Mindfulness and Depressive Symptoms Among College Students: Multiple Mediation Effect of Sleep Quality and BMI

doi:10.21203/rs.3.rs-3816950/v1

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Mindfulness and Depressive Symptoms Among College Students: Multiple Mediation Effect of Sleep Quality and BMI

https://doi.org/10.21203/rs.3.rs-3816950/v1

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Objective

This study was to examine whether sleep quality and BMI play mediating roles in the relationship of mindfulness and depressive symptoms via a cross-sectional study.

Methods

A total of 1182 college students were recruited. The Chinese version of the Five Facet Mindfulness Questionnaire, Pittsburgh Sleep Quality Index questionnaire, BMI, and the nine-item scale, Patient health Questionnaire-9 were used to gather data. Associations among mindfulness, sleep quality, BMI, and depressive symptoms were assessed via correlation and serial-multiple mediation analyses.

Results

The mindfulness, sleep quality, BMI, and depressive symptoms were found to be significantly correlated. Mindfulness can have a direct negative impact on depressive symptoms, but also an indirect impact through three paths: independent mediating role of sleep quality, independent mediating role of BMI, and chain-mediating role of sleep quality and BMI.

Conclusions

Mindfulness can affect depressive symptoms through improved sleep quality and decreasing BMI among college students. Interventions aimed at improving the level of mindfulness would be beneficial for sleep quality, body weight, and depressive symptoms.

Mindfulness

Depressive symptoms

Sleep quality

Body mass index

College students

Depression is one of the most significant causes of disability and death. The World Health Organization estimates depression will exceed respiratory and heart diseases as the third most prevalent disease burden worldwide by 2030.¹ College students face many pressures, mainly from environment changes, academic performance pressure, higher education programmes, interpersonal difficulties, and so on.² However, they are in a distinct transition period from adolescence to mature adulthood, are immature in mental development³ and are therefore a vulnerable group in developing depressive symptoms.⁴ A systematic review revealed that the prevalence of depressive symptoms among university students ranged from 10–85%, with a weighted mean prevalence of 30.6%, which is substantially higher than in the general population.⁵ Comorbid depressive symptoms can worsen outcomes, including problems with relationships, learning ability, socialisation, a lower quality of life, and can even threaten their life.⁶ Considering the importance of depressive symptoms and the high incidence of among college students, it is important to investigate the factors related to depressive symptoms and their mechanisms of action.

Mindfulness is considered an inherent trait and defined as paying attention to purpose in the present moment and non-judgemental acceptance of internal experiences.⁷ Mindfulness-based complementary training or psychotherapy has proven that focusing one’s awareness and attention can provide authentic feelings and perceptions, relieve physical and mental suffering, and improve coping and negative emotions.⁸ Mindfulness-based stress reduction training (MBSR) has been proven to significantly improve depressive symptoms and mental health of college students.⁸ Reangsing et al. (2021) conducted a meta-analysis and found that mindfulness interventions can effectively reduce depressive symptoms among adolescents.⁹ Mindfulness and related theories are a system developed on the basis of practice, and the application research of mindfulness is far more than its theoretical research.¹⁰ Although mindfulness-based intervention training can improve depressive symptoms, few studies have explored the mechanism underlying the relationship between mindfulness and depressive symptoms in college students. To further understand the relationship and consolidate the theoretical basis, the relationship between mindfulness and depressive symptoms and the underlying mechanism is worth investigating.

Owing to the use of electronic media, caffeine consumption, and erratic schedules, college students exhibit poor sleep quality. Disturbed sleep may adversely affect 40% of college students.¹¹ It may have a negative effect on academic performance and mental health such as depressive symptoms.^12,13 Mindfulness practices can ameliorate sleep disorder and improve sleep quality.¹⁴ Several studies established that low levels of mindfulness significantly predict poor sleep quality.^15,16 Considering the associations between mindfulness, sleep quality, and depressive symptoms, high level of mindfulness may increase college students’ sleep quality and further reduce their depressive symptoms.

Besides sleep quality, being underweight or overweight/obese is also associated with the development of mental disorders. Increased body mass index (BMI) leads to an increase in severity of depression. ¹⁷ Luppino et al. (2010) conducted a meta-analysis and suggest that obesity is a predicting factor of developing depression.¹⁷ This association between BMI and depression may be due to increased social discrimination and weight stigma.¹⁸ Mindfulness could be a potential adjuvant therapy to reduce body weight,¹⁹ and individuals with high levels of mindfulness negatively predicted their BMI.²⁰ However, few studies investigate the mediating role of BMI in the association between mindfulness and depressive symptoms among college students.

Noteworthy, poor sleep quality has been highlighted as an important predictor of obesity. Kristicevic et al. (2018) estimated that young adults with poor sleep quality have at least 1.40 more odds of the risk of being overweight or obese than young adults without sleep disorders.²¹ Dweck et al. (2014) demonstrated that short sleep duration could act as a stressor, further increasing food consumption.²² We hypothesise that sleep quality and BMI would have a serial mediation effect on the relationship between mindfulness and depressive symptoms among college students.

In summary, given the links between mindfulness, sleep quality, BMI, and depressive symptoms, we propose the following hypotheses:

Hypothesis 1

(H1). Sleep quality uniquely (independent of BMI) mediates the relationship between mindfulness and depressive symptoms among college students.

Hypothesis 2

(H2). BMI uniquely (independent of sleep quality) mediates the relationship between mindfulness and depressive symptoms among college students.

Hypothesis 3

(H3). Sleep quality and BMI co-play a serial mediating role in the relationship between mindfulness and depressive symptoms among college students. The sequence of the pathway will be mindfulness sleep quality BMI depressive symptoms.

2.1 Study Design

This study used a cross-sectional design.

2.1.1 Setting and Sample

We adopted a convenience sampling strategy. This survey was conducted among college students from **, ** Province, China, of one comprehensive university, from 10 August 2022 to 10 October 2022. Wen Juanxing, a web-based survey platform, collected data. Questionnaires were distributed through instant messaging software QQ and WeChat. A total of 1,200 college students were recruited and 1182 effective responses (response rate: 98.50%) were acquired.

The study was conducted according to the latest version of the Declaration of Helsinki and approved by ethics committee of school of medicine of Liaocheng University (FLE number: 20220702). The electronic informed consent was obtained from students before the survey. No other ethical permission is applied.

2.2 Measurements

2.2.1 Demographic Characteristics

We collected demographic characteristics, including age, sex, ethnicity, year in college, class officer, only child, marital status of parents, residence, monthly household income, and BMI. We categorised ethnicity as Han, Hui, or other and monthly household income as ≤ ¥2000, ¥2001–¥4000, ¥4001–¥6000, or > ¥6001. BMI was calculated as weight/height² (kg/m²) ²³.

2.2.2 Mindfulness

The Chinese version of the Five Facet Mindfulness Questionnaire (FFMQ) was used to measure the level of mindfulness.²⁴ The FFMQ has five facets: observing, describing, acting with awareness, non-judging, and non-reacting. It includes 39 items rated on a 5-point Likert scale, ranging from 1 (never or very rarely true) to 5 (very often or always true). Items 3, 5, 8, 10, 12, 13, 14, 16, 17, 18, 22, 23, 25, 28, 30, 34, 35, 38, and 39 were reverse scored. The total score is summed by adding each item after the scores of negatively stated items were reversed, with higher scores indicating higher level of mindfulness. The FFMQ exhibited good internal consistency reliability, with Cronbach’s alpha ranging from 0.67 to 0.89 for a sample of college students.²⁵ In the current study, the Cronbach’s alphas for the five facets were 0.879, 0.666, 0.904, 0.860, and 0.853, respectively.

2.2 .3Sleep Quality

The Pittsburgh Sleep Quality Index (PSQI) questionnaire was used to evaluate college students’ sleep quality over the past mont.²⁶ The PSQI contains 19 questions and measuring seven dimensions: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleep medication, and use of sleep medication. According to the scoring protocol, each dimension is scored from 0–3. The scores were then summed to produce a total score, ranging from 0 to 21, with higher score indicating worse sleep quality. The PSQI has shown good internal consistency reliability, and the Cronbach’s alpha was 0.74 for a sample of college students.²⁷ In the current study, the Cronbach’s alpha of the PSQI was 0.725.

2.2.4 Depressive Symptoms

The severity of depressive symptoms was evaluated using the nine-item scale, Patient health Questionnaire-9 (PHQ-9).²⁸ The PHQ-9 corresponds to the Diagnostic and Statistical Manual of Mental Disorders (fourth edition) and is a popular instrument for assessing depressive symptoms in college students. Each item score ranged from 0 (not at all) to 3 (nearly every day), with higher scores indicating more frequent and a higher number of depressive symptoms. The PHQ-9 has exhibited good internal consistency reliability, and the Cronbach’s alpha was 0.870 for a sample of college students.²⁹ In the current study, the Cronbach’s alpha for the PHQ-9 was 0.929.

The study was conducted according to the guidelines of the Declaration of Helsinki. The Ethics Committee for Liaocheng people’s hospital with reference 2022- 07-21 has issued a favourable opinion.

2.3 Statistical Analysis

Descriptive analysis was used to describe the demographic data and BMI, mindfulness, sleep quality, and depressive symptoms of the sample. Continuous variables were presented as means (standard deviations), and categorical variables were presented as frequencies (percentages). Pearson’s correlation analysis was performed to determine whether mindfulness, BMI, sleep quality, and depressive symptoms were correlated. To test whether there were serial-multiple mediation effects of BMI and sleep quality between mindfulness and depressive symptoms, we adopted Model 6 of IBM SPSS Statistics PROCESS.³⁰ We set the bootstrap sample number to 5,000 and the confidence level for confidence intervals (CI) to 95%. If the confidence level for CI did not include zero, this suggested that the mediating effect was significant. BMI and PSQI scores were entered as mediators, FFMQ score was entered as the independent variable, and PHQ-9 was used as the dependent variable.

We used SPSS 20.0 to analyse all the data and considered a p-value (two-tailed) of < 0.05 to be statistically significant.

Ethics approval

Consent to participate

Written informed consent was obtained from all participants.

3.1 College Students Characteristics

A total of 1,182 college students participated; the demographic characteristics and results for mindfulness, sleep quality, and depressive symptoms are reported in Table 1. College students average age was 19.69±3.99 years old. Of the participants, 771(65.23%) were female and 411(34.77%) male. Most students (96.45%) were Han, and 54.06% were sophomores. A total of 253 (21.40%) were class officers and 306 (25.89%) were only children. For 4.74%, their parents were divorced. More than 50% lived in rural areas. The BMI was 21.60±4.08. Overall, the participants gave rating scores of 122.56±10.35, 4.15±2.58, and 3.16±4.03 for mindfulness, sleep quality, and depressive symptoms, respectively.

3.2 Correlations Among Mindfulness, Sleep Quality, BMI, and Depressive Symptoms

The correlation coefficients of mindfulness, sleep quality, BMI, and depressive symptoms are presented in Table 2. The results revealed that mindfulness was negatively related to sleep quality (r=-0.176, p<0.001), BMI (r=-0.073, p<0.05), and depressive symptoms (r=-0.251, p<0.001). Second, sleep quality was positively correlated with BMI (r=0.073, p<0.05) and depressive symptoms (r=0.579, p<0.001). Third, BMI positively correlated with depressive symptoms (r=0.101, p<0.01). All p-values between the aforementioned variables were statistically significant at the level of p<0.05 (two-tailed).

3.3 Mediation Analysis of Sleep Quality and BMI

The serial mediation analysis results of sleep quality and BMI on mindfulness and depressive symptoms are presented in Table 3 and Figure 1. The total effects of mindfulness on depressive symptoms were significant (p<0.001), indicating the higher the level of mindfulness, the less likely depressive symptoms were to occur.

Direct and all three indirect paths were significant. First, the direct pathway was that sleep quality significantly mediated the effect of mindfulness on depressive symptoms, with an effect value of -0.0352. Second, the direct pathway was that effect of mindfulness on depressive symptoms was significantly mediated by BMI, with an effect value of -0.0014. Third, the indirect pathway was the effect of mindfulness on depressive symptoms was significantly mediated by both sleep quality and BMI, with an effect value of -0.0002. Sleep quality had a significant direct effect on BMI, and its effect value was 0.0999. These results indicate that sleep quality and BMI play a partial mediating role in the relationship between mindfulness and depressive symptoms.

Our primary objective was to determine whether sleep quality and BMI mediate the relationship between mindfulness and depressive symptoms among college students. The results revealed that mindfulness significantly affected depressive symptoms. Sleep quality and BMI partially mediate the relationship between mindfulness and depressive symptoms and also have a serial mediation effect between mindfulness and depressive symptoms. Hence, our results support our hypotheses.

The results suggest that mindfulness is negatively correlated with depressive symptoms in college students, consistent with previous studies.^{31, 32} Some scholars have proposed theoretical models of how mindfulness can improve mood. The mindfulness-to-meaning theory suggests that mindfulness improves emotional distress through mindful attention to positive information and reappraisal of stressful events into positive meanings of life.³³ Shapiro et al. (2006) proposed the “reperception model,” which argues that mindfulness training encourages individuals to process internal and external experiences and psychological phenomena with an open and non-judgemental attitude.³⁴ This attention processing leads to “reperception,” which reduces an individual’s emotional response to the present unpleasant experience. According to the emotional regulation model of mindfulness, mindfulness training is not to suppress, re-evaluate, or change emotional experiences, but to consciously perceive thoughts and emotions by cultivating an attitude of awareness and non-response, so as to gradually eliminate the automatic evaluation of individual negative emotions and disturbances and reduce negative emotions.³⁵ Therefore, mindfulness can predict lower depressive symptoms in individuals.

We demonstrated that sleep quality and BMI can mediate the indirect effect of mindfulness on depressive symptoms in college students. Our results demonstrated that the level of mindfulness of college students can positively predict their sleep quality, which, in turn decreases depressive symptoms. These results are similar to those reported in previous studies. Mindfulness can be conceptualised as a positive trait and is referred to as being present in the moment and being aware of inner and outer experiences while acquiring a non-judging perspective.⁷ To some extent, the openness, tolerance, and acceptance contained in mindfulness are similar to the nature of the mind embodied in sleep, and these qualities can reduce the activity of an individual’s cognition and psychological awakening, and help an individual to get out of the bondage and struggle of “self-thought.” Therefore, mindfulness can help individuals improve their flexibility to adapt to sleep disorders, reduce the occurrence of disturbed sleep beliefs and abnormal wake response behaviours, and thus promote and improve sleep quality.³⁶ The dual regulation model of sleep indicates that an individual’s sleep-wake cycle and sleep quality are regulated by both rhythmic and homeostasis processes. The cooperative work of the two systems enables an individual to have a stable sleep rhythm and to maintain daily psychological activitie.³⁷ From the biological mechanism, poor sleep quality and depressive symptoms are biologically correlated with functional connectivity of the dorsolateral prefrontal cortex, later orbitofrontal cortex, and precuneu.³⁸

Our results indicated that mindfulness can decrease college students’ BMI, thus affecting depressive symptoms. Based on previous studies, mindfulness could be a potential adjuvant therapy to reduce body weight.³⁹ This mechanism is explained by the fact that mindfulness may affect cortisol by reducing stress, which may further affect hormones involved in appetite regulation, such as leptin, insulin, and ghrelin.^40-42Regarding the relationship between BMI and depression, there is growing research support that individuals with obesity have an increased risk of anxiety and depression, as well as lower general health.⁴³ Evidence of physiological and psychological pathways for the development of depressive symptoms in obesity may indicate that individuals with obesity have many psychological drivers, such as chronic inflammation, low self-esteem, high chronic stress, or passive coping, all of which could contribute to depression. ^{44, 45} Our results indicate that concerns about college students’ sleep quality and BMI, along with their level of mindfulness, cannot be overstated. Exploring how to promote sleep quality and participation in proper physical exercise to a normal BMI in college students with low levels of mindfulness may be helpful in decreasing their depressive symptoms.

We also tested whether a chain-mediating role exists between sleep quality and BMI. The results indicated that mindfulness first had a positive correlation with sleep quality and then decreased BMI, which was in turn related to reduced college students’ self-reported depressive symptoms. Zerón-Rugerio et al. (2022) demonstrated that poor sleep quality was a significant predictor of obesity.⁴⁶ Poor sleep quality may act as a stressor, increasing food consumption in participants who are prone to emotional eating.²² Eating fatty and sweet foods is known to alleviate behavioural signs of distress, like sleep quality.⁴⁷ Therefore, college students with high levels of mindfulness may display more attention and acceptance of the current situation, pay more attention to the physical experience in the moment, promote their sleep quality, help them maintain a normal BMI, and ultimately maintain their positive emotional state.

Limitations

The current study has some limitations. First, the study design was cross-sectional, which cannot allow for the observation of the temporality order of the variables and limits the inference of causality. Second, college students were randomly recruited from only one university; future research should include those from multiple universities. Third, we employed self-reported measures; therefore, response bias was unavoidable.

Our results suggest that mindfulness can affect depressive symptoms among college students by improving sleep quality and decreasing BMI. Interventions aimed at improving mindfulness would be beneficial for depressive symptoms. First, college leaders and teachers should take action to improve the level of mindfulness, such as involvement in mindfulness improvement training programmes. Moreover, enhancing sleep quality and reducing body weight could be viable targets for decreasing depressive symptoms.

Data availability

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

Author contributions

Q.Q.Y. conceived the research and designed the study. J.F.X. and Z.E.L. analysed the data, drafted and finalized the manuscript. C.X.Z., M.Y.S., S.P.L., and M.Q.G. conducted study and complete data curation. All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.

Funding

This work was sponsored by the Shandong Provincial Department of Education of China (S202210447072).

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Table 1. Demographic Characteristics, Mindfulness, Sleep Quality, BMI, and Depressive Symptoms among College Students (N = 1182)
Variables	Category	Mean (±SD) / n(%)
Demographic Characteristics
Age (years)		19.69±(3.99)
Sex
	Male	411(34.77)
	Female	771(65.23)
Ethnicity
	Han	1140(96.45)
	Hui	9(0.76)
	Other races	33(2.79)
Year in college
	Freshmen	62(5.25)
	Sophomores	639(54.06)
	Juniors	203(17.17)
	Seniors	278(23.52)
Class officer
	Yes	253(21.40)
	No	929(78.60)
Only child
	Yes	306(25.89)
	No	876(74.11)
Marital status of parents
	Divorced	56(4.74)
	Others	1126(95.26)
Residence
	Urban	500(42.30)
	Rural	682(57.70)
Monthly household income
	≤ ¥2000	111(9.39)
	¥2001–¥4000	354(29.95)
	¥4001–¥6000	301(25.47)
	> ¥6001	416(35.19)
BMI		21.60 (±4.08)
Mindfulness		122.56 (±10.35)
Sleep Quality		4.15 (±2.58)
Depressive Symptoms		3.16 (±4.03)
Note: BMI = body mass index

Table 2 Correlations between Mindfulness, Sleep Quality, BMI, and Depressive Symptoms among College Students (N = 1182)
Variables	Mindfulness	Sleep Quality	BMI	Depressive Symptoms
Mindfulness	1
Sleep Quality	-0.176^***	1
BMI	-0.073^*	0.073^*	1
Depressive Symptoms	-0.251^***	0.579^***	0.101^**	1
Note: BMI = body mass index; p< 0.05 (two-tailed); p< 0.01(two-tailed); **p< 0.001 (two-tailed);

Table 3 Hypothesized serial mediation model of Sleep Quality and BMI between Mindfulness and Depressive Symptoms among College Students (N = 1182)
Pathway	Effect	SE	BootLLCI	BootULCI
Total effect (c)	-0.0964	0.0107	-0.1173	-0.0755
Direct effect (c’)	-0.0596	0.0090	-0.0772	-0.0420
a1	-0.0426	0.0071	-0.0566	-0.0286
a2	-0.0244	0.0117	-0.0474	-0.0015
a3	0.0999	0.0473	0.0070	0.1928
b1	0.8264	0.0363	0.7553	0.8976
b2	0.0568	0.0224	0.0128	0.1008
Indirect effects
Total indirect effects	-0.0368	0.0062	-0.0494	-0.0248
Indirect 1	-0.0352	0.0059	-0.0474	-0.0238
Indirect 2	-0.0002	0.0002	-0.0009	-0.0001
Indirect 3	-0.0014	0.0010	-0.0043	-0.0001
Abbreviation: Indirect 1, mindfulness→sleep quality→depressive symptoms; Indirect 2, mindfulness→sleep quality→BMI→depressive symptoms; Indirect 3, mindfulness→BMI→depressive symptoms; BootLLCI, bootstrapping lower limit confidence interval; BootULCI, bootstrapping upper limit confidence interval; SE, standard error; Effect, standardized regression coefficient.

No competing interests reported.

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Mindfulness and Depressive Symptoms Among College Students: Multiple Mediation Effect of Sleep Quality and BMI

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Abstract

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Introduction

Methods

2.1 Study Design

2.1.1 Setting and Sample

2.2 Measurements

2.2.1 Demographic Characteristics

2.2.2 Mindfulness

2.2 .3Sleep Quality

2.2.4 Depressive Symptoms

2.3 Statistical Analysis

Results

Discussion

Conclusion

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References

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