10.24265/horizmed.2024.v24n4.03
Original Article
Nutritional status and depression among young adults treated in an outpatient consultation service at a national hospital in Junín, Peru, 2023
Yuliza Beronica Lara Romero 1,a
Henry Guija Guerra 2,b
1.Universidad Nacional Mayor de San Marcos, School of Medicine. Lima, Peru.
2.Universidad de San Martín de Porres, School of Human Medicine, Centro de Investigación de Bioquímica y Nutrición (Biochemistry and Nutrition Research Center). Lima, Peru.
a Professional title in Nutrition
b PhD in Health Sciences, professional title in Nutrition.
ABSTRACT
Objective: To assess the association between nutritional status and depression among young adults treated in an outpatient consultation service at a national hospital in Junín in 2023.
Materials and methods: This quantitative, cross-sectional study was conducted on 346 young adults treated at Hospital Regional Docente Clínico Quirúrgico Daniel Alcides Carrión in Junín, Peru. Depression levels were assessed using the Beck Depression Inventory, while nutritional status was determined through anthropometric measurements such as weight, height, waist circumference (WC) and neck circumference (NC). The statistical analysis was performed using the Kolmogorov-Smirnov normality test, followed by the nonparametric chi-square test with IBM SPSS Statistics 27. The study received approval from the Hospital’s Ethics Committee. Results: A total of 54.91 % of the participants were female, and the predominant age group was 18 to 24 years. Moderate to severe depression was observed in 27.46 % of the participants and over 50 % showed some degree of depression. Additionally, 25.72 % were overweight, 4.05 % were obese, 17.34 % were at high risk for central obesity and 22.83 % were at high cardiometabolic risk. However, when assessing the association between the indicators of nutritional status and depression, no statistically significant relationships were found, evidenced by a p value of 0.283 for body mass index (BMI), 0.095 for WC and 0.069 for NC.
Conclusions: Among young adults in the sample, no association was found between the nutritional status of those with central obesity and cardiometabolic risk and their depression levels.
Keywords: Nutritional Status; Depression; Waist Circumference; BMI-Age (Source: MeSH NLM).
INTRODUCTION
According to the World Health Organization (WHO), in 2015, the global prevalence of depression was 4.4 % (322 million individuals), with a higher rate observed among females (5.1 %) (1). In 2021, a study in Peru reported that 25.2 % of a sample of 2,375 individuals over the age of 20 experienced depression (2). In Lima, 28 % of adolescents aged 12 to 17 experienced a major depressive episode (3).
Depression in young adults may be associated to immune system dysregulation and cause changes in appetite, which can adversely affect nutritional status and potentially lead to malnutrition (4). Nutritional imbalances can also influence mood and neurological function; indeed, inadequate nutritional status may contribute not only to metabolic disorders but also to neurological conditions (5).
Furthermore, excess weight has been linked to chronic inflammation, characterized by elevated levels of pro-inflammatory cytokines and acute-phase proteins, which have been related to the pathogenesis of depression (6). Environmental factors, such as obesity and nutrient-poor diets, can elevate inflammatory markers like C-reactive protein (CRP). Higher CRP levels have been associated with increased cell permeability of the blood-brain barrier, which may raise the risk of episodes of depression, schizophrenia and bipolar disorder (7).
A study by Cofré et al. examined the relationship between depression, anxiety and nutritional status among adolescents. The findings revealed that 83.6 % of the participants exhibited mild, moderate and severe depressive symptoms, and among them, 58.8 % were classified as overweight based on their body mass index (BMI) (8). Similarly, a study by Mantzorou et al. involving older adults found that 35 % were at risk of malnutrition, 11.3 % were malnourished and 32.3 % exhibited symptoms of depression (9).
According to Silva et al., anthropometric parameters, body image and BMI were associated with depression in adults. Women tended to overestimate their body size, influenced by the idealization of a lean body, whereas men often perceived themselves as underweight or expressed dissatisfaction with their appearance due to the idealization of a larger body (10).
Depression is increasing among young adults (1), with women being particularly affected (1). Its consequences can impair the immune system, disrupt sleep and appetite, reduce academic performance, and contribute to suicidal ideation- ultimately affecting personal development (9). Assessing the nutritional status of individuals with depression is essential, as poor nutrition may compromise overall health and contribute to the development of other comorbidities, whether related to excess weight (overweight or obesity), low weight (underweight) or eating disorders such as anorexia (7).
The aim of this study was to assess the association between nutritional status and depression among young adults treated in an outpatient consultation service at a national hospital in Junín in 2023.
MATERIALS AND METHODS
Study design and population
This was a quantitative, cross-sectional study (11). The population consisted of young adults aged 18 to 30 treated in an outpatient consultation service at a national hospital in Junín, first in the triage unit and subsequently in dentistry, nutrition, general medicine and specialty offices. Individuals undergoing pharmacological treatment with psychostimulants were excluded. A non-probability convenience sampling method was used. A sample size of 281 young adults was previously calculated, based on a 95 % confidence level, a z-score of 1.96 and a maximum allowable margin of error of 5 %. The formula for estimating a mean in a finite population was applied, using a reference prevalence of depression (25.2 %) reported in a nationwide study of young adults (2).
Variables and measurements
The Beck Depression Inventory was used to assess depression levels, with the following cut-off points: severe (29-63), moderate (20-28), mild (14-19) and minimal (0-13) symptoms. This instrument evaluates the severity of depressive symptoms and is widely used internationally. In Peru, it has demonstrated high internal consistency (average Cronbach’s alpha = 0.91), content validity, and the ability to discriminate between depressed and nondepressed individuals (12,13).
Nutritional status was determined through anthropometric measurements such as weight, height, waist circumference (WC) and neck circumference (NC). Data collection was carried out in coordination with hospital administration, following approval from the Hospital’s Ethics Committee to collect patient information. A formal communication was also sent to the heads of each department to inform them about the study. Participants were recruited in the triage unit, where anthropometric data were recorded using a patient data sheet. For this purpose, a mechanical scale with a measuring rod (Seca 700; capacity: 220 kg; precision: 0.1 kg) was used, along with an anthropometric tape measure (Lufkin; precision: 0.1 cm) to assess central obesity, overweight, obesity and cardiometabolic risk factors (14). Anthropometric measurements were taken by researchers and technical staff in the triage unit. Data collection was conducted during June, July and September 2023.
Statistical analysis
The statistical analysis was performed using the Kolmogorov-Smirnov normality test, yielding a p value of 0.001, which indicated a non-normal distribution. Descriptive statistics were used, including measures of central tendency (median) and dispersion (interquartile range). Frequency tables were generated for categorical variables. To examine the associations between variables, the chi-square test was applied, with a 95 % confidence level. All analyses were conducted using IBM SPSS Statistics 27.
Ethical considerations
This study was approved by the Ethics Committee of Hospital Regional Docente Clínico Quirúrgico Daniel Alcides Carrión (Report No. 005-2023-DRSJ-HRDCQ-DAC-HYO-CEI; File No.4625966) and endorsed by the Graduate Program Steering Committee of Universidad Nacional Mayor de San Marcos (UNMSM) (Ruling No. 000717-2023-UPG-VDIP-FM/UNMSM). All participants provided informed consent prior to their inclusion in the study. The principles of the Declaration of Helsinki were followed, and each participant had the right to decide whether or not to participate in the study. Confidentiality was ensured by assigning a unique identification code to each participant.
RESULTS
A total of 346 young adults were evaluated, the majority of whom were female and aged between 18 and 30 years. The median age was 23 years (interquartile range = Q3-Q1 = 4). The predominant age group was 18 to 24 years. Among those evaluated, 6.94 % presented with severe depression, just under one-third exhibited moderate symptoms, 28.90 % had mild symptoms and 43.64 % presented with minimal depressive symptoms (Table 1).
In terms of nutritional status, more than half of the participants had a normal weight, a normal WC and a low risk of cardiometabolic disease. The statistical analysis showed no significant association between depression levels and BMI-for-age, WC or NC, with p values greater than 0.05 for all variables (Table 1).
Table 1. Description of the sample and statistical analysis in relation to depression levels (n = 346)
|
Characteristics |
n |
% |
Chi-square |
|
Sex |
|
|
|
|
Female |
190 |
54.91 |
- |
|
Male |
156 |
45.09 |
- |
|
Age group |
|
|
|
|
18-24 |
253 |
73.12 |
- |
|
25-30 |
93 |
26.88 |
- |
|
Depression levels |
|
|
|
|
Severe |
24 |
6.94 |
- |
|
Moderate |
71 |
20.52 |
- |
|
Mild |
100 |
28.90 |
- |
|
Minimal |
151 |
43.64 |
- |
|
Anthropometric indicators |
|
|
|
|
BMI |
|
|
0.283 |
|
Normal weight |
243 |
70.23 |
- |
|
Overweight |
89 |
25.72 |
- |
|
Obesity |
14 |
4.05 |
- |
|
WC |
|
|
0.095 |
|
Normal |
286 |
82.66 |
- |
|
High risk |
60 |
17.34 |
- |
|
NC |
|
|
0.069 |
|
High risk |
79 |
22.83 |
- |
|
Low risk |
267 |
77.17 |
- |
One-third of the sample presented signs of overnutrition (overweight or obesity), and among them, 30 % exhibited moderate to severe depression and more than 50 % showed some degree of depressive symptoms. Less than one-third were at high risk for central obesity, out of whom 36.6 % reported moderate to severe depression. Similarly, 22.8 % of the sample was classified as having a high cardiometabolic risk, and within this group, 34 % exhibited moderate to severe depressive symptoms (Table 2).
Table 2. Nutritional status and depression levels in young adults treated at a national hospital in Junín (n = 346)
|
Anthropometric Indicators |
Severe |
Moderate |
Mild |
Minimal |
|
|
n (%) |
n (%) |
n (%) |
n (%) |
|
BMI |
|
|
|
|
|
Normal weight |
21 (87.50) |
43 (60.56) |
69 (69.00) |
110 (72.85) |
|
Overweight |
3 (12.50) |
24 (33.80) |
27 (27.00) |
35 (23.18) |
|
Obesity |
0 (0.00) |
4 (5.63) |
4 (4.00) |
6 (3.97) |
|
WC |
|
|
|
|
|
Normal |
22 (91.67) |
51 (71.83) |
85 (85.00) |
128 (84.77) |
|
High risk |
2 (8.33) |
20 (28.17) |
15 (15.00) |
23 (15.23) |
|
NC |
|
|
|
|
|
High risk |
3 (12.50) |
24 (33.80) |
22 (22.00) |
30 (19.87) |
|
Low risk |
21 (87.50) |
47 (66.20) |
78 (78.00) |
121 (80.13) |
DISCUSSION
The study sample showed signs of depression. Nearly one-third of the participants exhibited moderate to severe symptoms, and more than half showed some degree of depressive symptoms, a prevalence that contrasts with lower rates reported in previous studies. For instance, research by Álvarez et al. found that 28 % of the adolescents who participated in their study showed signs of depression (3). Similar findings were reported by Vinaccia, Ortega, who observed that 32.2 % of young adults exhibited depressive symptoms (15), while Pacheco, Guerrero identified a 25 % prevalence among adults over 20 years old (2). Conversely, Cerecero-García et al., in a Mexican sample of 143,874 adults, reported a prevalence of 15 % (16). In contrast, countries such as Chile have reported rates closer to those of the present study. For example, research by Cofré et al. found a 26.6 % prevalence of moderate depressive symptoms and 42.6 % of severe depression (8). However, the present study revealed predominantly minimal to mild depression, indicating some divergence in symptom severity. Likewise, Prieto et al. reported a 39 % prevalence of depressive symptoms (17), while Astocondor et al. found a 42.3 % prevalence of depression among university students (18), findings that closely align with the results of the current study.
Regarding the relationship between BMI and depression, the findings differ from those reported by Nour et al., who observed a significant positive correlation between the two variables (p = 0.006). In their study, 26.4 % of the participants were overweight, 21 % obese and 43.3 % depressed, with mild depression being the most common at 25.2 % (19). Similarly, Miranda et al. reported that among their obese participants, 6.9 % had depressive syndrome and 34.5 % exhibited depressive symptoms-figures consistent with the present study’s findings regarding excess weight (20).
As for the association between cardiometabolic and central obesity risks and depression, Tolentino found no significant relationship; in his study, 91 % of participants with minimal depression were at low risk (21). Likewise, Arenas reported no significant association between overweight and depression (p = 0.167), although he found that obesity increased the likelihood of depression by 1.88 times compared to non-obese individuals (p = 0.001). He also examined the relationship between at-risk WC and depression but no significant association was observed (p = 0.07) (22). In line with these findings, Cofré et al. reported no association between nutritional status (overweight and obesity) and depression levels (p = 0.220) (8). Chauca also found no statistically significant relationship between excess weight and depression (p = 0.752) (23). Similarly, Gutiérrez et al. reported no significant association between obesity types and depression in adolescents (p = 0.578) (24).
The findings of the present study are therefore consistent with the most recent literature, which suggests a bidirectional relationship between excess weight and depression. That is, depression may be both a cause and a consequence of excess weight. Both conditions are linked to dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, as well as to pro-inflammatory and oxidative stress responses. Central obesity, for example, produces pro-inflammatory cytokines such as interleukin-6, interleukin-1β and tumor necrosis factor alfa (TNF-α), which can cross the blood-brain barrier and promote neuroinflammation. In addition, excess weight can lead to elevated cortisol and leptin levels, which in turn intensify inflammation and may worsen depressive symptoms (25,26).
It is also important to consider diet as a modifiable behavioral factor, as a healthy diet may play a positive role in preventing depression and anxiety (27,28). The connection between eating patterns and mental health deserves particular attention, as poor eating habits may predispose individuals to depression- or, conversely, depression may negatively influence eating behaviors. Most depressive disorders are accompanied by anxiety, which can increase appetite and weight. In contrast, melancholic or severe depression is often associated with reduced appetite and weight loss, along with lower intake of fruits, vegetables, cereals, dairy products and animal proteins such as fish and poultry (29).
The presence of depression is also influenced by other variables, including life experiences, socioeconomic status, eating habits and nutrient deficiencies. Among these, vitamin D plays a key role in neuromodulation, neuroplasticity and neuroprotection, and helps regulate the secretion of brain-derived neurotrophic factor (BDNF). Deficiencies in vitamin B12 and iron are also notable. For example, anemia is considered a risk factor for depression, particularly in older adults, as this stage of life-like depression-is associated with elevated levels of pro-inflammatory markers such as interleukin-6. This cytokine promotes the synthesis of hepcidin, a regulator of iron metabolism. Additionally, other pro-inflammatory markers such as interleukin-1, TNF-α and interferon-γ inhibit the proliferation of erythroid progenitor cells, further linking iron deficiency to depressive symptoms (6,30). These findings highlight the need for healthcare professionals to conduct thorough and careful assessments of both nutritional deficiencies and overall nutritional status in patients with mental health concerns.
The limitations of the present study included the additional time required to take measurements in the triage unit and the inconsistencies in how technical staff performed them across the unit’s various stations.
In conclusion, the results of this study suggest that in young adults, nutritional status-defined by excess weight (overweight and obesity), central obesity and cardiometabolic risk-was not significantly associated with depression.
BIBLIOGRAPHIC REFERENCES
1.Organización Mundial de la Salud. Depresion y otros trastornos mentales comunes. Estimaciones sanitarias mundiales [Internet]. Washington: OMS; 2017. Available from: https://iris.paho.org/ bitstream/handle/10665.2/34006/PAHONMH17005-spa.pdf.
2.Pacheco Vásquez DR, Guerrero Alcedo JM. Prevalencia de trastornos mentales en población peruana con COVID-19 atendida en el programa "Te cuido Perú". AVFT [Internet]. 2021;40(9):5.
3.Álvarez M, Arias JP, Cayo J, Morón G, Pomalima R, Ramírez R. Impacto en la salud mental de los niños y adolescentes de Lima Metropolitana en el contexto de la COVID-19. Rev Psicol Hered [Internet]. 2022;15(1):21-34.
4.Leonard BE. Inflammation and depression: a causal or coincidental link to the pathophysiology. Acta Neuropsychiatr [Internet]. 2018;30(1):1- 16.
5.Pisula P, Pulimens C, Vietto V. El rol de los suplementos vitamínicos en pacientes con depresión. Evid actual práct ambul [Internet]. 2022;25(1).
6.Alonso R, Olivos C. La relación entre la obesidad y estados depresivos. Rev Med Clin Condes [Internet]. 2020;31(2):130-8.
7.Rico-de la Rosa L, Cervantes-Pérez E, Robledo-Valdez M, Cervantes- Guevara G, Cervantes-Cardona GA, Ramírez-Ochoa S, et al. El rol de la nutrición en la salud mental y los trastornos psiquiátricos: una perspectiva traslacional. Rev Nutr Clin Metab [Internet]. 2022;5(1).
8.Cofré A, Gallardo G, Maripillán L, Sepúlveda L, Parra M. Depresión, ansiedad y estado nutricional en adolescentes de la ciudad de Temuco. REMA [Internet]. 2022;24(1):13-25.
9.Mantzorou M, Vadikolias K, Pavlidou E, Serdari A, Vasios G, Tryfonos C, et al. Nutritional status is associated with the degree of cognitive impairment and depressive symptoms in a Greek elderly population. Nutr Neurosci [Internet]. 2020;23(3):201-9.
10.Silva D, Ferriani L, Viana MC. Depression, anthropometric parameters, and body image in adults: a systematic review. Rev Assoc Med Bras [Internet]. 2019;65(5):731-8.
11.Argimon Pallás M, Jiménez Villa J. Métodos de investigación clínica y epidemiológica. 4.a ed. Gac Sanit [Internet]. 2013;27(6):402.
12.Richter P, Werner J, Heerlein A, Kraus A, Sauer H. On the validity of the Beck Depression Inventory. Psychopathology [Internet]. 1998;31(3):160-8.
13.Sánchez-Villena AR, Farfán Cedrón E, de La Fuente-Figuerola V, Chávez-Ravines D. Estructura factorial y datos normativos del Inventario de Depresión de Beck (BDI-II) en población general peruana. Acta colomb psicol [Internet]. 2022;25(2):158-70.
14.Stabe C, Junqueira Vasques AC, Oliveira Lima M, Tambascia MA, Pareja JC, Yamanaka A, et al. Neck circumference as a simple tool for identifying the metabolic syndrome and insulin resistance: results from the Brazilian Metabolic Syndrome Study. Clin Endocrinol [Internet]. 2013;78(6):874-81.
15.Vinaccia Alpi S, Ortega Bechara A. Variables asociadas a la ansiedad- depresión en estudiantes universitarios. Univ Psychol [Internet]. 2020;19:1-13.
16.Cerecero-García D, Macías-González F, Arámburo-Muro T, Bautista- Arredondo S. Síntomas depresivos y cobertura de diagnóstico y tratamiento de depresión en población mexicana. Salud Publica Mex [Internet]. 2020;62(6):840-50.
17.Prieto-Molinari DE, Aguirre Bravo GL, de Piérola I, Luna Victoria- de Bona G, Merea Silva A, Lazarte Nuñez CS, et al. Depresión y ansiedad durante el aislamiento obligatorio por el COVID-19 en Lima Metropolitana. Liberabit [Internet]. 2020;26(2).
18.Astocondor Altamirano V, Ruiz Solsol LE, Mejía CR. Influencia de la depresión en la ideación suicida de los estudiantes de la selva peruana. Horiz Med [Internet]. 2019;19(1):53-8.
19.Nour MO, Hafiz TA, Alharbi KK. Measuring the relationship between body mass index and depression among Saudi adult population: A nationwide cross-sectional study. PLoS One [Internet]. 2023;18(11):1-14.
20.Miranda T, Villalta D, Paoli M. Asociación entre obesidad y depresión: influencia del género, la edad, el grado de adiposidad y la actividad física. Rev Venez Endocrinol Metab [Internet]. 2019;17(2):69-80.
21.Tolentino Luciano P. Asociación entre depresión, calidad de sueño, actividad física, punto de corte de circunferencia abdominal y riesgo de obesidad en trabajadores de una institución pública de salud, Lima, 2019 [Undergraduate thesis]. Lima: Universidad Privada Norbert Wiener; 2019. Retrieved from: https://repositorio.uwiener. edu.pe/bitstream/handle/20.500.13053/5936/T061_44001242_T. pdf?sequence=1&isAllowed=y
22.Arenas Lazarte PR. Depresión asociada a sobrepeso y obesidad en estudiantes de pregrado de la Facultad de Medicina Humana de la Universidad Ricardo Palma del ciclo 2019 - II, Lima [Undergraduate thesis]. Lima: Universidad Ricardo Palma; 2019. Retrieved from: https://repositorio.urp.edu.pe/bitstream/ handle/20.500.14138/4075/PARENAS.pdf?sequence=1&isAllowed=y
23.Chauca Vergaray M. Consumo de alimentos y estado nutricional relacionado con depresión en adolescentes de una Institución Educativa Privada, San Juan de Lurigancho-2020 [Undergraduate thesis]. Lima: UNMSM; 2020. Retrieved from: https://cybertesis. unmsm.edu.pe/bitstream/handle/20.500.12672/17891/Chauca_ vm.pdf?sequence=3&isAllowed=y
24.Gutiérrez Sánchez G, Salazar Barajas ME, Ruiz Cerino JM, Ávila Alpirez H, Martínez Aguilar MDlL, Guerra-Ordoñez A. Depresión como factor asociado a la obesidad en adolescentes. J Health NPEPS [Internet]. 2019;4(2):16-27.
25.Fu X, Wang Y, Zhao F, Cui R, Xie W, Liu Q, et al. Shared biological mechanisms of depression and obesity: focus on adipokines and lipokines. Aging [Internet]. 2023;15(12):5917-50.
26.Milaneschi Y, Simmons WK, Van Rossum EF, Penninx B. Depression and obesity: evidence of shared biological mechanisms. Mol Psychiatry [Internet]. 2019;24(1):18-33.
27.Qi R, Sheng B, Zhou L, Chen Y, Sun L, Zhang X. Association of plant- based diet indices and abdominal obesity with mental disorders among older Chinese adults. Nutrients [Internet]. 2023;15(12):2721.
28.Khiroya K, Sekyere E, McEwen B, Bayes J. Nutritional considerations in major depressive disorder: current evidence and functional testing for clinical practice. Nutr Res Rev [Internet]. 2023:1-12.
29.Nowicki GJ, Polak M, Slusarska B, Czernecki K. The relationship between diet and the occurrence of depressive symptoms in a community example with high rates of social deprivation: a cross- sectional study. Nutrients [Internet]. 2023;15(17):3778.
30.Michalak SS, Sterna W. Coexistence and clinical implications of anemia and depression in the elderly population. Psychiatr Pol [Internet]. 2023;57(3):517-28.
Author contributions: YBLR and HGG participated in the conception, development of the research and manuscript drafting.
Funding sources: The article was funded by the authors.
Conflicts of interest: The authors declare no conflicts of interest.
*Corresponding author:
Yuliza Beronica Lara Romero yuliza.lara@unmsm.edu.pe
Received: January 3, 2024
Reviewed: February 19, 2024
Accepted: March 19, 2024