disorders |
67 |
67 |
Duration of illness |
2-10 years |
67 |
67.0 |
>10 years |
33 |
33.0 |
Comorbidity |
Nil |
48 |
48.0 |
Present |
52 |
52.0 |
Drugs |
Antipsychotics |
42 |
42.0 |
Antidepressant |
19 |
19.0 |
Antipsychotics+ antidepressant |
23 |
23.0 |
Antipsychotics+ Mood stabilizers |
12 |
12.0 |
Thyroid medications |
Taking |
7 |
7.0 |
Not taking |
93 |
93.0 |
Obesity in parents |
Yes |
13 |
13.0 |
No |
87 |
87.0 |
Eating behaviour of participants
As shown in the table 2, the subscales of eating behaviour cognitive restraint, uncontrolled eating, and emotional eating had mean scores of 11.51 (SD ±3.58), 13.60 (SD ±4.73) and 3.70 (SD ±1.57) respectively. Also, the subscale, cognitive restraint had the highest mean percentage score (48%), compared to that of other subscales. The mean BMI was found to be 26.08 kg/m2 (SD± 4.79).
| Table 2: Mean and standard deviation of Eating behaviour subscales and BMI |
|
Range |
Mean |
SD |
Mean percentage |
Eating Behaviour subscales |
Cognitive restraint |
6-22 |
11.51 |
3.58 |
47.95 |
Uncontrolled eating |
9-27 |
13.60 |
4.73 |
37.77 |
Emotional eating |
3-9 |
3.70 |
1.57 |
30.83 |
BMI |
15.41- 40.40 |
26.08 |
4.79 |
- |
BMI of participants
Figure 1 indicates the body mass index of the participants. Normal body weight (BMI between 18.5- 24.9 kg/m2) was seen only in 39% of the subjects. Another 39% had overweight (BMI between 25.0- 29.9 kg/m2) and 19% had obesity in different grades (Class-I in 14%, class-II, in 4% and morbid obesity in 1% ). Three percentage of the subjects were observed to have underweight (BMI<18.5 kg/m2) also.
 |
Figure 1: Distribution of patients based on Body Mass Index |
| Table 3: Relationship between subject’s eating behaviours, BMI and age. n=100 |
|
TFEQ-R18 scores |
BMI r (p) |
Age r (p) |
Uncontrolled eating r (p) |
Emotional
Eating r (p) |
Cognitive restraint |
0.286** (0.004) |
0.124ns (0.221) |
0.169ns (0.092) |
-0.216* (0.031) |
Uncontrolled eating |
|
0.613** (0.000) |
0.244* (0.015) |
-0.35** (0.000) |
Emotional eating |
|
|
0.223*(0.026) |
-0.243*(0.015) |
Eating behaviour Total |
|
|
0.293** (0.003) |
-0.385** (0.000) |
BMI |
|
|
|
-0.093ns (0.355) |
Age |
|
|
|
|
| * p <0.05, ** p <0.01 |
BMI, TFEQ-R18 scores, subscale scores and age of the patients were correlated using the Karl Pearson's correlation coefficient computation (Table:3). BMI was detected to have weak positive correlation with uncontrolled eating (r= 0.244, p=0.015), emotional eating (r= 0.223, p=0.026) and eating behavior total score (r= 0.293, p=0.003). Higher the uncontrolled eating, higher the emotional eating (r= 0.613, p=0.000) and the cognitive restraint ((r= 0.286, p<0.004). Cognitive restraint is not related to BMI. Weak but significant negative correlations were observed between subjects’ age and the three eating behaviour subscale scores.
| Table 4: Association between eating behaviours and selected patient variables n=100 |
| Patient Variables |
Group |
N |
Mean |
SD |
t value |
p value |
Cognitive restraint |
Age |
18-50 years |
46 |
34.88 |
19.07 |
2.014* |
0.047 |
Above 50 years |
54 |
26.94 |
20.11 |
Uncontrolled eating |
Age |
18-50 years |
46 |
24.02 |
18.77 |
3.63*** |
0.000 |
Above 50 years |
54 |
11.78 |
14.15 |
Food habit |
Vegetarian |
15 |
7.85 |
9.17 |
2.35* |
0.021 |
Non vegetarian |
85 |
19.09 |
18.06 |
Thyroid medication |
Yes |
7 |
33.72 |
18.01 |
2.637* |
0.010 |
No |
93 |
16.19 |
16.89 |
Obesity in parents |
Present |
17 |
25.34 |
19.63 |
2.088* |
0.039 |
Absent |
83 |
15.79 |
16.65 |
Emotional eating |
Age |
18-50 years |
46 |
4.11 |
1.93 |
2.349* |
0.022 |
Above 50 years |
54 |
3.35 |
1.10 |
Education |
Primary |
22 |
3.14 |
0.47 |
3.271** |
0.001 |
Above primary |
78 |
3.86 |
1.741 |
| * p<0.05, ** p<0.01, *** p<0.001. |
As per Table 4, the three eating behaviours, were found to be significantly associated with age of the subjects, i.e, < 50 years (p<0.05). Uncontrolled eating was also associated with non-vegetarian subjects (p=0.021), subjects who are on thyroid medications (p= 0.010) and also who reported obesity among parents (p=0.039). Emotional eating was significantly less in subjects with primary education (p=0.001). No other participant variables showed any association with eating behaviours.
| Table 5: Association between BMI and selected patient variables |
Patient Variables |
Group |
N |
Mean |
SD |
t value |
p value |
Age (years) |
18-50 |
46 |
26.60 |
5.33 |
1.006ns |
0.317 |
Above 50 |
54 |
25.63 |
4.27 |
Gender |
Male |
46 |
25.01 |
4.21 |
2.095* |
0.039 |
Female |
54 |
26.99 |
5.09 |
Domicile |
Urban/Semi urban |
38 |
27.37 |
4.83 |
2.141* |
0.035 |
Rural |
62 |
25.29 |
4.63 |
Occupational status |
Employed |
27 |
27.23 |
5.62 |
1.472ns |
0.144 |
Unemployed |
73 |
25.65 |
4.41 |
Food habit |
Vegetarian |
15 |
24.56 |
5.12 |
1.34ns |
0.183 |
Non vegetarian |
85 |
26.35 |
4.71 |
Psychiatric disorder |
Mood disorders |
67 |
26.16 |
4.58 |
0.246 ns |
0.806 |
Schizophrenia & other psychoses |
33 |
25..91 |
5.26 |
Drugs |
Antipsychotics only |
42 |
25.72 |
4.14 |
0.638ns |
0.525 |
Antidepressants, mood stabilizers, and antipsychotics in combination with these |
58 |
26.35 |
5.23 |
Co morbidity |
Absent |
50 |
25.27 |
4.36 |
1.702ns |
0.092 |
Present |
50 |
26.89 |
5.09 |
Thyroid medication |
Taking |
7 |
29.86 |
3.29 |
2.204* |
0.030 |
Not taking |
93 |
25.8 |
4.77 |
Obesity in parents |
Yes |
17 |
29.08 |
4.75 |
2.938** |
0.004 |
No |
83 |
25.47 |
4.59 |
| * p<0.05, ** p<0.01, ns- not significant. |
Table 5 depicts statistically significant associations between BMI and personal variables like female gender (t=2.095, p=0.039), urban and semi urban dwelling (t=2.141, p=0.035), thyroid medications (t=2.204, p=0.030) and obesity in parents (t=2.938, p=0.004).
| Table 6: Result of regression analysis to determine the effect of eating behaviours and personal variables on Body Mass Index. |
| Variables |
B |
Standard error |
ß |
t |
p |
Constant |
29.705 |
3.339 |
|
8.897389 |
0.000 |
Gender |
1.788 |
0.930 |
0.187 |
1.924 |
0.057 |
Obesity in parents |
-2.872 |
1.224 |
-.226 |
-2.347 |
0.021 |
Domicile |
-1.215 |
0.959 |
-.124 |
-1.267 |
0.208 |
Uncontrolled eating |
0.040 |
0.33325 |
0.147 |
1.230 |
0.222 |
Emotional eating |
0.021 |
0.032 |
0.079 |
0.662 |
0.468 |
F=4.198, R=0.427, R2 = 0.183, P<0.002 |
As depicted in the Table 6, stepwise linear regressions showed that obesity in the parents is the most significant predictor of BMI, accounting for 18.3% of the variance (F(1) = 4.198, p = 0 .002). No other variables got to statistical significance.
Discussion
The current study concentrated on a disadvantaged population, persons with severe mental illness. The primary objective of the study was to examine their eating behaviour and BMI and to correlate these two. As shown in table 2, the subscales of eating behaviour; cognitive restraint, uncontrolled eating, and emotional eating had mean scores of 11.51 (SD ±3.58), 13.60 (SD ±4.73) and 3.70 (SD ±1.57) respectively. Cognitive restraint, which refers to the individual’s concern over weight control and limiting food intake, was found to have the highest mean percentage score compared to that of other subscales. Studies conducted in both clinical and nonclinical populations (18,22,23) have reported the similar findings.
Normal body weight was seen only in 39% of the subjects. Thirty-nine percentage had overweight and 19% had obesity (BMI>30 kg/m2) in different grades ranging from class I to class III obesity figure:1. Overweight and obesity in this study sample may be attributed to factors like unhealthy food preferences, physical inactivity, social deprivation, treatment with psychotropic medications and disease-specific factors such as changed neuro-endocrine functioning. High rates of obesity have been reported in previous studies among clients with schizophrenia (14,15) and bipolar disorder. (8, 24-26) Significant bidirectional association has also been established between depression and obesity. (12)
The present study showed statistically significant correlations between eating behaviours and BMI of patients with severe mental illness. Uncontrolled eating (r= 0.244, p=0.015) and emotional eating (r= 0.223, p<0.026) are positively correlated with BMI. Similar findings have been reported in an investigation done on eating behavior and obesity in patients with bipolar disorder. (19,27) This type of relationship between emotional eating and body weight has also been established in studies done among general populations. (22,23) Uncontrolled eating is a tendency to take large amounts of food because of loss of control during eating accompanied by internal feelings of hunger and emotional eating is taking food in response to negative emotions. The study established a connection between these two eating behaviours and BMI. In contrast to our finding that no association between ‘cognitive restraint’ and BMI, some previous studies reported significant negative relation between ‘cognitive restraint’ and BMI. (19) All the three eating behaviours were negatively correlated with participant’s age. Our study showed significant associations between eating behaviours and individual variables (Table: 4). Uncontrolled eating was associated with non-vegetarian subjects (p=0.021), subjects who were on thyroid medications (p= 0.010) and who reported parental obesity (p=0.039). Evidences suggest that the hypothalamic-pituitary-thyroid axis can directly affect food consumption and altered thyroid function may lead to clinically significant outcomes on appetite and body weight. (28.29) Associations between eating behaviours and individual characteristics like age, education and parental obesity have been showed in studies done in nonclinical populations also. (22)
Our study also showed significant associations between BMI and personal variables like female gender (p=0.039), urban and semi urban dwelling (p=0.035), thyroid medications (p=0.030) and parental obesity (p=0.004). In a study which assessed the quality of life of obese clients attending outpatient departments of a tertiary care hospital, showed that type I obesity is high among females whereas type II and type III are high among males. (30) The subjects who were on thyroid medications were having a mean BMI of 29.89 kg/m2. Persistence of overweight and obesity have been reported in patients with thyroid dysfunctions, even after the normalization of thyroid levels with medications. (31)
The parental overweight and obesity appeared as the greatest predictor of BMI in these patients with severe mental illness and this is the most interesting finding of this study which shows the contribution of genetic factors in the aetiology of overweight and obesity.
Conclusion
Overweight and obesity are significant problems in individuals with severe mental illness and these are related to their eating behaviours like emotional eating and uncontrolled eating. All the three eating behaviours were negatively correlated with age. Uncontrolled eating was associated with non-vegetarians, subjects who were on thyroid medications and who reported parental obesity. This study throws light to a clear and pressing need for counseling and education to the chronic mentally ill about the need and ways of controlling overweight and obesity and the role of eating behaviours in increasing body weight. Also many individual factors to be considered while planning weight reduction strategies for this population.
Limitation
Only small sample from a single setting could be included in the study hence there is shortcomings in generalization of the results.
Conflict of Interest: The authors affirm no conflict of interest.
Source of Funding: This research was self-funded.
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