Food consumption frequency and perceived stress and depressive symptoms among female university students in the UAE: A cross-sectional study

Background College students lack experience and ability to cope and adapt with their new life events which make them more prone to experience stress or depression that could affect their dietary behavior. There may be an increase or a decrease in the consumption of a certain food group under stress or depression, and the amount of food ingested in general may differ as well. These changes in eating behavior could lead to lifestyle behaviors affecting the overall health and well-being of a population. This study assessed whether perceived stress and depressive symptoms predict the frequency of consumption of specific food groups among female university students. Methods A cross-sectional study was conducted among female university students using a simple random sampling method. The response rate was 97% yielded a total number of 385 participants. The associations between stress levels and the most/least consumed food groups, and between depressive symptoms levels and the most/least consumed food groups were assessed. The questionnaire included a 12-item self-administered food frequency questionnaire, Cohen’s Perceived Stress Scale, and Beck Depression Inventory-II. The study was approved by the University Ethical Committee before data collection. One-way Analysis of Variance (ANOVA) or the independent-sample t-test were carried out to test the equality of population means across the categories of each independent variable (predictor) depending on the independent variable number of categories. Results Overall, this group of female university students fell under the mild mood disturbance category (depressive symptoms) (BDI-II) and had moderate perceived stress (PSS). Perceived stress was associated with more frequent consumption of

salad/raw vegetables and cooked vegetables, and less frequent consumption of cake/cookies and meat/sausage products (p<.05). Additionally, depressive symptoms were associated with less frequent consumption of fresh fruits and more consumption of fast food/canned food and soft drinks (p<.05).
Conclusions The data showed that stress and depression predicted different dietary preferences consistent with distinctions between stress and depression on human behavior. Specifically, the results revealed associations between soft drinks consumption and higher depressive symptoms, and between frequent consumption of salad/raw vegetables and cooked vegetables and higher perceived stress among this group of female university students.

Background
Stress and depression could contribute to several complications including maladaptive eating behaviors either by overeating or undereating (1,2). These inconsistencies in dietary habits are results of stress and other reasons, and that could cause either a noticeable weight gain or weight loss among stressed or depressed persons. Eventually, these changes in eating habits can lead to lifestyle behaviors (3). Additionally, undergoing stressful life situations could be a risk factor for developing depression (2).
One definition of stress states that it is a person's response to a stimulation in the environment that resembles danger, or from the person's own understanding of threat (4). Stress and dietary behavior were linked in previous findings in uni-or bidirectional ways. For instance, in 2014, the fifth most reported cause of stress in the USA was poor nutrition which includes over-consumption of caffeine, processed foods, and refined sugars (5). In the Middle East, 23.8% of female and 17.1% of male medical students in Egypt reported severe levels of perceived stress (6). In the UAE, a study showed that 65% of medical students believed that their stress level was too high, and 50% of them stated that their diet was unhealthy (7). Another study conducted in the UAE reported a high degree of stress among female students from different faculties (8).
Depression is a medical disorder that affects mood, and is known by the distressed nature, hopelessness, and misery of the patient (9). According to the World Health Organization, over 264 million people around the world suffer from depression (10).
Above third of Jordanian adolescents reported moderate to severe depression and females showed the highest rates of depression (11). In (12), female university students in the UAE had a mean score of depressive symptoms indicating mild mood disturbances.
The relationship between the type and the frequency of dietary intake and mental health has been studied over the past years, and this growing field of study concluded that higher consumption of processed and Western food indicates higher risk of developing poor mental health (13). Prospective studies rely on causality to explain the nature of this relationship; unhealthy diets at baseline showed higher risk of depression and poor mental health while healthier diets at baseline showed better mental health and lower risk of depression (14)(15)(16).
Several studies reported association between stress levels and the consumption of certain types of food. For example, when participants were exposed to a stressful situation, they tended to consume more of high-density foods and sweets (1,17). In addition, cross-sectional studies suggested that higher perceived stress is positively associated with higher intake of fat, sodium and carbohydrates (18,19). Despite that, other studies found that higher levels of stress did not mean more sweets consumption, but lower stress levels were associated with higher fruits and vegetables intake (20). Overall, studies that looked into food choice under stress found that people; particularly females, consume more of the food types they usually avoid for health reasons (17).
Regarding depression and dietary habits, most studies focused on the effects of certain diets on depression. These studies showed that the adherence to certain diets that provide healthier choices of food resulted in improved mental health in depressed individuals (21). Evidence also suggests that certain nutrients could positively affect mood and could be used for the treatment of depression, while other nutrients could increase the risk of it (9,22). Moreover, it was reported that, despite the effect of the socioeconomic status, poor dietary patterns could promote depressive symptoms (23).
In general, studies that sought to map the relationship between mental health symptoms (stress and depressive symptoms) and diet reported that unhealthy food intake increased with perceived stress and depressive symptoms levels.
Furthermore, it was found that unhealthy food consumption was linked to perceived stress in females only; however, depressive symptoms were linked to the intake of unhealthy food in both males and females (24,25). Similar research concluded that levels of perceived stress and depressive symptoms increased with the decrease of fresh-food intake, and the increase of ready-to-eat food and vice versa (26).
With increased competition, high expectations, and rapidly-increasing life demands, for college students, they become particularly vulnerable to vicious cycles where poor diet choices and mental health symptoms perpetuate each other. Due to their new environment, responsibilities, financial pressure, and time management struggles, students are more prone to experience stress (3). Long-lasting stress was found to be associated with weight gain since it triggers eating more frequently and less healthy (27,28). Furthermore, depression may lead to overeating or undereating (2, 9). However, the research on the effects of stress and depression on dietary habits and choices in the UAE or in the Middle East, specifically in the countries of the Gulf Cooperation Council (GCC), is limited and outdated. To the best of our knowledge, there have been no studies conducted on UAE college students regarding the relationship between dietary habits, depressive symptoms and perceived stress. Therefore, in this study, the relationship between mental health symptoms (specifically, perceived stress and depressive symptoms) and dietary habits was explored among female university students, with the goal of achieving better understanding of how these variables influence one another in this population.

Study Design and Materials
A cross-sectional study was conducted following obtaining ethical clearance from Zayed University's Research Ethics Committee. A 12-item food frequency questionnaire, Beck Depression Inventory and Cohen's Perceived Stress Scale were compiled in one questionnaire.

Population and sampling
The sample was drawn from female students at a national university in United Arab Emirates (UAE). A number of classes were chosen randomly from the list of courses of spring 2018, then emails were sent to the instructors of these classes to ask for permission to administer the questionnaire during the class time starting. Data collection was done from April. 3. 2018 to May. 3. 2018. The sample represented approximately 10% of the targeted population of 4000 students resulted in a total sample size of 389 students. 385 questionnaires were accepted in the study resulting in a response rate of 98.9%. Before data collection, a pilot study was conducted on a sample of 10 students to check that the questionnaire was well understood and was appropriate to use with the intended sample. The pilot study members were not included in the final data analysis reported here.

Materials
Data was collected through a self-reported questionnaire that consisted of three sections; a 12-item food frequency questionnaire, the 10-item Cohen's Perceived Stress Scale (PSS) and Beck Depression Inventory-II (BDI-II). Weight and height were self-reported which could be a potential source of bias.

Food Frequency Questionnaire (FFQ)
The food frequency questionnaire (24) assessed the frequency of consumption of 12 food groups; sweets, cake/cookies, snacks, fast food/canned food, fresh fruits, salad/raw vegetables, cooked vegetables, soft drinks, meat/sausages products, fish/seafood, milk/ milk products, and cereal/cereal products. Students were asked to answer the question "How often do you eat the following foods?" on a 5-point scale (several times a day =5, daily =4, several times a week=3, 1-4 times a month=2, and never=1). Cronbach's = 0.68.

Cohen's Perceived Stress Scale (PSS)
The PSS estimates the degree of which situations in a person's life are considered stressful through 10 items (29,30). Students expressed their feelings and thoughts for each item during the past month on a 5-point scale (0=Never, 1= Almost never, 2= Sometimes, 3= Fairly often, and 4= Very often). In this sample, Cronbach's = 0.68.

Beck Depression Inventory-II (BDI-II)
The BDI-II measures the behavioral manifestation of depression (31,32

Main Variables and Statistical Analysis
The FFQ is measured on a five-point scale (several times a day =5, daily =4, several times a week=3, 1-4 times a month=2, and never=1). There are 12 items in the FFQ, the sum of all answers from each respondent to all 12 items was calculated and called the "food frequency sum" (FF Sum).
In order to compare the results to other studies (24)

Sociodemographic Characteristics
The study population consisted mainly of Emiratis who made 97.1% of the sample. Association between food intake and Perceived stress or Depressive symptoms Associations between the consumption of each food group and stress and depression were assessed separately using linear regression. Table 1 shows that the significant associations between food groups and perceived stress and depressive symptoms were not equal, while there are 4 associations for perceived stress, only Additionally, positive associations were observed with perceived stress and salad/raw vegetables and cooked vegetables, and with depressive symptoms and soft drinks and fast food/canned food.
For every unit increase in PSS, the cake/cookies consumption will decrease by 0.106, and the meat/sausage products consumption will decrease by 0.130. On the other hand, the salad/raw vegetables consumption will increase by 0.103 and cooked vegetables consumption will increase by 0.107. Regarding depressive symptoms, for every unit increase in BDI-II, the fresh fruits consumption will decrease by 0.122, and the fast/canned food consumption will increase by 0.114 while soft drinks consumption will increase by 0.124.
Multiple linear regressions were used to assess associations between the consumption of all food groups together and both PSS and BDI-II (Table 2). It was found that the consumptions of Unhealthy Food, Fresh Food, fish/sea food, milk/milk products, and cereal/cereal products were not significantly associated with perceived stress and depressive symptoms among this group of university students.
In addition, increased consumption of soft drinks was significantly associated with higher depressive symptoms, while increased consumption of meat/sausage products was significantly associated with lower perceived stress.

Discussion
The objective of this study was to assess whether perceived stress and depressive symptoms predict the frequency of consumption of specific food groups among female university students. As mentioned previously, habits that are formed during youth are likely to be sustained throughout later adulthood (3). Therefore, studying the complex relationship between food choice and mental state is of high importance to clarify and predict what type of eating behavior could be influenced by stress or depression or vice versa.
Our results from the univariable analysis showed that consumption of cake/cookies and meat/sausage products was negatively associated with stress while consumption of salad/raw vegetables and cooked vegetables was positively associated with stress. This result does not line-up with findings from crosssectional studies conducted on different populations that reported higher consumption of sweets, snacks and fast food with higher stress levels, or higher consumption of fruits/vegetables with lower stress levels (20,24). Nevertheless, a study that was conducted in Palestine found similar results to the current study. It was found that among females, the consumption of cake/cookies was negatively associated with stress, and among males all food groups except for cereal/cereal products were negatively associated with stress (37). The latter study suggested that lower consumption of cake/cookies with higher stress could be linked to the fact that people consume foods high in carbohydrates (CHO) to relieve their stress.
This could be interpreted by the fact that highly palatable foods high in CHO and fat such as cake/cookies enhance opioid levels in the brain which was linked to feelings of pleasure, and they were eaten as a reward after stress; hence, students' stress level was lower when they consumed these foods (37,38). However, this suggestion is built on the assumption that students with lower stress levels who consumed more cake and cookies were stressed before and consumed more of this food group to relieve the symptoms. This is a weak assumption and cannot be confirmed with the current study design. Another possible explanation could be based on the behavioral differences that stress and depression have on people. Recall that the consumption of fast food/canned food and soft drinks was found in the current study to be positively associated with depressive symptoms while consumption of fresh fruits was negatively associated with it. These results are consistent with what similar studies found regarding these food groups and depressive symptoms (24,25). Depression reflects the behavioral changes in people with higher depressive symptoms. Unlike stress, depression creates feelings of emptiness and hopelessness, pointlessness of efforts and severe reduction in perception of selfefficacy (39-41). As such, making an effort to eat healthier food to persons with depression would not be of significance, and hence the tendency we report here to consume more of the easily accessible foods that fall under unhealthy food groups in the high-depression group. The high-stress group, on the other hand, may still consider it important, and possible, to eat healthily, and hence the positive link between higher levels of stress and healthier eating behaviors. It may be of interest in the future to investigate the extent to which there is a discrepancy between the wish to eat healthily and the actual dietary behavior of the high-stress group.
Importantly, it would be of interest to unearth the extent to which higher discrepancy (between the wish and the actual dietary behavior) is linked, via dissonance, to the levels of stress reported in this group.
The results of the multivariable analysis showed that there was only one significant association with stress, and one with depressive symptoms. The consumption of meat/sausage products was negatively associated with stress while the consumption of soft drinks was positively associated with depressive symptoms. This is not similar to findings from studies which found positive associations with Unhealthy Food (sweets/snacks/cookies/fast food) and stress and depression, nor studies that found negative associations with Healthy Food (fruits/vegetables) and stress and depression (24,25). However, Yassin, Sarsour and Alharazin found that stress was negatively associated with Unhealthy Food consumption among males only, which is similar to the insignificant result this study found regarding the Unhealthy Food subscale and stress (37). First, the explanation of negative association found between meat/sausage products consumption and stress is not known though it could mean that lower stress leads to an increased consumption of protein

Consent for publication
Not applicable

Availability of data and materials
The datasets analyzed during the current study are available from the corresponding author on reasonable request.
addition to contributing to the discussion. RM provided guidance regarding the food frequency questionnaire and suggested the adjustments of the BDI-II scoring system to compensate for the obligatory removal of one item.