1. 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.

2. 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 Lancet 2012;380(9859):
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.

3. 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

4. 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

5. 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 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

6. 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

7. 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)

8. 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 ( kg/m2)
Overweight ( kg/m2)
Obese (≥30 kg/m2)
Modified BMI cut-offs for China and India (WHO, 2004)
Normal ( kg/m2)
Overweight ( 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.

9. 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.

10. 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.

11. 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.

12. Results: Underweight Prevalence Based on BMI

13. Results: Obesity Prevalence Based on BMI

14. 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

15. 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)

16. 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)

17. 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

18. 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

19. 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

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