Examining links between depression and body composition among older adults: Results from the World Health Organization’s Study on global AGEing and adult health (SAGE) Wave 1 Melissa A. Liebert1, William J. Olson1, Heather H. McClure1,2, Theresa E. Gildner1, Nirmala Naidoo3, Paul Kowal3,4, & J. Josh Snodgrass1 1Department of Anthropology, University of Oregon, Eugene, OR; 2Center for Equity Promotion, University of Oregon, Eugene, OR; 3World Health Organization, Geneva, Switzerland; 4University of Newcastle Research Centre for Gender, Health and Ageing, Newcastle, NSW, Australia HI! THANKS FOR THE OPPORTUNITY TO PRESENT DURING THIS SESSION.

Global Prevalence of Depression Depression is a significant contributor to the global disease burden 350 million people affected (WHO, 2012) Major depressive disorder increased from 15th to 11th leading cause of DALYs worldwide (Murray, 2012) Depression prevalence increasing Associated with disability, poorer health and death (Rodda, 2011) Decreased physical, cognitive, and social functioning (Blazer, 2003) 1) Recent studies have revealed/demonstrated that depression is a… 2) Depression has a high prevalence in both developed and developing nations 3) Affecting 4) Major depressive disorder increased from 15th to 11th rank (37% increase) . Murray et al. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990—2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380(9859):2197-223. Results of Ferrari 2013 study Show findings based on graph Illuminates the global prevalence and variability of this common mental disorder Rodda J, Walker Z, Carter J. Depression and older adults. BMJ 2011;343:d5219 Depression in later life is associated with disability, increased mortality, and poorer outcomes from physical illness. Treatment is as effective for older patients as for younger adults, yet the condition is often under-recognised and under-treatedin older adults. See also, Moussavi et al. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet, 2007;370;851-8.

Depression and Body Composition Results mixed for links between depression and body composition (Stunkard et al., 2003; de Wit et al., 2010) Inconsistent findings Sex differences Primarily among Western populations Complex patterns among older adults Depression associated with increased underweight risk (Ho et al., 2008; Mezuk et al., 2012) Depression associated with greater body mass and obesity (Han et al., 1998) Few studies available in lower- and middle-income countries Given the array of negative health consequences of depression, recent studies have examined the links between depression and changes in body composition However, various population-based studies provide mixed results For example… -In some studies, depression is positively associated with obesity -While in other studies, depression is positively associated with an increased risk of being underweight -Additional studies have demonstrated a U-SHAPED pattern, in which both underweight and obesity are associated with depression 4) Moreover, the relationship between depression and body composition tends to vary by sex -For example, some studies demonstrate that depression is related to obesity among females -While others have shown an inverse relationship between depression and obesity among males 5) These studies are also limited given that they have primarily been conducted in Western populations reduced central fat and …underweight Show locations of studies  those studies are the only ones conducted outside wealthy nations Few studies have systematically evaluated links between late-life depression and body composition in lower- and middle-income countries

Objectives of the Current Study Present data from WHO’s Study on global AGEing and adult health (SAGE), by sex and country, in order to: Examine depression prevalence and body composition patterns among older adults Investigate if depression significantly predicts body composition measures

Study on global AGEing and adult health (SAGE) Longitudinal study of adult health in lower- and middle-income countries China, Ghana, India, Mexico, Russian Federation, and South Africa Nationally-representative samples of adults aged 50 years and older Wave 1 interviews conducted in 2007-2010 to collect household- and individual-level data: Sociodemographic information Health status and chronic conditions Measured weight and height Longitudinal project designed to gather comprehensive information on the aging process among lower- and middle-income countries (however, this presents cross-sectional data from China, etc.) (2 countries were low income at outset of data collection , one lower-middle and three upper-middle) Longitudinal project designed to gather information on the aging process among lower- and middle-income countries Includes participants aged 50 years and older from nationally-representative samples Data included in the present study is based on WAVE ONE of the SAGE project

35,325 total participants: 16,180 men (46%) and 19,145 women (54%) Sample 35,325 total participants: 16,180 men (46%) and 19,145 women (54%) RUSSIA 3938 total 35% men, 65% women CHINA 13,367 total 47% men, 53% women MEXICO 2306 total 40% men, 60% women INDIA 7150 total 51% men, 49% women GHANA 4724 total 50% men, 50% women SOUTH AFRICA 3840 total 43% men, 57% women

Depression Classification Assessed with two methods: Depression diagnosis during lifetime Presence of depressive symptoms and length of duration over 12 months Questions based on the World Mental Health Survey version of the Composite International Diagnostic Interview (CIDI) Diagnostic algorithm to determine depression classification (ICD-10-DCR) Based on the International Classification of Diseases (10th Revision) Diagnostic Criteria for Research (ICD-10-DCR)

Body Composition: Body Mass Index Height and weight measured according to standard procedures to calculate BMI (kg/m2) Standard BMI cut-offs (WHO, 2000) Underweight (<18.5 kg/m2) Normal (18.5-24.9 kg/m2) Overweight (25.0-29.9 kg/m2) Obese (≥30 kg/m2) Modified BMI cut-offs for China and India (WHO, 2004) Normal (18.5-22.9 kg/m2) Overweight (23.0-27.5 kg/m2) Obese (≥27.5 kg/m2) Since the relationships among BMI, body fat percentage, and health risk are different in Asian populations compared to other groups, we adjusted the analyses for respondents from China and India according to these modified standards. Stadiometers were used to measure height and weighing scales for weight.

Body Composition: Waist Circumference Waist circumference (WC; cm) measured using standard procedures Standard WC Categories (WHO, 2011) Normal (≤94 cm) and increased risk (>94 cm) for males Normal (<80 cm) and increased risk (>80 cm) for females Modified WC categories for China and India (IDF, 2006) Only adjusts the risk classifications for males: normal (<90 cm) and increased risk (>90 cm) Since the relationships among BMI, body fat percentage, and health risk are different in Asian populations compared to other groups, we adjusted the analyses for respondents from China and India according to these modified standards. Gulick tape was used to measure waist.

Statistical Analyses Weighted prevalence estimates calculated by sex and country Depression classification (presence or absence) BMI categories (underweight, normal, overweight/increased risk, obese/higher high risk) WC categories (normal, increased risk) Chi-square and t-tests used to examine sex differences in depression classification, and BMI and WC measures Multiple linear regression used to predict BMI and WC from depression classification Controlling for age, smoking behavior, drinking patterns, marital status, and income Conducted separately by sex and country Individual weights were generated based on the selection probability at each stage of selection. Individual weights are post-stratified by province, sex and age groups.

Results: Depression Prevalence by Sex and Country Across all countries, women demonstrate higher depression prevalence compared to men. Sex differences particularly striking in Mexico. Low prevalence in China consistent with literature.

Results: Underweight Prevalence Based on BMI

Results: Obesity Prevalence Based on BMI

Results: Increased CVD Risk Based on WC Prevalence This result displays a much more balance risk across the countries than BMI – with marked differences from BMI for China, Ghana and India, compared to the other three countries

Results: Depression and Body Composition, Men All men combined, depression was a significant predictor of BMI (B = -0.47, p = 0.020) Depression associated with lower BMI levels For Indian men, effect of depression on variation in BMI was approaching significance (B = -0.60, p = 0.060) Not Depressed Depressed Predicted BMI (kg/m2) 30.00 27.50 25.00 22.50 20.00 17.50 Not Depressed Depressed Predicted BMI (kg/m2) 24.00 22.00 20.00 18.00 16.00 When examined by country…Indian men For Indian men, the effect of depression on variation in BMI was approaching significance With all men combined and by country, depression diagnosis was not a significant predictor of WC 2) WC RESULTS: For South African men, the effect of depression on variation in WC was approaching significance (B = 8.21, p = 0.06) Unstandardized Predicted BMI Values (kg/m2)

Results: Depression and Body Composition for women For South African women, depression was significant predictor of BMI (B = 5.59, p = 0.004) Depression associated with higher BMI levels All women combined, depression was not a significant predictor of BMI (B = 0.65, p = 0.292) Not Depressed Depressed Predicted BMI (kg/m2) 35.00 30.00 25.00 20.00 15.00 Not Depressed Depressed Predicted BMI (kg/m2) 40.00 35.00 30.00 25.00 20.00 For all women combined and by country, depression was not a significant predictor of WC 2) WC RESULTS: For South African women, the effect of depression on variation in WC was approaching significance (B = 9.07, p = 0.06)

Summary & Implications Variation in depression prevalence by sex and country More prevalent for women than men Chinese men and women had lowest prevalence Indian men and Mexican women had highest prevalence Sex and cultural differences in the clinical diagnosis and symptomatic expression of depression Implications for effective clinical interventions **Address based on methods to determine depression classification: Clinical Diagnosis -Identify clinically important cultural variation -Need to account for differences in the clinical diagnosis of depression  affects the rate at which people are diagnosed with depression -People who live in countries with a greater awareness of and easier access to mental health services will be diagnosed at a higher rate -Taboos or stigmas against mental health disorders may also decrease diagnosis rates 2) Need to account for different cultural meanings of depression; symptomatic expression -Culture-specific connotations -Expression of depression may be elaborated in distinct ways in each social and cultural context -For example, it is important to acknowledge variability in environmental factors  unemployment, low incomes, high income inequality  which may influence depression rates Highlights sex and cultural differences in the clinical diagnosis and symptomatic expression of depression **Provides implications for clinical intervention -Including developing a diagnostic interpretation and treatment strategy that will be acceptable and effective

Summary & Implications Large variation in body composition measures by sex and country Underweight: 0.5% in Mexican men to 40.3% in Indian men BMI: 4.3% in Indian men to 52.7% in South African women WC: 17.3% in Indian men to 91.0% in Mexican women High prevalence of obesity, particularly in Mexico and South Africa Dietary risks remain high some populations 18% difference in depression prevalence between sexes in Mexico Largest difference in Mexico, but women consistently higher than men Low prevalence in China High prevalence in India, + women in Ghana, Mexico, Russia Ranging from 4.3% in Indian men to 52.7% in South African women Emphasizes that some populations face health burdens associated with malnutrition Address issues associated with the spectrum of body composition, including both underweight and obesity

Summary & Implications Depression significant negative relationship with BMI for men but not women in pooled sample Depression linked to an increased risk of being underweight in men Depression linked to an increased risk for being obese in South African women Depression among older adults does not have a simple, homogenous effect on health Complex associations between late-life depression and changes in body composition Develop effective health care policies to reduce disease burden Suggests that depression is linked to an increased risk of being underweight

Acknowledgements We thank WHO SAGE team, and all of the study participants, PIs and teams. Funding NIH NIA Interagency Agreement YA1323-08-CN-0020 NIH R01-AG034479 University of Oregon.