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EMPIRICAL STUDIES doi: 10.1111/j.1471-6712.2011.00940.x Anxiety and depression in obese and normal-weight individuals with


doi: 10.1111/j.1471-6712.2011.00940.x

Anxiety and depression in obese and normal-weight individuals with diabetes type 2: A gender perspective

Irene Svenningsson RN (Doctoral Student) 1,2 , Cecilia Bjo¨ rkelund MD (Professor) 1 , Bertil Marklund MD

(Professor) 1,2 and Birgitta Gedda PhD (Senior Lecturer) 2

1 Sahlgrenska School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden and 2 Research and Development Unit, Primary Health Care FyrBoDal, Vanersborg, Sweden

Scand J Caring Sci; 2012; 26; 349–354

Anxiety and depression in obese and normal-weight individuals with diabetes type 2: A gender perspective

Background: Obesity is a problem that is increasing worldwide, leading to an increased incidence of type 2 diabetes mellitus (T2DM). Depression is more common among individuals with diabetes, and they are more likely than non-diabetic individuals to experience emotional problems. People with both T2DM and obesity bear an additional emotional burden, which affects their quality of life. Objectives: To describe the prevalence of symptoms of anxiety and depression in groups of obese and normal- weight individuals with T2DM who are undergoing pri- mary care and to investigate possible differences between the groups and between genders. Method: Three hundred and thirty-nine patients with T2DM from nine primary-care centres participated in a cross-sectional study (n = 180 + 159). The response rate was 67%. The Hospital Anxiety and Depression Scale

(HADS) and the Beck Depression Inventory – second edi- tion (BDI-II) were employed to estimate the patients’ symptoms of depression and anxiety. Results: An association between T2DM, obesity and depression was observed in both genders. More than one in three women and one in five men with T2DM and obesity exhibited symptoms of anxiety or depression. In the normal-weight group, the females presented more symptoms of anxiety than did their male counterparts. Conclusion: In primary healthcare, the fact that both obese men and women with T2DM are at increased risk of anxiety and depression is an important finding, which must be recognised and considered in the course of pri- mary healthcare consultations. Meeting the unique needs of each individual requires an understanding of both lab- oratory data and the individual’s emotional status.

Keywords: anxiety, depression, diabetes mellitus type 2, gender, obesity, patient, primary health care, questionnaire.

Submitted 6 May 2011, Accepted 30 September 2011


Obesity is a problem that is increasing worldwide, leading to an increased incidence of type 2 diabetes mellitus (T2DM), as obesity and T2DM are closely linked (1). An association between obesity and depression has been indicated (2), and depressed people in general, especially younger women, present an increased risk of subsequent obesity. At the same time, obese women exhibit an increased risk of developing depression (3), while, among obese males, a lower risk of depression than among

Correspondence to:

Irene Svenningsson, Research and Development Unit, Primary Health Care Fyrbodal, Edsvagen 1 C, SE-462 35 Vanersborg, Sweden. E-mail:

normal-weight men is observed (1). People exhibiting obesity in combination with T2DM bear an additional emotional burden that affects their quality of life, espe- cially that of women, and they may suffer from an underlying state of depression (4). The combination of T2DM and obesity increases the risk of developing a number of complications. T2DM increases the risk of complications such as macro- and microvascular disorders. Similarly, obesity increases the risk of chronic diseases such as heart attack, stroke and is also linked to several complications such as mobility impairment, obstructive sleep apnoea and depression (5). Evidence from prior studies strongly suggests that T2DM and depression are associated, as individuals with T2DM are more likely than others to experience emotional problems (6, 7). Also, a gender difference is observed, as anxiety and depression are more common among women with T2DM than in men with T2DM (6, 8).

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350 I. Svenningsson et al.

The direction of the association between T2DM and depression has not been fully elucidated (9). Various researchers have obtained varied results. Both psychosocial and biological factors may be involved (8). Some researchers argue that depression and being diagnosed with diabetes are associated (10). Another report suggests that diabetes and depression are related regardless of diagnosis and that depression may not only be induced by psychological distress caused by the diagnosis of T2DM (11). Being diagnosed with T2DM has been demonstrated to carry little psychological impact, and diabetes is not predictive of emotional symptoms, such as depression or anxiety (12). At the same time, some researchers have indicated that depression is a risk factor for developing diabetes (12, 13) and that prolonged emotional stress and anxiety have been suggested to increase the risk of developing diabetes (14). Unhealthy behaviours, such as smoking, physical inac- tivity and unhealthy diet, are more common among indi- viduals with diabetes and depression than in individuals with diabetes who do not have depression (15). Psycho- logical factors, as such wellbeing and eating disorders, influence the possibility of losing weight or maintaining weight (16). People with diabetes in combination with depression present a higher risk of developing complications (17). When people exhibit both diabetes and depression, the combination of comorbid chronic disease mediates a higher prevalence of depression (18). People who suffer from diabetes complications have demonstrated a higher prevalence of depression compared with people with dia- betes and without depression, (13) and, also, they indicate an increased risk of death from all causes (17, 19). Depression requires increased utilisation of health care


Because of the emotional burden of depression, rec- ognising depressive symptoms in individuals with diabetes is necessary (21, 22), and screening for depression in people with diabetes is recommended, but methods of screening and intervention have not been sufficiently characterised (17). The purpose of this study was to describe the prevalence of anxiety and depression symptoms in groups of obese and normal-weight individuals with T2DM who are undergoing primary care and to investigate the differences between the groups and between genders.

Material and methods

Patients and procedure

All primary-care centres (PCCs) in an area of western Sweden were asked to participate in the study and nine centres accepted. From the local diabetes register, which included information from the PCCs, we selected all of the

people with T2DM and normal weight (BMI of 18.5–25) who were between the ages of 30 and 75. As the procedure allowed an equal number of individuals in both groups, and the number of obese (BMI of 30–40) people in the register between 30 and 75 years with T2DM was much greater than the number of normal-weight people, every third individual in this group was selected. This procedure provided 255 individuals exhibiting obesity and T2DM and 248 individuals exhibiting normal weight and T2DM. The mode of treatment and the duration of diabetes were not considered.

Instruments used in the study

Hospital Anxiety and Depression Scale. Symptoms of depres- sion and anxiety were measured using the Hospital Anxiety and Depression Scale (HADS) (23). The HADS is a self-reported rating scale that is designed to measure both anxiety and depression. The HADS consists of two sub- scales, anxiety (HADS-A) and depression (HADS-D), each of which contains seven items on a four-point Likert scale (ranging from 0 to 3). The scores are categorised as noncases (0–7), possible cases (8–10) and probable cases (11–21). The maximum score on each subscale is 21. Robust screening ability and a high level of agreement between individuals scores on the HADS and structured psychiatric interviews have been observed (23). Strong psychometric properties have also been demonstrated (24).

Beck Depression Inventory II. The Beck Depression Inventory

– second edition (BDI-II) – is one of the most widely used

psychiatric rating scales for depression and was developed as an indicator of the presence and severity of depressive symptoms. Patients respond to the scale by rating each symptom item with a score ranging from 0 (absent) to 3

(severe or persistent presence of the symptom). The BDI-II is scored by adding the ratings for the 21 items to yield a total score that can range from 0 to 63 (25). This instrument yields valid and reliable scores in a primary- care setting (26). The scores from the BDI-II are classified as noncases (minimal, 0–13), possible cases (mild, 14–19), probable cases (moderate, 20–28) and probable cases (severe, 29–63).

Statistical process and analysis

The results of this study are presented descriptively as

means and medians ± standard deviation. The Mann– Whitney U-test was employed to analyse the differences of mean between normal-weight and obese diabetics, between women and men, between obese men and normal-weight men and between obese women and nor- mal-weight women. Statistical significance was defined as

a p-value of 0.05. The statistical analyses were performed using SPSS 18.0 software (IBM, New York, NY, USA).

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Anxiety and depression in obese and normal-weight individuals with diabetes type 2


30–40 Female

BMI 18.5–25






BMI 18.5–25

30–40 Male







Mean/Median/SD Mean/Median/SD p-value





Table 1 Differences in mean between normal-weight and obese diabetic individuals, as well as of males and females, as measured by the HADS and the BDI-II

4.5/4.0 ± 4.1 3.9/3.0 ± 3.4 8.3/5.5 ± 8.1

Male n = 93

6.1/5.8 ± 3.9 5.3/4.0 ± 3.6 13.8/13.0 ± 8.8

BMI 30–40

Female n = 66


Mean/Median/SD Mean/Median/SD p-value





3.8/3.0 ± 3.7 3.7/3.0 ± 3.6 7.7/5.0 ± 8.0

Male n = 105

BDI-II, Beck Depression Inventory – second edition; HADS, Hospital Anxiety and Depression Scale. Significance of bold values are 0.05.

5.4/4.0 ± 4.8 4.3/3.0 ± 4.1 10.7/8.0 ± 10.5

BMI 18.5–25

Female n = 75

BMI 18.5–25/

BMI 30–40

Mean/Median/SD Mean/Median/SD p-value




5.2/5.0 ± 4.1 4.5/4.0 ± 3.5 10.5/9.0 ± 8.8

BMI 30–40 n = 159

4.5/4.0 ± 4.3 4.0/3.0 ± 3.8 8.9/6.0 ± 9.1

BMI 18.5–25 n = 180





Ethical considerations

The study was approved by the Regional Ethics Committee of the Medical Department of Gothenburg University (691-



The mean age of the female normal-weight respondents was 65.3 (SD of 8.8, n = 75), and the mean age of the obese females with T2DM was 62.6 (SD of 7.7, n = 66). The mean age of the normal-weight males was 65.4 (SD of 7.1, n = 105), and the mean age of the obese males with T2DM was 63.3 (SD of 8.5, n = 93). The response rate was


No differences between normal-weight and obese individuals with T2DM were observed in symptoms of anxiety (measured by the HADS-A) or depression (mea- sured by the HADS-D). Significant differences were measured in symptoms of depression measured by the BDI-II with higher scores presented by obese individuals with T2DM. When female and male individuals with T2DM and normal weights were compared, significant differences were observed in symptoms of anxiety (mea- sured by the HADS-A) among the females presenting higher scores. Significant differences were observed between obese females and males with T2DM in symp- toms of depression (measured by the HADS-D and the BDI-II) and anxiety (measured by the HADS-A) with the females displaying significantly higher scores than their obese male counterparts. No differences were detected between normal-weight and obese men with T2DM. When comparing normal-weight and obese females with T2DM, the latter produced higher scores in symptoms of depression measured with the BDI-II (Table 1). As depicted in Table 2, the obese individuals with T2DM indicated a greater risk of developing anxiety than the normal-weight individuals with T2DM, as measured with the HADS-A. The obese individuals with T2DM also pre- sented a greater risk of depression when measured with the HADS-D and the BDI-II compared with the normal- weight individuals. When comparing normal-weight females and males with T2DM, the females presented a greater risk of developing anxiety and depression, as measured by all three questionnaires (the HADS-A, the HADS-D and the BDI-II). Obese females exhibited a much greater risk of developing anxiety and depression than did obese males with diabetes, as measured by all three questionnaires (Table 2).


These results demonstrate an association between diabetes type 2, obesity and emotional status in both genders and that more than one in three women and one in five men

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352 I. Svenningsson et al.



BMI 18.5–25

BMI 30–40


BMI 18.5–25 n = 180

BMI 30–40 n = 159

Female n = 75

Male n = 105

Female n = 66

Male n = 93

BDI-II (%)








Possible cases







Probable cases







HADS-A (%)








Possible cases







Probable cases







HADS-D (%)








Possible cases







Probable cases







Table 2 Prevalence of BDI-II, HADS-A and HADS-D scores in normal and obese individuals with type 2 diabetes mellitus, presented as mean percentages

BDI-II, Beck Depression Inventory – second edition; HADS-A, Hospital Anxiety and Depression Scale-anxiety; HADS-D, Hospital Anxiety and Depression Scale-depression.

with T2DM and obesity present symptoms of anxiety and depression. These results highlight a problem concerning both men and women with T2DM in Swedish primary healthcare that has not been studied previously.

Methodological considerations

The HADS questionnaire is a useful clinical indicator of depression and anxiety symptoms (27). The BDI-II is one of the most widely used self-rating instruments worldwide for the assessment of the severity of depression in everyday clinical practice, as well as in research settings. Impor- tantly, the screening of depression does not diagnose depression but only provides an indication of the severity of symptoms over a period of time (28). These instruments provide important information concerning the emotional status of individuals with T2DM for the primary healthcare without being disturbed of somatic symptoms. When analysing results based on self-reporting, the pos- sibility of bias and over-reporting or under-reporting of data cannot be ignored (29). However, this possibility should not influence gender differences. Complications of T2DM were not taken into account in this study, which can be seen as a limitation, as people with diabetes and complications exhibit a higher prevalence of depression compared with people with diabetes without complications (13). Clearly, individuals exhibiting T2DM in combination with obesity carry an additional emotional burden of depression or anxiety. The combination of these diseases reduces the abilities of individuals to cope with the demands of daily life and decreases their abilities to self- care and undertakes necessary lifestyle changes. Depres- sion represents an additional burden for individuals with diabetes, and exhibiting both diseases is associated with nonadherence to self-care (15, 22) and medical treatment

(15). When the symptoms of depression remain unknown and untreated, serious consequences may result, as an association has been demonstrated between depression among individuals with diabetes and poor metabolic con- trol (30). Also, people with symptoms of depression have indicated difficulty in integrating advice regarding lifestyle changes or medical treatment into their daily lives, resulting in poorer metabolic control and increased risk of long-term or short-term complications (10, 22, 31). In addition, poor metabolic control has been reported to exacerbate depression in individuals with T2DM (10). The risks of serious diabetes complications and mortality are greater among individuals with depression and T2DM, which could be another consequence of failing to recognise depression in those individuals (19, 32, 33). Importantly, some researchers believe that this risk is possible to manage, as treated depression decreases the risks of complications (33). However, other studies have indicated no significant effect on diabetes outcomes when treating depression (31). Exhibiting T2DM in combination with obesity leads to physical limitations for both men and women (4), and functional limitations have been observed to contribute to an increased risk of developing depression (18). When healthcare professionals fail to identify depressive symp- toms, they are at risk of not meeting the individual’s needs. Obese women have reported that when their needs are not taken into account by healthcare professionals, they have difficulty in handling advice regarding lifestyle changes, resulting in feelings of guilt and shame (34). This difficulty may also be a problem for obese men with T2DM, as findings in our study indicate that even these men have symptoms of depression. The reason that healthcare pro- fessionals are not aware of the men’s emotional status can be explained by the fact that the men do not express their

2011 The Authors Scandinavian Journal of Caring Sciences 2011 Nordic College of Caring Science

Anxiety and depression in obese and normal-weight individuals with diabetes type 2


feelings of depression and anxiety as clearly as the women do (6, 34). It is well known that even in the absence of a chronic illness, women report more emotional symptoms than men (35) and that diabetes increases the risk of developing depression (6, 10, 12, 36, 37), especially in women (6). Our results provide further evidence that normal-weight women with T2DM are more emotionally affected by anxiety and depression than are normal-weight men with T2DM. This study indicates that men exhibiting obesity and T2DM are more emotionally affected than men of normal weight with T2DM. This finding is in line with the findings of a previous study (6). Diabetes has been reported to be a risk factor for the development of depression in men (6, 8). Haslam and James (1) observed that normal-weight men without diabetes presented a higher risk of depression compared with obese men without diabetes. Clearly, dia- betes influences the risk of depression in both genders, and obesity, combined with diabetes, increases the risk, even in men. Individuals exhibiting T2DM and obesity are a large group within the primary healthcare system, and if their needs cannot be met, the individuals will suffer. The emotional impact of T2DM and obesity needs to be recognised and considered by healthcare providers, rather than only drawing conclusions from laboratory data.


This study indicates a link between diabetes type 2, obesity and depression in both genders. Importantly, obesity and T2DM must be classified as a problem affecting both males and females in primary healthcare. The emotional impact of T2DM and obesity on both genders must be recognised and considered by the primary healthcare providers.


The authors wish to thank Tobias Arvemo, University West, Trollha¨ ttan, Sweden for statistical advice. The study was financed by FyrBoDal Primary Health Care with funding from the FyrBoDal Research and Development Council.

Author contributions

Irene Svenningsson contributed to the study conception and design; collected and analysed the data; and drafted the manuscript. Cecilia Bjo¨ rkelund and Bertil Marklund contributed to the study conception and design, and supervised. Birgitta Gedda contributed to the study con- ception and design; analysed the data; and drafted the manuscript and supervised.


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