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Psychosomatics 47:513-518, December 2006
doi: 10.1176/appi.psy.47.6.513
© 2006 Academy of Psychosomatic Medicine
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The Triple Threat for Chronic Disease: Obesity, Race, and Depression

Tracy Stecker, Ph.D., John C. Fortney, Ph.D., Diane E. Steffick, Ph.D., and Sarita Prajapati, M.D.

Received October 5, 2005; revised December 29, 2005; accepted January 6, 2006. From the Veterans Affairs Health Services Research and Development (HRS&D) Center for Mental Health and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, and the Division of Health Services Research, Dept. of Psychiatry, College of Medicine, Univ. of Arkansas for Medical Sciences, Little Rock, AR. Send correspondence and reprint requests to Tracy Stecker, Ph.D., VA HRS&D CeMHOR (152/NLR), 2200 Fort Roots Drive, North Little Rock, AR 72114. e-mail: steckertracy{at}uams.edu


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 CONCLUSIONS
 REFERENCES
 
The authors investigated the interrelationships between race, obesity, depression, and chronic disease by abstracting data from all primary-care patients seen at a family-medicine clinic over a 3-year period. A total of 8,197 patients were included in the analysis. Sixty-three percent of patients were either overweight (26%) or obese (37%). African-American race, obesity, and having a diagnosis of depression each independently and significantly increased the likelihood of having a chronic disease. Also, these risk factors interacted to create an increased likelihood of disease prevalence. Thus, obesity, race, and depression interacted to create a "triple threat" of developing certain chronic diseases.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 CONCLUSIONS
 REFERENCES
 
The prevalence of persons meeting criteria for being overweight or obese has been increasing dramatically for the past 30 years.1 One out of every three adults is considered obese, which is defined as having a body mass index (BMI) of 30 or more.1,2 Also, two of every three adults are considered overweight, defined as having a BMI of 25 or more.1,2 It is well documented that obesity is a risk factor for many chronic diseases, including type II diabetes,3,5 hypertension,3,4,6–8 dyslipidemia, coronary heart disease (CHD), gall bladder disease, respiratory disease, cancer, and osteoarthritis.9,10 In fact, in one study, almost half of high CHD risk was attributable to excess body weight.6 Obesity is also responsible for clinically significant reduction in quality of life11 and higher healthcare costs.12–14

Depression has also been associated with increased risk of developing certain disease states, including hypertension15–21 and diabetes.22–25 Depression has been associated with both development of diabetes and symptom exacerbation.23 The link between depression and subsequent hypertension has also been widely studied. One study followed 1,190 male medical students for 40 years and found those with depression to have significantly greater risk for subsequent CHD (relative risk [RR]: 2.12) and myocardial infarction (RR: 2.12).21 Jonas et al.20 followed healthy men and women without baseline hypertension for 7–16 years and found both baseline depression and anxiety to be independent significant predictors of subsequent hypertension. Thus, evidence suggests that depression can have profound effects on both mental and physical health.

Ethnicity is also associated with rates of chronic disease. Higher rates of obesity-related hypertension have been found in African Americans as compared with non-Hispanic whites, and higher rates of obesity-related diabetes have been found in Mexican Americans.26 African Americans, especially women, have a higher likelihood of developing cardiovascular disease.4,27–29 In contrast, a higher prevalence of hyperlipidemia has been found among non-Hispanic whites.28

The purpose of this study was to assess the interrelationship between race, obesity, depression, and chronic disease. We hypothesized that the likelihood of having a chronic disease (i.e., hypertension, hyperlipidemia, or diabetes) increases with each risk factor assessed (i.e., depression, obesity, or race). We hypothesized that being African American would increase the likelihood of having diabetes and hypertension and that being (non-Hispanic) white would increase the likelihood of hyperlipidemia. We also hypothesized that the "triple threat" (i.e., the interaction between obesity, depression, and African-American ethnicity) would be associated with the highest risk of chronic disease prevalence.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 CONCLUSIONS
 REFERENCES
 
Participants and Procedures
Data for the period from January 1, 1999 to January 1, 2002 were abstracted from an electronic medical record used by a university-based family-medicine clinic. This clinic site houses 7 family-physician faculty members, 1 practicing psychologist, 1 health educator, 1 dietician, clinic staff, and 18 resident physicians. Approximately 5,000 patients are seen annually, resulting in 20,000–24,000 patient visits per year. The majority of patients are considered low-income, although 90% have some form of insurance (mostly Medicaid and Medicare). Patients come from both rural and urban locations in a southern state. The clinic population includes approximately equal numbers of non-Hispanic whites (52%) and African Americans (43%); 65% are women. Also, there were a small number of Hispanic and Asian individuals; however, because of the small percentage of these groups, they were dropped from the analysis. Data abstracted included most recent weight, height, age, race, gender, pregnancy status, and current diagnoses (including only depression, diabetes, hyperlipidemia, and hypertension). No identifying information was extracted from the medical record, and therefore information could not be tied back to individual patients seen within the clinic. The diagnoses were made by the clinician in routine practice, and were therefore based on patient complaints and presentation rather than systematic screening. To be included in the analysis, the patient had to be over the age of 18, not pregnant, and have current height and weight information documented in the chart. Very few individuals were missing data for weight/height, although occasionally a patient does refuse to be weighed. This study was reviewed by the Institutional Review Board associated with the university and approved as exempt.

Data Analysis
Descriptive data were tabulated concerning BMI, chronic diseases, number of visits, and patients’ number and type of medications. We conducted two separate analyses: 1) an additive risk-factor model; and 2) an interaction risk-factor model.

The additive risk-factor model used logistic regression to determine whether race, obesity, and depression independently predicted chronic-disease prevalence. The dependent variables were dichotomous, indicating the presence or absence of each chronic disease studied (i.e., hypertension, hyperlipidemia, diabetes). Race, the absence or presence of depression, and BMI group: normal (BMI <25), overweight (BMI 25–30), and obese (BMI >30) were specified as dummy variables in the regression equations. Other case-mix variables included age-group, which was classified as 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and 80–89.

The interaction risk-factor model used logistic regression to assess whether the interaction between race/ethnicity, BMI, and depression status also significantly predicted disease occurrence, controlling for age. The dependent variables remained the same; however, 12 mutually-exclusive risk-factor categories were specified, representing various combinations of race, obesity, and depression (i.e., two-way and three-way interactions). The reference group was defined as non-Hispanic white, with no depression diagnosis, and normal weight.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
CONCLUSIONS
 REFERENCES
 
A total of 8,197 patients were included in the analysis. Sixty-five percent were women; 53% were non-Hispanic white; and 38% were African American. Ages ranged between 21 and 97 years, with a mean of 45. As shown in Table 1, mean BMI across all participants was 29.49 (which is classified as overweight). Individuals who fall within this weight range are close to meeting criteria for Class I Obesity (which is defined as having a BMI of 30 or above). BMI levels ranged from underweight to morbidly obese (14–77.8). Obesity, depression, diabetes, hypertension, and hyperlipidemia were all significantly (p<0.05) correlated with one another (correlation coefficients ranged from 0.03 to 0.32).


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TABLE 1. Demographic Data by Race



Table 1 illustrates the differences in BMI among non-Hispanic whites and African Americans. Overall, 40% of patients were obese, with an additional 29% overweight. African American women had the highest percentage of obesity.

Additive Risk-Factor Model
Table 2 contains the results of the logistic regressions predicting hypertension, hyperlipidemia, and diabetes from the three risk factors: obesity, depression, and race.


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TABLE 2. Odds Ratios (OR) from Logistic Regressions, Additive-Risk Factors



Hypertension Twenty-five percent of the clinic population had a diagnosis of hypertension in their charts during the 3-year observation period (Figure 1). Rates were higher for African American patients than for non-Hispanic white patients (odds ratio [OR]: 2.14; p <0.01). Prevalence rates increased with BMI (OR: 1.70 if patients were overweight and 3.39 if obese; p <0.01). Having a diagnosis of depression also increased the odds of being diagnosed with hypertension (OR: 2.08; p <0.01).


Figure 1
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FIGURE 1.  Patients With Hypertension, Percent


Hyperlipidemia Eight percent of the clinic population had a diagnosis of hyperlipidemia (Figure 2). The rates of hyperlipidemia were higher for non-Hispanic white patients than for African Americans (OR: 0.91; p=0.299). Much the same pattern of increasing prevalence rate occurred as BMI increased (OR: 1.86 if overweight and 2.31 if obese; p <0.01). Having a diagnosis of depression also increased the odds of being diagnosed with hyperlipidemia (OR: 1.64; p <0.01).


Figure 2
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FIGURE 2.  Patients With Hyperlipidemia, Percent


Diabetes Nine percent of the clinic population had a diagnosis of diabetes (Figure 3). Rates were higher for African Americans than non-Hispanic whites (OR: 2.04; p <0.01). Diagnoses of diabetes significantly increased as BMI increased (OR: 1.78 if patients were overweight and 3.98 if obese; p <0.01). Having a diagnosis of depression was again a significant predictor, increasing the odds of having diabetes (OR: 1.65; p <0.01).


Figure 3
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FIGURE 3.  Patients With Diabetes, Percent


Interaction Risk-Factor Model
The odds of being diagnosed with hypertension, hyperlipidemia, or diabetes increased additively and multiplicatively as a function of risk factors. Table 3 displays the odds ratios (ORs) for each disease, demonstrating the increased odds of having a diagnosis as the number of risk factors increase. All of the two-way and three-way interactions were statistically significant (p <0.01). African Americans who were depressed and obese had the highest likelihood of also having a diagnosis of hypertension (OR: 12.24; p <0.01) and/or diabetes (OR: 14.93; p <0.01) as compared with non-Hispanic whites of normal weight who were not depressed. For example, on the basis of the regression results in Table 3, obese African Americans with depression were predicted to have a 56.3% incidence of hypertension, as compared with only 10.9% of normal-weight non-Hispanic whites without depression. Similarly, obese African Americans with depression were predicted to have a diabetes incidence of 24.6%, compared with only 2.5% of normal-weight, non-Hispanic whites without depression. Likewise, the likelihood of having hyperlipidemia was highest for obese, depressed, non-Hispanic whites (OR: 6.03; p <0.01). Eighteen percent of obese non-Hispanic whites with depression were predicted to have hyperlipidemia, versus only 4% of normal-weight African Americans without depression.


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TABLE 3. Odds Ratios (OR) From Logistic Regressions, Multiplicative (Triple Threat) Risk Factors




  CONCLUSIONS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 CONCLUSIONS
REFERENCES
 
Our findings demonstrate a strong relationship between race, obesity, depression, and chronic disease. The risk of chronic disease increases with each additional risk factor, although these factors are not just additive; they are multiplicative. Of the three risk factors examined, all of the additive and interaction effects were clinically and statistically significant. The data used in this study are derived from the entire population of patients seen at a family-practice clinic, rather than a selected sample, and, thus, the results should not be subject to sampling or bias. However, there may be geographic factors involved that would limit generalizability to primary-care clinics in other regions of the country.

A limitation of this study is that data were cross-sectional, and, therefore, no inferences about causality can be made between obesity, depression, and chronic illness. Future research should explore causative mechanisms between physical and mental health. Another limitation is the fact that we observe only diagnoses, which do not necessarily represent true prevalence, given that these conditions often go undiagnosed for some period of time. Potential medication side effects could also be considered as a confounding variable not addressed in this study. For example, some commonly used antidepressants (i.e., Elavil, venlafaxine) can elevate blood pressure.30,31 This could lead to a spurious association between depression and hypertension, wherein the elevated blood pressure is actually iatrogenic.

Race and obesity have been widely documented as risk factors for disease.6,29 In fact, the consequences of obesity have been a current focus of much research. Although this research is both timely and important, given the crisis of obesity in our country, the relationship between obesity, depression, and disease has not had as much attention. Because we know that obesity is related to higher incidence of disease, and depression is considered a risk factor for both cardiovascular disease and diabetes21,22 and is also associated with worse outcomes for those diseases,19,22 it is imperative that we understand the interaction between the impacts of obesity and depression on health.

Although the relationship between depression and health must continue to receive attention in research, it is also imperative that depression screening occur within primary-care settings and that timely treatment be initiated. Ludman et al.22 indicate that only half of the individuals with diabetes seen in primary care who screened positive for depression had their depression detected in routine care, and, of these, only half received adequate treatment for their depression. Also, even in those with detected depression, competing demands limit the amount of time spent treating it.32,33 Rost et al.32 also found that the number of other physical complaints presented during the primary-care visit was a more significant (negative) predictor of the likelihood of receiving treatment for depression than the severity of depression symptoms. Given both the additive and multiplicative effects of depression on the risk of hypertension, hyperlipidemia, and diabetes found in this study, it is important for clinicians to make time to assess depression during primary-care encounters. This could be done with ease, given the availability of brief screening instruments already adapted for primary-care administration (e.g., the PRIME-MD).


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 CONCLUSIONS
 REFERENCES
 

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This Article
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* Articles by Stecker, T.
* Articles by Prajapati, S.
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PubMed
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* Articles by Stecker, T.
* Articles by Prajapati, S.
Related Collections
* Minority Issues
* Primary Care
* Eating Disorders
* Depression
* Syndromes Secondary to General Medical Disorders

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