ABSTRACT

Objective:

To analyze the association of depression with various health behaviors and to verify if they differ according to gender or income.

Methods:

This is a cross-sectional study based on data of 65,803 Brazilian adults (18–59 years old) interviewed in the National Health Survey, conducted in 2019. Presence or absence of depression was evaluated using the Patient Health Questionnaire (PHQ)-9. The prevalence of smoking, alcohol consumption, physical activity, sedentary lifestyle and food indicators were estimated according to the presence of depression. Stratified analyses were made according to sex and income, and prevalence ratios were estimated using the Poisson Regression.

Results:

We found a significant association between depression and all indicators studied, except occasional alcohol consumption. Depression was associated with heavy episodic drinking and insufficient consumption of fruits and vegetables only in women. In men, the associations of depression with sedentary lifestyle and with being a former smoker were stronger than in women. The occasional consumption of alcohol was more prevalent only in men without depression. The analysis stratified by income showed that the association of depression with physical inactivity is stronger in the higher-income group, while with heavy episodic drinking is only significant in the lower-income stratum.

Conclusion:

The results point to the need to consider mental health in programs aimed at reducing harmful health behaviors and the specificity of sociodemographic groups.

Keywords:
Depression; Health behavior; Tobacco use disorder; Alcohol drinking; Eating; Sedentary behavior

INTRODUCTION

The association of health-related behaviors with chronic diseases and early mortality is widely recognized¹1. Ng R, Sutradhar R, Yao Z, Wodchis WP, Rosella LC. Smoking, drinking, diet and physical activity-modifiable lifestyle risk factors and their associations with age to first chronic disease. Int J Epidemiol 2020; 49 (1): 113-30. https://doi.org/10.1093/ije/dyz078
https://doi.org/10.1093/ije/dyz078... ,²2. World Health Organization. Depression and other common mental disorders: global health estimates. Geneva: World Health Organization; 2017. [cited on Apr. 15, 2021]. Available from: apps.who.int/iris/bitstream/10665/254610/1/WHOMSD-MER-2017.2-eng.pdf
apps.who.int/iris/bitstream/10665/254610... , and an increase in social inequalities in mortality³3. Mackenbach JP, Valverde JR, Bopp M, Brønnum Hansen H, Costa G, Deboosere P, et al. Progress against inequalities in mortality: register based study of 15 European countries between 1990 and 2015. Eur J Epidemiol 2019; 34: 1131-42. https://doi.org/10.1007/s10654-019-00580-9
https://doi.org/10.1007/s10654-019-00580... ,⁴4. Buajitti E, Frank J, Watson T, Kornas K, Rosella LC. Changing relative and absolute socioeconomic health inequalities in Ontario, Canada: a population-based cohort study of adult premature mortality, 1992 to 2017. PloS One 2020; 15 (4): e0230684. https://doi.org/10.1371/journal.pone.0230684
https://doi.org/10.1371/journal.pone.023... and in health-related behaviors has been detected in recent decades⁵5. Maldi KD, San Sebastian M, Gustafsson PE, Jonsson F. Widespread and widely widening? Examining absolute socioeconomic health inequalities in northern Sweden across twelve health indicators. Int J Equity Health 2019; 18: 197. https://doi.org/10.1186/s12939-019-1100-5
https://doi.org/10.1186/s12939-019-1100-... ,⁶6. Teng A, Blakely T, Atkinson J, Kalėdienė R, Leinsalu M, Martikainen PT, et al. Changing social inequalities in smoking, obesity and cause-specific mortality: cross-national comparisons using compass typology. PLoS One 2020; 15 (7): e0232971. https://doi.org/10.1371/journal.pone.0232971
https://doi.org/10.1371/journal.pone.023... . These findings highlight the need to better understand the role of health behaviors in increasing inequalities in morbidity and mortality⁷7. Stait E, Calnan M. Are differential consumption patterns in health-related behaviours an explanation for persistent and widening social inequalities in health in England? Int J Equity Health 2016; 15: 171. https://doi.org/10.1186/s12939-016-0461-2
https://doi.org/10.1186/s12939-016-0461-... and draws attention to the importance of the quality of the health programs implemented to prevent unhealthy behaviors.

In addition to the consistent association of lifestyle factors with the incidence of chronic non-communicable diseases (CNCDs), research has shown relations between health behaviors and mental disorders (MD). MDs are very prevalent worldwide⁸8. GBD 2015 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the global burden of disease study 2015. Lancet 2016; 388 (10053): 1545-602. https://doi.org/10.1016/S0140-6736(16)31678-6
https://doi.org/10.1016/S0140-6736(16)31... and, in Brazil, they account for 9.5% of the total disability-adjusted life years (DALYs), of which 35% are for depressive disorders, 28% for anxiety disorders and 7% for disorders resulting from alcohol use. MDs are the third leading cause of the burden of disease in Brazil⁹9. Souza MFM, França EB, Cavalcante A. Burden of disease and health situation analysis: results of the Global Burden of Disease (GBD) Brazil network. Rev Bras Epidemiol 2017; 20 (Suppl 1): 1-3. https://doi.org/10.1590/1980-5497201700050001
https://doi.org/10.1590/1980-54972017000... . The literature on the associations between health-related behaviors and mental health, a field that has been called lifestyle psychiatry, has shown that several psychiatric conditions, including schizophrenia, bipolar disorder, depression, anxiety and stress-related conditions, are associated with harmful health behaviors such as poor diet, low levels of physical activity, high rates of smoking and inadequate sleep patterns¹⁰10. Firth J, Solmi M, Wootton RE, Vancampfort D, Schuch FB, Hoare E, et al. A meta-review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry 2020; 19 (3): 360-80. https://doi.org/10.1002/wps.20773
https://doi.org/10.1002/wps.20773... . Studies have also shown that the associations differ according to specific behavior, social and cultural contexts, as well as sociodemographic segments analyzed¹¹11. St-Pierre M, Sinclair I, Elgbeili G, Bernard P, Dancause KN. Relationships between psychological distress and health behaviors among Canadian adults: differences based on gender, income, education, immigrant status, and ethnicity. SSM Popul Health 2019; 7: 100385. https://doi.org/10.1016/j.ssmph.2019.100385
https://doi.org/10.1016/j.ssmph.2019.100... ,¹²12. Jang BN, Lee HJ, Joo JH, Park EC, Jang SI. Association between health behaviours and depression: findings from a national cross-sectional study in South Korea. BMC Psychiatry 2020; 20: 238. https://doi.org/10.1186/s12888-020-02628-7
https://doi.org/10.1186/s12888-020-02628... .

The fight against CNCDs has led to the implementation of programs aimed at reducing unhealthy behaviors. The interventions in most countries have shown different results in terms of effectiveness and success¹³13. World Health Organization. Tackling NCDs – ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2017 [cited on Apr. 20, 2021]. Available from:https://apps.who.int/iris/handle/10665/259232
https://apps.who.int/iris/handle/10665/2... . Deeper knowledge about the associations of different health behaviors with mental disorders in each context is needed so that interventions can be more appropriate and effective.

From this perspective, the aim of this study was to analyze the association between depression and various health-related behaviors in the adult Brazilian population and to verify whether the associations differ according to sex and income.

METHODS

The study was developed with data from the National Health Survey (PNS) 2019, which interviewed a sample of the Brazilian population residing in private households throughout the country. The sampling process included three stages; in the first, the census tracts were drawn and, in the second, the households. In the third stage, one resident aged 15 years or more was drawn from each selected household. The questionnaire applied by the PNS is divided in three parts addressing characteristics of: (1) household, (2) all residents and (3) the selected resident. Details about the sampling process and methods of PNS 2019 are available in other publications¹⁴14. Stopa SR, Szwarcwald CL, Oliveira MM, Gouvea ECDP, Vieira MLFP, Freitas MPS, et al. National Health Survey 2019: history, methods and perspectives. Epidemiol Serv Saude 2020; 29 (5): e2020315. https://doi.org/10.1590/S1679-49742020000500004
https://doi.org/10.1590/S1679-4974202000... .

In this study, data from 65,803 adults aged 18–59 years were analyzed. The presence of depression was assessed using the Patient Health Questionnaire-9 (PHQ-9), which measures the frequency of depressive symptoms in the two previous weeks¹⁵15. Santos IS, Tavares BF, Munhoz TN, Almeida LSP, Silva NTB, Tams BD, et al. Sensibilidade e especificidade do Patient Health Questionnaire-9 (PHQ-9) entre adultos da população geral. Cad Saude Publica 2013; 29 (8): 1533-43. https://doi.org/10.1590/0102-311X00144612
https://doi.org/10.1590/0102-311X0014461... . The score for each question varied according to the frequency of symptoms, from zero (no day) to three (almost every day), which generates a maximum score of 27. The sum of items allows for grading between no depression (0–4), mild depression (5–9), moderate depression (10–14), moderately severe depression (15–19) and severe depression (20–27)¹⁶16. Zimmerman M. Using the 9-item patient health questionnaire to screen for and monitor depression. JAMA 2019; 322 (21): 2125-6. https://doi.org/10.1001/jama.2019.15883
https://doi.org/10.1001/jama.2019.15883... . Individuals with ten or more points were considered “with depression”. This is the cutoff point that maximizes the PHQ-9 sensitivity and specificity¹⁷17. Levis B, Benedetti A, Thombs BD. Accuracy of patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression: individual participant data meta-analysis. BMJ 2019; 9 (365): l1476. http://doi.org/10.1136/bmj.l1476
http://doi.org/10.1136/bmj.l1476... .

The Stata software version 15.0 was used in the analyses, and the sample and post-stratification weights were taken into account. The prevalence of health behaviors was estimated according to the presence of depression. Prevalence ratios (PR) adjusted for sex, age and education, with respective 95% confidence intervals (95%CI) estimated by the Poisson multiple regression with robust variation. Analyses were stratified by sex and per capita family income. To assess possible interactions of sex and income in the associations of depression with health behaviors, Poisson multiple regression models were used including multiplicative interaction terms (sex vs. depression and income vs. depression) adjusted for age, education, depression, sex and income. Significance level was set at 5%.

The PNS project was approved by the National Research Ethics Committee (process No. 3.529,376, of August 23, 2019). All respondents signed an informed consent form.

RESULTS

The results show that, in 2019, 12.9% of Brazilian adults were smokers, 22.3% were former smokers, 16.4% were passive smokers, 32.0% drank alcoholic beverages at least once a month, 4.6% drank six or more times a week, and 20.2% had at least one HED in the month prior to the interview. Also, 63.2% were inactive in the context of leisure and 4.9% watched six or more hours of television per day. Regarding eating habits, 34.9% ingested FV less than five times a week, 6.9 and 11.1% consumed soft drinks and sweets more than five times a week, respectively, and 3.7% replaced lunch with snacks more than three times a week. Approximately 8.0% of the population accumulated five or more unhealthy behaviors (Table 1). Ten or more points on the PHQ-9, with probable presence of depression, were reached by 10.9% (95%CI 10.4–11.3) of Brazilian adults.

The study shows that Brazilian adults with depression, compared to adults without depression, have higher prevalence of smokers (RP 1.55), ex-smokers (RP 1.21), passive smoking (RP 1.56), frequent consumption of alcoholic beverages (RP 2.25), HED (RP 1.13), physical inactivity (RP 1.12), sedentary lifestyle (RP 1.83), replacing lunch with quick snacks (RP 1.92), less frequent consumption of FV (RP 1.16) and more frequent intake of soft drinks (RP 1.51) and sweets (RP 1.37), and five or more unhealthy behaviors (RP 2.29; 95%CI 1.78–2.93) (Table 1).

In the analyses stratified by sex, some associations were only present in females, such as the association of depression with HED and with a lower frequency of consumption of FV. The associations of sedentary lifestyle, being a former smoker and the presence of five or more unhealthy behaviors with depression have a significant higher PR in men than in women. Only in men, alcohol consumption at least once a month was a protective factor against depression, with a significant interaction (Table 2).

Considering the analyses stratified by income, the association of depression with HED was significant only in the low-income segment, but the interaction was not significant. The association of depression with physical inactivity had a higher PR in the higher-income stratum, while the association of depression with having five or more unhealthy behaviors was stronger in the lower-income segment (Table 3).

DISCUSSION

The results point to the existence of a significant association of depression with all behaviors analyzed, with the exception of alcohol consumption once or more per month, and show that the highest prevalence ratios were observed in: almost daily consumption of alcohol, replacing lunch with quick snacks, sedentary lifestyle, smoking, passive smoking at home, and frequent consumption of soft drinks. The findings also show interactions of sex and income in the associations of depression with some health behaviors.

Smoking

The association between depression and smoking verified in Brazilian adults has been reported by studies developed elsewhere. A meta-analysis carried out to assess this association showed a 50% greater chance of depression among smokers in cross-sectional studies, and, in longitudinal studies, a 62% greater risk of smokers developing depression¹⁸18. Luger TM, Suls J, Weg MWV. How robust is the association between smoking and depression in adults? A meta-analysis using linear mixed-effects models. Addict Behav 2014; 39 (10): 1418-29. https://doi.org/10.1016/j.addbeh.2014.05.011
https://doi.org/10.1016/j.addbeh.2014.05... . Another meta-analysis assessed the role of lifestyle factors in the prevention and treatment of mental disorders and reported that recent research brings emerging evidence that smoking acts as a causal factor in the incidence of major depression, bipolar disorder and schizophrenia¹⁰10. Firth J, Solmi M, Wootton RE, Vancampfort D, Schuch FB, Hoare E, et al. A meta-review of “lifestyle psychiatry”: the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders. World Psychiatry 2020; 19 (3): 360-80. https://doi.org/10.1002/wps.20773
https://doi.org/10.1002/wps.20773... . A recent systematic review¹⁹19. Gutiérrez-Rojas L, Porras-Segovia A, Dunne H, Andrade-González N, Cervilla JA. Prevalence and correlates of major depressive disorder: a systematic review. Braz J Psychiatry 2020; 42 (6): 657-72. https://doi.org/10.1590/1516-4446-2020-0650
https://doi.org/10.1590/1516-4446-2020-0... reports an association between smoking and major depression and the tendency of people with depression and anxiety to be heavy smokers. A study carried out in the United States found that the use of tobacco, alcohol and other drugs before the age of 18 is associated with an increased risk of depression in adulthood²⁰20. Wang K, Liu Y, Ouedraogo Y, Wang N, Xie X, Xu C, et al. Principal component analysis of early alcohol, drug and tobacco use with major depressive disorder in US adults. J Psychiatr Res 2018; 100: 113-20. https://doi.org/10.1016/j.jpsychires.2018.02.022
https://doi.org/10.1016/j.jpsychires.201... . Additionally, MDs are associated with heavy smoking, greater degree of nicotine dependence, increased withdrawal symptoms, and lower cessation rates. The literature also shows that smoking cessation is associated with a reduction in depression, anxiety and stress, in addition to being related to an improvement in quality of life²¹21. Taylor G, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P. Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ 2014; 348: g1151. https://doi.org/10.1136/bmj.g1151
https://doi.org/10.1136/bmj.g1151... . These data are corroborated by our study, which shows a reduction in the adjusted prevalence of depression in former smokers when compared to smokers.

An association of current smoking with depression was present for both sexes and in the same intensity, but the association of depression with being a former smoker was significantly stronger among males. Studies have found different results regarding the variable sex. Research carried out in Korea found that the association of depression with current smoking was present for both sexes, but significantly more pronounced among women (odds ratio — OR = 1.99 in women and 1.17 in men)¹²12. Jang BN, Lee HJ, Joo JH, Park EC, Jang SI. Association between health behaviours and depression: findings from a national cross-sectional study in South Korea. BMC Psychiatry 2020; 20: 238. https://doi.org/10.1186/s12888-020-02628-7
https://doi.org/10.1186/s12888-020-02628... , while a study carried out in Canada showed that smoking was associated with depression only among men²²22. Davison KM, Lung Y, Lin SL, Tong H, Kobayashi KM, Fuller-Thomson E. Depression in middle and older adulthood: the role of immigration, nutrition, and other determinants of health in the Canadian longitudinal study on aging. BMC Psychiatry 2019; 19: 329. https://doi.org/10.1186/s12888-019-2309-y
https://doi.org/10.1186/s12888-019-2309-... . It is important to highlight that there has been a relevant reduction in the prevalence of smoking in Brazil. Data from the first and the second National Survey on Alcohol and Drugs (LENAD)²³23. Laranjeira R, Organização. Segundo levantamento nacional de álcool e drogas: Relatório 2012. São Paulo: Instituto Nacional de Ciência e Tecnologia para Políticas Públicas de Álcool e Outras Drogas; 2012 [cited on Apr. 10, 2021]. Available from:https://inpad.org.br/wp-content/uploads/2014/03/Lenad-II-Relat%C3%B3rio.pdf
https://inpad.org.br/wp-content/uploads/... show a decrease in smoking prevalence from 20.8% in 2006 to 16.9% in 2012, with a more prominent decline among men (27 to 21%) than among women (15 to 13%). It is argued that the higher prevalence of depression in females could partially explain the lower rate of smoking cessation among them. Measures to address smoking cessation among women should give special attention to comorbidities with depressive conditions and the concern with gaining weight.

In our study, the association between current smoking and depression was significant and with similar magnitude in both income strata analyzed. Studies evaluating the association between depression and smoking per income are scarce, but a survey conducted in Canada found an association between the number of cigarettes smoked per day and psychological stress only in low-income groups¹¹11. St-Pierre M, Sinclair I, Elgbeili G, Bernard P, Dancause KN. Relationships between psychological distress and health behaviors among Canadian adults: differences based on gender, income, education, immigrant status, and ethnicity. SSM Popul Health 2019; 7: 100385. https://doi.org/10.1016/j.ssmph.2019.100385
https://doi.org/10.1016/j.ssmph.2019.100... . Further studies are needed to clarify the role of income in the association between smoking and depression. The association of depression with smoking detected in this study reinforces the need for attention to mental health conditions in programs aimed at controlling and quitting smoking, especially in the more vulnerable and marginalized segments of society, in which depression²⁴24. Schlax J, Jünger C, Beutel ME, Münzel T, Pfeiffer N, Wild P, et al. Income and education predict elevated depressive symptoms in the general population: results from the Gutenberg health study. BMC Public Health 2019; 19: 430. https://doi.org/10.1186/s12889-019-6730-4
https://doi.org/10.1186/s12889-019-6730-... and nicotine dependence rates are higher²⁵25. Chen A, Machiorlatti M, Krebs NM, Muscat JE. Socioeconomic differences in nicotine exposure and dependence in adult daily smokers. BMC Public Health 2019; 19: 375. https://doi.org/10.1186/s12889-019-6694-4
https://doi.org/10.1186/s12889-019-6694-... .

Alcohol

Among Brazilian adults, depression was particularly associated with very frequent consumption of alcohol (six or seven days a week) and, to a lesser extent, with HED.

Some studies have reported the consumption of alcohol in low or moderate doses as a protective factor against depression²⁶26. Bellos S, Skapinakis P, Rai D, Zitko P, Araya R, Lewis G, et al. Cross-cultural patterns of the association between varying levels of alcohol consumption and the common mental disorders of depression and anxiety: secondary analysis of the WHO Collaborative Study on psychological problems in general health care. Drug Alcohol Depend 2013; 133: 825-31. https://doi.org/10.1016/j.drugalcdep.2013.08.030
https://doi.org/10.1016/j.drugalcdep.201... . A study carried out in 19 European countries showed that long-term abstainers and those who use alcohol heavily are more likely to have depressive episodes when compared to those who use it moderately. The authors emphasize that, although the literature presents evidence of a bidirectional relation, the strongest one is heavy alcohol consumption predicting the onset of depressive episodes²⁷27. Keyes KM, Allel K, Staudinger UM, Ornstein KA, Calvo E. Alcohol consumption predicts incidence of depressive episodes across 10 years among older adults in 19 countries. Int Rev Neurobiol 2019; 148: 1-38. https://doi.org/10.1016/bs.irn.2019.09.001
https://doi.org/10.1016/bs.irn.2019.09.0... . Moderate, risky and abusive alcohol consumption have different determinants and consequences, and protection against depression associated with moderate consumption would be related to social and cultural contexts known to be protective of mental health¹⁹19. Gutiérrez-Rojas L, Porras-Segovia A, Dunne H, Andrade-González N, Cervilla JA. Prevalence and correlates of major depressive disorder: a systematic review. Braz J Psychiatry 2020; 42 (6): 657-72. https://doi.org/10.1590/1516-4446-2020-0650
https://doi.org/10.1590/1516-4446-2020-0... .

In this study, we report an interaction of sex in the association between alcohol and depression. For both sexes, the almost daily consumption of alcohol was associated with depression, but HED was associated with depression only in women. We also found that only in men the consumption of alcoholic beverages once or more times a month is a protective factor against depression. Studies show that women are 1.5 to twice more likely to have depression throughout their lives when compared to men, and differences between sexes are also observed in the course of depressive disorders²⁸28. McHugh RK, Weiss RD. Alcohol use disorder and depressive disorders. Alcohol Res 2019; 40 (1): arcr.v40.1.01. https://doi.org/10.35946/arcr.v40.1.01
https://doi.org/10.35946/arcr.v40.1.01... . Retrospective studies show that there is a greater chance that depression precedes the problematic use of alcohol among women, while the opposite occurs among men²⁹29. Prescott CA, Aggen SH, Kendler KS. Sex-specific genetic influences on the comorbidity of alcoholism and major depression in a population based sample of U.S. twins. Arch Gen Psychiatry 2000; 57 (8): 803-11. https://doi.org/10.1001/archpsyc.57.8.803
https://doi.org/10.1001/archpsyc.57.8.80... . It should be noted that there has been a considerable increase in the prevalence of alcohol use among women³⁰30. Wolle CC, Sanches M, Zilberman ML, Caetano R, Zaleski M, Laranjeira RR, Pinsky I. Differences in drinking patterns between men and women in Brazil. Braz J Psychiatry 2011; 33 (4): 367-73. https://doi.org/10.1590/s1516-44462011000400010
https://doi.org/10.1590/s1516-4446201100... globally and in Brazil. Gender differences related to motivation for use, metabolic specificities, sociocultural factors, physical and psychiatric comorbidities imply particular losses to women, including this gender’s different pattern for the association between HED and depression highlighted in this study.

In the analysis per income, it appears that the association of HED with depression is significant only in the lower-income segment, but without significant interaction. International data point to disparities in health care for comorbid conditions of depression with alcohol use disorders, to the detriment of minority ethnic groups³¹31. Nam E, Matejkowski J, Lee S. Racial/ethnic differences in contemporaneous use of mental health and substance use treatment among individuals experiencing both mental illness and substance use disorders. Psychiatr Q 2017; 88 (1): 185-98. https://doi.org/10.1007/s11126-016-9444-0
https://doi.org/10.1007/s11126-016-9444-... .

Among people with alcohol consumption problems, depression is the most common mental disorder, and this concurrency tends to worsen the severity and prognosis of both situations³²32. Hasin D, Liu X, Nunes E, McCloud S, Samet S, Endicott J. Effects of major depression on remission and relapse of substance dependence. Arch Gen Psychiatry 2002; 59 (4): 375-80. https://doi.org/10.1001/archpsyc.59.4.375
https://doi.org/10.1001/archpsyc.59.4.37... ,³³33. Conner KR, Gamble SA, Bagge CL, He H, Swogger MT, Watts A, et al. Substance-induced depression and independent depression in proximal risk for suicidal behavior. J Stud Alcohol Drugs 2014; 75 (4): 567-72. https://doi.org/10.15288/jsad.2014.75.567
https://doi.org/10.15288/jsad.2014.75.56... . The literature shows that the prevalence of depression is higher among individuals who are dependent on alcohol than in those who abuse it³²32. Hasin D, Liu X, Nunes E, McCloud S, Samet S, Endicott J. Effects of major depression on remission and relapse of substance dependence. Arch Gen Psychiatry 2002; 59 (4): 375-80. https://doi.org/10.1001/archpsyc.59.4.375
https://doi.org/10.1001/archpsyc.59.4.37... . The findings of this study reinforce the need to include mental health in programs to promote healthy behaviors, considering differences in gender and socioeconomic status.

Food

This study showed lower intake of FV by individuals with depression, and other studies have confirmed this association³⁴34. Radavelli-Bagatini S, Anokye R, Bondonno NP, Sim M, Bondonno CP, Stanley MJ, et al. Association of habitual intake of fruits and vegetables with depressive symptoms: the AusDiab study. Eur J Nutr 2021; 60 (7): 3743-55. https://doi.org/10.1007/s00394-021-02532-0
https://doi.org/10.1007/s00394-021-02532... –³⁶36. Głąbska D, Guzek D, Groele B, Gutkowska K. Fruit and vegetable intake and mental health in adults: a systematic review. Nutrients 2020; 12 (1): 115. https://doi.org/10.3390/nu12010115
https://doi.org/10.3390/nu12010115... . Among these, two meta-analyses found that FV consumption is inversely related to depressive symptoms³⁵35. Saghafian F, Malmir H, Saneei P, Milajerdi A, Larijani B, Esmaillzadeh A. Fruit and vegetable consumption and risk of depression: accumulative evidence from an updated systematic review and meta-analysis of epidemiological studies. Br J Nutr 2018; 119 (10): 1087-101. https://doi.org/10.1017/S0007114518000697
https://doi.org/10.1017/S000711451800069... ,³⁷37. Liu X, Yan Y, Li F, Zhang D. Fruit and vegetable consumption and the risk of depression: a meta-analysis. Nutrition 2016; 32 (3): 296-302. https://doi.org/10.1016/j.nut.2015.09.009
https://doi.org/10.1016/j.nut.2015.09.00... , with a 14% lower risk of depressive symptoms in segments with higher FV consumption, indicating that each 100 g increment in the intake of these foods per day could reduce the risk of depression by 5%³⁵35. Saghafian F, Malmir H, Saneei P, Milajerdi A, Larijani B, Esmaillzadeh A. Fruit and vegetable consumption and risk of depression: accumulative evidence from an updated systematic review and meta-analysis of epidemiological studies. Br J Nutr 2018; 119 (10): 1087-101. https://doi.org/10.1017/S0007114518000697
https://doi.org/10.1017/S000711451800069... . This association may stem, among other reasons, from the content of minerals, vitamins, amino acids, phytochemicals and antioxidant compounds present in FV and their influence on depression³⁴34. Radavelli-Bagatini S, Anokye R, Bondonno NP, Sim M, Bondonno CP, Stanley MJ, et al. Association of habitual intake of fruits and vegetables with depressive symptoms: the AusDiab study. Eur J Nutr 2021; 60 (7): 3743-55. https://doi.org/10.1007/s00394-021-02532-0
https://doi.org/10.1007/s00394-021-02532... ,³⁷37. Liu X, Yan Y, Li F, Zhang D. Fruit and vegetable consumption and the risk of depression: a meta-analysis. Nutrition 2016; 32 (3): 296-302. https://doi.org/10.1016/j.nut.2015.09.009
https://doi.org/10.1016/j.nut.2015.09.00... .

An association of consumption of soft drinks and sweets with depression was found and the literature confirms this relation. Knuppel et al. identified an increased risk of depressive symptoms associated with high intake of foods and beverages containing sugar³⁸38. Knüppel A, Shipley MJ, Llewellyn CH, Brunner EJ. Sugar intake from sweet food and beverages, common mental disorder and depression: prospective findings from the Whitehall II study. Sci Rep 2017; 7 (1): 6287. https://doi.org/10.1038/s41598-017-05649-7
https://doi.org/10.1038/s41598-017-05649... and, specifically regarding soft drinks, there is evidence that the daily intake of two cups of cola soda would be enough to increase the risk of depression³⁹39. Hu D, Cheng L, Jiang W. Sugar-sweetened beverages consumption and the risk of depression: a meta-analysis of observational studies. J Affect Disord 2019; 245: 348-55. https://doi.org/10.1016/j.jad.2018.11.015
https://doi.org/10.1016/j.jad.2018.11.01... . The consumption of foods with a high glycemic index, such as soft drinks and sweets, is associated with inflammatory markers and oxidative stress. These and the morbidities they cause (obesity, diabetes and other metabolic diseases) are related to depressive symptoms⁴⁰40. Guo X, Park Y, Freedman ND, Sinha R, Hollenbeck AR, Blair A, et al. Sweetened beverages, coffee, and tea and depression risk among older US adults. PLoS One 2014; 9 (4): e94715. https://doi.org/10.1371/journal.pone.0094715
https://doi.org/10.1371/journal.pone.009... ,⁴¹41. Mwamburi DM, Liebson E, Folstein M, Bungay K, Tucker KL, Qiu WQ. Depression and glycemic intake in the homebound elderly. J Affect Disord 2011; 132 (1-2): 94-8. https://doi.org/10.1016/j.jad.2011.02.002
https://doi.org/10.1016/j.jad.2011.02.00... ,⁴²42. Aparicio A, Robles F, López-Sobaler AM, Ortega RM. Dietary glycaemic load and odds of depression in a group of institutionalized elderly people without antidepressant treatment. Eur J Nutr 2013; 52 (3): 1059-66. https://doi.org/10.1007/s00394-012-0412-7
https://doi.org/10.1007/s00394-012-0412-... .

The associations of depression with low consumption of FV and with regular consumption of soft drinks and sweets were observed in both income strata, but in relation to gender, the associations were only significant in females. Studies conducted in Australia and the United Kingdom also found that the association of depression with worse dietary pattern and lower dietary quality index (AHEI), respectively⁴³43. Akbaraly TN, Sabia S, Shipley MJ, Batty GD, Kivimaki M. Adherence to healthy dietary guidelines and future depressive symptoms: evidence for sex differentials in the Whitehall II study. Am J Clin Nutr 2013; 97 (2): 419-27. https://doi.org/10.3945/ajcn.112.041582.
https://doi.org/10.3945/ajcn.112.041582... ,⁴⁴44. Hart MJ, Milte CM, Torres SJ, Thorpe MG, McNaughton SA. Dietary patterns are associated with depressive symptoms in older Australian women but not men. Br J Nutr 2019; 122 (12): 1424-31. https://doi.org/10.1017/S0007114519002435
https://doi.org/10.1017/S000711451900243... . There are, however, studies in which the association of food with depression is reported in both sexes⁴⁵45. Gomes AP, Gonçalves H, Santos Vaz J, Kieling C, Rohde LA, Oliveira IO, et al. Do inflammation and adiposity mediate the association of diet quality with depression and anxiety in young adults? Clin Nutr 2021; 40 (5): 2800-8. https://doi.org/10.1016/j.clnu.2021.03.028
https://doi.org/10.1016/j.clnu.2021.03.0... ,⁴⁶46. Le Port A, Gueguen A, Kesse-Guyot E, Melchior M, Lemogne C, Nabi H, et al. Association between dietary patterns and depressive symptoms over time: a 10-year follow-up study of the GAZEL cohort. PLoS One 2012; 7 (12): e51593. https://doi.org/10.1371/journal.pone.0051593
https://doi.org/10.1371/journal.pone.005... , indicating that gender differentials in the relationship between food intake and depression need to be further studied.

A strong association was found between depression and the replacement of lunch with quick snacks (or fast food) in the Brazilian adult population, which is in line with studies conducted in other countries⁴⁷47. Crawford GB, Khedkar A, Flaws JA, Sorkin JD, Gallicchio L. Depressive symptoms and self-reported fast-food intake in midlife women. Prev Med 2011; 52 (3-4): 254-7. https://doi.org/10.1016/j.ypmed.2011.01.006
https://doi.org/10.1016/j.ypmed.2011.01.... ,⁴⁸48. Lazarevich I, Irigoyen Camacho ME, Velázquez-Alva MC, Flores NL, Nájera Medina O, Zepeda Zepeda MA. Depression and food consumption in Mexican college students. Nutr Hosp 2018; 35 (3): 620-6. https://doi.org/10.20960/nh.1500
https://doi.org/10.20960/nh.1500... ,⁴⁹49. Sánchez-Villegas A, Toledo E, Irala J, Ruiz-Canela M, Pla-Vidal J, Martínez-González MA. Fast-food and commercial baked goods consumption and the risk of depression. Public Health Nutr 2012; 15 (3): 424-32. https://doi.org/10.1017/S1368980011001856
https://doi.org/10.1017/S136898001100185... . The literature also shows that the consumption of ultra-processed foods, usually chosen as a substitute for lunch or dinner, is positively associated with the risk of depression⁵⁰50. Gómez-Donoso C, Sánchez-Villegas A, Martínez-González MA, Gea A, Mendonça RD, Lahortiga-Ramos F, et al. Ultra-processed food consumption and the incidence of depression in a Mediterranean cohort: the SUN Project. Eur J Nutr 2020; 59 (3): 1093-103. https://doi.org/10.1007/s00394-019-01970-1
https://doi.org/10.1007/s00394-019-01970... . Again, it is worth noting that metabolic diseases such as obesity are associated with depression and fast-food consumption, indicating a sharing of biological mechanisms between the diseases⁵¹51. Milaneschi Y, Simmons WK, van Rossum EFC, Penninx BW. Depression and obesity: evidence of shared biological mechanisms. Mol Psychiatry 2019; 24 (1): 18-33. https://doi.org/10.1038/s41380-018-0017-5
https://doi.org/10.1038/s41380-018-0017-... ,⁵²52. Strawbridge R, Arnone D, Danese A, Papadopoulos A, Herane Vives A, Cleare AJ. Inflammation and clinical response to treatment in depression: a meta-analysis. Eur Neuropsychopharmacol. 2015; 25 (10): 1532-43. https://doi.org/10.1016/j.euroneuro.2015.06.007
https://doi.org/10.1016/j.euroneuro.2015... . This association was observed in the two income strata analyzed and was significant for both sexes.

Physical Activity and Sedentary Lifestyle

The prevalence of physical inactivity and sedentary behavior was, respectively, 12 and 83% higher in individuals with depression—associations also found in other population-based studies⁵³53. Marques A, Peralta M, Gouveia ER, Martins J, Sarmento H, Gomez-Baya D. Leisure-time physical activity is negatively associated with depression symptoms independently of the socioeconomic status. Eur J Sport Sci 2020; 20 (9): 1268-76. https://doi.org/10.1080/17461391.2019.1701716
https://doi.org/10.1080/17461391.2019.17... ,⁵⁴54. Fukai K, Kuwahara K, Chen S, Eguchi M, Kochi T, Kabe I, et al. The association of leisure-time physical activity and walking during commuting to work with depressive symptoms among Japanese workers: a cross-sectional study. J Occup Health 2020; 62 (1): e12120. https://doi.org/10.1002/1348-9585.12120
https://doi.org/10.1002/1348-9585.12120... ,⁵⁵55. Werneck AO, Oyeyemi AL, Szwarcwald CL, Vancampfort D, Silva DR. Associations between TV viewing and depressive symptoms among 60,202 Brazilian adults: The Brazilian national health survey. J Affect Disord 2018; 236: 23-30. https://doi.org/10.1016/j.jad.2018.04.083
https://doi.org/10.1016/j.jad.2018.04.08... . A meta-analysis of 111 studies showed that any level of PA attenuates the risk of depression, but moderate and high levels are more strongly associated with lower risk⁵⁶56. Dishman RK, McDowell CP, Herring MP. Customary physical activity and odds of depression: a systematic review and meta-analysis of 111 prospective cohort studies. Br J Sports Med 2021; 55 (16): 926-34. https://doi.org/10.1136/bjsports-2020-103140
https://doi.org/10.1136/bjsports-2020-10... . Another meta-analysis showed PA as a protective factor against the onset of depression, regardless of age and geographic region⁵⁷57. Schuch FB, Vancampfort D, Firth J, Rosenbaum S, Ward PB, Silva ES, et al. Physical activity and incident depression: a meta-analysis of prospective cohort studies. Am J Psychiatry 2018; 175 (7): 631-48. https://doi.org/10.1176/appi.ajp.2018.17111194
https://doi.org/10.1176/appi.ajp.2018.17... . There is also evidence of the importance of PA in the treatment of depressive symptoms⁵⁸58. Bueno-Antequera J, Munguía-Izquierdo D. Exercise and depressive disorder. Adv Exp Med Biol 2020; 1228: 271-87. https://doi.org/10.1007/978-981-15-1792-1_18
https://doi.org/10.1007/978-981-15-1792-... .

In this study, an association between depression and leisure time physical inactivity was found in both income strata, but PR was higher among those who reported higher monthly earnings—precisely who have greater access to leisure practices—, but these practices would be more affected by the presence of depressive disorders.

The association of depression with physical inactivity portrayed in this study and the existing evidence of the protective effect of mental health by PA⁵⁶56. Dishman RK, McDowell CP, Herring MP. Customary physical activity and odds of depression: a systematic review and meta-analysis of 111 prospective cohort studies. Br J Sports Med 2021; 55 (16): 926-34. https://doi.org/10.1136/bjsports-2020-103140
https://doi.org/10.1136/bjsports-2020-10... emphasize the need to encourage its practice in the care of patients with mental disorders and the consideration of mental health in health promotion programs⁵⁹59. Pelletier L, Shanmugasegaram S, Patten SB, Demers A. Self-management of mood and/or anxiety disorders through physical activity/exercise. Health Promot Chronic Dis Prev Can 2017; 37 (5): 149-59. https://doi.org/10.24095/hpcdp.37.5.03
https://doi.org/10.24095/hpcdp.37.5.03... .

The relation between sedentary behavior and depression observed in this study corroborates the findings of two meta-analyses. One shows high level of sedentary lifestyle among people with depression⁶⁰60. Schuch F, Vancampfort D, Firth J, Rosenbaum S, Ward P, Reichert T, et al. Physical activity and sedentary behavior in people with major depressive disorder: A systematic review and meta-analysis. J Affect Disord 2017; 210: 139-50. https://doi.org/10.1016/j.jad.2016.10.050
https://doi.org/10.1016/j.jad.2016.10.05... and the other shows a greater chance of depression associated with sedentary behavior—considered as two hours or more of screen time per day (OR 1.28; 95%CI 1.17–1.39)⁶¹61. Wang X, Li Y, Fan H. The associations between screen time-based sedentary behavior and depression: a systematic review and meta-analysis. BMC Public Health 2019; 19 (1): 1524. https://doi.org/10.1186/s12889-019-7904-9
https://doi.org/10.1186/s12889-019-7904-... . However, according to a study conducted with 59,401 Brazilians, PA can reduce the association between time spent on television and depressive symptoms⁶²62. Werneck AO, Stubbs B, Fernandes RA, Szwarcwald CL, Silva DR. Leisure time physical activity reduces the association between TV-viewing and depressive symptoms: a large study among 59,401 Brazilian adults. J Affect Disord 2019; 252: 310-4. https://doi.org/10.1016/j.jad.2019.03.066
https://doi.org/10.1016/j.jad.2019.03.06... .

The association between sedentary lifestyle and depression was stronger among men, corroborating the findings of another Brazilian study⁵⁵55. Werneck AO, Oyeyemi AL, Szwarcwald CL, Vancampfort D, Silva DR. Associations between TV viewing and depressive symptoms among 60,202 Brazilian adults: The Brazilian national health survey. J Affect Disord 2018; 236: 23-30. https://doi.org/10.1016/j.jad.2018.04.083
https://doi.org/10.1016/j.jad.2018.04.08... , but differing from what was observed in a meta-analysis carried out by Wang et al. (2019), in which this association was only significant among women. A possible explanation for these divergences is that men and women use different coping strategies when dealing with depression, depending on their sociocultural context⁶³63. Nolen-Hoeksema S. Sex differences in unipolar depression: evidence and theory. Psychol Bull 1987; 101 (2): 259-82. https://doi.org/10.1037/0033-2909.101.2.259
https://doi.org/10.1037/0033-2909.101.2.... .

Taken together, the results of this study point to the existence of an important association, in Brazilian adults, between lifestyle factors and depression. Although studies indicate stronger interactions with smoking and physical activity⁶⁴64. Kingsbury M, Dupuis G, Jacka F, Roy-Gagnon MH, McMartin SE, Colman I. Associations between fruit and vegetable consumption and depressive symptoms: evidence from a national Canadian longitudinal survey. J Epidemiol Community Health 2016; 70: 155-61. https://doi.org/10.1136/jech-2015-205858
https://doi.org/10.1136/jech-2015-205858... , a strong association with indicators of diet, sedentary lifestyle and alcohol consumption was also found.

In view of such research results, the promotion of healthy behaviors, essential for reducing the prevalence and premature deaths caused by CNCDs, requires comprehensive and integrated strategies that take into account the association of depression with health behaviors and the specificities of this association per sex and socioeconomic strata.

ACKNOWLEDGMENTS

The authors would like to thank the National Council for Scientific and Technological Development (CNPq) for funding MBA Barros and DC Malta productivity grants and the São Paulo State Research Support Foundation (FAPESP) for the postdoctoral grant to LPB Medina.

REFERENCES

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