Xie et al.

BMC Psychology (2023) 11:116 BMC Psychology

[Link]

RESEARCH Open Access

Gender differences in the associations

between body mass index, depression,
anxiety, and stress among endocrinologists
in China
Fei Xie1, Licong Jiang2, Yuanli Liu3, Mingxiao Wang4, Huanzhong Liu5,6,7, Feng Jiang8,9*, Yinuo Wu10* and
Yi-Lang Tang11,12

Abstract
Background Depression, anxiety, and stress symptoms have been found to be associated with overweight or
obesity, but the gender differences in the associations have not been well-examined. Based on a national sample of
endocrinologists in China, we examined such associations with a focus on gender differences.
Methods Data were collected from endocrinologists in China using an online questionnaire, which included
demographic data, body weight, and height. Depression, anxiety, and stress symptoms were assessed using the
Depression, Anxiety, and Stress Scale-21 (DASS-21).
Results In total, 679 endocrinologists (174 males and 505 females) completed the survey. One-fourth (25.6%) were
classified as overweight, with a significant gender difference (48.9% in males vs. 17.6% in females, p < 0.05). Overall,
43.4% of the participants endorsed probable depressive symptoms (54.6% in males and 39.6% in females, p = 0.004),
47.6% for anxiety (51.7% in males vs. 46.1% in females, p = 0.203), and 29.6% for stress symptoms (34.5% in males vs.
27.92% in females, p = 0.102). After controlling for confounders, in the whole group, male gender (aOR = 4.07, 95%
CI:2.70–6.14, p < 0.001), depression (aOR = 1.05, 95% CI:1.00-1.10, p = 0.034) and age (aOR = 1.03, 95% CI:1.00-1.05,
p = 0.018) were positively associated with overweight. In males, depression (aOR = 1.14, 95% CI:1.05–1.25, p = 0.002),
administration position (aOR = 4.36, 95% CI:1.69–11.24, p = 0.002), and night shifts/month (aOR = 1.26, 95% CI:1.06–
1.49, p = 0.008) were positively associated with overweight, while anxiety (aOR = 0.90, 95% CI:0.82–0.98, p = 0.020) was
negatively associated with overweight. In females, only age (aOR = 1.04, 95% CI:1.01–1.07, p = 0.014) was significantly
associated with overweight status, while depression and anxiety were not associated with overweight. Stress
symptoms were not associated with overweight in either gender.
Conclusions One-fourth of endocrinologists in China are overweight, with a rate in males nearly triple the one in
females. Depression and anxiety are significantly associated with overweight in males but not females. This suggests

*Correspondence:
Feng Jiang
fengjiang@[Link]
Yinuo Wu
wuyinuo_pumc@[Link]
Full list of author information is available at the end of the article

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Xie et al. BMC Psychology (2023) 11:116 Page 2 of 8

possible differences in the mechanism. Our findings also highlight the need to screen depression and overweight in
male physicians and the importance of developing gender-specific interventions.
Keywords Endocrinologists, Body mass index, Overweight, Mental health, Gender difference

Introduction Women are often expected to conform to a thinner body

Overweight and obesity, abnormal or excessive fat accu- image, which can contribute to increased levels of body
mulation in the body, have become a worsening public dissatisfaction, anxiety, and depression. In contrast, men
health concern in China [1]. In recent years, the preva- are often expected to be strong and muscular, which can
lence of overweight increased rapidly, parallel to Chi- lead to increased pressure to maintain a larger body size
nese social, economic, and environmental transitions [25, 26].
[2]. According to a recent national survey, more than The gender differences in the relationship between
half of Chinese adults were overweight or obese [3]. The mental health symptoms and body weight highlight the
increase in overweight and obesity is believed to impact importance of including gender in health research and
the burden of non-communicable diseases, such as type 2 interventions. Interventions tailored to gender-specific
diabetes, cardiovascular disease, and cancer [4–6]. challenges may improve healthy body weight and men-
Overweight and obesity are often multifactorial, tal health. Such interventions may also better address the
including factors contributing to gaining and retaining unique challenges faced by each gender.
excess weight. Commonly mentioned factors include Due to the high prevalence of diabetes and other meta-
social and environmental factors (such as fast food cul- bolic disorders, endocrinologists play an important and
ture, sedentary work environment, etc.), and personal unique role in the Chinese healthcare system. For exam-
factors (such as diet, lack of exercise, genetics, and men- ple, diabetes is a major public health challenge in China
tal health symptoms) [7–12]. with a prevalence of 9.7% or over 114 million people
Mental health symptoms and body weight may interact living with the disease in 2017 [27]. This statistic is esti-
in several manners. First, mental health symptoms may mated to rise to over 131 million people living with the
lead to changes in eating habits and levels of physical disease by 2040 [28]. Thyroid disorders are also a major
activity [13, 14]. Depression, anxiety, and stress can dis- health concern in mainland China, where a significant
rupt normal eating habits and lead to overeating or loss portion of the population is affected by thyroid nodules
of appetite, both of which can contribute to weight gain and subclinical hypothyroidism. The prevalence of thy-
[15]. Second, overweight or obesity can lead to mental roid nodules in China is reported to be 20.43%, while
health symptoms. Being overweight or obese can lead to subclinical hypothyroidism affects 12.93% of the popu-
low self-esteem, body dissatisfaction, and depression [16]. lation [29]. Endocrinologists are medical specialists who
Overweight or obesity can also lead to medical problems have the necessary training and expertise to diagnose,
that can cause pain, limited mobility, and decreased qual- treat and manage diabetes and other endocrine disor-
ity of life, all of which can contribute to anxiety and stress ders. Endocrinologists often provide comprehensive care
[17]. Third, mental health problems and overweight share to patients with diabetes, including medical manage-
some common risk factors, such as genetics [18], biologi- ment, lifestyle modifications, and ongoing monitoring of
cal mechanisms [19], and environmental factors [20]. For diabetes-related complications. Endocrinologists are also
example, high-calorie foods, lack of physical activity, and equipped to manage other metabolic disorders, such as
high levels of stress can contribute to both mental health obesity, which is a major risk factor for diabetes in China.
symptoms and overweight/obesity [21]. Through their specialized training, they can provide
With respect to the relationship between mental health effective interventions to help prevent the development
symptoms and overweight/obesity, gender may be a of obesity and related conditions [30].
potential moderating factor [22]. On one hand, males and While they may have a better awareness of the impor-
females have different physiological responses to stress, tance of keeping a healthy weight and have more profes-
with men being more likely to overeat and women being sional knowledge of healthy diets and lifestyles [31], they
more likely to lose their appetite. Women may be more may also experience mental health symptoms, owing to
likely to cope with depression through emotional eat- stress related to heavy caseloads, long working hours,
ing, while men may be more likely to cope through binge and difficulty maintaining work-life balance. To date,
drinking or other behaviors. These differences may be the prevalence of overweight and obesity and their cor-
due to differences in hormonal responses to depression, relates in Chinese endocrinologists have not been exam-
as cortisol is a key intermediate factor in this relation- ined, especially in a large, national sample. Additionally,
ship [23, 24]. On the other hand, there are often different the relationships between overweight and mental health
cultural and societal expectations for men and women.
Xie et al. BMC Psychology (2023) 11:116 Page 3 of 8

symptoms are of interest, as they may shed light on for BMI (unit: kg/m²) in Chinese adults are: underweight:
interventions. <18.5; normal: 18.5–24.0; overweight but not obesity:
In this study, based on a nationwide survey of practic- 24.0 ≤ BMI<30.0; obesity:≥30.0 [1, 2, 37].
ing endocrinologists, we aimed to examine: (1) the preva- Mental health symptoms were assessed using the
lence of overweight and obesity and their correlates, (2) Chinese version of the Depression, Anxiety, and Stress
the prevalence of probable depressive, anxiety, and stress Scales-21 (DASS-21) [38, 39]. DASS-21 is a 21-item
symptoms, (3) the associations between overweight and self-report questionnaire to investigate three symp-
mental health symptoms, and (4) gender differences in tom domains, including depressive, anxious, and stress
the associations. We hypothesize that: (1) there is a sig- symptoms. The instrument uses a 4-point Likert scale.
nificant association between obesity and depression Each item was scored from 0 (did not apply to me at all
among women, but not in men, and (2) there is a signifi- over the last week) to 3 (applied to me very much over
cant association between obesity and anxiety/stress in the past week). As the DASS-21 is a short-form version
both genders. of the Long Form DASS, the final score of each item was
multiplied by two. The level of symptoms was ranked as
Materials and methods normal, mild, moderate, severe, and extremely severe,
Study design and participants according to certain cut-off values [38]. The Cronbach’s
The study was conducted between March 18th and 31st, alpha of DASS-21 was 0.96 in this study.
2019. It was part of the China Healthcare Improvement
Initiative (CHII) supported by the National Health Com- Data analysis
mittee [32]. The goal of CHII was to improve the health The normality of research data was detected through
and well-being of medical staff and healthcare quality a one-sample K-S test. Quantitative variables were
in China’s province-level top-tier general hospitals. The expressed as mean (SD) or median (IQR), and qualitative
Provincial People’s Hospitals of each province in main- variables were expressed as frequencies (percentages).
land China were purposely selected by CHII, as they The mean/median scores and prevalence rates of depres-
are the top-tier hospitals in the region. In the Chinese sion, anxiety, and stress were calculated.
healthcare system, each province has one Provincial Depression, anxiety, and stress scores were compared
People’s Hospital and it often has the best resources in using the Mann-Whitney test or Kruskal-Wallis test
budget, equipment, and staffing. It also usually serves as among different BMI groups and different gender groups,
a tertiary referral center for the province. We recruited as appropriate. The gender and BMI groups interactions
31 hospitals, which are all government-owned, province- were also tested in the same process with a newly gener-
level, general tertiary hospitals. They accounted for 1.85% ated variable of gender×BMI groups. Depression, anxiety,
of the beds of all tertiary hospitals and 2.68% of all patient and stress prevalence rates were compared using Pear-
care among tertiary hospitals in mainland China [33]. All son’s χ2 test or Fisher’s exact test, among different BMI
endocrinologists working in those hospitals were invited groups and different gender groups.
to participate in an anonymous online survey, which was We used the Pearson correlation analysis to test the
delivered using WeChat, a popular Social App in China. correlation between depression, anxiety, stress scores,
To avoid duplicate responses, each cell phone could only and continuous BMI values between males and females,
submit responses once. respectively.
The survey protocol was reviewed and approved by the We performed separate multilevel binary logistic
Ethics Committee of Emergency General Hospital in Bei- regression analyses with endocrinologists in level 1 and
jing. Each participant had to complete the consent form hospitals in level 2. Only the overweight and normal
before they could proceed to the survey. BMI groups (reference group) were involved in the logis-
tic regression, and the weight status was treated as the
Measures dependent variable. Depression, anxiety, and stress scores
The basic sociodemographic features and work-related were treated as continuous independent variables and
information were collected based on a literature review were purposely included in the regression, while other
[34–36]. They included age, gender, number of children, confounders were screened through backward stepwise
education, relationship status, height, weight, cigarette regression. We performed the regression models in entire
smoker or not, professional title, administration posi- groups, male and female subgroups, respectively.
tion, sleep hours/day, work hours/week, and night shifts/ We performed all analyses using the STATA software
month. version 16.0 (Stata Corporation, College Station, TX,
Body mass index (BMI) was calculated using the partic- USA). Two-sided p < 0.05 was considered significant.
ipants’ self-reported height and weight. According to the
Working Group on Obesity in China, the cutoff values
Xie et al. BMC Psychology (2023) 11:116 Page 4 of 8

Results After merging the overweight and obese groups, about

Sample characteristics one-fourth (25.6%) were overweight, 48.85% in males,
At the beginning of the survey, 879 endocrinologists 17.6% in females; 5.6% underweight, 1.2% in males, and
were invited to participate in this survey, and 711 endo- 7.1% in females. A significant gender difference was
crinologists responded (response rate = 80.9%). Finally, found in BMI categories (p < 0.001). Nearly one-quarter
679 endocrinologists completed the questionnaire with- (24.7%) of overweight endocrinologists were less than 35
out logical errors. Table 1 shows their detailed sociode- years old, 39.7% were between 35 and 44 years old, and
mographic features, job-related factors, and gender 35.6% were in the group of 45 years or older.
differences. In this sample, we found the overall prevalence of prob-
Categorical variables are reported as N (%). Continuous able depression was 43.4%, with a significant gender dif-
variables (age, sleep hours, work hours, and BMI) were ference (54.6% in males and 39.6% in females, p = 0.004).
reported as Mean (SD) unless indicated otherwise. Based We also found a significant gender difference (p = 0.032)
on the Chinese criteria, 24.0% of the endocrinologists and gender×BMI category interaction for depression
were classified as overweight but not obese, 1.62% were scores (p = 0.035).
obese. As the sample of obese participants was small, we Nearly one-half (47.6%) of endocrinologists endorsed
combined the two groups as “overweight” in our analysis probable anxious symptoms, 51.7% in males and 46.1%
unless specified otherwise. in females (p = 0.203), respectively. We did not find a

Table 1 Basic Characteristics of 679 endocrinologists in China

Characteristic N (%) Male (174) Female (505) p
Relationship status (N, %) 0.841
Not married 73(10.75) 18(10.34) 55(10.89)
Married 606(89.25) 156(89.66) 450(89.11)
Children (N, %) 0.004
None 145(21.35) 29(16.67) 116(22.97)
One 432(63.62) 106(60.92) 326(64.55)
Two or more 102(15.02) 39(22.41) 63(12.48)
Educational level* (N, %)
Medical/college degree 118(17.38) 34(19.54) 84(16.63) 0.221
Add on a Master’s degree 339(49.93) 77(44.25) 262(51.88)
Add on a Doctoral degree 222(32.70) 63(36.21) 159(31.49)
Professional title (N, %) 0.003
Junior 113(16.64) 19(10.92) 94(18.61)
Middle 241(35.49) 53(30.46) 188(37.23)
Senior 325(47.86) 102(58.62) 223(44.16)
Administration position (N, %)
No 580(85.42) 133(76.44) 447(88.51) < 0.001
Yes 99(14.58) 41(23.56) 58(11.49)
Cigarette Smoker (N, %) < 0.001
No 654(96.32) 149(85.63) 505(100.00)
Yes 25(3.68) 25(14.37) 0(0)
BMI category (N, %) < 0.001
Underweight (BMI < 18.5 kg/m2) 38(5.60) 2(1.15) 36(7.13)
Normal (18.5 kg/m2 ≤ BMI < 24.0 kg/m2) 467(68.78) 87(50.00) 380(75.25)
Overweight (24 kg/m2 ≤ BMI) 174(25.63) 85(48.85) 89(17.62)
Mean (SD) Mean (SD) Mean (SD) p
Age (years) 39.59(8.48) 42.56(8.48) 38.57(8.25) < 0.001
Sleep hours /day 6.35(0.76) 6.41(0.72) 6.33(0.77) 0.226
Work hours/week 55.08(13.98) 54.65(13.49) 55.22(14.15) 0.645
BMI 22.30(2.64) 23.91(2.45) 21.74(2.46) < 0.001
Median (IQR) Median (IQR) Median (IQR) p
Night shifts/month 4(3) 4(3) 4(2.5) 0.124
*In China, medical school graduates are awarded a bachelor’s degree in medicine (similar to the European system). Some obtain a master’s or doctoral degree in
addition to their medical degree. Bold value for p < 0.05.
Xie et al. BMC Psychology (2023) 11:116 Page 5 of 8

significant gender difference (p = 0.549) nor gender×BMI Discussion

category interaction for anxiety scores (p = 0.615). This research was one of the first to focus on overweight
The rate of probable stress symptoms was 29.6% in this and mental health among Chinese physicians. Our main
sample, 34.5% in males, and 27.92% in females (p = 0.102), findings include: (1) one-fourth of endocrinologists were
respectively. There was a gender difference (p = 0.036) in overweight, nearly half of the participants endorsed
stress scores, but no gender×BMI category interaction for depression or anxiety, and one-third endorsed feeling
anxiety scores (p = 0.087) (see Table 2). stressed; (2) overweight was significantly associated with
We performed Pearson correlations between depres- depression and anxiety scores in male endocrinologists,
sion, anxiety, stress scores, and continuous BMI values, but not in females; (3) stress scores were not significantly
but did not find significant correlations (Supplemental associated with overweight in males or females. Our find-
Table 1). ings suggest that gender might moderate the relationship
Supplemental Table 2 shows detailed information on between depression/anxiety and body weight.
depression, anxiety, and stress symptoms in categories. In this survey, the prevalence of overweight/obese
We then performed stepwise multilevel logistic regres- among endocrinologists was 25.6% (1.62% for obese
sion analysis, using overweight status (overweight + obe- only). This figure is lower than the average level of Chi-
sity) as a dependent variable, and others as independent nese adults, as the China Chronic Disease and Nutrition
variables. Depression, anxiety, and stress scores were Surveillance 2015-19 survey showed that the prevalence
purposely maintained. We performed the analysis in for overweight and obesity was 34.3% and 16.4% in peo-
the whole sample, and male and female participants, ple aged 18 years and older [1]. This encouraging finding
separately. may be related to better awareness and body weight man-
In the whole group, male gender (aOR = 4.07, 95% agement skills in this population [31].
CI:2.70–6.14, p < 0.001), depression scores (aOR = 1.05, Our findings show that a significant association
95% CI:1.00-1.10, p = 0.034) and age (aOR = 1.03, 95% between overweight status and depression was only
CI:1.00-1.05, p = 0.018) were positively associated with found in males (not in females), which is contrary to
overweight status. our hypothesis but is consistent with one prior study, a
In the male group, depression scores (aOR = 1.14, survey involving German and Chinese participants [40].
95% CI:1.05–1.25, p = 0.002), administration position Another study showed that a lack of positive emotion was
(aOR = 4.36, 95% CI:1.69–11.24, p = 0.002), and night associated with being overweight in females, whereas sig-
shifts/month (aOR = 1.26, 95% CI:1.06–1.49, p = 0.008), nificant associations were found between all dimensions
were positively associated with overweight status, while of depression and overweight in males [36].
anxiety scores (aOR = 0.90, 95% CI:0.82–0.98, p = 0.020) Similar to the association between overweight and
were negatively associated with overweight status. Stress depression, we also found that the association between
scores were not associated with overweight status in overweight/obesity and anxiety was only significant in
males. males, not in females, which partially aligned with the
In the female group, only age (aOR = 1.04, 95% CI:1.01– research hypothesis. This is in line with the findings of
1.07, p = 0.014) was positively associated with overweight an international study. In their study of 9,007 Chinese
status. While depression, anxiety, and stress scores were university students and 364 German students, Lavallee
not associated with overweight status. For details, please et al. only found significant associations in Chinese male
see Table 3. students between overweight and mental health symp-
In the sensitivity analysis, we excluded the participants toms, as assessed using DASS-21 [40]. Other studies have
who were classified as obese (5 males and 6 females), and reported no gender-specific association between over-
the overall findings remained largely unchanged com- weight and anxiety [41–43], while one reported the asso-
pared with the analysis which included obese partici- ciation only in female empty nesters [44]. Therefore, this
pants (see supplemental Table 3). interesting finding needs further research.

Table 2 DASS scores in male and female endocrinologists in China

Total Male (N = 174) Female (N = 505) Gender BMI Gender*BMI
(N = 679) Under- Normal Over- Under- Normal Over- χ2 category category
weight (N = 87) weight weight (N = 380) weight (p value) χ2 χ2
(N = 2) (N = 85) (N = 36) (N = 89) (p value) (p value)
Depression score 8(12) 7(14) 8(10) 12(12) 7(11) 8(12) 6(12) 2.14(0.032) 3.83(0.147) 11.95(0.035)
Anxiety score 6(10) 9(18) 6(10) 8(12) 8(14) 6(10) 6(10) 0.60(0.549) 1.76(0.415) 3.56(0.615)
Stress score 12(10) 8(16) 12(14) 14(8) 12(10) 12(10) 10(12) 2.10(0.036) 0.83(0.662) 9.60(0.087)
Bold value for p < 0.05. The numbers in the table are the DASS-21 subscale scores, and the numbers in the parenthesis are the interquartile range.
Xie et al. BMC Psychology (2023) 11:116 Page 6 of 8

The finding that stress was not significantly associated

0.014
0.730
0.796
0.304
with overweight in both genders was not consistent with

p
-

-
-
our hypothesis. The relationships between stress and

95% CI (Upper)
obesity in susceptible individuals can be partly traced
back to a third key player: increased glucocorticoid (GC)
action, which is influenced by individual GC sensitiv-
1.07 ity [45]. Multiple genetic and disease-related factors can
1.08
1.03
1.07
influence GC sensitivity with variations among different
-

-
-
populations [46]. The biological characteristics of Chi-
aOR 95% CI (Lower)

nese endocrinologists might be the potential factors for

Female (N = 505)

lack of the association.

We found that depression and anxiety may contribute
1.01 0.95
1.01 0.94
0.97 0.91
1.04 1.01

to being overweight in males but not in females, which

-

-
-

has theoretical and held practical implications for the

understanding of the complex relationship between men-
-

-
-

tal health and body weight. Gender-specific pathways

0.002
0.020

0.002
0.008
0.915
Table 3 Gender differences in the association between DASS scores and overweight status in male and female endocrinologists

may moderate the relationship between mental health

p
-

and body weight. Identifying these pathways could lead

95% CI (Upper)

to gender-specific interventions which may help prevent

and treat overweight. These findings highlight the impor-
tance of considering gender when evaluating and treating
11.24
1.25
0.98
1.07

1.49

overweight, as well as addressing depression and anxiety

-

symptoms. Healthcare providers should take a gender-

aOR 95% CI (Lower)

specific approach when working with patients to manage

weight, considering the potential role of mental health
in the development and maintenance of overweight. The
Male (N = 174)

results of this research have implications for public health

1.14 1.05
0.90 0.82
1.00 0.92

4.36 1.69
1.26 1.06

as well as the role of gender-specific factors, including

-

Bold value for p < 0.05. – indicates the variable was not included in the final model of the stepwise regression.

the role of depression and anxiety, which should be con-

sidered when developing interventions for overweight or
-

obesity.
< 0.001
0.034

0.018
0.474
0.394

The present study has a few limitations. First, the find-

p

ings were based on a cross-sectional survey, and it is diffi-

-

cult to infer causality between different variables. Second,

95% CI (Upper)

the survey data may have recall bias, as collected through

self-report. Third, the sample was only from 31 tertiary
public hospitals in China, so the generalizability of the
6.14
1.10
1.03
1.03
1.05

study conclusions may be limited. Fourth, mental health

-
-

was measured by questionnaires, and no clinical diagno-

aOR 95% CI (Lower)

ses can be provided. Finally, some important information

related to BMI and mental health, such as health status
and other lifestyle information (such as diet, exercise,
All (N = 679)

4.07 2.70
1.05 1.00
0.98 0.93
0.98 0.94
1.03 1.00

etc.) were not collected.

-
-

Conclusions
-
-

In a large national sample, we found that one-fourth of

Administration position (ref. No)

endocrinologists were overweight, which is lower than

the data in the general population. Depression and anxi-
ety may be significant contributors to overweight in
Gender (ref. Female)

Night shifts/month

males, but not in females, which suggests the mecha-

nism of the association between overweight and men-
Depression

tal health in males and females are different. Further

Variable

Anxiety

studies are needed to identify mechanisms that lead

Stress
Age

to more gender-dependent screening and therapies.

Xie et al. BMC Psychology (2023) 11:116 Page 7 of 8

11
Department of Psychiatry and Behavioral Sciences, Emory University,
Different interventional strategies may also be needed Atlanta, GA, USA
when addressing overweight issues in male and female 12
Atlanta VA Medical Center, Decatur, GA, USA
physicians.
Received: 30 August 2022 / Accepted: 29 March 2023

Supplementary Information
The online version contains supplementary material available at [Link]
org/10.1186/s40359-023-01150-1.

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