The relationship between psychological distress and the health-related quality of life of middle-aged Korean females: A serial mediation model

doi:10.21203/rs.3.rs-2450215/v1

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Research Article

The relationship between psychological distress and the health-related quality of life of middle-aged Korean females: A serial mediation model

https://doi.org/10.21203/rs.3.rs-2450215/v1

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published 23 Apr, 2023

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Background

This study aimed to provide primary data for developing an intervention program to improve the health-related quality of life of middle-aged females. This study examined the effects of psychological distress, depression, and emotional eating behaviors on the health-related quality of life of middle-aged Korean females.

Methods

Middle-aged females between 35 and 64 years old, from July 22 to August 10, 2021, were included in this study. The mediating effect of depression and emotional eating behaviors on the relationship between psychological distress and health-related quality of life was investigated. A cross-sectional survey was conducted on 325 subjects. Researchers conducted questionnaires measuring general health, depression, emotional eating behavior, and health-related quality of life.

Results

The findings of this study demonstrated a correlation between the severity of a person’s depression and the degree of their psychological distress, indicating that severe depression was associated with negative emotions, which increased emotional eating behavior. Additionally, more severe depression indicated a lower health-related quality of life. Higher psychological distress was associated with increased levels of emotional eating behaviors and lower health-related quality of life. The total and direct effects of psychological distress on the health-related quality of life were statistically significant.

Conclusions

These findings suggest that evidence-based intervention programs that alleviate emotional health problems, such as psychological distress and depression in middle-aged females, are crucial. Moreover, nurses help implement evidence-based intervention programs that could assess potential symptoms of psychological distress, depression, and emotional eating behaviors and develop effective treatment strategies to improve the health-related quality of life. Based on the results of this study, when developing a health promotion program that improves the health-related quality of life of middle-aged females, a nursing intervention plan that alleviates emotional health problems, such as psychological distress and depression in middle-aged women, should be prepared.

psychological distress

quality of life

mental health

depression

women

Middle adulthood or middle age is a stage of decline among the developmental stages of life and ranges from the age of 35 to the age of 64. Middle age is a period of many physical, mental, and social changes, challenges, and changes in various areas and life roles [1]. For Females, middle age is a period of menopause and aging due to changes in the life cycle [2]. In particular, menopause results in a sense of loss as females age and experiences a decline in physical functions due to changes in hormones [3]. In addition, the weakening of ties within the family and the reduction of social networks due to the growth and independence of their children lead to feelings of alienation and social and psychological developmental crises. If middle-aged females in this period adequately cope with the various physical changes, it will have a positive effect on their quality of life after middle adulthood; however, if middle-aged females experience physical, psychological, or emotional confusion, it will negatively affect their health-related quality of life [2, 3].

Looking at the demographic trend by the age of Korean females, the proportion of females aged 40 to 60 out of the total female population was the highest at 32.3% in 2020. This percentage has continuously increased since 2010, when it was 30.8% [4]. Moreover, the female population in their 40s or older increased from 2000 to 2021 due to the low birth rate and increased aging population [5]. There is a high incidence of depression among Middle-aged females in Korea due to the psychological distress of the increased responsibilities and conflicts between them and their adult children, changes in physical aging, and maladaptation to the loss of physiological ability [6]. The psychological distress experienced by middle-aged women can cause physical and mental symptoms, such as peripheral vascular disorder, gastrointestinal discomfort, muscle tension, and depression [7]. This psychological distress can harm their physical and mental health resulting in a lower health-related quality of life [6, 8]. Therefore, it is important to examine how psychological distress affects the health-related quality of life of middle-aged females in Korea.

Health-related quality of life is a subjective evaluation of health-related factors, including overall health, physical functions, body role, pain, vitality, and social and mental functions [9]. Health-related quality of life is defined as the meaning of life in terms of health and functional status [10]. Health-related quality of life is a comprehensive health state with a high correlation to diseases and physical conditions [11].

The health-related quality of life of middle-aged females is an indicator that reflects their daily functioning and well-being. It has been reported that the health-related quality of life of middle-aged females is affected by psychological stress, social support, and dietary habits [8, 12]. The higher the psychological distress experienced by middle-aged females, the higher the emotional states of depression-disappointment, tension-anxiety, and anger-hostility are [7]. Additionally, the most common symptoms experienced are depression, anxiety, and nervousness [13]. Depression is a typical mental health problem for middle-aged Korean females. It was reported that 13.7% of Korean females had depression, about twice as high as the percentage of Korean males (6.6%) [14]. A previous study reported that depression in middle-aged females lowered their health-related quality of life [13]. These results indicate that plans to improve the health-related quality of life through the continuous management of depression are required.

Meanwhile, psychological distress and stress have been associated with dietary behaviors affecting dietary intake patterns, inducing overeating or meal-skipping. Overeating can lead to obesity, and meal-skipping can reduce body weight resulting in serious adverse effects on health [15]. In addition, excessive psychological distress can lead to eating disorder behaviors, which can lead to psychological pressure and eating disorders, such as anorexia and bulimia [16]. Emotional eating is an eating disorder characterized by the tendency to overeat in response to stress or negative emotions [17, 18]. Such eating behaviors can result from impulsive food consumption in response to negative moods [18]. Emotional eating behaviors induced by emotional stimuli can cause changes in individuals’ dietary habits and can result in health problems [19, 20]. Emotional eating behaviors can cause a loss of balance in daily eating habits and negatively affect mental and physical health, leading to a decrease in health-related quality of life.

It was reported that the health-related quality of life of middle-aged Korean females was lower than that of male adults and females of other age groups [12]. Therefore, it is necessary to pay attention to middle-aged Korean females’ health-related quality of life.

Previous studies have investigated the effect of fragmentary factors, such as smoking, menopause, physical activity, and metabolic syndrome, on the health-related quality of life in middle-aged females [21, 22]. Studies have examined the effects of lifestyle, appearance satisfaction, and self-esteem on the overall quality of life in adult females and middle-aged adults [23, 24].

Psychosocial factors, such as stress, social support, and lifestyle, can affect an individual’s health or health-related quality of life [25]. However, few studies have comprehensively investigated the relationship between psychological distress and health-related quality of life in middle-aged Korean females using depression and emotional eating behaviors as a medium.

Therefore, this study aimed to provide primary data for developing an intervention program to improve the health-related quality of life of middle-aged females. This study examined the effects of psychological distress, depression, and emotional eating behaviors on the health-related quality of life of middle-aged Korean females.

Design

This study was a cross-sectional survey conducted on middle-aged females aged between 35 to 64 years old from July 22 to August 10, 2021. This study investigated the mediating effects of depression and emotional eating behaviors on the relationship between psychological distress and health-related quality of life.

Participants

The researchers who conducted this study visited three community centers in Seoul to obtain in-person consent for participation from middle-aged females who could communicate and understand the purpose of this study. Participants had to be middle-aged and female between the ages of 35 and 64 years old who could read and understand the details of the informed consent forms and reside in Seoul. The researchers retrieved a total of 336 questionnaires from the three community centers, of which 325 were included in this analysis (response rate: 96.7%), and 11 questionnaires with missing data were excluded. Calculations were made using the G*Power 3.1 analysis software with a significance level of 0.05, a median size of regression analysis of 0.15, and a power of 0.95 to confirm the suitability of the sample size. The minimum number of subjects was calculated to be 129 [26]. Given that this study included 325 subjects, the number of subjects was found to be adequate.

Measurement

General Health Questionnaire (GHQ-12)

In this study, the 12-Item General Health Questionnaire (GHQ-12), a self-reported scale developed by Goldberg and Williams [27], was used to screen for and measure the early discovery of minor psychiatric disorders and psychological distress. The questionnaire asked the respondents about experiences with psychological conditions in the preceding two to three weeks to identify current issues. Responses were measured on a 4-point Likert scoring scale (from 0 = not at all to 3 = more than usual), with a total score in the range of 0 to 36. A higher total score indicated greater psychological distress.

Depression

Depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9). The PHQ-9 consists of nine items corresponding to the diagnostic criteria of major depressive disorders according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; 2013 Edition). The PHQ-9 is a self-reported test created for the purpose of screening for depression in the preceding two weeks and assessing the severity of the depression. Each question on the PHQ-9 was scored on a 4-point scale ranging from 0 (not at all) to 3 (nearly every day). The total scores ranged from 0 to 27 and were obtained by adding the scores of all nine items; higher scores indicated higher depression. PHQ-9 scores of 5, 10, 15, and 20 were categorized as the cut-off values for no depressive symptoms (0–4), mild depressive symptoms (5–9), moderate depressive symptoms (10–14), moderately severe depressive symptoms (15–19), and severe depressive symptoms (20–27) [28]. In this study, Cronbach’s α was 0.93, indicating excellent reliability.

Emotional eating behavior

Emotional eating behaviors were measured using the Dutch Eating Behavior Questionnaire (DEBQ), consisting of 13 questions, and scored on a 5-point scale ranging from 1 (never) to 5 (very often) [29]. The Emotional Eating subscale consists of 13 questions, including “Do you have a desire to eat when you are irritated?” Emotional eating is eating in response to negative emotions. Higher scores indicate a higher tendency toward emotional eating behaviors. The Cronbach’s α was 0.90, indicating high reliability.

Health-related quality of life

The 12-Item Short Form Health Survey (SF-12) was developed by Ware et al. [30]. The physical components summary scale (PCS) consists of four subdomains, physical functioning (PF), role-physical (RP), body pain (BP), and general health (GH). The mental components summary scale (MCS) consists of four subdomains, mental health (MH), role emotion (RE), social functioning (SF), and vitality (VT). A higher PCS score indicates a better physical health-related quality of life, while a higher MCS score indicates a better mental health-related quality of life. The raw scores were converted to scores between 0 (the worst) and 100 (the best). The Cronbach’s α in this study was 0.87, indicating good reliability.

Data collection

This study was conducted at three community centers from July 22 to August 10, 2021. Data were collected from middle-aged females using a structured questionnaire. The researchers distributed the questionnaires to the participants in person, and the participants returned them to the researchers upon completion.

Ethical considerations

This study was approved by the Institutional Review Board at the University (No. 1040647-202105-HR-002-02). All participants were provided with detailed information on the purpose and process of this study and were provided with a written consent form before completing the questionnaire. The questionnaire was provided only to the participants in this study. The participants voluntarily participated, and data obtained from the questionnaires were not used for any purposes other than those of this study. Participants could withdraw from this study at any time without incurring any repercussions. Participants took approximately 20 minutes to complete the questionnaire.

A statement to confirm that all methods were carried out in accordance with relevant guidelines and regulations.

Statistical analyses

The analyses of this study’s data were conducted using SPSS 27.0 statistical software (version 23; IBM Corp, Armonk, New York, USA) and SPSS PROCESS Macro. Frequency and descriptive statistical analyses were performed to identify the general characteristics and characteristics of the major variable. Independent t-tests and ANOVAs were conducted to check for differences in the health-related quality of life according to the general characteristics. A Scheffé’s test was conducted for the post-hoc analysis. A Pearson correlation analysis was performed to confirm the correlation between each variable. The serial multiple mediating effects of depression (M1) and emotional eating behaviors (M2) on the relationship between psychological distress (X) and health-related quality of life (Y) were verified. The serial mediation analysis was performed using SPSS Macro Process Model 6 developed by Hayes [31], which we identified as the most appropriate verification method for this study. All effects were reported with 95% confidence intervals (CIs). The mediating effect was analyzed with a 95% CI to test the significance using the bootstrapping method with 5,000 resampled data; if 0, the mediating effect was not included.

General characteristics and health-related quality of life according to the general characteristics

Table 1 shows the general characteristics of the participants. Among the 262 questionnaires retrieved, 11 had incomplete responses and were excluded. A total of 257 subjects were included in the analysis (response rate: 98.0%). The majority (56.4%) of the participants were between the ages of 40 and 49 years old; the median age was 45.76 years. Most of the participants were married (77.8%), non-drinkers (58.8%), non-smokers (94.2%), did not engage in regular exercise (53.7%), had a college-level education (77.8%), had an economic status in the median range (79.4%), and did not have a chronic disease (60.7%). There was a significant difference in the total health-related quality of life scores according to marital status (F = 4.441, p = .013).

Table 1

General characteristics of the subjects *(n = 257)*
Variable	Category	n (%)	Mean (SD)	Health-related quality of life
Age (years)	35–39	49 (19.1)	45.76 (7.67)	65.63 (6.62)
(35–64)	40–49	145 (56.4)		64.12 (7.84)
	50–59	48 (18.7)		65.91 (6.05)
	≥ 60	15 (5.8)		64.00 (8.95)
F(p)				1.037 (.377)
Marital status	Single	43 (16.7)		67.66 (7.11)
	Married	200 (77.8)		64.25 (7.04)
	Divorced or Widowed	14 (5.4)		62.71 (7.38)
F(p)				4.441 (.013)
Alcohol	Yes	106 (41.2)		64.88 (7.22)
	No	151 (58.8)		64.63 (7.52)
t(p)				0.263 (.793)
Smoking	Yes	15 (5.8)		62.50 (10.82)
	No	242 (94.2)		64.87 (7.13)
t(p)				-1.206 (.229)
Regular exercise	Yes	119 (46.3)		64.64 (7.23)
	No	138 (53.7)		64.81 (7.54)
t(p)				-0.184 (.854)
Education	≤ High school	57 (22.2)		64.86 (8.22)
	≥ College	200 (77.8)		64.70 (7.15)
t(p)				0.149 (.882)
Economic status	High	17 (6.6)		61.33 (8.49)
	Middle	204 (79.4)		64.98 (7.07)
	Low	36 (14.0)		64.98 (8.38)
F(p)				1.947 (.145)
No. of chronic disease	0	156 (60.7)		65.19 (7.78)
	1	89 (34.6)		63.66 (6.88)
	≥ 2	23 (4.7)		66.74 (4.54)
F(p)				1.685 (.188)
SD = standard deviation

Levels of depression, psychological distress, emotional eating behavior, and health-related quality of life

Table 2 shows the mean score of each variable. The mean depression score was 6.28 points, indicating mild depression. The mean psychological distress score was 13.55, and the mean emotional eating behaviors score was 27.63. The mean total health-related quality of life score was 64.74 out of 100 points, the mean MCS was 69.58, and the mean PCS was 59.89.

Table 2

Levels of the variables *(n = 257)*
Variables	Range	Mean (SD)
Depression	0–25	6.28 (4.87)
GHQ-12	4–29	13.55 (4.57)
Emotional eating behavior	13–65	27.63 (11.33)
Total health-related quality of life	37.07–81.38	64.74 (7.38)
MCS	43.33–96.67	69.58 (9.19)
PCS	24.14–82.76	59.89 (7.64)
SD = standard deviation; GHQ = general health questionnaire; MCS = mental components summary scale; PCS = physical components summary scale

Correlation between variables

Table 3 shows the correlations among depression, psychological distress, emotional eating behavior, and health-related quality of life in the participants of this study. Depression was positively correlated with psychological distress (r = .657, p < .001) and emotional eating behaviors (r = .321, p < .001). This correlation indicated that the more severe the depression, the worse a person’s psychological distress and that severe depression was associated with negative emotions, which increased emotional eating behaviors. Depression was also significantly negatively correlated with health-related quality of life (r = − .283, p < .001). A more severe depression score indicated a lower health-related quality of life. A statistically significant positive correlation was shown between psychological distress and emotional eating behaviors (r = .290, p < .001). A statistically significant negative correlation was seen between psychological distress and health-related quality of life (r = − .348, p < .001). This correlation indicated that higher psychological distress was associated with increased emotional eating behaviors and a lower health-related quality of life. A statistically significant negative correlation was shown between emotional eating behaviors and health-related quality of life (r = − .222, p < .001). In conclusion, the health-related quality of life decreased as emotional eating behaviors increased.

Table 3

Correlations among the variables *(n = 257)*
Variables	Depression	GHQ-12	Emotional eating behavior	Health-related quality of life
Depression	―
GHQ-12	.657 (< .001)	―
Emotional eating behavior	.321 (< .001)	.290 (< .001)	―
Health-related quality of life	− .283 (< .001)	− .348 (< .001)	− .222 (< .001)	―
GHQ = general health questionnaire; p < .05, *p < .01

Mediating effects of depression and emotional eating behaviors in the relationship between psychological distress and health-related quality of life

The SPSS PROCESS Macro Model 6 suggested by Hayes [31] was used to verify the mediating effects of depression and emotional eating behaviors in the relationship between psychological distress and health-related quality of life among the participants of this study, and the results of the standardized path coefficients are presented in Fig. 1. The results of the serial multiple mediation analysis are shown in Table 4. The effects of psychological distress on the health-related quality of life were statistically significant (B = − .3318, SE = .0561, t = -5.9201, p < .001). In addition, the direct effects of psychological distress on the health-related quality of life were statistically significant (B = − .2552, SE = .0743, t = -3.4344, p = .0007). The increased psychological pain directly translated to decreased health-related quality of life. However, the indirect effect of depression on the mediating variable (M1) (B = − .0427, SE = .0571, 95% BC CI [-.1622, .0630]) and the indirect effect of emotional eating behaviors on the mediating variable (M2) (B = − .0177, SE = .0134, 95% BC CI [-.0492, .0025]) were not statistically significant in the relationship between psychological distress and health-related quality of life. Moreover, the bootstrapped indirect effect of emotional eating behaviors on the mediating variable (M2) (B = − .0162, SE = .0135, 95% BC CI [-.0464, .0062]) and the bootstrapped indirect effect of depression on the mediating variable (M1) was found not to be statistically significant in the relationship between psychological distress and the health-related quality of life. The total indirect effect on the mediating variables was insignificant. Therefore, reducing psychological distress may directly enhance the health-related quality of life.

Table 4

Total, direct, and indirect effects for a multiple mediator model *(n = 257)*
Model	Effect	SE	t-test	p-value	95% BC CI
Total effect of GHQ-12 on HRQOL	− .3318	.0561	-5.9201	< .001	[-.4422, − .2214]
Direct effect of GHQ-12 on HRQOL	− .2552	.0743	-3.4344	.0007	[-.4015, − .1089]
Total indirect effect	− .0766	.0606			[-.2011, .0363]
Indirect effect via
Depression	− .0427	.0571			[-.1622, .0630]
Depression and emotional eating behavior	− .0177	.0134			[-.0492, .0025]
Emotional eating behavior	− .0162	.0135			[-.0464, .0062]
SE = standard error; BC CI = bias-corrected confidence interval; GHQ = general health questionnaire; HRQOL = health-related quality of life

This study was conducted to investigate the relationship and effects of psychological distress, depression, and emotional eating behaviors on the health-related quality of life of middle-aged Korean females. This study found that the health-related quality of life of middle-aged Korean females was 64.74 out of 100, indicating mild depressive symptoms. The more severe the depressive symptoms, the more severe the individual's psychological distress, and these negative emotions were found to increase emotional eating behaviors. Depression showed a negative correlation with the health-related quality of life. The higher the psychological distress, the higher the depression and emotional eating behaviors and the lower the health-related quality of life.

According to the general characteristics of this study, the health-related quality of life of middle-aged Korean females was found to be significantly different according to marital status. Personal factors that affect the overall quality of life include health-related factors, such as age, education level, economic status, job status, marital status, smoking, drinking, and regular physical activity [32]. Marital status is a social support that allows people to feel cared for, supported, and affectionate through positive relationships with their families, including their spouses, and makes an individual feel worthwhile. The social support of a positive marital status has a preventive effect on maintaining physical and emotional health and alleviates psychological distress [33]. In this study, the higher the marital status with spouse and family, the higher their health-related quality of life. It is necessary to consider the support of the family to manage the health-related quality of life of middle-aged females. Unmarried middle-aged females or those with a low average monthly income showed a relatively high level of depression [34]. In the study by Kim [35], the depression scores of divorced, separated, or widowed females were higher than that of females with a spouse, which is consistent with the results of this study. These results, along with the results of this study, indicate that the higher the depressive symptoms, the lower the health-related quality of life. A supportive marital status would reduce psychological distress and depression and thus improve the health-related quality of life. Therefore, community-centered attention and efforts should be made to improve the health-related quality of life of middle-aged, single, widowed, or divorced females.

The psychological distress, depression, and emotional eating behaviors of middle-aged females affected their health-related quality of life. Depression in middle-aged females is highly correlated with life stress, and the higher the life stress, the more severe the depression [36]. Psychological distress and stress were found to be the strongest predictors of depression in middle-aged females [37]. In 2013, the average annual increase rate of depression was 2.6% for males and 4.7% for females. The rate of experiencing depressive symptoms among females aged 45–65 was found to account for 20.1% of all people experiencing depressive symptoms, indicating that depression in middle-aged females is severe [38]. Middle-aged adults are more likely to be exposed to psychological distress and stress, and when faced with changes and crises, they are more likely to experience negative emotions such as anxiety, depression, and anger. Uebelacker et al. reported that females who experienced many life-stress events had a 4.02 times higher depression than females who did not, supporting the results of this study [33]. If depression in middle-aged adults persists, it can negatively affect the health-related quality of life and life satisfaction by affecting various aspects, including emotional eating behaviors, fatigue, and physical problems, such as insomnia [39].

Traditionally, in a patriarchal society, like Korea, the primary responsibility of the family, such as the children’s education, family health, and relationships with the in-laws, is the female’s responsibility. These responsibilities are psychological distress and can lead to depression when life stress is severe [40]. In the United States, there is little difference in depression between male and female children and the elderly. However, in the middle-aged adult group, female depression is 1.7 times higher than male depression. This difference in depression indicates that depression among middle-aged females is a social problem [41]. This depression in middle-aged females can lead to emotional eating behaviors [42].

Emotional eating behaviors refer to eating triggered by emotional cues and are generally defined as eating in response to negative emotions [43]. Christensen reported a cyclical relationship between an individual’s mental suffering and emotional eating behaviors [44]. The emotional eating behaviors of inappropriate eating due to a failure of self-control caused by negative emotions are a serious threat to a person’s health [15]. When a female has psychological distress and depression related to negative life events, they exhibit emotional eating behaviors as an avoidant coping method [45]. Previous studies have reported that psychological distress, stress, and sadness were related to emotional eating behaviors [46, 47]. Therefore, identifying the causes of psychological distress and comforting and resolving the negative emotions are necessary [15].

This study verified the mediating effect of depression and emotional eating behaviors on the relationship between psychological distress and the health-related quality of life via a multiple mediation analysis. This study found that psychological distress had a direct effect on the health-related quality of life. The increase in psychological distress was directly related to the deterioration of the health-related quality of life. However, the indirect effect of depression and emotional eating behaviors on the relationship between psychological distress and health-related quality of life was insignificant. Although depression and emotional eating behaviors do not directly affect the health-related quality of life, there is a cyclical relationship with negative emotions, such as depression, that appear due to psychological distress, which is linked to emotional eating behaviors [48, 49]. Therefore, it is necessary to identify these factors related to psychological distress and the health-related quality of life to understand the health-related quality of life of middle-aged females [50].

This study is meaningful since it was interested in the health-related quality of life of middle-aged females in Korea, the factors affecting their health-related quality of life were identified, and their mediating effect was confirmed. The health-related quality of life of middle-aged females changes the physical and emotional health statuses and affects the function and well-being of females until old age [32]. Therefore, if the psychological distress of middle-aged females is appropriately managed and their depression is reduced with sufficient support from their family, the health-related quality of life can also be increased.

This study had a few limitations. First, it used a restricted sample resulting in limited generalizability. Second, this study examined the correlation between the variables; therefore, it is limited to identifying the cause and result of the fragmentary variables since an experimental test was not conducted to analyze the relationship between cause and effect. Third, since only the effects of depression and emotional eating behaviors were analyzed to understand the relationship between psychological distress and health-related quality of life, the model could not identify the effects of various mediating variables. However, this study is significant because it provides evidence for improving the health-related quality of life by identifying the relationship between psychological distress and the health-related quality of life. Therefore, the health-related quality of life of middle-aged females can be improved by managing their psychological distress.

Management is required from the transitional period into middle age to improve the health-related quality of life of middle-aged females. In this study, psychological distress, depression, and emotional eating behaviors affected the health-related quality of life of middle-aged Korean females. It was found that marital status affected the health-related quality of life. This study also confirmed that psychological distress had a direct effect on the health-related quality of life.

Based on the results of this study, a nursing intervention plan that alleviates emotional health problems, such as psychological distress and depression, of middle-aged females should be prepared to develop a health promotion program that improves their health-related quality of life. In addition, since the health-related quality of life of middle-aged females changes with age and there are individual differences, interventions in the physical aspect should also be considered.

Additional studies to identify the longitudinal influence of factors affecting the changes in the health-related quality of life of middle-aged females are needed. In addition, studies are also needed to determine how the health-related changes in the quality of life in middle-aged adults affect their health and overall quality of life during old age.

Ethics approval and Consent to participate:

This study was conducted in accordance with the principles of the Declaration of Helsinki and the study plan and process were approved by the Clinical Ethics Committee of Daejeon University (1040647-202105-HR-002-02). The participants were assured that their information would be kept strictly confidential and used only for research purposes. The ability to exit the study at any time has been ensured. Informed consent obtained from all the participants included in the study. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication:

Not applicable

Availability of data and materials:

The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request

Competing interests:

The authors declare that they have no competing interests.

Funding:

This research was funded by the National Research Foundation of Korea (NRF) grant funded by the Korean government (MSIT) (Grant number 2020R1C1C1015358) and (Grant number 2022R1H1A2093192).

Authors' contributions:

Study concepts and design: JO and SK

Data collection: JO and SK

Data analysis: JO and SK

Manuscript writing: JO and SK

Acknowledgements:

We thank all those who have helped in carrying out the research and anonymous reviewers.

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No competing interests reported.

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The relationship between psychological distress and the health-related quality of life of middle-aged Korean females: A serial mediation model

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Materials & Methods

Design

Participants

Measurement

General Health Questionnaire (GHQ-12)

Depression

Emotional eating behavior

Health-related quality of life

Data collection

Ethical considerations

Statistical analyses

Results

General characteristics and health-related quality of life according to the general characteristics

Levels of depression, psychological distress, emotional eating behavior, and health-related quality of life

Correlation between variables

Mediating effects of depression and emotional eating behaviors in the relationship between psychological distress and health-related quality of life

Discussion

Conclusion

Declarations

References

Additional Declarations

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Journal Publication

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