Prevalence and associated factors of overweight/obesity among severely ill psychiatric patients in Eastern Ethiopia: A comparative cross-sectional study.

BACKGROUND: Globally, the burden of overweight and obesity is a major cardiovascular disease risk factor and is even higher among patients with psychiatric disorders compared to the general population. This is mainly due to the deleterious lifestyles characterized by physical inactivity, excessive substance use, and unhealthy diets common among patients with psychiatric disorders, as well as the negative metabolic effects of psychotropic medications. Despite these conditions being a high burden among patients with psychiatric illness, little attention is given to them during routine reviews in psychiatric clinics in most African nations, including Ethiopia. Therefore, this study aimed to estimate and compare the prevalence of and associated risk factors for overweight and obesity among patients with psychiatric illnesses.
METHODS: A comparative cross-sectional study was conducted between severely ill psychiatric patients and non-psychiatric patients in Dire Dawa, Eastern Ethiopia. The study included 192 study participants (96 psychiatric patients and 96 non-psychiatric controls). Weight and height were measured for 192 study participants. Baseline demographic and clinical characteristics of psychiatric and non-psychiatric patients were described. The data were cleaned and analyzed using the Statistical Package for Social Sciences, Version 21. The intergroup comparisons were performed using an independent sample t-test and Chi-square tests. Logistic regression analysis was used to identify the association between overweight/obesity and the associated variables.
RESULTS: The magnitude of overweight/obesity was significantly higher in the severely ill psychiatric groups (43.8%) than in the non-exposed controls (20.80%). The prevalence of overweight/obesity was highest in major depressive disorders (40%), followed by schizophrenia (32%), and bipolar disorder (28%).
CONCLUSIONS: There was a high prevalence of obesity/overweight among psychiatric patients. Educational status, unemployment, and late stages of the disease were significant predictors of overweight/ obesity. Clinicians should be aware of the health consequences of overweight/obesity, and considering screening strategies as a part of routine psychiatric care is strongly recommended.

Introduction

Obesity/overweight have reached an epidemic burden globally, with at least 2.8 million people dying each year as a result of being overweight or obese [1]. According to World Health Organization (WHO) European Region, an estimated 23% of women and 20% of men are obese or overweight [2]. The magnitude of overweight and obesity among adults in Africa is 27% and 8% respectively [3] and the report from the Ethiopia Demographic and Health Survey(EDHS) the burden of overweight/obesity is 8% [4]. Overweight and obesity are major risk factors for a number of chronic diseases, including diabetes, cardiovascular diseases, and cancer. Obesity is frequently accompanied by depression, and the two can trigger and influence each other. Obesity and overweight are major public health issues, as well as the leading preventable cause of death in both developed and developing countries [5].

A study has shown that the burden of obesity reveals that more than 1.9 billion adults aged 18 and older were overweight in 2014; over 600 million were obese; 39% of adults aged 18 and over were overweight, and 13% were obese [6]. Overweight and obesity are on the rise worldwide, not only in the general population but also in psychiatric patients. The major causes of overweight and obesity are not clear but are considered multi-disciplinary and related to genetic, metabolic, and psychological factors [7, 8].

The relationship between abnormal body weight and psychiatric disorders has continuous, complex relations that are still being debated. Some scholars suggest that overweight/obesity may cause common psychiatric disorders, whereas others have found that psychiatric patients are more prone to obesity [9, 10]. A community-based study of Saudi Arabian university students showed that obesity and overweight were positively associated with several mental disorders, especially mood disorders and anxiety disorders [11]. Another study done in Egypt showed that the prevalence of obesity and overweight in psychiatric patients was 66.93% (22.31% were obese, and 44.62% were overweight). The prevalence of obesity was highest in bipolar disorder (41.38%), followed by depression (37.93%), schizophrenia (10.34%), anxiety disorder (6.9%), and finally substance abuse disorder (3.45%), but the difference was not statistically significant. There was a significant correlation between the sociodemographic characteristics of patients with obesity and the distribution of psychiatric disorders [12].

In developing countries, along with economic development and income growth, the number of people who are overweight or obese is increasing. Among the reasons for the increasing obesity in the population of poor people are higher unemployment, lower education level, irregular meals, and low physical activity, which among the poor is associated with a lack of money for sports equipment [13]. In spite of such a burden of overweight/obesity in the community, there is no available scientific data in our region, Ethiopia. Thus, the purpose of this study is to compare the prevalence of overweight/obesity in patients with severely ill psychiatric patients at an Eastern Ethiopia psychiatric center as compared to non-exposed controls. The authors hypothesized that the prevalence would be higher in patients with psychiatric disorders. This study also determined the associated factors of overweight/obesity.

Study area and period

The study was conducted at Dire Dawa mental health center in Eastern Ethiopia from January to June 2021. The mental health center provides both inpatient and outpatient services to the community residing in the region and neighboring countries like Somalia and Djibouti.

Study design and population

A facility-based comparative cross-sectional study was conducted between patients with psychiatric disorders and without psychiatric disorders. All clients visiting outpatient departments for treatment or medical advice during the study period were considered as the source population, whereas only selected clients attending outpatient departments for treatment or medical advice during the study period were the study population. Severely ill psychiatric patients (exposed)-established diagnoses of a common psychiatric disorder include schizophrenia, schizoaffective disorder, major depressive disorder, and bipolar disorder. The psychiatric diagnosis of the subjects was obtained from the patients’ records diagnosed by psychiatrist specialist and relied on the Diagnostic and Statistical Manual of Mental Disorders(DSM-5) [14]. Non-psychiatric study groups (non-exposed group/controls) were age and sex-matched individuals, who had no lifetime diagnosis or treatment for a mental illness and who attended outpatient departments for general medical or surgical treatment other than psychiatric illnesses with in the same health institution.

Selection criteria

All study groups, aged 18 years and above, were included in the study. The current history of pregnancy and physical deformities were excluded from the study. Clients who were unstable or unable to consent (as determined by the attending physician) were also excluded.

Sample size determination and sampling technique

The sample size was determined using the analytical study sample size calculation formula by taking a two-sided confidence level of 95%, a power of 80% with a double proportion formula and an equal number of cases to controls [15]. A total sample of 192 study participants (96 psychiatric patients and 96 non-psychiatric individuals) was endorsed after considering a 10% non-response rate [16, 17]. All psychiatric patients were selected using consecutive sampling techniques. After collecting data from a single psychiatric patient, one corresponding age and sex-matched non-psychiatric control was chosen.

Operational definition

Body mass Index (BMI) was calculated as the weight of the individual in kilograms divided by height in meter square. With respect to the body mass index (BMI), there are four groupings: underweight (BMI < 18.5 Kg/m2), normal (BMI between 18.5 and 24.9.Kg/m2), overweight (BMI between 25 and 29.9 Kg/m2), and obese (BMI ≥ 30 Kg/m2) [18].

Vigorous-intensity activity was defined as any activity that results in a significant increase in breathing or heart rate if performed for at least 75 minutes per week. Moderate-intensity activity was defined as any activity that causes a small increase in breathing or heart rate if continued for at least 150 minutes per week or walking for at least 30 minutes per day. Sedentary involves a person not meeting any of the above-mentioned criteria for the moderate- or high-level categories [19].

Smoking state

Non-smoker or ever not smoked, which is coded as (0 = no) and all smoker (current, current daily, and past smokers) which is coded as (1 = yes) [20].

Alcohol consumption

Ever consumer / consumer of any alcohol represents current alcoholic drinker (past 30 days) which is coded as (0 = No and 1 = Yes) and past alcoholic drinker (drank in the past 12 months) which is coded as (0 = No and 1 = Yes) [21].

Data collection tools and procedures

After the interview, anthropometric measurements were performed. The height and weight of each subject were measured by using a scale to the nearest 1 cm and 1 kg, respectively. The height of a subject was measured by using an erect height measuring scale. Measurements of height were made with the subject’s bare feet. The subjects stood straight against the erect measuring scale, and their heads, shoulders, buttocks, and heels touched the scale. The subject’s axis of vision was horizontal. Then, they took a deep breath to relax their shoulders. With a flat object, the upper level of their heads was marked against the scale and measured to the nearest 1 cm. Weight was measured using a weighing scale with light clothing and without shoes.

Data quality control

The data collection tools prepared in English were translated to the local language and retranslated back to English to confirm the correctness of the translation. Training was given to the data collectors and supervisors about the purpose of the study, measurement technique, and ethical consideration. All questionnaires were checked daily for completeness, accuracy, and clarity by the investigators. A pretest of the data collection tool (questionnaire) was done by pre-testing 5% of the questionnaires at Sabian primary hospital, and necessary corrections were made prior to the actual data collection period.

Data analysis and report

Data were checked for completeness and entered into Epi-data version 3.1 before being exported to IBM Statistic Package for Social Science (SPSS) Version 21 for analysis. The chi-square test was used to conduct statistical analysis of the differences between groups. The mean scores of continuous variables were compared using an independent sample t-test between groups. Bivariate and multivariate logistic regression with odds ratio were used to determine independent predictors of overweight and obesity.

Results

Socio demographic status of study participant

A total of 192 study participants (96 cases and 96 controls) participated in the study to determine the burden of overweight or obesity among severely ill psychiatric patients. The mean age (years) of psychiatric patients was 37.18 ±12.59 and 36.59±13.56 in the non-exposed group, which was a statically insignificant difference (p = 0.754). Around 32.2% (31) of the exposed patients and 44.8% (43) of the non-exposed study participants attended college and above educational level (Table 1).

Table 1

Sociodemographic characteristics of psychiatric and non-psychiatric controls, Dire Dawa, Eastern Ethiopia 2021.

Characteristics	Cases (psychiatric patients)	Controls	p value
Sex			.561*
Male	55 (57.3%)	56(58.3%)
Female	41(42.7%)	40(41.7%)
Age in years (mean±SD)	37.18±12.59	36.59±13.56	0.754**
Educational status			.076*
No formal education	45(46.9%)	26(27.1%)
Primary education	3(-)	6(6.3%)
Secondary education	17(17.7%)	21(21.9%)
College & above	31(32.2%)	43(44.8%)
Marital status			0.743 *
Single/unmarried	35(36.5%)	33(34.4%)
married	12(12.5%)	33(34.4%)
Divorced/separated/died	12(12.5%)	13(13.5%)
Residence			0.009 *
Rural	59 (61.5%)	41(42.7%)
Urban	37(38.5%)	55 (57.3%)
Employment			0.061 *
Unemployed	72(75.0%)	36(37.5%)
Employed	24(25.0%)	60(62.5%)
Ever smoked			0.86*
No	79 (82.3%)	82 (85.4%)
Yes	17 (17.7%)
Ever Alcohol Intake			.401*
No	70(72.9%)	75 (78.1%)
Yes	26(27.1%)	21 (21.9%)
physical activity			0.521 *
Yes	39(40.6%)	29(30.2%)
No	57(59.4%)	67(69.8%)
Family history of hypertension			0.082 *
Yes	36(37.5%)	13(13.5%)
No	69(71.9%)	83(86.5%)
Family history of diabetes			0.013 *
Yes	27(28.1%)	13(13.5%)
No	68(70.8%)	83(86.5%)

SD = standard deviation, Independent sample t test,

*Pearson’s chi square test.

The prevalence of overweight/obesity

The prevalence of overweight/obesity was significantly higher among the severely ill psychiatric groups than the in non-exposed controls (p = 0.001). The prevalence of overweight/obesity among psychiatric patients was 43.8% (95% CI: 33.3–55.3%), whereas the magnitude of overweight/obesity among non-psychiatric controls was 20.80% (95% CI: 16.5–28.9%) (Fig 1).

Fig 1

Shows the prevalence of overweight/obesity among psychiatrically exposed groups and non-psychiatric controls in Dire Dawa, Eastern Ethiopia, 2021.

Overweight/obesity patterns in various psychiatric disorders

The prevalence of overweight/obesity was highest in 40% of patients with major depressive disorder (MDD), followed by schizophrenia 32%, bipolar disorder, and 28%. There was a significant correlation between overweight/obesity and the distribution of psychiatric illnesses (Fig 2).

Fig 2

The Burden of overweight/ obesity among different psychiatric disorders Dire Dawa, Eastern Ethiopia, 2021.

Factors associated with overweight or obesity

All covariates that with a p-value ≤0.2 in the bivariate analysis were included in the multivariate analysis. In this study age, sex, marital status, educational level, physical activity level, occupational status, and duration of psychiatric illness were significantly associated with overweight or obesity status in the bivariate analysis. After adjusting variables such as study participants who were uneducated (AOR = 2.2, 95% CI (1.57, 8.5), p = 0.014), unemployed (AOR = 6.5, 95% CI (1.8, 35.20), p = 0.023), and duration of psychiatric illness (AOR = 2.9, 95% CI (1.23, 4.1), p = 0.02), were independent predictors of overweight/obesity (Table 2).

Table 2

Factors associated to overweight/ obesity among severely ill psychiatric patients, Dire Dawa, Eastern Ethiopia, 2021.

Variables	Category	Overweight/Obesity		COR (95%CI)	AOR (95%CI)
		Yes	No
Age (years)	18–30	8(26.7%)	22(73.3%)	1	1
	31–40	12(46.2%)	14(53.8%)	2.3(.77,7.20)	1.4(.33,5.9)
	41–50	13(61.9%)	8(38.1%)	4.4(1.35,14.7)	1.6(.3,7.9)
	>50	9(47.4%)	10(52.6%)	2.4(.73,8.3)	.71(.13,3.7)
Gender	Male	20(38.5%)	32(61.5%)	1	1
	Female	22(50.0%)	22(50.0%)	1.6(.70,3.60)	1.3(.53,5.02)
Marital status	Single	12(34.3%)	23(65.7%)	1	1
	Married	23(46.9%)	26(53.1%)	1.6(.69,4.1)	2.3(.75,7.41)
	Widowed	7(58.3%)	5(41.7%)	2.6(.70,10.2)	2.8(.42,18.8)
Education status	Uneducated	25(55.6%)	20(44.4%)	3.6(3.13,18.9)	2.2(1.57,8.5)
	primary	2(66.7%)	1(33.3%)	.33(.10,1.1)	7.7(.16,8.9)
	secondary	5(29.4%)	12(70.6%)	.38(.14,.99)	1.1(.19,6.9)
	college and above	10(32.3%)	21(67.7%)	1	1
Occupation	employed	3(12.5%)	21(87.5%)	1	1
	Non employed	39(54.2%)	33(45.8%)	8.2(2.26,30.2)	6.5(1.8,35.20)
Residency	rural	20(33.9%)	39(66.1%)	1	1
	urban	22(59.5%)	15(40.5%)	2.8(1.22,6.6)	1.3(.38,4.5)
Smoking	yes	11(64.7%)	6(35.3%)	2.8(.95,8.4)	2.9(.6,13.5)
	No	31(39.2%)	48(60.8%)	1	1
Alcohol intake	yes	13(50.0%)	13(50.0%)	1.4(.5,3.4)	1.01(.25,4.01)
	No	29(41.4%)	41(58.6%)	1	1
physical exercise	Yes	14(35.9%)	25(64.1%)	1	1
	No	28(49.1%)	29(50.9%)	1.7(.74,3.9)	1.2(.41,3.7)
Duration of psychiatric illness (years)	<5	10(40.0%)	15(60.0%)	1	1
	5–10	7(31.8%)	15(68.2%)	.45(.04,4.2)	1.3(.28,6.1)
	>10	25(51.0%)	24(49.0%)	3.58(2.10,3.18)	2.9(1.23,4.1)

Discussion

To the best of our knowledge, no previous study has been conducted in Ethiopia to determine the prevalence of excess weight among severely ill psychiatric patients. The results showed that the study groups (severely ill psychiatric patients and non-psychiatric controls) were similar in terms of age, sex, marital status, and educational level; with no statistically significant difference.

Our findings revealed a significantly higher prevalence of overweight/obesity (43.8%) among psychiatric patients than among non-psychiatric controls (20.8%), p<0.05. Thus, possibly due to the deleterious lifestyles characterized by physical inactivity, excessive substance use, and unhealthy diets common among patients with psychiatric disorders, they may be predisposed to overweight or obesity. This study is consistent with the findings reported from the United States, where patients with severe psychiatric disorders had a higher average BMI than the subjects in the general population controls(32.11, SD = 7.72vs 27.62, SD = 5.93,P = 0.000) in 2017 [22], and in Egypt by Ahmed Kamel et al., in 2016 [12]. However, the current study has a higher prevalence of overweight/obesity as compared to the WHO report in 2016 [6] and by Mekonnen et al. in 2018 [23]. This could be due to variations in study participants (in our study, the study participants were severely ill psychiatric patients) and lifestyle and physical activity differences.

Furthermore, the current study shows a higher prevalence of overweight/obesity among those with major depressive disorders (MDD) as compared to schizophrenia and bipolar disorders. This finding is supported by previous studies done in the Campania region by Micanti F, Pecoraro G, Mosca P, et al., 2017 [24] and in McLean Hospital, Belmont, MA, USA by Chouinard, V.-A., et al. [25] and Francesco Weiss, Margherita et al. 2020 [26]. This is partly explained by depressed patients reduced physical activity, which results in positive energy balance and overweight/obesity disorders. Many people who have difficulty recovering from sudden or emotionally draining events unknowingly begin eating too much of the wrong foods or forgoing exercise [27]. Mechanisms underlying this weight gain include lifestyle and environmental factors and psychiatric medications, though emerging evidence has also suggested the role of genetic and neuroendocrine processes [28]. The current study also, found that education status, employment, and increased duration of psychiatric illness were significant predictor of obesity/overweight among psychiatric patients. The current study also found that education status, employment, and increased duration of psychiatric illness were significant predictors of obesity/overweight among psychiatric patients. This finding is consistent with the study conducted by Husky et al. in 2017 [29, 30].

Limitations of the study

To the best of our knowledge, this is the first study in Ethiopia to provide information on the problem of overweight/obesity among the psychiatric population as compared to the non-psychiatric population. The study’s shortcomings include the absence of dietary habits, social desirability, and the possibility that recall biases influenced the results.

Conclusion

The current study described the burden of overweight or obesity and associated factors among psychiatric patients compared to non-psychiatric controls at Dire Dawa psychiatric center, Ethiopia. The magnitudes of overweight and obesity were significantly higher among the severely ill psychiatric group (43.8%) than in non-exposed controls (20.80%). It was found that educational status, unemployment, and late stages of the disease were significant predictors of overweight or obesity. Clinicians should be aware of the health consequences of overweight and obesity and consider instituting targeted weight treatment programs as a part of routine psychiatric care. This is strongly recommended. The current study also found that education status, non-employment, and the late stage of psychiatric diseases were significant predictors of obesity and overweight. Physicians should be aware of the health consequences of obesity and should consider instituting targeted weight treatment programs as a part of routine psychiatric care.

Overweight-obesity.

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9 Nov 2021

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Reviewer #1: The overall research hypothesis and how the research question were technically sound and interesting to share with the readers, however the way the data were presented had major problems. Numerous mistakes or inaccuracies with language made some parts of the manuscript difficult to read or follow the idea. Examples include:

- Line 36 : It's ninety six, sex and age matched. Such a mistake in the abstract is very confusing to the reader.

- Line 46: It's weight reduction not treatment, since the scope of your paper is around obesity. The term wight treatment might refer to treating underweight as well.

Other problems with literature review or methodology that had missing important information for example:

- Line 51: I'd rather see statistics from Africa not Europe, since your research is done in Ethiopia. Same data can be obtained from WHO statistics too.

- Line 73: Which sociodemographic characteristics exactly? the was it's written in your review is vague.

- Line 91: There is nothing called non=psychiatric individuals. It could be normal controls not suffering from psychiatric illnesses for example.

- Line 97: Which edition of the DSM? Were the diagnoses made by specialist psychiatrists or GPs and family physicians?

- Line 101: Why were those populations specifically excluded from the study?

I would suggest doing this revisions and also doing an English proof reading by more fluent researcher or possibly whose native language is English and then resubmit.

Reviewer #2: I hope you will find these comments to be helpful

1) some paragraphs need references ; first paragraph of the abstract and introduction ; to make the facts more reliable

2) the authors mentioned that their population was severely ill psychiatric patients, and again they mentioned they were selected from the outpatient! I find this to be contradicting . Do they mean chronic visitors?

3) what are the criteria of severely ill ?

4) Would severely ill patients be able to give a consent ?

5) the manuscript needs language editing

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4 Dec 2021

Comments from Reviewer #1

The overall research hypothesis and how the research question were technically sound and interesting to share with the readers, however the way the data were presented had major problems. Numerous mistakes or inaccuracies with language made some parts of the manuscript difficult to read or follow the idea.

The response of the authors: We thank the reviewer for the comment. We have identified the problem and made the necessary corrections throughout the revised manuscript.

Examples include:

1. Line 36 : It's ninety six, sex and age matched. Such a mistake in the abstract is very confusing to the reader.

The response of the authors: We thank the reviewer for the comment and sorry for vague statements. Correction has made in the revised manuscript (page 2, line no.35-36).

2. Line 46: It's weight reduction not treatment, since the scope of your paper is around obesity. The term wight treatment might refer to treating underweight as well.

The response of the authors: The reviewer is correct, it is out of our scope and we have modified the contents in the revised manuscript (page 3, line no.48-49)-

Other problems with literature review or methodology that had missing important information for example:

3. Line 51: I'd rather see statistics from Africa not Europe, since your research is done in Ethiopia. Same data can be obtained from WHO statistics too.

The response of the authors: We thank the reviewer for the suggestions and concern. We have added references indicate about African and Ethiopia to the manuscript on (page 3, line no. 54-56).

4. Line 73: Which sociodemographic characteristics exactly? the was it's written in your review is vague

The response of the authors: We would like to appreciate the reviewer’s comment and concern. We have modified the suggested content to the revised manuscript on (page 4, line no. 87-88).

5. Line 91: There is nothing called non=psychiatric individuals. It could be normal controls not suffering from psychiatric illnesses for example.

The response of the authors: We thank the reviewer for the comment. We have identified the problem and made the necessary corrections in the revised manuscript (page 5, line no.102-105).

6. Line 97: Which edition of the DSM? Were the diagnoses made by specialist psychiatrists or GPs and family physicians?

The response of the authors: The reviewer is correct, and we have incorporated the contents into the revised manuscript (page 5, line no. 100-102). DSM-5 and psychiatrists specialist

7. Line 101: Why were those populations specifically excluded from the study?

Response of the authors: We would like to appreciate the reviewer’s comment and concern. We exclude those who were pregnant and physically deformed study participants because Body Mass Index (BMI) was measured by dividing a person’s weight in kilograms by his or her height in meters squared (kg/m2). The height of the participants was measured using a stadiometer with the participant standing upright with the heel, buttock, and upper back along the same vertical plane. The weight of the participants was measured using a calibrated weighing scale with the participant not wearing shoes and heavy clothes. We believe that physically deformed and pregnant individual measurements might result in abnormal BMI status, thus affecting the final outcomes.

I would suggest doing this revisions and also doing an English proof reading by more fluent

researcher or possibly whose native language is English and then resubmit.

The response of the Authors: We would like to thank you for your comment and we have edited the grammatical issues in the revised manuscript.

Reviewer #2: I hope you will find these comments to be helpful

The response of the Authors: Thank you very much

1) some paragraphs need references ; first paragraph of the abstract and introduction ; to make the facts more reliable

The response of the authors: The reviewer is correct, and we have incorporated the comments into the revised manuscript (page 3, line no.52). However, the first paragraph of the abstract was taken from(references 1,3,4)

2) the authors mentioned that their population was severely ill psychiatric patients, and again they mentioned they were selected from the outpatient! I find this to be contradicting. Do they mean chronic visitors?

The response of the authors: We appreciate the reviewer’s concern and are sorry for the unclarity. Severely ill psychiatric patients (=patients with a diagnosis of one or more of those psychiatric disorders such as schizophrenia, bipolar disorder, major depressive disorder, and schizoaffective disorders) and have chronic follow-up/chronic psychiatric outpatient visitors.

3) what are the criteria of severely ill?

The response of the authors: We would like to appreciate your concern. We were considered the severity of psychiatric disorders as described in DSM-5. Our criteria was based on the number of symptoms, level of distress caused by the intensity of symptoms, and impairment in social and occupational functioning.

4) Would severely ill patients be able to give a consent?

The response of the authors: We would like to appreciate your concern. We were selected severely psychiatric patients (schizophrenia, bipolar disorder, major depressive disorder, and schizoaffective disorders) and who attended the outpatient psychiatric clinic. Severely ill Clients who were unstable or unable to consent due to acute symptoms (as determined by the attending physician) were excluded. We were considered only stable study participants (those able to give consent).

5) the manuscript needs language editing

The response of the Authors: We would like to thank you for your constructive comments and concerns for forwarding them to us to enrich our paper. We have corrected all the comments and we have also edited the language in the revised manuscript

Submitted filename: renamed_e168b.docx

Click here for additional data file.

11 Feb 2022

Prevalence and Associated Factors of Overweight/Obesity among severely ill Psychiatric Patients in Eastern Ethiopia: A Comparative Cross-Sectional Study

PONE-D-21-28472R1

Dear Dr. Fentie,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Aleksandra Barac

Academic Editor

PLOS ONE

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Comments to the Author

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The revision put in consideration all of the comments. Except for 2-3 typing mistakes, the current manuscript is in a much better shape.

Reviewer #2: (No Response)

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Reviewer #1: Yes: Ahmed Abdelkarim

Reviewer #2: No

18 Feb 2022

PONE-D-21-28472R1

Prevalence and Associated Factors of Overweight/Obesity among severely ill Psychiatric Patients in Eastern Ethiopia: A Comparative Cross-Sectional Study

Dear Dr. Fentie:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. Aleksandra Barac

Academic Editor

PLOS ONE