Draft ugrp 5.0 (2)

BODY MASS INDEX AND MENTAL HEALTH STATUS 2
The Relationship between Body Mass Index and Mental Health Status
1.0 Introduction
Nowadays, in the developing countries obesity can be represented as a major public health
problem (Doll, Petersen & Steward-Brown, 2000). As reported by World Health Organization
(WHO) in 2013, the numbers of people in the state of overweight and obesity are estimated to be
1.4 billion adults with over 200 million men and 300 million women approximately. According
to Marylin, Malaysia ranked top of the obese country in Southeast Asia (Hazim, Hartini &
Shamsuddin, 2014). Based on the quality-studies, overweight and obesity levels were highest
among people in the age between 40 to 59 years old of adult (Khambalia & Seen, 2010). Higher
BMI increased vascular mortality, while lower BMI increased deaths from vascular diseases,
cancers, and, especially, respiratory diseases (Hong, Yi, & Sull, 2015). Obesity is defined as a
condition of excessive fat accumulation in adipose tissue, which may affect physical health
(Jokela, 2012). In term of Body Mass Index (BMI), obesity is defined when someone has BMI
reading 30kg/m2 and over (Lee & Yen, 2014).
Zivin et al. (2009) reported the number of cases related to mental health problems among
people are increasing every year (Che, Asbah & Rajalingam, 2013). World Health Organization
reported that up to 450 million people suffer from a mental disorder. Plus, four out of six people
suffered from neuropsychiatric disorders (WHO, 2003). It has been reported that nowadays,
Malaysian teenagers experienced a quite high rates of mental health problems and it can be seen
from the percentage of emotional problems is 49% and aggressiveness is 41% (Teoh, Woo &
Chong, n.d). A survey report by National Health and Morbidity Survey 2011 stated that, among
the adults (16 years and above) experienced 1.7% (0.3 million) have Generalised Anxiety

Disorders, 1.8% (0.3 million) have current depression, 1.7% (0.3 million) have suicidal ideation
and 1.1% (0.2 million) reported to have attempted suicide in the past (NHMS, 2011). A report
from Ministry of Health Malaysia demonstrated that about 11% of Malaysian in the age between
18 to 60 experienced mental health illness such as stress, anxiety and depression (Malaysian
Welfare Report) (Laporan Kesejahteraan Rakyat Malaysia, 2013). The example of mental health
diseases are depression, anxiety and stress (Mumford, Liu, Hair & Yu, 2013). Jokela (2012)
reported that depression and anxiety are part of the dangerous mental illnesses that can affect our
community nowadays.
Previous research shows obesity has a positive association with the level of mental health
in an individual. Mumford et al. (2013) stated that obesity can lead someone into depression. In
addition, Becker, Margraf, Turke, Soder, and Neumer (2001) reported that obesity can increase
the rates mental disorder of “unhealthy BMI” person especially in anxiety disorder. Furthermore,
Baumeister and Harter (2007) verified there is association between body weight and stress as
they found out people who were in the state of obese experienced the most frequent mental
health occurrence reported such as mood, anxiety and somatoform disorders. Nonetheless,
according to Barber, Bayer and Pietrzak, (2011), there was no relationship between obesity and
mental health.
Hence, this study plans to examine the relationship between BMI and mental health status
in term of depression, anxiety and stress. This present research is to find out whether body
weight can contribute the changes in term of mental health status within the Malaysian context.

1.1 Statement of Problem
As mentioned by Marylin, Malaysia ranked as the most obese country in Southeast Asia, and
followed by the Asia-Pacific in the sixth rank. (Hazim et al., 2014). World Health Organization
(2000) recorded among adults aged 18 to 60 years in Malaysia, 4.7% of men and 7.9% of women
were found to have BMI above 30. Indian population shows more serious overweight and
obesity problem which are 17.7%, compared to Malay which are 8.8% and Chinese, 4.3% (p.
30). A lot of researches stated that obesity can lead to several numbers of mental health problems
(Lee et al., 2014; Doll et al., 2000; Mumford, Liu, Hair & Yu, 2013). For example, psychological
status which is significant with the unhealthy weight are depression (Mumford, 2013; Lee et al.,
2014; Mukamal, Kawachi, Miller & Rimm, 2007) as well as anxiety (Lee et al., 2014; Mumford
et al., 2013; Mukamal et al., 2007; Zhao, Ford, Dhingra, Li1, Strine & Mokdad, 2009) and stress
(Lee et al., 2014; Mumford et al., 2013; Zhao et al., 2009).
According to those past researches, it is proved that obesity is among the major issues
that may risk the status of mental health. Taking care of physical health especially in term of
body weight is one of essential aspects in order to maintain individual mental well-being. Thus,
in order to sustain the status of mental health, individual should keep their body weight in the
state of “healthy weight”. However, there are limited number of studies regarding body mass
index and mental health status within the Malaysian context. In response to this problem, this
present study propose to investigate the issue of obesity in relation with the status of mental
health. Hence, this research is design to discover the association between body mass index and
mental health status within Malaysian context.

1.2 Significance of the study
The present research is important to be conducted because it can provide the information
regarding the issue of body weight and mental health status. Furthermore, as there was a few
numbers of researches has been conducted which examine the relationship between BMI and
mental health in the context of Malaysia, therefore, this study will review on this particular
relationship specifically in the population of International Islamic University Malaysia. As a
result of discovering this particular topics, solutions can be proposed to remedy this problem,
ensuring people know the importance of keeping an ideal weight in order to sustain mental
health well-being. This study would be expected to create the awareness on the importance of
taking care their physical body to avoid negative influences on mental health.
1.3 ResearchObjective
This study aimed to examine the following:-
1.3.1 The association between BMI and mental health status which includes depression,
anxiety and stress among IIUM students.
1.3.2 The level of mental health status of IIUM students.

1.4 ResearchQuestion
This present study aims to answer the following research question:
1. What are the level of BMI among IIUM students?
2. What are the level of mental health status among IIUM students?
3. What are the relationship between BMI and mental health status among IIUM students?
4. Is there any significant differences between the “healthy BMI group” and the “unhealthy
BMI group” in term of mental health status?
2.0 Literature Review
2.0.1 BMI and depression
According to past researches, it showed higher rates of obesity in persons with depression (Pratt
& Brody, 2014). According to Pratt and Brody (2014), in 2005–2010, 34.6% of U.S. adults aged
20 and over were obese and 7.2% had depression. A study conducted by Mumford et al. (2013)
among adults found out that, individuals who were in the state of obese may experience
depression. In addition, Lykouras & Michopoulos (2011) also stated that normally, obesity will
be accompanied with depression, low self-esteem, hard to adjust themselves with society and
interpersonal problem.
On the other hand, there are also researches that found out depression can lead to obesity
which turns the other way round. A study conducted by Needham, Epel, Adler & Kiefe (2010) in
order to see the association between depressions and the changes of body weight. Result showed
that respondents who already with higher levels of depressive symptoms, experienced a quicker
rate of raising in BMI than those who reported fewer symptoms of depression. Another research

proved depression can lead someone to obese was conducted by Maguen, Madden and
Bertenthal (2013). The study had been conducted among Iraqi and Afghanistan veterans. The
finding showed that veterans with depression were at the highest risk to either be obese without
weight loss or overweight or obese and continuing to gain weight. Moreover, people in the state
of depression may gain weight faster than people who are not in the state of depression (Ladwig,
2006).
On top of that, there were also differences of the findings between BMI and mental health
in term of gender. According to Zhao et al. (2009), men who underweight were 85% more likely
have diagnosed depression during their lives, and those who had BMI > 40 kg/m2 (severely
obese), 38% of them are more likely experience current depression, 40% more likely have
lifetime diagnosed depression and 42% more likely have lifetime diagnosed anxiety. Meanwhile,
obese women also show correlation with depression (Baumeister & Harter, 2007). A research
conducted by Zhao et al. (2009) stated those who had BMI more than 25kg/m2 (overweight and
obesity) experienced higher prevalence of depression than men. Moreover, among the women
who are either overweight or obese, 17 to 31% more likely experience current depression and
17% to 53% more likely have diagnosed depression.
The link between BMI and depression also showed differences in term of ethnic group.
According to Mumford et al. (2013), non-Hispanic whites had the lowest occurrence of current
depression yet, the highest occurrence of lifetime diagnosed depression. For non-Hispanic
blacks, it was reported that they had the lowest prevalence of lifetime diagnosed depression and
anxiety (Mumford et al., 2013).

2.0.2 BMI and anxiety
Another symptom of mental health which may have correlation with body weight is anxiety. A
longitudinal study had been conducted at Germany to investigate the prevalence rates of mental
disorder in obese people compared with physically healthy people by Baumeister and Harter in
2007. The study found out people who were in the state of obese experienced the most frequent
mental health incidence reported such as mood, anxiety and somatoform disorders. In term of
prevalence rates, overweight individuals got less rates compared to obese individuals. Moreover,
as compared to healthy probands, overweight and obese individuals were more likely display
more than one mental disorder. In short, according to this research there was a strong
relationship between obesity and mental disorder. Besides that, there was also another cross-
sectional research that examined the relationship of body mass index and anxiety by
Hatzenbuehler, Keyes and Hasin (2009). A study that had been conducted among US adults who
were in the state of overweight and obesity. The result demonstrated that obesity was
significantly associated with mental health such as anxiety and stress (Hatzenbuehler et al.,
2009). Another research that sought to ascertain the relationship of BMI and anxiety can be seen
in the research of Puhl and Heuer in 2009. The research was conducted upon US adults.
According to Puhl and Heuer (2009), when someone being discriminated for being obese, it was
significantly associated with mood and anxiety disorder and also other mental health issues such
as stress.
Other than that, the relationship of BMI and anxiety can be seen in term of gender. A
research conducted at United States of America (USA) by Zhao et al. (2009) sought to examine
the association of anxiety with body mass index with consideration of other psychosocial factors.
There was a significant relationship between anxiety and BMI in this study. The result was

varied by gender. In both male and female, anxiety is higher in both genders who were
underweight. Whereas, for overweight and obese the result showed higher only in women and
for severely obese, the rates of anxiety showed higher in men only (Zhao et al., 2009). Men tend
to experience anxiety disorder when they were in the state of underweight (Puhl & Heuer,
2010).Similarly, Puhl & Heuer (2010) also proved there was variety result in term of gender.
Puhl & Heuer (2010) stated that obese women are more socially discriminated than men which
may risk them to anxiety disorder.
Nonetheless, there was less numbers of studies conducted to scrutinize the influence of
anxiety on body weight. A future research should be conducted in order to analyze this
correlation.
2.0.3 BMI and stress
Stress is one of mental health that is going to be examine in this present research. Stress can be
seen into numbers of types and condition. As reported by Shaley (2009), there are differences
between Posttraumatic Stress Disorder (PTSD) and stress. PTSD is one of mental health illnesses
that should be treated where it had been listed in Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5). Whereas, Posttraumatic Stress (PTS) or stress is a common
responses when someone experiences stressful events. Stress also one of mental health
conditions that seemed to have correlations with body mass index. There are a lot of perceptions
and perspectives whether stress may influence the weight gain among people.
According to American Psychological Association (APA) survey, about one-fourth
Americans rate their stress level to the point scale of 8 to 10. As reported in the Hazard Health

Publications (2012), there is relationship between stress and appetite which may lead to obesity.
Physiologically, stress can both increase and decrease appetite of an individual. If someone
experience a temporary stress, it may shut down appetite as a hormone named corticotropin
which was released from hypothalamus, which suppresses appetite. In contrast, if stress
happened persistently, it may increase one’s appetite and arise the motivation to eat as a hormone
named cortisol was released from adrenal glands (http://www.health.harvard.edu, 2012).
Therefore, this situation might be the reason of BMI trajectory in an individual.
Numerous studies have documented associations between obesity and various forms of
psychological distress (Luppino, deWit, Bouvy, Stiinen & Cuiipers, 2010). A research conducted
by Pagoto, Schneider and Bodenlos in 2012. This research aimed to examine the relationship
between PTSD and obesity of the US population. Among 20,013 participants, the highest rate of
obesity was among people with past year PTSD (32.6%), following with people with history of
PTSD which is (25.5%) and those with no PTSD (24.1%) (Pagoto et al., 2012). Therefore, it was
proved that PTSD may lead to obesity. Additionally, as reported by Kubzansky, Bordelois and
Jun (2014), posttraumatic stress disorder (PTSD) may give a possible factor for weight gain and
also obesity. This symptom could lead the weight gain faster and may increase risk of obesity in
women. Plus, greater numbers of PTSD symptoms were associated with greater BMI increases
over time. The result was equivalent with the study conducted at Virginia among 252 male
veterans by Vieweg, Fernandez, Julius, Satterwhite and Benesek in 2006. This research was to
examine the BMI among PTSD veterans. The result demonstrated there was positive relationship
between BMI and PTSD. It showed that veterans with PTSD tend to gain weight and, to be
overweight (37%) or obese (39.7%) and severely obese (6.7%) (Vieweg et al., 2006). Therefore,
from those retrospective researches, it showed that there are high correlation between PTSD and

obesity in an individual. Furthermore, another study that may prove PTSD has a high correlation
with obesity is from a study by Perkonigg, Toshimi, and Stein (2009) which has been conducted
in Germany. This study aim to scrutinize the association between PTSD and obesity among
adults. The finding showed there was association adults with a lifetime PTSD with obesity.
Other than PTSD, psychosocial stress may also lead someone in gaining a high BMI. A
research by Dallman (2010) which has been conducted at San Francisco sought to examine the
relationship of stress toward obesity. In this study, Dallman (2010) stated that stress can arise
eating behaviors and this situation may lead to obesity among people. It was also reported that
stress can influence eating pattern of a person. In the other word, stress can incline the
motivation of someone to eat often. In addition, Dallman (2010) also found out that stress can
also cause the secretion of glucocorticoids, a hormone which can incline appetite hence lead one
to obese. The result demonstrated that people who are overweight at the first place tend to
experience weight gain when stress. . In contrast, those people with underweight do not
experience the same situation (Dallman, 2010). Besides that, there was a study that has been
conducted in US to see the relationship of psychosocial stress and the changes of BMI among
adults by Block, Yulei, Zaslavsky, Lin, and Ayanian in 2009. This longitudinal study assessed
from 1995 to 2004 and sought to determine the level of BMI in term of gender. This particular
study measured the changes of body weight by numerous domains which are psychosocial stress
related to work, personal relationships, life constraints, and finances. The result showed that
psychosocial stress has a high correlation with inclination of body weight for both gender.
However, women had higher level of psychological stress compared to men (Block et al., 2009).
There were differences finding on the association PTSD and obesity between male and
female. According to Perkonigg et al. in 2009, it was reported that there was a significant

association between obesity threshold lifetimes PTSD among women. Perkonigg et al. (2009)
also reported that women with PTSD tend to obese rather than men. However, men tend to
overweight rather than women.
On the other hand, there was difference result in term of relationship of BMI and mental
health status according to Barber et al. (2011). Barber et al. (2011) conducted a study on sample
of Operation Iraqi Freedom Veterans which examined the relationship between weight and
trajectory of Posttraumatic Stress Disorder (PTSD). However, the result showed there were no
relationship between obesity and mental health.
Nevertheless, there was very few research that studied the other way round which is to
see the influences of obesity toward stress. A future research need to be conducted in order to
verify this association.
2.1 Conceptual Definition
Body Mass Index (BMI)
Body Mass Index (BMI) or also known as body weight is a formula to measure the ideal body
mass by calculating weight in kilograms divided by height in meters squared (WHO, 2003).
Mental Health Status
According to WHO, mental health is defined as when someone is in a good state of well-being
and can understand the potential in himself. In addition, it is also when someone can handle his

or her stressful life and can work productively thus he can contribute his potential to the
community (WHO, 2003).
Meanwhile, mental health status is defined as the level of the mental health itself. For
example, the level of depression which has been evaluated by using DASS21 scale. The higher
the result of depression scale, the lower the level of mental health status Nurasikin, Aini, Aida, &
Ng (2010). As a result, a low level of mental health can risk someone to experience mental
health illnesses such as schizophrenia, bipolar disorder and many more (Tran, Tran & Fisher,
2013).
Depression
The depression scale assesses dysphoria, hopelessness, devaluation of life, self-deprecation, lack
of interest/involvement, anhedonia, and inertia (Willemsen, Markey, Declercq & Vanheule,
2010).
Anxiety
The anxiety scale assesses autonomic arousal, skeletal muscle effects, situational anxiety, and
subjective experience of anxious affect (Willemsen et al., 2010).
Stress
The stress scale is sensitive to levels of chronic non-specific arousal. It assesses difficulty
relaxing, nervous arousal, and being easily upset/agitated, irritable/over-reactive and impatient.
(Willemsen et al., 2010).

2.2 Operational Definition
According to World Health Organization, BMI is categorized into four groups which are
underweight, normal weight, overweight, and obese. Underweight is defined as BMI below 18.5,
normal weight between 18.5 and 24.9, overweight between 25 and 29.9, and obesity as BMI of
30 or higher. Therefore, obesity is defined when an individual’s BMI is more than 30kg/m2.
Mental health status
Mental health status will be measured by using DASS21. This scale was made by
Lovibond and Lovibond in 1995. In this scale, mental health is being measured in term of
depression, anxiety and stress.
According to the scale, items that evaluate depression are items number 2 (dryness of my
mouth), 4 (breathing difficulty), 7 (trembling), 9 (fool myself), 15 (panic), 19 (heartbeat) and 20
(scared). Next, items 3 (permissive), 5 (difficult to initiate things), 10 (demotivated), 13 (down-
hearted), 16 (not enthusiastic), 17(feel worthless) and 21(meaningless life) are to evaluate
anxiety. Meanwhile, stress are being evaluate from the item 1 (calm down), 6 (over-react), 8
(nervous), 11 (agitated), 12 (difficult to relax), 14 (intolerant), and 18 (touchy) (Pouralkhas,
Rajabi & Pishgar, 2012).
The result of DASS21 scale will be referred in order to determine the status of mental
health. If the score of mental health in term of depression, anxiety and stress are high therefore
the worse mental health status will be considered.

2.3 Theoretical framework
This present research sought to determine whether body mass index may influence the status of
mental health in an individual among students of International Islamic University Malaysia
(IIUM). It is based on the three construct of distress of DASS by Lovibond and Lovibond (1995)
which are depression, anxiety and stress. This study will sought to see mental health changes due
to the factor of body weight. For example, BMI more than 30kg/m2 will lead to low level of
mental health status. The relationship are important in order to understand that body weight may
lead the changes of individual level of mental health. Therefore, the hypothesis for this present
study to determine if there is any relationship between BMI and mental health status would be
there is relationship between BMI and mental health status in term of depression, anxiety and
stress.
3.0 Method and Procedures
Research Design
This study will use quantitative research design and correlation design to examine the
relationship between BMI and mental health status.
Participants
The participants of this research will be enrolled from undergraduate student of International
Islamic University Malaysia (IIUM) and the participant will be recruited by using random
sampling design. There are 200 students between the ages of 20 to 26 years old.

Procedures
The study will be divided into two parts: data collection part and data analysis part. Before
collecting the data, participants will be given informed consent form. Participants also will be
informed that they have rights to decline to participate and to withdraw from the research once it
has started. Participants also will be briefed that their details and information are private and
confidential. After that, the researcher will collect the BMI data by taking self-report from the
participants itself and distributing DASS 21 to the participants afterwards. After data collection
finished, the researchers will analyze the data by using Statistical Package for Social Science
(SPSS).
Measure
The participants’ BMI will be collected by self-report during the fill-up of demographic data
process. BMI is categorized into four groups which are underweight, normal weight, overweight,
and obese. Underweight is defined as BMI below 18.5, normal weight between 18.5 and 24.9,
overweight between 25 and 29.9, and obesity as BMI of 30 or higher.
Depression Anxiety Stress Scale 21 (DASS21)
Depression Anxiety Stress Scale 21 (DASS 21) will be used in this research. This scale is
suitable to use as it has been used before and the internal consistency (Cronbach’s alpha) of each
subscale is high (DASS21-D subscale 0.72; DASS21-A subscale 0.77; and DASS21-subscale

0.70). The overall score, which includes all items, also had high consistency (Cronbach’s alpha =
0.88) (Tran, Tran & Fisher, 2013).
DASS 21 is a brief version the scale of DASS 42 which measures depression, anxiety and
stress emotional states over the past week. DASS 21 contains 21 items which used four-point
evaluation scale (0: Did not apply to me at all, 1: Applied to me to some degree, or some of the
time, 2: Applied to me to a considerable degree, or a good part of time, 3: Applied to me very
much, or most of the time) to assess the level of mental health status which focus more on
depression, anxiety and stress. In order to obtain the scores of the depression, anxiety and stress
scale, the relevant of seven items should be sum up. The higher the scores, the severe the
emotional status. The samples of the items are ‘I felt that I had nothing to look forward to’
(depression) ‘I was aware of dryness of my mouth’ (anxiety) and ‘I found it difficult to relax’
(stress) (Meredith, Strong & Feeney, 2007).
Instead of DASS42, the present study will use DASS21 as the inventory as is shorter and
may reduce the administration of time which make it convenience to be answered by the
participants. Moreover, DASS21 always being administered by psychologists or clinicians via
pencil-and-paper questionnaires or structured clinical interviews (Antony, Bieling, Cox, Enns, &
Swinson, 1998) to examine the level of mental health, specifically depression, anxiety and stress
(Lovibond & Lovibond, 1995).

Data Analysis
This research will be analyze by using SPSS according to the variables itself which are
BMI and mental health status (depression, anxiety and stress). The data analysis will be
conducted in accordance to the research questions.
Descriptive statistics will be used to identify the frequency of general information such as
gender, age, marriage status and others. Moreover, the data of mental health status as a result of
DASS21 also will be used descriptive statistics. In addition, Pearson Correlation will be used to
analysis the relationship between BMI and mental health status. Furthermore, T-Test will be
used to analyze the significant differences between the “healthy BMI group” and the “unhealthy
BMI group” in term of mental health status.

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Appendix
Please tick ( ) wherever appropriate.
GENERAL INFORMATION
1. Name :
2. Matric Number :
2. Contact Number :
4. Age :
5. Gender: Male Female
6. Marriage Status Single Married
7. Nationality: Malaysian Non-Malaysian
8. Kuliyyah
AIKOL KENMS IRKHS ICT
KAED INSTEAD ENGIN Others: _________
9. Level of Study:
1st
Year 2nd
Year 5th
Year
3rd
Year 4th
Year Others:_________
10. Weight:
11. Height:
12. Physical Health Status. Chronic Illness? (Example: Asthma, Cardiovascular, Diabetic, Hypertension, etc.)
Yes No
Please State:________________________
FOR RESEARCHER USE
Serial Number :
BMI :
Category :
DEMOGRAPHIC SURVEY DATA

DASS21 Name: Date:
Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the
past week. There are no right or wrong answers. Do not spend too much time on any statement.
The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree,or some ofthe time
2 Applied to me to a considerable degree,or a good part of time
3 Applied to me very much,or mostof the time
1 I found it hard to wind down 0 1 2 3
2 I was aware of dryness ofmy mouth 0 1 2 3
3 I couldn'tseem to experience any positive feeling at all 0 1 2 3
4 I experienced breathing difficulty (eg, excessivelyrapid breathing,
breathlessness in the absence ofphysical exertion)
0 1 2 3
5 I found it difficult to work up the initiative to do things 0 1 2 3
6 I tended to over-react to situations 0 1 2 3
7 I experienced trembling (eg,in the hands) 0 1 2 3
8 I felt that I was using a lot of nervous energy 0 1 2 3
9 I was worried aboutsituations in which I mightpanic and make
a fool of myself
0 1 2 3
10 I felt that I had nothing to look forward to 0 1 2 3
11 I found myselfgetting agitated 0 1 2 3
12 I found it difficult to relax 0 1 2 3
13 I felt down-hearted and blue 0 1 2 3
14 I was intolerantofanything that kept me from getting on with
what I was doing
0 1 2 3
15 I felt I was close to panic 0 1 2 3
16 I was unable to become enthusiastic aboutanything 0 1 2 3
17 I felt I wasn'tworth much as a person 0 1 2 3
18 I felt that I was rather touchy 0 1 2 3
19 I was aware of the action of my heart in the absence ofphysical
exertion (eg, sense ofheartrate increase,heartmissing a beat)
0 1 2 3
20 I felt scared withoutany good reason 0 1 2 3
21 I felt that life was meaningless 0 1 2 3

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