Obesity and mental health issues among healthcare workers: a cross-sectional study in Sabah, Malaysia

Obesity and mental health issues among healthcare workers: a cross-sectional study in Sabah, Malaysia

Narinderjeet Kaur Dadar Singh

Department of Community and Family Medicine,

Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah,

Kota Kinabalu, Malaysia

Jiann Lin Loo

Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham, UK

Azlan Ming Naing Ko

Kota Kinabalu District Health Office, Sabah State Health Department,

Kota Kinabalu, Malaysia

Syed Shajee Husain

Department of Community and Family Medicine,

Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah,

Kota Kinabalu, Malaysia

Jiloris Frederick Dony

Public Health Laboratory, Sabah State Health Department,

Kota Kinabalu, Malaysia, and

Syed Sharizman Syed Abdul Rahim

Department of Community and Family Medicine,

Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah,

Kota Kinabalu, Malaysia

Abstract

Purpose – This study aims to determine the prevalence of obesity and its relationship with mental health

issues among healthcare workers in Kota Kinabalu District Health Office, Sabah Borneo and its associating

factors.

Design/methodology/approach – This cross-sectional study was conducted among 387 healthcare workers

working in the Kota Kinabalu District Health Office, Sabah. Sociodemographic data and anthropometric

measurements were collected and DASS 21 questionnaire was used to assess mental health status.

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© Narinderjeet Kaur Dadar Singh, Jiann Lin Loo, Azlan Ming Naing Ko, Syed Shajee Husain, Jiloris

Frederick Dony and Syed Sharizman Syed Abdul Rahim. Published in Journal of Health Research.

Published by Emerald Publishing Limited. This article is published under the Creative Commons

Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works

of this article (for both commercial and non-commercial purposes), subject to full attribution to the

original publication and authors. The full terms of this licence may be seen at http://creativecommons.

org/licences/by/4.0/legalcode

The authors would like to express their deepest gratitude to the staff of the Kota Kinabalu District

Health Office and lectures of University Malaysia Sabah. The authors would also like to thank the

Director General of Health Malaysia for his permission to publish this article.

Conflict of interest: The authors declare no conflict of interest.

The current issue and full text archive of this journal is available on Emerald Insight at:

https://www.emerald.com/insight/2586-940X.htm

Received 13 July 2020

Revised 3 October 2020

16 November 2020

Accepted 22 December 2020

Journal of Health Research

Vol. 36 No. 5, 2022

pp. 939-945

Emerald Publishing Limited

e-ISSN: 2586-940X

p-ISSN: 0857-4421

DOI 10.1108/JHR-07-2020-0269

Findings – The prevalence of obesity among healthcare workers was 29%, which is significantly associated

with years of service (p 5 0.016) and abnormal depression subscale scores (p 5 0.012) at univariate analysis.

The percentage of abnormal subscale score for depression, anxiety and stress was 16, 26 and 12%, respectively.

Multivariable logistic regression revealed that more than five years of service years (OR 2.23, 95%CI 1.16–4.28)

and high depressive subscale score (OR 2.09, 95%CI 1.18–3.71) were both significantly associated with obesity.

Originality/value – This study has affirmed the link between physical and mental health. Policies that tackle

both issues should be put in place to promote wellness among healthcare workers.

Keywords Healthcare workers, Mental health, Obesity, Physical health, Malaysia

Paper type Research paper

Introduction

The world that we live in today is challenged by a new pandemic called obesity. About 1.9

billion people were overweight in 2016. Of these, more than 650 million were obese [1]. In the

past three decades, the number of people who are either overweight or obese has increased

three times; that is 875 million in 1980 and a staggering 2.1 billion in 2013 [2]. Since the

classification of obesity as a disease by the American Medical Association [3], 65 % of the

world’s population today are overweight, and obesity currently kills more people than

undernutrition [1]. Malaysia ranks high in Southeast Asia in terms of obesity, with a

prevalence of 17%, which is 4% higher than the world obesity rate [2]. In the face of this obesity

epidemic, healthcare workers play an important role in being exemplary and also in promoting

healthy lifestyle practices to the general population [4]. Unfortunately, they are not spared, as

confirmed in a study in 2008 that very interestingly observed that nurses had a higher

incidence of obesity compared to the general population [5]. This is despite the fact that

healthcare workers are presumed to have access to and knowledge of both the health-related

risks of obesity as well as obesity managing methods. This phenomenon may affect the

expectation of the general public in weight control and a healthy lifestyle when the healthcare

workers are not practicing it themselves. This increase in obesity prevalence among healthcare

workers also puts them at a higher risk to develop chronic diseases that will eventually have a

negative impact on the availability of human resources for the health system [6].

Mental health issues are prevalent among healthcare workers [7]. All around the world,

they are present with high rates of burnouts, sick leave and almost one-third of them suffer

from psychological distress [8]. The reasons behind this are thought to be due to high levels of

work-related stress as well as having more responsibility and accountability compared to

other professions [9]. A recent study identified the prevalence of anxiety among medical

officers to be 28.6% followed by depression at 10.7% and stress at 7.9% in Malaysia. These

values are comparable to the prevalence of psychological distress obtained from Western

nations, which range from 7 to 29% [10]. It has been established that obesity is associated

with a high-demand job, fatigue, depression and anxiety [11].

There could be multiple explanations for the relationship between obesity and mental

status, particularly among healthcare workers, as it has been stated that there is an

association between being obese and having depression [12]. Work stress promotes

unhealthy eating habits and sedentary behaviors that may contribute to weight gain [13].

Nevertheless, there is limited information available regarding the prevalence of obesity

among healthcare workers in Malaysia. Therefore, this study aimed to explore the prevalence

as well as the associating factors for obesity among healthcare workers and to ascertain if

mental health status in terms of depression, anxiety and stress is associated with obesity.

Methods

Study design and sample

This cross-sectional study was conducted from January to June 2018 using a systematic

sampling method in four healthcare clinics under the jurisdiction of the Kota Kinabalu district

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health office in Malaysia. The sample size was calculated using the Cochran formula with the

required sample size being 387 accounting for 20% of incomplete data using the prevalence of

30% [14] of overweight Malaysians [15]. The inclusion criteria were healthcare workers, (for

example doctors, nurses, medical attendants and health inspectors) who were working at the

Kota Kinabalu District Health Office and had given written consent. The exclusion criteria

were pregnancy and any physical disability.

Study instruments and data collection

Sociodemographic information was obtained using data collection sheets. The DASS 21

questionnaire was used to assess the mental health of participants. This questionnaire has a

high internal consistency for each subscale (Cronbach’s alpha of 0.94 for depression, 0.88 for

anxiety and 0.93 for stress) and overall composite score (Cronbach’s alpha 5 0.88) [16]. The

validated Malay version of DASS has good internal consistency, with Cronbach’s alpha

values of 0.94 for depression, 0.90 for anxiety and 0.87 for stress domains respectively [17].

The recommended cut-off point was used to determine the abnormal score for each subscale,

which was ten and above for the subscale of depression, nine and above for the subscale of

anxiety and 15 and above for the subscale of stress (Table 1).

Variable definitions

The anthropometric measurements, for example, weight, height and body mass index (BMI),

were done in each respective health clinic by the Occupational Safety and Health Unit of Kota

Kinabalu District Health Office. BMI was calculated from weight and height measured using

calibrated machines. The World Health Organization (WHO) Asian classification of BMI was

used: Underweight (<18.50 kg/m2

), normal weight (18.50–22.9 kg/m2

), overweight (≥23.0 kg/

Variables Obese (%) Not obese (%) p-value

Gender

Male 38 (38) 62 (62.0) 0.093

Female 78 (28.9) 192 (71.1)

Marital status

Married 98 (33.1) 198 (66.9) 0.145

Single/divorced/separated/widow 18 (24.3) 56 (75.7)

Years of service (years)

≥5 102 (34.1) 197 (65.9) 0.011*

<5 13 (18.6) 57 (81.4)

Income (monthly)

≥Rm 3,500.00 64 (31.4) 140 (68.6) 0.992

<Rm 3,500.00 52 (31.3) 114 (68.7)

Living status

Living with family 101 (32.4) 211 (67.6) 0.326

Living alone/shared accommodation with nonfamily 15 (25.9) 43 (74.1)

DASS

Abnormal subscale score for depression 27 (45.8) 32 (54.2) 0.009*

Abnormal anxiety subscale scores 31 (32.3) 65 (67.7) 0.817

Abnormal stress subscale scores 15 (34.1) 29 (65.9) 0.676

Note(s): *p < 0.05 using χ2 test

(n 5 370)

Table 1.

Demographic data and

score of DASS-21

according to obese and

nonobese groups

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m2

), preobese (23.00–27.49 kg/m2

), obese class I (27.50–34.9 kg/m2

), obese class II (35.0–

39.9 kg/m2

) and obese class III (≥40 kg/m2

) [18]. Participants with a BMI of 18.5–27.49

were categorized under the “Nonobese” group while BMI above this range was classified

as “Obese”.

In the DASS, depression is evaluated by question numbers, 2 (dryness of mouth), 4

(breathing difficulty), 7 (trembling), 9 (self-deception), 15 (panic), 19 (heartbeat) and 20

(scared). Anxiety is evaluated by question numbers 3 (permissive), 5 (difficult to initiate

things), 10 (demotivated), 13 (down- hearted), 16 (not enthusiastic), 17 (feeling worthless) and

21(meaningless life). Stress is evaluated by question numbers 1 (calm down), 6 (over-react), 8

(nervous), 11 (agitated), 12 (difficult to relax), 14 (intolerant) and 18 (touchy).

Statistical analysis

The data were first analyzed using a chi-square test. Simple logistic regression was then

performed, and variables with p < 0.25 were included for subsequent multivariable binary

logistic regression analysis. The explanatory variable was selected using forward and

backward selection. Subsequently, multicollinearity and interaction were checked.

Variables with large standard errors were omitted, and the preliminary final model was

obtained.

Ethical statement

Ethical approval was obtained from both the Research Ethics Committee (JK Etika 1/18(7)) of

University Malaysia Sabah and the National Medical Research Registry (NMRR) (NMRR-18-

775-40711).

Results

The prevalence of obesity among healthcare workers employed in the Kota Kinabalu

District Health Office was 29% (95%CI 25%–34%) based on the Asian BMI classification.

The overall prevalence of abnormal DASS scores among the respondents was 29.6% (95%

CI 25%–33%). The prevalence of participants with an abnormal score in the anxiety

subscale was highest at 26% (95%CI 22%–30%), followed by a subscale of depression at

16% (95%CI 12%–20%) and subscale of stress at 12% (95%CI 9%–15%). Table 1 detailed

the demographic data and the distribution of participants with an abnormal subscale score

according to the obese and nonobese groups. Variables found significantly associated via

chi-square test were five years or more of service (p 5 0.011) and abnormal subscale score

for depression (p 5 0.009). Analysis was carried out further with simple logistic regression

for all variables, and significant variables found were years of service cOR 2.27 95% CI

(1.19,4.34) and abnormal subscale score for depression cOR 2.11 95% CI (1.19,3.72) were

significant (Table 2). Those with a p-value < 0.25 were included in the final model.

The final model of multivariable regression analysis is shown in Table 2. From the final

model, years of service of five years and more and depression were associated with obesity.

The odds of being obese among those who were in service for five years or more were twice

Variables Crude OR (95%CI) p-value Adjusted OR (95%CI) p-value

Service for ≥ five years 2.27 (1.19–4.34) 0.013* 2.23 (1.16–4.28) 0.016*

Abnormal subscale score for depression 2.11 (1.19–3.72) 0.010* 2.08 (1.18–3.71) 0.012*

Note(s): n 5 370; *refers to significant p-value of <0.05

Table 2.

Final model of

multivariable binary

logistic regression

analysis

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that of those in service for less than five years (aOR 2.23 95%CI 1.16,4.28). The odds of being

obese among those with abnormal depression levels were twice that of those who had normal

depression levels (aOR 2.08 95%CI 1.18,3.71). This adjustment made via multivariate

analysis considered confounders as part of the analysis to reduce bias in the final research

conclusions.

Discussion

The prevalence of obesity among the study population was 29%, which is higher than both

the worldwide and national prevalence of obesity [3, 15]. Compared to another study in a

different center among healthcare workers, which was 18.5%, the prevalence obtained in

this study was still higher [19]. This alarming figure should prompt employers to seriously

commit to interventions as employees spend more hours in the workplace during the day

each week compared to at home. Absence from work is significantly linked to overweight

and obesity among staff. An active workplace health promotion program is very important

for overweight and obese workers’ weight management and for reducing absenteeism in

the workplace [20, 21]. Researchers and policymakers frequently underestimate the

comprehensive efforts and substantial effects of employer-sponsored fitness and health

improvement programs. Public and private businesses may support their own economic

interests by combating obesity. Important role models can be set by healthcare

organizations, particularly hospitals, as well as public employers [22].

A healthcare worker who serves five years or more has twice the risk of being obese, and

this association between years of service and obesity was similarly seen in a study of another

state of Malaysia [19]. The reasons behind this may be due to seniority in the workplace

where there is a shift from a physically demanding job scope to a more sedentary job such as a

supervisory role or a job scope that is less demanding physically, suiting employees of a more

senior age [23]. Job commitments also increase with seniority, which is translated into

reduced time for physical activities [24].

We found that the abnormal depression score was a significant associating factor for

obesity among healthcare workers. This could be attributed to overeating due to unhappiness

or perhaps neglected physical activity [25] and unhealthy eating in those who are depressed

[26]. As the link is bidirectional, tackling both issues together is necessary.

Obesity greatly raises the chances of developing depression. A depressed mood not only

impairs morale, quality of life and general functioning but raises the risk of complications of

obesity as well. Abdominal obesity is a greater indicator of the likelihood of depression and

anxiety than the adipose mass in general. Metabolic anomalies caused by central obesity that

lead to metabolic disease may also be responsible for the increased incidence of obesity

depression. Studies addressing the connection between adiposity, diet and negative

emotional conditions examine evidence that there may be alterations in glucocorticoids,

hormones derived from adipose, insulin and inflammatory signals characteristic of central

obesity [27, 28]. Obesity as well as the mental health status among healthcare workers needs

immediate attention. Another way to reduce depression prevalence is by conducting teambuilding activities as well as group counseling sessions. This can help workers to feel more

comfortable and happier with their work environment. To the best of our knowledge, this

study is the first of its kind on both obesity and mental health in Sabah among healthcare

workers. As the DASS- 21 questionnaire is not a diagnostic tool, the prevalence does not

reflect the real prevalence of depressive disorder and anxiety disorder. Potential confounders,

including dietary habits, physical activity, smoking and alcohol consumption, are not

captured in this study. The temporal relationship of obesity and mental health problems also

cannot be established as limited by cross-sectional design. Lastly, the generalizability of this

study is uncertain.

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Conclusion

The prevalence of obesity and mental health issues among healthcare workers in a district

health office is higher than that in the documented literature. As there is an established

association, policies to promote both physical and mental health should be promptly

implemented for the healthcare workers; in other words, a healthy population begins with

having healthy healthcare workers. A larger multicentre longitudinal study is suggested to

better ascertain the risk factors in a larger population.

Conflicts of Interest: None

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Corresponding author

Syed Shajee Husain can be contacted at: shajee@ums.edu.my, doctor.shajee@gmail.com

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