Yonago Acta medica 2013;56:1–6

Original Article

Physical and Mental Factors Associated with Obesity in Individuals with Mental
Disorders Attending Psychiatric Day-Care Facilities
Michiko Saiga,* Tadasu Ikeda† and Shin-ichi Yoshioka**Department of Nursing Care Environment and Mental Health, School of Health Science, Tottori University Faculty of Medicine,
Yonago 683-8503, Japan and †Sumiyoshi Naika Ganka Clinic, Yonago 683-0846, Japan

ABSTRACTThe prevalence of obesity as well as metabolic syndrome
is high among individuals with chronic mental disorders
who lived in communities.1, 2 Metabolic syndrome encompasses a cluster of abnormalities, including obesity,
elevated blood pressure, dysregulation of glucose andlipid metabolism, and insulin resistance, thereby resulting in the onset and progression of arteriosclerosis-related diseases such as cerebral stroke and cardiovasculardisease.3 Being overweight is a significant risk factor for
metabolic syndrome, and several factors, including antipsychotic medications,4, 5 have been implicated in theoccurrence of high rates of obesity and metabolic abnormalities in psychiatric patients. Lifestyle factors can also
result in the onset of metabolic syndrome because patients with psychiatric disorders often cannot look after
themselves, consuming unbalanced diets and avoiding
physical activities.6, 7
Belloc and Breslow reported that 7 daily healthy
lifestyle habits, namely sleep, breakfast, snacking, weight
monitoring, physical exercise, smoking and drinking
were associated with overall health status, obesity andhypertension.8 There is a strong relationship between
dietary habits, obesity and metabolic syndrome.9–12 In
the general population, abnormal dietary behaviors arecommonly observed among metabolic patients. The association between obesity and lifestyle-related diseases
has been reported in the general population, while few
studies have involved individuals with mental disorders.
The prevalence of obesity and/or the metabolic
syndrome in outpatients with psychiatric illnesses ishigh compared with that in inpatients.12–17 Psychiatricrehabilitation programs such as psychiatric day care areutilized by outpatients with mental disorders to prevent
relapses in psychiatric symptoms and/or to maintaindaily activities and lead to normal lives in their communities. Psychiatric day-care facilities provide psychiatricpatients with regular schedules, communication, socialization and exercise programs.18 Weight management
programs for psychiatric patients living in communities
are offered at psychiatric rehabilitation units, including day-care facilities,19–21 where the modification oflifestyle choices such as dietary and exercise habits areencouraged by medical staff. Therefore, in the present
study, we examined the relationship between obesity andBackground

Individuals with mental disorders haveincreased rates of obesity and metabolic syndrome. Herewe evaluated factors influencing obesity in individuals
with mental disorders who were attending psychiatric
day-care facilities on an outpatient basis.
Methods The subjects (n = 108) were outpatients attending hospital-based rehabilitation programs. We
assessed body fat, weight, height, waist circumference,
body mass index (BMI), blood pressure, Geriatric Depression Scale-15 (GDS) scores, frequency of day-carevisits, satisfaction with body shape, physical comorbidity
and lifestyle habits. Lifestyle habits were evaluated using
Breslow’s health index based on health-related choices.
Results
The subjects were divided into 2 groups:
obese group (BMI ≥ 25 kg/m2) and non-obese group(BMI < 25 kg/m2). The physical parameters and attributes of both groups were compared, and factors related
to BMI were statistically analyzed. The prevalence ofobesity was 47.2% in all patients, 42.4% in males and54.8% in females. Weight, waist circumference, body
fat and systolic and diastolic blood pressure were significantly higher in the obese group than in the nonobese group. Body fat, waist circumference, systolicblood pressure and diastolic blood pressure exhibited
significant positive correlations with BMI, whereas
the frequency of day-care visits, satisfaction with body
shape, GDS score and Breslow’s health index exhibited
significant negative correlations with BMI.
Conclusion The present results showed that the prevalence of obesity was high in outpatients with mental disorders. Improvement in lifestyle choices is necessary to
prevent obesity and the onset of metabolic syndrome insuch patients.
Key words
Breslow’s health index; metabolic syndrome; mental disorder; obesity; psychiatric day-carefacility
Corresponding author: Michiko Saiga
michi15@med.tottori-u.ac.jp
Received 2012 November 30
Accepted 2012 December 7
Abbreviations: BMI, body mass index; GDS, Geriatric Depression
Scale

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M. Saiga et al.
Table 1. Characteristics of the study participantsa various kind of factors including physical measuresand lifestyle choices and also investigated the effects ofgender on their relationship among patients with mental
disorders who were attending psychiatric day-care facilities on an outpatient basis.

Total
n
(%)

Male
n (%)

Femalen (%)

Gender108 (100%) 66 (61.1%) 42 (38.9%)
Age (yr)†52.7 [13.5] 52.0 [13.4]
53.8 [13.8]
Main disease
Schizophrenia
92 (85.1%) 58 (63.0%) 34 (37.0%)
Others16 (14.9%) 8 (50.0%) 8 (50.0%)
Living arrangements
Living alone
33 (30.6%) 23 (69.6%) 10 (30.4%)
Living with family 54 (50.0%) 29 (53.7%) 25 (46.3%)
Living in institution 21 (19.4%) 14 (66.6%) 7 (33.4%)
Duration of
day-care use (yr)†5.7 [5.9]
6.0 [6.3]
5.2 [5.4]
Frequency of day-carevisits (times/wk)†
3.2 [1.5]
3.0 [1.5]
3.6 [1.3]
Satisfaction
with body shape†
4.6 [2.7]
5.0 [2.7]
4.0 [2.7]
Breslow’s health index† 4.0 [1.1]
3.9 [1.2]
4.2 [1.0]

SUBJECTS AND METHODS
Subjects

This cross-sectional study was conducted from July 2010
to August 2010 and was approved by the Ethics Committee of Tottori University Faculty of Medicine. The
subjects included 111 outpatients who were attending ahospital-based psychiatric day-care program in 2 psychiatric hospitals. All subjects provided written informed
consents prior to participation.
Measurements† Mean [s].

Physical examinations included the measurement ofheight, weight, body fat, body mass index (BMI), waist
circumference and blood pressure. Weight, body fat and
BMI were measured using the Tanita TBF-310 bodycomposition analyzer (Tanita, Tokyo, Japan) with correction for clothing. Waist circumference was measured
as the smallest horizontal girth around the navel using anonstretchable fiber measuring tape. The subjects wereasked to stand erect in a relaxed position with both feet
together on a flat surface.22 On the basis of BMI values,
the subjects were divided into 2 groups: non-obese group(BMI < 25 kg/m2) and obese group (BMI ≥ 25 kg/m2).
In addition, males with waist circumference ≥ 85 cm andfemales with that ≥ 90 cm were considered as having
visceral fat obesity. Systolic and diastolic blood pressures were recorded in a sitting position using a mercury
sphygmomanometer.
A structured questionnaire was administered to thesubjects to record age, sex, living arrangements, maindisease, physical comorbidities and lifestyle habits. Life-

style habits were assessed on the basis of the 7 healthhabits advocated by Belloc and Breslow.8 The subjects
were to answer the 7 questions with either “true” or“false.” For each question, a score of 1 was given fora “true” answer and 0 for “false”. The score, which iscalled the Breslow’s health index, was calculated bysumming the scores for the 7 health habits to yield a total score of 0–7. In addition, the subjects were questioned
about the number of years of day-care use, including thenumber of visits per week. The level of satisfaction withthe day-care and the level of satisfaction with one’s body
shape were measured using the visual analog scale. A
score of 0 indicated minimal satisfaction while a scoreof 10 indicated maximal satisfaction. The degree of depression was measured using the Geriatric Depression
Scale-15 (GDS).23 A higher GDS score indicates severer
depression state leading to the maximal score of 15.
Statistical analyses

Descriptive statistical analyses were performed to describe patient demographics and clinical variables. Data
are presented as mean and standard deviation (s). Statistical differences were determined using the unpaired ttests and chi-square tests. The correlation between BMI
and each factor was examined using the Peason’s rankcorrelation coefficient test. The data were analyzed using the PASW Statistics software for Windows ver.18.0(SPSS: IBM, Tokyo). A P value of < 0.05 was considered
statistically significant.

Table 2. Physical assessment of the study participants

Height (cm)Body weight (kg)BMI (kg/m2)
Body fat (%)
WC (cm)SBP (mmHg)
DBP (mmHg)

Total
Mean [s]MaleMean [s]FemaleMean [s]162.1 [8.8]66.4 [14.6]
25.1 [4.6]26.2 [8.4]91.0 [12.0]
117.3 [15.7]
73.6 [9.4]167.1 [6.3]69.2 [14.2]
24.6 [4.0]23.1 [7.1]
90.6 [11.9]
118.0 [16.2]
74.4 [9.8]154.5 [6.2]**
62.0 [14.3]*
25.9 [5.3]**
31.4 [7.9]**
91.8 [12.2]
116.1 [14.9]
72.3 [8.6]

BMI, body mass index; DBP, diastolic blood pressure; SBP, systolic blood pressure; WC, waist circumference.
*P < 0.05; **P < 0.001: comparison between males and females.

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Obesity in mentally disordered persons
Table 3. Comparison between the non-obese and the obese groups

Participants: n (%)
Age (yr)†
Height (cm)†Body weight (kg)†BMI (kg/m2)†
Body fat (%)†
WC (cm)†VFO patients: n (%)
SBP (mmHg)†
DBP (mmHg)†
Satisfaction with body shape†
GDS score†
Duration of day-care use (yr)†Frequency of day-carevisits (times/wk)†
Breslow’s health index

Total (n = 108)
Non-obese 		
group
Obese group

Male (n = 66)
Non-obese 		
group
Obese group

Female (n = 42)
Non-obese
group
Obese group57 (52.8%) 51 (47.2%)
54.1 [13.2]
51.1 [13.8]
161.2 [8.9]163.2 [8.5]56.4 [8.7]
77.5 [11.5]**
21.6 [2.2]29.0 [3.3]**
21.0 [5.8]32.1 [6.8]**
82.9 [7.8]
100.1 [9.0]**
20 (18.5%) 46 (42.5%)
114.2 [15.2]
120.7 [15.6]*
71.1 [8.2]76.3 [9.9]*
5.4 [2.8]
3.9 [2.5]*
6.1 [3.2]
4.5 [3.5]*
6.1 [6.7]
5.3 [5.1]

38 (57.6%)
53 [13.6]
165.4 [6.5]59.6 [7.3]
21.7 [2.1]
18.8 [4.4]82.6 [7.6]
15 (22.7%)
113.1 [14.9]
71.1 [8.4]5.7 [2.6]
6.0 [3.0]
6.4 [7.3]

28 (42.4%)
50.6 [13.1]
169.3 [5.2]
82.2 [10.3]**
28.5 [2.4]**
28.9 [5.8]*
101.3 [7.3]*
28 (42.4%)
124.7 [15.5]*
78.9 [10.0]*
4.2 [2.7]*
4.5 [3.7]
5.5 [4.7]

19 (45.2%) 23 (54.8%)
56.4 [12.3]
51.6 [14.9]
152.8 [7.2]155.7 [5.0]50.2 [7.9]71.8 [10.4]*
21.4 [2.4]
29.6 [4.1]*
25.5 [6.0]36.3 [5.8]*
83.5 [8.4]98.6 [10.6]*
5 (11.9%) 18 (42.9%)
116.5 [15.8]
115.9 [14.5]
71.2 [7.9]73.3 [9.2]
4.6 [3.2]
3.6 [2.3]
6.2 [3.6]
4.6 [3.2]
5.4 [5.4]
5.1 [5.6]

3.3 [1.7]
4.6 [1.0]

2.5 [1.2]*
3.0 [0.9]**

3.4 [1.6]
4.6 [1.0]

3.0 [1.4]
3.3 [0.9]**

3.6 [1.3]
4.8 [1.0]

3.7 [1.4]
3.7 [0.8]† Mean [s].
BMI, body mass index; DBP, diastolic blood pressure; GDS, Geriatric Depression Scale; SBP, systolic blood pressure; VFO, visceral fat
obesity; WC, waist circumference.
* P < 0.05; ** P < 0.001: comparison between the non-obese and obese groups.

RESULTSWith regard to physical comorbidities, 16 subjects (14.8%)
had diabetes, 14 (12.9%), hypertension and 17 (15.7%),
dyslipidemia. The mean GDS score of both males andfemales was 5.3, s = 3.4, with no significant sex difference.

Subject characteristics

The sample size for the clinical audit was 111. Amongthem, 108 patients completed the study assessments [66males (61.1%); 42 females (38.9%); mean age 52.7 years,s = 13.5]. The characteristics of the subjects are listed inTable 1. The most common disease was schizophrenia(n = 92). Fifty-four patients lived with their families, 33
lived alone and 21 resided in institutions. The mean duration of day-care use was 5.7 years, s = 5.9. The meanfrequency of day-care visits was 3.2 times/week, s = 1.5.
The mean visual analog scale score for satisfaction withthe day-care facility was 6.7, s = 2.1, whereas that forsatisfaction with one’s body shape was 4.6, s = 2.7. The
mean Breslow’s health index was 4.0, s = 1.1.
The results of physical assessments of the subjects
are shown in Table 2. The mean height and mean weightof the subjects were 162.1 cm, s = 8.8, and 66.4 kg, s =14.6, respectively. The mean height and weight of males
were significantly greater than those of females. The
mean BMI was 25.1 kg/m2, s = 4.6 (range: 16.8–41.0)
while the mean body fat was 26.2%, s = 8.4. Both BMI
and body fat values for females were significantly greater than those for males.
As for factors associated with obesity, the mean
waist circumference was 91.0 cm, s = 12.0; mean systolic blood pressure 117.3 mmHg, s = 15.7, and mean
diastolic blood pressure 73.6 mmHg, s = 9.4. There wereno significant sex differences in these measurements.

Comparison between obese and non-obese groups

Table 3 shows the results of physical assessments of the
2 groups. Weight, BMI, waist circumference, body fat,systolic and diastolic blood pressures in the obese groupwere significantly higher than those in the non-obese
group. The overall proportion of visceral fat obesity was
42.5% in the obese group, higher than 18.5% in the nonobese group as well. However, satisfaction with body

Table 4. Correlation of BMI and other factors
WC
Body fat
SBP
DBP
Duration of day-care use
Frequency of day-care visits
Satisfaction with body shape
GDS score
Breslow’s health index

Coefficient

P value

0.892
0.767
0.240
0.289
–0.027–0.202–0.362–0.217–0.405

**
**
*
*
*
**
*
**

DBP, diastolic blood pressure; GDS, Geriatric Depression Scale;
SBP, systolic blood pressure; WC, waist circumference.
*P < 0.05; **P < 0.001.

3M. Saiga et al.

shape, Breslow’s health index and GDS score were lower
in the obese group than in the non-obese group.
Gender effect on the comparison between the 2groups is also shown in Table 3. Only in males, systolicand diastolic blood pressures were higher, and the frequency of day-care visits, satisfaction with body shapeand Breslow’s health index were lower in the obese
group than in the non-obese group.
As shown in Table 4, body fat, waist circumference,systolic and diastolic blood pressures exhibited significant positive correlations with BMI, whereas the frequency of day-care visits, satisfaction with body shape,
GDS score and Breslow’s health index exhibited significant negative correlations with BMI.

in outpatients using psychiatric day-care facilities.
The prevalence of metabolic syndrome in individuals with mental disorders as well as those in the general
population has been reported to be higher in males thanin females.17, 25 As for the physical and mental factors
associated with obesity, several factors were still sexdependent. Only in males, significant differences inthe satisfaction with body shape, frequency of day-carevisits and Breslow’s health index were observed between
the obese and non-obese groups. Therefore, an establishment of healthy lifestyle habits is necessary for obese
males with mental disorders because they are likely
to have lower health scores as well as lower frequencyof day-care visits. In addition, Hiruta26 found that theability to maintain a sense of reality was weak andself-image was vague in patients with schizophrenia.
Concerning the satisfaction with body shape, the obese
males were shown to recognize their obese state because their level of satisfaction was low. However, they
could not readily adopt different lifestyles to improvetheir quality of life. Therefore, it is necessary to improve
lifestyle in such patients because they will not be able
to improve their lifestyle with the present condition forthemselves despite their ability to recognize their own
figure. Furthermore, it is well known that administrationof antipsychotic drugs induces excessive weight gain.4, 5
One of the various mechanisms of antipsychotic-induced
weight gain is the deterioration of appetite regulation.
Therefore, it is necessary for doctors to reexamine prescription contents because antipsychotics are at risk ofbringing about overeating and obesity.
The present study showed a negative correlation
between BMI and Breslow’s health index. Therefore,
an improvement in daily lifestyle habits could decreaseobesity in individuals with mental disorders as well as
healthy individuals. Brown et al.27 reported that patientswith schizophrenia consumed more fatty foods and lessdietary fiber and spent less time exercising comparedwith the general population. Intervention programs
including psychological education on obesity, dietary
habits and regular exercise patterns are recommended
to prevent weight gain and development of metabolic
syndrome in individuals with mental disorders.19, 28–31
Efficient utilization of psychiatric rehabilitation units
such as psychiatric day-care facilities can encourage
lifestyle changes and improve cognitive function inthese individuals.19–21 In addition, a negative correlation
between BMI and GDS scores was also found. A lot of
studies about obesity and depression have been reported.
However, the relation of obesity and depression remains
still controversial with studies showing positive,32 null33
and negative34–36 association. Luppino et al.37 reported,DISCUSSION
In the present study, we performed physical and mental
assessments on the individuals with mental disorders
who were attending psychiatric day-care facilities onan outpatient basis and found that the prevalence ofobesity (BMI ≥ 25 kg/m2) was 47.2%. According to asurvey conducted by the Ministry of Health, Labour andWelfare in Japan,24 the prevalence of obesity (BMI of≥ 25 kg/m2) in healthy individuals aged > 20 years wasreportedly 25.3% overall, 30.4% for males and 21.1% forfemales. Therefore, the prevalence of obesity is noticeably higher in individuals with mental disorders than in
the general population, as confirmed by the results ofour study and previous studies.
Tirupati and Chua1 reported that the prevalence ofobesity in individuals with mental disorders who lived incommunities was 59% while the prevalence of the metabolic syndrome was 68%. Hasegawa et al.15 reported that
32% of psychiatric inpatients examined had a BMI of≥ 25 kg/m2 during the study period. In addition, Yamada
et al.16 reported that among 153 psychiatric inpatients,
there were 16 (10.5%) with diabetes, 32 (20.9%) with hypertension and 30 (19.8%) with BMI of ≥ 25 kg/m2. The
prevalence of physical comorbidities such as diabetes,
hypertension and dyslipidemia in our study were similar
to those reported by Yamada et al.16
In Japan, a WC of ≥ 85 cm for males or ≥ 90 cm forfemales is indicative of visceral fat obesity, which is significantly related to metabolic syndrome as well as obesity. Shimizu14 reported that the incidence of metabolic
syndrome in outpatients with schizophrenia was 22.1%.
In addition, Sugawara et al.17 also found that the prevalence of metabolic syndrome in outpatients with schizophrenia and schizoaffective disorders was higher thanthat in inpatients with the same disorders. The present
study indicated a higher visceral fat obesity prevalence4Obesity in mentally disordered persons

through a systemic review and meta-analysis of longitudinal studies, that obesity was found to increase the riskof depression. Multivariate and longitudinal studies areneeded to clarify this issue. Our study indicated that theprevalence of obesity was high among the individuals
with mental disorders who were attending psychiatric
day-care facilities on an outpatient basis and that themeasures of obesity were significantly correlated tolifestyle choices. Therefore, it is important to modify
lifestyle and dietary habits to prevent the development of
metabolic syndrome or obesity in individuals with mental disorders.

11 Miyatake N, Matsumoto J, Nishikawa H, Kunihashi Y, Fujii M,
Miyachi M, et al. [Association between metabolic syndrome
and lifestyle]. Hoken No Kagaku. 2007;49(suppl 5):355-9.
Japanese. NAID: 40015474718.
12 Ministry of Health, Labour and Welfare [Internet]. Tokyo:
the National Health and Nutrition Survey 2008 [updated 2010
Dec 7; cited 2012 Aug 6]. [1 screen]. Available from: http://
www.mhlw.go.jp/stf/houdou/2r9852000000xtwq.html
13 Ido Y, Makino J, Okushima R, Tsutsumi S, Sakai T. Factors
on life-style-related disorders found in day-care schizophrenics. Aino j. 2002;1:29-33. NAID: 110000041432.
14 Shimizu K. [From large-scale findings about the metabolic
syndrome of the schizophrenia going to hospital patient].
Seishin Shinkeigaku Zasshi. 2008;110:1197-218. Japanese.
NAID 10024918785.
15 Hasegawa Y, Sekii A. [The actual situation of a factor leading
to the onset of the lifestyle-related disease of the ward inpatient for psychiatry chronicity period]. Nihon Kango Gakkai
Ronbunsyu Seishinkango. 2009;40:125-7. Japanese. NAID:
40016960133.
16 Yamada J, Miwa T, Ikeda R, Mimura E, Ogawa S, Tanaka
S, et al. Current state of metabolic syndrome in psychiatry.
Kyushu Yakugakkai Kaiho. 2009;63:51-4. Japanese.
17 Sugawara N, Yasui-Furukori N, Sato Y, Kishida I, Yamashita
H, Saito M et al. Comparison of prevalence of metabolic
syndrome in hospital and community-based Japanese patientswith schizophrenia. Ann Gen Psychiatry. 2011;10:21. PMCID:
PMC3179440.
18 Ohta T. [Convalescence rehabilitation]. In: Sakata M, ed.
Psychiatry rehabilitation nursing. Tokyo: Nakayama Syoten;
2009. p. 55. Japanese.
19 Liu YC, Wang HY, Huang HL, Chen ML. Project to improve
abdominal obesity in day care ward psychiatric patients. Hu Li
Za Zhi. 2011;58(suppl 3):3-11. Chinese with English abstract.
20 Fujita E, Kato D. A nutrition and exercise-management program for patients with schizophrenia: Follow-up after a 10week program. Kodo Ryoho Kenkyu. 2008;34:325-37. Japanese with English abstract.
21 Hata M, Yamasaki M, Kunishita T, Yamase K, Maeda T. [Action of the SST wellness program by the day-care]. Shinyaku
To Rinsyo. 2007;56:1730-5. Japanese.
22 Nakamura T, Ryo M, Noguchi M, Hirobe K. The role of waist
circumference in diagnosis for metabolic syndrome. Igaku No
Ayumi. 2005;213:585-8. Japanese. NAID: 40006699787.
23 Furukado Y, Inaga K, Miura C. On a validity of geriatricdepression scale (GDS) short from Japanese version. Chikusuikai Sinkei Joho Kenkyusyo Chikusuikai Byoin Nenpo. 1992;11:35-40. Japanese with English abstract. NAID:
80007079805.
24 Ministry of Health, Labour and Welfare [Internet]. Tokyo:
the National Health and Nutrition Survey 2010 [updated
2012 January 31]. Available from: http://www.mhlw.go.jp/stf/
houdou/2r98520000020qbb-att/2r98520000021c0o.pdf. Japanese.
25 Ministry of Health, Labour and Welfare [Internet]. Tokyo:
The Ministry; c2009- [updated 2009 Nov; cited 2012 Aug 6].
[The National Health and Nutrition Survey 2009]. [1 screen].
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26 Hiruta G. [Action properties of the schizophrenia patient]. Tokyo: Kongo Syuppan; 2011. p.71. Japanese.
27 Brown S, Birtwistle J, Roe L, Thomson C. The unhealthy life-

Acknowledgments: We are grateful to Professor Keiichi Hanaki,
Department of Women’s and Children’s Family Nursing, Schoolof Health Science, Tottori University Faculty of Medicine, andProfessor Koichi Kaneko, Division of Neuropsychiatry, Department of Brain and Neurosciences, School of Medicine, Tottori
University Faculty of Medicine, for their helpful suggestions.
The authors declare no conflict of interest.
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