Neuroscience & Medicine, 2013, 4, 181-187
http://dx.doi.org/10.4236/nm.2013.43029 Published Online September 2013 (http://www.scirp.org/journal/nm)
181
Prevalence and Correlates of Obesity and Overweight in
Tunisian Bipolar I Patients
Asma Ezzaher1,2*, Anwar Mechri2, Dhouha Haj Mouhamed1,2, Wahiba Douki1,2, Lotfi Gaha2,
Mohamed Fadhel Najjar1
1Biochemistry and Toxicology Laboratory, Monastir University Hospital, Monastir, Tunisia; 2Research Laboratory “Vulnerability to
Psychotic Disorders LR 05 ES 10”, Department of Psychiatry, Monastir University Hospital, Monastir, Tunisia.
Received January 11th, 2013; accepted February 12th, 2013; accepted March 2nd, 2013
Copyright © 2013 Asma Ezzaher et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Objective: We aim to determine the prevalence of obesity and overweight in bipolar I patients, and to examine their
associations with the demographic, clinical and therapeutic characteristics of this population. Patients and Methods:
Our study included 120 bipolar I patients (79 men and 41 women, mean age = 39.5 ± 11.9 years). Weight and height
were evaluated by body mass index (BMI). Obesity was defined when BMI ≥ 30 kg/m² and overweight when BMI ≥ 25
kg/m². Results: The prevalence of obesity and overweight was respectively 32.5% and 30.8%. Obesity was signifi-
cantly more frequent in women than men. The illness duration was significantly longer in obese patients than in those
with normal weight. Moreover, the family history of medical disorders and concomitant medical disorders was signifi-
cantly more frequent in obese patients than in those with normal weight. However, any significant association between
therapeutic characteristics and obesity or overweight was found. Conclusions: Obesity and overweight were frequent in
bipolar I patients. Obesity was significantly frequent in women and significantly associated with illness duration, medi-
cal disorders, and concomitant medical disorders. These results emphasized the need for specific treatment strategies
and programs for weight control for these patients.
Keywords: Bipolar I Disorder; Obesity; Overweight
1. Introduction
Bipolar disorder (previously also labelled as manic-depres-
sive illness) is typically referred to as an episodic, yet
lifelong and clinically severe affective (or mood) disorder,
affecting approximately 3.5% of the population [1-5]. It is
a chronic disease that is associated with a potentially de-
vastating impact on patients’ wellbeing and social, oc-
cupational, and general functioning [6]. The disorder
ranks as the sixth leading cause of disability in the world,
with an economic burden that in the US alone that is es-
timated more than a decade ago at $7 billion in direct
medical costs and $38 billion (1991 values) in indirect
costs [7].
A number of reviews and studies have shown that
people with severe mental illness, including bipolar dis-
order, have an excess mortality, being two or three times
as high as that in the general population. This mortality
gap, which translates to a 13 - 30 year shortened life ex-
pectancy in severe mental illness patients, has widened in
recent decades, even in countries where the quality of the
health care system is generally acknowledged to be good.
About 60% of this excess mortality is due to physical
illness especially cardiovascular disease [8].
Cardiovascular risk factors in this pathology include
nonmodifiable risk factors, such as sex, family history,
personal history, and age, as well as such modifiable risk
factors as obesity, smoking, diabetes, hypertension, and
dyslipidemia [9].
Obesity is the condition of having an abnormally high
proportion of body fat. It is most commonly operation-
ally defined as a body mass index (BMI) of 30 or greater.
Abdominal obesity reflects fat that is centrally distributed
between the thorax and pelvis as opposed to lower body
obesity, which reflects fat that is distributed around the
hips, thighs, and buttocks. Abdominal obesity is often
operationally defined by the waist circumference or the
waist-to-hip ratio. In contrast to lower body obesity, ab-
dominal obesity is particularly associated with type 2
*Corresponding author.

Prevalence and Correlates of Obesity and Overweight in Tunisian Bipolar I Patients
182
diabetes mellitus, dyslipidemia, hypertension, coronary
heart disease, stroke, and early mortality.
Although the pathogenesis of obesity is unknown, it is
often viewed as a polygenic, heterogeneous metabolic
disorder due to consuming more calories than expended
as energy.
Factors etiologically associated with obesity are family
history of obesity, overeating, and physical inactivity.
Low resting metabolic rate is not thought to play a major
role in causing or maintaining most obesity. Of theoreti-
cal note, dysfunction in neurotransmitter and neuropep-
tide systems hypothesized to underlie various mental
disorders, including bipolar disorder, has also been hy-
pothesized to be involved in obesity. Implicated shared
neurotransmitter systems have included serotonin, dopa-
mine and norepinephrine. Implicated neuropeptides have
included corticotrophin-releasing factor and neuropeptide
Y [10].
Our study aims to determine the prevalence of obesity
and overweight in patients with bipolar I disorder, and to
examine their associations with the demographic, clinical
and therapeutic characteristics of this population.
2. Patients and Methods
2.1. Subjects
Our study included 120 patients with bipolar I disorder
from the psychiatry department of the University Hospital
of Monastir, Tunisia, aged 39.5 ± 11.9 years, 79 men (39.6
± 10.9 years) and 41 women (39.3 ± 13.7 years). Con-
sensus on the diagnosis, according to the Diagnostic and
Statistical Manual of Mental Disorders, fourth edition
(DSM-IV) criteria [11], was made by psychiatrists. The
exclusion criteria were age < 18 years, other psychiatric
illnesses, epilepsy or mental retardation. This study was
approved by the local ethical committee and all subjects
were of Tunisian origin. Written informed consent was
obtained from all voluntary participants.
All subjects were questioned about their age, gender,
cigarette and alcohol consumption habits and clinical and
therapeutic history. The socio-demographic and clinical
characteristics (age at onset, the total number of episodes,
number of manic episodes, depressive polarity at index
episode, severity of index episode, duration of illness and
the number of lifetime suicide attempts) are shown in
Table 1.
2.2. Body Mass Index (BMI) Determination
BMI was calculated as weight (kg) divided by height (m²).
For the present study, we adopted the classification of
overweight and obesity formalized by the World Health
Organization [12]. This classification uses the same cutoff
points reported in the evidence-based clinical guidelines
for the identification, evaluation, and treatment of over-
weight and obesity in adults, published by the National
Heart, Lung, and Blood Institute of the National Institutes
of Health [13]. Men and women were considered to be
underweight if their BMI was less than 18.5, normal
weight if their BMI was between 18 and 24.9, overweight
if their BMI was between 25 and 29.9, and obese if their
BMI was equal to or greater than 30 kg/m².
2.3. Statistical Analysis
Statistical analyses were performed using SPSS 17.0
(SPSS, Chicago, IL, USA). Quantitative variables were
presented as mean ± SD and comparisons were performed
using the Student’s t test. Qualitative variable compari-
sons were performed using the Chi-squared test (χ2) and
Fisher’s exact test (when n < 5).
The statistical significance level was set at P < 0.05. All
variables with a p value < 0.25 between the two studied
groups were considered as potential confounder factors
for this analysis.
3. Results
In bipolar I patients, the prevalences of obesity and
overweight were 32.5% and 30.8% respectively (Table 1).
Obesity was more frequent in women than men (46.3%
Vs 25.3%, p = 0.04) (Tables 1 and 2). Women have also
the highest rate of unemployment (63.4% Vs 31.6%, P =
0.001) (Table 1).
We noted that men were so much more likely to be
smokers and alcoholic consumers than women (91.1% Vs
2.4%, P < 0.0001; 57% Vs 2.4%, P < 0.0001). In addition,
they have the highest number of manic episodes (3.8 ± 2.3
Vs 2.8 ± 2.6; P = 0.04) (Table 1).
We showed that there were no significant differences in
demographic characteristics, in terms of age, education
years and unemployed status, between study groups
(obese, overweight and normal patients). Tobacco and
alcoholic use were also not significantly associated with
obesity or overweight.
Concerning clinical characteristics, we showed that the
duration of disease was longer in obese patients (14.8 ±
7.8 years) and overweight patients (12.6 ± 8.4 years) than
in those with normal weight (9.6 ± 7.7 years), with sig-
nificant difference only between the first and the last
groups (P = 0.01) (Table 2).
The family history of medical disorders and concomi-
tant medical disorders were significantly more frequent in
obese patients (41.7% for the two) than other groups.
The number of previous depressive episodes was higher
in obese (1.5 ± 1.8) and in overweight patients (1.1 ± 1.7)
than in those with normal weight (0.8 ± 1.1). The depres-
sive polarity at index episode was also more frequent in
obese and overweight patients (21% and 16.2%; respec-
tively) than the other group (13%), while, these differ-
ences were not significant (Table 2).

Prevalence and Correlates of Obesity and Overweight in Tunisian Bipolar I Patients
183
Table 1. Subject characteristic s.
Men (n = 79) Women (n = 41)P Total population (n = 120)
Characteristics
Age (years) 39.6 ± 10.9 39.3 ± 13.7 0.24 39.5 ± 11.9
BMI (kg /m²)
<25, n (%) 34 (43) 10 (24.4) 44 (36.7)
[25-30], n (%) 25 (31.6) 12 (29.3) 37 (30.8)
≥30, n (%) 20 (25.3) 19 (46.3)
0.04
39 (32.5)
Education years, mean ± SD 8.2 ± 3.9 7.1 ± 5.3 0.23 7.8 ± 4.4
Unemployed status, n (%) 25 (31.6) 26 (63.4) 0.001 51 (42.5)
Family history of medical disorders, n (%) 19 (24.1) 13 (31.7) 0.36 32 (26.7)
Concomitant medical disorders, n (%) 26 (32.9) 11 (26.8) 0.54 37 (30.8)
Age at onset, mean ± SD 30.3 ± 9.9 29.1 ± 11.7 0.58 29.9 ± 10.5
Total number of episodes, mean ± SD 5.1 ± 3.3 4.4 ± 4.1 0.30 4.9 ± 3.6
Number of depressive episodes, mean ± SD 1.0 ± 1.3 1.3 ± 1.9 0.49 1.1 ± 1.5
Number of manic episodes, mean ± SD 3.8 ± 2.3 2.8 ± 2.6 0.04 3.4 ± 2.4
Depressive polarity at index episode, n (%) 13 (16.5) 8 (19.5) 0.67 21 (17.5)
Severity of index episode, n (%) 65 (87.8) 32 (82.1) 0.40 97 (80.8)
Duration of illness, mean ± SD 12.6 ± 7.9 11.8 ± 8.7 0.58 12.3 ± 8.2
Number of lifetime suicide attempts, mean ±SD 0.09 ± 0.29 0.10 ± 0.30 0.89 0.09 ± 0.30
Number of prescribed drugs, mean ± SD 2.9 ± 0.5 2.8 ± 0.8 0.42 2.8 ± 0.6
Tobacco use, n (%) 72 (91.1) 1 (2.4) 0.001 73 (60.8)
Alcohol use, n (%) 45 (57) 1 (2.4) 0.001 46 (38.3)
Current treatment
Mood stabilizers, n (%) 59 (74.7) 25 (61) 84 (70)
Valproic acid, n (%) 41 (51.9) 18 (43.9) 59 (49.2)
Lithium, n (%) 6 (7.6) 3 (7.3) 9 (7.5)
Carbamazepine, n (%) 7 (8.9) 3 (7.3) 10 (8.3)
Valproic acid/Lithium, n (%) 5 (6.3) 1 (2.4) 6 (5)
Antipsychotics, n (%) 20 (25.3) 16 (39)
0.57
36 (30)
No significant difference was found between study
groups for age at onset, the total number of episodes,
number of manic episodes, severity of index episode and
the number of lifetime suicide attempts.
The study of the therapeutic characteristics showed that
was no significant difference in the study groups for the
type of medication uses and the number of prescribed
drugs. However, obesity and overweight were more fre-
quent (76.3% and 48.6%; respectively) in patients taking
valproic acid or lithium (Table 2).
4. Discussion
Our study showed that the prevalences of obesity and
overweight in bipolar I patients were respectively 32.5%
and 30.8%. These findings were similar to those reported
by Elmslie et al. (2000) and Fagiolini et al. (2002) (36%
and 32%) [14,15]. However, higher values were reported
by McElroy et al. (2004) (44% and 20%) [16]. Addition-
ally, the prevalence of obesity greatly exceeded that found
n the general population (20%) [17]. i

Prevalence and Correlates of Obesity and Overweight in Tunisian Bipolar I Patients
184
Table 2. Differences in demographic, clinical and therapeutic charac teristics between obese, overw eight and neither obese or
overweight patients.
Normal weight
patients (n = 44)
Overweight patients
(n = 37)
Obese patients
(n = 39) p
Gender
Men, n (%) 34 (43) 25 (31.6) 20 (25.3)*
Women, n (%) 10 (24.4) 12 (29.3) 19 (46.3)
0.04
Age, mean ± SD 36.7 ± 12.3 41.3 ± 11.2 39.3 ± 11.9 0.21
Education years, mean ± SD 8.3 ± 3.8 6.9 ± 4.8 8.0 ± 4.6 0.35
Unemployed status, n (%) 17 (36.9) 17 (45.9) 18 (47.1) 0.57
Tobacco use, n (%) 31 (67.4) 23 (62.2) 19 (50.0) 0.25
Alcohol use, n (%) 20 (43.5) 15 (40.5) 11 (28.9) 0.36
Family history of medical disorders, n (%) 9 (20.5) 8 (22.9) 15 (41.7)* 0.08
Concomitant medical disorders, n (%) 8 (17.4) 11 (29.7) 15 (41.7)* 0.07
Age at onset, mean ± SD 27.9 ± 10.5 31.5 ± 10.2 30.3 ± 10.8 0.32
Total number of episodes, mean ± SD 4.4 ± 2.9 4.6 ± 3.7 5.6 ± 4.1 0.31
Number of depressive episodes, mean ± SD 0.8 ± 1.1 1.1 ± 1.7 1.5 ± 1.8 0.14
Number of manic episodes, mean ± SD 3.4 ± 2.3 3.1 ± 2.4 3.8 ± 2.6 0.51
Depressive polarity at index episode, n (%) 6 (13.0) 6 (16.2) 8 (21.0) 0.61
Severity of index episode, n (%) 33 (75) 32 (86.5) 32 (82.1) 0.38
Duration of illness, mean ± SD 9.6 ± 7.7 12.6 ± 8.4 14.8 ± 7.8* 0.01
Number of lifetime suicide att empts, mean ± SD 0.07 ± 0.3 0.06 ± 0.2 0.2 ± 0.4 0.26
Number of prescribed drugs, mean ± SD 2.8 ± 0.6 2.9 ± 0.7 2.8 ± 0.7 0.87
Current treatment, n (%)
Valproic acid (n = 59) 20 (33.9) 15 (25.4) 24 (40.7)
Lithium (n = 9) 1 (11.1) 3 (33.3) 5 (55.6)
Carbamazepine (n = 10) 3 (30) 5 (50) 2 (20)
Valproic acid/Lithium (n = 6) 1 (16.7) 3 (50) 2 (33.3)
Antipsychotics (n = 36) 19 (52.8) 11 (30.6) 6 (16.7)
0.09
*Significant difference between obese and normal weight patients (p < 0.05).
Obesity in patients with bipolar I disorder thus consti-
tutes a major public health problem and suggests that the
development and testing of specific interventions that
target the obesity epidemic in this particular population
are urgently needed. Bipolar disorder and obesity both
have a tremendous impact on the physical and mental
well-being of affected individuals. Therefore, both ill-
nesses should be treated with a coordinated intensive and
multifaceted treatment [18].
Moreover, these results could be one of the missing
factors in understanding the relationship between psychi-
atric disorders and increased cardiovascular risk. In fact,
some studies have reported that psychiatric disorders,
particularly bipolar disorder, are significantly associated
with adverse cardiovascular events and coronary heart
disease [19]. The mechanisms through which obesity
leads to coronary heart disease remain hotly debated, but
the accumulation, particularly, of visceral fat is widely
favoured as the primary mechanism, leading, through the
release of fatty acids and other mediators, to insulin re-
sistance, dyslipidaemia, and a pro-inflammatory state.
Insulin resistance is a primary factor in obesity-related
disorders. By stimulating cellular glucose uptake and
acting as an antilipolytic hormone, insulin may cause
weight gain via direct effects on adipose tissue and in-
fluencing appetite through hypoglycemia. Leptin, which

Prevalence and Correlates of Obesity and Overweight in Tunisian Bipolar I Patients 185
is synthesized by adipocytes, regulates appetite and body
weight by activating leptin receptors in the satiety center
of the hypothalamus. Adiponectin a hormone that plays a
significant role in regulating insulin sensitivity is reduced
in obesity and type 2 diabetes. Adiponectin is involved in
lipid and glucose metabolism and insulin resistance.
Administration of recombinant adiponectin stimulates
glucose uptake and lipid oxidation in muscles while re-
ducing lipid uptake and glucose synthesis in the liver, and
increases the overall insulin resistance. In addition to
these effects, adiponectin acts as an anti-inflammatory
factor and reduces the risk of atherosclerosis, hyperten-
sion and coronary heart disease. Excess body fat, par-
ticularly abdominal visceral lipid deposition, is frequently
accompanied by hypoadiponectinemia, which mediates
the relationship between obesity and atherosclerotic vas-
cular diseases [20,21].
Obesity was more frequent in women than men. These
results are in consistent with the Wang et al. (2006) and
McIntyre et al. (2006) studies [22,23]. In addition, this
finding could be related to lack of exercise in women,
indeed, we showed that approximately 60% of them were
unemployed.
Our study showed that men were so much more likely
to be smokers and alcoholic consumers than women.
These results were in agreement with those reported by
previous studies [19,24].
In addition, men have the highest number of manic
episodes. This confirms the higher risk of cardiovascular
diseases in men compared with women. In fact, previous
studies suggested that mania, either directly (through
factors intrinsic to illness) or indirectly (through other
mediators or associated variables), increased the risk of
cardiovascular disease [25].
No significant association was observed between obe-
sity or overweight and age, year number of education, the
employment status, tobacco status, and alcohol use. These
results are in consistent with those reported by Fagiolini et
al. (2002) [15]. In contrast, other studies showed that
obesity had psychosocial consequences, including dis-
crimination and stigmatization in multiple areas of daily
life, such as health care, education and employment.
The study of clinical characteristics showed that the
number of previous depressive episodes was higher in
obese and in overweight patients than normal patients.
Additionally, the depressive polarity at index episode was
also more frequent in obese and overweight patients than
the other group. Previous studies reported that patients
who had depressive symptomatology were more likely to
have excessive caloric and cholesterol intake, to smoke
and to be inactive than non-depressed subjects. Another
explanation might involve biological mechanisms: it is
ascertained that hypothalamic-pituitary-adrenal (HPA)
axis dysregulation and high cortisol blood levels lead to
increasing visceral fat. HPA axis dysregulation has been
a common finding in both unipolar and bipolar disorders;
recently, some studies reported that increased cortisol
blood levels correlated to the amount of intra-abdominal
fat in major depression [26].
In addition, we showed that the duration of disease was
longer in obese and in overweight patients than in those
with normal weight. This could confirm the effect of
bipolar disorder on the weight gain.
The family history of medical disorders and concomi-
tant medical disorders was significantly more frequent in
obese patients than in those with normal weight. Our
findings are in agreement with previous studies [16,23,
27].
No significant difference was found between study
groups for age at onset, the total number of episodes,
severity of index episode and the number of lifetime sui-
cide attempts. These results are in part in consistent with
the Maina et al. (2008) study [26]. In contrast, Fagiolini et
al. (2002) [15] showed that appetite, diet and energy ex-
penditure are greatly influenced by both the polarity and
acuity of an episode. Obesity may contribute to the se-
verity of bipolar disorder by negatively impacting pa-
tients’ general physical health and functioning, quality of
life, self-esteem, and psychological well-being. Obese
patients have an increased risk of sleep apnea, which
causes sleep disruptions and may lead to mood destabili-
zation in patients with bipolar disorder [18,28,29].
Additionally, no significant difference was found be-
tween study groups for a number of manic episodes. Our
findings are in agreement with those reported by Fagiolini
et al. (2003) [18].
About therapeutic characteristics, we found that obe-
sity and overweight were more frequent (76.3% and
48.6%; respectively) in patients taking valproic acid or
lithium. These findings are in line with those reported by
De Hert et al. (2011) [8]. Moreover, Casey et al. (2005)
[9] reported that lithium have been shown to stimulate
appetite through different mechanisms. The “carbohy-
drate craving” that is thought to be one of the mecha-
nisms of increased calorie intake in people taking lithium
is well known. In addition, it is believed that valproate
also stimulates weight gain through a variety of mecha-
nisms, especially the development of insulin resistance
and diabetes mellitus type. Valproic acid also decreases
leptin secretion and mRNA levels in adipocytes in vitro,
suggesting that valproic acid therapy may be associated
with altered leptin homeostasis contributing to weight
gain in vivo [30,31].
In conclusion, the prevalence of obesity and overweight
in bipolar I patients was respectively 32.5% and 30.8%.
Obesity was significantly more frequent in women than
men. The illness duration was significantly longer in
obese patients than in those with normal weight. More-

Prevalence and Correlates of Obesity and Overweight in Tunisian Bipolar I Patients
186
over, the family history of medical disorders and con-
comitant medical disorders were significantly more fre-
quent in obese patients than in those with normal weight.
However, any significant association between therapeutic
characteristics and obesity or overweight was found.
These results emphasize the need for specific treatment
strategies and programs for weight control for these pa-
tients. Ideally, diet and exercise counselling should be
provided to all bipolar disorder patients-before weight
gain and definitely provided once weight gain has oc-
curred. Exercise, diet, and individual or group behavioral
therapy are the principal nonpharmacological means for
inducing and maintaining weight loss. However, these
may be particularly difficult to implement in individuals
suffering from mood disorders.
5. Acknowledgements
The authors thank the patients and control subjects for
their assistance in this study.
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