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 Table of Contents  
Year : 2019  |  Volume : 9  |  Issue : 3  |  Page : 228-235

Associations between dietary patterns and depression and anxiety in middle-aged adults: A large cross-sectional analysis among Iranian manufacturing employees

1 Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapour University of Medical Sciences, Ahvaz, Iran
2 Food Security Research Centre, Isfahan University of Medical Sciences; Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
3 Isfahan Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
4 Isfahan Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences; Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
5 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Web Publication6-Sep-2019

Correspondence Address:
Awat Feizi
Department of Biostatistics and Epidemiology, School of Health, Isfahan University of Medical Sciences, Isfahan
Hamidreza Roohafza
Cardiac Rehabilitation Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AIHB.AIHB_34_19

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Background: Workers have to spend a substantial proportion of their income on foods and despite the high prevalence of stress among them, little is known about the association of dietary patterns and mental health disorders in this group. We examined whether dietary patterns are associated with depression and anxiety risk in the Iranian workers of steel mill company. Materials and Methods: We conducted a cross-sectional study among 3060 workers (2803 males and 260 females) in 2015. Dietary intake was assessed using a validated semiquantitative food frequency questionnaire during the preceding year, and depression and anxiety were evaluated using a Persian-validated Hospital Anxiety and Depression Scale. Major dietary patterns were determined using exploratory factor analysis and the risk of depression and anxiety was assessed across the tertiles of dietary patterns using logistic regression. Results: Three dietary patterns were identified: healthy (loaded by fruit, vegetables and skim dairy products), Western (loaded by processed foods, butter and sweets), and Iranian traditional diet (loaded by refined grains, red meat, poultry and legumes). After adjustment for various confounders, individuals in the highest tertile of healthy diet had lower risk of depression (odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.32, 0.68) and anxiety (OR: 0.71; 95% CI: 0.52, 0.99) compared with those in the first tertile, whilst greater adherence to the Iranian traditional diet was associated with increased risk of depression (OR: 1.82; 95% CI: 1.24, 2.67) and anxiety (OR: 1.50; 95% CI: 1.08, 2.09). The Western-style diet was marginally associated with increased risk of depression, but not anxiety. Conclusion: Overall, we found healthy diet might be associated with decreased risk of depression and anxiety, but the Iranian traditional diet might be associated with increased risk of depression and anxiety. Therefore, to improve public health, Iranian traditional diet should be adjusted according to the healthy diet recommendations.

Keywords: Anxiety, depression, dietary pattern, healthy diet, mental disorders

How to cite this article:
Zakizadeh E, Saraf-Bank S, Haghighatdoost F, Roohafza H, Feizi A, Fazelian S, Sarrafzadegan N. Associations between dietary patterns and depression and anxiety in middle-aged adults: A large cross-sectional analysis among Iranian manufacturing employees. Adv Hum Biol 2019;9:228-35

How to cite this URL:
Zakizadeh E, Saraf-Bank S, Haghighatdoost F, Roohafza H, Feizi A, Fazelian S, Sarrafzadegan N. Associations between dietary patterns and depression and anxiety in middle-aged adults: A large cross-sectional analysis among Iranian manufacturing employees. Adv Hum Biol [serial online] 2019 [cited 2022 Sep 27];9:228-35. Available from: https://www.aihbonline.com/text.asp?2019/9/3/228/266221

  Introduction Top

Among all psychiatry disorders, the anxiety disorders are the most common with a high burden of disease.[1] Major depression is also another common and recurrent psychiatry disorder which adversely affect the quality of life.[2] Both anxiety disorders and depression are closely associated with other mental disorders, medical comorbidity and mortality.[1],[2] Based on the Iranian Mental Health Survey report, depressive disorders, with the prevalence of 12.7%, are the second mental problem after anxiety disorders among the Iranian people.[3]

Although numerous studies have evaluated the association between the intake of individual nutrients and mental disorders, particularly depression, which resulted in the inconsistent findings,[4],[5] studying individual nutrients is challenging because of potential interactions between nutrients. On the other hand, nutrients with the same food sources are closely correlated or even may affect the absorption or metabolism of each other. Therefore, assessing the whole dietary pattern analysis, as a snapshot of whole dietary intakes, have been recommended to consider any potential synergistic or antagonist interaction between nutrients and consequently their relation with disease risk.[6] To date, many studies have evaluated the association between dietary patterns and depression; nevertheless, there are scarce studies on the role of dietary patterns and anxiety. The majority of studies have suggested that a healthier dietary pattern, characterised by high intake of fruit, vegetables and whole grains, is associated with lower risk of depression and anxiety,[7],[8],[9],[10] whereas a Western-style diet, characterised by high intake of sweets, fat, refined grains and low intake of fruits and vegetables, may increase the risk of depression and anxiety.[7],[11]

Given that the association between diet quality and depression might be to some extent affected by demographic and socioeconomic variables,[2],[12] examining such association in different populations would be relevant. In our earlier publications derived from this population, we investigated the association of dietary patterns and mental health profile (a combination of anxiety, depression and psychological distress),[9] as well as the role of stressors in dietary patterns-mental disorders relation using structural equation model.[10] However, to our knowledge, there is no study evaluating the relationship between dietary patterns and depression and anxiety risk among workers having high degrees of stress. Although these persons are exposed to high degrees of job stress, little emphasis has been made about the contributed factors of depression in this specific group of subjects so far. Therefore, the purpose of the present study is to examine the relationship between dietary patterns and depression and anxiety in a relatively large sample size of Iranian steel mill workers.

  Materials and Methods Top


This cross-sectional study was performed among 16,000 Iranian employees in steel mill company in 2015 to assess lifestyle factors as well as individual, familial, occupational and socioeconomical characteristics of the participants.

Inclusion and exclusion criteria

All formal and contractual employees who had at least 1 year of work experience in Isfahan steel mill company were included in our study. Participants who did not answer to a large fraction of questions (>10% of questionnaires' pages, included 37 employees) were excluded from the analysis.

Participants were selected using a multistage random cluster sampling method based on managerial departments and considering the number of employees who worked in each department. From total 16,000 employees of Isfahan mill factory, 800 persons were female. To have a sufficient sample size of women, we invited 280 women to participate in the study. Finally, a total sample size of 3060 participants was included into the statistical analysis. All participants provided written informed consent and the study protocol was approved by the Medical Research Ethics committee of the Isfahan University of Medical Sciences approved the study protocol (research project number: 87115). Detailed information about the methodology has been described elsewhere.[9],[10]

Dietary assessment

Using a semi-quantitative food frequency questionnaire, dietary intakes of participants were assessed during the last year.[13] This questionnaire has 38 predefined food groups, in which similar food items are integrated into one item. The participants reported their foods consumption in a dichotomous form: yes or No. After that, for those foods which had been consumed, participants reported the frequency of consumption per day/week/month or year and explained about the consumed portion sizes. The reported portion sizes were converted to grams/day for each food item using household measures.[14] To compute nutrient intakes of participants, the consumed amounts of foods were analysed by Nutritionist IV software that its nutrients database was based on the USDA national nutrient databank but modified for Iranian foods. To determine dietary patterns, we put similar foods in terms of their nutrients contents in the same group, which led to 38 food groups with similar contents with respect to their nutrients.

Depression and anxiety assessment

A Persian version of Hospital Anxiety and Depression Scale (HADS) that was validated for Iranian population was used to assess the depression and anxiety scores of employees.[15] HADS questionnaire can predict the presence of depression and anxiety, as well as their intensity. The HADS measure anxiety and depression through 14 questions in two subscales. Each question could receive a score of four-point which higher scores indicate higher levels of anxiety and depression. A maximum score of 21 could be retrieved for each section. Scores of 11 and more for each subscale of HADS presents a significant case of depression or anxiety, scores of 8–10 are an indicator for borderline status and scores of 0–7 are considered as the lack of depression or anxiety.

Assessment of other variables

Job Stress Questionnaire (JSQ) designed based on inconsistency between effort and rewards was used to determine the stress levels of employees. JSQ contains 23 questions in three different sections: effort section (6 questions), rewards section (11 questions) and work commitment (6 questions). Effort section provides a score of 6–30 for demands and work requirements. Rewards section evaluates the compensation or stress of participants. The final score of rewards section (ranged from 11 to 55) was obtained from summing up the scores of all questions for each participant. The lower scores of this section is an indicator of lower rewards sense or having more stress at workplace. Effort-Reward-Imbalance (ERI) was calculated by dividing total score of effort section by total score of rewards section.[16] Other variables including age, sex, education, number of family members, smoking status, sleep duration, job type (permanent and shift) and having second job were collected through questionnaire. Body mass index (BMI) was calculated by dividing weight (kg) by height squared (m2). Physical activity levels of participants were assessed through short format of International Physical Activity Questionnaire.[17]

Statistical analysis

Major dietary patterns were determined through factor analysis based on 38 main food groups. Based on the results of scree plot test and eigenvalues >1 and scientific interpretability, factors were selected for the next statistical analysis. Varimax rotation method was used to rotate factors for interpretability of extracted factors. Accordingly, three factors were identified as the main dietary patterns and nominated based on our scientific background and previous studies. Factor scores of each dietary pattern were calculated by regression modelling approach. Factor scores of dietary patterns were categorised in tertiles, and they were used in statistical analysis. To compare the mean values of continuous data either independent sample t-test or one-way analysis of variance (with Tukey's post hoc comparison) was performed. For assessing the distribution of categorical variables, Chi-square test was applied. To determine the associations between dietary patterns and depression and anxiety, multivariable-logistic regression test in crude and several adjusted models was applied. Model I was adjusted for age, sex, education, marital status and number of family members. Model II was additionally adjusted for job type, having second job and sleep duration. Model III was further controlled for BMI, cigarette smoking and physical activity. Further adjustment was made for ERI ratio in Model IV. The first tertile of dietary patterns was considered as the reference group in all analysis. Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS, Inc., Chicago, IL, USA; version 16). P < 0.05 was considered significant in all analyses.

  Results Top

Mean age of the participants was 36.73 ± 7.30 years. [Table 1] shows the general characteristics of 3063 participants (2803 males and 260 females) according to the status of depression and anxiety. Participants without anxiety or depression had higher physical activity levels and slept more compared with those had anxiety or depression. People with anxiety were less likely to be male, and shift workers but had greater family size. Both anxious and depressed subject were more probably to be smoker. No significant differences were found in the educational level, marital status and having second job between participants with and without anxiety and depression symptoms.
Table 1: General characteristics of the study population according to the depression and anxiety statusa

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[Table 2] shows the factor-loading matrixes for extracted dietary patterns. Three dietary patterns were extracted using factor analysis: Western dietary pattern (loaded by beverage, processed meats, organ meat, jam, butter, sweets, cake, cookie, commercial fruit juices, biscuit and mayonnaises), the healthy dietary pattern (loaded by fruit, fresh vegetable and skim dairy products), and the traditional dietary pattern (loaded by refined bread, rice, poultry, red meat and legumes). Three patterns explained 20.17% variance of dietary intakes. Factor loadings <0.2 were not reported.
Table 2: Factor-loading matrix for major dietary patterns

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Distribution of covariates across tertiles of dietary patterns is shown in [Table 3]. Participants who were in top tertile of the Western dietary pattern were younger and had greater BMI and physical activity levels. They were more likely to have second job, be single and smoker compared with those in the first and second tertiles. People with greater adherence to the healthy diet compared with those with lower adherence were older, had greater BMI, family size and physical activity level and were more probably to be male, highly educated, shift workers and married. Individuals in the third tertile of the traditional dietary pattern had lower physical activity level, slept more and were probably to have greater family size, be male, shift workers and smokers in comparison with those in lower tertiles.
Table 3: Distribution of covariates across the tertiles of dietary patternsa

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The results of multivariable logestic regression in crude and adjusted models are presented in [Table 4]. Individuals with higher scores of healthy dietary pattern had lower risk of depression and anxiety in crude and all adjusted models (P < 0.001). Participants in the top tertile of healthy dietary pattern in Model IV had 53% (95% confidence interval [CI]: 0.32, 0.68; P trend <0.001) and 29% (95% CI: 0.52, 0.99; P trend = 0.041) lower risk for depression and anxiety, respectively. No significant relation was observed between adherence to the Western-style diet and depression (tertile 3: odds ratio [OR] =1.37, 95% CI: 0.97, 1.94; P trend = 0.128) and anxiety (tertile 3: OR = 1.18, 95% CI: 0.86, 1.60; P trend = 0.50) in the crude model; however, considering the potential effect of confounders strengthened the association for depression and suggested a marginal increment in the odds of depression in individuals with higher adherence to the Western diet (tertile 3: OR = 1.42, 95% CI: 0.98, 2.06; P trend = 0.095). Regarding the Iranian traditional diet, in the crude model, a trend towards significance was found for depression (tertile 3: OR = 1.19, 95% CI: 1.09, 2.25; P trend = 0.053), which additional adjustment for confounders strengthened it, and in the fully-adjusted model, the risk of depression in the third tertile was 82% greater than those in the first tertile (95% CI: 1.24, 2.67; P trend = 0.008). Higher adherence to the Iranian traditional diet was also associated with increased risk of anxiety either in the crude or all adjusted models (P trend < 0.05).
Table 4: Multivariate-adjusted odds ratios (95% confidence intervals) for depression and anxiety across tertile categories of dietary pattern score

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  Discussion Top

In this large cross-sectional study, we observed that a healthy dietary pattern was associated with reduced risk of depression and anxiety, whereas an Iranian traditional dietary pattern was associated with increased risk of both anxiety and depression after adjustment for various confounders. In spite of a marginal significant increase in the depression risk with higher adherence to the Western dietary pattern, no association was found between Western-style diet and anxiety.

A major public health problem among workers is the high prevalence of depressive symptoms and anxiety[18],[19] which is closely correlated with chronic stress exposure[18] and their socioeconomic status.[12] Therefore, developing some approaches to reduce mental health disorders in this group would be worthwhile. To date, many investigators have studied the association of dietary patterns and mental disorders. Nevertheless, to the best of our knowledge, no study has been run among workers, who not only experience high levels of stress, but also because of their low income, have to spend a substantial proportion of their income on foods, which consequently leads to lower food affordability and diet quality.[20] Therefore, taking into account that, the inverse association between a prudent diet and depression is somewhat mediated by socioeconomic status,[21] further studies are warranted to explore the diet-depression association in this group.

Our findings receive support from earlier observational studies.[7-10,22] However, there are some inconsistences between studies. For example, Vermeulen et al. in a prospective study among middle-aged population showed no association between high-sugar, high-saturated fatty acids dietary pattern and depressive symptoms.[23] Similarly, some other studies failed to reveal any significant association for inflammatory dietary pattern in Italian older adults,[24]a priori healthy diet quality measured by the Australian Recommended Food Score in a cohort of middle-aged Australian women,[25] and dietary patterns derived from principal components analysis in a community-dwelling older Canadians[26] and depressive symptoms. In a cross-sectional analysis, Hosseinzadeh et al. found no significant associations either for lactovegetarian or the Western dietary pattern with depression or anxiety in a large sample of medical university staff in Iran,[27] while in stratified analysis by sex or BMI; they found that associations are different in subgroups. In another large population-based study, men with higher scores of a healthy diet were more likely to be anxious, whereas women were less likely to be anxious or depressed.[28] Compared with these studies, our study population was younger and included both men and women with low socioeconomic status which may lead to the inconsistency between our results and other studies.

The association between a healthy or Western dietary pattern and mental disorders risk might be attributable to their effects on inflammation and oxidative stress. There is evidence indicating that a Western-style diet characterised by high intakes of energy, sugar, protein and fat has pro-inflammatory and oxidative properties.[29],[30] Increased reactive oxygen species (ROS), following consuming a poor diet, can induce low-grade inflammation,[31] and consequently cause apoptosis and cerebral atrophy, especially in the hippocampus[32],[33],[34] which is associated with increased risk of depression.[35] Conversely, a healthy diet by reducing ROS and inflammation, besides its high contents of essential nutrients for neural function, e.g., zinc and magnesium, can decrease risk of mental disorders.[36],[37],[38]

In the present study, we observed that a traditional Iranian dietary pattern was associated with increased risk of anxiety and depression. This association can be attributed to its unhealthy food components such as foods with high glycemic index (rice, bread and potato) and high saturated and transfatty acids (high-fat milk and yogurt, red meat, chicken, French fries and restaurant foods). There is evidence indicating a direct association between a diet high in glycemic index and depression and anxiety risk among Iranians.[39] In addition, a nationally representative population among American adults revealed that higher serum concentrations of elaidic acid, a major transfatty acid, was positively associated with the risk of depression.[40] Similarly, a cross-sectional study among Japanese workers showed a positive correlation between serum palmitic acid and depressive symptoms.[41] The association of dietary glycemic index and saturated and transfatty acids with anxiety and depression might be because of their adverse effect on inflammatory processes.[42],[43]

The main limitation of the present study was its cross-sectional design which could not provide any evidence of causality. On the other hand, it is possible that participants with greater depressive syndromes and stress had more tendency towards emotional eating and consuming a poor diet.[44],[45] Subjectivity of the decisions in factor analyses might influence our results. Although we tried to run appropriate statistical analyses and adjusted all known and measured confounders, the potential effect of residual or unknown confounding variables might attenuate the observed relationships. Moreover, a recent meta-analysis of prospective cohort studies suggested a null association between diet quality and depression incidence in studies which assessed depression using diagnostic criteria, whereas in studies which used symptom severity scales, an inverse association was found between a high-quality diet and depression.[46] Therefore, giving that, we assessed depression and anxiety using HADS which only measures the symptoms severity, regardless of the presence of all formal diagnostic criteria, our results should be interpreted cautiously. The remarkable large sample size of participants in a developing country with relatively high degrees of job stress could be considered as the main strength of the current study. This is the first study that quantified the magnitude of depression and anxiety risk across tertiles of dietary patterns in this specific target group in a Middle-Eastern country. Moreover, adjusting the potential confounders provides reliable results in terms of depression- and anxiety-dietary patterns relationship.

  Conclusion Top

In this cross-section analysis among Iranian steel mill workers, higher scores of healthy dietary patterns were associated with decreased risk of depression and anxiety, whereas higher scores of an Iranian traditional dietary pattern were significantly associated with increased risk of depression and anxiety. Prospective studies are needed to confirm the results of the present study in such specific target group of participants.


The authors are grateful from all the employees of Esfahan Steel Company who kindly participated in our study.

Financial support and sponsorship

The study was financially supported by the Isfahan University of Medical Sciences and the funder had no involvement in the design, analysis and interpretation of the data.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4]

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