Body mass index, waist circumference, waist–hip ratio and depressive symptoms in Chinese elderly: a population-based study

Body mass index, waist circumference, waist–hipratio and depressive symptoms in Chinese elderly:a population-based study

Roger C. M. Ho1*, Matthew Niti1,2, Ee Heok Kua1 and Tze-Pin Ng1,2

1Department of Psychological Medicine, National University of Singapore2Gerontological Research Programme, Faculty of Medicine, National University of Singapore

SUMMARY

Background Studies that investigated the relationship between obesity and depressive symptoms in the elderly havegenerated conflicting findings, partly because of the use of body mass index (BMI) alone to measure obesity in the elderly.The use of BMI fails to account for varying proportions of muscle, fat and bone, and few studies have used other measures ofcentral obesity, such as waist–hip ratio (WHR) and waist circumference (WC).Objectives We examined whether individually BMI, WHR and WC were consistently associated with depressivesymptoms in the elderly.Methods Analysis of cross-sectional data of 2604 community dwelling Chinese elderly aged 55 and above, includingsocio-emotional characteristics, self-rated health and functional status, anthropometric measurements and GeriatricDepression Scale (15 items, GDS-15).Results There was a negative trend in the prevalence of depressive symptoms (GDS�5) across increasing BMI categories:16.9% in low BMI, 14.2% in normal weight, 12.1% in moderate to high BMI. The associations for moderate to high BMI(OR, 0.77; p¼ 0.04) relative to normal BMI, were statistically significant after controlling for confounding variables.However, no consistent trends in the prevalence of depressive symptoms and OR’s were observed for increasing WHR andWC categories.Conclusion Our results suggest that waist–hip and circumference measures of central obesity did not support an inverserelationship of obesity and depressive symptoms. An inverse relationship of BMI with depressive symptoms may indicategreater physiologic and functional reserve from greater muscle mass that protects against depressive symptoms. Copyright# 2007 John Wiley & Sons, Ltd.

key words—body mass index; central obesity; depressive symptoms; Chinese elderly

INTRODUCTION

Research on the relationship between obesity andlate-life depression has generated controversial find-ings. In support of the ‘Jolly Fat’ hypothesis, a numberof studies have shown that high body mass index(BMI) was associated with lowered risk of depression(Crisp and McGuiness, 1976; Palinkas et al., 1996; Li

et al., 2004; Kuriyama et al., 2006). However, otherauthors (Roberts et al., 2002) have shown that olderadults with BMI� 30 were more likely to developdepression. In these studies, the estimation of body fatin the elderly using BMI is easily distorted by musclemass and bone structure, since it does not account forthe differing ratios of adipose to lean tissue, nor does itdistinguish between general or central obesity. In thepresent study, we examined the relationships betweenBMI, vis-a-vis two measures of central obesity,waist–hip ratio (WHR) and waist circumference(WC), with depressive symptoms in Chinese elderly.

INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY

Int J Geriatr Psychiatry 2008; 23: 401–408.

Published online 18 September 2007 in Wiley InterScience

(www.interscience.wiley.com) DOI: 10.1002/gps.1893

*Correspondence to: Dr R. C. M. Ho, Department of PsychologicalMedicine, National University Hospital, 5 Lower Kent Ridge Road,Singapore 119074. E-mail: [email protected]

Copyright # 2007 John Wiley & Sons, Ltd.Received 20 March 2007Accepted 23 July 2007

METHODS

Data was collected from the ongoing SingaporeLongitudinal Ageing Studies (SLAS), a prospectivecohort study of ageing and health among community-dwelling older adults who were aged 55 and above. Therespondents were identified using door-to-door census.Those who were unable to complete the interviewbecause they were too frail or terminally ill, such asstroke aphasia and profound dementia, were excluded.All participants signed written informed consent for thestudy that was approved by the National University ofSingapore Institutional Review Board. The response ratefor the total of 2,804 participants was 78.5%. Structuredquestionnaire interviews, physical performance tests,clinical assessments, neuropsychological tests wereperformed by trained research nurses and medically-qualified assessors.

Measurements

Depressive symptoms was assessed using the Chineseversion of the 15-item Geriatric Depression Scale(GDS-15) (Yesavage, 1988), which has been validatedfor use in Chinese subjects, locally and elsewhere (Leeet al., 1993; Lim et al., 2000). The presence ofdepressive symptoms was defined by GDS score �5.Body mass index. Height (meter) was measured

using a stadiometer with subjects standing upright,without shoes to the nearest 0.5 cm; weight (kg) wasmeasured on a calibrated SECA beam balance (Model708 1314004, Vogel and Hake, Hamburg, Germany),and in lightweight clothing to the nearest 0.1 kg. BMI(kg/m2) was categorized into four groups: very low(BMI< 18.5), low (BMI 18.5–22.9), moderate (BMI23.0–27.4), and high (BMI� 27.5), based on therevised cut-offs for Asian adult population, asrecommended by the World Health Organisation(WHO Expert Consultation, 2004; Health PromotionBoard of the Ministry of Health Singapore, 2005).Waist circumference (WC) was measured using a

steel measuring tape, halfway between the lowerborder of the ribs and the iliac crest in a horizontalplane. Hip circumference was measured at the widestpoint over the buttocks. For each waist and hipcircumference, two measurements to the nearest0.5 cm were recorded. If the variation between themeasurements was greater than 2 cm, a thirdmeasurement was taken, and the mean of the twoclosest measurements calculated.The absolute waist circumference (WC) (>90 cm in

men and >80 cm in women) or waist–hip ratio (>0.9for men and >0.8 for women) were used to define

central obesity. For the purpose of the present study,WCs were further classified as follows: in men, verylow risk (WC< 85cm), low risk (85–89 cm), moderaterisk (90–99 cm), high risk (�100 cm); in women, verylow risk (WC< 75 cm, low risk (75–79 cm), moderaterisk (80–89 cm), and high risk (�90 cm).

Waist–hip Ratio (WHR) was obtained by dividingwaist circumference by hip circumference. Menhaving a WHR< 0.85, 0.85–0.89, 0.90–0.94, and�0.95 were classified as very low, low, moderate, andhigh risks, respectively. Similarly, women were alsoclassified into four groups using different cut-offs(<0.75; 0.75–0.79; 0.80–0.84, and �0.85).

Socio-demographic characteristics included age,gender, ethnicity and education. Social-emotionalsupport was assessed by questions on marital status,living arrangement, frequency of visits and regularphone calls by children, relatives, or friends, havingsomeone to help when needed or to confide, andfinancial ability to pay for medical care. The aggregatescore for social-emotional support was derived bytaking the average of standardized t-scores of theindividual items. The presence of any chronic medicalillness and hospitalization in the past 1 year or longerprior to the interview was determined from self-reportsand corroborated with current medications identified.The same information were also used to determine theuse of drugs with known potential to cause depressivesymptoms (Patten and Burbui, 2004), and to classifyparticipants by the number of co-morbid chronicmedical conditions. Physical functional status wasassessed by Basic Activities of Daily Living (Mahoneyand Barthel, 1965) and Instrumental Activities of DailyLiving (Lawton and Brody, 1969). Cognitive status wasmeasured using the Mini-Mental State Examination(MMSE) (Folstein et al., 1975). The participants werecategorized as non-smokers, past and current smokers,and as daily alcohol drinkers (at least 1 alcoholic drink:1 can of beer or equivalent amounts of other alcoholicdrinks). The frequency of physical exercise was used toclassify participants with a low physical fitnessactivities level as ‘never or less than a month’.

Statistical analysis

To allow for comparison with the study of Hong KongChinese by Li et al. (2004), we analysed the data of2,604 Chinese after excluding seven participants withmissing values of BMI measurements. Descriptivestatistics and significance tests for continuous andcategorical variables were used. Multivariable logisticregression was used to calculate Odd Ratios (OR) ofdepressive symptoms with BMI, WC and WHR

Copyright # 2007 John Wiley & Sons, Ltd. Int J Geriatr Psychiatry 2008; 23: 401–408.

DOI: 10.1002/gps

402 r. c. m. ho ET AL.

categories separately, which adjusted for age, gender,education, social and emotional support, smoking,alcohol, physical fitness activities, comorbidities, useof potentially depressogenic drugs, physical func-tional status, cognitive status, self rated health status,hospitalization in the past one year. The finalmultivariate models consisted of 14 independentvariables with 23 degree of freedom. All statisticalanalyses were performed using SPSS statisticalsoftware version 15.0 (SPSS Inc, Chicago, IL).

RESULTS

In the sample of 2,604 Chinese older adults, the meanagewas 67.8 year (SD¼ 8.6); 60.4%were women; 6%

(n¼ 156) were classified as having very low BMI,40% (n¼ 1041) as low BMI and 54.0% (n¼ 1407) asmoderate to high BMI. The number of respondentswith depressive symptoms (GDS score �5) was 347(13.3%). The average number of depressive symptomswas 1.9 (SD¼ 2.7; median¼ 1).Across increasing BMI categories, there was an

increasing trend in the proportions of hypertension,diabetes, heart diseases, arthritis, number of comorbiddisorders, and the use of depression-causing drugs;and decreasing trend in the proportions of smokers,osteoporosis and gastric disorders (Table 1). The sametrends were also observed with increasing categoriesof WHR (Table 2) and WC (Table 3), but additionallythere were increasing trends in the proportions of

Table 1. Subjects’ characteristics by BMI categories (n¼ 2,604)

Characteristics Very low(BMI< 18.5)

Low(BMI 18.5–22.9)

Moderate(BMI 23.0–27.4)

High(BMI� 27.5)

P-valuey

Numbers 156 1041 1062 345Sociodemographic and behaviouralAge, year Mean (SD) 67.7 (8.5) 66.0 (8.0) 66.2 (7.3) 65.1 (7.1) 0.005Gender Female 60.9 66.3 59.0 66.7 0.003Education Primary & below 57.7 48.2 53.5 56.2 0.029

Secondary/ITE 30.8 34.6 29.7 29.9Pre U & above 11.5 17.2 16.9 13.9

Low socio-emotional support# 64.1 53.4 48.3 51.9 0.001Smoking status Non-smoker 78.2 85.0 82.3 84.6 0.002

Past smoker 9.6 8.4 11.9 11.6Current smoker 12.2 6.6 5.8 3.8

Daily alcohol drinking 8.3 7.6 7.7 5.2 0.23Low fitness activity level* 28.1 23.7 23.8 29.1 0.39

Health and functional statusChronic medical illnessHypertension 34.0 47.1 61.0 74.5 <0.001Eye disorders (Glaucoma, Cataract, etc) 37.8 33.7 34.1 31.9 <0.001Diabetes 5.1 13.3 19.8 27.8 <0.001Arthritis 12.2 14.0 16.5 26.4 <0.001Cardiac disease (IHD, Heart failure, AF) 3.2 7.3 9.3 8.7 <0.001Asthma/ COPD 3.8 3.7 4.0 4.6 <0.001Stroke 3.8 4.1 3.6 3.8 <0.001Osteoporosis 6.4 4.6 3.1 2.9 <0.001Thyroid problems 2.6 3.4 3.5 3.8 <0.001Prostate problems 1.3 2.0 2.7 1.7 <0.001Gastric problems 4.5 1.9 2.4 1.7 <0.001

Comorbidities None 17.3 11.3 6.5 5.51–2 60.3 51.8 47.8 39.1 <0.001>¼ 3 22.4 36.9 45.7 55.4

‘Fair or poor’ self-rated health status 32.9 30.3 32.6 40.1 0.12Hospitalized in the past 1-year 3.8 2.9 4.6 5.8 0.063Cognitive impairment (MMSE� 23) 21.2 11.4 11.2 10.4 0.003Use of depression causing drug(s) 25.6 29.3 38.1 53.3 <0.001Physical functional IADL 19.1 17.6 18.3 20.8 0.033

BADL 12.5 6.0 5.4 6.5

Values are percentages unless otherwise stated.#Using median as the cut-off.yChi-square tests.#‘Never or less than a month’ participation in any fitness activities.


DOI: 10.1002/gps

obesity and depressive symptoms in chinese elderly 403

female sex, low education, eye disorders, hospitaliz-ation, cognitive impairment, poor self-rated health,low fitness activity, and functional disability; incontrast, these relationships were either reversed or‘U-shaped’ from very low to high BMI categories.Table 4 shows the prevalence of depressive

symptoms and its OR’s with increasing categoriesof BMI, WHR and WC. Across very low, low andmoderate-high BMI categories, these appeared toshow a negative trend (p¼ 0.041). Also, the associ-ations for moderate to high BMI (OR, 0.77; p¼ 0.04)relative to normal BMI, were statistically significant

after controlling for confounding variables. However,no consistent trends in the prevalence of depressivesymptoms and its odds of association were observedfor increasing WHR and WC categories.

DISCUSSION

Central obesity and depressive symptoms

In this study, we confirmed the results of a number ofstudies of the elderly that increasing BMI wasassociated with lower prevalence of depressive

Table 2. Subjects’ characteristics by waist–hip ratio categories (n¼ 2,604)

Characteristics Very lowrisk (<0.85in male,<0.75

in women)

Low risk(0.85–0.89in male,0.75–0.79in women)

Moderate risk(0.90–0.94in male,0.80–0.84in women)

High risk(�0.95in male,�0.85

in women) P-valuey

Number 224 683 901 792Sociodemographic and behaviouralAge, year Mean (SD) 65.8 (7.9) 65.1 (7.3) 65.8 (7.4) 67.1 (8.1) <0.001Gender Female 50.0 59.4 63.0 70.2 <0.001Education Primary & below 42.0 45.5 51.3 61.1 <0.001


Low socio-emotional support# 52.2 51.5 49.7 54.3 0.30Smoking status Non-smoker 82.1 84.9 82.2 84.3 0.004

Past smoker 8.9 8.8 13.1 8.5Current smoker 8.9 6.3 4.7 7.2


Health and functional statusChronic medical illnessHypertension 37.5 49.5 56.0 65.5 <0.001Eye disorders (Glaucoma, Cataract, etc) 31.3 31.3 34.7 35.7 <0.001Diabetes 5.8 11.4 15.6 27.7 <0.001Arthritis 14.7 16.0 16.1 18.1 <0.001Cardiac disease (IHD, Heart failure, AF) 9.4 5.1 7.3 10.9 <0.001Asthma/ COPD 2.2 3.8 3.8 4.7 <0.001Stroke 4.5 2.9 3.6 4.5 <0.001Osteoporosis 6.3 3.4 4.4 3.0 <0.001Thyroid problems 2.2 3.8 3.6 3.3 <0.001Prostate problems 2.2 2.0 2.7 1.9 <0.001Gastric problems 2.2 2.0 2.3 2.3 <0.001


‘Fair or poor’ self-rated health status 27.3 29.1 32.3 37.5 0.002Hospitalized in the past 1-year 4.9 2.0 3.4 6.1 0.001Cognitive impairment (MMSE� 23) 8.9 10.2 10.7 15.1 0.006Use of depression causing drug(s) 22.3 32.5 35.1 43.4 <0.001Physical functional IADL 22.1 15.9 17.2 21.0 0.003

BADL 5.1 5.2 5.3 8.3

Values are percentages unless otherwise stated.#Using median as the cut-off.yChi-square tests.*‘Never or less than a month’ participation in any fitness activities.


DOI: 10.1002/gps


symptoms, independent of known confounding riskfactors (Palinkas et al., 1996; Li et al., 2004). Inparticular, it is worth noting that our study of Chineseelderly in Singapore yielded remarkably similarresults to the study of Chinese elderly in Hong Kong.However, we failed to demonstrate that increasingcategories of WHR and WC were inversely associatedwith depressive symptoms in parallel fashion, aftercontrolling for confounding risk factors for depressivesymptoms. The lack of consistency leads us to believe

that BMI measures of obesity may give misleadingresults.

Limitations of BMI

A drawback of published studies which used BMI toinvestigate the relationship between obesity anddepressive symptoms in the elderly is that they failto account for the fact that at any given BMI value,changes in body composition (decreases in skeletal

Table 3. Subjects’ characteristics by waist circumference categories (n¼ 2,604)

Characteristics Very low risk(<85 cmin male,<70 cm

in women)

Low risk(85–89 cmin male,75–79 cmin women)

Moderate risk(90–99 cmin male,80–89 cmin women)

High Risk(�100 cmin male,�90 cm

in women) P-valuey

Number 853 602 868 278Sociodemographic and behaviouralAge, year Mean (SD) 65.4 (7.9) 66.1 (7.4) 66.3 (7.4) 66.7 (8.3) 0.034Gender Female 57.8 62.6 65.7 72.7 <0.001Education Primary & below 44.4 52.7 55.6 62.2 <0.001


Low socio-emotional support# 52.5 50.6 50.9 54.7 0.64Smoking status Non-smoker 83.1 84.2 83.6 83.1

Past smoker 9.3 10.0 10.5 12.9 0.22Current smoker 7.6 5.8 5.9 4.0


Health and functional statusChronic medical illnessHypertension 43.1 54.3 63.1 73.4 <0.001Eye disorders (Glaucoma, Cataract, etc) 31.3 35.4 35.3 34.2 <0.001Diabetes 10.2 15.8 20.5 33.1 <0.001Arthritis 12.2 15.4 18.3 26.6 <0.001Cardiac disease (IHD, Heart failure, AF) 6.1 7.8 8.6 12.6 <0.001Asthma/COPD 3.5 3.8 3.7 6.1 <0.001Stroke 4.1 3.8 3.0 5.0 <0.001Osteoporosis 4.0 5.5 3.2 2.2 <0.001Thyroid problems 3.3 3.7 3.1 4.3 <0.001Prostate problems 2.0 2.5 2.3 2.2 <0.001Gastric problems 2.3 2.0 2.6 1.1 <0.001


‘Fair or poor’ self-rated health status 29.8 29.9 33.5 44.7 <0.001Hospitalized in the past 1-year 3.0 4.5 3.3 7.9 0.002Cognitive impairment (MMSE� 23) 10.6 11.0 12.7 14.4 0.25Use of depression causing drug(s) 27.3 33.6 41.2 50.4 <0.001Physical functional IADL 16.3 17.7 18.6 25.8 <0.001

BADL 5.7 5.6 5.6 11.1

Values are percentages unless otherwise stated.#Using median as the cut-off.yChi-square tests.*‘Never or less than a month’ participation in any fitness activities.


DOI: 10.1002/gps


Table

4.

OddsRatiosofAssociationofDepressionwithdifferentBMIandcentral

obesityindices

bygender

(n¼2,604)

Sam

ple

size

(%)

Prevalence

of

Depression(%

)CrudeOR&

95%

CI

P-value

Adjusted

OR&

95%

CI#

P-value

Generalobesity

BodyMassIndex

(BMI)

Verylow

(<18.5)

156(6.0)

16.9

1.22(0.78–1.93)

0.39

0.90(0.53–1.54)

0.71

Low

(18.5–22.9)

1041(40.0)

14.2

1.00

1.00

Moderate(23.0–27.4)

1062(40.7)

11.2

0.76(0.59–0.99)

0.04

0.74(0.56–0.98)

0.04

High(�

27.5)

345(13.2)

14.8

1.05(0.74–1.48)

0.80

0.91(0.61–1.36)

0.66

Moderate-to-high(�

23)

1407(54.0)

12.1

0.83(0.66–1.05)

0.13

0.77(0.59–0.99)

0.04

Abdominalobesitya

1.Waist–hip

Ratio

(WHR)

Verylow

(<0.85in

male,

<0.75in

women)

224(8.6)

12.9

1.06(0.67–1.66)

0.81

1.02(0.62–1.69)

0.94

Low

(0.85–0.89in

male,

0.75–0.79in

women)

683(26.3)

12.3

1.00

1.00

Moderate(0.90–0.94in

male,

0.80–0.84in

women)

901(34.7)

14.1

1.17(0.87–1.57)

0.30

1.13(0.82–1.57)

0.46

High(�

0.95in

male,

�0.85in

women)

792(30.5)

13.3

1.09(0.80–1.48)

0.58

0.88(0.62–1.26)

0.49

2.WaistCircumference

(WC)

Verylow

(<85cm

inmale,

<70cm

inwomen)

853(15.2)

15.0

1.15(0.84–1.58)

0.37

0.99(0.68–1.43)

0.94

Low

(85–89cm

inmale,

75–79cm

inwomen)

602(23.1)

12.1

1.00

1.00

Moderate(90–99cm

inmale,

80–89cm

inwomen)

868(33.4)

12.7

1.05(0.77–1.44)

0.76

0.98(0.68–1.42)

0.53

High(�

100cm

inmale,

�90cm

inwomen)

278(10.7)

16.3

1.41(0.94–2.11)

0.095

1.03(0.58–1.82)

0.93

Nosignificantinteraction:BMI*WHR,p¼0.89;BMI*WC,p¼0.41.

#Adjusted

forage,gender,education,socio-emotional

support,comorbidity,depressioncausingdrugs,physicalfunctional

status,cognitivestatus,self-rated

healthstatus,sm

oking,

alcohol,hospitalizationin

thepastoneyear.

aAdjusted

additionally

forBMI.


DOI: 10.1002/gps


muscle mass and increases in fat mass) in the elderlywould tend to underestimate fatness whereas the lossof height (caused by compression of vertebral bodiesand kyphosis) would tend to overestimate fatness(Villareal et al., 2005).

Low BMI and depressive symptoms

In crude analyses, the highest prevalence of depressivesymptoms (16.2%) was observed in respondents withlow BMI. They included significantly more respon-dents who were older and men, lacking in socio-emotional support, smoking, had osteoporosis, gastricproblems, cognitively impairment, and physicallydisability. Adjustment for these confounding variablessignificantly reduced the OR. Rantanen et al. (2000)suggested that low BMI in combination withdepressed mood may be an indicator of frailty.

High BMI and well-being

Subjects with higher BMI were found to experiencemore chronic medical problems and yet appeared tohave relatively lower prevalence of depressivesymptoms. On the other hand, they showed lesscognitive impairment and physical functional dis-ability. This contrasted to the greater cognitiveimpairment and functional disability associated withhigh WHR or WC. Physical functioning abilityreflects functional neural and muscular systems(Rantanen et al., 2000), and a greater reserve ofmuscle and skeletal mass is associated with higherBMI. Potter et al. (1988) have also shown that elderlypersons with high BMI have better protein reserve andmore frequently survive hospitalization.

Although we found no evidence in this study thatWHR or WC was associated with depressivesymptoms, our study does not absolutely excludethe possibility of an association of visceral adipositywith depressive symptoms. Evidence using CT scan tomeasure visceral abdominal fat appeared to favour apositive association of obesity with depressivesymptoms (Webber-Hamann et al., 2006). We havealso analyzed the data and examined whether theresults differed by gender, age or chronic disease strata(effect modification) by gender (p¼ 0.69), age(p¼ 0.50) and chronic disease (p¼ 0.15), and didnot find significant interaction terms.

Strengths and limitations of our study

The strengths of our study included a largepopulation-based sample of community-living elderly,

which covered a wide range of chronic illnesses anddepressive symptom severity, thus avoiding selectionbias of clinical samples. We controlled for a largenumber of potential confounders, including the pre-sence of comorbid medical conditions and the use ofdrugs which could potentially cause depressivesymptoms.Our study has some limitations. Cross-sectional

data analysis limits firm causal inferences. The use ofGDS score �5 identified cases with depressivesymptoms, which are not tantamount to clinicaldiagnoses of major depressive disorder. A number ofrespondents known to be on anti-depressants butrecorded low GDS score less than 5 (n¼ 28) wereincluded in the control group without depressivesymptoms. This might have attenuated the relation-ship between BMI, WHR or WC and depressivesymptoms. We have re-analyzed the data; theexclusion of these respondents did not materiallyinfluence the results.

CONCLUSION

The relationship between total body fat, centralobesity and mood is complex. Our results suggestthat waist-hip and waist circumference measures ofcentral obesity did not support an inverse relationshipof obesity with depressive symptoms. Increased BMIwas associated inversely with depressive symptoms,but it may instead indicate greater physiologic andfunctional reserve that protects against depressivesymptoms. This may have significance for mentalhealth promotion, since physical activity whichenhances muscle and skeletal strength may have a

KEY POINTS

� The relationship between total body fat, centralobesity and mood is complex.

� Increased BMI was associated inversely withdepressive symptoms and it may indicate greaterphysiologic and functional reserve that protectsagainst depression.

� Our results suggest that waist–hip and waistcircumference measures of central obesity didnot support an inverse relationship of obesitywith depression.

� Our findings may have significance for mentalhealth promotion, since physical activity whichenhances muscle and skeletal strength may havea favourable impact on psychological well beingin elderly.


DOI: 10.1002/gps


favourable impact on psychological well being inelderly.

CONFLICT OF INTEREST

None.

AUTHOR CONTRIBUTIONS

Dr Roger Chun Man Ho was involved in the literaturereview, and participated in the drafting and revisionsof the manuscript.Dr Matthew Niti formulated the hypothesis,

performed the literature review and statistical dataanalysis, drafted and revised the manuscript.Prof Ee-Heok Kua reviewed the results, revised and

approved the manuscript.A/P Tze-Pin Ng was the principal investigator who

conceptualized and designed the study, reviewedstatistical analysis and results, and revised themanuscript.

ACKNOWLEDGEMENTS

This study was supported by a grant (No. 03/1/21/17/214) from the Biomedical Research Council, Agencyfor Science, Technology and Research (A*STAR),Singapore.No commercial company sponsored or played any

role in the design, methods, subject recruitment, datacollections, data analysis and preparation of manu-script.

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Body mass index, waist circumference, waist–hip ratio and depressive symptoms in Chinese elderly: a population-based study