EMPIRICAL STUDIES
Anxiety and depression in obese and normal-weight
individuals with diabetes type 2: A gender perspective
Irene Svenningsson RN (Doctoral Student)1,2, Cecilia Björkelund MD (Professor)1, Bertil Marklund MD
(Professor)1,2 and Birgitta Gedda PhD (Senior Lecturer)2
1
Sahlgrenska School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden and 2Research and
Development Unit, Primary Health Care FyrBoDal, Vanersborg, Sweden
Scand J Caring Sci; 2012; 26; 349–354
Anxiety and depression in obese and normal-weight
individuals with diabetes type 2: A gender perspective
Background: Obesity is a problem that is increasing
worldwide, leading to an increased incidence of type 2
diabetes mellitus (T2DM). Depression is more common
among individuals with diabetes, and they are more likely
than non-diabetic individuals to experience emotional
problems. People with both T2DM and obesity bear an
additional emotional burden, which affects their quality
of life.
Objectives: To describe the prevalence of symptoms of
anxiety and depression in groups of obese and normal-
weight individuals with T2DM who are undergoing pri-
mary care and to investigate possible differences between
the groups and between genders.
Method: Three hundred and thirty-nine patients with
T2DM from nine primary-care centres participated in a
cross-sectional study (n = 180 + 159). The response rate
was 67%. The Hospital Anxiety and Depression Scale
Background
Obesity is a problem that is increasing worldwide, leading
to an increased incidence of type 2 diabetes mellitus
(T2DM), as obesity and T2DM are closely linked (1). An
association between obesity and depression has been
indicated (2), and depressed people in general, especially
younger women, present an increased risk of subsequent
obesity. At the same time, obese women exhibit an
increased risk of developing depression (3), while, among
obese males, a lower risk of depression than among
Correspondence to:
Irene Svenningsson, Research and Development Unit, Primary
Health Care Fyrbodal, Edsvagen 1 C, SE-462 35 Vanersborg,
Sweden.
E-mail: irene.svenningsson@vgregion.se
Ó 2011 The Authors
Scandinavian Journal of Caring Sciences Ó 2011 Nordic College of Caring Science
doi: 10.1111/j.1471-6712.2011.00940.
(HADS) and the Beck Depression Inventory – second edi-
tion (BDI-II) were employed to estimate the patients’
symptoms of depression and anxiety.
Results: An association between T2DM, obesity and
depression was observed in both genders. More than one
in three women and one in five men with T2DM and
obesity exhibited symptoms of anxiety or depression. In
the normal-weight group, the females presented more
symptoms of anxiety than did their male counterparts.
Conclusion: In primary healthcare, the fact that both obese
men and women with T2DM are at increased risk of
anxiety and depression is an important finding, which
must be recognised and considered in the course of pri-
mary healthcare consultations. Meeting the unique needs
of each individual requires an understanding of both lab-
oratory data and the individual’s emotional status.
Keywords: anxiety, depression, diabetes mellitus type 2,
gender, obesity, patient, primary health care, questionnaire.
Submitted 6 May 2011, Accepted 30 September 2011
normal-weight men is observed (1). People exhibiting
obesity in combination with T2DM bear an additional
emotional burden that affects their quality of life, espe-
cially that of women, and they may suffer from an
underlying state of depression (4).
The combination of T2DM and obesity increases the risk
of developing a number of complications. T2DM increases
the risk of complications such as macro- and microvascular
disorders. Similarly, obesity increases the risk of chronic
diseases such as heart attack, stroke and is also linked to
several complications such as mobility impairment,
obstructive sleep apnoea and depression (5).
Evidence from prior studies strongly suggests that T2DM
and depression are associated, as individuals with T2DM
are more likely than others to experience emotional
problems (6, 7). Also, a gender difference is observed, as
anxiety and depression are more common among women
with T2DM than in men with T2DM (6, 8).
349
350 I. Svenningsson et al.
The direction of the association between T2DM and
depression has not been fully elucidated (9). Various
researchers have obtained varied results. Both psychosocial
and biological factors may be involved (8). Some
researchers argue that depression and being diagnosed
with diabetes are associated (10). Another report suggests
that diabetes and depression are related regardless of
diagnosis and that depression may not only be induced by
psychological distress caused by the diagnosis of T2DM
(11). Being diagnosed with T2DM has been demonstrated
to carry little psychological impact, and diabetes is not
predictive of emotional symptoms, such as depression or
anxiety (12). At the same time, some researchers have
indicated that depression is a risk factor for developing
diabetes (12, 13) and that prolonged emotional stress and
anxiety have been suggested to increase the risk of
developing diabetes (14).
Unhealthy behaviours, such as smoking, physical inac-
tivity and unhealthy diet, are more common among indi-
viduals with diabetes and depression than in individuals
with diabetes who do not have depression (15). Psycho-
logical factors, as such wellbeing and eating disorders,
influence the possibility of losing weight or maintaining
weight (16).
People with diabetes in combination with depression
present a higher risk of developing complications (17).
When people exhibit both diabetes and depression, the
combination of comorbid chronic disease mediates a
higher prevalence of depression (18). People who suffer
from diabetes complications have demonstrated a higher
prevalence of depression compared with people with dia-
betes and without depression, (13) and, also, they indicate
an increased risk of death from all causes (17, 19).
Depression requires increased utilisation of health care
(20).
Because of the emotional burden of depression, rec-
ognising depressive symptoms in individuals with diabetes
is necessary (21, 22), and screening for depression in
people with diabetes is recommended, but methods of
screening and intervention have not been sufficiently
characterised (17).
The purpose of this study was to describe the prevalence
of anxiety and depression symptoms in groups of obese
and normal-weight individuals with T2DM who are
undergoing primary care and to investigate the differences
between the groups and between genders.
Material and methods
Patients and procedure
All primary-care centres (PCCs) in an area of western
Sweden were asked to participate in the study and nine
centres accepted. From the local diabetes register, which
included information from the PCCs, we selected all of the
Scandinavian Journal of Caring Sciences Ó 2011 Nordic College of Caring Science
people with T2DM and normal weight (BMI of 18.5–25)
who were between the ages of 30 and 75. As the procedure
allowed an equal number of individuals in both groups,
and the number of obese (BMI of 30–40) people in the
register between 30 and 75 years with T2DM was much
greater than the number of normal-weight people, every
third individual in this group was selected. This procedure
provided 255 individuals exhibiting obesity and T2DM and
248 individuals exhibiting normal weight and T2DM. The
mode of treatment and the duration of diabetes were not
considered.
Instruments used in the study
Hospital Anxiety and Depression Scale. Symptoms of depres-
sion and anxiety were measured using the Hospital
Anxiety and Depression Scale (HADS) (23). The HADS is a
self-reported rating scale that is designed to measure both
anxiety and depression. The HADS consists of two sub-
scales, anxiety (HADS-A) and depression (HADS-D), each
of which contains seven items on a four-point Likert scale
(ranging from 0 to 3). The scores are categorised as
noncases (0–7), possible cases (8–10) and probable cases
(11–21). The maximum score on each subscale is 21.
Robust screening ability and a high level of agreement
between individuals scores on the HADS and structured
psychiatric interviews have been observed (23). Strong
psychometric properties have also been demonstrated (24).
Beck Depression Inventory II. The Beck Depression Inventory
– second edition (BDI-II) – is one of the most widely used
psychiatric rating scales for depression and was developed as
an indicator of the presence and severity of depressive
symptoms. Patients respond to the scale by rating each
symptom item with a score ranging from 0 (absent) to 3
(severe or persistent presence of the symptom). The BDI-II is
scored by adding the ratings for the 21 items to yield a
total score that can range from 0 to 63 (25). This
instrument yields valid and reliable scores in a primary-
care setting (26). The scores from the BDI-II are classified
as noncases (minimal, 0–13), possible cases (mild, 14–19),
probable cases (moderate, 20–28) and probable cases
(severe, 29–63).
Statistical process and analysis
The results of this study are presented descriptively as
means and medians ± standard deviation. The Mann–
Whitney U-test was employed to analyse the differences of
mean between normal-weight and obese diabetics,
between women and men, between obese men and
normal-weight men and between obese women and nor-
mal-weight women. Statistical significance was defined as
a p-value of 0.05. The statistical analyses were performed
using SPSS 18.0 software (IBM, New York, NY, USA).
Ó 2011 The Authors
 Anxiety and depression in obese and normal-weight individuals with diabetes type 2 351

30–40 Female
Ethical considerations

BMI 18.5–25
Female/BMI
The study was approved by the Regional Ethics Committee

p-value

0.106
0.052
0.010
of the Medical Department of Gothenburg University (691-
09).

BMI 18.5–25

30–40 Male
Male/BMI

p-value
Results

0.279
0.616
0.549
The mean age of the female normal-weight respondents
was 65.3 (SD of 8.8, n = 75), and the mean age of the

Female/

p-value

0.005
0.010
0.000
Male
obese females with T2DM was 62.6 (SD of 7.7, n = 66).
The mean age of the normal-weight males was 65.4 (SD of

Table 1 Differences in mean between normal-weight and obese diabetic individuals, as well as of males and females, as measured by the HADS and the BDI-II
7.1, n = 105), and the mean age of the obese males with

Mean/Median/SD
T2DM was 63.3 (SD of 8.5, n = 93). The response rate was

4.5/4.0 ± 4.1
3.9/3.0 ± 3.4
8.3/5.5 ± 8.1
67%.

n = 93
No differences between normal-weight and obese

Male
individuals with T2DM were observed in symptoms of
anxiety (measured by the HADS-A) or depression (mea-

Mean/Median/SD

6.1/5.8 ± 3.9
5.3/4.0 ± 3.6
13.8/13.0 ± 8.8
sured by the HADS-D). Significant differences were
measured in symptoms of depression measured by the

BMI 30–40
BDI-II with higher scores presented by obese individuals

Female
n = 66
with T2DM. When female and male individuals with
T2DM and normal weights were compared, significant
differences were observed in symptoms of anxiety (mea-

Female/

p-value

0.038
0.435
0.061
Male
sured by the HADS-A) among the females presenting
higher scores. Significant differences were observed

Mean/Median/SD
between obese females and males with T2DM in symp-

3.8/3.0 ± 3.7
3.7/3.0 ± 3.6
toms of depression (measured by the HADS-D and the

7.7/5.0 ± 8.0
BDI-II) and anxiety (measured by the HADS-A) with the n = 105

BDI-II, Beck Depression Inventory – second edition; HADS, Hospital Anxiety and Depression Scale.
females displaying significantly higher scores than their
Male

obese male counterparts. No differences were detected

between normal-weight and obese men with T2DM.
Mean/Median/SD

10.7/8.0 ± 10.5
When comparing normal-weight and obese females with
5.4/4.0 ± 4.8
4.3/3.0 ± 4.1
BMI 18.5–25

T2DM, the latter produced higher scores in symptoms of

depression measured with the BDI-II (Table 1).
Female
n = 75

As depicted in Table 2, the obese individuals with T2DM

indicated a greater risk of developing anxiety than the
BMI 18.5–25/

normal-weight individuals with T2DM, as measured with

BMI 30–40

the HADS-A. The obese individuals with T2DM also pre-

p-value

sented a greater risk of depression when measured with

0.054
0.096
0.040

the HADS-D and the BDI-II compared with the normal-

weight individuals. When comparing normal-weight
Mean/Median/SD

females and males with T2DM, the females presented a

5.2/5.0 ± 4.1
4.5/4.0 ± 3.5
10.5/9.0 ± 8.8

greater risk of developing anxiety and depression, as

BMI 30–40
n = 159

measured by all three questionnaires (the HADS-A, the

Significance of bold values are 0.05.

HADS-D and the BDI-II). Obese females exhibited a much

greater risk of developing anxiety and depression than did
Mean/Median/SD

obese males with diabetes, as measured by all three

4.5/4.0 ± 4.3
4.0/3.0 ± 3.8
8.9/6.0 ± 9.1

questionnaires (Table 2).

BMI 18.5–25
n = 180

Discussion
These results demonstrate an association between diabetes
HADS-A
HADS-D
Scales

type 2, obesity and emotional status in both genders and

BDI-II

that more than one in three women and one in five men

Ó 2011 The Authors

Scandinavian Journal of Caring Sciences Ó 2011 Nordic College of Caring Science
352 I. Svenningsson et al.

Table 2 Prevalence of BDI-II, HADS-A and

Total BMI 18.5–25 BMI 30–40 HADS-D scores in normal and obese individuals
with type 2 diabetes mellitus, presented as
BMI 18.5–25 BMI 30–40 Female Male Female Male
mean percentages
Questionnaire n = 180 n = 159 n = 75 n = 105 n = 66 n = 93

BDI-II (%)
Noncases 79.2 69.3 72.9 83.7 56.7 77.8
Possible cases 8.3 12.7 8.6 8.2 15.0 11.1
Probable cases 12.5 18.0 18.6 8.2 28.3 11.1
HADS-A (%)
Noncases 78.9 74.2 72.0 83.8 69.7 77.4
Possible cases 11.1 16.4 12.0 10.5 18.2 15.1
Probable cases 10.0 9.4 16.0 5.7 12.1 7.5
HADS-D (%)
Noncases 83.3 75.5 77.3 87.6 69.7 79.6
Possible cases 8.9 17.6 14.7 4.8 19.7 16.1
Probable cases 7.8 6.9 8.3 7.6 10.6 4.3

BDI-II, Beck Depression Inventory – second edition; HADS-A, Hospital Anxiety and Depression
Scale-anxiety; HADS-D, Hospital Anxiety and Depression Scale-depression.

with T2DM and obesity present symptoms of anxiety and
depression. These results highlight a problem concerning
both men and women with T2DM in Swedish primary
healthcare that has not been studied previously.
Methodological considerations
The HADS questionnaire is a useful clinical indicator of
depression and anxiety symptoms (27). The BDI-II is one
of the most widely used self-rating instruments worldwide
for the assessment of the severity of depression in everyday
clinical practice, as well as in research settings. Impor-
tantly, the screening of depression does not diagnose
depression but only provides an indication of the severity
of symptoms over a period of time (28). These instruments
provide important information concerning the emotional
status of individuals with T2DM for the primary healthcare
without being disturbed of somatic symptoms.
When analysing results based on self-reporting, the pos-
sibility of bias and over-reporting or under-reporting of data
cannot be ignored (29). However, this possibility should not
influence gender differences. Complications of T2DM were
not taken into account in this study, which can be seen as a
limitation, as people with diabetes and complications
exhibit a higher prevalence of depression compared with
people with diabetes without complications (13).
Clearly, individuals exhibiting T2DM in combination
with obesity carry an additional emotional burden of
depression or anxiety. The combination of these diseases
reduces the abilities of individuals to cope with the
demands of daily life and decreases their abilities to self-
care and undertakes necessary lifestyle changes. Depres-
sion represents an additional burden for individuals with
diabetes, and exhibiting both diseases is associated with
nonadherence to self-care (15, 22) and medical treatment
(15). When the symptoms of depression remain unknown
and untreated, serious consequences may result, as an
association has been demonstrated between depression
among individuals with diabetes and poor metabolic con-
trol (30). Also, people with symptoms of depression have
indicated difficulty in integrating advice regarding lifestyle
changes or medical treatment into their daily lives,
resulting in poorer metabolic control and increased risk of
long-term or short-term complications (10, 22, 31). In
addition, poor metabolic control has been reported to
exacerbate depression in individuals with T2DM (10).
The risks of serious diabetes complications and mortality
are greater among individuals with depression and T2DM,
which could be another consequence of failing to recognise
depression in those individuals (19, 32, 33). Importantly,
some researchers believe that this risk is possible to
manage, as treated depression decreases the risks of
complications (33). However, other studies have indicated
no significant effect on diabetes outcomes when treating
depression (31).
Exhibiting T2DM in combination with obesity leads to
physical limitations for both men and women (4), and
functional limitations have been observed to contribute to
an increased risk of developing depression (18). When
healthcare professionals fail to identify depressive symp-
toms, they are at risk of not meeting the individual’s needs.
Obese women have reported that when their needs are not
taken into account by healthcare professionals, they have
difficulty in handling advice regarding lifestyle changes,
resulting in feelings of guilt and shame (34). This difficulty
may also be a problem for obese men with T2DM, as
findings in our study indicate that even these men have
symptoms of depression. The reason that healthcare pro-
fessionals are not aware of the men’s emotional status can
be explained by the fact that the men do not express their

Ó 2011 The Authors

Scandinavian Journal of Caring Sciences Ó 2011 Nordic College of Caring Science
 Anxiety and depression in obese and normal-weight individuals with diabetes type 2 353

feelings of depression and anxiety as clearly as the women Conclusion

do (6, 34).
This study indicates a link between diabetes type 2, obesity
It is well known that even in the absence of a chronic
and depression in both genders. Importantly, obesity and
illness, women report more emotional symptoms than men
T2DM must be classified as a problem affecting both males
(35) and that diabetes increases the risk of developing
and females in primary healthcare. The emotional impact
depression (6, 10, 12, 36, 37), especially in women (6). Our
of T2DM and obesity on both genders must be recognised
results provide further evidence that normal-weight women
and considered by the primary healthcare providers.
with T2DM are more emotionally affected by anxiety and
depression than are normal-weight men with T2DM.
This study indicates that men exhibiting obesity and Acknowledgements
T2DM are more emotionally affected than men of normal
The authors wish to thank Tobias Arvemo, University
weight with T2DM. This finding is in line with the findings
West, Trollhättan, Sweden for statistical advice. The study
of a previous study (6). Diabetes has been reported to be a
was financed by FyrBoDal Primary Health Care with
risk factor for the development of depression in men (6, 8).
funding from the FyrBoDal Research and Development
Haslam and James (1) observed that normal-weight men
Council.
without diabetes presented a higher risk of depression
compared with obese men without diabetes. Clearly, dia-
betes influences the risk of depression in both genders, and Author contributions
obesity, combined with diabetes, increases the risk, even in
Irene Svenningsson contributed to the study conception
men.
and design; collected and analysed the data; and drafted
Individuals exhibiting T2DM and obesity are a large
the manuscript. Cecilia Björkelund and Bertil Marklund
group within the primary healthcare system, and if their
contributed to the study conception and design, and
needs cannot be met, the individuals will suffer. The
supervised. Birgitta Gedda contributed to the study con-
emotional impact of T2DM and obesity needs to be
ception and design; analysed the data; and drafted the
recognised and considered by healthcare providers, rather
manuscript and supervised.
than only drawing conclusions from laboratory data.

the Netherlands. Diabet Med 2010; population-based study. J Psychosom

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