Next Article in Journal
Mitigating Age-Related Cognitive Decline and Oxidative Status in Rats Treated with Catechin and Polyphenon-60
Next Article in Special Issue
Nutrient Intake and Its Association with Appendicular Total Lean Mass and Muscle Function and Strength in Older Adults: A Population-Based Study
Previous Article in Journal
Daily Consumption of Golden Berry (Physalis peruviana) Has Been Shown to Halt the Progression of Insulin Resistance and Obesity in Obese Rats with Metabolic Syndrome
Previous Article in Special Issue
Obesity in Nursing Home Patients: Association with Common Care Problems
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
Nutrients
Volume 16
Issue 3
10.3390/nu16030366
nutrients-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Adherence to a Mediterranean Diet Is Inversely Associated with Anxiety and Stress but Not Depression: A Cross-Sectional Analysis of Community-Dwelling Older Australians

by
Lisa Allcock
1,
Evangeline Mantzioris
2 and
Anthony Villani
1,*
1
School of Health, University of the Sunshine Coast, Sippy Downs, QLD 4556, Australia
2
Clinical and Health Sciences & Alliance for Research in Exercise, Nutrition and Activity (ARENA), University of South Australia, Adelaide, SA 5000, Australia
*
Author to whom correspondence should be addressed.
Nutrients 2024, 16(3), 366; https://doi.org/10.3390/nu16030366
Submission received: 20 November 2023 / Revised: 7 December 2023 / Accepted: 23 January 2024 / Published: 26 January 2024
(This article belongs to the Special Issue Geriatric Nursing Nutrition)
Review Reports Versions Notes

Abstract

:
Diet quality may be an important modifiable risk factor for mental health disorders. However, these findings have been inconsistent, particularly in older adults. We explored the independent associations between adherence to a Mediterranean diet (MedDiet) and severity of symptoms related to depression, anxiety and stress in older adults from Australia. This was a cross-sectional analysis of older Australians ≥ 60 years. MedDiet adherence was assessed using the Mediterranean Diet Adherence Screener (MEDAS), and the Depression, Anxiety and Stress Scale (DASS−21) was used to assess the severity of negative emotional symptoms. A total of n = 294 participants were included in the final analyses (70.4 ± 6.2 years). Adherence to a MedDiet was inversely associated with the severity of anxiety symptoms (β = −0.118; CI: −0.761, −0.012; p = 0.043) independent of age, gender, BMI, physical activity, sleep, cognitive risk and ability to perform activities of daily living. Furthermore, MedDiet adherence was inversely associated with symptoms of stress (β = −0.151; CI: −0.680, −0.073; p = 0.015) independent of age, gender, BMI, physical activity and sleep. However, no relationship between MedDiet adherence and depressive symptoms was observed. We showed that adherence to a MedDiet is inversely associated with the severity of symptoms related to anxiety and stress but not depression. Exploring these findings with the use of longitudinal analyses and robust clinical trials are needed to better elucidate these findings in older adults.

1. Introduction

With the unprecedented global trend in population ageing [1,2], supporting healthy ageing is paramount. Although different conceptual approaches have been used to define healthy ageing, the World Health Organization recently introduced the concept of intrinsic capacity, resulting in a shift away from a deficit-orientated to a function-based approach [2]. As such, intrinsic capacity is largely defined as a composite measure of an individual’s physical and mental capacity that an individual can draw upon throughout their lifespan [3,4]. Nevertheless, despite population ageing, increased longevity does not accompany healthy ageing. Non-communicable diseases and multi-morbidity are major contributors to years lived with disability, with musculoskeletal conditions being a major contributor to global disability [5,6]. Literature supporting the benefits associated with the maintenance of physical function and strength with age is compelling [7,8,9]. However, non-communicable diseases, including musculoskeletal disorders, only partially contribute to years lived with disability, with mental health disorders being a major influence for disability and disease burden, particularly in older adults [10,11].
Mental health disorders, including depressive and anxiety disorders, are commonly reported in older adults [12,13,14]. Despite the marked heterogeneity in its clinical presentation [15], risk factors for depression and anxiety in older adults can be identified as biological, psychological and social risk factors. Multi-morbidity, low self-perceived quality of life, reduced autonomy, functional disability, financial stress, inadequate social networks, social isolation and female gender have all been identified as important risk factors for both the prevalence and incidence of anxiety and depression in older people [14]. Furthermore, there is meta-analytic evidence suggesting a bi-directional relationship between various comorbidities and incident depression, including cardiometabolic disease [16,17,18], overweight and obesity [19] and physical frailty [20]. Of interest, depression and the aforementioned conditions appear to share similar underlying pathophysiological mechanisms, such as higher levels of pro-inflammatory cytokines (e.g., TNF-α, IL−6, etc.) [21,22,23]. Despite this shared interaction, mental health disorders are not homogenous and are indeed a complex phenomenon with complex pathophysiology and multiple aetiologies [24].
An increasing body of evidence has emerged suggesting that lifestyle behaviours, including diet quality, may be an important modifiable risk factor for mental health disorders [25,26,27]. The Mediterranean diet (MedDiet) is often described as an anti-inflammatory diet and has been thoroughly investigated and endorsed as a dietary pattern beneficial for reducing chronic disease risk and supporting healthy ageing [28,29]. The traditional MedDiet is generally described as plant-based in origin, with smaller quantities of fish and seafood and eggs and fermented dairy, as well as a low or infrequent intake of red and processed meats, butter and ultra-processed foods [30,31]. Greater adherence to a MedDiet and/or anti-inflammatory diet is inversely associated with a risk of depression or depressive symptoms in both younger and middle-aged adults [32,33,34,35]. However, these findings have not always been consistent [36,37,38]. A comparison of these findings is somewhat challenging due to the heterogeneity in study designs (e.g., cross-sectional, longitudinal, interventions), age groups (e.g., younger vs. middle aged vs. older adults) and the examined outcomes of interest (e.g., incident depression, depressive symptoms, anxiety vs. depression).
Given the complexity of mental health aetiology and its interrelation with lifestyle behaviours such as diet, together with a paucity of evidence from older adults, the purpose of this study was to explore the relationship between adherence to a MedDiet, including its individual dietary constituents, and severity of symptoms related to depression, anxiety and stress in older adults living in Australia.

2. Materials and Methods

2.1. Study Design, Setting and Participants

We conducted an online survey using a cross-sectional study design in independently living older adults aged ≥ 60 years from Australia. Participants aged < 60 years who lived outside of Australia and/or were unable to complete the questionnaire in English were excluded. Participants were recruited using social media platforms and through networking with Local Government Councils. Qualtrics™ (Provo, UT, USA; https://www.qualtrics.com/, accessed on 7 February 2022) survey software was used to develop and administer the survey. This study was conducted according to the guidelines outlined in the Declaration of Helsinki and was approved by the Research Ethics Committees at the University of the Sunshine Coast (S221680) and the University of South Australia (204450). Participants acknowledged an informed consent statement at the beginning of the online questionnaire prior to participation.

2.2. Outcome Measures

We used a self-administered online questionnaire (75-items) to assess the potential association between adherence to a MedDiet and severity of symptoms related to depression, anxiety and stress. We previously published the comprehensive methodology elsewhere [39]. In brief, we used previously validated tools including the Lawton’s iADLs scale [40,41], AD8 dementia screening intervention [42,43,44], the Depression, Anxiety and Stress Scale (DASS-21) [45] and the MEDAS [46,47]. In this study, we used the Lawton’s iADLs scale [40,41] and the AD8 dementia screening intervention [42,43,44] as potential confounders in our statistical analyses. The Lawton’s iADL scale assesses an individual’s functional capabilities for the following tasks: use of the telephone, food shopping and preparation, housekeeping, laundry, transportation, medication use and the ability to handle one’s own finances. The AD8 dementia screening intervention was used to discern between normal cognitive status and signs and symptoms of dementia risk.

2.3. Symptoms of Depression, Anxiety and Stress

The DASS-21 was used to assess the severity of symptoms related to depression, anxiety and stress. This 21-item validated screening tool [48] comprises a set of three subscales (depression, anxiety and stress), each containing seven items where participants were asked to identify the presence of depression, anxiety or stress symptoms over the previous week. The depression subscale evaluates symptoms of low mood or loss of motivation; the anxiety subscale assesses symptoms of ongoing anxiety and worry; the stress subscale evaluates ongoing irritability and difficulty with unwinding. Responses to each statement were rated using a 4-point Likert scale with each item scored from 0 (did not apply to me) to 3 (applied to me very much or most of the time), with 0 indicating no presence of the symptom and 3 indicating that the symptom was present most of the time [45,49]. To identify the degree of severity for each of these emotional states, DASS-21 sub-scale severity ratings were calculated based on the original DASS-42 severity rating [49]. Specifically, each subscale was multiplied by 2 and divided into severity categories to yield equivalent scores for clinical purposes (Table 1) [49]. The DASS-21 has previously demonstrated positive psychometric properties when applied in older adults, demonstrating high convergent validity, acceptable discriminative validity and good-to-excellent internal consistency with a Cronbach alpha of 0.86–0.90 [50].

2.4. Mediterranean Diet Adherence

MedDiet adherence was evaluated using the 14-item MEDAS [47], which was developed and used in the PREDIMED study [46]. We have previously described the scoring and serve size and frequency of consumption criteria for the MEDAS elsewhere [39]. In brief, each of the 14 questions were scored as 0 (did not meet criteria) or 1 (achieved criteria), to generate a maximum score of 14, where higher scores indicate greater adherence (Table 2) [47].

2.5. Statistical Analysis

All continuous variables were presented as means ± standard deviation (SD), or median and interquartile ranges (IQR), with categorical data presented as frequencies and percentages. Independent samples t-tests were used to identify differences in demographic characteristics between genders. Multiple regression diagnostics were performed to ensure the basic assumptions of multicollinearity and homoscedasticity were not infringed. Multivariable linear regression analyses were used to investigate the independent association between adherence to a MedDiet (and the individual dietary constituents) on the severity of symptoms related to depression, anxiety and stress. In our regression analysis, we used covariates including age, gender, BMI, physical activity status, sleep duration, risk of cognitive impairment and ability to perform iADLs. Analyses were performed using the Statistical Package for the Social Sciences (SPSS) for Windows 27.0 software (IDM Corp., Armonk, NY, USA), with statistical significance set a p < 0.05.

3. Results

A total of n = 303 community-dwelling older Australians commenced the questionnaire; however, n = 294 participants (Females, n = 201; Males, n = 91; n = 2 unspecified) completed all components of the questionnaire, which was used in the final analysis. Demographic characteristics are reported in Table 3. Few participants self-reported a diagnosis of depression or anxiety (Depression: n = 41; 13.5%; Anxiety: n = 5; 1.7%). According to DASS-21 subscale scores, the total sample did not show ‘greater than normal’ symptoms of depression (6.0 (10.0); range: 0–40), anxiety (4.0 (8.0); range: 0–28) or stress (8.0 (10.0); range: 0–30). However, a total of n = 99 participants (33.7%) scored ‘mild’ or above for depressive symptoms in accordance with the DASS-21. A similar number of participants (n = 80; 27.2%) scored ‘mild’ or above for symptoms related to anxiety. By contrast, n = 47 participants (16%) scored ‘mild’ or greater for symptoms associated with stress. No significant differences for symptoms related to depression, anxiety or stress were observed between genders.
MedDiet adherence scores of the entire sample were moderate (5.6 ± 2.0; range: 1–11), with females reporting greater adherence to the diet relative to males (Females: 5.9 ± 1.9; Males: 4.9 ± 2.2; p = <0.001). MedDiet adherence was inversely associated with the severity of anxiety symptoms (β = −0.118; CI: −0.761, −0.012; p = 0.043) in the fully adjusted model (Table 4). We also showed that MedDiet adherence was inversely associated with symptoms of stress (β = −0.151; CI: −0.680, −0.073; p = 0.015). However, significance was lost after adjusting for cognitive risk. No relationship between MedDiet adherence and depressive symptoms was observed.
When we assessed individual dietary components of the MEDAS, increased vegetable intake was inversely associated with depressive symptoms, independent of age, gender, BMI, physical activity and sleep duration (β = −0.117; CI: −4.069, −0.063; p = 0.043). Nevertheless, significance was lost after adjusting for cognitive risk. Furthermore, fruit intake was inversely associated with symptoms of stress, independent of all covariates used in the fully adjusted model (β = −0.119; CI: −3.537, −0.133; p = 0.035). We also showed that nut consumption was inversely associated with both stress and anxiety symptoms independent of age, gender, BMI, physical activity and sleep duration (stress: β = −0.180; CI: −4.145, −0.789; p = 0.004; anxiety: β = −0.159; CI: −2.901, −0.392; p = 0.010). However, these findings were no longer significant after we adjusted for cognitive risk. We also observed an inverse relationship between legume intake and the severity of anxiety symptoms (β = −0.133; CI: −3.210, −0.199; p = 0.027). Nevertheless, significance was lost after adjusting for cognitive risk. Lastly, a low consumption of sugar-sweetened beverages was inversely associated with symptoms of anxiety, independent of all covariates used in the fully adjusted model (β = −0.136; CI: −2.897, −0.361; p = 0.012). No other significant findings for any other individual dietary constituent included in the MEDAS were observed.

4. Discussion

We explored the independent associations between adherence to a MedDiet and severity of symptoms related to depression, anxiety and stress in older adults. We showed that adherence to a MedDiet was inversely associated with severity of symptoms related to anxiety and stress. However, adherence to a MedDiet was not related to depressive symptoms. In addition, we showed that certain individual dietary elements of a MedDiet, including fruit, nuts, legumes and a low consumption of sugar-sweetened beverages (<250mL per day) were inversely associated with the severity of symptoms related to anxiety and stress. Nevertheless, these findings should be interpreted with caution given the potential for selection bias in the recruitment of study participants in an online survey.
Our findings are inconsistent with the previous literature, including clinical trials and meta-analytical evidence, suggesting that greater adherence to a MedDiet is inversely associated with depressive symptoms [32,33,34,35,51,52,53]. Nevertheless, all previously published systematic reviews and meta-analysis have also reported high heterogeneity between studies. This could be related to several factors including methodological differences in the tools used to assess MedDiet adherence, making the interpretation between results challenging. As such, much of the previously published literature assessed MedDiet adherence using the Mediterranean Diet Score (MDS) (or an adaptation of it) developed by Trichopoulou et al. [54], which is largely dependent on the usual dietary behaviours and intake of the studied population and not necessarily reflective of a traditional MedDiet. In this study, we assessed MedDiet adherence using the MEDAS, which is based on previously established normative criteria and is more aligned with a traditional Mediterranean-style diet. Furthermore, inconsistent results in the literature could also be explained, at least in part, by differences in the modalities used to identify depression or depressive symptoms. Consistent with our findings, Bardinet et al. [37] reported no significant association between MedDiet adherence and the risk of depression after 15 years of follow-up in French older adults from the Three-City (3C) cohort. Unlike this study, the aforementioned longitudinal analysis [37] assessed depressive symptoms across multiple time points using the CES-D, scale which was administered by a neuropsychologist during face-to-face interviews. Nevertheless, the DASS-21 used in this study has previously exhibited evidence for bifactor structural validity, internal consistency, criterion validity and construct validity. As such, the psychometric robustness of the DASS-21 suggests that it can be applied to both healthy and clinical populations for the assessment of negative emotions related to depression, anxiety and stress [48].
Importantly, only a limited number of studies have been conducted in older adults, with many of these failing to adjust for important covariates including cognitive status, which tends to co-exist with depression in older adults [55,56]. In this study, we adjusted for cognitive status using the AD8 dementia screening intervention. In contrast to our findings, after excluding participants with known dementia and controlling for baseline cognitive status, Mamalaki et al. [57] reported that an increase in MedDiet adherence was associated with a 6.2% decreased risk for depression in a longitudinal analysis of older adults from Central Greece. Given that adherence to a MedDiet is also inversely associated with cognitive risk in older adults [58], adjusting for cognitive function is likely to be an important consideration when exploring the relationship between diet and depressive symptomology. Moreover, given that depression is multidimensional, involving a number of biological, psychological and social risk factors, the adoption of a healthy dietary pattern as a single preventative strategy is unlikely to attenuate depressive symptoms alone. Irrespective, additional research is needed to better understand the inconsistencies in results between different aged participants.
Despite the null association with depression, we showed that adherence to a MedDiet was inversely associated with the severity of symptoms related to anxiety and stress. Although this finding is consistent with the previous literature [59,60,61], evidence remains scant in older adults. Although the underlying mechanisms are not completely established, there are likely to be a number of physiological mechanisms connecting MedDiet adherence with the attenuation of negative emotional status, including symptoms of depression, anxiety and stress. Specifically, there is consistent evidence generated over numerous decades suggesting an imbalance between oxidative stress, and antioxidant defences is an important pathophysiological consideration in the aetiology of depression and associated disorders [62,63]. Additionally, the consumption of fruits, vegetables and naturally occurring antioxidants, including vitamin C and beta cryptoxanthin, are inversely associated with depression in older adults [64]. There is also meta-analytical evidence derived from observational studies supporting this finding [65]. In this study, we showed that increased vegetable intake, as defined by the MEDAS, was inversely associated with symptoms of depression, and fruit intake was inversely associated with stress-related symptoms. In addition, there is mounting evidence to support reciprocal pathways between the upregulation of pro-inflammatory cytokines and mood disturbances [66,67,68,69]. There is now evidence emerging that this may indeed be mediated by changes to the gut microbiota [70,71]. We also observed that the increased intake of nuts and legumes, as defined by the MEDAS, was inversely associated with the severity of symptoms related to anxiety. Both nuts and legumes, which are key dietary constituents of a MedDiet, are rich in dietary fibre, unsaturated fatty acids and bioactive compounds (e.g., antioxidants and polyphenols), which elicit a favourable prebiotic effect on the gut microbiota composition and metabolite production [72]. Lastly, sugar-sweetened beverages, the hallmark of a Western dietary pattern, are associated with a number of poor health outcomes, including depression and anxiety [73], and have been shown to cause unfavourable changes to the composition and function of the gut microbiota [74]. In this study, we observed that the low consumption of sugar-sweetened beverages (<250 mL per day) was inversely associated with symptoms of anxiety. Although we observed no relationship between MedDiet adherence and depressive symptoms, this may be due to the focus of our study being on older adults, where the literature has been inconsistent. As such, a Mediterranean-style diet should be promoted to support healthy ageing due to its efficacy on reducing the risks associated with multiple chronic diseases, including depression and associated disorders [75]. Nevertheless, further prospective studies and robust clinical trials with adequate samples, particularly in older adults with established mental health disorders, are needed before such interventions can be effectively integrated into clinical guidelines and practice. An approach that integrates knowledge about healthy dietary patterns, such as the MedDiet, combined with the pathophysiological mechanisms of action is needed to help develop such evidence-based clinical guidelines. Specifically, future research should be positioned to address the efficacy of MedDiet interventions as an adjunctive treatment for attenuating symptoms of mental health disorders in older adults. This will allow practitioners to adopt nutritional medicine as an adjunct therapy in psychiatric practice for the management of mental health symptomology.
A number of important limitations should be considered when interpreting these results. Firstly, the cross-sectional nature of this study prevents causality from being established. Furthermore, our results may also be overstated, given that our sample was relatively healthy, independent and generally free from major mental health disorders (13.5% with self-reported depression and 1.7% with self-reported anxiety). Our recruitment methods (online survey) were also likely to introduce selection bias, with potential participants not active on social media platforms being unable to participate to ensure a more representative sample. Other limitations include the collection of MedDiet adherence data, and symptoms of depression, anxiety and stress were self-reported, thus increasing the potential for recall or social desirability bias. Furthermore, the DASS-21, despite its clinical application, is not a clinical diagnostic tool for depression and may not identify true psychological manifestations that are unique to older adults. Moreover, it is possible that any observed association between MedDiet adherence and severity of symptoms related to anxiety were secondary to a reduction in disease risk, improved health-related quality of life or improvements in the management of clinical perturbations, rather than a direction association with mental health and psychological well-being. Lastly, residual confounding should also be considered. Specifically, our regression analyses were not controlled for a previous history of disordered eating, socioeconomic status, smoking status, medical history or medication use.

5. Conclusions

We report that adherence to a MedDiet was inversely associated with severity of symptoms related to anxiety and stress in community-dwelling older Australians. However, this relationship was not observed for depressive symptoms. We also observed that specific dietary components of a MedDiet, including a low consumption of sugar-sweetened beverages as well as increased fruit, nut and legume consumption were all independently and inversely associated with symptoms of anxiety. Our results therefore contribute to the wider literature in support of adherence to a healthy dietary pattern to mitigate mental health disorders. Nevertheless, these findings should be investigated further using well-controlled longitudinal analyses and robust clinical trials to better elucidate these findings in older adults.

Author Contributions

L.A. and A.V. were responsible for conceptualization, methodology, data curation, formal analysis, writing—original draft and writing—review and editing. E.M. was responsible for data curation, formal analysis and writing—review and editing. A.V. and E.M. were additionally responsible for supervision. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was approved by the Research Ethics Committees at the University of the Sunshine Coast (S231800; 19 January 2022) and the University of South Australia (205348; 1 February 2022). Prior to participating in the study, participants acknowledged and agreed to an informed consent statement.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data that support these findings are available from the corresponding author upon reasonable request.

Acknowledgments

We thank our participants for their time and efforts that made this study possible.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Cheng, X.; Yang, Y.; Schwebel, D.C.; Liu, Z.; Li, L.; Cheng, P.; Ning, P.; Hu, G. Population ageing and mortality during 1990–2017: A global decomposition analysis. PLoS Med. 2020, 17, e1003138. [Google Scholar] [CrossRef]
  2. World Heath Organization. Decade of Healthy Ageing: Baseline Report. 2020. Available online: https://apps.who.int/iris/handle/10665/338677 (accessed on 1 August 2023).
  3. Beard, J.R.; Officer, A.; De Carvalho, I.A.; Sadana, R.; Pot, A.M.; Michel, J.P.; Lloyd-Sherlock, P.; Epping-Jordan, J.E.; Peeters, G.M.E.E.G.; Mahanani, W.R.; et al. The World report on ageing and health: A policy framework for healthy ageing. Lancet 2016, 387, 2145–2154. [Google Scholar] [CrossRef]
  4. Belloni, G.; Cesari, M. Frailty and intrinsic capacity: Two distinct but related constructs. Front. Med. 2019, 6, 133. [Google Scholar] [CrossRef]
  5. Smith, E.; Hoy, D.G.; Cross, M.; Vos, T.; Naghavi, M.; Buchbinder, R.; Woolf, A.D.; March, L. The global burden of other musculoskeletal disorders: Estimates from the Global Burden of Disease 2010 study. Ann. Rheum. Dis. 2014, 73, 1462–1469. [Google Scholar] [CrossRef]
  6. Ärnlöv, J.; Larsson, A. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015, 386, 743–800. [Google Scholar]
  7. Dipietro, L.; Campbell, W.W.; Buchner, D.M.; Erickson, K.I.; Powell, K.E.; Bloodgood, B.; Hughes, T.; Day, K.R.; Piercy, K.L.; Vaux-Bjerke, A.; et al. Physical activity, injurious falls, and physical function in aging: An umbrella review. Med. Sci. Sports Exerc. 2019, 51, 1303–1313. [Google Scholar] [CrossRef] [PubMed]
  8. Justice, J.N.; Cesari, M.; Seals, D.R.; Shively, C.A.; Carter, C.S. Comparative approaches to understanding the relation between aging and physical function. J. Gerontol. A Biol. Sci. Med. Sc. 2016, 71, 1243–1253. [Google Scholar] [CrossRef] [PubMed]
  9. Yates, T.; Zaccardi, F.; Dhalwani, N.N.; Davies, M.J.; Bakrania, K.; Celis-Morales, C.A.; Gill, J.M.R.; Franks, P.W.; Khunti, K. Association of walking pace and handgrip strength with all-cause, cardiovascular, and cancer mortality: A UK Biobank observational study. Eur. Heart J. 2017, 38, 3232–3240. [Google Scholar] [CrossRef] [PubMed]
  10. Rehm, J.; Shield, K.D. Global burden of disease and the impact of mental and addictive disorders. Curr. Psychiatry Rep. 2019, 21, 10. [Google Scholar] [CrossRef] [PubMed]
  11. Friedrich, M.J. Depression is the leading cause of disability around the world. JAMA 2017, 317, 1517. [Google Scholar] [CrossRef]
  12. Byers, A.L.; Yaffe, K.; Covinsky, K.E.; Friedman, M.B.; Bruce, M.L. High occurrence of mood and anxiety disorders among older adults: The National Comorbidity Survey Replication. Arch. Gen. Psychiatry 2010, 67, 489–496. [Google Scholar] [CrossRef]
  13. Wolitzky-Taylor, K.B.; Castriotta, N.; Lenze, E.J.; Stanley, M.A.; Craske, M. Anxiety disorders in older adults: A comprehensive review. Depress. Anxiety 2010, 27, 190–211. [Google Scholar] [CrossRef] [PubMed]
  14. Vink, D.; Aartsen, M.J.; Schoevers, R.A. Risk factors for anxiety and depression in the elderly: A review. J. Affect. Disord. 2008, 106, 29–44. [Google Scholar] [CrossRef]
  15. Lesch, K.P. Gene–environment interaction and the genetics of depression. J. Psychiatry Neurosci. 2004, 29, 174–184. [Google Scholar] [PubMed]
  16. Wium-Andersen, M.K.; Wium-Andersen, I.K.; Prescott, E.I.B.; Overvad, K.; Jørgensen, M.B.; Osler, M. An attempt to explain the bidirectional association between ischaemic heart disease, stroke and depression: A cohort and meta-analytic approach. Br. J. Psychiatry 2020, 217, 434–441. [Google Scholar] [CrossRef] [PubMed]
  17. Pan, A.; Keum, N.; Okereke, O.I.; Sun, Q.; Kivimaki, M.; Rubin, R.R.; Hu, F.B. Bidirectional association between depression and metabolic syndrome: A systematic review and meta-analysis of epidemiological studies. Diabetes Care 2012, 35, 1171–1180. [Google Scholar] [CrossRef] [PubMed]
  18. Ogunmoroti, O.; Osibogun, O.; Spatz, E.S.; Okunrintemi, V.; Mathews, L.; Ndumele, C.E.; Michos, E.D. A systematic review of the bidirectional relationship between depressive symptoms and cardiovascular health. Prev. Med. 2022, 154, 106891. [Google Scholar] [CrossRef] [PubMed]
  19. Luppino, F.S.; de Wit, L.M.; Bouvy, P.F.; Stijnen, T.; Cuijpers, P.; Penninx, B.W.; Zitman, F.G. Overweight, obesity, and depression: A systematic review and meta-analysis of longitudinal studies. Arch. Gen. Psychiatry 2010, 67, 220–229. [Google Scholar] [CrossRef] [PubMed]
  20. Soysal, P.; Veronese, N.; Thompson, T.; Kahl, K.G.; Fernandes, B.S.; Prina, A.M.; Solmi, M.; Schofield, P.; Koyanagi, A.; Tseng, P.-T.; et al. Relationship between depression and frailty in older adults: A systematic review and meta-analysis. Ageing Res. Rev. 2017, 36, 78–87. [Google Scholar] [CrossRef]
  21. Schachter, J.; Martel, J.; Lin, C.S.; Chang, C.J.; Wu, T.R.; Lu, C.C.; Lai, H.C.; Ojcius, D.M.; Young, J.D. Effects of obesity on depression: A role for inflammation and the gut microbiota. Brain Behav. Immun. 2018, 69, 1–8. [Google Scholar] [CrossRef]
  22. Shao, M.; Lin, X.; Jiang, D.; Tian, H.; Xu, Y.; Wang, L.; Ji, F.; Zhou, C.; Song, X.; Zhuo, C. Depression and cardiovascular disease: Shared molecular mechanisms and clinical implications. Psychiatry Res. 2020, 285, 112802. [Google Scholar] [CrossRef]
  23. Alexopoulos, G.S.; Morimoto, S.S. The inflammation hypothesis in geriatric depression. Int. J. Geriatr. Psychiatry 2011, 26, 1109–1118. [Google Scholar] [CrossRef] [PubMed]
  24. Tian, H.; Hu, Z.; Xu, J.; Wang, C. The molecular pathophysiology of depression and the new therapeutics. MedComm 2022, 3, e156. [Google Scholar] [CrossRef] [PubMed]
  25. Quirk, S.E.; Williams, L.J.; O’Neil, A.; Pasco, J.A.; Jacka, F.N.; Housden, S.; Berk, M.; Brennan, S.L. The association between diet quality, dietary patterns and depression in adults: A systematic review. BMC Psychiatry 2013, 13, 175. [Google Scholar] [CrossRef] [PubMed]
  26. Teasdale, S.B.; Ward, P.B.; Samaras, K.; Firth, J.; Stubbs, B.; Tripodi, E.; Burrows, T.L. Dietary intake of people with severe mental illness: Systematic review and meta-analysis. Br. J. Psychiatry 2019, 214, 251–259. [Google Scholar] [CrossRef] [PubMed]
  27. Molendijk, M.; Molero, P.; Sánchez-Pedreño, F.O.; Van der Does, W.; Martínez-González, M.A. Diet quality and depression risk: A systematic review and dose-response meta-analysis of prospective studies. J. Affect. Disord. 2018, 226, 346–354. [Google Scholar] [CrossRef] [PubMed]
  28. Dinu, M.; Pagliai, G.; Casini, A.; Sofi, F. Mediterranean diet and multiple health outcomes: An umbrella review of meta-analyses of observational studies and randomised trials. Eur. J. Clin. Nutr. 2018, 72, 30–43. [Google Scholar] [CrossRef] [PubMed]
  29. Critselis, E.; Panagiotakos, D. Adherence to the Mediterranean diet and healthy ageing: Current evidence, biological pathways, and future directions. Crit. Rev. Food Sci. Nutr. 2020, 60, 2148–2157. [Google Scholar] [CrossRef] [PubMed]
  30. Trichopoulou, A.; Martínez-González, M.A.; Tong, T.Y.; Forouhi, N.G.; Khandelwal, S.; Prabhakaran, D.; Mozaffarian, D.; de Lorgeril, M. Definitions and potential health benefits of the Mediterranean diet: Views from experts around the world. BMC Med. 2014, 12, 112. [Google Scholar] [CrossRef]
  31. Davis, C.; Bryan, J.; Hodgson, J.; Murphy, K. Definition of the Mediterranean diet: A literature review. Nutrients 2015, 7, 9139–9153. [Google Scholar] [CrossRef]
  32. Gianfredi, V.; Dinu, M.; Nucci, D.; Eussen, S.J.; Amerio, A.; Schram, M.T.; Schaper, N.; Odone, A. Association between dietary patterns and depression: An umbrella review of meta-analyses of observational studies and intervention trials. Nutr. Rev. 2023, 81, 346–359. [Google Scholar] [CrossRef]
  33. Altun, A.; Brown, H.; Szoeke, C.; Goodwill, A.M. The Mediterranean dietary pattern and depression risk: A systematic review. Neurol. Psychiatry Brain Res. 2019, 33, 1–10. [Google Scholar] [CrossRef]
  34. Wu, P.Y.; Chen, K.M.; Belcastro, F. Dietary patterns and depression risk in older adults: Systematic review and meta-analysis. Nutr. Rev. 2021, 79, 976–987. [Google Scholar] [CrossRef] [PubMed]
  35. Lassale, C.; Batty, G.D.; Baghdadli, A.; Jacka, F.; Sánchez-Villegas, A.; Kivimäki, M.; Akbaraly, T. Healthy dietary indices and risk of depressive outcomes: A systematic review and meta-analysis of observational studies. Mol. Psychiatry 2019, 24, 965–986. [Google Scholar] [CrossRef]
  36. Shafiei, F.; Salari-Moghaddam, A.; Larijani, B.; Esmaillzadeh, A. Adherence to the Mediterranean diet and risk of depression: A systematic review and updated meta-analysis of observational studies. Nutr. Rev. 2019, 77, 230–239. [Google Scholar] [CrossRef]
  37. Bardinet, J.; Chuy, V.; Carriere, I.; Galéra, C.; Pouchieu, C.; Samieri, C.; Helmer, C.; Cougnard-Grégoire, A.; Féart, C. Mediterranean Diet Adherence and Risk of Depressive Symptomatology in a French Population-Based Cohort of Older Adults. Nutrients 2022, 14, 4121. [Google Scholar] [CrossRef] [PubMed]
  38. Matison, A.P.; Mather, K.A.; Flood, V.M.; Reppermund, S. Associations between nutrition and the incidence of depression in middle-aged and older adults: A systematic review and meta-analysis of prospective observational population-based studies. Ageing Res. Rev. 2021, 70, 101403. [Google Scholar] [CrossRef]
  39. Dufournet, M.; Moutet, C.; Achi, S.; Delphin-Combe, F.; Krolak-Salmon, P.; Dauphinot, V.; MEMORA Group. Proposition of a corrected measure of the Lawton instrumental activities of daily living score. BMC Geriatr. 2021, 21, 39. [Google Scholar] [CrossRef]
  40. Hassani Mehraban, A.; Soltanmohamadi, Y.; Akbarfahimi, M.; Taghizadeh, G. Validity and reliability of the persian version of lawton instrumental activities of daily living scale in patients with dementia. Med. J. Islam. Repub. Iran. 2014, 28, 25. Available online: http://mjiri.iums.ac.ir/ (accessed on 1 August 2023).
  41. Shaik, M.A.; Xu, X.; Chan, Q.L.; Hui, R.J.; Chong, S.S.; Chen, C.L.; Dong, Y. The reliability and validity of the informant AD8 by comparison with a series of cognitive assessment tools in primary healthcare. Int. Psychogeriatr. 2016, 28, 443–452. [Google Scholar] [CrossRef]
  42. Galvin, J.E.; Roe, C.M.; Coats, M.A.; Morris, J.C. Patient’s rating of cognitive ability: Using the AD8, a brief informant interview, as a self-rating tool to detect dementia. Arch. Neurol. 2007, 64, 725–730. [Google Scholar] [CrossRef]
  43. Usarel, C.; Dokuzlar, O.; Aydin, A.E.; Soysal, P.; Isik, A.T. The AD8 (Dementia Screening Interview) is a valid and reliable screening scale not only for dementia but also for mild cognitive impairment in the Turkish geriatric outpatients. Int. Psychogeriatr. 2019, 31, 223–229. [Google Scholar] [CrossRef]
  44. Parkitny, L.; McAuley, J. The depression anxiety stress scale (DASS). J. Physiother. 2010, 56, 204. [Google Scholar] [CrossRef]
  45. Martínez-Lapiscina, E.H.; Clavero, P.; Toledo, E.; Estruch, R.; Salas-Salvadó, J.; San Julián, B.; Sanchez-Tainta, A.; Ros, E.; Valls-Pedret, C.; Martinez-Gonzalez, M.Á. Mediterranean diet improves cognition: The PREDIMED-NAVARRA randomised trial. J. Neurol. Neurosurg. Psychiatry. 2013, 84, 1318–1325. [Google Scholar] [CrossRef]
  46. Schröder, H.; Fitó, M.; Estruch, R.; Martínez-González, M.A.; Corella, D.; Salas-Salvadó, J.; Lamuela-Raventós, R.; Ros, E.; Salaverría, I.; Fiol, M.; et al. A short screener is valid for assessing Mediterranean diet adherence among older Spanish men and women. J. Nutr. 2011, 141, 1140–1145. [Google Scholar] [CrossRef]
  47. Allcock, L.; Mantzioris, E.; Villani, A. Adherence to a Mediterranean Diet is associated with physical and cognitive health: A cross-sectional analysis of community-dwelling older Australians. Front. Public. Health 2022, 10, 1017078. [Google Scholar] [CrossRef]
  48. Lee, J.; Lee, E.H.; Moon, S.H. Systematic review of the measurement properties of the Depression Anxiety Stress Scales-21 by applying updated COSMIN methodology. Qual. Life Res. 2019, 28, 2325–2339. [Google Scholar] [CrossRef] [PubMed]
  49. Marijanović, I.; Kraljević, M.; Buhovac, T.; Cerić, T.; Mekić Abazović, A.; Alidžanović, J.; Gojković, Z.; Sokolović, E. Use of the Depression, Anxiety and Stress Scale (DASS-21) Questionnaire to Assess Levels of Depression, Anxiety, and Stress in Healthcare and Administrative Staff in 5 Oncology Institutions in Bosnia and Herzegovina During the 2020 COVID-19 Pandemic. Med. Sci. Monit. 2021, 27, e930812. [Google Scholar] [CrossRef] [PubMed]
  50. Gloster, A.T.; Rhoades, H.M.; Novy, D.; Klotsche, J.; Senior, A.; Kunik, M.; Wilson, N.; Stanley, M.A. Psychometric properties of the Depression Anxiety and Stress Scale-21 in older primary care patients. J. Affect. Disord. 2008, 110, 248–259. [Google Scholar] [CrossRef] [PubMed]
  51. Parletta, N.; Zarnowiecki, D.; Cho, J.; Wilson, A.; Bogomolova, S.; Villani, A.; Itsiopoulos, C.; Niyonsenga, T.; Blunden, S.; Meyer, B.; et al. A Mediterranean-style dietary intervention supplemented with fish oil improves diet quality and mental health in people with depression: A randomized controlled trial (HELFIMED). Nutr. Neurosci. 2019, 22, 474–487. [Google Scholar] [CrossRef] [PubMed]
  52. Jacka, F.N.; O’Neil, A.; Opie, R.; Itsiopoulos, C.; Cotton, S.; Mohebbi, M.; Castle, D.; Dash, S.; Mihalopoulos, C.; Chatterton, M.C.; et al. A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’trial). BMC Med. 2017, 15, 23. [Google Scholar] [CrossRef]
  53. Vicinanza, R.; Bersani, F.S.; D’Ottavio, E.; Murphy, M.; Bernardini, S.; Crisciotti, F.; Frizza, A.; Mazza, V.; Biondi, M.; Troisi, G.; et al. Adherence to Mediterranean diet moderates the association between multimorbidity and depressive symptoms in older adults. Arch. Gerontol. Geriatr. 2020, 88, 104022. [Google Scholar] [CrossRef]
  54. Trichopoulou, A.; Costacou, T.; Bamia, C.; Trichopoulos, D. Adherence to a Mediterranean diet and survival in a Greek population. N. Eng. J. Med. 2003, 348, 2599–2608. [Google Scholar] [CrossRef]
  55. Burhanullah, M.H.; Tschanz, J.T.; Peters, M.E.; Leoutsakos, J.M.; Matyi, J.; Lyketsos, C.G.; Nowrangi, M.A.; Rosenberg, P.B. Neuropsychiatric symptoms as risk factors for cognitive decline in clinically normal older adults: The cache county study. Am. J. Geriatr. Psychiatry 2020, 28, 64–71. [Google Scholar] [CrossRef]
  56. Freire, A.C.C.; Pondé, M.P.; Liu, A.; Caron, J. Anxiety and depression as longitudinal predictors of mild cognitive impairment in older adults. Can. J. Psychiatry 2017, 62, 343–350. [Google Scholar] [CrossRef]
  57. Mamalaki, E.; Ntanasi, E.; Hatzimanolis, A.; Basta, M.; Kosmidis, M.H.; Dardiotis, E.; Hadjigeorgiou, G.M.; Sakka, P.; Scarmeas, N.; Yannakoulia, M. The Association of Adherence to the Mediterranean Diet with Depression in Older Adults Longitudinally Taking into Account Cognitive Status: Results from the HELIAD Study. Nutrients 2023, 15, 359. [Google Scholar] [CrossRef]
  58. Coelho-Júnior, H.J.; Trichopoulou, A.; Panza, F. Cross-sectional and longitudinal associations between adherence to Mediterranean diet with physical performance and cognitive function in older adults: A systematic review and meta-analysis. Ageing Res. Rev. 2021, 70, 101395. [Google Scholar] [CrossRef]
  59. Sadeghi, O.; Keshteli, A.H.; Afshar, H.; Esmaillzadeh, A.; Adibi, P. Adherence to Mediterranean dietary pattern is inversely associated with depression, anxiety and psychological distress. Nutr. Neurosci. 2021, 24, 248–259. [Google Scholar] [CrossRef] [PubMed]
  60. Dinu, M.; Lotti, S.; Napoletano, A.; Corrao, A.; Pagliai, G.; Tristan Asensi, M.; Gianfredi, V.; Nucci, D.; Colombini, B.; Sofi, F. Association between Psychological Disorders, Mediterranean Diet, and Chronotype in a Group of Italian Adults. Int. J. Environ. Res. Public. Health. 2022, 20, 335. [Google Scholar] [CrossRef] [PubMed]
  61. Torabynasab, K.; Shahinfar, H.; Jazayeri, S.; Effatpanah, M.; Azadbakht, L.; Abolghasemi, J. Adherence to the MIND diet is inversely associated with odds and severity of anxiety disorders: A case–control study. BMC Psychiatry 2023, 23, 330. [Google Scholar] [CrossRef] [PubMed]
  62. Bhatt, S.; Nagappa, A.N.; Patil, C.R. Role of oxidative stress in depression. Dug Discov. Today 2020, 25, 1270–1276. [Google Scholar] [CrossRef] [PubMed]
  63. Abshirini, M.; Siassi, F.; Koohdani, F.; Qorbani, M.; Mozaffari, H.; Aslani, Z.; Soleymani, M.; Entezarian, M.; Sotoudeh, G. Dietary total antioxidant capacity is inversely associated with depression, anxiety and some oxidative stress biomarkers in postmenopausal women: A cross-sectional study. Arch. Gen. Psychiatry 2019, 18, 3. [Google Scholar] [CrossRef] [PubMed]
  64. Payne, M.E.; Steck, S.E.; George, R.R.; Steffens, D.C. Fruit, vegetable, and antioxidant intakes are lower in older adults with depression. J. Acad. Nutr. Diet. 2012, 112, 2022–2027. [Google Scholar] [CrossRef] [PubMed]
  65. Saghafian, F.; Malmir, H.; Saneei, P.; Milajerdi, A.; Larijani, B.; Esmaillzadeh, A. Fruit and vegetable consumption and risk of depression: Accumulative evidence from an updated systematic review and meta-analysis of epidemiological studies. Br. J. Nutr. 2018, 119, 1087–1101. [Google Scholar] [CrossRef] [PubMed]
  66. Beurel, E.; Toups, M.; Nemeroff, C.B. The bidirectional relationship of depression and inflammation: Double trouble. Neuron 2020, 107, 234–256. [Google Scholar] [CrossRef] [PubMed]
  67. Majd, M.; Saunders, E.F.; Engeland, C.G. Inflammation and the dimensions of depression: A review. Front. Neuroendocrinol. 2020, 56, 100800. [Google Scholar] [CrossRef]
  68. Messay, B.; Lim, A.; Marsland, A.L. Current understanding of the bi-directional relationship of major depression with inflammation. Biol. Mood Anxiety Disord. 2012, 2, 4. [Google Scholar] [CrossRef]
  69. Hayley, S.; Hakim, A.M.; Albert, P.R. Depression, dementia and immune dysregulation. Brain 2021, 144, 746–760. [Google Scholar] [CrossRef]
  70. Simpson, C.A.; Diaz-Arteche, C.; Eliby, D.; Schwartz, O.S.; Simmons, J.G.; Cowan, C.S. The gut microbiota in anxiety and depression–a systematic review. Clin. Psychol. Rev. 2021, 83, 101943. [Google Scholar] [CrossRef]
  71. Carlessi, A.S.; Borba, L.A.; Zugno, A.I.; Quevedo, J.; Réus, G.Z. Gut microbiota–brain axis in depression: The role of neuroinflammation. Eur. J. Neurosci. 2021, 53, 222–235. [Google Scholar] [CrossRef]
  72. Berding, K.; Vlckova, K.; Marx, W.; Schellekens, H.; Stanton, C.; Clarke, G.; Jacka, F.; Dinan, T.G.; Cryan, J.F. Diet and the microbiota–gut–brain axis: Sowing the seeds of good mental health. Adv. Nutr. 2021, 12, 1239–1285. [Google Scholar] [CrossRef] [PubMed]
  73. Hu, D.; Cheng, L.; Jiang, W. Sugar-sweetened beverages consumption and the risk of depression: A meta-analysis of observational studies. J. Affect. Disord. 2019, 245, 348–355. [Google Scholar] [CrossRef] [PubMed]
  74. Ramne, S.; Brunkwall, L.; Ericson, U.; Gray, N.; Kuhnle, G.G.; Nilsson, P.M.; Orho-Melander, M.; Sonestedt, E. Gut microbiota composition in relation to intake of added sugar, sugar-sweetened beverages and artificially sweetened beverages in the Malmö Offspring Study. Eur. J. Nutr. 2021, 60, 2087–2097. [Google Scholar] [CrossRef] [PubMed]
  75. Opie, R.; Itsiopoulos, C.; Parletta, N.; Sanchez-Villegas, A.; Akbaraly, T.N.; Ruusunen, A.; Jacka, F.N. Dietary recommendations for the prevention of depression. Nutr. Neurosci. 2017, 20, 161–171. [Google Scholar] [CrossRef]
Table 1. Categorization of the severity of symptoms of depression, anxiety and stress derived from individual subscale scores identified with the DASS-21.
Table 1. Categorization of the severity of symptoms of depression, anxiety and stress derived from individual subscale scores identified with the DASS-21.
DepressionAnxietyStress
Normal0–90–70–14
Mild10–138–915–18
Moderate14–2010–1419–25
Severe21–2715–1926–33
Extremely Severe≥28≥20≥34
Abbreviations: DASS-21—Depression, Anxiety, Stress scale 21 items.
Table 2. Serve size and frequency of consumption scoring criteria for the MEDAS.
Table 2. Serve size and frequency of consumption scoring criteria for the MEDAS.
MEDAS QuestionsCriteria for 1 Point
Use of olive oil as the main source of fat when cooking?Yes
How much olive oil do you consume per day?Greater than 4 tablespoons (where 1 tablespoon = 15 g)
How many serves of vegetables per day?Greater than 2 serves of vegetables per day (where 1 × serve is equivalent to 2 × cups vegetables)
How many pieces of fruit do you consume per day?Greater than 3 pieces of fruit per day (this includes whole, tinned or dried fruit but excludes juice)
Serves of red meat per day?Less than 1 serving of red meat per day (where 1 × serve is equivalent to 100–150 g)
Serves of butter, margarine or cream per day?Less than 1 serving of butter, margarine or cream per day (where 1 × serve is equivalent to 10 g)
Serves of sugar-sweetened beverages per day?Less than 250 mL of sugar-sweetened beverages per day
Red wine consumption per week?Greater than 7 serves of red wine per week (where 1 × serve is equivalent to 100 mL)
Serves of pulses/legumes per week?Greater than 3 servings of legumes per week (where 1 × serve is equivalent to 1 × cup)
Servings of fish/seafood per week?Greater than 3 servings of fish or seafood per week (where 1 × serve is equivalent to 100–150 g)
Consumption of commercial pastries such as cookies or cake per week?Less than 3 commercial sweets or pastries per week
Serves of nuts (including peanuts) per week?Greater than 3 or more servings of nuts per week (where 1 × serve is equivalent to 30 g)
Preferential consumption of white meat over red meat? Yes
Frequency of consumption of vegetables, pasta, rice or other dishes with a sauce made with tomato, garlic, onion or leeks sautéed in olive oil?Greater than 2 or more servings per week
Table 3. Participant demographic characteristics by gender *.
Table 3. Participant demographic characteristics by gender *.
CharacteristicsTotalMaleFemale
Age (years)70.4 ± 6.272 ± 6.969.67 ± 5.8
Gender n, % 96 (31.7)205 (67.7)
BMI (kg/m2)28.8 ± 7.229.1 ± 8.728.8 ± 6.5
Education status n, %
No schooling completed1 (0.3) 1 (0.3) 0 (0.0)
Junior or primary school6 (2.0) 5 (5.2) 1 (0.5)
Secondary school58 (19.1) 11 (11.5) 45 (22.0)
Trade/technical/vocational training60 (19.8) 24 (25.0) 36 (17.6)
Diploma56 (18.5) 18 (18.8) 38 (18.5)
Advanced diploma/associate degree22 (7.3) 4 (4.2) 18 (8.8)
Bachelor’s degree54 (17.8) 18 (18.8)36 (17.6)
Postgraduate degree or doctorate45 (14.9) 15 (15.6) 30 (14.6)
Level of mobility n, %
Independent without the use of any aids279 (92.1) 87 (90.6) 190 (92.7)
Mostly dependent on a walking stick15 (5.0) 8 (8.3) 7 (3.4)
Dependent on a four-wheeled walker4 (1.4)0 (0.0) 4 (2.0)
Dependent on a scooter3 (1.0)1 (1.0) 2 (1.0)
Services n, %
No services, fully independent268 (88.4) 83 (86.5) 183 (89.3)
Domiciliary care17 (5.6) 4 (4.2) 13 (6.3)
Other (including DVA, local council, TCP residential/community, MOWs)18 (5.9) 9 (9.4) 9 (4.4)
Self-reported depression/anxiety n, %
No depression or anxiety257 (84.8) 85 (88.5) 171 (83.4)
Depression41 (13.5) 9 (9.4)31 (15.1)
Anxiety5 (1.7)2 (2.1) 3 (1.5)
Smoking status n, %
Non-smoker163 (53.8) 47 (48.0) 114 (55.6)
Former smoker125 (41.3)45 (45.9) 80 (39.0)
Current smoker12 (4.0) 4 (4.1) 8 (3.9)
Physical activity duration (min/day)94.8 ± 81.1 85.6 ± 74.7 98.5 ± 83.9
Sedentary activity duration (min/day)381.1 ± 171.7390.3 ± 170.8375.1 ± 172.0
Sleep duration (min/night)405.5 ± 73.3414.6 ± 66.3402 ± 78.2
Sleep quality n, %
Very bad7 (2.3) 2 (2.1) 5 (2.4)
Fairly bad76 (25.1) 15 (15.6) 60 (29.3)
Fairly good172 (56.8)60 (62.6)111 (54.1)
Very good48 (15.8) 19 (19.8) 29 (14.1)
Depression symptoms (DASS-21) **6.0 (10.0) 6.0 (10.0)4.0 (10.0)
Anxiety symptoms (DASS-21) **4.0 (8.0)4.0 (6.0)4.0 (8.0)
Stress symptoms (DASS-21) **8.0 (10.0)8.0 (12.0) 8.0 (10.0)
MedDiet adherence (MEDAS)5.6 ± 2.14.9 ± 2.2 5.9 ± 1.9
* Two participants did not disclose gender but are included in the total column. ** Median score (IQR). Abbreviations: BMI, Body Mass Index; DASS-21, Depression, Anxiety, Stress scale 21 items; DVA, Department of Veterans Affairs; TCP, Transitional Care Program; MOWs, Meals on Wheels; MedDiet, Mediterranean diet; MEDAS, Mediterranean Diet Adherence Screener.
Table 4. Univariable and multivariable linear regression coefficients expressing independent associations between adherence to a Mediterranean diet and the severity of depression, anxiety and stress symptoms.
Table 4. Univariable and multivariable linear regression coefficients expressing independent associations between adherence to a Mediterranean diet and the severity of depression, anxiety and stress symptoms.
ModelDepressionAnxietyStress
BetapBetapBetap
1 a−0.085 (−0.768–0.114)0.146−0.159 (−0.901–−0.143)0.007−0.173 (−0.712–−0.145)0.003
2 b−0.087 (−0.786–0.117)0.146−0.172 (−0.949–−0.180)0.004−0.178 (−0.731–−0.150)0.003
3 c−0.074 (−0.749–0.180)0.229−0.190 (−1.016–0.028)0.002−0.182 (−0.752–−0.151)0.003
4 d−0.076 (−0.759–0.171)0.214−0.189 (−1.015–−0.223)0.002−0.179 (−0.748–−0.145)0.004
5 e−0.049 (−0.661–0.282)0.430−0.171 (−0.965–−0.160)0.006−0.151 (−0.680–−0.073)0.015
6 f0.000 (−0.436–0.436)1.000−0.119 (−0.762–−0.021)0.038−0.102 (−0.537–0.025)0.074
7 g0.008 (−0.411–0.472)0.892−0.118 (−0.761–−0.012)0.043−0.080 (−0.479–0.079)0.159
Abbreviations: Beta, Standard beta coefficient; Standardised beta coefficient represents the change in a SD-unit increase in the Mediterranean Diet Adherence Screener score per change in outcome measure; Depression, Anxiety, Stress scale 21 items. a Non-adjusted model. b Adjusted for age and gender. c Adjusted for age, gender and Body Mass Index (BMI). d Adjusted for age, gender, BMI and average physical activity duration/day. e Adjusted for age, gender, BMI, average physical activity duration/day and average sleep duration/night. f Adjusted for age, gender, BMI, average physical activity duration/day, average sleep duration/night and cognitive risk (AD8 dementia screening intervention). g Adjusted for age, gender, BMI, average physical activity duration/day, average sleep duration/night, cognitive risk (AD8 dementia screening intervention) and ability to perform Instrumental Activities of Daily Living.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Allcock, L.; Mantzioris, E.; Villani, A. Adherence to a Mediterranean Diet Is Inversely Associated with Anxiety and Stress but Not Depression: A Cross-Sectional Analysis of Community-Dwelling Older Australians. Nutrients 2024, 16, 366. https://doi.org/10.3390/nu16030366

AMA Style

Allcock L, Mantzioris E, Villani A. Adherence to a Mediterranean Diet Is Inversely Associated with Anxiety and Stress but Not Depression: A Cross-Sectional Analysis of Community-Dwelling Older Australians. Nutrients. 2024; 16(3):366. https://doi.org/10.3390/nu16030366

Chicago/Turabian Style

Allcock, Lisa, Evangeline Mantzioris, and Anthony Villani. 2024. "Adherence to a Mediterranean Diet Is Inversely Associated with Anxiety and Stress but Not Depression: A Cross-Sectional Analysis of Community-Dwelling Older Australians" Nutrients 16, no. 3: 366. https://doi.org/10.3390/nu16030366

APA Style

Allcock, L., Mantzioris, E., & Villani, A. (2024). Adherence to a Mediterranean Diet Is Inversely Associated with Anxiety and Stress but Not Depression: A Cross-Sectional Analysis of Community-Dwelling Older Australians. Nutrients, 16(3), 366. https://doi.org/10.3390/nu16030366

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop