Hostname: page-component-78c5997874-dh8gc Total loading time: 0 Render date: 2024-11-05T04:17:29.492Z Has data issue: false hasContentIssue false

The relationship between the World Index for Sustainability and Health (WISH) score and mental health in women: a cross-sectional study

Published online by Cambridge University Press:  29 April 2024

Alireza Jafari
Affiliation:
Physiology Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
Keyhan Lotfi
Affiliation:
Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
Hadis Mozaffari
Affiliation:
Faculty of Land and Food Systems, University of British Columbia, Vancouver, Canada
Behzad Zamani
Affiliation:
Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
Manije Darooghegi Mofrad
Affiliation:
Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
Ali Sheikhi
Affiliation:
Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran
Pamela J. Surkan
Affiliation:
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
Leila Azadbakht*
Affiliation:
Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, Tehran, Iran Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Science, Isfahan, Iran
*
*Corresponding author: Leila Azadbakht, email [email protected]
Rights & Permissions [Opens in a new window]

Abstract

Diet quality has been associated with mental health, and recently, there has been growing interest in the association between the sustainability of diets and human health. The objective of this cross-sectional study was to explore the relationship between a newly developed dietary index for health and sustainability and psychological disorders among Iranian women. Participants in this cross-sectional study included 479 women living in Tehran with no history of chronic disease. A validated 168-item FFQ was used to assess dietary intake. The World Index for Sustainability and Health was calculated, consisting of four sub-scores: less healthy, healthy, low environmental impact and high environmental impact. Participants’ psychological status was assessed using the Depression Anxiety Stress Scale-21. Logistic regression models were used to examine the association between the World Index for Sustainability and Health and psychological disorders. Participant ages ranged from 20 to 50 years, with a mean age of 31·86 (sd 7·68) years. After adjusting for potential confounders (age, energy, BMI, marital status, education, family history of chronic disease, body satisfaction, socio-economic status, physical activity, smoking), women in the highest tertile of the healthy sub-score had significantly lower odds of experiencing depression (OR 0·40; 95 % CI 0·24, 0·67), anxiety (OR 0·45; 95 % CI 0·23, 0·87) and psychological distress (OR 0·46; 95 % CI 0·28, 0·77) compared with the reference group. Similarly, the less healthy sub-score was significantly associated with depression (OR 0·51; 95 % CI 0·32, 0·89), anxiety (OR 0·44; 95 % CI 0·25, 0·78) and psychological distress (OR 0·57; 95 % CI 0·36, 0·90). An inverse association was observed between the low environmental impact sub-score and depression (OR 0·32; 95 % CI 0·19, 0·54), anxiety (OR 0·38; 95 % CI 0·18, 0·76) and psychological distress (OR 0·30; 95 % CI 0·17, 0·51). However, no further significant associations were found with the high environmental impact sub-score, except with depression (OR 0·57; 95 % CI 0·33, 0·96). The healthy and low environmental impact sub-scores of the World Index for Sustainability and Health were found to be inversely associated with depression, anxiety and psychological distress. However, due to the cross-sectional study design, causality cannot be inferred. Further prospective studies are required to validate and expand upon these findings and explore potential mechanisms and alternative explanations, such as reverse causation. While this study suggests that choosing a diet that is both healthy for individuals and sustainable for the environment may be associated with a lower risk of mental health issues among women, more research is needed.

Type
Research Article
Copyright
© The Author(s), 2024. Published by Cambridge University Press on behalf of The Nutrition Society

Anxiety, depression and psychological distress are recognised as leading causes of disability, and according to the 2017 Global Burden of Disease report, depression has impacted 264 million people worldwide(1). Notably, international and national statistics consistently report a higher prevalence of depression among women compared with men(2). In Iran, approximately 20 % of the adult population experience anxiety and depression, with a higher prevalence among women compared with men(Reference Naghavi, Abolhassani and Pourmalek3). Recent reviews have highlighted strong connections between mental and physical health, particularly with CVD(Reference Nielsen, Banner and Jensen4), cancer(Reference Wang, Li and Shi5), all-cause mortality(Reference Machado, Veronese and Sanches6) and reduced life expectancy.

Research has consistently shown that women face unique challenges and vulnerabilities that can potentially impact their mental well-being. Recognising this sex-specific burden, the WHO has identified women’s health as a critical priority, highlighting the need for focused research in this area due to the historically limited and sometimes unreliable body of research dedicated to women’s health(7). Furthermore, women’s mental health during the reproductive years holds particular significance, as it can have far-reaching implications, including for fertility outcomes.

Diet has gained attention as a modifiable risk factor for mental health problems. A recent review emphasised the importance of EPA, DHA, vitamin E, Mg and folic in psychiatric disorders(Reference Muscaritoli8). Furthermore, previous studies have observed associations between higher consumption of fruits, vegetables, fish, legumes and nuts with lower risk of psychological disorders(Reference Anjom-Shoae, Sadeghi and Keshteli9Reference Walsh, Lee and Best16). Conversely, a recent meta-analysis demonstrated a positive association between intake of red and processed meat and depression(Reference Nucci, Fatigoni and Amerio17). Considering the synergistic effects of nutrients and foods, investigating diet-disease associations from a holistic perspective (examining the entire diet) is a desirable approach.

Previous studies have explored the relationship between mental health and various diet quality scores, including the Mediterranean diet score(Reference Sadeghi, Keshteli and Afshar18), the Healthy Eating Index(Reference Wang, Zhao and Nie19), the dietary phytochemical index(Reference Darooghegi Mofrad, Siassi and Guilani20), the food quality score(Reference Darooghegi Mofrad, Siassi and Guilani21), dietary total antioxidant capacity(Reference Daneshzad, Keshavarz and Qorbani22) and the recommended food score(Reference Lee, Kim and Park23). These indices primarily recommend increased consumption of plant-based foods while limiting intake of animal foods(Reference Sadeghi, Keshteli and Afshar18Reference Daneshzad, Keshavarz and Qorbani22).

In recent years, due to the growing prevalence of diet-related diseases and the bidirectional impact of food systems on climate change, researchers have shown increased interest in sustainable diets(Reference Myers, Smith and Guth24Reference Tepper, Geva and Shahar26). Sustainable diets are characterised by their affordability and cultural acceptability, health-promoting effects and lower environmental impacts(Reference Burlingame and Dernini27). They primarily consist of plant-based foods that provide protection against both adverse health outcomes and environmental consequences(Reference Tepper, Geva and Shahar26). Notably, Willett et al. recently developed specific guidelines known as the EAT-Lancet recommendations for a healthy diet from sustainable food systems(Reference Willett, Rockström and Loken25). These recommendations emphasise high consumption of whole grains, vegetables, fruits, legumes, nuts and unsaturated oils, moderate intake of poultry and seafood and limited or no consumption of refined grains, starchy vegetables, red and processed meat and added sugar(Reference Willett, Rockström and Loken25). Several indices have been proposed to combine the environmental and health aspects of diet(Reference Seconda, Baudry and Pointereau28,Reference Trijsburg, Talsma and Crispim29) . The (World Index for Sustainability and Health) WISH was established based on the EAT-Lancet recommendations(Reference Willett, Rockström and Loken25) and encompasses both diet quality and environmental sustainability in a single scoring system(Reference Trijsburg, Talsma and Crispim29). However, to date, the association between WISH and mental disorders has not been investigated. Therefore, the present observational study aims to evaluate the potential relationship between WISH and mental health outcomes, including depression, anxiety and psychological distress in a population of Iranian women.

Methods and materials

Study population

This cross-sectional study was conducted with women who attended ten healthcare centres in the south of Tehran from September 2017 to September 2018. The prevalence of mental disorders was used to estimate the sample size, with P = 26 %(Reference Noorbala, Bagheri Yazdi and Yasamy30); α = 0·05; d = 4·12, using the formula: $$\;N = {{\left[ {{{({z_{1 - { \propto \over 2}}})}^2}P\left( {1 - P} \right)} \right]} \over {{d^2}}}$$ . The following inclusion criteria were considered: (1) being an Iranian woman aged 20–50 years, (2) having no history of chronic disease (CVD, cancer, diabetes, thyroid disease, liver disease, pulmonary disease, multiple sclerosis, epilepsy or kidney dysfunction) or psychological disease requiring antipsychotic medications and (3) not currently following a specific diet. Pregnant, lactating and menopausal women were excluded. Participants with energy intake higher than 3500 or lower than 500 kcal/d (n 31) and those with missing psychological profile data on the Depression and Anxiety Stress Scale-21 (n 3) were excluded from the analysis. Ultimately, 479 individuals were eligible for the present study.

Dietary intake assessment

Participants’ dietary intakes were collected using a validated semi-quantitative 168-item Iranian FFQ, administered through face-to-face interviews(Reference Mirmiran, Esfahani and Mehrabi31). A trained dietitian asked about the frequency of consumption on a daily, weekly or monthly basis, as well as the usual serving size of food items. Then, a guideline for household measures(Reference Ghaffarpour, Houshiar-Rad and Kianfar32) was used to convert serving sizes to g/d. Finally, energy and main nutrients were computed using a modified version of Nutritionist IV software for Iranian foods (version 7.0; N-Squared Computing, Salem).

World Index for Sustainability and Health (WISH) calculation

The WISH was determined based on a method developed by Trijsburg et al. (Reference Trijsburg, Talsma and Crispim29), which scores both diet healthiness and environmental impact. Detailed information about the construction and validation of WISH has been provided elsewhere(Reference Trijsburg, Talsma and Crispim29). WISH scores have been applied and calculated to other lower- and middle-income countries (e.g. for women in rural East Africa), supporting the index’s broader applicability(Reference Keding, Sarfo and Pawelzik33). The WISH considered thirteen food groups, including vegetables, fruits, whole grains, fish, red meat, dairy products, chicken, eggs, nuts, legumes, saturated oils, unsaturated oils and added sugars. Food groups were categorised based on their health-related (protective, neutral or limited) and environmental (low, medium or high) impacts. This score includes four sub-scores: healthy (vegetables, fruits, whole grains, fish, dairy products, egg, chicken, nuts, legumes, unsaturated oils), less healthy (red meat, saturated oils, added sugar), low environmental impact (whole grains, vegetables, fruits, legumes, unsaturated oils, added sugars) and high environmental impact (red meat, dairy products, egg, chicken, nuts, fish, saturated oils). For the healthy and low environmental sub-scores, a value of 0–10 indicates the lowest to the highest consumption of the components. In the case of the less healthy and high environmental sub-score, higher values correspond to less consumption of the components. Finally, a higher total score indicates a healthier or more environmentally friendly diet.

Psychological profile assessment

The Depression Anxiety Stress Scale-21 (DASS-21), a validated self-reported questionnaire, consists of seven items in three subscales, to assess psychological distress, depression and anxiety. Answers are given on a four-point Likert scale ranging from 0 (never) to 3 (always). Scores on each subscale range from 0 to 21. The Iranian version of the DASS-21, which has been validated and deemed reliable, was used in this study(Reference Sahebi, Asghari and Salari34). Since the original scale of DASS is based on forty-two questions, DASS-21 final scores in each subscale were doubled. Finally, depression, anxiety and psychological distress were defined as scores of ≥ 10, ≥ 8 and ≥ 15, respectively. The Cronbach’s alpha indices for the subscales were as follows: depression = 0·81, anxiety = 0·74, and distress = 0·78.

Anthropometric and socio-demographic assessment

Body weight was measured using a digital scale (SECA, Hamburg, Germany) while participants wore minimal clothing and no shoes. Height was measured using an inflexible measuring rod with a precision of 0·1 cm. BMI was calculated as BMI = weight (kg)/height2 (m). Demographic information including age, marital status (married/single), smoking (yes/no), socio-economic status (SES)(Reference Shafiei, Yazdani and Jadidfard35) (education, family size, employment status and occupation, homeownership, home equipment diversity, number of rooms and domestic/international travel), education, body satisfaction (yes/no), medication or vitamin supplement usage (yes/no), history of chronic disease (cancer, diabetes, CVD, liver, pulmonary, kidney, thyroid diseases, hypertension, multiple sclerosis, epilepsy) and family history of these diseases (yes/no) were collected using an interview-based questionnaire. Physical activity level was determined by having participants directly log the average time and total duration that they devoted to various physical activities over a 24-h period. Then, the physical activity level was computed as metabolic equivalent minutes per week (MET/min/week)(Reference Ainsworth, Haskell and Whitt36). Finally, four categories were used to indicate the level of physical activity (light, moderate, strong and intense).

Statistical analysis

The distribution of variables was analysed using the Kolmogorov–Smirnov test. Continuous variables were presented as mean ± sd, while categorical variables were presented as frequencies (n) and percentages (%). X 2 and one-way ANOVA tests were used to compare the general characteristics of participants across the tertiles of WISH sub-scores. Study participants’ dietary intakes across tertiles of WISH scores were compared using ANCOVA adjusted for energy intake. Binary logistic regression analysis was also applied to assess the relationship between less healthy, healthy, low environmental impact and high environmental impact scores and odds of having each of the three psychological profiles (anxiety, depression and psychological distress) by including age, energy, BMI, marital status, education, family history of chronic disease, sleep duration, duration of time spent outside, prescription medications, vitamin supplementation, body satisfaction, SES and physical activity in the multivariable-adjusted model. Covariates were selected based on clinical knowledge and a comprehensive literature review(Reference Darooghegi Mofrad, Siassi and Guilani20,Reference Darooghegi Mofrad, Siassi and Guilani21,Reference Zamani, Zeinalabedini and Nasli Esfahani37) and baseline variables associated with having each of the three psychological profiles, as illustrated in online Supplementary Fig. 1 using a directed acyclic graph. Variables that met both the statistical criteria (favourable AIC/BIC values, low multicollinearity) and the practical significance criterion (10–15 % effect size change) were selected as confounders for inclusion in our multivariable logistic regression models. Statistical analyses were performed with SPSS statistical package software (SPSS Inc. version 27), and P < 0·05 was considered significant.

Results

Table 1 presents the characteristics of women categorised according to WISH sub-scores. The mean age, weight, BMI and physical activity of the participants were 31·9 (7·7) years, 64·5 (12·0) kg, 24·5 (4·5) kg/m2 and 39·9 (6·8) MET/min/week, respectively. We observed that higher healthy, less healthy, low environmental and high environmental scores were associated with lower odds of depression and psychological distress. Additionally, women with higher healthy and low environmental and lower less healthy sub-scores reported lower levels of anxiety. No significant differences in SES, education status, supplement usage, medication use, family history of chronic disease and body satisfaction were observed.

Table 1. General characteristic of participants across the tertiles of WISH sub-scores

WISH; World Index for Sustainability and Health.

Values are means ± sd; one-way ANOVA for continuous variables and x 2 test for categorical variables were used to generate P values; MET-h, metabolic equivalent task hours.

The energy-adjusted dietary intakes of participants across tertiles of healthy, less healthy, low environmental and high environmental impacts sub-scores are presented in Table 2. Higher intakes of carbohydrate, fibre, PUFA, vitamin A, vitamin B1, vitamin B6, vitamin C, Mg, vegetables, fruit, fish, legumes, nuts and unsaturated oil and lower intakes of cholesterol, vitamin B2, vitamin D, Ca, eggs, meat and dairy products were associated with third tertiles of the healthy sub-score. Women scoring in the highest less healthy tertile had lower consumption of energy, protein, carbohydrates, fat, fibre, MUFA, vitamin B1, vitamin B2, vitamin B6, vitamin B9, Ca, Mg, Zn, meat, fruit, dairy product, saturated oil and sugar but higher intakes of vitamin A, vegetables, chicken and unsaturated oil compared with those in the lowest tertile. Women in the third tertile of low environmental impact reported significantly greater intake of energy, protein, fibre, vitamin A, vitamin B2, vitamin B6, vitamin B9, vitamin C, Ca, Mg, vegetables, fruit, dairy products, meat, legumes and unsaturated oil compared with participants in the first tertile. However, they showed lower intakes of sugar. Participants in the top environmental tertile had lower intakes of energy, protein, carbohydrate, fat, fibre, MUFA, cholesterol, vitamin D, vitamin B1, vitamin B2, vitamin B6, Ca, whole grains, fruits, egg, dairy products, meat, chicken and saturated oil compared with those in the bottom environmental tertile. Women in the lowest tertile consumed less fish and nuts.

Table 2. Energy-adjusted dietary intakes of study participants across the tertiles of WISH sub-scores

WISH: World Index for Sustainability and Health.

Values are mean ± se. All values are adjusted for energy intake using ANCOVA.

Table 3 shows adjusted OR for depression, anxiety and stress comparing tertiles of healthy, less healthy, low and high environmental scores. The healthy score was inversely associated with the odds of depression (OR 0·40; 95 % CI 0·24, 0·67; P = 0·001), anxiety (OR 0·45; 95 % CI 0·23, 0·87; P = 0·023) and distress (OR 0·46; 95 % CI 0·28, 0·77; P = 0·003). The less healthy score was positively associated with distress (OR 0·57; 95 % CI 0·36, 0·90; P = 0·016), depression (OR 0·51; 95 % CI 0·32, 0·89; P = 0·004) and anxiety (OR 0·44; 95 % CI 0·25, 0·78; P = 0·004). In addition, scores for low environmental impact were inversely associated with depression (OR 0·32; 95 % CI 0·19, 0·54; P < 0·001), distress (OR 0·30; 95 % CI 0·17, 0·51; P < 0·001) and anxiety (OR 0·38; 95 % CI 0·18, 0·76; P = 0·012). An inverse association was found between scores indicating high environmental impact and depression (OR 0·57; 95 % CI 0·33, 0·96; P = 0·031). However, we failed to detect a significant association between high environmental score with anxiety (OR 0·56; 95 % CI 0·29, 1·08; P = 0·090) and distress (OR 0·62; 95 % CI 0·37, 1·06; P = 0·080).

Table 3. Multiple-adjusted OR and 95 % CI across the tertiles of WISH sub-scores

WISH: World Index for Sustainability and Health.

These values are OR (95 % CI).

* Logistic regression model included age, energy, BMI, marriage, education, family history of chronic disease, body satisfaction, SES, physical activity and smoking.

Discussion

In this cross-sectional study, we investigated the mental health of Iranian women in relation to WISH sub-scores. Our results revealed that healthier scores were correlated with lower odds of depression, anxiety and psychological distress. In addition, we found an inverse correlation between less healthy scores and psychological disorders. Considering environmental dietary indicators, a negative association was seen between the low environmental impact sub-score and depression, anxiety and psychological distress. However, the high environmental impact sub-score was not related to the odds of mental disorders, except for depression. To the best of our knowledge, this is the first study to assess WISH scores in relation to depression, anxiety and psychological distress.

The present study was conducted among a sample of Iranian adult women. Findings indicated that Iranian women consume vegetables, fruits, dairy products, fish, chickens, eggs, nuts, legumes and unsaturated oils within the EAT-Lancet guidelines suggested range. Nevertheless, due to the moderate environmental impact of dairy products, their consumption could be slightly decreased. In low- to middle-income countries, the majority of energy intake comes from carbohydrates(Reference Seidelmann, Claggett and Cheng38). Based on the results of the present study, the average amount of whole grains consumed by this population is considerably lower than the recommended range. On the other hand, the consumption of less healthy food groups, including red meats, saturated oils and added sugar, was relatively higher than the recommended values and should be decreased. In summary, our study population could improve their current WISH score by consuming higher amounts of whole grains and fish while limiting less healthy food intake. Notwithstanding the average amounts of food consumed by our population, we should be cautious in generalising these intake values to the whole Iranian female population, as adherence to the EAT-Lancet recommendations can be relatively expensive and may differ across individuals with various SES(Reference Hirvonen, Bai and Headey39).

Vegetables, legumes, whole grains, fruits and unsaturated oils are the components of both the healthy and low environmental impact sub-scores(Reference Trijsburg, Talsma and Crispim29). In addition, fish, chicken, eggs, dairy products and nuts are known to be healthy foods(Reference Trijsburg, Talsma and Crispim29). We found an inverse association between the healthy sub-score of WISH and mental disorders. Consistent with our findings, a previous meta-analysis of observational studies found fruits, vegetables and fish, intake to be inversely linked with psychological disorders within the general population(Reference Grosso, Micek and Marventano11,Reference Saghafian, Malmir and Saneei12) . Furthermore, another cross-sectional study among 24 776 Chinese participants revealed that consumption of whole grains ≥ 2 times/week was associated with 32 and 24 % lower odds of depression in males and females, respectively(Reference Wu, Zhang and Meng40). Similarly, another cross-sectional study of 3172 Iranian adults also reported a negative association between whole-grain consumption and odds of anxiety in women, while a positive association was observed for refined grains and anxiety and depression(Reference Sadeghi, Hassanzadeh-Keshteli and Afshar41). A review of thirteen studies investigating dairy products in relation to mental disorders found inconsistent results(Reference Hockey, McGuinness and Marx42). However, because of methodological differences and considering various sub-types of dairy products in the studies included, conclusions could not be made, and further studies were recommended(Reference Hockey, McGuinness and Marx42).

We found an inverse association between the low environmental impact sub-score and odds of depression, anxiety and psychological distress. Plant-based food groups as well as added sugars are considered to have less impact on the environment. We previously mentioned results from earlier studies that had investigated the relation between specific plant-based food groups and mental health(Reference Grosso, Micek and Marventano11,Reference Saghafian, Malmir and Saneei12) . Added sugars were also included in the less environmental impact sub-score(Reference Trijsburg, Talsma and Crispim29). Despite categorisation as a low environmental impact food, added sugars were found to be an unhealthy risk factor for mental health conditions. A meta-analysis by Hu et al. (Reference Hu, Cheng and Jiang43) revealed that intake of sugar-sweetened beverages could be modestly related to depression (OR = 1·31). Also, a cohort study of 935 Japanese adults reported that higher soft drink consumption was positively associated with the risk of depression(Reference Kashino, Kochi and Imamura44). Additionally, a study among 4741 adults in South Australia concluded there was a direct link between consuming soft drinks and psychological disorders(Reference Shi, Taylor and Wittert45). Similarly, sugar and sweeteners were positively associated with anxiety(Reference Hoerr, Fogel and Van Voorhees46). Wattick et al. demonstrated a similar relation between added sugar intake and anxiety in 1959 college students(Reference Wattick, Hagedorn and Olfert47). Nevertheless, it is worth mentioning that added sugar is one of the components of the low environmental impact sub-score, and other healthy components such as vegetables, fruits and whole grains might counteract the deleterious effects of added sugars on mental health. Furthermore, EAT-Lancet guidelines recommended caution associated with added sugar intake because of the possible health concerns, suggesting a cut-off value of 31 g/d(Reference Willett, Rockström and Loken25,Reference Trijsburg, Talsma and Crispim29) .

We found that having a less healthy WISH score on any of the sub-scales was related to lower odds of psychological disorders. Higher scores indicate healthier diets with lower consumption of red meats, saturated fats and added sugars. In our earlier report, Darooghegi et al. found that women with the highest levels of red meat intake had substantially increased odds of anxiety, depression and psychological distress(Reference Darooghegi Mofrad, Mozaffari and Sheikhi48). A study by Kouvari et al. on 1514 men and 1528 women revealed that moderate (second tertile) consumption of total meat and red meat was negatively associated with odds of depression indicating a U-shaped association(Reference Kouvari, Panagiotakos and Chrysohoou49). Also, Kazemi et al. found an increased chance of depression among adults who have higher intakes of red meat, especially among people of normal weight and males(Reference Kazemi, Keshteli and Saneei50). Olivan-Blazquez et al. concluded that adults who consume more than 1 serving/d of red meat had a higher likelihood of depressive symptoms(Reference Oliván-Blázquez, Aguilar-Latorre and Motrico51). Also, a meta-analysis found that red and processed meat intake could be positively linked to high levels of depression or depression(Reference Nucci, Fatigoni and Amerio17). Furthermore, several animal studies revealed that saturated fatty acids might be a responsible nutrient associated with anxiety(Reference Meichtry, Poetini and Dahleh52Reference Sivanathan, Thavartnam and Arif54). Despite the deleterious effect of animal products on health as well as the environment, some important nutrients including Fe, Ca, Zn and vitamin B12 are mainly provided by animal-based foods(Reference Magkos, Tetens and Bügel55). Strategies including supplementation, considering meat alternatives and promotion of nutrient absorption from plant-based foods should be considered to overcome the possible deficiencies(Reference Bastian, Buro and Palmer-Keenan56).

Dietary intake of individual nutrients and food groups is an important approach for exploring diet-disease associations. However, our dietary intakes are a combination of various foods with different nutritional values, and specific nutrients might interact in the human body. Therefore, considering dietary intake holistically could be a better option for investigating diet in relation to disease. In agreement with our findings, earlier meta-analyses reported an inverse association between the Mediterranean diet and Healthy Eating Index, which highly consists of plant-based foods as well as unsaturated fats and depression(Reference Lassale, Batty and Baghdadli57,Reference Shafiei, Salari-Moghaddam and Larijani58) . Furthermore, a cross-sectional study on Iranian adults found an inverse association between the Mediterranean diet and anxiety and psychological distress(Reference Sadeghi, Keshteli and Afshar18). Also, a cross-sectional study among Australian vegans and vegetarians found a protective relation between a plant-based diet and depression(Reference Lee, Eather and Best59). Similarly, our previous report using the same data revealed an inverse relation between overall and healthful plant-based dietary patterns and anxiety, depression and psychological distress(Reference Zamani, Daneshzad and Siassi60). However, higher scores for the unhealthful plant-based dietary pattern have been shown to be related to increased odds of depression by 91 %(Reference Zamani, Daneshzad and Siassi60). Another cross-sectional study among diabetic women in Iran found that the unhealthful plant-based diet was a predictor of increased depression, anxiety and stress, but no significant relation was found between the healthful plant-based diet and mental disorders(Reference Daneshzad, Keshavarz and Qorbani61). On the other hand, a recent meta-analysis did not find a significant relation between vegetarian diets and the risk of anxiety and depression(Reference Askari, Daneshzad and Darooghegi Mofrad62). It is important to note that discrepancies among studies may be due to different study designs and populations. Most prior studies on the relation between plant-based dietary patterns and mental disorders have been cross-sectional; thus, more prospective studies are required to rule out the possibility of reverse causation.

There are several proposed mechanisms by which healthy and low environmental impact sub-scores may be related to mental health. These sub-scores mainly reflect plant-based foods (providing considerable amounts of fibre, Mg and B vitamins), which have been found to be protective for mental disorders(Reference Skarupski, Tangney and Li63Reference Derom, Sayón-Orea and Martínez-Ortega65). Furthermore, these sub-scores recommend unsaturated fat consumption, which has been inversely associated with depression(Reference Sánchez-Villegas, Verberne and De Irala66). The low glycaemic index of plant-based diets could be another possible mechanism. Adhering to a low glycaemic index diet could reduce insulin resistance, which has been found to be negatively associated with mental health(Reference Kan, Silva and Golden67,Reference Haghighatdoost, Azadbakht and Keshteli68) . Also, inflammation is a key factor in the pathophysiology of psychological disorders(Reference Pariante69), and adherence to plant-based diets could be an important approach for controlling inflammation(Reference Medawar, Huhn and Villringer70,Reference Bonaccio, Pounis and Cerletti71) .

In the present study, we considered possible confounding of several factors in the association between WISH score and mental disorders. These confounders included age, energy, BMI, marital status, educational level, family history of chronic disease, body satisfaction, SES, physical activity and smoking. The associations we observed were mostly unchanged after adjusting for these confounders. It should be acknowledged that residual confounding may still exist due to errors in classifying participants based on the confounding variables or due to errors in measuring confounders. Also, there may be additional confounders that we did not collect data on. For instance, sleep and psychological disorders share common causes and also have bidirectional associations (e.g. sleep disturbances have been found to be a strong causal factor for mental disorders(Reference Freeman, Sheaves and Waite72)). Also, abundant evidence indicates a potential role of diet in sleep health(Reference St-Onge, Mikic and Pietrolungo73). Given the points mentioned above, the relation between diet and mental disorders in our study might still be confounded by some mismeasured or unmeasured factors, which should be considered in the interpretation of the results. In addition, reverse causality is an important phenomenon, and the actual associations might be in the reverse direction of which we hypothesised. In this scenario, individuals with depression, anxiety or stress might alter their dietary intakes in response to their specific mental health conditions. These dietary behaviours (e.g. eating sweet foods) may result from an effort to enhance their mood, poor appetite or lack of motivation to buy or prepare healthy foods(Reference van der Pols74,Reference Northstone, Joinson and Emmett75) . For instance, a longitudinal study observed that depressive symptoms were related to changes in vegetables, meats and dairy products intake,(Reference Elstgeest, Visser and Penninx76) suggesting that a bidirectional relationship could exist between diet and depression. Such studies in which the relation between diet and mental disorders is explored in both directions are scarce and need to be prioritised in future research. To control for bias from reverse causation, we did not include participants who had used antidepressant drugs as they tend to have more severe mental disorders and are more likely to alter their dietary intakes due to their condition. Notwithstanding, a bidirectional relation may exist between dietary intakes and mental disorders(Reference Elstgeest, Visser and Penninx76), and reverse causality cannot be ruled out in our study. It is important to consider this point in interpreting our findings. Further prospective cohort studies are required to understand reverse causation.

There are some strengths of our study. It is the first study to examine the association between WISH scores and mental health conditions. Furthermore, we used validated questionnaires for dietary intake, mental health and assessment of physical activity. Also, although residual confounding might still remain, several potential confounders were taken into account in our analyses. For the interpretation of the results, several limitations were also important. First, the cross-sectional nature of our study limited our ability to infer causal relationships. Therefore, prospective studies are needed to further explore the relationships between diet and mental disorders. Second, despite using validated DASS-21 and FFQ questionnaires, they are subjected to under- or over-reporting, leading to potential participant misclassification. Third, despite being a universal score, the WISH has not been specifically validated among females or among Iranians in particular. Therefore, we recommend that future studies examine the reliability and validity of this index among different populations to assess its robustness. Finally, caution should be taken in generalising our findings to other populations including males, older adults and those with other health conditions.

In conclusion, adherence to a healthier diet with less environmental impact was associated with better psychological health among women. Due to the worsening trends in our environment and the increasing prevalence of psychological disorders, more prospective studies that include both sexes are warranted to understand the causality of the observed associations and explore potential mechanisms.

Acknowledgements

The authors would like to gratitude to the study participants.

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

A. J. contributed to the conception, design, search and statistical analyses. A. J. and K. L. drafted the manuscript. L. A., H. M., B. Z., M. D. M. and A. S. contributed to design and data interpretation. P. J. S. edited and commented on the manuscript. L. A. supervised the study critically. All authors have read and approved the final manuscript.

The authors declare that they have no competing interests.

All participants were provided written consent based on the guidelines of the Declaration of Helsinki. The study protocol (98-01-161-42024) was approved by the Medical Research Ethics Committee of Tehran University of Medical Sciences.

The datasets used and/or analysed during the present study are available from the corresponding author upon reasonable request.

Supplementary material

For supplementary material/s referred to in this article, please visit https://doi.org/10.1017/S0007114524000771.

References

GBD 2017 Disease and Injury Incidence and Prevalence Collaborators (2018) Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 392, 17891858.10.1016/S0140-6736(18)32279-7CrossRefGoogle Scholar
Institute for Health Metrics and Evaluation (IHME). GBD Results. Seattle, WA: IHME, University of Washington, 2020. Available from https://vizhub.healthdata.org/gbd-results/ (accessed 6, 2023).Google Scholar
Naghavi, M, Abolhassani, F, Pourmalek, F, et al. (2009) The burden of disease and injury in Iran 2003. Popul Health Metr 7, 9.10.1186/1478-7954-7-9CrossRefGoogle ScholarPubMed
Nielsen, RE, Banner, J & Jensen, SE (2021) Cardiovascular disease in patients with severe mental illness. Nat Rev Cardiol 18, 136145.10.1038/s41569-020-00463-7CrossRefGoogle ScholarPubMed
Wang, YH, Li, JQ, Shi, JF, et al. (2020) Depression and anxiety in relation to cancer incidence and mortality: a systematic review and meta-analysis of cohort studies. Mol Psychiatry 25, 14871499.10.1038/s41380-019-0595-xCrossRefGoogle ScholarPubMed
Machado, MO, Veronese, N, Sanches, M, et al. (2018) The association of depression and all-cause and cause-specific mortality: an umbrella review of systematic reviews and meta-analyses. BMC Med 16, 112.CrossRefGoogle ScholarPubMed
Organization WH Women’s Health (2024). https://www.who.int/health-topics/women-s-health (accessed 6, 2023).Google Scholar
Muscaritoli, M (2021) The impact of nutrients on mental health and well-being: insights from the literature. Front Nutr 8, 656290.CrossRefGoogle ScholarPubMed
Anjom-Shoae, J, Sadeghi, O, Keshteli, AH, et al. (2020) Legume and nut consumption in relation to depression, anxiety and psychological distress in Iranian adults. Eur J Nutr 59, 36353645.10.1007/s00394-020-02197-1CrossRefGoogle ScholarPubMed
Grosso, G & Estruch, R (2016) Nut consumption and age-related disease. Maturitas 84, 1116.10.1016/j.maturitas.2015.10.014CrossRefGoogle ScholarPubMed
Grosso, G, Micek, A, Marventano, S, et al. (2016) Dietary n-3 PUFA, fish consumption and depression: a systematic review and meta-analysis of observational studies. J Affect Disord 205, 269281.10.1016/j.jad.2016.08.011CrossRefGoogle ScholarPubMed
Saghafian, F, Malmir, H, Saneei, P, et al. (2018) Fruit and vegetable consumption and risk of depression: accumulative evidence from an updated systematic review and meta-analysis of epidemiological studies. Br J Nutr 119, 10871101.CrossRefGoogle ScholarPubMed
Lee, MF, Eather, R & Best, T (2021) Plant-based dietary quality and depressive symptoms in Australian vegans and vegetarians: a cross-sectional study. BMJ Nutr Prev Health 4, 479486.CrossRefGoogle ScholarPubMed
Lee, M, Bradbury, J, Yoxall, J, et al. (2022) Is dietary quality associated with depression? An analysis of the Australian longitudinal study of women’s health data. Br J Nutr 129, 18.Google ScholarPubMed
Lee, M, Bradbury, J, Yoxall, J, et al. (2023) A longitudinal analysis of Australian women’s fruit and vegetable consumption and depressive symptoms. Br J Health Psychol 28, 829843.10.1111/bjhp.12656CrossRefGoogle ScholarPubMed
Walsh, H, Lee, M & Best, T (2023) The association between vegan, vegetarian, and omnivore diet quality and depressive symptoms in adults: a cross-sectional study. Int J Environ Res Public Health 20, 3258.CrossRefGoogle ScholarPubMed
Nucci, D, Fatigoni, C, Amerio, A, et al. (2020) Red and processed meat consumption and risk of depression: a systematic review and meta-analysis. Int J Environ Res Public Health 17, 6686.CrossRefGoogle ScholarPubMed
Sadeghi, O, Keshteli, AH, Afshar, H, et al. (2021) Adherence to Mediterranean dietary pattern is inversely associated with depression, anxiety and psychological distress. Nutr Neurosci 24, 248259.10.1080/1028415X.2019.1620425CrossRefGoogle ScholarPubMed
Wang, K, Zhao, Y, Nie, J, et al. (2021) Higher HEI-2015 score is associated with reduced risk of depression: result from NHANES 2005–2016. Nutrients 13, 348.CrossRefGoogle ScholarPubMed
Darooghegi Mofrad, M, Siassi, F, Guilani, B, et al. (2019) Association of dietary phytochemical index and mental health in women: a cross-sectional study. Br J Nutr 121, 10491056.10.1017/S0007114519000229CrossRefGoogle ScholarPubMed
Darooghegi Mofrad, M, Siassi, F, Guilani, B, et al. (2020) The association of food quality index with mental health in women: a cross-sectional study. BMC Res Notes 13, 557.10.1186/s13104-020-05401-xCrossRefGoogle ScholarPubMed
Daneshzad, E, Keshavarz, SA, Qorbani, M, et al. (2020) Dietary total antioxidant capacity and its association with sleep, stress, anxiety, and depression score: a cross-sectional study among diabetic women. Clin Nutr ESPEN 37, 187194.10.1016/j.clnesp.2020.03.002CrossRefGoogle Scholar
Lee, JE, Kim, YJ, Park, HJ, et al. (2019) Association of recommended food score with depression, anxiety, and quality of life in Korean adults: the 2014–2015 National Fitness Award Project. BMC Public Health 19, 956.10.1186/s12889-019-7298-8CrossRefGoogle ScholarPubMed
Myers, SS, Smith, MR, Guth, S, et al. (2017) Climate change and global food systems: potential impacts on food security and undernutrition. Ann Rev Public Health 38, 259277.CrossRefGoogle ScholarPubMed
Willett, W, Rockström, J, Loken, B, et al. (2019) Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet 393, 447492.10.1016/S0140-6736(18)31788-4CrossRefGoogle ScholarPubMed
Tepper, S, Geva, D, Shahar, DR, et al. (2021) The SHED Index: a tool for assessing a Sustainable Healthy Diet. Eur J Nutr 60, 38973909.10.1007/s00394-021-02554-8CrossRefGoogle ScholarPubMed
Burlingame, B & Dernini, S (2012) Sustainable Diets and Biodiversity Directions and Solutions for Policy, Research and Action. Rome: FAO Headquarters.Google Scholar
Seconda, L, Baudry, J, Pointereau, P, et al. (2019) Development and validation of an individual sustainable diet index in the NutriNet-Santé study cohort. Br J Nutr 121, 11661177.CrossRefGoogle ScholarPubMed
Trijsburg, L, Talsma, EF, Crispim, SP, et al. (2020) Method for the development of WISH, a globally applicable index for healthy diets from sustainable food systems. Nutrients 13, 93.CrossRefGoogle ScholarPubMed
Noorbala, AA, Bagheri Yazdi, SA, Yasamy, MT, et al. (2004) Mental health survey of the adult population in Iran. Br J Psychiatry 184, 7073.10.1192/bjp.184.1.70CrossRefGoogle ScholarPubMed
Mirmiran, P, Esfahani, FH, Mehrabi, Y, et al. (2010) Reliability and relative validity of an FFQ for nutrients in the Tehran lipid and glucose study. Public Health Nutr 13, 654662.10.1017/S1368980009991698CrossRefGoogle ScholarPubMed
Ghaffarpour, M, Houshiar-Rad, A & Kianfar, H (1999) The manual for household measures, cooking yields factors and edible portion of foods. Tehran: Nashre Olume Keshavarzy 7, 4258.Google Scholar
Keding, GB, Sarfo, J & Pawelzik, E (2023) Healthy diets from sustainable food systems: calculating the WISH scores for women in Rural East Africa. Nutrients 15, 2699.CrossRefGoogle ScholarPubMed
Sahebi, A, Asghari, MJ & Salari, RS (2005) Validation of Depression Anxiety and Stress Scale (DASS-21) for an Iranian Population. Developmental Pscychology 4, 299312.Google Scholar
Shafiei, S, Yazdani, S, Jadidfard, MP, et al. (2019) Measurement components of socioeconomic status in health-related studies in Iran. BMC Res Notes 12, 70.10.1186/s13104-019-4101-yCrossRefGoogle ScholarPubMed
Ainsworth, BE, Haskell, WL, Whitt, MC, et al. (2000) Compendium of physical activities: an update of activity codes and MET intensities. Med Sci Sports Exerc 32, S498S504.CrossRefGoogle ScholarPubMed
Zamani, B, Zeinalabedini, M, Nasli Esfahani, E, et al. (2023) Can following Paleolithic and Mediterranean diets reduce the risk of stress, anxiety, and depression: a cross-sectional study on Iranian Women. J Nutr Metab 2023, 2226104.CrossRefGoogle ScholarPubMed
Seidelmann, SB, Claggett, B, Cheng, S, et al. (2018) Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. Lancet Public Health 3, e419e428.CrossRefGoogle ScholarPubMed
Hirvonen, K, Bai, Y, Headey, D, et al. (2020) Affordability of the EAT–Lancet reference diet: a global analysis. Lancet Global Health 8, e59e66.CrossRefGoogle Scholar
Wu, H, Zhang, S, Meng, G, et al. (2021) The consumption of whole grain is related to depressive symptoms among Chinese adults: a cross-sectional study. Eur J Clin Nutr 76, 126–133.CrossRefGoogle Scholar
Sadeghi, O, Hassanzadeh-Keshteli, A, Afshar, H, et al. (2019) The association of whole and refined grains consumption with psychological disorders among Iranian adults. Eur J Nutr 58, 211225.CrossRefGoogle ScholarPubMed
Hockey, M, McGuinness, AJ, Marx, W, et al. (2020) Is dairy consumption associated with depressive symptoms or disorders in adults? A systematic review of observational studies. Crit Rev Food Sci Nutr 60, 36533668.CrossRefGoogle ScholarPubMed
Hu, D, Cheng, L & Jiang, W (2019) Sugar-sweetened beverages consumption and the risk of depression: a meta-analysis of observational studies. J Affect Disord 245, 348355.10.1016/j.jad.2018.11.015CrossRefGoogle ScholarPubMed
Kashino, I, Kochi, T, Imamura, F, et al. (2021) Prospective association of soft drink consumption with depressive symptoms. Nutrition 81, 110860.CrossRefGoogle ScholarPubMed
Shi, Z, Taylor, AW, Wittert, G, et al. (2010) Soft drink consumption and mental health problems among adults in Australia. Public Health Nutr 13, 10731079.CrossRefGoogle ScholarPubMed
Hoerr, J, Fogel, J & Van Voorhees, B (2017) Ecological correlations of dietary food intake and mental health disorders. J Epidemiol Glob Health 7, 8189.CrossRefGoogle ScholarPubMed
Wattick, RA, Hagedorn, RL & Olfert, MD (2018) Relationship between diet and mental health in a young adult Appalachian college population. Nutrients 10, 957.10.3390/nu10080957CrossRefGoogle Scholar
Darooghegi Mofrad, M, Mozaffari, H, Sheikhi, A, et al. (2021) The association of red meat consumption and mental health in women: a cross-sectional study. Complement Ther Med 56, 102588.10.1016/j.ctim.2020.102588CrossRefGoogle ScholarPubMed
Kouvari, M, Panagiotakos, DB, Chrysohoou, C, et al. (2020) Meat consumption, depressive symptomatology and cardiovascular disease incidence in apparently healthy men and women: highlights from the ATTICA cohort study (2002–2012). Nutr Neurosci 25, 266–275.Google ScholarPubMed
Kazemi, S, Keshteli, AH, Saneei, P, et al. (2021) Red and white meat intake in relation to mental disorders in Iranian adults. Front Nutr 8, 710555.10.3389/fnut.2021.710555CrossRefGoogle ScholarPubMed
Oliván-Blázquez, B, Aguilar-Latorre, A, Motrico, E, et al. (2021) The relationship between adherence to the Mediterranean diet, intake of specific foods and depression in an adult population (45–75 years) in primary health care. A cross-sectional descriptive study. Nutrients 13, 2724.CrossRefGoogle Scholar
Meichtry, LB, Poetini, MR, Dahleh, MMM, et al. (2020) Addition of saturated and trans-fatty acids to the diet induces depressive and anxiety-like behaviors in Drosophila melanogaster. Neurosci 443, 164175.CrossRefGoogle Scholar
Nakajima, S, Fukasawa, K, Gotoh, M, et al. (2020) Saturated fatty acid is a principal cause of anxiety-like behavior in diet-induced obese rats in relation to serum lysophosphatidylcholine level. Int J Obes (Lond) 44, 727738.CrossRefGoogle ScholarPubMed
Sivanathan, S, Thavartnam, K, Arif, S, et al. (2015) Chronic high fat feeding increases anxiety-like behaviour and reduces transcript abundance of glucocorticoid signalling genes in the hippocampus of female rats. Behav Brain Res 286, 265270.CrossRefGoogle ScholarPubMed
Magkos, F, Tetens, I, Bügel, SG, et al. (2020) A perspective on the transition to plant-based diets: a diet change may attenuate climate change, but can it also attenuate obesity and chronic disease risk? Adv Nutr 11, 19.10.1093/advances/nmz090CrossRefGoogle ScholarPubMed
Bastian, GE, Buro, D & Palmer-Keenan, DM (2021) Recommendations for integrating evidence-based, sustainable diet information into nutrition education. Nutrients 13, 4170.10.3390/nu13114170CrossRefGoogle ScholarPubMed
Lassale, C, Batty, GD, Baghdadli, A, et al. (2019) Healthy dietary indices and risk of depressive outcomes: a systematic review and meta-analysis of observational studies. Mol Psychiatry 24, 965986.CrossRefGoogle ScholarPubMed
Shafiei, F, Salari-Moghaddam, A, Larijani, B, et al. (2019) Adherence to the Mediterranean diet and risk of depression: a systematic review and updated meta-analysis of observational studies. Nutr Rev 77, 230239.CrossRefGoogle Scholar
Lee, MF, Eather, R & Best, T (2021) Plant-based dietary quality and depressive symptoms in Australian vegans and vegetarians: a cross-sectional study. BMJ Nutr Prev Health 4, 479486.CrossRefGoogle Scholar
Zamani, B, Daneshzad, E, Siassi, F, et al. (2020) Association of plant-based dietary patterns with psychological profile and obesity in Iranian women. Clin Nutr 39, 17991808.10.1016/j.clnu.2019.07.019CrossRefGoogle ScholarPubMed
Daneshzad, E, Keshavarz, S-A, Qorbani, M, et al. (2020) Association of dietary acid load and plant-based diet index with sleep, stress, anxiety and depression in diabetic women. Br J Nutr 123, 901912.10.1017/S0007114519003179CrossRefGoogle ScholarPubMed
Askari, M, Daneshzad, E, Darooghegi Mofrad, M, et al. (2020) Vegetarian diet and the risk of depression, anxiety, and stress symptoms: a systematic review and meta-analysis of observational studies. Crit Rev Food Sci Nutr 63, 261271.Google Scholar
Skarupski, KA, Tangney, C, Li, H, et al. (2010) Longitudinal association of vitamin B-6, folate, and vitamin B-12 with depressive symptoms among older adults over time. Am J Clin Nutr 92, 330335.10.3945/ajcn.2010.29413CrossRefGoogle ScholarPubMed
Xu, Y, Wang, C, J Klabnik, J, et al. (2014) Novel therapeutic targets in depression and anxiety: antioxidants as a candidate treatment. Curr Neuropharmacol 12, 108119.CrossRefGoogle ScholarPubMed
Derom, M-L, Sayón-Orea, C, Martínez-Ortega, JM, et al. (2013) Magnesium and depression: a systematic review. Nutr Neurosci 16, 191206.CrossRefGoogle ScholarPubMed
Sánchez-Villegas, A, Verberne, L, De Irala, J, et al. (2011) Dietary fat intake and the risk of depression: the SUN Project. PloS one 6, e16268.CrossRefGoogle ScholarPubMed
Kan, C, Silva, N, Golden, SH, et al. (2013) A systematic review and meta-analysis of the association between depression and insulin resistance. Diabetes Care 36, 480489.CrossRefGoogle ScholarPubMed
Haghighatdoost, F, Azadbakht, L, Keshteli, AH, et al. (2016) Glycemic index, glycemic load, and common psychological disorders. Am J Clin Nutr 103, 201209.CrossRefGoogle ScholarPubMed
Pariante, CM (2017) Why are depressed patients inflamed? A reflection on 20 years of research on depression, glucocorticoid resistance and inflammation. Eur Neuropsychopharmacol 27, 554559.CrossRefGoogle ScholarPubMed
Medawar, E, Huhn, S, Villringer, A, et al. (2019) The effects of plant-based diets on the body and the brain: a systematic review. Transl Psychiatry 9, 117.CrossRefGoogle ScholarPubMed
Bonaccio, M, Pounis, G, Cerletti, C, et al. (2017) Mediterranean diet, dietary polyphenols and low grade inflammation: results from the MOLI-SANI study. Br J Clin Pharmacol 83, 107113.CrossRefGoogle ScholarPubMed
Freeman, D, Sheaves, B, Waite, F, et al. (2020) Sleep disturbance and psychiatric disorders. Lancet Psychiatry 7, 628637.CrossRefGoogle ScholarPubMed
St-Onge, MP, Mikic, A & Pietrolungo, CE (2016) Effects of diet on sleep quality. Adv Nutr 7, 938949.10.3945/an.116.012336CrossRefGoogle ScholarPubMed
van der Pols, JC (2018) Nutrition and mental health: bidirectional associations and multidimensional measures. Public Health Nutr 21, 829830.Google ScholarPubMed
Northstone, K, Joinson, C & Emmett, P (2018) Dietary patterns and depressive symptoms in a UK cohort of men and women: a longitudinal study. Public Health Nutr 21, 831837.CrossRefGoogle Scholar
Elstgeest, LEM, Visser, M, Penninx, B, et al. (2019) Bidirectional associations between food groups and depressive symptoms: longitudinal findings from the Invecchiare in Chianti (InCHIANTI) study. Br J Nutr 121, 439450.10.1017/S0007114518003203CrossRefGoogle ScholarPubMed
Figure 0

Table 1. General characteristic of participants across the tertiles of WISH sub-scores

Figure 1

Table 2. Energy-adjusted dietary intakes of study participants across the tertiles of WISH sub-scores

Figure 2

Table 3. Multiple-adjusted OR and 95 % CI across the tertiles of WISH sub-scores

Supplementary material: File

Jafari et al. supplementary material

Jafari et al. supplementary material
Download Jafari et al. supplementary material(File)
File 158.7 KB