Association between depression and metabolic syndrome in korean women: Results from the korean national health and nutrition examination survey (2007–2013)

Author’s Accepted Manuscript AssociationBetween Depression and Metabolic Syndrome in Korean Women: Results from the Korean National Health and Nutrition Examination Survey (2007–2013) Se Jin Park, Sungwon Roh, Jaemin Hwang, Hyoung Ah Kim, Sohye Kim, Tae Kyung Lee, Shi Hyun Kang, Yu Jeong Ha, Jung Won Jang, Subin Park

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S0165-0327(16)30980-6 http://dx.doi.org/10.1016/j.jad.2016.08.022 JAD8438

To appear in: Journal of Affective Disorders Received date: 11 June 2016 Revised date: 13 July 2016 Accepted date: 14 August 2016 Cite this article as: Se Jin Park, Sungwon Roh, Jaemin Hwang, Hyoung Ah Kim, Sohye Kim, Tae Kyung Lee, Shi Hyun Kang, Yu Jeong Ha, Jung Won Jang and Subin Park, AssociationBetween Depression and Metabolic Syndrome in Korean Women: Results from the Korean National Health and Nutrition Examination Survey (2007–2013), Journal of Affective Disorders, http://dx.doi.org/10.1016/j.jad.2016.08.022 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Association Between Depression and Metabolic Syndrome in Korean Women: Results from the Korean National Health and Nutrition Examination Survey (2007–2013) Se Jin Parka, Sungwon Rohb, Jaemin Hwangc, Hyoung Ah Kimd, Sohye Kime, Tae Kyung Leef, Shi Hyun Kangg, Yu Jeong Haa, Jung Won Janga, Subin Parka* a

Department of Research Planning, Mental Health Research Institute, National Center for Mental Health, Seoul, Korea b

Department of Psychiatry, Hanyang University College of Medicine, Seoul, Korea c

Graduate School of Public Health, Korea University, Seoul, Korea

d

Department of Preventive Medicine, The Catholic University of Korea, Seoul, Korea

e

Health Promotion Center, Seoul National University Bundang Hospital, Seongnam, Korea f

Department of Addiction Psychiatry, National Center for Mental Health, Seoul, Korea g

Department of General Psychiatry, National Center for Mental Health, Seoul, Korea

*

Corresponding Author. Department of Research Planning, Mental Health Research Institute, National Center for Mental Health, 127 Youngmasan-ro, Gwangjin-gu, 04933 Seoul, Korea. Tel.: +82 2 22040108; Fax: +82 2 22040393. [email protected]

Abstract Background A considerable amount of research suggests that depression may be associated with cardiovascular disease (CVD) and the risk factors for the development of CVD such as metabolic syndrome (MetS).This study aimed to investigate the associations between depression, MetS, and combinations of the individual MetS components in Korean women.

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Methods Cross-sectional data for 23,385 women who aged 19 years and older were obtained from the nationally representative Korean National Health and Nutrition Examination Survey (2007– 2013). Associations between prior diagnosis of depression and MetS were estimated after adjusting for related factors using multivariable logistic regression analysis. Results MetS was more prevalent in women with a prior diagnosis of depression than those without diagnosed depression (26.20% vs. 19.07%, p < .001). Depression was significantly associated with MetS (odds ratio, 1.20; 95% confidence interval, 1.01–1.43) after adjusting for age, education, monthly household income, smoking status, alcohol use, physical activity, and postmenopausal status. There was a higher prevalence of most MetS combinations among women with depression than women without depression. Specifically, significant differences between the two groups were found for MetS combinations including high triglycerides. Limitations A cross-sectional study design and lack of a standardized objective measure for depression. Conclusions Diagnosed depression is associated with MetS in Korean women. Specifically, women with diagnosed depression have significantly elevated levels of several combinations of MetS components including high triglycerides. Addressing these MetS combinations could help reduce CVD events and mortality among women with depression. Keywords: depression, metabolic syndrome, triglyceride, cardiovascular disease

1. Introduction

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Depression is often comorbid with other physical diseases and can affect health outcomes such as health-related quality of life, disability, and mortality (Moussavi et al., 2007; Prince et al., 2007). Depression is especially associated with cardiovascular disease (CVD) and the risk factors for the development of CVD (Meijer et al., 2011; Park and Lee, 2011). In the recent years, the interest in the association and causal relationship between depression and metabolic syndrome (MetS), which is also known to be a risk factor for CVD (Lakka et al., 2002) has increased. Previous studies have shown that depression is independently associated with a higher risk of MetS, even after adjusting for related variables such as age, race, education level, medical history, lifestyle, and physical activity (Goldbacher et al., 2009; Kinder et al., 2004; Lakka et al., 2002; Skilton et al., 2007; Toker et al., 2008; Vanhala et al., 2009). Additionally, several studies have found a clear gender difference in the relationship between depression and the prevalence of MetS, with significant associations among women but not men (Kinder et al., 2004; Toker et al., 2008; Vanhala et al., 2009). A cross-sectional study based on data from the National Health and Nutrition Examination Study (NHANES) in the United States found that women with a history of major depression were twice as likely to have MetS than women without depression (Kinder et al., 2004). A follow-up study in Finland found that the risk of MetS occurring within the next 7 years was 2.5 times higher in women with depressive symptoms (Vanhala et al., 2009). In the United States, a cohort study that tracked people with a history of depression or current major depressive episodes for 7 years found that the incidence of MetS was 1.8 times higher in these participants (Goldbacher et al., 2009). One of the possible reasons for the association between depression and MetS is the unhealthy lifestyle of people with depression, which tends to include smoking, unhealthy dietary pattern, and poor compliance with medical care (Glassman et al., 1990; Jeffery et al., 2009; Moreira et

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al., 2016; Zigelstein et al., 1998). Especially, higher sugar content in dietary pattern were associated with higher fasting serum glucose and insulin concentration (Farhangi et al., 2015), thus the association between depression and MetS may be mediated by sweets consumption. In addition, the lower socioeconomic status (SES) of many individuals with depression is associated with poor health behaviors (Rozanski et al., 2005), and a high prevalence of MetS (Lim et al., 2012). A possible biological reason for the depression–MetS relationship is dysregulation of the adrenocortical and autonomic nervous systems, which may lead to increased insulin resistance and visceral adiposity (Brunner et al., 2002; Chrousos, 2000). Previous research in this area has only focused on the association between depression and MetS itself (which comprises of at least 3 MetS components) or the total number of MetS components, regardless of the specific combinations of MetS components that are present. Franco et al.(2009) reported that individuals diagnosed with MetS had different levels of CVD risk, and that their risk levels differed depending on the combination of MetS components present. In other words, some combinations of MetS components such as the triad of central obesity, high blood pressure, and hyperglycemia have stronger associations with outcomes such as CVD incidence and mortality, while other combinations have weaker or no associations (Franco et al., 2009; Lee et al., 2008). Despite such a difference in health outcomes based on the combination of MetS components, previous studies have not investigated which combinations of MetS components are most prevalent among people with depression. Clarifying the associations between depression, MetS, and combinations of MetS components would help to guide appropriate clinical management and treatment (Lim et al., 2012). Identifying the combinations of MetS components that are most prevalent among people with depression would provide useful information for the prevention of CVD and CVD-related

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mortality. Therefore, this study aimed to determine whether depression is associated with MetS in women aged 19 years and older, based on nationally representative data collected in Korea. Another aim of the study was to compare the prevalence of various combinations of MetS components between women who did and did not have depression.

2. Methods

2.1 Data source and study sample This study used cross-sectional data from the Korean National Health and Nutrition Examination Survey (KNHANES), which was conducted by the Korea Centers for Disease Control and Prevention between 2007 and 2013. KNHANES was designed to target the noninstitutionalized Korean civilian population, with the joint aims of monitoring trends in the prevalence, awareness, treatment, and control of selected chronic diseases; assessing trends in nutritional status and risk behaviors; and analyzing risk factors for chronic diseases (Oh et al., 2007). The survey used a stratified multistage probability sampling strategy based on selected geographical region, sex, and age groups (Korea Centers for Disease Control and Prevention, 2012; Oh et al., 2007). KNHANES included three components, the Health Interview Survey, the Health Examination Survey, and the Nutrition Survey. For the Health Interview Survey, selfadministered structured questionnaires were used to obtain information on sociodemographic characteristics, health status, and health behaviors. Physical examinations and clinical measurements were conducted in local community health centers and clinics, and standardized protocols were used to assess anthropometry, blood pressure, and laboratory indices. The Institutional Review Board of the Korea Centers for Disease Control and Prevention approved 5

the survey protocol. The KNHANES data used for the present study are publicly available. In total, 58,423 participants were included in KNHANES IV (2007–2009), V (2010–2012), and VI-1 (2013), of these 55,386 participated in the Health Interviews and Health Examinations, leading to a participation rate of 94.8%. The present study included 23,385 women (1,741 in 2007, 3,970 in 2008, 4,259 in 2009, 3,553 in 2010, 3,470 in 2011, 3,294 in 2012, and 3,098 in 2013, respectively) aged 19 years and older who participated in both the Health Interviews and Health Examinations.

2.2 Measures 2.2.1 Definition of depression Women were defined as having depression if they reported being clinically diagnosed with depression by a physician at some point during their lives. Therefore, for the purposes of this study the definition of depression included both past and current depression. The survey participants were asked the following questions: “Over your lifetime, have you ever had depression?” followed by “Have you ever been diagnosed with depression by a physician?” The cases of depression were limited to women who answered “yes” to both questions (Park and Lee, 2011).

2.2.2. Assessment of MetS components Anthropometric measurements included height, body weight, body mass index (BMI), and waist circumference. Height was measured to the nearest 0.1 cm with the subject standing barefoot. Body weight was measured to the nearest 0.1 kg using a balance scale. Waist circumference was measured to the nearest 0.1 cm at the midpoint between the subcostal bottom

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and the top of the iliac crest using a fiberglass tape. Blood pressure was measured three times by health professionals using a mercury sphygmomanometer after the participants had rested for 5 minutes in a stable state. The mean values of the second and third measurements of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were used. Blood samples were collected from the antecubital vein after fasting for at least 8 hours. The fasting levels of glucose, triglycerides, and high-density lipoprotein (HDL) cholesterol were measured using an automated hematology analyzer (ADVIA 1650 [Siemens, USA] in 2007; Hitachi automatic analyzer 7600 [Hitachi, Japan] during 2008–2010) in a laboratory at the Seoul Medical Science Institute (Seoul, Korea) in 2007 and at the Neodin Medical Institute (Seoul, Korea) during 2008–2010.

2.2.3. Definition of MetS We used a version of the National Cholesterol Education Program’s Adult Treatment Panel III criteria recommended by the American Heart Association and the National Heart, Lung, and Blood Institute (Grundy et al., 2005). MetS was defined as being present if at least three of the following five criteria were satisfied: (1) abdominal obesity (waist circumference ≥85 cm) using a Korean-specific standard (Lee et al., 2007), (2) high blood pressure (SBP ≥130 mmHg or DBP ≥85 mmHg), (3) high triglycerides (≥150 mg/dL), (4) low HDL cholesterol (HDL-C <50 mg/dL), and (5) elevated fasting plasma glucose (≥100 mg/dL).

2.2.4. Combinations of MetS components There were 16 possible combinations involving at least three MetS components. The MetS components are abbreviated herein as follows: W, abdominal obesity; T, high triglycerides; H, low HDL-C; G, elevated fasting plasma glucose; and P, high blood pressure. For example,

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“WTHG” refers to a combination of abdominal obesity, high triglycerides, low HDL-C, and elevated fasting plasma glucose, and excludes high blood pressure (Lee et al., 2007).

2.2.5. Factors related to MetS Socioeconomic characteristics included education level (
2.3. Statistical analysis

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Considering that KNHANES has a complex sampling design, weighted values were applied by using the survey-related procedure in SPSS software (version 20.0; IBM, USA) for all analyses, so as to produce nationally representative estimates and correct estimates of their variances (Korea Centers for Disease Control and Prevention, 2012). To compare the general characteristics and prevalence of MetS (its components and the various MetS component combinations) between women with and without depression, Student’s t-test and χ2 test were used for continuous and categorical variables, respectively. Linear trend analysis was used to evaluate the dose–response relationship between depression and the number of MetS components that had been identified. Finally, to determine the association between depression (independent variable) and MetS (dependent variable), multivariable logistic regression analysis was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). Possible related factors were adjusted for in the multivariable model, including age, education level, monthly household income, smoking status, alcohol consumption, physical activity, and postmenopausal status (Park and Lee, 2011; Skilton et al., 2007). The cutoff for significance was set at p < .05 for all analyses.

3. Results 3.1. General characteristics of subjects with and without depression Of the 23,385 women aged 19 years and older who were included in this study, 1,296 (5.5%) were diagnosed with depression by a physician. Women with depression were significantly older (mean = 51 years; SE = 0.56 years) than those without depression (mean = 46 years; SE = 0.18 years), and they also had a significantly lower education level and monthly household income (p < .001). Women with depression had a higher lifetime rate of smoking at least 100 cigarettes

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(18.87% vs. 10.48%, p < .001), but physical activity did not differ significantly between the two groups (p = .129). Women with depression also had a significantly higher rate of postmenopausal status (53.63% vs. 39.08%, p = .001). Finally, the prevalence of MetS was significantly higher in women with depression than in women without depression (26.20% vs. 19.07%, p < .001) (Table 1).

3.2. Depression and the number of MetS components The prevalence of depression increased significantly with the number of MetS components (for trend, p < .001). The prevalence of depression was the highest (7.5%) in women with at least four MetS components (Figure 1). 3.3. Association between depression and MetS Before adjusting for any potentially related factors (age, education, monthly household income, smoking status, alcohol use, physical activity, and postmenopausal status), the odds of having MetS were 1.51 times greater among women with depression than among women without depression (95% CI = 1.29–1.76). Furthermore, significantly elevated ORs were observed for the associations between depression and most MetS components (abdominal obesity, high triglycerides, elevated fasting plasma glucose, and hypertension), except for low HDL cholesterol. After adjusting for potentially related factors (age, education, monthly household income, smoking status, alcohol use, physical activity, and postmenopausal status), our results showed that there was still a significant positive association between depression and MetS (OR = 1.20, 95% CI = 1.01–1.43). However, of the positive associations between depression and MetS components, only those for high triglycerides (OR = 1.21, 95% CI = 1.02–1.43) and elevated

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fasting plasma glucose (OR = 1.20, 95% CI = 1.01–1.43) remained statistically significant (Table 2).

3.4. Prevalence rates of the combinations of MetS components by depression Among women diagnosed with depression, prevalence of most MetS combinations was higher than women who had not been diagnosed with depression. Specifically, significant differences between the groups were found for WTP (1.00% vs. 0.55%, p = .046), TGP (1.19% vs. 0.59%, p = .015), WTHG (1.87% vs. 0.91%, p = .012), WTHP (2.43% vs. 1.61%, p = .047), WTGP (1.36% vs. 0.79%, p = .047), and WTHGP (2.96% vs. 2.02%, p = .042). Of the combinations involving three MetS components, the prevalence of WGP and THP were the highest in women with depression (2.51% and 2.42% respectively), and of the combinations involving four MetS components, the prevalence of WTHP was the highest in the same group of women (2.43%). Finally, WTHGP was the MetS combination that had the highest prevalence in women with depression (2.96%) (Figure 2).

4. Discussion The prevalence of MetS was higher among women with depression than women without depression, and the number of MetS components was positively related to the prevalence of depression. Additionally, the prevalence of most combinations of MetS components was higher in women with depression than in women without depression. The most common MetS combination in women with depression included all 5 components (i.e., abdominal obesity, high triglycerides, low HDL-C, elevated fasting plasma glucose, and high blood pressure). The prevalence of this combination was significantly higher among women with depression than

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women without depression. Consistent with previous studies, the prevalence of depression increased significantly with the number of MetS components (Kinder et al., 2004; Räikkönen et al., 2007; Skilton et al., 2007; Viscogliosi et al., 2013). A cohort study involving healthy middle-aged women found that the Beck Depression Inventory score increased with the number of MetS components (Räikkönen et al., 2007). Similar results were obtained for women in a NHANES study targeting the general population from the US (Kinder et al., 2004). In addition, a cross-sectional study targeting people with CVD risk factors in France found that the Hospital Anxiety and Depression Scale score increased with the number of MetS components in both men and women (Skilton et al., 2007). A cross-sectional study targeting elderly people with MetS in Italy has also demonstrated such an association (Viscogliosi et al., 2013). The consistency of the positive quantitative association between depression and the number of MetS components despite global differences in the characteristics of research participants and study designs is noteworthy. Health behavior and biological mechanisms may underlie the association between depression and MetS. First, depression is known to increase the frequency of adverse health behaviors such as smoking, alcohol consumption, decreased physical activity, which may lead to MetS (Glassman et al., 1990; Rozanski et al., 2005; Zigelstein et al., 1998). However, in our study, the effect of such behaviors did not sufficiently explain the association, since depression was still significantly associated with MetS after adjusting for lifestyle factors such as smoking status, alcohol use, and physical activity. Second, depression is a risk factor for noncompliance with medical treatment (Lett et al., 2004), which may be related to MetS. A meta-analysis found that noncompliance with treatment to physical illness doubled among patients with depression compared to those without depression (DiMatteo et al., 2000). Third, the use of antidepressants

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affects abdominal obesity, hypertriglyceridemia, and hypertension (van Reedt Dortland et al., 2010), which may be associated with the incidence of MetS and increased mortality (Fuchs et al., 1995; Lett et al., 2004). Unfortunately, we were not able to take antidepressants into account in the present study. Fourth, autonomic (e.g., increased heart rate and decreased heart-rate variability), hematological (e.g., increased platelets and changes in the leukocyte concentration), and inflammatory (e.g., changes in blood vessels due to hypersecretion of inflammatory and aliphatic cytokines) changes in depression may be associated with MetS (Brunner et al., 2002; Chrousos, 2000). Another possible mechanism is related to hypothalamic-pituitaryadrenocortical system and neurotransmitters; depression increases cortisol secretion and slows down serotonin secretion, which may induce MetS (Muldoon et al., 2006). More importantly, our study showed the prevalence of various combinations of MetS components for women with and without depression. Although four previous studies examined the combination of MetS components and their correlates, such as socioeconomic status, sex, CVD events, and mortality (Franco et al., 2009; Lee et al., 2008; Lim et al., 2012; Tanomsup et al., 2007), the present study may be the first that investigated associations between MetS combinations and depression. A higher prevalence rate for most MetS combinations was seen in women with depression compared to women without depression. The most frequent combination included all 5 MetS components; i.e., abdominal obesity + high triglycerides + low HDL-C + elevated fasting plasma glucose + high blood pressure. The next most frequent combination included abdominal obesity + elevated fasting plasma glucose + high blood pressure, followed by the combination of high triglycerides + low HDL-C + high blood pressure, and finally abdominal obesity + high triglycerides + low HDL-C + high blood pressure. The order of the combinations of MetS components in terms of high prevalence among women without

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depression was similar to that of women with depression. Our results are similar to previous findings for women with and without depression (Franco et al., 2009; Lee et al., 2008; Lim et al., 2012; Tanomsup et al., 2007), and the top three most prevalent combinations of MetS components commonly include the combination of abdominal obesity + elevated fasting plasma glucose + high blood pressure, or the combination of high triglycerides + low HDL-C + high blood pressure. Notably, high triglyceride levels were present in all combinations that showed between-group differences. Additionally, high triglyceride levels were associated with depression independent of the other factors. In a recent study conducted in Korea that examined the relationship between depression and MetS, a high triglyceride level was the only MetS component that was significantly associated with depression in women. The authors suggested that depression may be associated with lipid abnormalities, including low HDL-C and high triglycerides (Kim et al., 2015). Previous studies have also found a significant association between depression and high triglyceride levels (Kinder et al., 2004; Skilton et al., 2007; van Reedt Dortland et al., 2010), which are known to be a key component of MetS (Garg et al., 2013). One possible mechanism may be that interleukin-2 lowers cholesterol and increases triglycerides and also suppresses melatonin secretion, thus causing depression (Penttinen, 1995). Another possible mechanism is changes in the lipid profile due to the use of antidepressants (Hiles et al., 2016). Because this study used cross sectional survey data, we could not examine the longitudinal effect of various combinations of MetS components on future occurrence of CVD or mortality. However, based on previous studies, it can be inferred that all individuals with MetS do not have the same risk levels with respect to CVD or mortality (Franco et al., 2009; Lee et al., 2008), and certain combinations (specifically, the combination of abdominal obesity + elevated fasting

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plasma glucose + high blood pressure, or that of high triglycerides + low HDL-C + high blood pressure) may have stronger association with outcomes such as CVD and mortality (Franco et al., 2009; Tanomsup et al., 2007). Franco el al. (2009) suggested that efforts should be made to provide appropriate treatment to people with particular combinations of MetS components at an early disease stage.

4.1. Limitations The present study was subject to some limitations. First, the cross-sectional design of the study has important implications regarding the bidirectional relationship of depression and MetS, in other words, depression can influence the incidence of MetS (Räikkönen et al., 2007), and MetS can influence the incidence of depression (Skilton et al., 2007). In the future, prospective longitudinal studies should be conducted to determine the causal effects of the factors reported in our study. Second, depression was not assessed using a standardized objective measure, and classification errors may have resulted from the use of self-reported data on past diagnoses that were made by physicians. Nevertheless, previous research indicates that self-reported diagnoses generally show good agreement with medical records data (Kehoe et al., 1994). Similarly, the need for a clinical diagnosis of depression by a physician is likely to result in underreporting of prevalent depression. Third, unhealthy dietary pattern (Moreira et al., 2016), antidepressant use (DiMatteo et al., 2000), compliance with medical care (van Reedt Dortland et al., 2010), and other major risk factors for depression and MetS were not considered in this study, which has limited our ability to determine the association between depression and MetS. Notwithstanding the aforementioned limitations, the strengths of this study include the use of a large, nationally representative sample that was collected with a complex sampling design, as

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well as the use of appropriate statistical procedures that were designed to produce accurate estimates from community-based surveys. We have also presented the associations between depression and different combinations of MetS components, which have yielded novel results that were missing from the prior literature. An in-depth understanding of the combinations of MetS components that are present in individuals with depression can provide basic data that would help to establish strategies for clinically managing patients and preventing the development CVD and other diseases.

Conflicts of interest The authors declare that they have no conflicts of interest.

Author Disclosure Contributors SJP designed the study, analyzed the data and prepared the first draft of the report. SP participated in its design and coordination and helped to draft the manuscript. JH and HAK supervised the data analysis. SR, SK, TKL, SHK, YJH, and JWJ interpreted the results. SJP wrote the final report. All authors critically reviewed the manuscript.

Role of the Funding source The funding source was not involved in the preparation of the article.

Institutional review board The Institutional Review Board of the Korea Centers for Disease Control and Prevention 16

(2007-02CON-04-P, 2008-04EXP-01-C, 2009-01CON-03-2C, 2010-02CON-21-C, 201102CON-06-C, 2012-01EXP-01-2C, 2013-07CON-03-4C) approved the survey protocol. The KNHANES data used for the present study is openly available.

Acknowledgments This study was supported by an Intramural Research Grant from the National Center for Mental Health, Ministry of Health & Welfare, Korea.

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Table 1. General characteristics of the female Korean survey subjects according to prior diagnosis of depression Characteristics

Total

Age, year, mean (SE)

With depression

Without depression

p-

(n = 1,296)

(n = 22,089)

valueb

46.13

(0.18)

50.38

(0.56)

45.89

(0.18)

<.001

19–29

2913

(18.70)

82

(3.05)

2831

(96.95)

<.001

30–39

4542

(20.38)

174

(4.24)

4368

(95.76)

40–49

4303

(21.22)

198

(4.62)

4105

(95.38)

50–59

4257

(17.51)

303

(7.14)

3954

(92.86)

60–69

3745

(11.04)

312

(7.95)

3433

(92.05)

≥70

3625

(11.15)

227

(5.76)

3398

(94.24)

13248

(64.35)

540

(4.04)

12708

(95.96)

10080

(35.65)

753

(7.26)

9327

(92.74)


7569

(28.26)

552

(6.75)

7017

(93.25)

Q1 to
5199

(24.14)

277

(5.40)

4922

(94.60)

Q2 to
5440

(25.56)

240

(4.27)

5200

(95.73)

4785

(22.04)

211

(4.15)

4574

(95.85)

≥100

2187

(10.92)

188

(18.87)

1999

(10.48)

<100

485

(2.59)

31

(3.01)

454

(2.57)

never

20630

(86.49)

1072

(78.12)

19558

(86.95)

more than once a month

8693

(41.46)

423

(38.59)

8270

(41.61)

no (include never)

14572

(58.54)

866

(61.41)

13706

(58.39)

<5.0

6120

(25.66)

361

(28.35)

5759

(25.51)

5.0 to <20.0

7250

(31.86)

383

(28.83)

6867

(32.03)

20.0 to <50.0

5391

(23.10)

295

(22.29)

5096

(23.14)

≥50.0

4624

(19.38)

257

(20.53)

4367

(19.32)

Postmenopausal status, n (%)

6651

(39.89)

516

(53.63)

6135

(39.08)

0.001

Metabolic syndrome, n (%)

5285

(19.44)

382

(26.20)

4903

(19.07)

<.001

a

Age groups, year, n (% )

Education, n (%) ≥high school
<.001

c

Monthly household income, n (%)

≥Q3

<.001

d

Smoking status, n (%) <.001

Alcohol use in the past year, n (%) 0.009

Physical activity (MET/h/wk), n (%)

a

% refers to population weighted proportions

b

statistical significance for difference between groups with and without depression

c

groups by quartiles

d

lifetime use of cigarettes.

24

0.129

SE, standard error; Q1–Q3, quartiles 1–3; MET, Metabolic Equivalent of Task.

Table 2. Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CI) for the association of prior diagnosis of depression with metabolic syndrome and its components in Korean women With depression

Without depression

Crude OR

Adjusted OR

n (%a)

n (%a)

(95% CI)

(95% CI)b

Dependent Variables Metabolic syndromec

382

(25.20)

4903

(19.07)

1.51

(1.29–1.76)

1.20

(1.01–1.43)

Abdominal obesity

434

(30.17)

5728

(23.27)

1.43

(1.23–1.66)

1.16

(0.99–1.36)

High triglycerides

360

(27.82)

4610

(20.52)

1.49

(1.27–1.76)

1.21

(1.02–1.43)

Low HDL cholesterol

524

(40.32)

8256

(37.35)

1.13

(0.98–1.31)

1.01

(0.87–1.18)

Elevated fasting plasma

382

(29.55)

5041

(22.13)

1.48

(1.26–1.73)

1.20

(1.01–1.43)

594

(40.03)

7886

(30.11)

1.55

(1.35–1.77)

1.16

(0.98–1.37)

glucose Hypertension a

% refers to population-weighted proportions

b

adjusted for age, education, monthly household income, smoking status, alcohol use, physical activity, and postmenopausal status

c

defined based on the Adult Treatment Panel III criteria

Figure 1. The relationship between the number of metabolic syndrome (MetS) components and the prevalence of depression in Korean women 25

Figure 2. Comparison of the prevalence (%) of various combinations of metabolic syndrome (MetS) components by history of depression among Korean women ●, with depression; ■, without depression.W, WC (abdominal obesity); T, TG (high triglyceride); H, HDL-C (low HDL cholesterol); G, FPG (elevated fasting plasma glucose); P, BP (high blood pressure).* p < .05, the difference between the groups with and without depression was statistically significant.

26

Highlights 

Cross-sectional data from a large, representative sample of Korean womenwere used 27



Depression was associated with metabolic syndrome (MetS) in these women



Similar associations were found between depression and the components of MetS



Addressing these MetS components might reduce mortality in women with depression



Addressing these MetS components might also reduce cardiovascular disease events

28