Associations of dietary diversity with depressive symptoms, anxiety symptoms and their co-occurrence among reproductive-age women in three low- and middle-income countries: a cross-sectional analysis.

Abstract

Background Depressive and anxiety symptoms are common among women of reproductive age in low- and middle-income countries (LMICs). Whether dietary diversity is associated with depressive symptoms, anxiety symptoms, and their co-occurrence in this population remains insufficiently characterized. Objectives To examine the associations between minimum dietary diversity for women (MDD-W) and depressive symptoms, anxiety symptoms, and co-occurring depressive and anxiety symptoms among reproductive-age women in three LMICs. Methods A cross-sectional analysis was conducted using Demographic and Health Surveys (DHS) data from Zambia, Mozambique, and Nepal, including 34,576 women aged 15-49 years. Depressive and anxiety symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7), respectively. Minimum dietary diversity for women (MDD-W) was classified as inadequate (<5 food groups) versus adequate (≥5 food groups). Survey-design-based multivariable logistic regression models accounting for DHS sampling weights, clustering, and stratification were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses assessed potential effect modification. Sensitivity analyses were performed by modeling dietary diversity as a continuous score and by repeating the primary analyses separately by country and after excluding currently pregnant women. Results The weighted prevalence of depressive symptoms, anxiety symptoms, and co-occurring depressive and anxiety symptoms was 5.7%, 6.4%, and 3.9%, respectively. In fully adjusted models, meeting MDD-W was associated with lower odds of depressive symptoms (OR = 0.69, 95% CI: 0.58-0.82), anxiety symptoms (OR = 0.63, 95% CI: 0.54-0.73), and co-occurring symptoms (OR = 0.58, 95% CI: 0.47-0.72). Food-group analyses showed inverse associations with depressive symptoms, anxiety symptoms, and co-occurring symptoms for other vegetables, pulses, eggs, flesh foods, other fruits, and dairy products, whereas dark green leafy vegetables were positively associated with all three mental health measures. Subgroup analyses indicated possible heterogeneity by residence, wealth status, and marital status for selected measures. Sensitivity analyses showed generally inverse associations across countries, although the magnitude and statistical significance varied; spline analyses indicated nonlinear associations, and results were similar after excluding currently pregnant women. Conclusion Among reproductive-age women in three LMICs, meeting MDD-W was associated with lower odds of depressive symptoms, anxiety symptoms, and their co-occurrence. Longitudinal and intervention studies are needed to clarify the temporal and causal relationships between dietary diversity and mental health symptoms.