Network analysis of depressive symptomatology in adults with low weight and obesity

(S6-S4, S2-S9,S2-S3,S2-S5,S2-S4,S2-S8).

Cristian Ramos-Vera 1 https://orcid.org/0000-0002-3417-5701

Lupe Garcia Ampudia 2 https://orcid.org/0000-0002-1204-660X

Antonio Serpa Barrientos2 https://orcid.org/0000-0002-7997-2464

1Research Area. Faculty of Health Sciences. Cesar Vallejo University.Lima. Peru

2The National University of San Marcos. Lima. Peru

ABSTRACT

The aim of the present study was to analyze the differences in symptomatology between
two categorical groups according to BMI measurement: underweight vs obesity in Peruvian
adults. A nationally representative cross-sectional study was conducted according to
secondary data from the 2019 Demographic and Family Health Survey (ENDES). This
study included 10053 participants (women: 55.96%), of whom 1510 (15.02%) were
underweight adults and 8543 (84.98%) were adults with obesity. Two Gaussian plot models
were estimated and symptom levels were compared between the two groups. Differences
were reported in the reporting of depressive symptomatology in the underweight group, the
most central items were depressed mood, low energy and psychomotor problems.

INTRODUCTION

The presence of depressive symptoms significantly affects the quality of life, the social
environment and in serious situations, can lead to suicidal behaviors (1,2). An estimated
300 million people worldwide suffer from this problem, being the main global cause of
disability and morbidity. The global prevalence of depressive disorders increased by 14.3%
between 2007 and 2017 (4), while in Latin America and the Caribbean, depression is the
leading cause of disability with 7.8%; especially among the age group of 15 to 50 years (5).

In Peru, an epidemiological study reported that 26.1% of the adult population of

Metropolitan Lima presented some mental health problem at some time in their lives, with
a greater frequency in depressive symptoms (6.2%) (6). In addition, in 2018 only 14.4% of
people with depressive symptoms received treatment from a health professional, although
the probability of receiving such treatment was 5 times higher in people with high income
compared to people with low economic income (7).

Depressive symptoms in the adult population have mostly been associated with emotional
and physical problems, for example, there is evidence of association with problems of
anxiety (8), hopelessness (9), attempted suicide (2), obesity (10), cancer (11),
cardiovascular problems, migraine and vision difficulties (8). On the other hand, the
evidence suggests a higher prevalence in women compared to men (7) and a greater
association with a low socioeconomic level (12).

The severity of depressive symptoms is evident and concurrence with other clinical
conditions can worsen the health status of adult patients (8) For example, a higher indicator
of body mass index (BMI) has presented more prevalent with other more common mental
disorders such as depression (10), however, findings have also been reported for a
relationship between a low BMI (low weight) and depression (13, 14). This strengthens the
psychiatric perspective where both weight measures are linked to depression, as reported in
the Diagnostic and statistical manual of mental disorders (DSM-4) (15) since eating
problems (too much or too little food) and altered physical activity tends to the
development of the major depressive disorder. Due to larger studies that included people
with obesity, a greater likelihood of increased intake and depression has been suggested,
however, mood disturbance can lead to loss of interest in daily activities including eating,
producing a decrease in appetite loss, the effect of which is negative on the health of people
with depression (13,16).

Several studies have shown evidence of a U-shaped relationship between BMI and
depression (16,17,18). Those researches focused on the relationship between obesity and
depression indicate divergent results that require new methodologies to explore findings
that explain the development of such health conditions as the network analysis since it
allows to evaluate the dynamic interactions of depressive symptomatology or that
depressive symptom is more influential/important according to specific groups.

It is important to reinforce new researches that include populations of underweight adults

due to less evidence of findings from this group compared to studies that only include
overweight and obese adults. One standpoint to address these issues is the network theory
of psychopathology, this approach proposes that symptoms and their interaction with other
symptoms are primarily the problems, considered as individual identities, i.e., they are not
explained by a common latent disorder or cause (19,20), but arise due to associations
between symptoms. In this sense, network theory is relevant to understand and explain
psychological phenomena in groups with different health states, to focus clinical
interventions on specific central symptoms to prevent and intervene measures that
exacerbate the comorbidity of depressive symptomatology.

Network theory can be investigated by network analysis, which allows analyzing the
psychological measures and symptoms (network elements) are associated with each other
and reinforce the development of mental disorders. In addition, it allows to examine the
most important symptoms of the network through the centrality indexes and to evaluate
their stability and differences. Recently this year, South American studies of the
symptomatic network have been reported (21-23). However, to date there are still no
depressive network studies that include low-weight adults (24), therefore, it is unknown
which depressive symptoms are more important in low-weight risk groups and their
contrast in those with obesity.

The simultaneous examination of two network models of depressive symptomatology for

both groups allows exploring new findings on the interactions of the most important
elements that reinforce the development of depression (25) to provide a concrete
explanation given the possible variations of mutual patterns of symptomatic relationship in
both risk groups. Therefore, the objective of the study was to evaluate the network
associations and measures of centrality in two groups of Peruvian adults: with low weight
(BMI less than 18.5) and obesity (BMI greater than or equal to 30).

Method

A cross-sectional secondary study was conducted based on data from the ENDES 2019,
which is a nationally representative survey that collects information on chronic non-
communicable diseases and gives access to diagnostic and treatment services in Peru. The
design of the ENDES includes a random sampling technique in two stages, differentiated
for rural and urban areas. Details of sampling, processing, and data collection can be found
in the ENDES technical report prepared by the National Institute of Statistics and
Information (INEI).

Our sample included adults who had completed the Patient Health Questionnaire (PHQ-9)
(26) and reported BMI levels categorized as low weight and obesity. The exclusion criteria
were those which did not present BMI measures in either category or omitted any PHQ-9
questions. This allows evaluating each of the nine DSM-IV depression criteria. PHQ-9 has
four response options (0 = nothing at all, 1 = several days, 2 = more than half of the days,
and 3 = almost every day) and evaluates the presence of depressive symptomatology in the
last two weeks, the global response score is in the range of 0 to 27.

Sample

A total of 10053 participants (women: 55.96%) were included in this study, of which 1510
(15.02%) were underweight adults and 8543 (84.98%) were adults with obesity. The mean
age was 42.21 years (standard deviation: 15.91). Of them, 2642 (26.28%) had completed
primary studies, 5503 (54.74%) secondary, 1396 (13.86%) higher education, and 514
(5.10%) did not answer. As for the mother tongue of participants, 7310 (72.71%) indicated
Spanish, 2255 (22.43%) Quechua, and 488 (4.86%) a different mother tongue.

Two Gauss graphical models (networks of partial correlation coefficients) for men and
women were calculated from the nine PHQ-9 reagents using the R qgrap packages and the
LASSO fused graph (27) which allows to graphically explore the patterns of the interactive
PHQ-9 symptom system according to weight level, this network approach is more reliable
than bivariate analysis because it eliminates spurious relationships and fixes independent
relationships beyond the other connections (28) considering the Bootstrap method of 5000
samples to reinforce the stability of network results, the stability of the force was also
estimated by calculating the correlation stability coefficient (CS), where the value should
not be less than .25 and preferably higher than .50 (28). Likewise, the force centrality index
is also reported as a measure that quantifies the importance of the magnitudes of network
association (28). In addition, the NetworkComparisonTest R package (NCT; 29.30) was
used to evaluate differences in network structure (evaluates that the structure of both
networks is equal), global strength, and concerning edges (equality in overall connectivity
and between the edges of both networks).
Results

Table 1 shows the descriptive statistics of the responses of participants. These data indicate
a higher report of reagents 1 and 2 and lower in measures 8 and 9, higher scores were
reported in the low weight group. The highest measures of centrality were 2, 4, and 6 and
the lowest were between items 5 and 8. All PHQ-9 items showed significantly higher mean
values in underweight adults than in the obese population, except for reagent 9.

Table 1

Average of the items and force of centrality in both groups

Items M-U M-OB FC-U FC-OB Hedges' g

I1. 0.47 0.42 0.21 -0.15 0,62*

I2. 0.54 0.49 1.42 1.72 0,56*

I3. 0.43 0.38 -0.2 -0.24 0,61*

I4. 0.38 0.33 1.47 0.93 0,61*

I5. 0.34 0.28 -1.29 -0.77 0,91*

I6. 0.28 0.24 0.67 0.45 0,76*

I7. 0.25 0.22 -0.16 -0.19 0,60*

I8. 0.15 0.11 -1.14 -1.78 0,95*

I9. 0.20 0.17 -0.56 -0.27 0,48

M: Mean, FC: force centrality, U: underweight, OB: obesity, * p < 0.05

The first network with the lowest BMI (Figure 1) presented a total of 32 connections (18
moderate magnitude relationships), while the other network had a total of 35 (15 moderate
magnitude ratios) out of 36 possible in both systems (Figure 2). Both networks presented
higher associations between measures 8 "psychomotor problems" and 9 "thoughts of death"
(partial r = .37; partial r = .35), 1 "loss of interest" and 2 "depressed mood " (partial r = .35;
partial r = .33), 6 "feeling of worthlessness" and 7 "concentration problems" (partial r = .27
partial r = .26) respectively.

The accuracy of the edge weights is shown in Figures 3 and 4, where the red line indicates
the weight of the edge of the sample (increasingly ordered) and the gray bars are the 95%
BMI based on the bootstrapping method. It is evident that most of the estimated edges were
greater than zero and in general, did not overlap with other edges, which reflects an
accurate estimate in both networks.

The stability of the force centrality index in both networks is presented in Figures 5 and 6,
where the red line is the correlation between the estimate of the force index and the
subsamples that would be used from the total sample. In this sense, it is observed that the
force estimate is maintained even after removing large proportions from the sample and the
CS coefficient showed a value of .69 in both networks, which indicates the stability of the
force centrality of the nodes in the network according to the BMI level.
Discussion

As far as we know, this is the first study to explore the network structures of depressive
symptomatology in two groups with a higher prevalence of depression according to BMI:
underweight and obesity (24). A systematic study of depressive networks revealed a greater
number of investigations between patients with and without depressive diagnosis (24). A
more recent brief review was conducted which found more recent research focused on the
comparison of networks according to sex (31,32), as well as in adults with and without loss
of the partner (widowers and non-widowers) (33,34).
In the research of psychological network models, they have focused mainly on the
evaluation of depressive symptomatology in people in patients with chronic conditions such
as high blood pressure (21), chronic pain, cancer, mood disorder, or stroke (24).

Higher scores of depressive symptoms were reported in patients with lower weight, which
reinforces recent findings from the May report in Chinese adults with lower weight (35).
Based on the NCT measure, dynamic network assessment suggests that PHQ-9 systems by
weight shared most edges and network characteristics. In both groups, higher relationships
were found between measures of psychomotor difficulties and suicidal ideation (8 and 9),
according to another network study in Peruvian adults with hypertension (21). It was found
that the most central reagents were depressed mood and energy loss, this reinforces the
previous evidence of two systematic network studies (24, 36) that refer to higher rates of
the centrality of such measures in depressive networks. Also, the depressed mood showed
more significant relationships in both networks. A depressive network investigation in
cancer patients showed a greater network measure in energy loss (37), such a reagent was
also more important in the lower BMI network.

A greater feeling of energy loss is more related to a lower food intake, being a
characteristic that should be addressed in future interventions because it has been shown
that this central depressive symptom presents a greater underlying relationship with somatic
alterations and cognitive difficulties (24). The study by Hartung et al. (37) also evaluated
the PHQ-9 network in 4020 adults where the feeling of worthlessness (reagent 6) was also
one of the most central in the systemic model, this network finding was more prevalent in
the low-weight network.

In the network of lower BMI were found higher values of association in the relationships of
a depressed state and suicidal thoughts, and in the covariance of energy loss and feeling of
worthlessness, since it is the first study that considers a categorical group of low weight it is
expected that other studies can confirm such results, considering that it is a group of a
lower frequency that requires more research in the Latin American context.

The network results obtained show concurrent statistical interactions after partializing the
effects of the other network relationships. In this sense, this dynamic model applicable to
instruments linked to the health and behavioral sciences offers a novel point of view. It is
also possible to integrate the results of self-report measures with different clinical
measurements used in previous studies, for example, the BMI measurement and its link
with depressive symptomatology have been included. This network study with national data
in adults from the Netherlands reported a higher relationship of BMI with the measures of
change in appetite (item 5) and motor difficulty (item 8) (38), which diverge with the
present study. The application of the network model has also considered the evaluation of
measures of polygenic risk of BMI, such as the research of Kappelmann and others (39),
who evaluated 3 national samples and found that, in two of them, the measure of the
polygenic risk of BMI presented the greater association with the measures of sleep
problems (item 1) and anhedonia (item 3; loss of interest and dissatisfaction). This finding
is consistent with our study that presented higher scores for such depressive symptoms in
the obesity group. It is also possible to use other neuroanatomical measures (40), genomics,
and biomarkers related to depression and obesity (41,42). The simultaneous application of
various clinical measurements in the network model guides a better comprehensive
assessment of depressive symptomatology as a risk factor in mental health (43), it might be
included as a network measure of chronic health status (44) and opening new ways of
investigation of the most comorbid clinical manifestations with COVID-19 infection (20).

The network results reported allowing us to understand the link between the nutritional
states at higher risk and depression that are inclusive with the clinical assessment and allow
us to explore new research questions to help better define the depressive treatments with the
highest metabolic risk (35).

CONCLUSION

This study provides further evidence of the dynamic relationship between the most
prevalent depressive health states as measured by BMI (low premarital and obesity) and
different patterns of depressive symptoms. Network models are a promising tool for
understanding these differential relationships, and can be used to compare those with low
BMI and obesity, respectively. A better understanding of these differences may, in turn,
help to tailor interventions to different risk groups and psychological vulnerability. We
conclude the invariance of the global structure and connectivity of both networks; higher
levels of depressive symptomatology were reported in underweight adults. This group
presented relationships with greater effect size between depressive mood and psychomotor
problems, and in the association of lower energy and feelings of worthlessness. Such
measures were central in both networks, with depressed mood being of greater importance
in both network structures.

BIBLIOGRAPHICAL REFERENCES