Depression, anxiety, and prevalent diabetes in the Chinese population: Findings from the China Kadoorie Biobank of 0.5 million people

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Abstract

Objective

Despite previous investigation, uncertainty remains about the nature of the associations of major depression (MD) with type 2 diabetes mellitus (T2DM), particularly in adult Chinese, and the relevance of generalized anxiety disorder (GAD) for T2DM.

Methods

Cross-sectional data from the China Kadoorie Biobank Study, a sample of approximately 500,000 adults from 10 geographically defined regions of China, were analyzed. Past year MD and GAD were assessed using the Composite International Diagnostic Inventory. T2DM was defined as either having self-reported physician diagnosis of diabetes at age 30 or later (“clinically-identified” cases) or having a non-fasting blood glucose  11.1 mmol/L or fasting blood glucose  7.0 mmol/L but no prior diagnosis of diabetes (“screen-detected” cases). Logistic regression was used to assess the relationship between MD and GAD with clinically-identified and screen-detected T2DM, adjusting for demographic characteristics and health behaviors.

Results

The prevalence of T2DM was 5.3% (3.2% clinically-identified and 2.1% screen-detected). MD was significantly associated with clinically-identified T2DM (odds ratio [OR]: 1.75, 95% confidence interval (CI): 1.47–2.08), but not with screen-detected T2DM (OR: 1.18, 95% CI: 0.92–1.51). GAD was associated with clinically-identified (OR: 2.14, 95% CI: 1.60–2.88) and modestly associated with screen-detected (OR: 1.44, 95% CI: 0.99–2.08) T2DM. The relationship between MD and GAD with T2DM was moderated by obesity.

Conclusion

MD is associated with clinically-identified, but not screen-detected T2DM. GAD is associated with both clinically-identified and screen-detected T2DM. The relationship between MD and T2DM is strongest among those who are not obese.

Introduction

Major depression (MD) often co-occurs with chronic medical conditions such as type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) [1], [2], [3]. Prospective studies indicate that the relationship between MD and T2DM is likely bi-directional, although the mechanisms underlying their relationship are largely unknown. There is recent evidence that undiagnosed T2DM is not strongly associated with MD, suggesting that the risk of MD subsequent to T2DM is likely driven by factors related to clinical treatment and self-management rather than hyperglycemia or related physiologic changes per se [4], [5].

MD often co-occurs with anxiety disorders, particularly generalized anxiety disorder (GAD) [6], and twin studies have indicated that part of the comorbidity between MD and GAD results from shared genetic liability [7]. However, relatively few studies have addressed the relationship between anxiety disorders and medical comorbidity [8]. In several cross-sectional reports and a recent meta-analysis, GAD and other anxiety disorders were modestly associated with T2DM [8], [9], [10], [11], [12], but a recent longitudinal study from our group found no association between common anxiety disorders (e.g., GAD, panic disorder, agoraphobia, social phobia) and T2DM incidence [13]. These findings contrast with the fairly robust relationship between MD and T2DM, suggesting that different biological or psychological processes may underlie the co-occurrence of chronic conditions like T2DM with MD versus GAD.

China is undergoing rapid urbanization and modernization, with significant increases over the last few decades in the incidence of major chronic non-communicable diseases such as obesity, T2DM, and CVD [14], [15]. For example, the prevalence of T2DM in China has increased from 2.6% in 2000 to 9.7% in 2010 [16]. Parallel increases in the prevalence of MD have also been reported [17], [18], with the lifetime risk for MD projected to be over 20 times greater for young adults compared with previous generations [19]. However, this increase in the prevalence of MD is likely confounded by improved awareness and detection of MD in the Chinese population [17], [20]. In addition, the relationships between psychiatric and medical conditions may be population-specific. There is evidence that people with depressive symptoms tend to have higher body mass index in Western non-Hispanic white populations, but the opposite is generally seen in Asian populations, supporting the so-called ‘jolly fat’ hypothesis (i.e., an inverse relationship between depressive symptoms and weight) [21], [22], [23], [24], [25]. Since obesity is a strong risk factor for T2DM, it is therefore possible that the relationship of MD and related psychiatric conditions with T2DM may differ between Chinese and Western populations.

To date only a few studies have examined the relationship between mood and anxiety disorders and T2DM in Asian populations, and the findings from these reports are mixed, partly due to limited sample sizes and the use of symptom scales rather than diagnostic instruments to assess psychiatric symptomology [26], [27], [28], [29]. Moreover, most such studies were based on clinic samples and thus have limited generalizability to the general population.

We report a detailed analysis of cross-sectional data from the China Kadoorie Biobank, a population-based study of 0.5 million people enrolled from 10 geographically defined regions of China. The aims of this study were to (1) examine the comorbidity between T2DM with MD and GAD, and further (2) to assess whether these relationships differ between clinically-identified versus undiagnosed diabetes.

Section snippets

Sample

Data come from the baseline interview of the China Kadoorie Biobank (CKB) Study, a population-based study of 10 geographically defined regions interviewed between 2004 and 2008 [30]. The 10 regions were selected to provide approximately equal coverage of rural (Gansu, Henan, Sichuan, Hunan, and Zhejiang) and urban (Harbin, Qingdao, Suzhou, Liuzhou, and Haikou) provinces. Details of the study design and sample characteristics are described elsewhere [32]. Briefly, potential participants were

Results

Baseline participant characteristics stratified by diabetes status are shown in Table 1. The overall prevalence of T2DM was 5.3% (3.2% clinically-identified and 2.1% screen-detected), and T2DM (both clinically-identified and screen-detected) was more common in urban provinces than in rural ones (7.2% versus 3.7%). The proportion of T2DM cases that were clinically-identified ranged from 78% in Zhejiang province to 39% in Gansu province (both rural provinces), with a median of 57%. For those with

Discussion

In the largest study to date of the relationship between common mental disorders and prevalent T2DM in the Chinese population, we found that MD was significantly associated with an increased likelihood of clinically-identified, but not screen-detected, T2DM. GAD was also significantly associated with higher prevalence of clinically-identified T2DM, and marginally associated with screen-detected T2DM. MD was inversely related to BMI, and the relationship between MD and T2DM was attenuated by

Author contributions

B. Mezuk developed the idea for the study and wrote the first draft of the manuscript. Canqing Yu conducted the data analysis and Yiping Chen supervised the data analysis. Kenneth S. Kendler, Zhengming Chen, Yu Guo, Zheng Bian, Junshi Chen, Zengchang Pang, Huijun Wang, Xiangsan Que, Hui Zhang, Zhongwen Tan, and Liming Li edited and critiqued the drafts of the manuscript. All the authors approved the final version of the manuscript for submission.

Funding

The baseline survey and the first re-survey were supported by a research grant from the Kadoorie Charitable Foundation in Hong Kong. The long-term continuation of the project is supported by program grants from the Wellcome Trust in the UK (088158/Z/09/Z, 2009–14) and the Chinese Ministry of Science and Technology (2011BAI09B01, 2011–15). The UK Medical Research Council, the British Heart Foundation and Cancer Research UK also provide core funding to the Clinical Trial Service Unit and

Competing interest statement

The authors have no completing interests to report.

Members of the China Kadoorie Biobank collaborative group

a) International steering committee: Liming Li (PI), Junshi Chen, Fan Wu (ex-member), Rory Collins, Richard Peto, and Zhengming Chen (PI)

b) Study coordinating Centres

International Co-ordinating Centre, Oxford: Zhengming Chen, Garry Lancaster, Xiaoming Yang, Alex Williams, Margaret Smith, Ling Yang, Yumei Chang, Iona Millwood, Yiping Chen, Qiuli Zhang, Sarah Lewington, and Gary Whitlock

Acknowledgments

We thank Judith MacKay in Hong Kong; Yu Wang, Gonghuan Yang, Zhengfu Qiang, Lin Feng, Maigen Zhou, Wenhua Zhao, and Yan Zhang at the Chinese Center for Disease Control and Prevention (CDC); Lingzhi Kong, Xiucheng Yu, and Kun Li at the Ministry of Health of China; and, Sarah Clark, Martin Radley, Mike Hill, at the Clinical Trial Service Unit, Oxford, for assisting with the design, planning, organization, and conduct of the study. We especially thank the participants in the study and the members

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