Association of stress, anxiety and depression with the body mass index and the body image perception among medical students

Depression is characterized by discomfort, loss of interest and anhedonia, feeling of guilt or low valor, sleep disturbance, appetite disturbance, feeling of fatigue, and poor concentration [2]. Depression can affect the job performance and social relations of the individuals [3]. This disorder involves many individuals in a manifest or latent way, to the extent where at fi nal stages is accompanied by death and suicidal thoughts [4,5]. It is expected to rank fi rst in disease burden in developed countries by 2030 [6]. Abbreviations

Stress is associated with fatigue and stressful mood, which takes effect from internal and external factors. Scientists depict that the term stress cannot fi t into just one defi nition, since it is a highly mental phenomenon. Stress may lead to physical and mental impairments and as observed in the studies, it can increase the risk of heart diseases and brain damages [7][8][9][10][11].
According to the World Health Organization's announcement, it is estimated that in 2015, 4.4% and 3.6% of the world population suffers from depression syndromes, worriedness and anxiety symptoms respectively [2].
Depression can be observed in almost every age group (children, adolescents, young adults, adults, and elderly), every educational grade, and every social position. However, many studies have shown that mental diseases are more prevalent in females than in males [2]. Stress, anxiety, and depression are more common than other mental disorders among the students. Students are going through a certain age stage (from adolescence to adulthood). Entering society and becoming independent are also stressful [12,13]. Moreover, fi nancial concerns among university students adversely affect their mental and physical health [14].
The students often encounter numerous stressors such as the pressure from the university, educational academies, and the families expecting high ranks and marks, unclear future, remoteness from the family for their studies, diffi culties of entering into the employment market, and fi nancial constraints, which are all among the issues considered as mental concerns among the majority of the students [16,17]. Regarding the above-mentioned, it may be stated that medical students' health condition is of special importance, as they are in charge of public health.
In a review carried out to determine the prevalence of stress among the students of four medical faculties in Tehran in 2007, it was reported as being 40.7% [18] which is much higher than that of the general public. Firth-Coze also claims that young doctors and medical students suffer extreme rates of stress and depression compared to the general public [19]. The prevalence of stress in medical universities of some countries are as follows, based on the undertaken studies: 30% medical students in Europe [20,21], 31.2% in the universities of Britain, 41.9% in Malaysia [15] and 61.4% in Thailand [22].
One of the factors that can cause a person to be isolated from society during adolescence and the onset of mental disorders is the standards imposed on the body appearance. During adolescence, people are very concerned about their appearance and overweight. Girls are looking for a lean body and boys are looking for a muscular and being taller. Distancing themselves from these standards imposed on communities can affect the prevalence of mental disorders [23]. Negative attitude towards body image perception can even affect dietary patterns and cause physical diseases especially it is more common in women [24].
A variety of studies have shown that the individuals' perception of their body image is not proportionate to their BMI, but it is a subject of mental origin and other factors including the family, friends, culture, society, level of individual awareness, and male and female biological aspects are effective, which is the ground for mental problems such as depression, stress, and anxiety [25].
Due to the potential expectations they have about themselves and their families, their training in conformity with accepting the responsibility of the patients' welfare, and because of their university courses and long hospital shifts, medical students are unable to spend reasonable time on recreational activities and therefore they are prone to suffer from anxiety and depression [26,27].
Hence, considering that this group of university students would become members of the medical staff and must be in good physical and mental health and conditions to deliver desirable services, we resolved to study on depression, anxiety, and stress prevalence and their association with the body mass and the body image perception among the medical students of basic medicals and physiopathology groups at the Azad Medical University of Tehran. This is to take a step forward in the promotion of the mental health of the medical students with the relevant authorities' assistance.

Methods
This is a cross-sectional and descriptive-analytical study conducted between December and June 2017 on 153 students of Azad Medical Sciences University of Tehran. A minimum of 145 respondents was required for this study based on prevalence (29.1%) of anxiety among university students in Iran, a confi dence level of 95% and a margin of error of 5% [28]. The participants were randomly selected from among the students of basic medicals and physiopathology disciplines, provided with questionnaires to collect the required data from them.
After fi nalizing the data collection, fi ve questionnaires were taken out of the samples, as they were not fully answered and failed to reach the statistical competence criteria. This made the fi nal sample size become 148.
Data collection was carried out after obtaining the written consent of the students and giving them a detailed explanation of the study purposes. The means of data collection for this research included three stages of demographic information questionnaire, the questionnaire of depression, anxiety, and stress symptoms index (DASS-21), and the body image perception test.
It has been hypothesized that stress, anxiety, and depression have association with BMI and the body image perception among medical students.
The demographic information questionnaire encompassed information such as age, gender, course (physiopathology and basic medicals), height, and weight.
DASS-21 questionnaire was employed to study the students' stress, anxiety, and depression status. This measure was prepared by Lovinband in 1995 and was tested on a large human sample [29]. It includes 21 questions in a way that each of the depression, anxiety, and stress factors are The questionnaire of body image perception includes 8 shapes that represent the general view of the body shape [32].
Its spectrum ranges from 1 to 8 (extremely thin to obese).
The participants select among eight shapes the one that best corresponds to the current size of their body (CBS). This selected shape shows the contour they believe they are. Additionally, they select a shape that best corresponds to their Ideal Body Size (IBS). The degree of dissatisfaction with the body size (DDBS) is yielded through the formula of CBS minus IBS. The DDBS score indicates the degree of dissatisfaction of the body shape, therefore a positive score means that the individual wants to lose weight, and the negative score indicates their tendency for gaining weight.

Statistical analysis
The data were analyzed by the statistical software (SPSS

Results
The rate of response in this study was 96.7% and the data for 148 medial students (51 male and 97 female) were analyzed. Table 1 indicates the demographic information and the mental health conditions of the participants among male and female students of basic medicals and physiopathology disciplines.

Discussion
The present study carried out on 148 medical students of basic medicals (semesters 1 to 5) and physiopathology (semesters 6 and 7) courses showed that about 47%, 54%, and about 59.15% of the medical students had depression, anxiety, and stress symptoms respectively. Mental symptoms of depression, anxiety, and stress are reported among medical students from around the world. Fawzy et al. have also reported respectively 65%, 73%, and 59.9% of depression, anxiety, and stress levels among 700 medical students in Egypt [17]. In their concluded that depression and anxiety have a high prevalence among medical students. This is generally more prevalent in comparison with the general public such that according to some articles, before entering into medical education, the said students were similar to the general public in terms of mental disorders prevalence [27]. This rate is depicted as being 15-25% among the general public [33].
Many of the different challenges the universities and colleges create to promote the educational status of the students, and the belief that the students' performance would go better by heavy competition lead to heavy pressures on and negative outcomes by the students [34]. Surbhi Sidana states in a study, that educational performance is related to the level of depression, and those students obtaining better marks are more exposed to mental pressures and depression [35].
In their study in 15 US universities on 8488 students in 2012, Eisenberg et al. reported that 22% of the students show depression symptoms in the acute phase [36].
In different studies conducted in Iran, the rate of depression prevalence was reported as follows: Eslami, et al. [37] and Kelyani, et al. [38] have reported this percentage as being 53.1%. The medical education system of some countries such as Iran, India, etc. bear several unique and different properties compared to other countries, such that the procedure of the students' qualifi cation is dependent on their marks and ranks obtained in special examinations, while in the Western countries this qualifi cation is considered based on the personal statements and interests, interviews and extracurricular history, in addition to other factors such as voluntary services or participation in research programs [39]. This can be a reason for the higher prevalence of stress, anxiety, and depression among the Iranian and Indian students.
Just like the results obtained from some other studies, no signifi cant difference was observed in mental disorders prevalence among females and males in the present study [40,41], while this rate is found to be higher among women in some of the studies [2,25,42,43].
Recent studies also reveal the prevalence of depression along different stages of medical education [43]. We have also found results showing 46.8% prevalence during the fi rst two years and 47% in the third year. In a study carried out in Mecca, the depression and stress prevalence among the third- year medical students was reported to be more than those of the second year [43]. However, the depression prevalence was not signifi cantly different among the second and third-year students in our study, while the stress prevalence among the second-year students was higher than those in their third year. and also depression measurement methods [32]. Some other studies also remind this fact [44,45].
The depression rate among the medical students may also be consequent to substance abuse, suicidal thoughts [45,46], weakness in their professional performance [32,47], and dissatisfaction about their body image [48].
Some articles have raised the relationship between body image dissatisfaction and depression [48].  provide some data on a bigger sample size and other university students rather than medical students to identify some more signifi cant associations. There are more basic factors to affect students and threat their mental health.

Conclusion
We have demonstrated cross-sectional relationship between BMI and body image perception with the symptoms of some mental disorders. Junior students were at risk for stress symptoms. The high prevalence of stress and depression among medical students compared to the general population can be related to academic stress and low self-awareness.
On the other hand, since according to the current study body image perception as a psychological factor in most participants was abnormal, self-awareness and self-confi dence courses should be requirement. Despite the limitations, this study may prepare some bases for researchers to develop studies on the association between stress and depression with more probable factors.

Ethics approval and consent to participate
The project got ethic approval from the ethical committee of faculty of medical sciences, Azad Medical University of Tehran.
Furthermore, after a short explanation at the beginning of the data collection, written consent forms were delivered and collected from participants.