Association of energy adjusts Nutrient-rich foods (ENRF) on mental health among obese and overweight women: a cross-sectional study


 Background

Mental health and obesity have a bilateral relationship with each other. No study has been done on the relation between mental health and the ENRF9.3 index so far. Therefore, for the first time, we examined the relationship between the ENRF9.3 index and mental health in women with overweight and obesity.
Methods

In this cross-sectional study, 124 overweight and obese women were selected. Food intakes in the last 1 year were collected with 147 items of semi-quantitative food frequency. Then, the ENRF9.3 index score was calculated for all individuals. Mental health was assessed with a 21-item Depression Anxiety Stress Scales (DASS) questionnaire.
Results

In the present study, before adjusting for potential confounders the total DASS score was marginal significance(P = 0.05), that after the adjustment, it became insignificant(P > 0.05), after adjusting for confounders stress also became significant(P = 0.04). But no significant relationship was observed between depression and anxiety, even after adjustment(P > 0.05).
Conclusions

The present study showed that a nutritious diet is not associated with overall mental health score, among subgroups of the DASS total score, the relationship was seen only for the stress subgroup.

persuasion, conforms the FDA explanation of healthy foods [30]), minus the entirety of the percentage of maximum suggested values for the 3 nutrients that are limited [29]. By the residual method, all the components we mentioned are adjusted with energy. We can use this index as follows: First, ENRF 9.3 algorithms based on the Dronovsky method score all foods eaten by each individual. [33], This results in an ENRF9.3 score (per 100 kcal) for each food item, meaning a food score of ENRF9.3. (see Table 1) [19].
Therefore, participants with a higher ENRF index score have a healthier dietary pattern than individuals with a lower ENRF index score.

Mental health assessment
The mental status of the subjects was assessed using a validated questionnaire with 21 questions )DASS-21) [36]. This questionnaire measures the mood states of depression, stress, and anxiety. Each state has 7 items that are rated in a range of 4 points. Participants were asked by a trained dietitian to indicate how much each item was correct about them during the last week. A higher score indicates more severe mental distress. For the stress subgroup, the range of 15 to 18 is considered mild, 19 to 25 moderate, 26 to 33 severe, and ≥ 34 very severe.

Other variables
To evaluate physical activity during the last 7 days, the valid and reliable Persian version of the International Physical Activity Questionnaire(IPAQ) was used [37]. Then the activity was converted into a daily metabolic equivalent (MET)-min per week. Researchers received demographic characteristics by questionnaire.

Statistical analysis
Analyzes were performed on 124 women. Kolmogorov-Smirnov method was used to assess the normality of the population. Quantitative variables across the ENRF 9.3 tertiles were shown as mean ± standard deviations (SDs), and discrete variables were also expressed in numbers and percentages. analysis of variance (ANOVA) used for quantitative variables and Chi-square test for qualitative ones confounders such as age, BMI and physical activity, energy intake were adjusted by analysis of covariance (ANCOVA). The Bonferroni method is used for posthoc analyses. Multi-nominal logistic regression is used to compute odds ratio(OR) and 95% CIs, for the assessment association of the total DASS and its subgroups scores with the ENRF index. There was a signi cant difference when it was p ≤ 0.05. Data were analyzed using IBM SPSS version 25.0 (SPSS, Chicago, IL, USA).

Results
In this cross-sectional study, 124 individuals were eligible for inclusion in the study. DASS total score and its subgroups among quartiles of the ENRF9.3 index score In Table 3, the DASS total score and its subgroups among ENRF9.3 index score quartiles assessed, so that the mean of total DASS score was lower in higher quartiles, there was a signi cant relationship (P=0.05), which change to marginal signi cance after adjustment with potential confounders in model 1(age and energy intake) (P=0.07), lost its signi cance with further adjustment with confounders in model 2and model 3 and 4(P=0.08).

Discussion
In the present study, the mental health subgroups, such as the stress, anxiety, and depression, before and after adjustment for the confounders, were lower mean in the upper ENRF quartiles, but signi cance was observed only for the stress subgroup after controlling the confounders.
Diet plays an important role in improving or advancing mental illness In line with our study concerning depression and anxiety, Lizanne JS. Schweren and et al. in a cohort study showed that diet is unlikely to prevent depression and anxiety in the community in the long run[38] and Murakami et al. also in their systematic review, found no association between dietary variables and depressive symptoms [39]. However, against these studies, Poorrezaeian and colleagues in two cross-sectional study found an inverse relationship between anxiety and depression with dietary diversity score as the healthy eating index in women [40,41], because dietary diversity is positively associated with dietary micronutrients and negatively correlated with micronutrient de ciencies intake [42], and the relationship between the consumption of processed foods, commercial baked goods, fast foods, and sweets, with an increased risk of depression, due to the high content of saturated fats, trans-fatty acids, added sugar and re ned carbohydrates and low content of ber and nutrients, has been seen in observational studies [43]. Gibson-Smith et al. found that the quality of the diet was poorer in people with anxiety disorders and depression [44]. Another opposed study has shown, people who received a Mediterranean diet in 3 months had better scores on depression and overall mental health scores than those who did not, due to improvements in the quality of their diet [45].
De ciency in some B and C vitamins and iron has been linked to psychological symptoms [46], and many of the nutrients offered are effective against depression [47,48], in this context, Lisa and colleagues report that folate, B12, iron, selenium, and zinc de ciency are more common in depressed people [49]. Because vitamin D affects brain structure, neuronal differentiation, binding, dopamine pathways, neurotransmitters, brain calcium homeostasis, in ammatory markers, nerve growth factor synthesis, and the response of the hypothalamicpituitary-adrenocortical axis to threat, zinc is important for energy metabolism, macronutrient stabilization, regulation of protein synthesis, neuronal progenitor cell activity, neurotransmitters, neutrophils, and antioxidants, iron is needed for energy production, phospholipid metabolism, myelination and the synthesis of neurotransmitters and DNA [50], calcium works by activating tryptophan hydroxylase and synthesizing serotonin [51] and omega-3 fatty acid has anti-in ammatory or neuroendocrine modulating effects [52]. Folatederived coenzymes, B12 and B6, are also involved in the synthesis and metabolism of dopamine and serotonin. Besides, vitamins B6 and B12, as a cofactor, convert homocysteine, that inadequate nutrition of these vitamins can lead to the accumulation of homocysteine and reduced monoamines synthesis in the brain, which may play a vital role in mental health etiology [53]. Therefore, perhaps the reason for not meaningful of anxiety and depression in the present study can be related to a signi cant reduction in B vitamins and zinc, and meaninglessness of nutrients such as vitamin D, omega 3, iron, and vitamin C in quartiles of ENRF index score.
In our study, among all of the food groups, vegetables, dairy, meat and poultry, and tea and coffee were signi cant across ENRF quartiles. Micronutrients in vegetables like B group vitamins and their metabolites [54][55][56] and the others such as vitamin C [57], calcium[58], and zinc [59], which regulate brain pathways [60]. green leafy vegetables are proper sources of magnesium that insu cient magnesium can cause headaches and fatigue and exacerbate the effects of stress[61]. In our study, magnesium intake also increased with increasing ENRF quartile, which can be one of the reasons for a signi cant stress reduction. Because magnesium is the main cofactor in the synthesis of neurotransmitters and adrenaline and is participated in neuronal cell metabolism [62]. It was seen that low serum magnesium concentrations, in response to stress, increase the release of stress-related hormones, including cortisol, adrenocorticotrophic hormone, and catecholamines[63, 64], which affects their access to the brain and creates a vicious cycle of reduced stress resistance and further magnesium depletion [65,66]. In addition to the vegetables, in the study of Laugero et al., stress was also associated with lower protein intake[67], because of the amino acid tryptophan in meat, which can play a momentous role in relieving mood, satiety, and sleep regulation by converting to serotonin that could help mental health [68]. The positive relationship between dairy consumption, with some cognitive and psychological health measures, has been found in the study of Crichton et al [69]. In our study, calcium was higher at the top of the ENRF quartile, since milk and other dairy products account for more than half of the dietary calcium intake in most parts of the world [70], their stress-relieving properties can also be attributed to more calcium intake. People with higher HEI scores are more likely to eat nutritious foods [71]that when replacing junk food with fresh, highber plant-based foods, they will consume few nutrients that are essential for healthy metabolism and provide signi cant stress protection [72]. Vitamin B is used as a cofactor for adrenaline synthesis in stress response, and it is also used to synthesize neurotransmitters such as serotonin and dopamine that affect stress [73,74].
The present study is the rst study that examines the relationship between ENRF index score and mental health can be considered as one of its strengths. However, there were some limitations, the cross-sectional design of the study, which makes the result can't nd out the casualty, use the FFQ questionnaire to assess food intake, which depends on a person's memory, and restricting the gender of the study population, that decreased generalisability.

Conclusions
In this study, there was no signi cant relationship between overall DASS score, anxiety, and depression with the ENRF index score. There was a signi cant relationship between stress and ENRF, more studies are needed especially with a prospective plan.