The protective effect of mushroom consumption on depressive symptom in Korean population

doi:10.21203/rs.3.rs-1977206/v1

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The protective effect of mushroom consumption on depressive symptom in Korean population

https://doi.org/10.21203/rs.3.rs-1977206/v1

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Mushrooms are nutraceutical food with health benefit. However, data is still limited in identifying the protective effect of mushroom consumption on depressive symptom. In a cohort of 87,822 Korean, we longitudinally assessed the risk of depressive symptom according to mushrooms consumption. Study participants were categorized into 5 groups by the frequency of one serving size of mushrooms (30 g) as follows: rare/never, <1/month, 1/month-1/week, 1-3/week, ≥ 3/week. The development of depressive symptom was determined in Center for epidemiological studies-depression (CES-D) scale ≥ 16. Cox proportional hazards model was used to calculate adjusted hazard ratio (HR) and 95% confidence intervals (CI) for depressive symptom (adjusted HR [95% CI]). Subgroup analysis was performed for gender and age. Compared with group with rare/never consumption, groups with mushrooms consumption ≥ one serving size/month had the significantly decreased levels in adjusted HR and 95% CI for depressive symptom (rare/never consumption: reference, < 1/month: 0.92 [0.83 - 1.02], 1/month-1/week: 0.88 [0.83 – 0.94], 1-3/week: 0.88 [0.82 – 0.94], ≥ 3/week: 0.86 [0.80 – 0.93]). This association was similarly observed in both gender and age subgroup analyses. However, women and participants ≥ age of 40 showed the more prominent association than men and participants < age of 40.

mushrooms

depression

diet

Depression is a serious neuropsychiatric disorder, leading to depressed mood, loss of interest, low self-esteem, cognitive impairment, sleep disturbance and eating disorder (1). Studies have demonstrated that depression is associated with the development and progression of chronic illness including diabetes mellitus (DM), hypertension and cardiovascular disease (2–4). Lifetime prevalence of depression varies among countries from 16.2% in USA to 53% in low income countries (5, 6). World Health Organization (WHO) has reported that more than 300 million people suffer from depressive symptoms over all ages globally (7). Therefore, it is important health challenge to investigate ways to alleviate depressive symptoms.

It is widely believed that good dietary habit and nutritional foods are helpful in controlling mood disorder. In practice, a randomized trial indicated that improvement of diet is potentially effective in treating depression (8). A meta-analysis from 21 studies of ten countries presented that the risk of depression was inversely associated with high intake of fruits, vegetables, whole grains, and antioxidants (9).

Mushrooms are functional foods with high nutritional values and great sources for novel therapeutic compounds, linking to good dietary habit (10–12) Studies have demonstrated that some types of mushrooms have therapeutic potential for cognitive impairments (13) and Alzheimer’s disease (14). Mushrooms are rich in bioactive components including antioxidants and neutrotrophic factors, which are helpful in preventing neuropsychiatric disorders (15, 16). Results from these works give rise to interest for the effect of mushrooms on depression. Clinical trials have shown that high intake of Hericium erinaceus has potential benefit in attenuating the depressive symptoms (17, 18). However, these studies are limited in generalization due to small number of participants less than 100. Moreover, there is only a few data about the association between comprehensive mushrooms intake and the risk of depressive symptoms (19).

Therefore, to identify the effect of mushroom intake on depression, we longitudinally investigated the risk of depressive symptom according to the consumption of mushrooms in 87,822 Korean adults.

The baseline clinical and sociodemographic characteristics among study groups are presented in Table 1. The cohort of present study is characterized by relatively young age with mean age of 39.6 ± 6.9 years and preponderance of men with 56,112 male participants (63.89%). The proportion of participants consuming mushrooms ≥ one serving size/week was higher in women (51.2%) than men (38.4%). Groups with mushrooms consumption > one serving size/month tended to have the higher levels in total calorie intake, the proportion of marriage and the proportion of high education, compared with rare/never consumption. In addition, they had the lower levels in the proportion of current smoker, average alcohol use, the prevalence of hypertension, baseline CES-D score and the incidence of depressive symptom than group with rare/never consumption.

Table 1

Baseline clinical characteristics of study participants according to the mushroom consumption
Characteristics	Serving
Characteristics	Rare/never	< 1/month	≥ 1/month and < 1/ week	≥ 1 and < 3/week	≥ 3/week	P value
number	7,665	3,782	38,491	23,842	14,042
Men	5,790 (10.3%)	2,565 (4.5%)	26,130 (46.5%)	14,511 (25.8%)	7,116 (12.6%)	< 0.001
Women	1,875 (5.9%)	1,217 (3.8%)	12,361 (38.9%)	9,331 (29.4%)	6,926 (21.8%)	< 0.001
Age (year)	39.4 ± 7.3	39.5 ± 7.3	39.6 ± 6.9	39.5 ± 6.7	39.7 ± 6.7	0.026
Age ≥ 40 years (%)	42.6%	42.6%	43.8%	42.7%	44.4%	0.003
BMI (kg/m²)	23.9 ± 3.2	23.2 ± 3.1	23.4 ± 3.2	23.4 ± 3.2	23.2 ± 3.3	< 0.001
Average alcohol use (g/day)	18.0 ± 24.4	15.4 ± 20.3	15.6 ± 21.9	14.6 ± 21.9	13.5 ± 21.5	< 0.001
Total calorie intake (kcal/day)	1437.7 ± 627.5	1422.3 ± 541.6	1546.3 ± 586.8	1696.9 ± 621.7	1902.7 ± 870.8	< 0.001
Current smoker (%)	31.0%	25.5%	25.0%	23.0%	19.2%	< 0.001
Hypertension (%)	13.5%	10.5%	10.9%	10.8%	10.0%	< 0.001
DM (%)	5.0%	3.7%	3.7%	3.5%	3.7%	< 0.001
Married (%)	81.9%	85.0%	87.2%	89.8%	91.6%	< 0.001
High education (%)	71.0%	72.2%	74.9%	75.0%	71.9%	< 0.001
Baseline CESD score	5.3 ± 4.1	5.0 ± 4.1	5.0 ± 4.1	4.9 ± 4.2	5.1 ± 4.2	0.014
Incident depressive symptom (n, [%])	1201 (15.7%)	551 (14.6%)	5522 (14.3%)	3516 (14.7%)	2135 (15.2%)	0.014
Continuous variables are expressed as mean (± SD), and categorical variables are expressed as number (percentage (%)).
< 1/month: <1 serving size/month, 1/month-1/week: 1 serving size/month ≤ and < 1 serving size/week, 1–3/week: 1 serving size/week ≤ and < 3 serving sizes/week, ≥ 3/week: ≥ 3 serving sizes/week
BMI: body mass index, DM: diabetes mellitus, CESD: Center for Epidemiologic Studies Depression

During 5.8 years of median follow-up period, 12,925 subjects (14.3%) reported new onset of depressive symptom (CES-D ≥ 16), and group with rare/never mushrooms consumption presented the highest values in the baseline CES-D score (5.3 ± 4.1) and the incidence of depressive symptom (15.7%).

Table 2 shows the unadjusted and the multivariable adjusted HR and 95% CI for depressive symptom according to the groups with mushrooms consumption. In all participants, compared with group with rare/never consumption, groups with mushrooms consumption ≥ one serving size/month had the significantly decreased levels in adjusted HR and 95% CI for depressive symptom (rare/never consumption: reference, < 1/month: 0.92 [0.83–1.02], 1/month-1/week: 0.88 [0.83–0.94], 1–3/week: 0.88 [0.82–0.94], ≥ 3/week: 0.86 [0.80–0.93], P for trend < 0.001). Gender subgroup analysis indicated the similar pattern of relationship between mushroom consumption and depressive symptom in both men and women. However, women showed the more distinct association than men (rare/never consumption: reference, < 1/month: 0.82 [0.69–0.98], 1/month-1/week: 0.86 [0.77–0.96], 1–3/week: 0.85 [0.76–0.95], ≥ 3/week: 0.81 [0.72–0.92], P for trend < 0.001).

Table 2

Hazard Ratio (HR) and 95% confidence intervals (CI) for depressive symptom (CESD ≥ 16) according to the mushroom consumption
Characteristics			Serving			P for trend
Characteristics	Rare/never	< 1/month	1/month − 1/ week	1–3/week	≥ 3/week	P for trend
All participants (n)	7,665	3,782	38,491	23,842	14,042	0.64
Unadjusted HR	1.00 (Reference)	0.92 (0.84– 1.02)	0.89 (0.84–0.95)	0.92 (0.86– 0.98)	0.95 (0.89–1.02)	0.64
Adjusted HR	1.00 (Reference)	0.92 (0.83–1.02)	0.88 (0.83–0.94)	0.88 (0.82–0.94)	0.86 (0.80–0.93)	< 0.001
Incidence case [n, (%)]	1,201 (15.7%)	551 (1.46%)	5,522 (14.3%)	3,516 (14.7%)	2,135 (15.2%)
Incidence density	31.4	29.0	28.1	29.0	30.0
Person year	38,291	18,984	196,448	121,386	71,172
Men (n)	5,790	2,565	26,130	14,511	7,116
Unadjusted HR	1.00 (Reference)	0.96 (0.85–1.09)	0.88 (0.82–0.95)	0.90 (0.83–0.98)	0.94 (0.86–1.03)	0.178
Adjusted HR	1.00 (Reference)	0.97 (0.86–1.10)	0.89 (0.82–0.96)	0.89 (0.82–0.97)	0.90 (0.82–0.99)	0.021
Incidence case [n, (%)]	827 (14.3%)	353 (13.8%)	3,389 (13.0%)	1,911 (13.2%)	977 (13.7%)
Incidence density	28.2	27.1	25.0	25.5	26.7
Person year	29,345	13,043	135,639	75,036	36,6327
Women (n)	1,875	1,217	12,361	9,331	6,926
Unadjusted HR	1.00 (Reference)	0.79 (0.67–0.94)	0.83 (0.75–0.93)	0.82 (0.73–0.92)	0.79 (0.71–0.89)	0.002
Adjusted HR	1.00 (Reference)	0.82 (0.69–0.98)	0.86 (0.77–0.96)	0.85 (0.76–0.95)	0.81 (0.72–0.92)	0.005
Incidence case [n, (%)]	374 (19.9%)	198 (16.3%)	2,133 (17.3%)	1,605 (17.2%)	1,158 (16.7%)
Incidence density	41.8	33.3	35.1	34.6	33.5
Person year	8,945	5,940	60,809	46,349	34,545
Adjusting covariates: age, BMI, sex, alcohol intake, hypertension, diabetes, smoking, marital status, education, and total calorie intake
< 1/month: <one serving size/month, 1/month-1/week: one serving size/month ≤ ~ < one serving size/week, 1–3/week: one serving size/week ≤ ~ < three serving sizes/week, ≥ 3/week: ≥ three serving sizes/week
Adjusted HR: multivariate-adjusted hazard ratio

In age subgroup analysis by age of 40 years, subgroup with age < 40 years presented the marginally significant association between mushrooms consumption ≥ one serving size/week and the decreased risk of depressive symptom (Table 3). However, in subgroup with age ≥ 40 years, participants consuming mushrooms ≥ one serving size/month had the significantly decreased HR and 95% CI for depressive symptom (rare/never consumption: reference, < 1/month: 0.96 [0.82–1.12], 1/month-1/week: 0.80 [0.73–0.89], 1–3/week: 0.82 [0.74–0.91], ≥ 3/week: 0.79 [0.70–0.88], P for trend < 0.001).

Table 3

Hazard Ratio (HR) and 95% confidence intervals (CI) for depressive symptom (CESD ≥ 16) according to the mushroom consumption in subgroups stratified by age
Characteristics			Serving			P for trend
Characteristics	Rare/never	< 1/month	1/month − 1/ week	1–3/week	≥ 3/week	P for trend
Age < 40 years old	4,403	2,171	21,621	13,666	7,814
Unadjusted HR	1.00 (Reference)	0.89 (0.78–1.02)	0.95 (0.87–1.03)	0.95 (0.87–1.03)	1.00 (0.91–1.09)	0.66
Adjusted HR	1.00 (Reference)	0.89 (0.78–1.02)	0.94 (0.86–1.02)	0.92 (0.84–1.00)	0.91 (0.83–1.00)	0.082
Incidence case [n, (%)]	692 (15.7%)	309 (14.2%)	3,272 (15.1%)	2,081 (15.2%)	1,242 (15.9%)
Incidence density	30.2	27.0	28.7	28.9	30.3
Person year	22,909	11,432	113,955	72,068	41,048
Age ≥ 40 years old	3,262	1,611	16,870	10,176	6,228
Unadjusted HR	1.00 (Reference)	0.97 (0.83–1.13)	0.82 (0.75–0.91)	0.88 (0.79–0.97)	0.89 (0.80–0.996)	0.214
Adjusted HR	1.00 (Reference)	0.96 (0.82–1.12)	0.80 (0.73–0.89)	0.82 (0.74–0.91)	0.79 (0.70–0.88)	< 0.001
Incidence case [n, (%)]	509 (15.6%)	242 (15.0%)	2,250 (13.3%)	1,435 (14.1%)	893 (14.3%)
Incidence density	33.1	32.0	27.3	29.1	29.6
Person year	15,382	7,552	82,493	49,318	30,124
Adjusting covariates: age, BMI, sex, alcohol intake, hypertension, diabetes, smoking, marital status, education, and total calorie intake
< 1/month: < one serving size/month, 1/month-1/week: one serving size/month ≤ ~ < one serving size/week, 1–3/week: one serving size/week ≤ ~ < three serving sizes/week, ≥ 3/week: ≥ three serving sizes/week
Adjusted HR: multivariate-adjusted hazard ratio

In a longitudinal analysis for 87,822 Koreans with mean age of 39.6 ± 6.9 years, we showed that high mushrooms consumption was significantly associated with the decreased risk of depressive symptom. This association was independent of potential confounding factors for depressive symptom such as age, BMI, sex, alcohol intake, hypertension, diabetes, smoking, marital status, education, and total calorie intake. In particular, it is noted that these findings were reproduced in both gender subgroup analysis and age subgroup analysis. Our results suggest that high mushrooms consumption has the protective effect on depression. Previous studies have reported the potential benefit of mushrooms consumption on depressive symptom.

In a clinical trial for 40 subjects to randomized to supplementation of Hericium erinaceus and 37 subjects to randomized to control, the eight weeks of oral supplementation of Hericium erinaceus decreased the scales of depression, anxiety and sleep disorder (17). Additionally, Nagano et al. demonstrated that four weeks’ intake of Hericium erinaceus led to the decreased score of CES-D scale in 12 subjects with Hericium erinaceus intake and 14 subjects with placebo (18). However, these findings can’t be extrapolated into the effect of general mushrooms consumption on general population because they focused only on the effect of Hericium erinaceus in a small number of subjects. Although cross-sectional analysis for 24,699 U.S adults showed the lower odds ratio and 95% CI for depression in the middle tertile of comprehensive mushrooms consumption than those with lowest tertile, the highest tertile didn’t show the statistically significant association with depression (19). Moreover, cross-sectional study survey can’t allow for the determination of the cause-effect relationship between mushroom consumption and the risk of depression. In contrast, our longitudinal analysis showed that high mushroom consumption was significantly associated with decreased risk of depressive symptom in 87,822 participants. Therefore, our results may provide clearer evidence for the potential benefit of mushroom consumption on depression.

Mushrooms contain bioactive components with health benefit, which can be explanations for our findings. It has been proposed that inflammation and oxidative stress are involved in the pathophysiology of depression (20, 21). Subjects with depression have higher levels of inflammatory immune activation, along with other immunological changes (21). Meta-analyses have demonstrated that peoples suffering from depression have an increase in proinflammatory cytokines including tumor necrosis factor-α and interleukin-6 (22). It has been suggested that oxidative stress plays a significant role in the pathophysiology of numerous neuropsychiatric disorders including major depression (21). Studies demonstrated that the levels of oxidative stress markers such as superoxide dismutase, malondialdehyde and nitrite were altered in depressive disorders (24, 25). Therefore, it is postulated that anti-inflammatory agents and anti-oxidants contribute to prevent depressive disorder. Mushrooms are rich in antioxidants and anti-inflammatory agents. Mushrooms may be effective in reducing oxidative stress as are a potent source of powerful antioxidants (26). Additionally, anti-inflammatory effect of mushrooms may have a protective function on depressive symptom. In the present study, a major type of mushrooms is oyster mushroom that is most commonly consumed in Koreans. Oyster mushroom is considered as a functional food due to its anti-inflammatory and immunomodulatory activity (27). Thus, it is plausible that anti-inflammatory and anti-oxdiative activity in mushrooms lead to the decreased risk of depressive symptom.

In our subgroup analyses by gender and age, all of subgroups show the similar pattern of relationship between mushrooms consumption and the risk of depressive symptom. However, the protective effect of mushrooms consumption on depressive symptom seems to be more prominent in women and people ≥ age of 40. It is challenging to identify the correct mechanism for this finding. However, it is likely that the protective effect of mushrooms consumption functions more strongly in high risk group for depressive symptom. It is known that women have the higher prevalence of depression than men. Additionally, our study shows the higher incidence of depressive symptom in women than men, which may lead to the stronger statistical power in women. In terms of age subgroup analysis, a survey from U.S.A presented that the percentage of adults who experienced depressive symptom was higher among those aged 45–64, compared with those aged 30–44 (28). Therefore, the results from our subgroup analyses may be explained by difference in the risk of depression and statistical power from number of incidence among subgroups.

The merits of the present study are large number of study participants, survey for comprehensive mushrooms consumption and investigation for depressive symptom through CES-D scale. These merits allowed us to quantify the risk of depressive symptom according to mushrooms consumption in all participants and each subgroup.

Nonetheless, our study has several limitations.

First, the incidence of depressive symptom was evaluated only by CES-D scale. Despite reasonability and reproducibility of CES-D scale in epidemiological setting, CES-D scale is not a gold standard in diagnosing depressive disorder. Thus, there is a concern for the underestimation or overestimation of depressive symptom.

Second, survey for mushrooms consumption is performed for oyster mushroom and other mushrooms. Therefore, we are unable to specify the type of mushrooms consumed in our study participants. Although oyster mushroom is most commonly consumed in Koreans, other mushrooms can be consumed as a major type. Our results should be interpreted as a protective effect of general mushrooms consumption rather than specific type of mushrooms.

Third, because FFQ was based on self-administered questionnaire, there was a possibility of misclassification for type and frequency of consumed mushrooms.

In conclusion, our study indicated that increase in mushrooms consumption more than specific levels was associated with the decreased risk of depressive symptom. Subgroup analyses identified that this association is similarly observed in both gender and age subgroups. However, women and participants ≥ age of 40 showed the more prominent association between increased mushrooms consumption and the decreased risk of depressive symptom than men and participants < age of 40. These findings suggest that high intake of mushrooms has the protective effect on depressive symptom.

Study participants and exclusion criteria

Relevant clinical and sociodemographic data were obtained from Kangbuk Samsung Health Study (KSHS). KSHS is a cohort study to investigate the medical data of Koreans who have received medical health check-up in Kangbuk Samsung Hospital. Korea’s Industrial Safety and Health law orders that all of Korean employees should receive medical health check-up annually or biennially. Ethics approvals for the study protocol and analysis of the data were obtained from the institutional review board (IRB) of Kangbuk Samsung Hospital (IRB No. KBSMC 2020-09-25). All procedures performed in studies involving human participants were in accordance with the ethical standards of the IRB of the Kangbuk Samsung Hospital and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. IRB of Kangbuk Samsung Hospital approved the exemption of informed consent for the study because we only assessed retrospective data with de-identified personal information obtained from routine health check-up.

Among study participants in KSHS, we initially enrolled 136,405 subjects who had responded to semi-quantitative food frequency questionnaire (FFQ) including mushrooms consumption and Center for Epidemiologic Studies Depression (CES-D) between March 2011 and December 2012. Among these subjects, we excluded 820 subjects with taking sedative or anxiolytic medications and 15,148 subjects with depressive symptom in baseline analysis. Furthermore, 14,541 subjects with missing value in covariate data (e.g. BMI, hypertension, education) and 3,340 subjects with a history of serious medical diseases (e.g. coronary heart disease, stroke, and cancer) were further excluded. Out of the remaining 102,556 subjects, we finally recruited 87,822 participants who revisited and responded to the CES-D questionnaire from January 2013 to December 2018. Therefore, the total number of eligible study participants was 87,822.

Clinical and sociodemographic data

Study data include medical history assessed by self-administered questionnaire, anthropometric measurements and laboratory measurements. All study subjects were asked to respond to a health-related behavior questionnaire, which included the topics of alcohol consumption, smoking and exercise. Marriage, education, income, and occupation, which may influence psychological state and dietary patterns, were also included in the questionnaire. Hypertension was defined as a prior diagnosis of hypertension or having a measured BP ≥140/90 mmHg at initial and follow up examinations. Trained nurses measured BP on sitting position by automatic device (53000-E2, Welch Allyn, USA) three times after a 5 min rest with at least 30 seconds interval. Final BP levels were obtained as average of second and third BP measurements. The BMI was calculated by dividing weight (kilograms) by square of height (meters²). DM was defined as one of following conditions; fasting glucose ≥ 126 mg/dL, hemoglobin A1 c (HbA1c) ≥ 6.5%, and a prior diagnosis of DM (29).

Blood samples were collected after more than 12 hours of fasting and were drawn from an antecubital vein. The fasting serum glucose was measured using the hexokinase method, and hemoglobin A1c (Hba1c) was measured using an immunoturbidimetric assay with a Cobra Integra 800 automatic analyzer (Roche Diagnostics, Basel, Switzerland). Serum uric acid levels were measured enzymatically using an automatic analyzer Advia 1650 Autoanalyzer, Bayer Diagnostics; Leverkusen, Germany).

Assessment of FFQ data

We assessed the dietary intake of KSHS participants using the FFQ that was developed for the Korean genome epidemiologic study. The dietary data to design the FFQ were obtained from the Korea Health and Nutrition Examination Survey (30, 31). A detailed description of the FFQ (30) and its validation in the Korean population has been described in a previous study (31). The frequency of food consumption was composed of nine categories (e.g., mushroom intake was categorized never or rarely, once a month, two or three times a month, once or twice a week, three or four times a week, five or six times a week, one times a day, two times a day, and more than three times a day) and three serving sizes for each food. In mushrooms consumption, one serving size in mushrooms consumption was 30g and the serving size was classified into 15g, 30g, and 45g per day.

Participants answered their intake of oyster mushrooms and other mushrooms were categorized into five group according to mushroom consumption as follows: rare/never, <1/month (<one serving size/month), 1/month-1/week (one serving size/month ≤ ~ < one serving size/week), 1-3/week (one serving size/week ≤ ~ < three serving sizes/week), ≥ 3/week (≥ three serving sizes/week). Total energy and nutrient intake was calculated by the Can-Pro 3.0 software developed by The Korean Nutrition Society (32).

Assessment of depressive symptom

Depressive symptoms were assessed using the Korean versions of CES-D scale (33). The CES-D is a self-report questionnaire designed to assess the current presence of depressive symptoms in the general population (34). We used the 4-factors 20-items CES-D Scale with scores ranging from 0 to 3, with 0 indicating that the depressive symptom was experienced rarely and 3 indicating that the symptom was experienced most of the time in the past week. (e.g. “I thought my life had been a failure.” 0=seldom (not at all or less than 1 day), 1= sometimes (1~2 days), 2 = often (3~4 days), 3 = almost always (5~7 days)). This scale has been widely used across the world and shown the validity and reliability in the Korean general population (33). Depressive symptom was defined in the total score of CES-D ≥16. Therefore, in baseline analysis, subjects with CES-D ≥16 were regarded as the presence of depressive symptom in baseline and excluded from study participants. During follow-up, the subjects who newly fulfilled CES-D ≥16 were determined as the cases of incident depressive symptom.

STATISTICAL ANALYSES

The baseline parameters among groups of mushrooms consumption are presented as means ± standard deviation for continuous variables and as proportions for categorical variables. Main clinical characteristics and parameters among study groups were compared using ANOVA for continuous variables and chi-square test for categorical variables.

A Cox proportional hazards model was used to calculate the unadjusted and multivariable-adjusted hazard ratio (HR) and 95% confidence intervals (CI) for depressive symptom (multivariable adjusted HR [95% CI]) in each study group. The models were adjusted for multiple covariates including age, BMI, sex, alcohol intake, hypertension, diabetes, smoking, marital status, education, and total calorie intake. The covariates of the multivariable model were selected for the presence of significant differences between groups or established risk factors for depression. The incidence cases, incidence density (incidence cases per 1,000 person-years), person years of each group were calculated. Trend analysis conducted with median value of mushroom consumption. Given the different prevalence of depression in men and women, gender subgroup analyses were conducted. Furthermore, analyses by age subgroup were also conducted in consideration of different food preferences for each age subgroup (< 40 or ≥ 40 years old).

All statistical analyses were performed using R 3.6.3 (R Foundation for Statistical Computing, Vienna, Austria), and a value of P < 0.05 (two-sided) was considered statistically significant in all analyses.

Acknowledgement

This study was based on medical data collected and arranged by Kangbuk Samsung Cohort Study (KSCS). Therefore, this study could be done by virtue of the labor of all staffs working in KSCS and Total Healthcare Center, Kangbuk Samsung Hospital.

Availability of Data and Materials

The data that support the findings of this study are available from Kangbuk Samsung Cohort Study, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of Kangbuk Samsung Cohort Study.

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No competing interests reported.

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The protective effect of mushroom consumption on depressive symptom in Korean population

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