The Relationship between Double Burden of Malnutrition and Mental Health among Adult Females

Background: The coexistence of overweight or obesity with concurrent deciency of one or more nutrients, referred to as double burden of malnutrition (DBM). A number of mental health impairments have been associated with a wide variety of nutrient deciencies. In the current environment, the co-occurrence of obesity, overweight and mental health impairments have emerged as a signicant global health concern. Although DBM is relevant for a number of health outcomes, the ubiquitous involvement of vitamin D across multiple systems and tissues suggests D insuciency as a viable target for nutritional modication. Purpose: This study aimed to evaluate the contribution of DBM to mental health among adult females. Methods: Study participants included 231 females ages 18-59 years who presented to one of the 25 health centers in Tehran. Women were overweight or people with obesity and BMI ranging from 25 to 40 Kg/m 2 . The 147-item food frequency questionnaire (FFQ) was used to estimate their dietary intake. Body composition was measured by bioelectric impedance assay, anthropometrics including waist circumference (WC) hip circumference were determined and BMI was calculated. Mental health status was assessed using the depression, anxiety, and stress scales-21 (DASS-21). Venipuncture was performed to assess plasma vitamin D level and lipid prole. Results were analyzed by SPSS software. Results: The mean ± standard deviation (SD) age, weight, and BMI of the participants were 36.49±8.38, 80.89±12.45 kg and 31.04±4.31 Kg/m 2 , respectively. DBM was signicantly associated with stress after adjusting for potential confounders including age, energy and marital status in the model 1 (OR;1.28, 95% condence interval (CI)=1.00-1.65 P=0.04) in comparison to crude model (OR=1.22; 95% CI=0.96-1.55 P=0.09). No signicant relationship was seen among DBM and DASS-21 outcomes were observed. Conclusions: the relationship is unclear. Vitamin D insuciency is associated with mental health and obesity in opposing directions. Whether vitamin D supplementation can decrease mental health impairments requires further evaluation.


Introduction
The continued rise in overweight and obesity remain a global health concern. In particular, the increases and consequent adverse health effects widely recognized among developing countries are introducing a tremendous health challenge (1). In particular, the emergence of double burden of malnutrition (DBM), the co-existence of caloric overconsumption with essential nutrient insu ciency has been reported as more prevalent in developing countries in comparison to developed countries (2,3). While the contributors include egregiously increasing urbanization, alteration dietary pattern and lifestyle (4), some nutrients are more likely to be implicated in adverse health effects.
The physiologic effects of DBM are well-recognized. However, a comprehensive understanding of modi able health outcomes requires an understanding of the psychological effects of DBM, as well.
A link between obesity and a number of mental health impairments across the life course have been reported (5,6).
Since, poor mental health a icts more than 300 million people all ages, the additive effect of the obesity epidemic and mental health impairments could have profound effect on mortality in the ensuing decade.
Indeed, a bidirectional link between obesity and mental health has been suggested, (7), with obesity increasing the risk of depression incidence, and a suggested mechanistic role (8)of inadequate amount of essential nutrient intake as a moderator (9,10). Suboptimal nutrient including cobalamin, folic acid, niacin and ascorbic acid, zinc, iron and selenium have been associated to depression (11). However, the ubiquitous involvement of vitamin D in neurocognition and obesity-related disorders offer a viable area of investigation as a modi able intervention (12,13).
In this cross-sectional study we consider to assessing association between DBM and mental health including depression, anxiety and stress within Iranian people with obesity and overweight females focusing on vitamin D as a potential moderator.

Study design
A cohort of 231 people with obesity and overweight Iranian females aged 18-59 years participated in this study. Women were randomly selected from those presenting to 25 health centers in Tehran. All participants signed a written consent form. Inclusion criteria were age 18-59 years; no current weight loss program; no use of weight loss supplements. Participants with a history of type 2 diabetic (T2D), cardiovascular disease (CVDs), polycystic ovary syndrome (PCO), stroke, non-alcoholic fatty liver disease (NAFLD), in ammatory disease, hypertension, cancer, thyroid diseases, or who were currently pregnant were excluded because of possible changes in diet. In addition, the women reporting intake energy lower or higher than 800-4200 K/Cal excluded. The study procedure was approved by the ethics committee of Tehran University of Medical Science (IR.TUMS.VCR.REC.1398.819).

Anthropometric assessments
The individuals wore light clothing and without shoes for measuring weight and height. All the measurements were assessed by A trained technician. The waist circumference (WC) measured by a none elastic tape to the nearest 0.1 cm the narrowest area at the end of a normal exhalation. In addition, hip circumference determines at the largest part of the hip over light clothing. Body mass index (BMI) was calculated based on Quetelet's index (14) According to WHO guidelines (15), the individuals were classi ed as underweight (BMI <18.50 kg/m2), normal weight (18.50-24.99kg/m 2 ), overweight (25.0-29.9kg/m 2 ) and people with obesity (≥30.0 kg/m 2 ).

Complete body composition analysis
The body composition of all participants analyzed by body analyzer devices (model BC-418, MA-Tanita, product by the UK) followed body analyzer recommendation. This instrument measured the body composition including; Body fat mass (BFM), Fat-free mass) FFM), Visceral fat area (VFA) by data from bioelectrical impedance analysis (16). According to the manufacturer's instructions, after shoes, coats, and sweaters had been removed, subjects were required to stand on the balance scale in bare feet and hold the handles of the machine. The measurements took approximately 20 s, and the output was printed.

Dietary intake assessment
The individual diet intake was assessed by a 147-item food-frequency questionnaire (FFQ) that was validated before (17). The data documented in household measures and serving size and changed to gram and millimeter. The nutritionist IV (First Data Bank, San Bruno, CA) food analyzer used for analyzing dietary intake. Moreover, through analysis of residuals, the energies were calculated for each category and adjusted that means.

Blood sampling and biochemical parameters
At rst 10-milligram blood after 8-12 hours fasting obtained and The serum was centrifuged then, it isolated and stored at 80 Ċ. All data evaluated by the Endocrinology & Metabolism Research Institute (EMRI) Bionanotechnology laboratory of Tehran University of Medical Science. Serum fasting glucose assessment by glucose oxidase-phenol 4-amino antipyrine peroxidase (GOD-PAP) that is a colorimetric method, triglyceride(TG), total cholesterol(TC) cholesterol(CH), measured by glycerol-3-phosphate oxidase-phenol 4-amino antipyrine peroxidase (GPOPAP), enzymatic endpoint, respectively. Also lowdensity-lipoprotein(LDL) and high-density lipoprotein(HDL) cholesterol measured by direct enzymatic clearance assay. This laboratory assessment performed by Seven Randox Laboratories kits (Random Laboratories Ltd., Ardmore, UK).
The level of vitamin D in individuals assessed by immunoassay immunodiagnostic system(IDS) kits. nally, we considered the level of Serum Vitamin D concentration between 20-30 ng/L, and, less than 20 ng/ml called insu ciency and de ciency, respectively (18).

Calculation of the double burden malnutrition and mental disorders
Double burden malnutrition(DBM) assessed by calculating Body mass index (BMI) was calculated based on Quetelet's index (14) from participants with measuring weight and height. The participants BMI were greater than 25 kg/m 2 along with plasma concentration of vitamin D lower than 20ng/ml (25OHD<20ng/ml) considered DBM.

DASS Questionnaire
Mental health status was calculated by the Depression, Anxiety, and Stress Scales (DASS) is a 42-items self-report for measuring symptoms of depression, anxiety, and stress over the past week which generates three scale score. Also, the participant responded to three scales of which consist of 14-items of 0-3 scale. where responded 0=did not apply to me at all and 3=applied to me very much, or most of the time (possible scale range for each scale is 0-42). When score take 42 scales that means increase depression, anxiety and stress (19,20).
Statistical analysis Normality distribution was tested by applying Kolmogorov-Smirnov's test; data that were not normally distributed and could not be transformed appropriately for normal distribution were used for z-scores. Data on quantitative characteristics were reported as the mean ± SD and data on qualitative characteristics were expressed as a percentage. chi-squire analysis performed for detection confounders and recognize mental health disorders. one whey ANOVA and TUKEY POC HOC used for in comparison variables. The logistic regression performed for the relationship between vitamin D de ciency in overweight and people with obesity by mental disorders. An initial model (0) was created and included only vitamin D de ciency (using 20 as a cut point) and secondary model (1)

Discussion
This is a novel investigation aiming to identify vitamin D as a moderator in the association between DBM and mental health was the rst conducted in Iranian women. We observed at this study a signi cant relationship between DBM and stress.
Today's obesity and overweight are the main problems as well as they associated with in ammatory status. They play important roles in depression conditions (21)(22)(23)(24). Moreover, obesity caused to a mutation in the leptin/melanocortin pathway in the central nervous system. It appears the leptin/melanocortin pathway regulates body energy hemostasis. Moreover, obesity-related to many brain disorders and psychopathology conditions including eating and mood disorders (25-27). Furthermore, the high BMI modestly associated with mood disorders (OR 1.23) and major depression (OR 1.27). In addition, evidence showed a signi cant relationship between high BMI and anxiety disorders such as post-traumatic stress disorders (OR 2.64) (28). Rebecca E. S et al performed a systematic review and meta-analysis in 2013 on one case-control, three cohorts and ten cross-sectional studies. The showed signi cantly relationship between vitamin D de ciency and depression (10).
In similar our nding, Aya Mousa et al performed a study on 63 overweight participant and people with obesity (39 mal/24 female) in 2017 at rst, they performed a cross-sectional analysis on individuals with mean age = 31.3 ± 8.5 along with vitamin D de ciency (25(OH) D nmol/l) and BMI 25 kg/m 2 without clinical depression. Also, the participants consume a bolus oral dosage of 100000IU and followed 4000IU daily cholecalciferol for 16 weeks. After 16 weeks they observed an increasing concentration of vitamin D in plasma. Finally, they reported that vitamin D de ciency no has a correlation with depression, also vitamin D supplementation has not warranted for reducing depression symptoms (29).
In contrast with our nding, Kelly A. Schaad et al preformed a study in 2019 on 18-67 years old in both gender for assessing correlation between vitamin D de ciency and depression. They nally found signi cant relationship among participant with vitamin D de ciency and depression. But the number of male (n = 9799) is more than the female(1121) (30). Similarly, John C. Umhau reported the signi cant correlation between suicide and vitamin D de ciency in 2013 among active duty military. the number of male(n = 467) are more than female(n = 19) at this studies (31). It seems the correlation between depression and vitamin D de ciency in male are more than female.
Limitations of our study were no assessed normal weight participant with vitamin D de ciency for comparing together with DBM individuals. Moreover, the future studies should be design the studies in considering to both gender.

Conclusion
In this cohort study, we represented that stress and DBM were signi cantly associated. However, the directionality of the relationship is unclear. Vitamin D insu ciency is associated with mental health and obesity in opposing directions. Whether vitamin D supplementation can decrease mental health impairments requires further evaluation.