See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/221982657

Risk factors for depressive symptom changes in

Indonesian geriatric outpatient

Article in Acta medica Indonesiana · January 2012

Source: PubMed

CITATION READS

1 217

5 authors, including:

Edy rizal Wahyudi Siti Setiati

University of Indonesia cipto mangunkusumo hospital
1 PUBLICATION 1 CITATION 70 PUBLICATIONS 225 CITATIONS

SEE PROFILE SEE PROFILE

Kuntjoro Harimurti Rahmi Istanti

University of Indonesia Cipto Mangunkusumo Hospital Jakarta / Fac…
27 PUBLICATIONS 63 CITATIONS 8 PUBLICATIONS 29 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

AIHA in Thalassemia View project

Indonesian Frailty Aging and QoL Longitudinal Study View project

All content following this page was uploaded by Siti Setiati on 01 May 2015.

The user has requested enhancement of the downloaded file.

 ORIGINAL ARTICLE

Risk Factors for Depressive Symptom Changes

in Indonesian Geriatric Outpatient

Edy R. Wahyudi, Siti Setiati, Kuntjoro Harimurti, Esthika Dewiasty,

Rahmi Istanti
Department of Internal Medicine, Faculty of Medicine, University of Indonesia - dr. Cipto Mangunkusumo
Hospital. Jl. Diponegoro No. 71 Jakarta 10430, Indonesia. Correspondence mail: er_wahyudi@yahoo.com.

ABSTRAK
Tujuan: mendapatkan faktor risiko perubahan gejala depresi pada pasien geriatri rawat jalan.
Metode: penelitian dengan metode kohort prospektif dilakukan terhadap 106 pasien geriatri yang berobat jalan
di Poliklinik Geriatri Terpadu RS dr. Cipto Mangunkusumo Jakarta pada tahun 2010. Kuesioner terstruktur
digunakan untuk mendapatkan data variabel independen, seperti usia, jenis kelamin, tingkat pendidikan,
penyakit-penyakit kronik (diabetes mellitus, penyakit ginjal kronik, hipertensi, dislipidemia, dan osteoarthritis),
status fungsional (Skor WHO-Unescap), status gizi (indeks massa tubuh), kualits hidup terkait kesehatan (skor
Eq5D), total asupan kalori, dan kejadian rawat inap dalam 6 bulan masa pengamatan, Gejala depresi sebagai
variabel dependen diukur dengan menggunakan kuesioner Geriatric Depression Scale (GDS). Hubungan
antara beberapa faktor risiko dengan perubahan gejala depresi danalisis menggunakan regresi logitik.
Hasil: sebagian besar subjek adalah wanita (63,2%), berusia 70 tahun atau lebih (71,0%), dan menderita
hipertensi (82,1%). Terdapat 22,6% subjek yang mengalami peningkatkan skor GDS selama 6 bulan pengamatan.
Analisis bivariat menunjukkan bahwa diabetes mellitus dan penyakit ginjal kronik berhubungan bermakna dengan
perubahan gejala depresi. Hasil analisis regresi logistik menunjukkan adanya hubungan yang bermakna antara
perubahan gejala depresi dengan penyakit ginjal kronik yang tidak terkontrol (OR 3,39; 95% CI 1,07-10,76).
Kesimpulan: penyakit ginjal kronik yang tidak terkontrol merupakan faktor risiko perubahan gejala depresi
pada pasien geriatri rawat jalan.

Kata kunci: status mental, geriatri, gejala depresi.

ABSTRACT
Aim: to determine risk factors for depressive symptom changes in geriatric outpatients. Methods: a prospective
cohort study was conducted on 106 geriatric outpatients at Integrated Geriatric Clinic Cipto Mangunkusumo
Hospital, Jakarta in 2010. A structured questionnaire was applied to obtain independent variable such as age, sex,
educational level, chronic diseases (diabetes mellitus, chronic kidney diseases, hypertension, dyslipidemia, and
osteoarthritis), functional status (WHO-Unescap score), nutritional status (body mass index), health related quality
of life (Eq5D score), hospitalization within 6 months, and total calorie intake. Depressive symptom as dependent
variable was assessed using Geriatric Depression Scale. The association between aforementioned various factors
with depressive symptom changes were analyzed using multiple logistic regression analysis. Results: most of
subjects were women (63.2%), aged 70 years old and older (71.0%) and had hypertension (82.1%). There were
22.6% subjects with increase in GDS score during 6-month follow-up. Bivariable analysis showed that diabetes
mellitus and chronic kidney diseases were significantly associated with depressive symptom changes. Multiple
logistic regression showed that variable which independently associated with depressive symptom changes was
uncontrolled chronic kidney disease (OR 3.390; 95% CI 1.07–10.76. Conclusion: uncontrolled chronic kidney
disease is risk factor for depressive symptom changes in geriatric outpatients.

Key words: mental status, geriatric, depressive symptom.

Acta Medica Indonesiana - The Indonesian Journal of Internal Medicine 47

Edy R. Wahyudi
INTRODUCTION
Elderly populations in Asia is estimated
will reach 1.2 billion (59% of the total elderly
population in the world) by the year 2050. 1
Elderly population in Indonesia is also estimated
increasing, by the year 2020 it will reach
29 million (11.2% of the total population in
Indonesia). As the elderly population increasing,
the health related problems will also increase in
this population. Depression is common health
condition among elderly, which is adversely
affects the lives of this population.2,3
Prevalence of depression in elderly ranging
from 8 to 15% in community settings and 40% in
hospitalized patients.4 Other study found the point
prevalence of major depression was estimated
4.4% in elderly women and 2.7% in elderly
men in community.5 Prevalence of susceptibility
to depression and depression was 17.2% in
an Indonesian community dwelling elderly
population.6 Elderly with depression commonly
have more functional impairment, poorer well-
being and quality of life, and cognitive decline.7-9
Studies showed that depressive disorders
among elderly in primary care setting have poor
prognosis and increased mortality.10-11 It has been
projected that by 2020, depression will be the
second leading cause of disability worldwide.12
Chronic diseases, poor health status, cognitive
disorders, and functional impairment are a risk
factor for depression among elderly and high
prevalence of comorbid depression is also found
in patients with chronic medical illness. 13-16
Depression is also influence the cost of health care
among individuals with chronic diseases.17,18As
an elderly population increase in Indonesia, it is
predicted that the number of chronic diseases and
depressive elderly will also increase, which will
lead to higher risk to socioeconomic burdens.
Indonesian Geriatric outpatients are commonly
having more than 2 comorbidities. Considering
the specific characteristics of Indonesian geriatric
outpatients such as such as high prevalence
of illness, lower level of education, higher
economic burden, and limited access to health
services, which contribute to psychological
condition of this population, it is important to
identify risk factors for depressive symptom in
Indonesian elderly. Information about risk factors
for depressive symptom changes in Indonesian
elderly is important to give direction to health
professional in the management and care of
48
Acta Med Indones-Indones J Intern Med
Indonesian geriatric outpatients. We, therefore,
conducted this study to determine risk factors for
depressive symptom changes.
METHODS
Design, Setting, and Study Population
A prospective cohort study with 6 months
follow-up was conducted among 106 geriatric
patients who visited geriatric clinic at Cipto
Mangunkusumo Hospital. The inclusion criteria
were those who have at least two of these following
diseases (hypertension, diabetes mellitus, chronic
kidney diseases, malnutrition, osteoarthritis, and
dislypidemia), have no inability to answer the
assessment questionnaire due to serious hearing
problems or severe communication disorders and
not refused to participate in the study. All subjects
were informed about the objectives and contents
of the study, and verbal informed consents were
obtained. Subjects were follow-up for 6 months
in this study.
Assessment of Factors Associated with
Depressive Symptom
A structured questionnaire was applied
to collect demographic data such as age,
sex, and educational status, chronic diseases
(hypertension, diabetes mellitus, chronic kidney
diseases, malnutrition, osteoarthritis, and
dislypidemia), functional status, nutritional
status, quality of life, calorie intake, history of
hospitalization within 6 months of the study,
and mental status. All subjects were evaluated
by face to face interview technique done by a
trained staff. Data collections for all variables
were done two times, at baseline and at 6 month
after follow up.
Chronic diseases (hypertension, diabetes
mellitus, chronic kidney diseases, malnutrition,
osteoarthritis, and dislypidemia), were
categorized into no diseases, controlled diseases
and uncontrolled. Hypertension, diabetes
mellitus, and chronic kidney diseases were
categorized based on systolic-diastolic blood
pressure, HbA1C value, and glomerulus filtration
rate respectively. Osteoarthritis and dislypidemia
were categorized based on VAS and total
cholesterol value. Controlled diseases were
defined if there was a positive value change
within 6-months follow-up.
Functional status was measured by WHO-
Unescap questionnaire, which was consisted
Vol 44 • Number 1 • January 2012 Risk Factors for Depressive Symptom Changes in Indonesian Geriatric

of 6 questions. Nutritional status was measured Table 1. Characteristic of subjects

by body mass index (BMI). We defined normal Characteristics n (%)
nutritional status as BMI score 18.5–22.9,
Sex
underweight as BMI score less than 18.5, and
-- Men 39 (36.8)
overweight/obese as BMI score 23.0 or more.
-- women 67 (63.2)
Quality of life was assessed by Euroqol-5D (Eq-
5D) which describes health status according to Educational level

five dimensions (mobility, self care, usual activity, -- No school 1 (0,9)

pain/discomfort, and anxiety/depression). Calorie -- Elementary school 15 (14,2)
intake was assessed by 24-hour food recall. -- Junior high school 16 (15,1)
Depressive symptom was measured by geriatric -- Senior high school 25 (23,6)
depression scale (GDS) questionnaire, which was -- University 49 (46,2)
consisted of 15 questions. Age group
-- 60-69 year 35 (33.0)
Data Analysis
-- > 70 year 71 (67.0)
Characteristics of subjects are presented
as number and percentage; including age, sex, Chronic diseases

education, and chronic diseases. Bivariable -- Diabetes Mellitus 39 (36.8)

analysis using Chi square test were done between -- Hypertension 87 (82.1)
each independent variable and depressive -- Dyslipidemia 48 (45.3)
symptom. Multivariable analysis using logistic -- Osteoarthritis 55 (51.9)
regression was performed. A 2-sided p-value less -- Chronic kidney disease 34 (31.1)
than 0.05 was considered to indicate statistical -- Malnutrition 77 (72.6)
significance. Data were analyzed using statistical Mental status
package software. -- Normal 85 (80.2)
-- Succeptibility to depression 18 (17.0)
RESULTS -- Depression 3 (2.8)

Table 1 summarizes subject characteristics.

Most of subjects were women (63.2%), aged 70
years old and older (71.0%) and had hypertension
(82.1%). There were 22.6% subjects with
increase in GDS score during 6-month follow-up.
Prevalence of depression in this study was 2.8%.
Table 2 shows the results of Chi-square test
using GDS score as dependent variable and other
variables as independent variables. Significant
associations were found in diabetes mellitus
and chronic kidney diseases (p<0.05). Table 3
shows the results of multiple logistic regression.
We found uncontrolled chronic kidney diseases
significantly associated with depressive symptom
changes (OR 4.30; 95% CI 1.26 – 14.68).
DISCUSSION
Geriatric depression scale is commonly used
to assess mental status of elderly. The current
study used the changes in GDS score to indicate
depressive symptom changes which represent
the mental status of the geriatric patients in this
population. We found that chronic diseases such
as diabetes mellitus and chronic kidney disease
were associated with depressive symptom which
is represented by the change in GDS score within
6 months follow-up among geriatric outpatient.
This result is in line with meta-analysis study
which found that the presence of chronic disease
was a risk factor for development of depression.19
Diabetes mellitus are common health
condition among geriatric patients. Comorbid
depressive symptoms are prevalent among older
adults with diabetes.20 Study done by Sandra
found that 31.1% of the older diabetic individuals
reported high levels of depressive symptoms.3
Bivariable analysis showed that subjects with
diabetes mellitus have a higher risk of increase
GDS score compare to subjects without diabetes
mellitus in this study. This result is in line with
longitudinal study done by Maraldi et al which
found diabetes mellitus was associated with a
depressed mood (OR 1.31).18 Groot also reported
that depression is twice as common in diabetic
people that it is in non-diabetic people. As
diabetes complication worsen, it will increase
the chances of becoming depression.21
Elevated prevalence of depression among
diabetic subjects was related to poor glycemic

49
Edy R. Wahyudi Acta Med Indones-Indones J Intern Med

Table 2. Bivariable analysis on factors associated with depressive symptom changes

GDS Score
OR (95% CI) p value
Decrease/steady Increase
Sex
-- Men 28 (71.8) 11 (28.2)
-- Women 54 (80.6) 13 (19.4) 0.61 (0.24 - 1.54) 0.29
Age group
-- 60-69 years 27 (77.1) 8 (22.9)
-- > 70 years 55 (77.5) 16 (22.5) 0.98 (0.37 – 2.58) 0.97
Educational level
-- Junior high school or less 55 (74.3) 19 (25.7)
-- Senior high school or higher 27 (84.4) 5 (15.6) 0.54 (0.18 – 1.59) 0.25
Hypertension
-- No hypertension 15 (78.9) 4 (21.1)
-- Controlled hypertension 44 (80.0) 11 (20.0) 0.94 (0.26 – 3.39) 0.92
-- Uncontrolled hypertension 23 (71.9) 9 (28.1) 1.47 (0.38 – 5.64) 0.57
Chronic kidney diseases
-- No chronic kidney diseases 61 (84.7) 11 (15.3)
-- Controlled chronic kidney diseases 10 (66.7) 5 (33.3) 2.77 (0.79 – 9.67) 0.11
-- Uncontrolled chronic kidney diseases 11 (57.9) 8 (42.1) 4.03 (1.32 – 12.29) 0.01
Diabetes mellitus
-- No diabetes mellitus 57 (85.1) 10 (14.9)
-- Controlled diabetes mellitus 5 (55.6) 4 (44.4) 4.56 (1.04 – 19.96) 0.04
-- Uncontrolled diabetes mellitus 20 (66.7) 10 (33.3) 2.85 (1.03 – 7.86) 0.04
Dyslipidemia
-- No dyslipidemia 46 (79.3) 12 (20.7)
-- Controlled dyslipidemia 20 (76.9) 6 (23.1) 1.15 (0.38 – 3.49) 0.81
-- Uncontrolled dyslipidemia 16 (72.7) 6 (27.3) 1.44 (0.46 – 4.46) 0.53
Osteoarthritis
-- No osteoarthritis 39 (76.5) 12 (23.5)
-- Controlled osteoarthritis 30 (73.2) 11 (26.8) 1.19 (0.46 – 3.07) 0.72
-- Uncontrolled osteoarthritis 13 (92.9) 1 (7.1) 0.25 (0.03 – 2.11) 0.20
Nutritional status
-- Normal (BMI 18.5 – 22.9) 21 (72.4) 8 (27.6)
-- Underweight (BMI < 18.5) 4 (80.0) 1 (20.0) 0.66 (0.06 – 6.79) 0.72
-- Overweight/obese (BMI > 23) 57 (79.2) 15 (20.8) 0.69 (0.26 – 1.87) 0.47
Hospitalized history within 6 months
-- No 49 (73.1) 18 (26.9)
-- Yes 22 (78.6) 6 (21.4) 0.74 (0.29 – 2.13) 0.58
Total calorie intake
-- Increase 45 (81.8) 10 (18.2)
-- Decrease 37 (72.5) 14 (27.5) 1.70 (0.68 – 4.28) 0.25
Functional status (WHO-Unescap score)
-- Decrease 72 (78.3) 20 (21.7)
-- Increase 10 (71.4) 4 (28.6) 1.44 (0.41 – 5.08) 0.52
Quality of life (Eq5d score)
-- Increase 73 (79.3) 19 (20.7)
-- decrease 9 (64.3) 5 (35.7) 2.14 (0.64 – 7.12) 0.21

50
Vol 44 • Number 1 • January 2012 Risk Factors for Depressive Symptom Changes in Indonesian Geriatric
Table 3. Multivariable analysis on factors associated with
depressive symptom changes in elderly
OR
Variables Coefficient
(95% CI)
Controlled chronic
0.99
2.45
kidney diseases (0.67–9.52)
Uncontrolled
3.39
chronic kidney 1.22
diseases
(1.07–10.76)
Controlled Diabetes 4.24
1.44
Mellitus (0-.9–19.90)
Uncontrolled 2.24
0.81
Diabetes Mellitus (0.77–6.52)
control, diabetes mellitus related complications,
and obesity.22-24 Subjects with diabetes mellitus
also have a higher risk for physical disability and
cognitive impairment which can also contribute
to the development of depression.18 Depression
or impairment of mental status in elderly with
diabetes mellitus will have a bad impact on
treatment adherence such as diet and exercise
which may lead to increasing severity and
complications of the diseases. This will increase
the use of health care service which will lead to
higher health care cost.18,25
Depression is affecting up to 21% of patients
with chronic kidney diseases (CKD). One in 5
patients with CKD had depression.26 Brian et
al found 45% subjects with end stage kidney
diseases positive for depression.27 Our study
found lower prevalence, 42.1% subjects with
uncontrolled CKD had increased GDS score,
which is indicate decreased mental status.
Subjects with uncontrolled CKD had higher risk
for having decreased GDS score in this study (OR
3.39; 95% CI 1.07-10.76).
Depression in CKD patients was associated
with an increased risk of poor outcomes, such as
hospitalization, higher kidney diseases severity,
and death.28 Some medical aspects of diseases can
be affected by depression in CKD patients, such
as limiting utilization of health care, adherence
of treatment (dialysis regimen or compliance
with prescribed medication), nutritional status
(probably through eating disorders), changes in
immune function or inflammatory responses.29,30
Survival of the CKD patients could also be
influenced by depression through the use of
medication or effect of underlying diseases.29
Mental management such as depression is
considered to be important to maintain a high
level of quality of life in geriatric patients.31 It
is important for health care workers to screen
geriatric patients routinely for depression in
P order to prevent the incidence of chronic disease
value complications. Screening alone does not improve
0.17
outcomes, but screening in combination with
monitoring of adherence to therapy of the chronic
diseases may be useful. This study emphasizes
0.04
the importance of maintaining chronic medical
conditions and screening routinely for depression.
0.06
Need for multidisciplinary care and the role of
geriatric team for geriatric patients care is
0.14
apparent.
One of the limitation of the present study
was time of the observation was 6 month which
only can see the change in the GDS score. It is
important to do the same study with a longer time
observation to see the incidence of depression in
geriatric patients with chronic medical condition.
CONCLUSION
Uncontrolled chronic kidney diseases was
risk factors for depressive symptom changes in
geriatric patients.
ACKNOWLEDGEMENT
This study was supported by University of
Indonesia
REFERENCES
1. Population Division of The Department of Economic
and Social Affairs of the United Nations Secretariat
(2007). World Population Prospects: the 2006 revision.
New York: United Nations.
2. Polly-Hitchock N, John WW, Jurgen U, Shuko Lee,
Cornell J, Katon W, Linda HH, Enid H. Depression and
comorbid illness in elderly primary care patients:impact
on multiple domains of health status and well being.
Ann Fam Med. 2004;2:555-62.
3. Black SA. Increased health burden associated with
comorbid depression in older diabetic Mexican
American. Diabetes Care. 1999;22:56-64.
4. Leon FG, Ashton AK, Mello DA, Dantz B. Depression
and comorbid medical illness: therapeutic and
diagnostic challenges. J Fam Pract. 2003;19-23.
5. David C S, Ingmar S, Maria CN, Andrea DH, JoAnn
TT, Brenda LP, Bonita WW, Kathleen AWB, John CSB.
Prevalence of depression and its treatment in an elderly
population. Arch Gen Psychiatry. 2000;57:601-7.
6. Setiati S, Harimurti K, Dewiasty E, Istanti R. Predictors
and scoring system for health-related quality of life in
an Indonesian community dwelling elderly population.
Acta Med Indones. 2011;43(4):237-42.
7. Blazer D. Depression in the elderly. N Engl J Med.
1989;320:164-6.
8. Unutzer J, Patrick DL, Simon G, Grembowski D,
Walker E, Rutter C, et al. Depressive symptoms and
51
 Edy R. Wahyudi
the cost of health services in HMO patients aged
65 and over: a 4-year prospective study. JAMA.
1997;277:1618-23.
9. Palsson S, Skoog I. The epidemiology of affective
disorders in the elderly: a review. Int Clin
Psychopharmacol. 1997;12:S3-S13.
10. St Jhon PD, Montgomery PR. Do depressive symptoms
predict mortality in older people. Aging Men Health.
2009;13:675-81.
11. Licht-Strunk E, Van Marwijk HW, Hoekstra T, Twist
JW. De Haan M, Beekman AT. Outcome depression in
later life in primary care:longitudinal cohort study with
three years follow-up. BMJ. 2009;338:a3079.
12. Murray CJL, Lopez AD. Global mortality, disability,
and the contribution of risk factors: Global Burden of
Disease Study. Lancet. 1997;349:1436–42.
13. Blay SL, Andreoli SB, Fillenbaum GG, Gastal FL.
Depression morbidity in later life: prevalence and
correlates in a developing country. Am J Geriatr
Psychiatry. 2007;15:790-9.
14. Katon W. Clinical and health services relationships
between major depression, depressive symptoms, and
general medical illness. Biol Psychiatry. 2003;54:216-
26.
15. Cole MG, Dendukuri N. Risk factors for depression
among elderly community subjects: a systematic review
and meta analysis. Am J Psychiatry. 2003;160:1147-56.
16. Djernes JK. Prevalence and predictors of depression
in populations of elderly: a review. Acta Psych Scand.
2006;113:372-87.
17. Hurkeler EM, Spector WD, Fireman B, Weisner C.
Psychiatric symptoms, impaired function, and medical
care cost in an HMO setting. Gen Hosp Psychiatry.
2003;25:178-84.
18. Cinzia Maraldi, Stefano Volpato, Brenda W, et al.
Diabetes mellitus, glycemic control, and incident
depressive symptoms among 70- to 79-year-old
persons. The health, aging, and body composition study.
Arch Intern Med. 2007;167:1137-44.
19. Huang CQ, Zhang XM, Dong BR, Lu ZC, Yue JR, Liu
QX. Health status and risk for depression among the
elderly: a meta-analysis of published literature. Age
and Ageing. 2010;39:23-30.
20. Konen JC, Curtis LG, Summerson JH. Symptoms and
complications of adult diabetic patients in a family
practice. Arch Fam Med. 1996;135-45.
52
View publication stats
Acta Med Indones-Indones J Intern Med
21. De Groot M, Anderson R, Freedland KE, Clouse RE,
Lustman PJ. Association of depression and diabetes
complications: a meta-analysis. Psychosomatic Med.
2001;63:619-30.
22. Anderson RJ, Freedland KE, Clouse RE, Lustman
PJ. The prevalence of comorbid depression in adults
with diabetes: a meta-analysis. Diabetes Care. 2001;
24:1069-78.
23. de Groot M, Anderson R, Freedland KE, Clouse RE,
Lustman PJ. Association of depression and diabetes
complications: a meta-analysis. Psychosom Med. 2001;
63:619-30.
24. Roberts RE, Deleger S, Strawbridge WJ, Kaplan
GA. Prospective association between obesity and
depression: evidence from the Alameda County Study.
Int J Obes Relat Metab Disord. 2003;27:514-521.
25. Roberts RE, Kaplan GA, Shema SJ, et al. Depressive
symptoms and the cost of health services in HMO
patients aged 65 years and older: a 4-year prospective
study. JAMA. 1997;277:1618-23.
26. Hedayati SS, Minhajuddin AT, Toto RD, Morris DW,
Rush AJ. Prevalence of major depressive episode in
CKD. Am J Kidney Dis. 2009;54(3):424-32.
27. Brian AJW, Ron DH, Karen LS, Moshe F, William BC.
Helath-related quality of life, depressiove symptoms,
anemia, and malnutrition at hemodialysis initiation.
Am J Kidney Dis. 2002;40:1185-94.
28. Hedayati SS, Minhajuddin AT, Afshar M, Toto RD,
Trivedi MH, Rush AJ. Association between major
depressive episodes in patients with chronic kidney
disease and initiation of dialysis, hospitalization, or
death. JAMA. 2010;303:1946-53.
29. Paul LK, Samir SP, Rolf AP. Depression in African-
American patients with kidney disease. J Nat Med
Assoc. 2002;94(8):92S-103S.
30. Kimmel PL. Depression in patients with chronic renal
disease:what we know and what we need to know. J
Psychosom Res. 2002;53(4):951-6.
31. Demura S, Sato S. Relationship between depression,
lifestyle, and quality of life in the community dwelling
elderly: A comparison between gender and age group.
J Physiol Anthropol. 2003;22(3):159-66.