Poor dietary quality is associated with anxious and depressive symptoms in university students

Poor dietary quality is associated with anxious and depressive symptoms in university students | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Poor dietary quality is associated with anxious and depressive symptoms in university students Melissa Ionara Ribeiro Sabbagh, Adriana Lúcia Meireles, Carolina Martins dos Santos Chagas, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6185181/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Anxiety and depression are common among university students and are aggravated by the academic pressures and personal changes typical of this phase. Unbalanced diets, especially those rich in ultra-processed foods, have been linked to worsening mental health. On the other hand, a healthy diet can act as a protective factor, eliminating the risk of these disorders. This study aims to assess the quality of the diet of university students with symptoms of anxiety and depression. Methods Multicenter cross-sectional study involving students from eight Brazilian public universities, with data collected between October 2021 and February 2022. Symptoms of anxiety and depression were assessed using the Depression, Anxiety and Stress Scale-21. Diet quality was assessed based on the frequency of consumption of healthy and unhealthy foods. Poisson regression was used to analyze the association between diet quality and mental health symptoms, with significance set at p ≤ 0.05. Results The results indicate that 58.9% and 62.5% of university students had moderate to extremely severe symptoms of anxiety and depression, respectively. Students with poor diet quality were 25% more likely (PR = 1.25, 95%CI 1.19–1.32) to have symptoms of anxiety and 24% more likely (PR = 1.24, 95%CI 1.18–1.30) to report symptoms of depression, compared to those with high diet quality. Conclusion The high prevalence of anxiety and depression among university students, associated with poor dietary quality, reinforces the importance of promoting healthy habits and self-care practices among university students. Mental health Anxiety Depression Dietary consumption University students Introduction Mental disorders constitute a growing public health concern around the world and are responsible for major social and economic problems, representing approximately 14% of the total years lived with disability [ 1 , 2 ]. Depression and anxiety are the two main categories of mental disorders most commonly diagnosed in the world [ 3 ]. Depression can be characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-esteem, sleep or appetite disturbances, feelings of tiredness, and a lack of concentration [ 3 ]. Anxiety is characterized as a reaction generated by excessive concern about something that is about coming. It is a normal reaction among human beings and is fundamental to self-preservation, consisting of a natural physiological cause of our body [ 4 ]. On the other hand, when apprehension and worrying thoughts impact daily life activities, anxiety tends to be classified as a pathological condition, presenting signs that can vary from mild to severe, being more frequent and intense, and becoming chronic over time [ 3 ]. The prevalence of these disorders in university students has been high and varies according to the country studied and the instrument used to track symptoms. The prevalence of depression in foreign university students ranges from 18.1 to 69.5% [ 5 – 8 ]. Anxiety has a prevalence ranging from 22.8 to 85.1% [ 5 – 8 ]. These problems have been frequently reported in the literature in Brazilian university students, with rates ranging from 28.5–60.5% for depression [ 9 – 12 ] and from 37.7–52.5% for anxiety [ 9 – 12 ]. University students are a group very affected by these disorders, probably because of the phase of life they are in, that is, they are undergoing a transition process, and they can often be quite stressed, as they face changes related to the academic environment, distance from family, financial difficulties, lack of time for leisure, high study hours, high expectations and social and institutional demands, and from the university student himself [ 7 , 12 – 14 ]. These changes resulting from entering university also corroborate the consumption of an unhealthy diet. University students tend to choose foods rich in fat, sugar, and sodium and low in fiber as their first option, to the detriment of fresh and healthy foods (fruits and vegetables). This can be explained, at least in part, by the practicality of ultra-processed products, lack of time management to prepare food due to long hours of study, culinary inability, classes at different times, increased nightlife, and lack of budget, among other factors. other factors [ 2 , 7 , 13 , 15 ]. Thus, university life can affect students doubly, favoring mental disorders and a poor diet. Inadequate nutrition has been strongly associated with depression and anxiety in several countries and cultures [ 14 , 16 – 19 ], as certain eating patterns precede the appearance of mental disorders and other chronic noncommunicable diseases. In this context, some studies have identified an association between the consumption of a healthy diet and a lower risk of developing anxiety and depression [ 2 , 14 , 17 , 20 ], whereas meals with a higher intake of ultra-processed products have been associated with mental health problems [ 17 , 20 , 23 ]. These studies revealed that the quality of food can act as a risk or protective factor for anxiety and depression. However, it is important to note that most existing research has focused on analyzing the prevalence of mental health problems and their relationships with demographic factors and lifestyle habits in university students. The assessment of diet quality among this population has been, in part, little explored. Importantly, many of these studies were conducted with relatively small samples and often focused on health-related courses, which restricts the generalizability of the results to the university population as a whole. Considering the aforementioned aspects, this study aims to evaluate the quality of nutrition among university students with symptoms of anxiety and depression. Materials and methods Type of study, participants, and research instrument This is a multicenter, cross-sectional study carried out with university students from eight Brazilian higher education institutions (HEIs). This study is part of a study on the mental health of university students entitled “Symptoms of anxiety disorder and depression among university students in Minas Gerais: prevalence and associated factors (PADu-Multicentric)”, whose main objective is to determine the prevalence of anxiety symptoms and depression in undergraduate students at Federal Higher Education Institutions in Minas Gerais and evaluate their associated factors. All undergraduate students, aged 18 years or over, who were regularly enrolled in courses at the participating HEIs, were invited to participate in the study. Data collection was carried out between October 2021 and February 2022 for three months at each university. Invitations were sent via electronic addresses found in the universities' databases. Everyone who agreed to participate in the study received the access link to the self-administered online questionnaire, available on the platform ( Google Forms ). In this study, sociodemographic characteristics (age, sex, skin color, religious belief), socioeconomic characteristics (family income), health conditions (symptoms of anxiety and depression), and dietary intake (consumption of legumes, greens and vegetables, fruits, sodas and artificial juices, processed meats, and sweet treats) were evaluated. Symptoms of depression and anxiety were assessed through the Depression Anxiety Stress Scale-21 (DASS-21) [ 24 ]. The determination of the sample composition took into account an eligible population of 118,828 university students from the eight public HEIs in Minas Gerais. The sample size calculation was carried out considering the following parameters: a prevalence of 59% for anxiety symptoms and 62% for depression, a margin of error of 2%, a design effect of 1.0, and a significance level of 5%. On the basis of these criteria, the sample size necessary to meet these specifications was calculated at 2,279 university students using the OpenEpi® program. This study was approved by the Ethics Committees for Research with Human Beings at the Federal University of Ouro Preto under CAAE (43027421.3.1001.5150), at the Federal University of Vale de Jequitinhonha and Mucuri (43027421.3.2009.5108) and subsequently at the other institutions participating in the study. All participants provided online consent to participate in the study. Outcome variable: presence of symptoms of depression and anxiety Outcome variable: presence of symptoms of depression and anxiety The version validated for Brazil of the DASS-21 [ 24 ] was used to identify symptoms of depression and anxiety in university students. The DASS-21 is composed of three scales that assess, in a self-reported manner, the symptoms of depression, anxiety, and stress presented by individuals in the previous week. The response scale to the items is a four-point Likert scale ranging from 0 (the item does not apply) to 3 (the item strongly applies). The scores are added and multiplied by two and subsequently classified into five levels (normal, mild, moderate, severe, and extremely severe) [ 24 ]. In the present study, the outcomes evaluated were the presence of symptoms of depression and anxiety. The sum of the scores for questions 3, 5, 10, 13, 16, 17, and 21, which assess depression, were used to classify the presence or absence of depressive symptoms. The sum of questions 2, 4, 7, 9, 15, 19, and 20 was used to assess anxiety and make it possible to classify the presence or absence of anxiety symptoms. The university students were divided into two groups: those without symptoms or with mild manifestations of depression (score ≤ 13) and those with moderate to extremely severe symptoms of depression (score ≥ 14). They were also divided into those with no symptoms or mild indications of anxiety (score ≤ 9) and those with moderate to extremely severe symptoms of anxiety (score ≥ 10). Exposure Variable: Dietary Quality Diet quality was assessed through the frequency of food consumption over the last 30 days. The groups included in the analysis were legumes, vegetables, fruits, soft drinks and artificial juices, processed meats, and sweet treats. With respect to the consumption frequency of each of these groups, the university students marked one of the following options: 1) rarely/never, 2) from 1 to 2 days a week, 3) from 3 to 4 days a week, 4) from 5 to 6 days per week, and 5) every day (including Saturday and Sunday). On the basis of these responses, a new consumption classification and score was developed considering the methodology proposed by Dimov et al. [ 16 ] to identify the quality of the diet. Thus, the frequency of consumption of legumes received the following scores: rarely/never (0), 1 to 2 days a week (1), 3 to 6 days a week (5), and every day (7). The frequency of consumption of vegetables received the following scores: rarely/never (0), 1 to 2 days a week (2), 3 to 6 days a week (6), and every day (8). The frequency of fruit consumption received the following scores: rarely/never (0), 1 to 2 days a week (2), 3 to 6 days a week (4), and every day (5). The frequency of consumption of soft drinks/artificial juices, processed meats, and sweets/sweets received the following scores: almost never/never (4), 1 to 2 days a week (3), 3 to 6 days a week (1) and every day (0). Notably, in this last group, which is made up of foods considered unhealthy, the score was reversed, meaning that not consuming food received a higher score. After coding the frequency of consumption of foods from each food group, scores ranging from 0 to 32 were added and analyzed according to the 25th, 50th and 75th percentiles, which were classified into three levels of food quality: low quality (p25 ≤ 18), intermediate (p50 ˃18 ≤ 26), and high (p75 > 26). The questionnaire used to evaluate the food consumption of university students was from a Brazilian population-based survey called the Surveillance of Risk and Protective Factors for Chronic Non-Communicable Diseases by Telephone Survey (VIGITEL) [ 25 ]. The questionnaire has good reproducibility and adequate validity for most of the indicators evaluated [ 26 ]. Covariates The covariates assessed include sociodemographic characteristics (age categorized as equal to or less than 22 years old and over 22 years old; biological sex: male and female; skin color: white and nonwhite and whether they have any religious beliefs: yes, no), economic (family income: ≤ 2 minimum wages, ˃ 2 ≤ 4 minimum wages, and > 4 minimum wages) and anthropometric (presence or not of excess weight, BMI ≥ 25 or < 25 kg/m²). Excess weight was assessed by calculating the body mass index (BMI) using the university students' self-reported weight and height information. Statistical analysis The participants were characterized via absolute (n) and relative (%) frequencies of sociodemographic, anthropometric, and food consumption variables. The analysis of the association between anxiety and depression symptoms and diet quality was conducted using Poisson regression analysis. In this analysis, sociodemographic, economic, and anthropometric variables were included as adjustment variables. To evaluate the fit of the model, the Pearson chi-square test value was divided by the degrees of freedom (Heck). The model is considered well adjusted when there is no overdispersion, and therefore, this proportion approaches 1. In all analyses, statistical significance was established at p ≤ 0.05. The analysis was conducted using the Statistical Package for the Social Sciences (version 29.0; IBM Corporation, NY, USA). Results Participant characteristics A total of 8,650 university students responded to the research questionnaire, which is equivalent to 7.28% of the university population, representing a sample three times larger than the minimum necessary sample (n = 2,279). However, only university students who answered all the questions regarding the outcome and exposure variables were included in this research, resulting in a final sample of 7,295 university students (Table 1 ). Table 1 Sociodemographic, anthropometric and dietary characteristics of university students. Minas Gerais, Brazil (n = 7295). Variables studied n % Biological sex Female 4814 66.0 Male 2481 34.0 Age (median in years) ≤ 22 3890 53.3 ˃ 22 3405 46.7 Skin color Nonwhite 3272 44.9 White 4023 55.1 Religious belief Yes 4794 65.7 No 2501 34.3 Overweight * No 4718 64.7 Yes 2577 35.3 Family income (SM) ** ≤ 2 2309 31,7 ˃ 2 ≤ 4 2193 30,1 Family income (SM) ** > 4 2793 38.3 Dietary Quality Low 2064 28.3 Intermediate 3237 44.4 High 1994 27.3 Depression symptoms Normal and mild 2734 37,5 Moderate to extremely severe 4561 62.5 Anxiety symptoms Normal and mild 2995 41.1 Moderate to extremely severe 4300 58.9 *Body mass index greater than 25 kg/m²; **Current minimum wage of R $ 1,100 (2021). The majority of university students had an average age of 24 years (SD = 6.43; range from 18–71), were female (66%), identified as white in terms of skin color/race (55.1%), and held some religious beliefs (65.7%). A significant percentage were overweight (35.3%), and the majority had food quality classified as intermediate (44.4%) (Table 1 ). The prevalence rates of moderate to extremely severe anxiety and depression symptoms in the last seven days before the survey were 58.9% (n = 4,300) and 62.5% (n = 4,561), respectively. When the severity levels of anxiety and depression symptoms are checked, it is noteworthy that individuals with extremely severe symptoms make up more than 30% of the cases of the two mental disorders in question, with 33.6% (n = 2449) of those with extremely severe symptoms. anxiety and 31.9% (n = 2327) for depression. Anxiety, depression, and quality of diet Table 2 presents the characteristics of the participants according to the prevalence of moderate to extremely severe depression and anxiety symptoms in the last seven days before the survey and the quality of their diet, according to the extract of covariates analyzed (Table 2 ). Table 2 Symptoms of anxiety, depression, and quality of diet according to sociodemographic, anthropometric, and socioeconomic variables of university students. Minas Gerais Brazil. Variables Anxiety symptoms ( p , n, %) Depression symptoms ( p , n, %) Dietary quality ( p value , n, %) Low (p25 = ≤ 18) Intermediate (p50= ˃18 ≤ 26) High (p75 = > 26) Biological sex p < 0.001 p < 0.001 p < 0.001 Female 3148 (73.2) 3118 (68.4) 1377 (66.7) 2109 (65.2) 1328 (66.6) Male 1152 (26.8) 1443 (31.6) 687 (33.3) 1128 (34.8) 666 (33.4) Age (median in years) p < 0.002 p = 0.173 p < 0.271 ≤ 22 2359 (54.9) 2404 (52.7) 1080 (52.3) 1760 (54.4) 1050(52.7) ˃ 22 1941 (45.1) 2157 (47.3) 984 (47.7) 1477 (45.6) 944 (47.3) Skin color p = 0.048 p < 0.001 p = 0.031 Nonwhite 1970 (45.8) 2120 (46.5) 880 (42.6) 1461 (45.1) 931 (46.7) White 2330 (54.2) 2441 (53.5) 1184 (57.4) 1776 (54.9) 1063 (53.3) Religious belief p = 0.297 p < 0.001 p < 0.098 Yes 2805 (65.2) 2833 (62.1) 1317 (63.8) 2152 (66.5) 1325 (66.4) No 1495 (34.8) 1728 (37.9) 747 (36.2) 1085 (33.5) 669 (33.6) Overweight p = 0.002 p < 0.001 p < 0.001 No 2718 (63.2) 2847 (62.4) 1222 (59.2) 2114 (65.3) 1382 (69.3) Yes 1582 (36.8) 1714 (37.6) 842 (40.8) 1123 (34.7) 612 (30.7) Family income (SM)* p < 0.001 p < 0.001 p < 0.001 ≤ 2 1565 (36.4) 1630 (35.7) 705 (34.2) 963 (29.7) 641 (32.1) ˃ 2 ≤ 4 1294 (30.1) 1398 (30.7) 646 (31.3) 979 (30.2) 568 (28.5) ˃ 4 1441 (33.5) 1533 (33.6) 713 (34.5) 1295 (40.0) 785 (39.4) Dietary quality p < 0.001 p < 0.001 Low 1350 (31.4) 1445 (31.7) - Intermediate 1921 (44.7) 2015 (44.2) - High 1029 (23.9) 1101 (24.1) - Depression symptoms p-valor = < 0.001 Normal and mild - - 619 (30.0) 1222 (37.8) 893 (44.8) Moderate to extremely severe - - 1445 (70.0) 2015 (62.2) 1101 (55.2) Anxiety symptoms p-valor = < 0.001 Normal and mild - - 714 (34.6) 1316 (40.7) 965 (48.4) Moderate to extremely severe - - 1350 (65.4) 1921 (59,3) 1029 (51.6) The difference was assessed by the χ 2 test. * Minimum wage in force during the survey of R $ 1,100 (2021). Moderate to extremely severe anxiety symptoms were significantly more prevalent among those who were female (p < 0.001), younger (p < 0.002), white (p = 0.048), not overweight (p = 0.002), had a lower income (p = 0.048), and had intermediate dietary quality (p < 0.001). However, religious belief was not significantly correlated with this profile (p = 0.297). Likewise, university students with moderate to extremely severe symptoms of depression also presented the same profile, and religious belief proved to be a protective factor against depression (Table 2 ). The analysis of the crude and covariate-adjusted associations between the presence of moderate to extremely severe symptoms of anxiety and depression and dietary quality is presented in Table 3 . Initially, a univariate analysis of the outcome and those variables that presented a p value less than 20% were used in the adjusted analysis as covariates in this outcome (Table 2 ). Table 3 – Crude and adjusted analyses of the associations between diet quality and symptoms of depression and anxiety in university students. Minas Gerais, Brazil (n = 7295). Dietary quality Anxiety symptoms PR Unadjusted (95% CI) p -valor PR Adjusted * (95% CI) p -valor Low 1.27 (1.20; 1.34) < 0.001 1.25 (1.19; 1.32) < 0.001 Intermediate 1.15 (1.09; 1.21) < 0.001 1.16 (1.10; 1.22) < 0.001 High 1 1 Dietary quality Depression symptoms RP Unadjusted (95% CI) p -valor RP Adjusted ** (95% CI) p -valor Low 1.27 (1.21; 1.33) < 0.001 1.24 (1.18; 1.30) < 0.001 Intermediate 1.13 (1.07; 1.18) < 0.001 1.13 (1.08; 1.18) < 0.001 High 1 1 Goodness of fit model: Deviance (Value/df) no modelo de ansiedade = 0.598. Covariáveis utilizadas para ajuste * : idade, cor da pele, sexo biológico, renda familiar e excesso de peso. Goodness of fit model: Deviance (Value/df) no modelo de depressão = 0.569. Covariáveis utilizadas para ajuste ** : idade, cor da pele, sexo biológico, renda familiar, crença religiosa e excesso de peso. The results of the univariate Poisson analysis between the presence of symptoms of these outcomes and dietary quality indicate that participants with a low-quality diet had a significantly greater prevalence of symptoms of anxiety and depression, with levels of worsening ranging from moderate to extremely severe. In other words, low-quality food was associated with worse levels of mental health. In the adjusted analysis, these results were maintained, indicating that university students with a low-quality diet had a 25% (PR = 1.25, 95% CI 1.19–1.32) and 24% (PR = 1.24, 95% CI 1.18–1.30) greater probability of having moderate to extremely severe symptoms of anxiety and depression, respectively, than did those who had a high-quality diet (Table 3 ). Discussion Depression and anxiety disorders represent prevalent mental health problems among university students in different countries, including Brazil [ 5 , 7 , 9 , 10 , 27 , 28 ]. Research conducted in recent decades has indicated that these disorders are more common among university students than in the general population [ 7 , 29 ]. Notably, during the period in which this study was being carried out, Brazil and the world were experiencing the COVID-19 pandemic, people were being vaccinated, and the mortality rate resulting from the SARS-CoV-2 virus was declining; however, the majority of Brazilian public universities were still teaching remotely, so university students still experienced stress and anxiety about returning to face-to-face activities and normal academic life. Furthermore, the turbulence in Brazil's political and social situation may also have influenced the results. The divergent position of the former president of the republic about the pandemic and the management of the health crisis provoked controversy and generated distrust among the population, resulting in feelings of uncertainty, fear, and insecurity. Importantly, trust in the government during the COVID-19 pandemic has had a direct and significant impact on people's overall well-being [ 30 ]. A systematic review revealed that governments that implemented strict measures to contain the spread of COVID-19 also contributed to the mental health of their populations [ 31 ]. Regarding the hypothesis of this study that the low quality of university students' diets could affect their mental health, the findings confirm what was expected. In other words, university students with poor diet quality were twenty-five times more likely to have moderate to extremely severe symptoms of anxiety and twenty-four times more likely to have moderate to extremely severe symptoms of depression than students who had high-quality food. This result corroborates the findings of Kundu et al. [ 29 ] and Keck et al. [ 14 ], who also reported that the reduced intake of fruits, cereals, meat, vegetables, and dairy products, together with greater consumption of fats and carbohydrates from sugary drinks, sweets, snacks, chocolates, and added sugar and the consumption of alcoholic beverages, were associated with symptoms of anxiety and depression in the university population studied. The low-quality food in the present study was characterized by low consumption of legumes, vegetables, and fruits and high consumption of soft drinks, artificial juices, sausages, sweets, and sweets. This reflects a dietary pattern that is poor in essential nutrients and rich in ingredients that are harmful to health. This explains the symptoms of depression and anxiety among university students since the regular consumption of fruits, vegetables and greens, whole grains and cereals, oilseeds, fish and seafood, vegetable oils and low-fat dairy products can exert protective effects on mental health [ 14 , 17 , 19 , 32 ] through the nutrients found in these foods, such as fiber, B vitamins, vitamin C, vitamin E, vitamin D, zinc, magnesium and omega-3 [ 17 , 33 ] polyunsaturated fatty acids [ 34 ]. On the other hand, the greater the intake of ultra-processed foods, sugary drinks, fast food, snacks and sweets, and products rich in fat, sugar, sodium, synthetic substances, and stabilizers are harmful and capable of increasing inflammation and vulnerability to depression and anxiety [ 2 , 17 , 20 , 21 , 23 , 25 ]. Alimentation has an important impact on mental health, with effects mediated by different mechanisms [ 19 ]. One of these mechanisms is inflammation, which is at the root of mental health problems. Inflammation can affect the brain through the transport of cytokines and influence the regulation of emotions through neurotransmitters such as serotonin, dopamine, noradrenaline and glutamate [ 13 , 18 , 19 , 23 , 33 ]. A healthy diet can reduce inflammation and oxidative stress through its antioxidant and anti-inflammatory effects [ 13 , 17 , 19 , 33 , 34 ]. Furthermore, other biological mechanisms, such as oxidative stress; inadequate intake of nutrients necessary for the production of neurotransmitters such as serotonin, dopamine, and norepinephrine, which are involved in the regulation of mood, appetite and cognition, and neuroplasticity and function, can also be considered. mitochondrial [ 17 , 19 , 33 , 35 ]. The influence of diet on mental health also occurs through the intestinal microbiota, which plays an important role in controlling anxiety, depression, and cognitive function throughout life. Diets rich in fiber and composed mainly of fresh and minimally processed foods promote diverse microbiota and are associated with a lower risk of mental health problems. Additionally, fermented foods can also have positive effects on the gut microbiota and mental health. However, the exact mechanisms by which the intestinal microbiota affects mental health are not yet completely understood [ 18 , 32 – 36 ]. In addition to the mechanisms mentioned, macronutrients such as carbohydrates are important, as adequate consumption is necessary to provide energy to the brain, with glucose being the main source. However, excessive carbohydrate and sugar consumption is linked to mental health risks, such as increased neuroinflammation in the hippocampus and an acute inflammatory response due to a high glycemic load. On the other hand, a diet rich in complex carbohydrates, such as whole grains and fiber along with vegetables, fruits, and legumes, is recommended because of its anti-inflammatory properties and mental health benefits [ 23 , 34 ]. Moreover, fatty acids play important roles in anti-inflammatory properties and the ability to modulate neurotransmitters such as serotonin and dopamine. Vitamins from complex B and vitamins C, D, and E and minerals such as magnesium and zinc present in natural and minimally processed foods play fundamental roles in regulating brain functions, such as cognitive performance, prevention of neurodegenerative disorders, protection against oxidative stress and promotion of the myelination of neurotransmitters [ 17 , 18 , 23 , 32 , 35 , 36 ]. The findings of this study strengthen the importance of adequate and healthy food for maintaining mental health and reinforce the need to develop effective strategies in the field of the human right to adequate food and nutrition (DHANA), assisting in the mental health of university students and the general population [ 17 , 19 ]. The Food Guide for the Brazilian Population (GAPB) emphasizes that healthy eating should be based on fresh or minimally processed foods, as well as culinary preparations that use these foods. Furthermore, it encourages other actions that can be protective of mental health in the dimension of commensality, such as eating in appropriate environments and in the company of other people to promote social interaction; adequately planning the use of time to have a complete diet, avoiding quick and disorganized meals; critically reflecting on the information and messages conveyed in commercial advertisements about food to avoid poor food choices; and the practice of home cooking, which is also encouraged as a way of promoting a healthy and balanced diet, in addition to strengthening family ties and promoting well-being. being emotional [ 22 , 37 ]. All of these precautions suggested in GAPB can be used to protect mental health. Although the present study contributes significantly to the literature on the associations between dietary quality and symptoms of anxiety and depression in university students, it is important to discuss several limitations. First, screening for anxiety and depression symptoms in this study was carried out via the DASS-21 questionnaire. Importantly, this instrument cannot be used to diagnose psychological disorders but rather to track signs and symptoms and provide valuable data on the prevalence of symptoms of anxiety, depression, and stress [ 6 , 7 , 12 ]. Furthermore, the methodology used allows us to identify only associations between variables and not causality, as occurs in other cross-sectional studies. However, the results provide relevant evidence that can be used for future longitudinal studies investigating the impact of depression and anxiety symptoms on diet quality in the long term. Diet quality was assessed by the frequency of consumption of food groups, without considering the quantity consumed, in an appreciation of the set of foods that are present in the daily diet of university students. However, self-reporting may lead to response bias, as responses may have been influenced by social desirability and/or memory. Furthermore, the generalizability of the results to the general population of Brazilian university students may be limited, as the study was carried out at eight public universities in the state of Minas Gerais. Therefore, future large-scale research at different universities in Brazil is needed to extend and generalize the findings of this study. Conclusion This study shows that the high prevalence of anxiety and depression symptoms among university students is associated with poor diet quality. These results highlight the importance of healthy eating habits in protecting the mental health of this population and reinforce the need for strategies that promote appropriate dietary choices to improve the mental well-being of young people. Declarations Ethics approval and consent to participate This study was approved by the Research Ethics Committee of the Federal University of Ouro Preto, under protocol number 31077320.7.1001.5150, and by the Ethics Committees of all participating universities (Federal University of Minas Gerais 43027421.3.2004.5149; Federal University of Uberlândia: 43027421.3.2001.5152; Juiz de Fora Federal University: 43027421.3.2003.5147; Federal University of São João del-Rei: 43027421.3.2002.5545; Federal University of Lavras: 43027421.3.2006.5148; Federal University of the Jequitinhonha and Mucuri Valleys: 43027421.3.2009.5108; Federal University of Alfenas: 43027421.3.2008.5142). All procedures adopted in this study followed the Declaration of Helsinki and the Brazilian guidelines and norms for research involving humans. Informed consent was obtained from all individual participants included in the study. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding This work was funded by the Research Support Foundation of the State of Minas Gerais (FAPEMIG) through the project Symptoms of anxiety and depression disorders in university students of Minas Gerais: prevalence and associated factors, under process nº CDS - APQ-01089–18, with the FAPEMIG/DOF grant term nº, 8288757/2019. Author Contribution MIRS: data analysis and interpretation; manuscript writing; critical review of the manuscript and final approval. ALM: conception and coordination of data collection; study conception and design; critical review of the manuscript and final approval; CMSC: study conception and design; coordination of data collection; critical review of the manuscript and final approval. CSC: study conception and design; coordination of data collection; critical review of the manuscript and final approval. LGF: study conception and design; coordination of data collection; critical review of the manuscript and final approval. LSS: study conception and design; coordination of data collection; critical review of the manuscript and final approval. FCV: study conception and design; coordination of data collection; critical review of the manuscript and final approval. HNO: study conception and design; coordination of data collection; critical review of the manuscript and final approval. EDF: study conception and design; coordination of data collection; critical review of the manuscript and final approval. WP: coordination of data collection; critical review of the manuscript and final approval. BCRB: coordination and conduct of data collection; critical review of the manuscript and final approval. LNN: coordination and conduct of data collection; data analysis and interpretation; critical review of the manuscript and final approval. Acknowledgement We would like to thank the Project on Symptoms of Anxiety Disorder and Depression among University Students of Minas Gerais: Prevalence and Associated Factors (PADu-Multicentric), as well as all the participants in this research and the ‘Fundação de Amparo à Pesquisa do Estado de Minas Gerais’ (FAPEMIG). Data Availability The data generated and/or analyzed during this study are not publicly available due to confidentiality agreements with the participants. However, they may be provided solely for review purposes, not for publication, by the corresponding author upon reasonable request. References World Health Organization. World mental health report: transforming mental health for all. https://www.who.int/publications/i/item/9789240049338 (2022) Cebrino J, Cruz SP. Diet Quality According to Mental Status and Associated Factors during Adulthood in Spain. Nutrients 2021;13(5):1727. https://doi.org/10.3390/nu13051727 World Health Organization. Depression and other common mental disorders: global health estimates. https://www.afro.who.int/publications/depression-and-other-common-mental-disorders-global-health-estimates-2017 (2017) American Psychiatric Association (2014). Manual diagnóstico e estatístico de transtornos mentais: DSM-5. 5ª ed. Porto Alegre. Islam S, Akter R, Sikder T, Griffiths MD. Prevalence and factors associated with depression and anxiety among first-year university students in Bangladesh: a cross-sectional study. Int J Ment Health Addict 2020;20:1289–1302. https://doi.org/10.1007/s11469-020-00242-y Fauzi MF, Anuar TS, Teh LK et al. Stress, anxiety, and depression among a cohort of health sciences undergraduate students: The prevalence and risk factors. Int J Environ Res Public Health 2021;18(6):3269. https://doi.org/10.3390/ijerph18063269 Ramón-Arbués E, Gea-Caballero V, Granada-Lopes JM et al. The prevalence of depression, anxiety and stress and their associated factors in college students. Int J Environ Res Public Health 2020;17(19):7001. https://doi.org/10.3390/ijerph17197001 Blanco V, Salmerón M, Otero P, Vázquez FL et al. Symptoms of depression, anxiety, and stress and prevalence of major depression and its predictors in female university students. Int J Environ Res Public Health 2021;18(11):5845. https://doi.org/10.3390/ijerph18115845 Lopes AR, Nihei OK. Depression, anxiety and stress symptoms in Brazilian university students during the COVID-19 pandemic: Predictors and association with life satisfaction, psychological well-being and coping strategies. PLoS one 2021;16(10):e0258493. https://doi.org/10.1371/journal.pone.0258493 Vidigal MCA, De Paula W, Barbosa BCR et al. Reflexos das mudanças nas rotinas acadêmicas e saúde mental de graduandos durante a pandemia: estudo PADu-COVID. Res Soc Dev 2022;11(8):e35611830860-e35611830860. http://dx.doi.org/10.33448/rsd-v11i8.30860 Demenech LM, Oliveira AT, Silva LN, Dumith SC et al. Prevalence of anxiety, depression and suicidal behaviors among Brazilian undergraduate students: A systematic review and meta-analysis. JJ Affect Disord 2021;282:147–159. https://doi.org/10.1016/j.jad.2020.12.108 De Paula W, Pereira JM, Guimarães NS et al. Key characteristics including sex, sexual orientation and internet use associated with worse mental health among university students in Brazil and implications. J Public Health 2022;44(4):e487-e498. https://doi.org/10.1093/pubmed/fdab406 Solomou S, Logue J, Reilly S, Algorta GP et al. A systematic review of the association of diet quality with the mental health of university students: implications in health education practice. Health Educ Res 2023;38(1):28–68. https://doi.org/10.1093/her/cyac035 Keck MM, Vivier H, Cassisi JE et al.Examining the role of anxiety and depression in dietary choices among college students. Nutrients 2020;12(7):2061. https://doi.org/10.3390/nu12072061 Sousa AR, Reis DM, Vasconcelos TM et al. Relação entre Transtornos Mentais Comuns e an ingestão dietética de universitários da área da saúde. Cien Saude Colet 2021;26:4145–4152. https://doi.org/10.1590/1413-81232021269.07172020 Dimov S, Mundy LK, Bayer JK et al. Diet quality and mental health problems in late childhood. Nutr Neurosci 2019;24(1):62–70. https://doi.org/10.1080/1028415X.2019.1592288 Etherton PMK, Petersen KS, Hibbeln JR et al. Nutrition and behavioral health disorders: depression and anxiety. Nutr Rev 2021;79(3):247–260. https://doi.org/10.1093/nutrit/nuaa025 Marx W, Lane M, Hockey M et al. Diet and depression: exploring the biological mechanisms of action. Mol Psychiatry 2021;26(1):134–150. https://doi.org/10.1038/s41380-020-00925-x Lassale C, Batty GD, Baghdadli A et al. Healthy dietary indices and risk of depressive outcomes: a systematic review and meta-analysis of observational studies. Mol Psychiatry 2019;24:965–986. https://doi.org/10.1038/s41380-018-0237-8 Gibson-Smith D, Bot M, Brouwer IA et al. Diet quality in persons with and without depressive and anxiety disorders. J Psychiatr Res 2018;106:1–7. https://doi.org/10.1016/j.jpsychires.2018.09.006 Adjibade M, Julia C, Allès B et al. Prospective association between ultra-processed food consumption and incident depressive symptoms in the French NutriNet-Santé cohort. BMC Med 2019;17(78):1–13. https://doi.org/10.1186/s12916-019-1312-y Brasil. Ministério da Saúde. Guia alimentar para a população brasileira. https://www.gov.br/saude/pt-br/assuntos/saude-brasil/publicacoes-para-promocao-a-saude/guia_alimentar_populacao_brasileira_2ed.pdf/view (2014). Coletro HN, Mendonça RD, Meireles AL et al. Ultra-processed and fresh food consumption and symptoms of anxiety and depression during the COVID–19 pandemic: COVID Inconfidentes. Clin Nutr ESPEN 2022;47:206–214. https://doi.org/10.1016/j.clnesp.2021.12.013 Vignola RCB, Tucci AM. Adaptation and validation of the depression, anxiety and stress scale (DASS) to Brazilian Portuguese. J Affect Disord 2014;155:104–109. https://doi.org/10.1016/j.jad.2013.10.031 Brasil. Ministério da Saúde Vigitel Brasil 2019: Vigilância de fatores de risco e proteção para doenças crônicas por inquérito telefônico. https://www.gov.br/saude/pt-br/centrais-de-conteudo/publicacoes/cartilhas/2019/vigitel-brasil-2019-vigilancia-fatores-risco-pdf/view (2019). Monteiro CA, Moura EC, Jaime PC, Claro RM. Validade de indicadores do consumo de alimentos e bebidas obtidos por inquérito telefônico. Rev Saude Publica 2008;42:582–589. https://doi.org/10.1590/S0034-89102008000400002 Gao W, Ping S, Liu X. Gender differences in depression, anxiety, and stress among college students: a longitudinal study from China. J Affect Disord 2020;263:292–300. https://doi.org/10.1016/j.jad.2019.11.121 Naser AY, Alwafi H, Amara NA et al. Epidemiology of depression and anxiety among undergraduate students. Int J Clin Pract 2021;75(9):e14414. https://doi.org/10.1111/ijcp.14414 Kundu S, Rejwana N, Banna HA et al. Linking Depressive and Anxiety Symptoms with Diet Quality of University Students: A Cross-Sectional Study during the COVID-19 Pandemic in India. Healthcare 2022;10(10):1848. https://doi.org/10.3390/healthcare10101848 Barrafrem K, Tinghög G, Västfjäll, D. Trust in the government increases financial well-being and general well-being during COVID-19. J. Behav. Exp. Finance 2021;(31):100514. https://doi.org/10.1016/j.jbef.2021.100514 Lee Y, Lui LMW, Chen-Li D et al. Government response moderates the mental health impact of COVID-19: A systematic review and meta-analysis of depression outcomes across countries. J Affect Disord 2021;(290):364–377. https://doi.org/10.1016/j.jad.2021.04.050 Gibson-Smith D, Bot M, Brouwer IA et al. Association of food groups with depression and anxiety disorders. Eur J Nutr 2020;59:767–778. https://doi.org/10.1007/s00394-019-01943-4 Lachance LR, Ramsey D. Antidepressant foods: An evidence-based nutrient profiling system for depression. World J Psychiatry 2018;8(3):97. https://dx.doi.org/10.5498/wjp.v8.i3.97 Godos J, Currenti W, Angelino D et al. Diet and Mental Health: Review of the Recent Updates on Molecular Mechanisms. Antioxidants 2020;9(4):346. https://doi.org/10.3390/antiox9040346 Oftedal S, Glozier N, Holliday EG, Duncan MJ. Diet quality and depressive symptoms. Assessing the direction of the association in a population-based cohort study. J Affect Disord 2020;274:347–353. https://doi.org/10.1016/j.jad.2020.05.046 Grajek M, Krupa-Kotara K, Białek-Dratwa A et al. Nutrition and mental health: A review of current knowledge about the impact of diet on mental health. Front Nutr 2022;9:1805. https://doi.org/10.3389/fnut.2022.943998 Oliveira MSS, Santos LAS. Guias alimentares para a população brasileira: uma análise a partir das dimensões culturais e sociais da alimentação. Cien Saude Colet 2020;25:2519–2528. https://doi.org/10.1590/1413-81232020257.22322018 Additional Declarations No competing interests reported. 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Rafael","lastName":"Barbosa","suffix":""},{"id":441588841,"identity":"b22c5fd0-756a-4be6-867b-174ad2c890c4","order_by":11,"name":"Luciana Neri Nobre","email":"","orcid":"","institution":"Federal University of the Jequitinhonha and Mucuri Valleys","correspondingAuthor":false,"prefix":"","firstName":"Luciana","middleName":"Neri","lastName":"Nobre","suffix":""}],"badges":[],"createdAt":"2025-03-08 16:53:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6185181/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6185181/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":81108396,"identity":"951ee56c-de2c-43d6-85df-dd775912b9fb","added_by":"auto","created_at":"2025-04-22 10:07:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1200057,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6185181/v1/e77b1da5-f3e0-47b2-aa02-fcdb3b15545a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Poor dietary quality is associated with anxious and depressive symptoms in university students","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMental disorders constitute a growing public health concern around the world and are responsible for major social and economic problems, representing approximately 14% of the total years lived with disability [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Depression and anxiety are the two main categories of mental disorders most commonly diagnosed in the world [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDepression can be characterized by sadness, loss of interest or pleasure, feelings of guilt or low self-esteem, sleep or appetite disturbances, feelings of tiredness, and a lack of concentration [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Anxiety is characterized as a reaction generated by excessive concern about something that is about coming. It is a normal reaction among human beings and is fundamental to self-preservation, consisting of a natural physiological cause of our body [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. On the other hand, when apprehension and worrying thoughts impact daily life activities, anxiety tends to be classified as a pathological condition, presenting signs that can vary from mild to severe, being more frequent and intense, and becoming chronic over time [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe prevalence of these disorders in university students has been high and varies according to the country studied and the instrument used to track symptoms. The prevalence of depression in foreign university students ranges from 18.1 to 69.5% [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Anxiety has a prevalence ranging from 22.8 to 85.1% [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These problems have been frequently reported in the literature in Brazilian university students, with rates ranging from 28.5\u0026ndash;60.5% for depression [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and from 37.7\u0026ndash;52.5% for anxiety [\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUniversity students are a group very affected by these disorders, probably because of the phase of life they are in, that is, they are undergoing a transition process, and they can often be quite stressed, as they face changes related to the academic environment, distance from family, financial difficulties, lack of time for leisure, high study hours, high expectations and social and institutional demands, and from the university student himself [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese changes resulting from entering university also corroborate the consumption of an unhealthy diet. University students tend to choose foods rich in fat, sugar, and sodium and low in fiber as their first option, to the detriment of fresh and healthy foods (fruits and vegetables). This can be explained, at least in part, by the practicality of ultra-processed products, lack of time management to prepare food due to long hours of study, culinary inability, classes at different times, increased nightlife, and lack of budget, among other factors. other factors [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, university life can affect students doubly, favoring mental disorders and a poor diet. Inadequate nutrition has been strongly associated with depression and anxiety in several countries and cultures [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], as certain eating patterns precede the appearance of mental disorders and other chronic noncommunicable diseases.\u003c/p\u003e \u003cp\u003eIn this context, some studies have identified an association between the consumption of a healthy diet and a lower risk of developing anxiety and depression [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], whereas meals with a higher intake of ultra-processed products have been associated with mental health problems [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These studies revealed that the quality of food can act as a risk or protective factor for anxiety and depression.\u003c/p\u003e \u003cp\u003eHowever, it is important to note that most existing research has focused on analyzing the prevalence of mental health problems and their relationships with demographic factors and lifestyle habits in university students. The assessment of diet quality among this population has been, in part, little explored. Importantly, many of these studies were conducted with relatively small samples and often focused on health-related courses, which restricts the generalizability of the results to the university population as a whole. Considering the aforementioned aspects, this study aims to evaluate the quality of nutrition among university students with symptoms of anxiety and depression.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eType of study, participants, and research instrument\u003c/h2\u003e \u003cp\u003eThis is a multicenter, cross-sectional study carried out with university students from eight Brazilian higher education institutions (HEIs). This study is part of a study on the mental health of university students entitled \u0026ldquo;Symptoms of anxiety disorder and depression among university students in Minas Gerais: prevalence and associated factors (PADu-Multicentric)\u0026rdquo;, whose main objective is to determine the prevalence of anxiety symptoms and depression in undergraduate students at Federal Higher Education Institutions in Minas Gerais and evaluate their associated factors.\u003c/p\u003e \u003cp\u003eAll undergraduate students, aged 18 years or over, who were regularly enrolled in courses at the participating HEIs, were invited to participate in the study. Data collection was carried out between October 2021 and February 2022 for three months at each university. Invitations were sent via electronic addresses found in the universities' databases. Everyone who agreed to participate in the study received the access link to the self-administered online questionnaire, available on the platform (\u003cem\u003eGoogle Forms\u003c/em\u003e).\u003c/p\u003e \u003cp\u003eIn this study, sociodemographic characteristics (age, sex, skin color, religious belief), socioeconomic characteristics (family income), health conditions (symptoms of anxiety and depression), and dietary intake (consumption of legumes, greens and vegetables, fruits, sodas and artificial juices, processed meats, and sweet treats) were evaluated. Symptoms of depression and anxiety were assessed through the Depression Anxiety Stress Scale-21 (DASS-21) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe determination of the sample composition took into account an eligible population of 118,828 university students from the eight public HEIs in Minas Gerais. The sample size calculation was carried out considering the following parameters: a prevalence of 59% for anxiety symptoms and 62% for depression, a margin of error of 2%, a design effect of 1.0, and a significance level of 5%. On the basis of these criteria, the sample size necessary to meet these specifications was calculated at 2,279 university students using the OpenEpi\u0026reg; program.\u003c/p\u003e \u003cp\u003e This study was approved by the Ethics Committees for Research with Human Beings at the Federal University of Ouro Preto under CAAE (43027421.3.1001.5150), at the Federal University of Vale de Jequitinhonha and Mucuri (43027421.3.2009.5108) and subsequently at the other institutions participating in the study. All participants provided online consent to participate in the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eOutcome variable: presence of symptoms of depression and anxiety\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eOutcome variable: presence of symptoms of depression and anxiety\u003c/div\u003e \u003cp\u003eThe version validated for Brazil of the DASS-21 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] was used to identify symptoms of depression and anxiety in university students. The DASS-21 is composed of three scales that assess, in a self-reported manner, the symptoms of depression, anxiety, and stress presented by individuals in the previous week. The response scale to the items is a four-point Likert scale ranging from 0 (the item does not apply) to 3 (the item strongly applies). The scores are added and multiplied by two and subsequently classified into five levels (normal, mild, moderate, severe, and extremely severe) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the present study, the outcomes evaluated were the presence of symptoms of depression and anxiety. The sum of the scores for questions 3, 5, 10, 13, 16, 17, and 21, which assess depression, were used to classify the presence or absence of depressive symptoms. The sum of questions 2, 4, 7, 9, 15, 19, and 20 was used to assess anxiety and make it possible to classify the presence or absence of anxiety symptoms.\u003c/p\u003e \u003cp\u003eThe university students were divided into two groups: those without symptoms or with mild manifestations of depression (score\u0026thinsp;\u0026le;\u0026thinsp;13) and those with moderate to extremely severe symptoms of depression (score\u0026thinsp;\u0026ge;\u0026thinsp;14). They were also divided into those with no symptoms or mild indications of anxiety (score\u0026thinsp;\u0026le;\u0026thinsp;9) and those with moderate to extremely severe symptoms of anxiety (score\u0026thinsp;\u0026ge;\u0026thinsp;10).\u003c/p\u003e\n\u003ch3\u003eExposure Variable: Dietary Quality\u003c/h3\u003e\n\u003cp\u003eDiet quality was assessed through the frequency of food consumption over the last 30 days. The groups included in the analysis were legumes, vegetables, fruits, soft drinks and artificial juices, processed meats, and sweet treats. With respect to the consumption frequency of each of these groups, the university students marked one of the following options: 1) rarely/never, 2) from 1 to 2 days a week, 3) from 3 to 4 days a week, 4) from 5 to 6 days per week, and 5) every day (including Saturday and Sunday). On the basis of these responses, a new consumption classification and score was developed considering the methodology proposed by Dimov et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] to identify the quality of the diet.\u003c/p\u003e \u003cp\u003eThus, the frequency of consumption of legumes received the following scores: rarely/never (0), 1 to 2 days a week (1), 3 to 6 days a week (5), and every day (7). The frequency of consumption of vegetables received the following scores: rarely/never (0), 1 to 2 days a week (2), 3 to 6 days a week (6), and every day (8). The frequency of fruit consumption received the following scores: rarely/never (0), 1 to 2 days a week (2), 3 to 6 days a week (4), and every day (5). The frequency of consumption of soft drinks/artificial juices, processed meats, and sweets/sweets received the following scores: almost never/never (4), 1 to 2 days a week (3), 3 to 6 days a week (1) and every day (0). Notably, in this last group, which is made up of foods considered unhealthy, the score was reversed, meaning that not consuming food received a higher score.\u003c/p\u003e \u003cp\u003eAfter coding the frequency of consumption of foods from each food group, scores ranging from 0 to 32 were added and analyzed according to the 25th, 50th and 75th percentiles, which were classified into three levels of food quality: low quality (p25\u0026thinsp;\u0026le;\u0026thinsp;18), intermediate (p50 ˃18\u0026thinsp;\u0026le;\u0026thinsp;26), and high (p75\u0026thinsp;\u0026gt;\u0026thinsp;26).\u003c/p\u003e \u003cp\u003eThe questionnaire used to evaluate the food consumption of university students was from a Brazilian population-based survey called the Surveillance of Risk and Protective Factors for Chronic Non-Communicable Diseases by Telephone Survey (VIGITEL) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. The questionnaire has good reproducibility and adequate validity for most of the indicators evaluated [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eThe covariates assessed include sociodemographic characteristics (age categorized as equal to or less than 22 years old and over 22 years old; biological sex: male and female; skin color: white and nonwhite and whether they have any religious beliefs: yes, no), economic (family income: \u0026le; 2 minimum wages, ˃ 2\u0026thinsp;\u0026le;\u0026thinsp;4 minimum wages, and \u0026gt;\u0026thinsp;4 minimum wages) and anthropometric (presence or not of excess weight, BMI\u0026thinsp;\u0026ge;\u0026thinsp;25 or \u0026lt;\u0026thinsp;25 kg/m\u0026sup2;). Excess weight was assessed by calculating the body mass index (BMI) using the university students' self-reported weight and height information.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003e The participants were characterized via absolute (n) and relative (%) frequencies of sociodemographic, anthropometric, and food consumption variables.\u003c/p\u003e \u003cp\u003eThe analysis of the association between anxiety and depression symptoms and diet quality was conducted using Poisson regression analysis. In this analysis, sociodemographic, economic, and anthropometric variables were included as adjustment variables. To evaluate the fit of the model, the Pearson chi-square test value was divided by the degrees of freedom (Heck). The model is considered well adjusted when there is no overdispersion, and therefore, this proportion approaches 1. In all analyses, statistical significance was established at p\u0026thinsp;\u0026le;\u0026thinsp;0.05. The analysis was conducted using the Statistical Package for the Social Sciences (version 29.0; IBM Corporation, NY, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eA total of 8,650 university students responded to the research questionnaire, which is equivalent to 7.28% of the university population, representing a sample three times larger than the minimum necessary sample (n\u0026thinsp;=\u0026thinsp;2,279). However, only university students who answered all the questions regarding the outcome and exposure variables were included in this research, resulting in a final sample of 7,295 university students (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic, anthropometric and dietary characteristics of university students. Minas Gerais, Brazil (n\u0026thinsp;=\u0026thinsp;7295).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables studied\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiological sex\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2481\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e (median in years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3890\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e˃ 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSkin color\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonwhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligious belief\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2501\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverweight\u003c/b\u003e*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4718\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e64.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily income\u003c/b\u003e (SM)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2309\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31,7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e˃ 2\u0026thinsp;\u0026le;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2193\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily income\u003c/b\u003e (SM)\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2793\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDietary Quality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2064\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1994\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal and mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2734\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate to extremely severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4561\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal and mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate to extremely severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e58.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e*Body mass index greater than 25 kg/m\u0026sup2;; **Current minimum wage of R\u003cspan\u003e$\u003c/span\u003e1,100 (2021).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe majority of university students had an average age of 24 years (SD\u0026thinsp;=\u0026thinsp;6.43; range from 18\u0026ndash;71), were female (66%), identified as white in terms of skin color/race (55.1%), and held some religious beliefs (65.7%). A significant percentage were overweight (35.3%), and the majority had food quality classified as intermediate (44.4%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe prevalence rates of moderate to extremely severe anxiety and depression symptoms in the last seven days before the survey were 58.9% (n\u0026thinsp;=\u0026thinsp;4,300) and 62.5% (n\u0026thinsp;=\u0026thinsp;4,561), respectively. When the severity levels of anxiety and depression symptoms are checked, it is noteworthy that individuals with extremely severe symptoms make up more than 30% of the cases of the two mental disorders in question, with 33.6% (n\u0026thinsp;=\u0026thinsp;2449) of those with extremely severe symptoms. anxiety and 31.9% (n\u0026thinsp;=\u0026thinsp;2327) for depression.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnxiety, depression, and quality of diet\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the characteristics of the participants according to the prevalence of moderate to extremely severe depression and anxiety symptoms in the last seven days before the survey and the quality of their diet, according to the extract of covariates analyzed (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSymptoms of anxiety, depression, and quality of diet according to sociodemographic, anthropometric, and socioeconomic variables of university students. Minas Gerais Brazil.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003cp\u003esymptoms\u003c/p\u003e \u003cp\u003e(\u003cem\u003ep\u003c/em\u003e, n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDepression symptoms\u003c/p\u003e \u003cp\u003e(\u003cem\u003ep\u003c/em\u003e, n, %)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003eDietary quality (\u003cem\u003ep value\u003c/em\u003e, n, %)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003cp\u003e(p25\u0026thinsp;=\u0026thinsp;\u0026le;\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003cp\u003e(p50= ˃18\u0026thinsp;\u0026le;\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003cp\u003e(p75\u0026thinsp;=\u0026thinsp;\u0026gt;\u0026thinsp;26)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBiological sex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3148 (73.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3118 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1377 (66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2109 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1328 (66.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1152 (26.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1443 (31.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e687 (33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1128 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e666 (33.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (median in years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.002\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.173\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.271\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2359 (54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2404 (52.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1080 (52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1760 (54.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1050(52.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e˃ 22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1941 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2157 (47.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e984 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1477 (45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e944 (47.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSkin color\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.048\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.031\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNonwhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1970 (45.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2120 (46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e880 (42.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1461 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e931 (46.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2330 (54.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2441 (53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1184 (57.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1776 (54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1063 (53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReligious belief\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.297\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.098\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2805 (65.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2833 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1317 (63.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2152 (66.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1325 (66.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1495 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1728 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e747 (36.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1085 (33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e669 (33.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOverweight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.002\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2718 (63.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2847 (62.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1222 (59.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2114 (65.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1382 (69.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1582 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1714 (37.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e842 (40.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1123 (34.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e612 (30.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily income\u003c/b\u003e (SM)*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1565 (36.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1630 (35.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e705 (34.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e963 (29.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e641 (32.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e˃ 2\u0026thinsp;\u0026le;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1294 (30.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1398 (30.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e646 (31.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e979 (30.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e568 (28.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e˃ 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1441 (33.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1533 (33.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e713 (34.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1295 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e785 (39.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDietary quality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1350 (31.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1445 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1921 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2015 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1029 (23.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1101 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepression symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep-valor\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal and mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e619 (30.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1222 (37.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e893 (44.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate to extremely severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1445 (70.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2015 (62.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1101 (55.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAnxiety symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep-valor\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal and mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e714 (34.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1316 (40.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e965 (48.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate to extremely severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1350 (65.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1921 (59,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1029 (51.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eThe difference was assessed by the χ\u003csup\u003e2\u003c/sup\u003e test. \u003csup\u003e*\u003c/sup\u003eMinimum wage in force during the survey of R\u003cspan\u003e$\u003c/span\u003e1,100 (2021).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModerate to extremely severe anxiety symptoms were significantly more prevalent among those who were female (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), younger (p\u0026thinsp;\u0026lt;\u0026thinsp;0.002), white (p\u0026thinsp;=\u0026thinsp;0.048), not overweight (p\u0026thinsp;=\u0026thinsp;0.002), had a lower income (p\u0026thinsp;=\u0026thinsp;0.048), and had intermediate dietary quality (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, religious belief was not significantly correlated with this profile (p\u0026thinsp;=\u0026thinsp;0.297). Likewise, university students with moderate to extremely severe symptoms of depression also presented the same profile, and religious belief proved to be a protective factor against depression (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe analysis of the crude and covariate-adjusted associations between the presence of moderate to extremely severe symptoms of anxiety and depression and dietary quality is presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Initially, a univariate analysis of the outcome and those variables that presented a p value less than 20% were used in the adjusted analysis as covariates in this outcome (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Crude and adjusted analyses of the associations between diet quality and symptoms of depression and anxiety in university students. Minas Gerais, Brazil (n\u0026thinsp;=\u0026thinsp;7295).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDietary quality\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eAnxiety symptoms\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePR Unadjusted\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-valor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePR Adjusted\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e(95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-valor\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.27 (1.20; 1.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.25 (1.19; 1.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.15 (1.09; 1.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.16 (1.10; 1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDietary quality\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDepression symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003eRP Unadjusted\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003cb\u003e-valor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eRP Adjusted\u003c/b\u003e\u003csup\u003e\u003cb\u003e**\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(95% CI)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003ep\u003c/b\u003e\u003cb\u003e-valor\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.27 (1.21; 1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.24 (1.18; 1.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntermediate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.13 (1.07; 1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.13 (1.08; 1.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eGoodness of fit model: Deviance (Value/df) no modelo de ansiedade\u0026thinsp;=\u0026thinsp;0.598. Covari\u0026aacute;veis utilizadas para ajuste\u003csup\u003e*\u003c/sup\u003e: idade, cor da pele, sexo biol\u0026oacute;gico, renda familiar e excesso de peso. Goodness of fit model: Deviance (Value/df) no modelo de depress\u0026atilde;o\u0026thinsp;=\u0026thinsp;0.569. Covari\u0026aacute;veis utilizadas para ajuste\u003csup\u003e**\u003c/sup\u003e: idade, cor da pele, sexo biol\u0026oacute;gico, renda familiar, cren\u0026ccedil;a religiosa e excesso de peso.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe results of the univariate Poisson analysis between the presence of symptoms of these outcomes and dietary quality indicate that participants with a low-quality diet had a significantly greater prevalence of symptoms of anxiety and depression, with levels of worsening ranging from moderate to extremely severe. In other words, low-quality food was associated with worse levels of mental health. In the adjusted analysis, these results were maintained, indicating that university students with a low-quality diet had a 25% (PR\u0026thinsp;=\u0026thinsp;1.25, 95% CI 1.19\u0026ndash;1.32) and 24% (PR\u0026thinsp;=\u0026thinsp;1.24, 95% CI 1.18\u0026ndash;1.30) greater probability of having moderate to extremely severe symptoms of anxiety and depression, respectively, than did those who had a high-quality diet (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDepression and anxiety disorders represent prevalent mental health problems among university students in different countries, including Brazil [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Research conducted in recent decades has indicated that these disorders are more common among university students than in the general population [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNotably, during the period in which this study was being carried out, Brazil and the world were experiencing the COVID-19 pandemic, people were being vaccinated, and the mortality rate resulting from the SARS-CoV-2 virus was declining; however, the majority of Brazilian public universities were still teaching remotely, so university students still experienced stress and anxiety about returning to face-to-face activities and normal academic life.\u003c/p\u003e \u003cp\u003eFurthermore, the turbulence in Brazil's political and social situation may also have influenced the results. The divergent position of the former president of the republic about the pandemic and the management of the health crisis provoked controversy and generated distrust among the population, resulting in feelings of uncertainty, fear, and insecurity. Importantly, trust in the government during the COVID-19 pandemic has had a direct and significant impact on people's overall well-being [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. A systematic review revealed that governments that implemented strict measures to contain the spread of COVID-19 also contributed to the mental health of their populations [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding the hypothesis of this study that the low quality of university students' diets could affect their mental health, the findings confirm what was expected. In other words, university students with poor diet quality were twenty-five times more likely to have moderate to extremely severe symptoms of anxiety and twenty-four times more likely to have moderate to extremely severe symptoms of depression than students who had high-quality food.\u003c/p\u003e \u003cp\u003eThis result corroborates the findings of Kundu et al. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] and Keck et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], who also reported that the reduced intake of fruits, cereals, meat, vegetables, and dairy products, together with greater consumption of fats and carbohydrates from sugary drinks, sweets, snacks, chocolates, and added sugar and the consumption of alcoholic beverages, were associated with symptoms of anxiety and depression in the university population studied.\u003c/p\u003e \u003cp\u003eThe low-quality food in the present study was characterized by low consumption of legumes, vegetables, and fruits and high consumption of soft drinks, artificial juices, sausages, sweets, and sweets. This reflects a dietary pattern that is poor in essential nutrients and rich in ingredients that are harmful to health. This explains the symptoms of depression and anxiety among university students since the regular consumption of fruits, vegetables and greens, whole grains and cereals, oilseeds, fish and seafood, vegetable oils and low-fat dairy products can exert protective effects on mental health [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] through the nutrients found in these foods, such as fiber, B vitamins, vitamin C, vitamin E, vitamin D, zinc, magnesium and omega-3 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] polyunsaturated fatty acids [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. On the other hand, the greater the intake of ultra-processed foods, sugary drinks, fast food, snacks and sweets, and products rich in fat, sugar, sodium, synthetic substances, and stabilizers are harmful and capable of increasing inflammation and vulnerability to depression and anxiety [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlimentation has an important impact on mental health, with effects mediated by different mechanisms [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. One of these mechanisms is inflammation, which is at the root of mental health problems. Inflammation can affect the brain through the transport of cytokines and influence the regulation of emotions through neurotransmitters such as serotonin, dopamine, noradrenaline and glutamate [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. A healthy diet can reduce inflammation and oxidative stress through its antioxidant and anti-inflammatory effects [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Furthermore, other biological mechanisms, such as oxidative stress; inadequate intake of nutrients necessary for the production of neurotransmitters such as serotonin, dopamine, and norepinephrine, which are involved in the regulation of mood, appetite and cognition, and neuroplasticity and function, can also be considered. mitochondrial [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe influence of diet on mental health also occurs through the intestinal microbiota, which plays an important role in controlling anxiety, depression, and cognitive function throughout life. Diets rich in fiber and composed mainly of fresh and minimally processed foods promote diverse microbiota and are associated with a lower risk of mental health problems. Additionally, fermented foods can also have positive effects on the gut microbiota and mental health. However, the exact mechanisms by which the intestinal microbiota affects mental health are not yet completely understood [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR33 CR34 CR35\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to the mechanisms mentioned, macronutrients such as carbohydrates are important, as adequate consumption is necessary to provide energy to the brain, with glucose being the main source. However, excessive carbohydrate and sugar consumption is linked to mental health risks, such as increased neuroinflammation in the hippocampus and an acute inflammatory response due to a high glycemic load. On the other hand, a diet rich in complex carbohydrates, such as whole grains and fiber along with vegetables, fruits, and legumes, is recommended because of its anti-inflammatory properties and mental health benefits [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Moreover, fatty acids play important roles in anti-inflammatory properties and the ability to modulate neurotransmitters such as serotonin and dopamine. Vitamins from complex B and vitamins C, D, and E and minerals such as magnesium and zinc present in natural and minimally processed foods play fundamental roles in regulating brain functions, such as cognitive performance, prevention of neurodegenerative disorders, protection against oxidative stress and promotion of the myelination of neurotransmitters [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe findings of this study strengthen the importance of adequate and healthy food for maintaining mental health and reinforce the need to develop effective strategies in the field of the human right to adequate food and nutrition (DHANA), assisting in the mental health of university students and the general population [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e The Food Guide for the Brazilian Population (GAPB) emphasizes that healthy eating should be based on fresh or minimally processed foods, as well as culinary preparations that use these foods. Furthermore, it encourages other actions that can be protective of mental health in the dimension of commensality, such as eating in appropriate environments and in the company of other people to promote social interaction; adequately planning the use of time to have a complete diet, avoiding quick and disorganized meals; critically reflecting on the information and messages conveyed in commercial advertisements about food to avoid poor food choices; and the practice of home cooking, which is also encouraged as a way of promoting a healthy and balanced diet, in addition to strengthening family ties and promoting well-being. being emotional [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. All of these precautions suggested in GAPB can be used to protect mental health.\u003c/p\u003e \u003cp\u003eAlthough the present study contributes significantly to the literature on the associations between dietary quality and symptoms of anxiety and depression in university students, it is important to discuss several limitations. First, screening for anxiety and depression symptoms in this study was carried out via the DASS-21 questionnaire. Importantly, this instrument cannot be used to diagnose psychological disorders but rather to track signs and symptoms and provide valuable data on the prevalence of symptoms of anxiety, depression, and stress [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, the methodology used allows us to identify only associations between variables and not causality, as occurs in other cross-sectional studies.\u003c/p\u003e \u003cp\u003eHowever, the results provide relevant evidence that can be used for future longitudinal studies investigating the impact of depression and anxiety symptoms on diet quality in the long term. Diet quality was assessed by the frequency of consumption of food groups, without considering the quantity consumed, in an appreciation of the set of foods that are present in the daily diet of university students. However, self-reporting may lead to response bias, as responses may have been influenced by social desirability and/or memory. Furthermore, the generalizability of the results to the general population of Brazilian university students may be limited, as the study was carried out at eight public universities in the state of Minas Gerais. Therefore, future large-scale research at different universities in Brazil is needed to extend and generalize the findings of this study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study shows that the high prevalence of anxiety and depression symptoms among university students is associated with poor diet quality. These results highlight the importance of healthy eating habits in protecting the mental health of this population and reinforce the need for strategies that promote appropriate dietary choices to improve the mental well-being of young people.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was approved by the Research Ethics Committee of the Federal University of Ouro Preto, under protocol number 31077320.7.1001.5150, and by the Ethics Committees of all participating universities (Federal University of Minas Gerais 43027421.3.2004.5149; Federal University of Uberl\u0026acirc;ndia: 43027421.3.2001.5152; Juiz de Fora Federal University: 43027421.3.2003.5147; Federal University of S\u0026atilde;o Jo\u0026atilde;o del-Rei: 43027421.3.2002.5545; Federal University of Lavras: 43027421.3.2006.5148; Federal University of the Jequitinhonha and Mucuri Valleys: 43027421.3.2009.5108; Federal University of Alfenas: 43027421.3.2008.5142). All procedures adopted in this study followed the Declaration of Helsinki and the Brazilian guidelines and norms for research involving humans. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCompeting interests\u003c/strong\u003e \u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was funded by the Research Support Foundation of the State of Minas Gerais (FAPEMIG) through the project Symptoms of anxiety and depression disorders in university students of Minas Gerais: prevalence and associated factors, under process n\u0026ordm; CDS - APQ-01089\u0026ndash;18, with the FAPEMIG/DOF grant term n\u0026ordm;, 8288757/2019.\u003c/p\u003e \u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMIRS: data analysis and interpretation; manuscript writing; critical review of the manuscript and final approval. ALM: conception and coordination of data collection; study conception and design; critical review of the manuscript and final approval; CMSC: study conception and design; coordination of data collection; critical review of the manuscript and final approval. CSC: study conception and design; coordination of data collection; critical review of the manuscript and final approval. LGF: study conception and design; coordination of data collection; critical review of the manuscript and final approval. LSS: study conception and design; coordination of data collection; critical review of the manuscript and final approval. FCV: study conception and design; coordination of data collection; critical review of the manuscript and final approval. HNO: study conception and design; coordination of data collection; critical review of the manuscript and final approval. EDF: study conception and design; coordination of data collection; critical review of the manuscript and final approval. WP: coordination of data collection; critical review of the manuscript and final approval. BCRB: coordination and conduct of data collection; critical review of the manuscript and final approval. LNN: coordination and conduct of data collection; data analysis and interpretation; critical review of the manuscript and final approval.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e We would like to thank the Project on Symptoms of Anxiety Disorder and Depression among University Students of Minas Gerais: Prevalence and Associated Factors (PADu-Multicentric), as well as all the participants in this research and the \u0026lsquo;Funda\u0026ccedil;\u0026atilde;o de Amparo \u0026agrave; Pesquisa do Estado de Minas Gerais\u0026rsquo; (FAPEMIG).\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data generated and/or analyzed during this study are not publicly available due to confidentiality agreements with the participants. 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Guias alimentares para a popula\u0026ccedil;\u0026atilde;o brasileira: uma an\u0026aacute;lise a partir das dimens\u0026otilde;es culturais e sociais da alimenta\u0026ccedil;\u0026atilde;o. Cien Saude Colet 2020;25:2519\u0026ndash;2528. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1590/1413-81232020257.22322018\u003c/span\u003e\u003cspan address=\"10.1590/1413-81232020257.22322018\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mental health, Anxiety, Depression, Dietary consumption, University students","lastPublishedDoi":"10.21203/rs.3.rs-6185181/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6185181/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAnxiety and depression are common among university students and are aggravated by the academic pressures and personal changes typical of this phase. Unbalanced diets, especially those rich in ultra-processed foods, have been linked to worsening mental health. On the other hand, a healthy diet can act as a protective factor, eliminating the risk of these disorders. This study aims to assess the quality of the diet of university students with symptoms of anxiety and depression.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eMulticenter cross-sectional study involving students from eight Brazilian public universities, with data collected between October 2021 and February 2022. Symptoms of anxiety and depression were assessed using the Depression, Anxiety and Stress Scale-21. Diet quality was assessed based on the frequency of consumption of healthy and unhealthy foods. Poisson regression was used to analyze the association between diet quality and mental health symptoms, with significance set at p\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe results indicate that 58.9% and 62.5% of university students had moderate to extremely severe symptoms of anxiety and depression, respectively. Students with poor diet quality were 25% more likely (PR\u0026thinsp;=\u0026thinsp;1.25, 95%CI 1.19\u0026ndash;1.32) to have symptoms of anxiety and 24% more likely (PR\u0026thinsp;=\u0026thinsp;1.24, 95%CI 1.18\u0026ndash;1.30) to report symptoms of depression, compared to those with high diet quality.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe high prevalence of anxiety and depression among university students, associated with poor dietary quality, reinforces the importance of promoting healthy habits and self-care practices among university students.\u003c/p\u003e","manuscriptTitle":"Poor dietary quality is associated with anxious and depressive symptoms in university students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-22 09:59:13","doi":"10.21203/rs.3.rs-6185181/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-06-16T14:42:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-14T21:46:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-12T18:19:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"207690974037055966554896020211197082204","date":"2025-05-05T10:39:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"291597754434850561826458045210891594731","date":"2025-05-02T11:21:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101788534527618749047595701277126927174","date":"2025-04-03T23:35:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-01T11:15:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"305254714433784732595011718603625793357","date":"2025-04-01T10:48:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-01T09:15:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-26T07:02:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-26T06:59:34+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Medicine","date":"2025-03-08T16:45:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Discover Medicine](https://link.springer.com/journal/44337)","snPcode":"44337","submissionUrl":"https://submission.springernature.com/new-submission/44337/3","title":"Discover Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7478fb80-390a-41d6-9d9b-e63f192ca095","owner":[],"postedDate":"April 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-06-25T09:08:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-22 09:59:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6185181","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6185181","identity":"rs-6185181","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}