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JNFS 2023, 8(3): 452-460 |
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Mohseni-Takalloo S, Salehi-Abargouei A, A.Ferns G, Ghayour-Mobarhan M, Khayyatzadeh S S. Adherence to the Healthy Eating Index-2015 and Its Association with Depression Score in A Sample of Iranian Adolescent Girls. JNFS 2023; 8 (3) :452-460
URL: http://jnfs.ssu.ac.ir/article-1-517-en.html
URL: http://jnfs.ssu.ac.ir/article-1-517-en.html
Sahar Mohseni-Takalloo 
, Amin Salehi-Abargouei , Gordon A.Ferns , Majid Ghayour-Mobarhan , Sayyed Saeid Khayyatzadeh *
, Amin Salehi-Abargouei , Gordon A.Ferns , Majid Ghayour-Mobarhan , Sayyed Saeid Khayyatzadeh *
Nutrition and Food Security Research Center, School of Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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1 Nutrition and Food Security Research Center, School of Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 2 Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran; 3 School of Public Health, Bam University of Medical Sciences, Bam, Iran; 4 Brighton & Sussex Medical School, Division of Medical Education, Falmer, Brighton, Sussex BN1 9PH, UK; 5 Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
Introduction
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Adherence to the Healthy Eating Index-2015 and Its Association with Depression Score in A Sample of Iranian Adolescent Girls
Sahar Mohseni-Takalloo; MSc1,2,3, Amin Salehi-Abargouei; PhD 1,2, Gordon A. Ferns; MD, PhD 4, Majid Ghayour-Mobarhan; PhD5 & Sayyed Saeid Khayyatzadeh; PhD*1, 2
Sahar Mohseni-Takalloo; MSc1,2,3, Amin Salehi-Abargouei; PhD 1,2, Gordon A. Ferns; MD, PhD 4, Majid Ghayour-Mobarhan; PhD5 & Sayyed Saeid Khayyatzadeh; PhD*1, 2
1 Nutrition and Food Security Research Center, School of Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran; 2 Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd,
Iran; 3 School of Public Health, Bam University of Medical Sciences, Bam, Iran; 4 Brighton & Sussex Medical School, Division of Medical Education, Falmer, Brighton, Sussex BN1 9PH, UK; 5 Metabolic Syndrome Research Center, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
Introduction
Depression in adolescents is an important public health concern that can impair educational achievement and interpersonal relationships, and also can increase the risk of drug abuse and suicide attempts (Gladstone and Beardslee, 2009). It is known that various physical and mental disorders including cardiovascular diseases, metabolic syndrome, type 2 diabetes, anxiety, and alcoholism are more prevalent among depressed people (Lasserre et al., 2017). According to the World Health Organization, depression and anxiety disorders cost the global economy one trillion dollars a year through reduced productivity (World Health Organization, 2019). In addition, it has been shown that current treatments resolve only one-third of the disease burden of depressive disorders (van Zoonen et al., 2014). Therefore, new approaches are required to prevent depression or delay its progression (Wu et al., 2018).
Previous studies have indicated the role of diet as a modifiable risk factor in the development of depression (Khayyatzadeh et al., 2021, Opie et al., 2017). It has been shown that some nutrients such as n-3 long-chain polyunsaturated fatty acids, vitamins B, zinc, iodine, magnesium, and selenium are involved in brain function and could prevent or delay the onset of depression. However, some other nutrients including saturated fatty acid have been associated with increased risk of depression (Li et al., 2020, Turan and Karaaslan, 2020, Van Dael, 2021, Wang et al., 2018, Wu et al., 2021). Dietary nutrient or food assessments are considered to be an inappropriate way to analyze the relationship between diet and health outcomes. The diet comprises food and nutrients that are not consumed as food or nutrients, but rather a pattern of food intake (Cespedes and Hu, 2015). Therefore, dietary pattern analyses have been developed as a comprehensive approach examining the effect of the whole diet rather than specific nutrients or food (Cespedes and Hu, 2015). The Healthy Eating Index 2015 (HEI-2015) assesses priori dietary patterns which reflect the 2015-2020 Dietary Guideline American (DGA) recommendations (Krebs-Smith et al., 2018). Although previous studies have demonstrated an inverse association between adherence to the healthy dietary pattern, measured by HEI, and depression in adults (Kuczmarski et al., 2010, Saneei et al., 2016, Wang et al., 2021), there are limited data for adolescents. Given the high prevalence of depression among Iranian adolescent girls (Moeini et al., 2019, Sajjadi et al., 2013), and its high socio-economic and health impact, the current study was designed to investigate the association between HEI-2015 and depression among Iranian adolescent girls.
Materials and Methods
Population and sampling: This cross-sectional study carried out on 734 adolescent girls aged 12-18 years in 2015. Participants were recruited from schools in the cities of Mashhad and Sabzevar, in northeastern Iran. Students who had no history of chronic disease (e.g. colitis, diabetes, cardiovascular diseases, cancer, and hepatitis) were included in the study. Moreover, participants were excluded if they were taking any medication related to anti-inflammatory, anti-depressant, anti-diabetic, or anti-obesity drugs, vitamin D or calcium supplement use, and hormone therapy during the past 6 months. Informed consent was obtained from the students and their parents. The study was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran (Ethic code: 931188).
Dietary assessment and HEI-2015 score computation: Dietary intakes of participants were collected using a valid and reliable food frequency questionnaire (FFQ), containing 168 food items (Esfahani et al., 2010). The US Department of Agriculture’s (USDA) data bank was used for analyzing nutrient intakes of each item (Pehrsson et al., 2000). Overall diet quality was assessed using HEI-2015. The HEI-2015 is designed with a score range of 0 to 100 and includes thirteen dietary components including total fruits, whole fruits, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids, refined grains, sodium, added sugars, and saturated fats. The first nine items are adequacy components and the last four items are moderation components.
Assessment of outcomes: Depression was assessed using the Persian version of the Beck Depression Inventory (BDI). BDI is a 21-items self-administered questionnaire that each item has different options and its total score ranged from 0 to 63 points. If the score was >13, the person was classified as depressed, and if the score was <13, the person was considered as not depressed. Previous studies have confirmed the validity and reliability of this questionnaire (Cronbach’s α=0.87 and acceptable test-retest reliability (r)=0.74) (Bonnet et al., 2005, Ghassemzadeh et al., 2005, Norrby, 2002).
Covariate assessment: Demographic data (including age, family members, parental death or divorce, medical history, using supplements, smoking status, menstrual status, a positive history of mental therapy, and chronic diseases) were collected by experienced interviewers. Also, weight, height, waist circumferences (WC), and blood pressure measures were gathered according to standard protocol. All measurements were performed twice and their mean scores were reported. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. Physical activity level was obtained using the validated modifiable activity questionnaire (MAQ), based on metabolic equivalent task (MET) minutes per week (Delshad et al., 2015).
Ethical considerations: This study was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran (Ethic code: 931188). All methods of the current study were performed in accordance with the Declaration of Helsinki, and all students and their parents completed the informed written consent.
Data analyses: The participants were categorized based on the HEI-2015 quartiles score. To compare general characteristics and dietary intakes across quartiles of HEI-2015, one-way ANOVA and Ch-square tests were used. Age and energy-adjusted intakes of nutrients and food groups within quartiles of HEI-2015 were calculated using one-way ANOVA. To find the association between HEI-2015 and odds of depression, logistic regression was examined in different models. First, the reserchers controlled for age and energy intake. The additional adjustment was carried out for physical activity and BMI in the second and third models. To calculate the trend of OR, HEI-2015 quartiles were considered as an ordinal variable and the first quartile was designated as the reference category. In accordance with quartile categories of HEI-2015, for continuous and dichotomous variables, Ptrend was determined by regression coefficient and logistic regression, respectively. Significance was set at two-tailed P-value<0.05 for all analyses. Statistical analyses were conducted using the statistical package for social sciences (SPSS), version 23.
Results
The mean age of the subjects was 14.51±1.53 years. The prevalence of depression with a high BDI score in the study population was 33.8%. The main characteristics of the participants according to quartile categories of HEI-2015 are provided in Table 1. Adolescents in the highest quartile of HEI-2015 were more likely to be younger and less depressed, compared to those in the lowest quartile. There were no significant differences in family members, parental death and divorce, being passive smoker, physical activity, and BMI percentile across categories of HEI-2015.
Adjusted intakes of several nutrients and food groups across HEI-2015 quartiles are presented in Table 2. The energy intake from saturated fatty acid and added sugars, and also intake of sodium and refined grains declined significantly across HEI-2015 quartiles. A greater adherence to the HEI-2015 was associated with higher consumption of cholesterol, n-3 fatty acids, vitamin B6, total fruits, whole fruits, total vegetables, greens and beans, whole grains, total protein foods, and seafood and plant proteins.
When depression was considered as a dichotomous variable, adolescents with the highest adherence to HEI-2015 had significantly 37% lower odds of depression compared to those with the lowest adherence (OR: 0.63; 95% CI 0·41, 0·99, Ptrend = 0.03) (Table 3). After adjusting the effect of age and energy received in the first model, as well as further adjustments for physical activity and BMI in the second and third models, the observed relationship did not change considerably (OR: 0.62, 95 % CI 0.40-0.98, Ptrend = 0.02, OR: 0.62, 95% CI 0.40-0.98, Ptrend = 0.02 and OR: 0.63, 95% CI 0.40-1.00, Ptrend=0.03, respectively).
Previous studies have indicated the role of diet as a modifiable risk factor in the development of depression (Khayyatzadeh et al., 2021, Opie et al., 2017). It has been shown that some nutrients such as n-3 long-chain polyunsaturated fatty acids, vitamins B, zinc, iodine, magnesium, and selenium are involved in brain function and could prevent or delay the onset of depression. However, some other nutrients including saturated fatty acid have been associated with increased risk of depression (Li et al., 2020, Turan and Karaaslan, 2020, Van Dael, 2021, Wang et al., 2018, Wu et al., 2021). Dietary nutrient or food assessments are considered to be an inappropriate way to analyze the relationship between diet and health outcomes. The diet comprises food and nutrients that are not consumed as food or nutrients, but rather a pattern of food intake (Cespedes and Hu, 2015). Therefore, dietary pattern analyses have been developed as a comprehensive approach examining the effect of the whole diet rather than specific nutrients or food (Cespedes and Hu, 2015). The Healthy Eating Index 2015 (HEI-2015) assesses priori dietary patterns which reflect the 2015-2020 Dietary Guideline American (DGA) recommendations (Krebs-Smith et al., 2018). Although previous studies have demonstrated an inverse association between adherence to the healthy dietary pattern, measured by HEI, and depression in adults (Kuczmarski et al., 2010, Saneei et al., 2016, Wang et al., 2021), there are limited data for adolescents. Given the high prevalence of depression among Iranian adolescent girls (Moeini et al., 2019, Sajjadi et al., 2013), and its high socio-economic and health impact, the current study was designed to investigate the association between HEI-2015 and depression among Iranian adolescent girls.
Materials and Methods
Population and sampling: This cross-sectional study carried out on 734 adolescent girls aged 12-18 years in 2015. Participants were recruited from schools in the cities of Mashhad and Sabzevar, in northeastern Iran. Students who had no history of chronic disease (e.g. colitis, diabetes, cardiovascular diseases, cancer, and hepatitis) were included in the study. Moreover, participants were excluded if they were taking any medication related to anti-inflammatory, anti-depressant, anti-diabetic, or anti-obesity drugs, vitamin D or calcium supplement use, and hormone therapy during the past 6 months. Informed consent was obtained from the students and their parents. The study was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran (Ethic code: 931188).
Dietary assessment and HEI-2015 score computation: Dietary intakes of participants were collected using a valid and reliable food frequency questionnaire (FFQ), containing 168 food items (Esfahani et al., 2010). The US Department of Agriculture’s (USDA) data bank was used for analyzing nutrient intakes of each item (Pehrsson et al., 2000). Overall diet quality was assessed using HEI-2015. The HEI-2015 is designed with a score range of 0 to 100 and includes thirteen dietary components including total fruits, whole fruits, total vegetables, greens and beans, whole grains, dairy, total protein foods, seafood and plant proteins, fatty acids, refined grains, sodium, added sugars, and saturated fats. The first nine items are adequacy components and the last four items are moderation components.
Assessment of outcomes: Depression was assessed using the Persian version of the Beck Depression Inventory (BDI). BDI is a 21-items self-administered questionnaire that each item has different options and its total score ranged from 0 to 63 points. If the score was >13, the person was classified as depressed, and if the score was <13, the person was considered as not depressed. Previous studies have confirmed the validity and reliability of this questionnaire (Cronbach’s α=0.87 and acceptable test-retest reliability (r)=0.74) (Bonnet et al., 2005, Ghassemzadeh et al., 2005, Norrby, 2002).
Covariate assessment: Demographic data (including age, family members, parental death or divorce, medical history, using supplements, smoking status, menstrual status, a positive history of mental therapy, and chronic diseases) were collected by experienced interviewers. Also, weight, height, waist circumferences (WC), and blood pressure measures were gathered according to standard protocol. All measurements were performed twice and their mean scores were reported. Body mass index (BMI) was calculated as weight in kilograms divided by height in meters squared. Physical activity level was obtained using the validated modifiable activity questionnaire (MAQ), based on metabolic equivalent task (MET) minutes per week (Delshad et al., 2015).
Ethical considerations: This study was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran (Ethic code: 931188). All methods of the current study were performed in accordance with the Declaration of Helsinki, and all students and their parents completed the informed written consent.
Data analyses: The participants were categorized based on the HEI-2015 quartiles score. To compare general characteristics and dietary intakes across quartiles of HEI-2015, one-way ANOVA and Ch-square tests were used. Age and energy-adjusted intakes of nutrients and food groups within quartiles of HEI-2015 were calculated using one-way ANOVA. To find the association between HEI-2015 and odds of depression, logistic regression was examined in different models. First, the reserchers controlled for age and energy intake. The additional adjustment was carried out for physical activity and BMI in the second and third models. To calculate the trend of OR, HEI-2015 quartiles were considered as an ordinal variable and the first quartile was designated as the reference category. In accordance with quartile categories of HEI-2015, for continuous and dichotomous variables, Ptrend was determined by regression coefficient and logistic regression, respectively. Significance was set at two-tailed P-value<0.05 for all analyses. Statistical analyses were conducted using the statistical package for social sciences (SPSS), version 23.
Results
The mean age of the subjects was 14.51±1.53 years. The prevalence of depression with a high BDI score in the study population was 33.8%. The main characteristics of the participants according to quartile categories of HEI-2015 are provided in Table 1. Adolescents in the highest quartile of HEI-2015 were more likely to be younger and less depressed, compared to those in the lowest quartile. There were no significant differences in family members, parental death and divorce, being passive smoker, physical activity, and BMI percentile across categories of HEI-2015.
Adjusted intakes of several nutrients and food groups across HEI-2015 quartiles are presented in Table 2. The energy intake from saturated fatty acid and added sugars, and also intake of sodium and refined grains declined significantly across HEI-2015 quartiles. A greater adherence to the HEI-2015 was associated with higher consumption of cholesterol, n-3 fatty acids, vitamin B6, total fruits, whole fruits, total vegetables, greens and beans, whole grains, total protein foods, and seafood and plant proteins.
When depression was considered as a dichotomous variable, adolescents with the highest adherence to HEI-2015 had significantly 37% lower odds of depression compared to those with the lowest adherence (OR: 0.63; 95% CI 0·41, 0·99, Ptrend = 0.03) (Table 3). After adjusting the effect of age and energy received in the first model, as well as further adjustments for physical activity and BMI in the second and third models, the observed relationship did not change considerably (OR: 0.62, 95 % CI 0.40-0.98, Ptrend = 0.02, OR: 0.62, 95% CI 0.40-0.98, Ptrend = 0.02 and OR: 0.63, 95% CI 0.40-1.00, Ptrend=0.03, respectively).
| Table 1. General characteristics of the participants according to quartile categories of the HEI-2015. | |||||||
| Variables | HEI-2015 quartile category | ||||||
| 1 (n=183) | 2 (n=184_ | 3 (n=184) | 4 (183) | P-valuea | |||
| HEI-2015 score (median) | 62.12 | 70.86 | 76.90 | 83.36 | ˂0.001 | ||
| BMI percentile | <25 | 37 (20.2)b | 29 (15.8) | 31 (16.8) | 22 (12.0) | 0.02 |
|
| 25-50 | 41 (22.4) | 38 (20.7) | 50 (27.2) | 47 (25.7) | |||
| 50-85 | 82 (44.8) | 82 (44.6) | 63 (34.2) | 66 (36.1) | |||
| ≥85 | 23 (12.6) | 35 (19.0) | 40 (21.7) | 48 (26.2) | |||
| Family members | 2-4 | 79 (43.2) | 87 (47.3) | 82 (44.6) | 93 (50.8) | 0.54 | |
| 5-7 | 98 (53.6) | 90 (48.9) | 96 (52.2) | 87 (47.5) | |||
| 8-10 | 5 (2.7) | 6 (3.3) | 4 (2.2) | 1 (0.5) | |||
| >11 | 1 (0.5) | 1 (0.5) | 2 (1.1) | 2 (1.1) | |||
| Parent death (yes) | 8 (4.4) | 10 (5.4) | 7 (3.8) | 4 (2.2) | 0.52 | ||
| Parent divorce (yes) | 7 (3.8) | 13 (7.1) | 8 (4.3) | 7 (3.8) | 0.76 | ||
| Passive smoker (yes) | None | 153 (83.6) | 149 (81.0) | 148 (80.4) | 144 (78.7) | 0.65 | |
| ˂ 1h | 13 (7.1) | 22 (12.0) | 22 (12.0) | 27 (14.8) | |||
| 1-3h | 8 (4.4) | 6 (3.3) | 7 (3.8) | 4 (2.2) | |||
| >3h | 9 (4.9) | 7 (3.8) | 7 (3.8) | 8 (4.4) | |||
| Age (years) | 14.88±1.50c | 14.46±1.52 | 14.49±1.46 | 14.21±1.59 | ˂0.001 | ||
| Physical activity score (MET) | 45.45±3.30 | 45.11±3.17 | 45.41±3.24 | 45.52±4.03 | 0.68 | ||
| Depression score, mean | 11.97±9.60 | 11.76±10.16 | 10.52±8.75 | 9.48±8.32 | 0.03 | ||
| a: ANCOVA for quantitative variables and Chi-square for qualitative variables; b: N (%); c: Mean±SD; MET: Metabolic equivalents | |||||||
| Table 2. Mean (SE) dietary intake of participants across HEI-2015 quartile categoriesa | ||||||||||||||
| Variables | Mean± SD Overall | HEI-2015 quartile category | ||||||||||||
| 1 | 2 | 3 | 4 | P-trendb | ||||||||||
| Mean | SE | Mean | SE | Mean | SE | Mean | SE | |||||||
| Total energy(kcal/d)c | 2713±831 | 2459.3 | 61.0 | 2774.9 | 60.4 | 2831.3 | 60.3 | 2789.1 | 60.84 | ˂0.001 | ||||
| Nutrients | ||||||||||||||
| Carbohydrate (% of energy intake) | 52.78±7.03 | 52.29 | 0.53 | 52.40 | 0.52 | 53.20 | 0.52 | 53.24 | 0.52 | 0.17 | ||||
| Protein (% of energy intake) | 13.09±2.14 | 12.37 | 0.16 | 12.89 | 0.15 | 13.37 | 0.15 | 13.75 | 0.15 | ˂0.001 | ||||
| Fat (% of energy intake) | 33.22±7.56 | 33.81 | 0.56 | 33.70 | 0.55 | 32.74 | 0.55 | 32.65 | 0.56 | 0.12 | ||||
| Saturated fats (% of energy intake) | 9.92±2.97 | 10.86 | 0.22 | 10.11 | 0.21 | 9.60 | 0.21 | 9.12 | 0.22 | ˂0.001 | ||||
| Added sugars (% of energy intake) | 5.06±3.17 | 5.41 | 0.24 | 5.25 | 0.23 | 4.90 | 0.23 | 4.69 | 0.23 | 0.003 | ||||
| n-3 Fatty acids (g/d) | 1.53±0.90 | 1.39 | 0.06 | 1.50 | 0.05 | 1.50 | 0.05 | 1.74 | 0.05 | ˂0.001 | ||||
| Cholesterol (mg) | 237.9±137.5 | 232.71 | 9.41 | 239.93 | 9.22 | 237.60 | 9.23 | 241.48 | 9.29 | 0.02 | ||||
| Sodium (mg) | 4185±1761 | 4651.42 | 98.06 | 4247.54 | 96.03 | 4235.90 | 96.19 | 3605.70 | 96.77 | ˂0.001 | ||||
| Vitamin B6 (mg/d) | 1.92±0.65 | 1.79 | 0.03 | 1.90 | 0.03 | 1.98 | 0.03 | 1.99 | 0.03 | ˂0.001 | ||||
| Food groups | ||||||||||||||
| Total Fruits (cup/d) | 1.67±1.44 | 1.20 | 0.10 | 1.46 | 0.09 | 1.73 | 0.09 | 2.31 | 0.10 | ˂0.001 | ||||
| Whole Fruits (cup/d) | 1.58±1.32 | 1.12 | 0.09 | 1.40 | 0.09 | 1.63 | 0.09 | 2.16 | 0.09 | ˂0.001 | ||||
| Total Vegetables (cup/d) | 2.84±1.67 | 2.55 | 0.11 | 2.70 | 0.11 | 3.04 | 0.11 | 3.09 | 0.11 | ˂0.001 | ||||
| Greens and Beans (cup/d) | 0.82±0.56 | 0.70 | 0.04 | 0.73 | 0.04 | 0.89 | 0.04 | 0.98 | 0.04 | ˂0.001 | ||||
| Whole grains (oz/d) | 7.56±6.08 | 6.08 | 0.45 | 7.12 | 0.44 | 8.62 | 0.44 | 8.41 | 0.44 | ˂0.001 | ||||
| Refine grains (oz/d) | 5.18±3.37 | 7.29 | 0.22 | 5.54 | 0.22 | 4.22 | 0.22 | 3.67 | 0.22 | ˂0.001 | ||||
| Dairy products (cup/d) | 1.95±1.27 | 2.01 | 0.09 | 1.84 | 0.09 | 2.03 | 0.09 | 1.93 | 0.09 | 0.86 | ||||
| Total protein foods (ozeq/d) | 5.15±3.04 | 4.16 | 0.19 | 5.18 | 0.19 | 5.26 | 0.19 | 6.01 | 0.19 | ˂0.001 | ||||
| Seafood and plant proteins (oz/d) | 3.13±2.51 | 2.38 | 0.17 | 3.03 | 0.16 | 3.27 | 0.16 | 3.83 | 0.16 | ˂0.001 | ||||
| a: Energy intake is adjusted for age, and all other values are adjusted for age and energy intake; b: P-value for trend was determined using linear regression; c: Obtained from ANCOVA. | ||||||||||||||
| Table 3. Odds ratio (95% CI) for depression score across quartile categories of HEI-2015. | |||||
| Quartiles of HEI-2015 score | P-trend b | ||||
| 1 | 2 | 3 | 4 | ||
| Depressiona | |||||
| Crude | 1 | 1.09 (0.71-1.66) | 0.86 (0.56-1.32) | 0.63 (0.41-0.99) | 0.03 |
| Model I | 1 | 1.07 (0.70-1.65) | 0.85 (0.55-1.31) | 0.62 (0.40-0.98) | 0.02 |
| Model II | 1 | 1.08 (0.70-1.65) | 0.85 (0.55-1.31) | 0.62 (0.40-0.98) | 0.02 |
| Model III | 1 | 1.09 (0.71-1.67) | 0.85 (0.55-1.32) | 0.63 (0.40-1.00) | 0.03 |
| a : Model I: Adjustment for age and energy intakes, Model II: Further adjustment for physical activity, Model III: Additional adjustments for BMI percentile; b : P-value for trend determined using logistic regression. | |||||
Discussion
Depression in adolescents has been independently related to a reduced quality of life and educational achievements, affected social behaviors, and increased risk of some health problems such as diabetes and obesity (Gladstone and Beardslee, 2009, Lasserre et al., 2017). Therefore, depression can impose a considerable burden on the healthcare system (World Health Organization, 2019). Improvement in the diet may play a role in the prevention of this disorder (Pano et al., 2021). The present study demonstrated an inverse association between adherence to HEI-2015 and the odds of developing depression in Iranian adolescents. After adjustment for potential confounders including age, energy intakes, physical activity, and BMI, the observed association remained significant.
Some studies have examined the association between dietary indices and depression in adults . Wang et al. reported that people with 70 or higher HEI-2015 score had 55% lower odds for developing depression (Wang et al., 2021). Another study suggested that long-term adherence to HEI-2010 protects against recurrent depressive symptoms (Recchia et al., 2020). Sanei et al. found a 45% reduction in depression odds by adherence to the AHEI-2010 in Iranian adults (Saneei et al., 2016). In army soldiers, the highest concordance with AHEI-2010 was associated with an 80% lower risk of depression (Rahmani et al., 2018). It has been also shown that adherence to the Mediterranean diet was associated with a 45% lower risk of moderate to severe depressive symptoms (Oddo et al., 2022). However, some studies reported no association between diet quality (based on AHEI and HEI-2005) and symptoms of depression (Exebio et al., 2011, Whitaker et al., 2014). In adolescents, greater adherence to a Dietary Approach to Stop Hypertension (DASH) diet was related to lower odds of depression (by 53%) (Khayyatzadeh et al., 2018), while the Mediterranean diet was not associated with depressive symptoms (Winpenny et al., 2018).
In adults, a lower risk of depression was associated with a diet rich in fruits, vegetables, fish, whole grains, and olive oil, moderate in red and processed meat, low percent of calories from saturated fats and sugars, and low intake of sodium (Appelhans et al., 2012, Kuczmarski et al., 2010, Tarelho et al., 2016, Vermeulen et al., 2016). On the other hand, it has been shown that depressed people eat more fast foods, are more involved in emotional eating, and prefer sweet food (Paans et al., 2019). It has not yet been determined whether depressive symptoms lead to more sugar and saturated fat intake or conversely, sugar and saturated fat intake leads to more depressive symptoms, or whether this is a two-way association. In addition, the preparation of unhealthy food is usually quicker and easier than healthy ones and requires less time and skill to cook (Gibson-Smith et al., 2018). The mood and motivation of depressed people are usually low and they prefer food types that are easier and faster to prepare, like fast foods (Gibson-Smith et al., 2018).
There are several mechanisms to explain the inverse relationship between HEI-2015 and depression. It has been suggested that factors such as oxidative stress, insulin resistance, inflammation, and changes in vascularization could lead to brain damage (Sarris et al., 2015). All of these factors, modified by dietary intake, have been related to depression (Sarris et al., 2015). Adherence to HEI-2015 results in high levels of antioxidants such as folate and vitamin E that could protect the nervous system from degenerative effects of inflammation and oxidative stress (Jiménez-Fernández et al., 2015). Moreover, this index paid attention to the intake of seafood and unsaturated fatty acids such as omega-3 (Krebs-Smith et al., 2018). Omega-3 fatty acids are one of the major components of synaptic nerve membranes and have a considerable role in neurotransmitter function, especially serotonin and dopamine (McNamara, 2016). The association between omega-3 fatty acids and depression symptoms may be explained by its neuroprotective effect.
The current study has some strengths. To the best of the auhors’ knowledge, it is the first study, which has investigated the relationship between adherence to specific diet-related practices and the prevalence of depression in Iranian adolescents. The second strength point was the high quality of data collection. In addition, to avoid misleading conclusions in the analysis and interpretation of data, rigorous statistical analyses were conducted, including several adjustment models for confounding factors for depression. However, some limitations should be noted when interpreting the findings. The cross-sectional design of this study does not allow us to determine the direction of the relationship between depression and diet quality and causative effects. Prospective cohort studies should be conducted to investigate the causal relationship. The validated FFQ assessed usual dietary intakes (Esfahani et al., 2010). However, it should be borne in mind that measuring food intake based on this questionnaire is memory dependent and this can lead to recall bias. In addition, depression was assessed by a self-administered questionnaire, BDI, and there was no specialized diagnosis of depression, which might lead to incorrect classification of study participants.
Conclusion
This study suggests that a greater adherence to HEI-2015 was associated with lower odds of depression in adolescents. These findings need to be confirmed with prospective studies and trials to clarify the causal association and determine the dose-response curve between diet quality and risk of depression. However, because of the complications and costs associated with treating depression in adolescents, its prevention is important.
Acknowledgment
This research was funded by Mashhad University of Medical Sciences. The authors are grateful to all study participants, volunteers.
Conflict of interests
The authors declare that they have no conflict of interest.
Authors’ contributions
The paper was drafted by Mohseni-Takalloo S and Salehi-Abargouei A with contributions from all authors. SS. Khayyatzadeh, Ferns GA, and Ghayour-Mobarhan M designed the study. Ferns GA, and Khayyatzadeh SS participated in field implementation and sampling. Ferns GA, Ghayour-Mobarhan M, and Khayyatzadeh SS were involved in clinical examination and patient confirmation. Mohseni-Takalloo S and Salehi-Abargouei A contributed to statistical analyses. Khayyatzadeh SS, and Ghayour-Mobarhan M supervised the study. All authors contributed to developing,reading, and approving the final version of the manuscript.
References
Appelhans BM, et al. 2012. Depression severity, diet quality, and physical activity in women with obesity and depression. Journal of the academy of nutrition and dietetics. 112 (5): 693-698.
Bonnet F, et al. 2005. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. Atherosclerosis. 178 (2): 339-344.
Cespedes EM & Hu FB 2015. Dietary patterns: from nutritional epidemiologic analysis to national guidelines–. American journal of clinical nutrition. 101 (5): 899-900.
Delshad M, et al. 2015. Reliability and validity of the modifiable activity questionnaire for an Iranian urban adolescent population. International journal of preventive medicine. 6 (3).
Esfahani FH, Asghari G, Mirmiran P & Azizi F 2010. Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. Journal of epidemiology. 20 (2): 150-158.
Exebio JC, Zarini GG, Exebio C & Huffman FG 2011. Healthy Eating Index scores associated with symptoms of depression in Cuban-Americans with and without type 2 diabetes: a cross sectional study. Nutrition journal. 10 (1): 135-141.
Ghassemzadeh H, Mojtabai R, Karamghadiri N & Ebrahimkhani N 2005. Psychometric properties of a Persian‐language version of the Beck Depression Inventory-Second edition: BDI-II-PERSIAN. Depression and anxiety. 21 (4): 185-192.
Gibson-Smith D, Bot M, Brouwer IA, Visser M & Penninx BW 2018. Diet quality in persons with and without depressive and anxiety disorders. Journal of psychiatric research. 106: 1-7.
Gladstone TR & Beardslee WR 2009. The prevention of depression in children and adolescents: A review. Canadian journal of psychiatry. 54 (4): 212-221.
Jiménez-Fernández S, et al. 2015. Oxidative stress and antioxidant parameters in patients with major depressive disorder compared to healthy controls before and after antidepressant treatment: results from a meta-analysis. Journal of clinical psychiatry. 76 (12): 13705.
Khayyatzadeh SS, et al. 2018. Adherence to a Dash-style diet in relation to depression and aggression in adolescent girls. Psychiatry research. 259: 104-109.
Khayyatzadeh SS, et al. 2021. Dietary antioxidants and fibre intake and depressive symptoms in Iranian adolescent girls. Public health nutrition. 24 (17): 5650-5656.
Krebs-Smith SM, et al. 2018. Update of the healthy eating index: HEI-2015. Journal of the academy of nutrition and dietetics. 118 (9): 1591-1602.
Kuczmarski MF, et al. 2010. Higher Healthy Eating Index-2005 scores associated with reduced symptoms of depression in an urban population: findings from the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) study. Journal of the American dietetic association. 110 (3): 383-389.
Lasserre A, et al. 2017. Prospective associations of depression subtypes with cardio-metabolic risk factors in the general population. Molecular psychiatry. 22 (7): 1026-1034.
Li D, Liang H, Tong Y, Zheng H & Li Y 2020. Association between saturated fatty acid intake and depressive symptoms in midlife women: A prospective study. Journal of affective disorders. 267: 17-22.
McNamara RK 2016. Role of omega-3 fatty acids in the etiology, treatment, and prevention of depression: current status and future directions. Journal of nutrition & intermediary metabolism. 5: 96-106.
Moeini B, Bashirian S, Soltanian AR, Ghaleiha A & Taheri M 2019. Prevalence of depression and its associated sociodemographic factors among Iranian female adolescents in secondary schools. BMC psychology. 7 (1): 1-11.
Norrby K 2002. Mast cells and angiogenesis. Apmis. 110 (5): 355-371.
Oddo VM, et al. 2022. Adherence to a Mediterranean Diet Is Associated with Lower Depressive Symptoms among US Adults. Nutrients. 14 (2): 278.
Opie R, et al. 2017. Dietary recommendations for the prevention of depression. Nutritional neuroscience. 20 (3): 161-171.
Paans NP, et al. 2019. Depression and eating styles are independently associated with dietary intake. Appetite. 134: 103-110.
Pano O, et al. 2021. Healthy diet, depression and quality of life: A narrative review of biological mechanisms and primary prevention opportunities. World journal of psychiatry. 11 (11): 997.
Pehrsson P, Haytowitz D, Holden J, Perry C & Beckler D 2000. USDA's national food and nutrient analysis program: food sampling. Journal of food composition and analysis. 13 (4): 379-389.
Rahmani J, Milajerdi A & Dorosty-Motlagh A 2018. Association of the Alternative Healthy Eating Index (AHEI-2010) with depression, stress and anxiety among Iranian military personnel. Journal of the royal army medical corps. 164 (2): 87-91.
Recchia D, et al. 2020. Associations between long-term adherence to healthy diet and recurrent depressive symptoms in Whitehall II Study. European journal of nutrition. 59 (3): 1031-1041.
Sajjadi H, et al. 2013. A systematic review of the prevalence and risk factors of depression among iranian adolescents. Global journal of health science. 5 (3): 16-27.
Saneei P, et al. 2016. Adherence to Alternative Healthy Eating Index in relation to depression and anxiety in Iranian adults. British journal of nutrition. 116 (2): 335-342.
Sarris J, et al. 2015. Nutritional medicine as mainstream in psychiatry. Lancet Psychiatry. 2 (3): 271-274.
Tarelho A, Duarte M, Melim J, Batista A & Almeida S 2016. Dietary pattern and mental health: review of literature. European psychiatry. 33: S517.
Turan E & Karaaslan O 2020. The relationship between iodine and selenium levels with anxiety and depression in patients with euthyroid nodular goiter. Oman medical journal. 35 (4): e161.
Van Dael P 2021. Role of n-3 long-chain polyunsaturated fatty acids in human nutrition and health: review of recent studies and recommendations. Nutrition research and practice. 15 (2): 137-159.
van Zoonen K, et al. 2014. Preventing the onset of major depressive disorder: a meta-analytic review of psychological interventions. International journal of epidemiology. 43 (2): 318-329.
Vermeulen E, et al. 2016. The association between dietary patterns derived by reduced rank regression and depressive symptoms over time: the Invecchiare in Chianti (InCHIANTI) study. British journal of nutrition. 115 (12): 2145-2153.
Wang J, Um P, Dickerman BA & Liu J 2018. Zinc, magnesium, selenium and depression: a review of the evidence, potential mechanisms and implications. Nutrients. 10 (5): 584.
Wang K, et al. 2021. Higher HEI-2015 score is associated with reduced risk of depression: result from NHANES 2005–2016. Nutrients. 13 (2): 348.
Whitaker KM, Sharpe PA, Wilcox S & Hutto BE 2014. Depressive symptoms are associated with dietary intake but not physical activity among overweight and obese women from disadvantaged neighborhoods. Nutrition research. 34 (4): 294-301.
Winpenny EM, van Harmelen A-L, White M, van Sluijs EM & Goodyer IM 2018. Diet quality and depressive symptoms in adolescence: no cross-sectional or prospective associations following adjustment for covariates. Public health nutrition. 21 (13): 2376-2384.
World Health Organization 2019. Mental health, https:// www.who.int/ health-topics/mental-health#tab=tab_2.
Wu P-Y, Lin M-Y & Tsai P-S 2018. Alternate healthy eating index and risk of depression: A meta-analysis and systemematic review. Nutritional neuroscience. 1-9.
Wu Y, Zhang L, Li S & Zhang D 2021. Associations of dietary vitamin B1, vitamin B2, vitamin B6, and vitamin B12 with the risk of depression: a systematic review and meta-analysis. Nutrition reviews.
Depression in adolescents has been independently related to a reduced quality of life and educational achievements, affected social behaviors, and increased risk of some health problems such as diabetes and obesity (Gladstone and Beardslee, 2009, Lasserre et al., 2017). Therefore, depression can impose a considerable burden on the healthcare system (World Health Organization, 2019). Improvement in the diet may play a role in the prevention of this disorder (Pano et al., 2021). The present study demonstrated an inverse association between adherence to HEI-2015 and the odds of developing depression in Iranian adolescents. After adjustment for potential confounders including age, energy intakes, physical activity, and BMI, the observed association remained significant.
Some studies have examined the association between dietary indices and depression in adults . Wang et al. reported that people with 70 or higher HEI-2015 score had 55% lower odds for developing depression (Wang et al., 2021). Another study suggested that long-term adherence to HEI-2010 protects against recurrent depressive symptoms (Recchia et al., 2020). Sanei et al. found a 45% reduction in depression odds by adherence to the AHEI-2010 in Iranian adults (Saneei et al., 2016). In army soldiers, the highest concordance with AHEI-2010 was associated with an 80% lower risk of depression (Rahmani et al., 2018). It has been also shown that adherence to the Mediterranean diet was associated with a 45% lower risk of moderate to severe depressive symptoms (Oddo et al., 2022). However, some studies reported no association between diet quality (based on AHEI and HEI-2005) and symptoms of depression (Exebio et al., 2011, Whitaker et al., 2014). In adolescents, greater adherence to a Dietary Approach to Stop Hypertension (DASH) diet was related to lower odds of depression (by 53%) (Khayyatzadeh et al., 2018), while the Mediterranean diet was not associated with depressive symptoms (Winpenny et al., 2018).
In adults, a lower risk of depression was associated with a diet rich in fruits, vegetables, fish, whole grains, and olive oil, moderate in red and processed meat, low percent of calories from saturated fats and sugars, and low intake of sodium (Appelhans et al., 2012, Kuczmarski et al., 2010, Tarelho et al., 2016, Vermeulen et al., 2016). On the other hand, it has been shown that depressed people eat more fast foods, are more involved in emotional eating, and prefer sweet food (Paans et al., 2019). It has not yet been determined whether depressive symptoms lead to more sugar and saturated fat intake or conversely, sugar and saturated fat intake leads to more depressive symptoms, or whether this is a two-way association. In addition, the preparation of unhealthy food is usually quicker and easier than healthy ones and requires less time and skill to cook (Gibson-Smith et al., 2018). The mood and motivation of depressed people are usually low and they prefer food types that are easier and faster to prepare, like fast foods (Gibson-Smith et al., 2018).
There are several mechanisms to explain the inverse relationship between HEI-2015 and depression. It has been suggested that factors such as oxidative stress, insulin resistance, inflammation, and changes in vascularization could lead to brain damage (Sarris et al., 2015). All of these factors, modified by dietary intake, have been related to depression (Sarris et al., 2015). Adherence to HEI-2015 results in high levels of antioxidants such as folate and vitamin E that could protect the nervous system from degenerative effects of inflammation and oxidative stress (Jiménez-Fernández et al., 2015). Moreover, this index paid attention to the intake of seafood and unsaturated fatty acids such as omega-3 (Krebs-Smith et al., 2018). Omega-3 fatty acids are one of the major components of synaptic nerve membranes and have a considerable role in neurotransmitter function, especially serotonin and dopamine (McNamara, 2016). The association between omega-3 fatty acids and depression symptoms may be explained by its neuroprotective effect.
The current study has some strengths. To the best of the auhors’ knowledge, it is the first study, which has investigated the relationship between adherence to specific diet-related practices and the prevalence of depression in Iranian adolescents. The second strength point was the high quality of data collection. In addition, to avoid misleading conclusions in the analysis and interpretation of data, rigorous statistical analyses were conducted, including several adjustment models for confounding factors for depression. However, some limitations should be noted when interpreting the findings. The cross-sectional design of this study does not allow us to determine the direction of the relationship between depression and diet quality and causative effects. Prospective cohort studies should be conducted to investigate the causal relationship. The validated FFQ assessed usual dietary intakes (Esfahani et al., 2010). However, it should be borne in mind that measuring food intake based on this questionnaire is memory dependent and this can lead to recall bias. In addition, depression was assessed by a self-administered questionnaire, BDI, and there was no specialized diagnosis of depression, which might lead to incorrect classification of study participants.
Conclusion
This study suggests that a greater adherence to HEI-2015 was associated with lower odds of depression in adolescents. These findings need to be confirmed with prospective studies and trials to clarify the causal association and determine the dose-response curve between diet quality and risk of depression. However, because of the complications and costs associated with treating depression in adolescents, its prevention is important.
Acknowledgment
This research was funded by Mashhad University of Medical Sciences. The authors are grateful to all study participants, volunteers.
Conflict of interests
The authors declare that they have no conflict of interest.
Authors’ contributions
The paper was drafted by Mohseni-Takalloo S and Salehi-Abargouei A with contributions from all authors. SS. Khayyatzadeh, Ferns GA, and Ghayour-Mobarhan M designed the study. Ferns GA, and Khayyatzadeh SS participated in field implementation and sampling. Ferns GA, Ghayour-Mobarhan M, and Khayyatzadeh SS were involved in clinical examination and patient confirmation. Mohseni-Takalloo S and Salehi-Abargouei A contributed to statistical analyses. Khayyatzadeh SS, and Ghayour-Mobarhan M supervised the study. All authors contributed to developing,reading, and approving the final version of the manuscript.
References
Appelhans BM, et al. 2012. Depression severity, diet quality, and physical activity in women with obesity and depression. Journal of the academy of nutrition and dietetics. 112 (5): 693-698.
Bonnet F, et al. 2005. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. Atherosclerosis. 178 (2): 339-344.
Cespedes EM & Hu FB 2015. Dietary patterns: from nutritional epidemiologic analysis to national guidelines–. American journal of clinical nutrition. 101 (5): 899-900.
Delshad M, et al. 2015. Reliability and validity of the modifiable activity questionnaire for an Iranian urban adolescent population. International journal of preventive medicine. 6 (3).
Esfahani FH, Asghari G, Mirmiran P & Azizi F 2010. Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. Journal of epidemiology. 20 (2): 150-158.
Exebio JC, Zarini GG, Exebio C & Huffman FG 2011. Healthy Eating Index scores associated with symptoms of depression in Cuban-Americans with and without type 2 diabetes: a cross sectional study. Nutrition journal. 10 (1): 135-141.
Ghassemzadeh H, Mojtabai R, Karamghadiri N & Ebrahimkhani N 2005. Psychometric properties of a Persian‐language version of the Beck Depression Inventory-Second edition: BDI-II-PERSIAN. Depression and anxiety. 21 (4): 185-192.
Gibson-Smith D, Bot M, Brouwer IA, Visser M & Penninx BW 2018. Diet quality in persons with and without depressive and anxiety disorders. Journal of psychiatric research. 106: 1-7.
Gladstone TR & Beardslee WR 2009. The prevention of depression in children and adolescents: A review. Canadian journal of psychiatry. 54 (4): 212-221.
Jiménez-Fernández S, et al. 2015. Oxidative stress and antioxidant parameters in patients with major depressive disorder compared to healthy controls before and after antidepressant treatment: results from a meta-analysis. Journal of clinical psychiatry. 76 (12): 13705.
Khayyatzadeh SS, et al. 2018. Adherence to a Dash-style diet in relation to depression and aggression in adolescent girls. Psychiatry research. 259: 104-109.
Khayyatzadeh SS, et al. 2021. Dietary antioxidants and fibre intake and depressive symptoms in Iranian adolescent girls. Public health nutrition. 24 (17): 5650-5656.
Krebs-Smith SM, et al. 2018. Update of the healthy eating index: HEI-2015. Journal of the academy of nutrition and dietetics. 118 (9): 1591-1602.
Kuczmarski MF, et al. 2010. Higher Healthy Eating Index-2005 scores associated with reduced symptoms of depression in an urban population: findings from the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) study. Journal of the American dietetic association. 110 (3): 383-389.
Lasserre A, et al. 2017. Prospective associations of depression subtypes with cardio-metabolic risk factors in the general population. Molecular psychiatry. 22 (7): 1026-1034.
Li D, Liang H, Tong Y, Zheng H & Li Y 2020. Association between saturated fatty acid intake and depressive symptoms in midlife women: A prospective study. Journal of affective disorders. 267: 17-22.
McNamara RK 2016. Role of omega-3 fatty acids in the etiology, treatment, and prevention of depression: current status and future directions. Journal of nutrition & intermediary metabolism. 5: 96-106.
Moeini B, Bashirian S, Soltanian AR, Ghaleiha A & Taheri M 2019. Prevalence of depression and its associated sociodemographic factors among Iranian female adolescents in secondary schools. BMC psychology. 7 (1): 1-11.
Norrby K 2002. Mast cells and angiogenesis. Apmis. 110 (5): 355-371.
Oddo VM, et al. 2022. Adherence to a Mediterranean Diet Is Associated with Lower Depressive Symptoms among US Adults. Nutrients. 14 (2): 278.
Opie R, et al. 2017. Dietary recommendations for the prevention of depression. Nutritional neuroscience. 20 (3): 161-171.
Paans NP, et al. 2019. Depression and eating styles are independently associated with dietary intake. Appetite. 134: 103-110.
Pano O, et al. 2021. Healthy diet, depression and quality of life: A narrative review of biological mechanisms and primary prevention opportunities. World journal of psychiatry. 11 (11): 997.
Pehrsson P, Haytowitz D, Holden J, Perry C & Beckler D 2000. USDA's national food and nutrient analysis program: food sampling. Journal of food composition and analysis. 13 (4): 379-389.
Rahmani J, Milajerdi A & Dorosty-Motlagh A 2018. Association of the Alternative Healthy Eating Index (AHEI-2010) with depression, stress and anxiety among Iranian military personnel. Journal of the royal army medical corps. 164 (2): 87-91.
Recchia D, et al. 2020. Associations between long-term adherence to healthy diet and recurrent depressive symptoms in Whitehall II Study. European journal of nutrition. 59 (3): 1031-1041.
Sajjadi H, et al. 2013. A systematic review of the prevalence and risk factors of depression among iranian adolescents. Global journal of health science. 5 (3): 16-27.
Saneei P, et al. 2016. Adherence to Alternative Healthy Eating Index in relation to depression and anxiety in Iranian adults. British journal of nutrition. 116 (2): 335-342.
Sarris J, et al. 2015. Nutritional medicine as mainstream in psychiatry. Lancet Psychiatry. 2 (3): 271-274.
Tarelho A, Duarte M, Melim J, Batista A & Almeida S 2016. Dietary pattern and mental health: review of literature. European psychiatry. 33: S517.
Turan E & Karaaslan O 2020. The relationship between iodine and selenium levels with anxiety and depression in patients with euthyroid nodular goiter. Oman medical journal. 35 (4): e161.
Van Dael P 2021. Role of n-3 long-chain polyunsaturated fatty acids in human nutrition and health: review of recent studies and recommendations. Nutrition research and practice. 15 (2): 137-159.
van Zoonen K, et al. 2014. Preventing the onset of major depressive disorder: a meta-analytic review of psychological interventions. International journal of epidemiology. 43 (2): 318-329.
Vermeulen E, et al. 2016. The association between dietary patterns derived by reduced rank regression and depressive symptoms over time: the Invecchiare in Chianti (InCHIANTI) study. British journal of nutrition. 115 (12): 2145-2153.
Wang J, Um P, Dickerman BA & Liu J 2018. Zinc, magnesium, selenium and depression: a review of the evidence, potential mechanisms and implications. Nutrients. 10 (5): 584.
Wang K, et al. 2021. Higher HEI-2015 score is associated with reduced risk of depression: result from NHANES 2005–2016. Nutrients. 13 (2): 348.
Whitaker KM, Sharpe PA, Wilcox S & Hutto BE 2014. Depressive symptoms are associated with dietary intake but not physical activity among overweight and obese women from disadvantaged neighborhoods. Nutrition research. 34 (4): 294-301.
Winpenny EM, van Harmelen A-L, White M, van Sluijs EM & Goodyer IM 2018. Diet quality and depressive symptoms in adolescence: no cross-sectional or prospective associations following adjustment for covariates. Public health nutrition. 21 (13): 2376-2384.
World Health Organization 2019. Mental health, https:// www.who.int/ health-topics/mental-health#tab=tab_2.
Wu P-Y, Lin M-Y & Tsai P-S 2018. Alternate healthy eating index and risk of depression: A meta-analysis and systemematic review. Nutritional neuroscience. 1-9.
Wu Y, Zhang L, Li S & Zhang D 2021. Associations of dietary vitamin B1, vitamin B2, vitamin B6, and vitamin B12 with the risk of depression: a systematic review and meta-analysis. Nutrition reviews.
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Received: 2021/11/8 | Published: 2023/08/28 | ePublished: 2023/08/28
Received: 2021/11/8 | Published: 2023/08/28 | ePublished: 2023/08/28
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