C:\Users\User\Documents\41 no 2 September-December 2022 UNIVERSA MEDICINA Vol.41- No.3 pISSN: 1907-3062 / eISSN: 2407-2230 Psychological distress and dyslipidemia in adult women: a 6-years follow up study in Bogor City, Indonesia Sulistyowati Tuminah1,2* , Sudarto Ronoatmodjo3 , Srilaning Driyah4, Dewi Kristanti4 , and Dwi Hapsari Tjandrarini2 BACKGROUND ABSTRACT 1Magister Program, Faculty of Public Dyslipidemia is of global occurrence, with a prevalence 30% or higher in several countries, including Indonesia. One risk factor of dyslipidemia is physical or mental stress, that is more frequent in women. This study aimed at investigating the association between psychological distress and dyslipidemia in adult women. METHODS This observational longitudinal study involved 1850 women aged 25 years and older at baseline. Dyslipidemia was determined from the ratio of low- density lipoprotein to high-density lipoprotein. Psychological distress was determined using the 20-item self-reporting questionnaire. Data analysis was by Cox regression for calculating the hazard ratio of the incidence of dyslipidemia as predicted by the psychological distress. RESULTS Among the 1474 participants without dyslipidemia at baseline, 545 (36.9%) developed dyslipidemia during 6 years of monitoring, while 93 (6.3%) had a history of psychological stress. There was a significant association between psychological distress and dyslipidemia (HR = 3.08; 95% CI: 2.33- 4.07). Cox regression revealed that the association was still found to be significant after a further adjustment for the variables of age, BMI, menopause, smoking status, physical activity, and carbohydrate and fat intakes (HR=2.8; 95% CI: 2.10 - 3.77). CONCLUSIONS Dyslipidemia incidence was high among adult women in Bogor. Women with psychological distress had higher incidence rates of dyslipidemia than women without psychological stress. Psychological distress in women was statistically significantly associated with incidence rate of dyslipidemia. This finding highlights the importance of the need for a dyslipidemia- reduction program in women through prevention and control of psychological distress. Keywords: Psychological distress, LDL/HDL ratio, dyslipidemia, longitudinal study, adult women Health - Universitas Indonesia (FKM UI), Indonesia 2Organization for Health Research - National Agency for Research and Innovation, Indonesia 3Department of Epidemiology, Faculty of Public Health - Universitas Indonesia, Indonesia 4Center for Health Management Policies - Agency for Health Development Policies, Ministry of Health, Republic of Indonesia, Indonesia *Correspondence: Sulistyowati Tuminah Badan Riset and Inovasi Nasional (BRIN) Gedung BJ. Habibie Jl. M.H. Thamrin No.8, Jakarta Pusat 10340 Email: suli017@brin.go.id / watidarjoko@gmail.com ORCID ID: 0000-0003-2839-3865 Date of first submission, May 25, 2022 Date of final revised submission, October 24, 2022 Date of acceptance, October 28, 2022 This open access article is distributed under a Creative Commons Attribution- Non Commercial-Share Alike 4.0 International License Cite this article as: Tuminah S, Ronoatmodjo S, Driyah S, Kristanti D, Tjandrarini DH. Psychological distress and dyslipidemia in adult women: a 6- year follow-up study in Bogor City, Indonesia. Univ Med 2022;41:236-43. doi: 10.18051/UnivMed.2022.v41.236- 245. 236 DOI: http://dx.doi.org/10.18051/UnivMed.2022.v41.236-245 Copyright@Author(s) - https://univmed.org/ejurnal/index.php/medicina/article/view/1348 ORIGINAL ARTICLE mailto:suli017@brin.go.id mailto:watidarjoko@gmail.com http://dx.doi.org/10.18051/UnivMed.2022.v41.236-245 https://univmed.org/ejurnal/index.php/medicina/article/view/1348 https://orcid.org/0000-0003-2839-3865 https://orcid.org/0000-0002-2317-0294 https://orcid.org/0000-0002-9694-2064 https://orcid.org/0000-0001-8313-4722 237 Univ Med Vol. 41 No 3 INTRODUCTION Dyslipidemia comprises one or more of the following abnormal lipid concentrations, namely high total cholesterol, high low-density lipoprotein (LDL), low high-density lipoprotein (HDL) or high triglycerides.(1,2) The occurrence and development of dyslipidemia frequently involves a continuous long-term process. Various risk factors, including changes in social and economic status, changes in life style, such as westernization of the diet, insufficient physical activity and long-term sedentary behavior, are believed to be contributing to the increased prevalence of dyslipidemia.(3,4) The prevalence of dyslipidemia varies between countries, because of differing LDL cutoffs. The prevalence of dyslipidemia in Thailand is 66.5%, using as reference the Third Adult Treatment Panels (ATP III) high LDL cutoff of 100 mg/dL and above.(2) The prevalence of dyslipidemia in Africa (LDL cutoff = 130 mg/ dL and above) is 25.5% and in Iran 83%.(5,6) The prevalence of dyslipidemia in Indonesia (LDL cutoff = 160 mg/dL or more) at ages 25 years and above is around 36% (33.1% in men and 38.2% in women).(2) In addition to being affected by nutrition, body weight, physical activity, treatment, and genetic factors, the blood lipid concentration may also be influenced by mental or physical stress.(7) Stress is the condition of physical and psychic stress as a result of individual and environmental demands, such as to cause anxiety, which is a ge neral and ear ly s ign of physica l and psychological abnormality.(8) The are 2 types of stress, namely eustress and distress. Eustress is a positive response that brings pleasure and health, whereas distress is a negative response of the body that has a deleterious impact on health.(9) Psychological distress (psychological stress) is one of the main causes of disability in the global disease burden. The morbidity resulting from psychological distress has reportedly a negative impact on the broader socio-economic health outcomes. The prevalence of psychological distress is especially reported to be higher in low- middle income countries (LMICs) and is significantly higher in women (as compared to men) and in those with comorbidities.(10,11) Because it is associated with different population characteristics and conditions, the prevalence of psychological distress varies widely, being 35.5% in Iraq, 16.0% in Mexico,(11) 37.6% in Br azil, (1 2) and 23.0% in Eri trea. (1 3) Psychological distress is associated with poor physical health and is predictive of the occurrence of chronic physical conditions.(14) The Indonesian national prevalence of psychological distress is 9.8% according to the Basic Health Research (Riskesdas) data for 2018. Psychological distress tends to increase with increasing age, its proportion being 8.5 - 15.8%. The prevalence of psychological distress is higher in women (12.1%) than in men (7.6%).(15) The proportion of psychological distress in the cohort study of risk factors of non-communicable disease (studi kohor faktor risiko penyakit tidak menular - FRPTM) in Bogor City in 2019 was 28.6%. The proportion of HDL concentration of less than 50 mg/dL in women (or less than 40 mg/dL in men) is around 36 - 42%.(16) The proportion of subjects with high LDL concentration (100 mg/dL and above) at baseline and in monitoring years 2, 4 and 6, was found to be higher than 80%.(17) Multivariate analysis of the study of Chen et al.(18) found a significant association between psychological distress and dyslipidemia, with a hazard ratio (HR) of 1.14 (95% CI: 1.04-1.25). On the other hand, the results of the study of Zhang et al.(19) showed that the group with mental health disorders had a significant relationship for awareness of dyslipidemia, with odds ratio (OR) =1.81, but not for treatment of dyslipidemia (OR=1.29) and for controlled dyslipidemia (OR=0.93). However, evidence showed that not all people with psychiatric disorders display metabolic impairments due to age and gender, these latter being the most significant factors influencing the relationship between metabolism and mental disorder. For instance, metabolic conditions (abdominal obesity, high triglyceride and glucose levels) are associated with an increased 238 risk of a future depressive episode in middle-aged adults.(20) The present study aimed at investigating the association between psychological distress and dyslipidemia in adult women. METHODS Design of the study This observational longitudinal study was conducted using data from 5 villages (kelurahan) of Bogor Tengah District, Bogor City, West Java Province from 2011/2012 until 2017/2018. The study was preceded by recruitment of candidate respondents and a baseline study comprising health screening that was conducted in 3 recruitment stages, namely stages 1 (2011), 2 (2012) and 3 (2015), to maintain the minimum sample size. For 6 years, 3 annual routine monitoring studies were performed.(16) New cases of dyslipidemia that occurred in the monitoring period were recorded as the incidence of dyslipidemia. Research subjects The study subjects were female respondents of the cohort study of risk factors of non- communicable Disease (FRPTM) aged 25 years and above (in the baseline study). The reason for selecting female re spondents was that dyslipidemia as well as psychological distress is more frequently found in women.(2,15) The inclusion criteria were: Respondents who did not have dyslipidemia at baseline and had been monitored for 6 years. The exclusion criterion was incomplete results of blood lipid examination. From a total of 5258 respondents of the FRPTM cohort study aged 25 years and above, the data of 3482 female respondents were collected. Of the latter, 1850 persons who did not have dyslipidemia at baseline were selected, from whom subsequently wer e collected 1642 respondents who had been monitored up to year 6, i.e. recruited in stages 1 and 2. The data of 168 persons, who had incomplete blood lipid results, were not included in the analysis, such that the number of respondents who met the criteria for analysis was 1474 (Figure 1). Definition of dyslipidemia Dyslipidemia as outcome was determined by the LDL to HDL ratio, because this ratio is a substitute marker for a decrease in lipids.(21) The result of the blood examination is categorized as dyslipidemia if the LDL/HDL ratio is high (2.5 and above) because according to the study of Chen et al.(22) this is the optimal cutoff value in women. The LDL and HDL concentrations were obtained from the results of blood lipid examination in the FRPTM cohort study that are conducted once in 2 years. Definition of history of psychological distress The data on exposure to psychological distress were obtained from the results of mental health screening using the 20-item self-reporting questionnaire (SRQ-20). Subjects are categorized as having “psychological distress” if they answer “yes” to at least 6 of the 20 SRQ-20 questions.(14) Subjects are categorized as having “history of psychological distress” if they had been detected as having psychological distress in at least 2 successive monitoring periods prior to the occurrence of the dyslipidemia. Covariates Seve ral covariate that were seen as potential confounders were included in this analysis. The age variable was divided into 2 groups, namely less than 55 years and 55 years and above, with reference to the study results of Sudikno et al.,(23 ) where LDL cholesterol concentration increases 3-fold in the age group of 55 years and above. The values of the menopause variable were obtained from the interview results ba sed on the subj ects’ admissions and were grouped into 2 categories, namely “yes” or “no”. Smoking status was estimated using the Brinkman index (BI), which is calculated by multiplying the duration of smoking (in years) by the number of cigarettes smoked.(24) Smoking status was categorized into 3 groups, namely non-smoker (0), light smoker (1—199), and heavy smoker (200 and above).(25) The physical activity variable is a composite of the type and duration of activity (days per week Tuminah, Driyah, Kristanti Psychological distress and dyslipidemia 239 Univ Med Vol. 41 No 3 A B and minutes per day) including the type of sport. Vigorous activity as well as vigorous sport has an 8-fold weight, moderate activity or sport has a 4-fold weight, while low activity has a 2-fold weight. Subjects were categorized as having insufficient physical activity if they had a total activity of less than 600 metabolic equivalent for task (MET) per week.(26) Fat and carbohydrate intakes were determined based on the General Guideline for Balanced Nutrition (Pedoman Umum Gizi Seimbang, PUGS). Fat intake was grouped into less than 25% and 25% and above of total energy requirement. Carbohydrate intake was grouped into less than 60% and 60% and above of total energy requirement.(27) The nutritional data were obtained through interviews using the food frequency questionnaire (FFQ) and food recall. Body mass index (BMI) was obtained from weight in kg divided by height in m2, referring to BMI standards for Asians. BMI was divided into 2 categories, namely obesity (BMI 25 kg/m2 and above) and no obesity (BMI less than 25 kg/ m2).(28,29) Subjects were categorized as having obesity if in at least 2 of 3 monitoring periods (per year) in 6 years they had a BMI of 25 kg/m2 and above. Statistical analyses Sample characteristics were compared between subjects with and without the onset of dyslipidemia at baseline, using the chi-square test for categorical variables. Multivariable analysis was performed with the Cox regression test to obtain the hazard ratio (HR) which is the ratio of the incidence dyslipidemia of the group with a history of psychological distress during monitoring to that of the group without such a history in the same period. The results are declared to be statistically significant if the p value is less than 0.05. Women respondents (n=3482) No dyslipidemia at baseline (n=1850) Monitoring up to 6th year (n=1642) Analyzed: complete blood lipid data (n=1474) Men respondents (n=1777) Dyslipidemia at baseline (n=1632) No monitoring up to 6th year (n=208) Incomplete blood lipid data (n=168) Respondents of FRPTM cohort study aged 25 yrs and above (n=5258) Figure 1. Flow of selection of analyzed sample (n=1474) 240 in a cumulative incidence of dyslipidemia (number of new cases) of 545 (36.9%). The Chi-square test results showed that the proportion of dyslipidemia incidence was significantly higher in the group with psychological stress, age less than 55 years, and BMI 25 kg/m2 (p<0.05) (Table 1). The results of bivariable analysis showed a higher risk of dyslipidemia incidence in subjects with psychological distress than in subjects without psychological distress (HR=3.08; 95% CI: 2.33-4.07) (Table 2). After controlling for the covariate variables of age, BMI, menopausal sta tus, smoking status, physical a ctivity, carbohydrate intake, and lipid intake, the risk of dyslipidemia incidence was higher in the group with psychological distress (HR= 2.8; 95% CI: 2.10 – 3.77 (Table 3). Ethical clearance The FRPTM cohort study obtains ethical clearance for each year of conduct, from the National Commission of Health Research Ethics (Komisi Nasional Etik Penelitian Kesehatan, KNEPK) of the Hea lth Resear ch and Development Agency, Ministry of Health, the current license being No. LB.02.01/2/KE.076/ 2018 dated March 1, 2018. RESULTS Among the 1474 women without dyslipidemia at baseline, 93 (6.3%) had a history of psychological stress, but the majority (1381 or 93.7%) did not. In the 6-year monitoring period, 57 (61.3%) of the 93 women and 488 (35.3%) of the 1381 women developed dyslipidemia, resulting Table 1. Comparison of characteristics of adult women with and without dyslipidemia during 6 years of monitoring (n=1474) Note: BMI = body mass index Risk factor Dyslipidemia p value Yes (n=545) No (n=929) n (%) n (%) Psychological distress <0.001 Absent 488 (35.3) 893 (64.7) Present 57 (61.3) 36 (38.7) Age (years) 0.030 Less than 55 412 (38.7) 652 (61.3) 55 and above 133 (32.4) 277 (67.6) BMI (kg/m2) 0.040 Less than 25 233 (34.2) 449 (65.8) 25 and above 312 (39.4) 480 (60.6) Menopause 0.060 No 340 (39.0) 531 (61.0) Yes 205 (34.0) 398 (66.0) Smoking status 0.080 Non smoker 454 (35.6) 822 (64.4) Light smoker 72 (44.4) 90 (55.6) Heavy smoker 11 (40.7) 16 (59.3) Physical activity 0.05 Sufficient 356 (35.3) 653 (64.7) Poor 189 (40.6) 276 (59.4) Carbohydrate intake (% of total energy) 0.180 Less than 60 376 (35.8) 673 (64.2) 60 and above 169 (39.8) 256 (60.2) Fat intake (% of total energy) 0.620 Less than 25 91 (35.4) 166 (64.6) 25 and above 454 (37.3) 763 (62.7) Tuminah, Driyah, Kristanti Psychological distress and dyslipidemia 241 Univ Med Vol. 41 No 3 DISCUSSION In this study it was found that the cumulative incidence of dyslipidemia that occurred in the monitoring period of 6 years was 36.9%. This is relatively low as compared with the study of Chen et al.(18) who found a cumulative incidence of dyslipidemia of 60.5% in a period of 2.6 years. This is because the definition of dyslipidemia in Chen et al. (18) study was at least one abnormal lipid level, whereas in our study dyslipidemia was determined by the combination of a high LDL and a low HDL, resulting in a smaller value. The results of multivariable analysis showed a statistically significant association between psychological distre ss and incidence of dyslipidemia, after controlling for covariate variables, namely age, BMI, menopause, smoking status, physical activity, and carbohydrates and fat intakes. Our study results are consistent with the results of other studies that associate stress with dyslipidemia. For the risk of dyslipidemia, the study of Catalina-Romero et al.(30) had an OR=1.11 (95% CI: 1.04 - 1.19), while the study of Assadi (31) had RR=14.54 (95% CI: 3.54 - 59.65). The study of Yu et al.(32) f ound a correlation between psychological distress and high LDL concentration in middle-aged women. The study results of Kim et al.(33) showed a significant relationship between chronic mental problems, such as depressive mood, and serum lipid concentration in male adolescents, but not in female adolescents. Although psychological distress in the FRPTM cohort study is determined with the SRQ-20 that is used to detect mental health in general, the results are consistent with a number of studies that use different and more specific instruments, in that there is a significant Table 2. Cox regression model of factors associated with the incidence of dyslipidemia in adult women Note: BMI = body mass index Risk factor Crude Hazard Ratio (CHR) 95% CI p value Psychological distress Absent 1 (Ref) Present 3.08 2.33—4.07 <0.001 Age (years) Less than 55 1 (Ref) 55 and above 0.79 0.65—0.96 0.020 BMI (kg/m2) Less than 25 1 (Ref) 25 and above 1.10 0.93—1.30 0.250 Menopause No 1 (Ref) Yes 0.83 0.70—0.99 0.040 Smoking status Non smoker 1 (Ref) Light smoker 1.39 1.09—1.79 0.010 Heavy smoker 1.14 0.63—2.08 0.660 Physical activity Sufficient 1 (Ref) Poor 1.37 1.15—1.64 <0.001 Carbohydrate intake (% of total energy) Less than 60 1 (Ref) 60 and above 1.21 1.01—1.46 0.030 Fat intake (% of total energy) Less than 25 1 (Ref) 25 and above 0.98 0.78—1.35 0.900 242 relationship between psychological distress and the incidence of dyslipidemia. Psychological distress may vary by type, number and duration of symptoms that are felt by the subjects, depending on the response of each individual and the way this individual overcome s the pr oblem. (8 ) Ac cord ing to Marcondes et al.,(34) increases in blood lipids that are triggered by stress are adaptive in nature and will return to normal when the stress disappears. However, if the stress persists for a long time, the dyslipidemia that is triggered by stress will persist, have a damaging effect and contributes to the occurrence of cardiovascular diseases, such as stroke, atherosclerosis, and coronary heart disease. The results of physiological studies show that stress from any source may affect the endocrine, hemopoietic and immune systems.(35) The stress response induces the secretion of cortisol and catecholamine hormones that influence the body metabolism including fat metabolism. There are 2 stress response pathways in the hypothalamus, namely the hypothalamic pituitary adrenal (HPA) and the sympathetic adrenal medullary (SAM) axes. Both are pathways that play a major role in regulating the balance of cortisol and catecholamine hormones. In a condition of distress, both of these pathways produce cortisol and catecholamines in non-homeostatic concentrations, that result in various types of metabolic changes, both for carbohydrates, proteins and fats.(9) Dyslipidemia that is triggered by stress involves a complex interaction between str ess hormones, ins ulin, adipose tissue metabolism and cytokines.(34) Table 3. Multivariate Cox regression analyses on the association between psychological distress and dyslipidemia in adult women *Covariates included age, BMI, menopausal status, smoking status, physical activity, carbohydrate intake, lipid intake, and psychological distress. Significance was set at p < 0.05. Note: BMI = body mass index; Ref = reference category Risk factor Adjusted Hazard Ratio 95% CI p value Psychological distress Absent 1 (Ref) Present 2.81 2.10—3.77 <0.001 Age (years) Less than 55 1 (Ref) 55 and above 0.86 0.65—1.14 0.310 BMI (kg/m2) Less than 25 1 (Ref) 25 and above 1.10 0.93—1.31 0.240 Menopause No 1 (Ref) Yes 0.92 0.72—1.18 0.540 Smoking status Non smoker 1 (Ref) Light smoker 1.29 1.00—1.67 0.040 Heavy smoker 1.02 0.56—1.71 0.930 Physical activity Sufficient 1 (Ref) Poor 1.38 1.15—1.65 <0.001 Carbohydrate intake (% of total energy) Less than 60 1 (Ref) 60 and above 1.32 1.05—1.66 0.010 Fat intake (% of total energy) Less than 25 1 (Ref) 25 and above 1.26 0.95—1.67 0.100 Tuminah, Driyah, Kristanti Psychological distress and dyslipidemia 243 Univ Med Vol. 41 No 3 From the results of the evaluation on each of the covariate variables, no confounder was found. This may have been due to the presence of other confounders that were not analyzed or because previously there had been a restriction in gender, in that only data from female respondents constituted the study sample, on the grounds that 65% of the respondents in the FRPTM cohort study are women. In addition, based on the literature, both dyslipidemia and psychological distress are more frequently found in women.(2,15) The limitation of this study is that the measurement of dyslipidemia as the outcome is done only once in 2 years. In addition, self- assessment may cause perception bias in the respondents towards the questions in the SRQ- 20. Our future studies will include more specialized scales on a particular aspect of psychological distress, such as depression. CONCLUSIONS Dyslipidemia incidence was high among adult women in Bogor. A psychological distress in women is statistically significantly associated with the incidence of dyslipidemia. Therefore, the incidence of dyslipidemia may be reduced if the psychological distress can be prevented or controlled, CONFLICT OF INTEREST There was no conflict of interest. FUNDING None. AUTHOR CONTRIBUTIONS ST contributed to literature search, data analysis, and wr iting of the manuscript (corresponding author); SR contributed to guidance and direction in writing the manuscript (corresponding author). SD contributed to guidance on lipids; DH and DK contributed to guidance and assisting in the preparation for data analysis. All authors have read and approved the contents of the final manuscript. ACKNOWLEDGMENTS Our heartfelt thanks to the following mental health researchers for their guidance: Ms. Rofingatul Mubasyiroh, SKM, M.Epid; and Ms. Alifa Syamantha Putri, S.Psi; M.Psi. REFERENCES 1. Perkumpulan Endokrinologi Indonesia (PERKENI). Panduan pengelolaan dislipidemia di Indonesia. Jakarta: PB PERKENI;2021. 2. Lin CF, Chang YH, Chien SC, Lin YH, Yeh HY. Epidemiology of dyslipidemia in the Asia Pacific region. Int J Gerontol 2018;12:2–6. https://doi.org/ 10.1016/j.ijge.2018.02.010. 3. Xi Y, Niu L, Cao N, et al. Prevalence of dyslipidemia and associated risk factors among adults aged e”35 years in northern China: a cross-sectional study. BMC Public Health 2020;20:1–10. https:// doi.org/10.1186/s12889-020-09172-9 4. Tabrizi JS, Nikniaz L, Sadeghi-Bazargani H, et al. Prevalence of dyslipidemia in urban and rural areas of the Northwest of Iran: the sociodemographic, dietary and psychological determinants. Iran J Public Health 2019;48:925– 33. DOI: 10.18502/ijph.v48i5.1810. 5. Gebreegziabiher G, Belachew T, Mehari K, Tamiru D. Prevalence of dyslipidemia and associated risk factors among adult residents of Mekelle city, Northern Ethiopia. PLoS One 2021;16:e0243103. https://doi.org/10.1371/journal.pone.0243103. 6. Hedayatnia M, Asadi Z, Zare-Feyzabadi R, et al. Dyslipidemia and cardiovascular disease risk among the MASHAD study population. Lipids Health Dis 2020;19:1–11. DOI: 10.1186/s12944-020- 01204-y. 7. Sonkar S, Kumar P. Determination of the effects of psychological stress on lipid profiles of patients. J Adv Med Dent Scie Res 2020;8:217– 20. 8. Eredoro CO, Egbochuku OO. Overview of stress and stress management. ARC J Nursing Healthcare 2019;5:12-8. DOI: http://dx.doi.org/ 10.20431/2455-4324.0502002. 9. Amir F, Zahriyah, Priyanto A. Analisis korelasi self acceptance, stres psikologis, dan kadar 244 kolesterol pada pasien hiperkolesterolemia. Nurs Update 2021;12:148–55. 10. Abdulshafea M, Rhouma AH, Gire N, AlMadhoob A, Arshad U, Husain N. The epidemiology of common mental disorders in Libya: a systematic review. Egypt J Neurol Psychiatry Neurosurg 2021;57. https://doi.org/10.1186/s41983-021- 00408-y 11. Idaiani S, Suryaputri IY, Mubasyiroh R, Indrawati L, Darmayanti I. Validity of the self reporting questionnaire-20 for depression based on national health survey. Med Psychol 2021;1–12. DOI: https://doi.org/10.21203/rs.3.rs-362342/v1. 12. do Carmo MBB, dos Santos LM, Feitosa CA, et al. Screening for common mental disorders using the SRQ-20 in Brazil: what are the alternative strategies for analysis? Rev Bras Psiquiatr.2018; 40:115–22. doi:10.1590/1516-4446-2016-2139. 13. Netsereab TB, Kifle MM, Tesfagiorgis RB, Habteab SG, Weldeabzgi YK, Tesfamariam OZ. Validation of the WHO self-reporting questionnaire-20 (SRQ-20) item in primary health care settings in Eritrea. Int J Ment Health Syst 2018;12:1–9. https://doi.org/10.1186/s13033-018- 0242-y. 14. Reuter A, Vollmer S, Aiyub A, Susanti SS, Marthoenis M. Mental distress and its association with sociodemographic and economic characteristics: community-based household survey in Aceh, Indonesia. BJ Psych Open 2020; 6:1–8. doi: 10.1192/bjo.2020.108. 15. Kementerian Kesehatan. Laporan Nasional Riset Kesehatan Dasar 2018. Jakarta: Lembaga Penerbit Badan Penelitian dan Pengembangan Kesehatan;2019. 16. Riyadina W, Sudikno, Pradono J, et al. Laporan akhir penelitian studi kohor faktor risiko penyakit tidak menular dan tumbuh kembang anak tahun 2018. Jakarta: Puslitbang Upaya Kesehatan Masyarakat, Badan Litbangkes Kemenkes RI; 2018. 17. Kristanti D, Rahajeng E, Sulistiowati E, Kusumawardani N, Dany F. Determinants of diabetes comorbidities in Indonesia: a cohort study of non-communicable disease risk factor. Univ Med 2021;40:3–13. DOI: http://dx.doi.org/ 10.18051/UnivMed.2021.v40.3-13. 18. Chen X, Leng L, Yu H, et al. Psychological distress and dyslipidemia in Chinese police officers: a 4- year follow-up study in Tianjin, China. J Occup Environ Med 2015;57:400–5. doi: 10.1097/ JOM.0000000000000372. 19. Zhang Z, Sum G, Qin VM, et al. Associations between mental health disorder and management of physical chronic conditions in China: a pooled cross-sectional analysis. Sci Rep 2021;11:5731. https://doi.org/10.1038/s41598-021-85126-4. 20. Ferri F, Deschênes SS, Power N, Schmitz N. Associations between cognitive function, metabolic factors and depression: a prospective study in Quebec, Canada. J Affect Disord 2021; 283:77–83. doi: 10.1016/j.jad.2021.01.039. 21. Lou Y, Li X, Cao L, et al. LDL-cholesterol to HDL- cholesterol ratio discordance with lipid parameters and carotid intima-media thickness: a cohort study in China. Lipids Health Dis 2020;19:1–9. https:// doi.org/10.1186/s12944-020-01324-5. 22. Chen QJ, Lai HM, Chen BD, et al. Appropriate LDL-C-to-HDL-C ratio cutoffs for categorization of cardiovascular disease risk factors among Uygur adults in Xinjiang, China. Int J Environ Res Public Health 2016;13. doi: 10.3390/ ijerph13020235. 23. Sudikno, Syarief H, Dwiriani C, Riyadi H, Pradono J. Hubungan obesitas sentral dengan profil lipid pada orang dewasa umur 25-65 tahun di kota Bogor. J Indones Nutr Assoc 2016;39:81–92. 24. Saito T, Miyatake N, Sakano N, et al. Relationship between cigarette smoking and muscle strength in Japanese men. J Prev Med Public Heal 2012;45: 381–6. http://dx.doi.org/10.3961/jpmph.2012.45. 6.381. 25. Amelia R, Nasrul E, Basyar M. Hubungan derajat merokok berdasarkan indeks Brinkman dengan kadar hemoglobin. J Kesehat Andalas 2016;5:619– 24. 26. Arija V, Villalobos F, Pedret R, et al. Effectiveness of a physical activity program on cardiovascular disease risk in adult primary health-care users: the “Pas-a-Pas” community intervention trial. BMC Public Health 2017;17:576. doi: 10.1186/ s12889-017-4485-3. 27. Utami RW, Sofia SN, Murbawani EA. Lipid pada pasien penyakit jantung koroner. J Kedokt Diponegoro 2017;6:1143–55. 28. Hussain A, Ali I, Kaleem WA, Yasmeen F. Correlation between body mass index and lipid profile in patients with type 2 diabetes attending a tertiary care hospital in Peshawar. Pakistan J Med Sci 2019;35:591–7. https://doi.org/10.12669/ pjms.35.3.7. 29. Kulanuwat S, Tungtrongchitr R, Billington D, Davies IG. Prevalence of plasma small dense LDL is increased in obesity in a Thai population. Lipids Health Dis 2015;14:1–9. doi: 10.1186/s12944-015- 0034-1. 30. Catalina-Romero C, Calvo E, Sánchez-Chaparro MA, et al. The relationship between job stress and dyslipidemia. Scand J Public Health 2013;41: 142–9. doi: 10.1177/1403494812470400. Tuminah, Driyah, Kristanti Psychological distress and dyslipidemia 245 Univ Med Vol. 41 No 3 31. Assadi SN. What are the effects of psychological stress and physical work on blood lipid profiles? Medicine (Baltimore) 2017;96:e6816. http:// dx.doi.org/10.1097/MD.0000000000006816. 32. Yu J, Zhang Z, Li C, et al. Serum lipid concentrations are associated with negative mental health outcomes in healthy women aged 35–49 years. Front Psychiatry 2021;12:1–6. doi: 10.3389/fpsyt.2021.773338. 33. Kim EJ, Hong J, Hwang JW. The association between depressive mood and cholesterol levels in Korean adolescents. Psychiatry Investig 2019; 16:737–44. https://doi.org/10.30773/pi.2019.03.24. 34. Marcondes FK, das Neves VJ, Costa R, et al. Dyslipidemia induced by stress. In: Kelishadi R,editor. Dyslipidemia - from prevention to treatment. IntechOpen;2012;p.367-90. doi: 10.5772/28163. 35. Subramanian S, Elango T, Malligarjunan H, Vinod K, Dayalan H. Role of sudarshan kriya and pranayam on lipid profile and blood cell parameters during exam stress: A randomized controlled trial. Int J Yoga 2012;5:21–7. doi: 10.4103/0973-6131.91702.