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Disturbed eating tendencies, health-related behaviors, and depressive symptoms among university students in Korea
Accepted Manuscript Disturbed eating tendencies, health-related behaviors, and depressive symptoms among university students in Korea Yuri Seo, Youjin Je PII:
S2352-9393(17)30055-6
DOI:
10.1016/j.yclnex.2018.02.001
Reference:
YCLNEX 53
To appear in:
Clinical Nutrition Experimental
Received Date: 1 August 2017 Revised Date:
21 February 2018
Accepted Date: 23 February 2018
Please cite this article as: Seo Y, Je Y, Disturbed eating tendencies, health-related behaviors, and depressive symptoms among university students in Korea, Clinical Nutrition Experimental (2018), doi: 10.1016/j.yclnex.2018.02.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Disturbed eating tendencies, health-related behaviors, and depressive symptoms among university students in Korea Running head: Factors related to depression among Korean students
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Authors: Yuri Seo and Youjin Je* (The last name of each author: Seo and Je)
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Affiliation: Department of Food and Nutrition, Kyung Hee University, Seoul, South Korea (Y.S., Y.J.)
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Corresponding author*
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Youjin Je, ScD
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Associate Professor
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Department of Food and Nutrition,
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Kyung Hee University,
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26 Kyunghee-daero, Dongdaemun-gu,
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Seoul 130-701, South Korea
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Tel: +82-2-961-0258
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Email: [email protected]
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Keywords: Depression, Disturbed eating attitude, Health behavior, Depressive symptoms,
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Korean students
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Abbreviations used in this paper:
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BMI, body mass index;
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BDI, Beck Depression Inventory;
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EAT, Eating Attitudes Test;
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RSES, Rosenberg Self-Esteem Scale;
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OR, odds ratio;
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CI, confidence interval.
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ABSTRACT
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Background and aims: There were few studies to investigate the related factors of
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depression among Korean students. Therefore, this study examined disturbed eating
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tendencies, health-related behaviors, and depressive symptoms among university students in
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Korea.
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Methods: We conducted a cross-sectional survey on a total of 637 students (279 men and 358
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women), and the Korean version of the Beck depression rating scale (K-BDI) was used to
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evaluate the students’ depression status.
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Results: Of the 637 students, 419 (65.8%) had no depressive symptoms (normal: K-
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BDI<10), whereas 136 (21.4%: K-BDI 10-16), 69 (10.8%: K-BDI 17-29), and 13 (2.0%: K-
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BDI ≥30) had mild, moderate, and severe depressive symptoms, respectively. Multivariable
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logistic regression showed that depressive symptoms (K-BDI≥10) were associated with
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female gender (odds ratio [OR] = 1.86, 95% confidence interval [CI] = 1.26 to 2.76;
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p=0.002), high level of life stress (OR = 4.37, 95% CI = 2.23 to 8.55; p<0.001), and disturbed
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eating behaviors (Korean version of Eating Attitude Test-26 ≥20; OR = 5.14, 95% CI = 2.52
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to 10.5; p<0.001). In contrast, depressive symptoms were inversely associated with a high
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body image satisfaction (OR = 0.37, 95% CI = 0.20 to 0.68; p=0.001) and self-esteem (self-
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esteem score ≥30) (OR = 0.29, 95% CI = 0.20 to 0.43; p<0.001).
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Conclusions: This study confirmed that students with depressive symptoms tended to have
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disturbed eating behaviors, low body image satisfaction, low self-esteem, and high levels of
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stress.
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ACCEPTED MANUSCRIPT Introduction
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Depression is a major contributor to the overall global burden of disease. The World Health
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Organization estimated that 322 million people live with depression worldwide. In 2015, 4.4%
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of the global population was estimated to live with depression. This figure was higher among
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women (5.1%) than men (3.6%) [1]. Between 2005 and 2015, the total estimated number of
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people with depression increased by 18.4% [2]. The prevalence of depression varies by
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country, with a rate of 4.2% in Japan and China, compared to 5.9% in the United States. In
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Korea, the prevalence of depression was 4.1% in 2015 and was more prevalent among
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women (4.8%) than men (3.4%) [3]. Although the prevalence of depression in Asian
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countries is lower than in Europe or America, the number of patients treated for depression in
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Korea exceeded 601,152 in 2015, representing an increase of 12.4% from 2011 [4].
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Depression has been associated with poor interpersonal relations, impaired memory, and, in extreme cases, suicide. In addition, depression and depressive symptoms are
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associated with undesirable lifestyle factors, such as physical inactivity, sedentary behavior,
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and poor dietary habits [5-8]. Several studies also associated depression and depressive
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symptoms with an increased risk of metabolic syndrome [9, 10], cardiovascular disease [11,
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12], and their risk factors [13].
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In Korea, the prevalence of depression was 4.9 % in the 20-24 years, which was
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much higher in females (6.4%) than males (3.5%) in 2015, and the prevalence has been
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steadily increased for the past decade [14]. Many college students in Korea are under
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significant stress due to job-seeking [15], which may affect their depressive symptoms and
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overall health. People with depressive symptoms in their twenties or younger may have a
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higher risk of cardiovascular disease and related diseases due to their disturbed eating
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behaviors and poor nutritional status. Nutrition interventions are therefore critical to treat
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people with depressive symptoms. Few studies have investigated depression among Korean
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ACCEPTED MANUSCRIPT university students using validated measurement tools to identify related factors. We
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conducted a cross-sectional survey of university students in Korea to examine their eating
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attitudes, health-related behaviors, and depression status and to explore the associations of
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these variables among the students. Given the increasing prevalence of depression in Korea,
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it is important to identify subjects with depressive symptoms at an early stage and provide
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them with targeted nutrition education intervention.
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Methods
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Participants and study design
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This study was a cross-sectional survey. The participants were selected by convenient
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purposive sampling of students attending universities in Seoul, South Korea. The survey used
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questionnaires and was conducted from March 10 to April 10, 2014. Twenty-three students
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with incomplete questionnaires were excluded. In total, 637 students (279 men, 358 women)
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were included. The Kyung Hee University Institutional Review Board approved this study for
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exemption review (KHSIRB-14-005[EA]).
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Study contents
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The questionnaire included questions regarding general and health-related characteristics,
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eating attitudes, self-esteem, and depression assessment.
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General and health-related characteristics
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The general characteristics of participants included their gender, age, grade, monthly
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household income, and monthly allowance. The health-related characteristics included the
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participants’ height, weight, perception of body shape, body image satisfaction, smoking
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status, alcohol consumption, exercise, coffee consumption, self-assessed level of life stress,
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and disease status. The body mass index (BMI, kg/m2) was calculated from the reported
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Korean Society for the Study of Obesity, the BMI was classified into underweight (<18.5),
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normal weight (18.5 to 22.9), and overweight/obese (≥23) [16].
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Depression
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The depression status of subjects was measured using a validated Korean version of the Beck
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Depression Inventory (K-BDI), modified by Hahn et al. [17] from the original version by
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Beck et al. [18] The K-BDI was composed of 21 questions, each with a score of 0, 1, 2, or 3.
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The total scores of K-BDI ranged from 0 to 63. A higher score indicated more severe
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depressive symptoms. In this study, scores of 0 to 9 were defined as normal, and scores of 10
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to 15, 16 to 23, and 24 and above were defined as mild, moderate, and severe depressive
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symptoms, respectively [19]. The Cronbach’s alpha for internal consistency or reliability of
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this test was 0.90.
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Eating attitudes
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Eating attitudes were measured using a validated Korean version of the Eating Attitudes Test-
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The KEAT-26 is composed of 26 questions, each with a score of 0, 1, 2, or 3. The total scores
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of the KEAT-26 range from 0 to 78. A higher score indicates more abnormal eating attitudes
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and behaviors. In this study, scores of 20 or more indicated disturbed eating behavior [22,
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23]. The Cronbach’s alpha of this test was 0.84.
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Self-esteem
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Self-esteem was measured using a validated Korean version of the Rosenberg Self-Esteem
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Scale (K-RSES), modified by Jeon [24] from the original version by Rosenberg [25]. This
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tool incorporates five positive and five negative questions, with each question scored by the
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Likert 4-point scale. The total scores for the K-RSES range from 10 to 40. In this study,
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scores of 30 or more indicated relatively high self-esteem [26]. The Cronbach’s alpha of this
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test was 0.82.
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Statistical analysis
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The data was analyzed using STATA software (v14.2, Stata Corporation, College Station,
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TX). Two sample t-tests (or Mann-Whitney test) and analysis of variance (or Kruskal-Wallis
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test) were used to compare the K-BDI scores among the groups. For categorical data, chi-
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square tests (or Fisher’s exact test) were used to compare the differences in frequency among
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the groups. We also used a general linear model to examine the difference in the scores for
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eating attitudes according to depression status, after adjusting for gender. To test the
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association of K-BDI scores among KEAT-26 and K-RSES scores, we carried out the
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Spearman correlation analysis. To determine factors related to depression (K-BDI≥10), we
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performed a multivariable logistic regression analysis and calculated adjusted odds ratios
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(ORs) and 95% confidence intervals (CIs). For the consistency of the questionnaire,
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Cronbach’s alpha values were used to evaluate the K-BDI, KEAT-26, and K-RSES.
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Results
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Table 1 shows the characteristics of the sample. In total, 358 students (56.2%) were women
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and 392 (61.5%) were in their third or fourth year of university. As for monthly household
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income, 249 students’ families (39.1%) earned 3 to 5 million won a month and 250 families
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(39.3%) earned more than 5 million won a month. In terms of monthly allowance, 293
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students (46.0%) spent 200,000 to 500,000 won a month, and 167 students (26.2%) spent
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more than 500,000 won a month. In terms of disease status, most students (94.5%) reported
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that they had no illness. The participants’ mean BMI was 21.2 kg/m2. The mean scores of
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KEAT-26 and self-esteem were 8.78 and 31.1, respectively. Table 2 shows the participants’ degree of depression. The K-BDI score ranged from 0 to 57, with a mean of 8.50. The K-BDI score was significantly higher among women than
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men (10.1 vs 6.44, p<.001). According to the K-BDI scores, participants were categorized
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into four groups: normal (<10), mild (10 to 16), moderate (17 to 29), and severe (≥30). The
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results showed that 419 participants (65.8%) were in the normal group, 136 (21.4%) were in
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the mild depression group, 69 (10.8%) were in the moderate depression group, and 13 (2.0%)
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were in the severe depression group. For men, 215 (77.1%) had no depressive symptoms
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(normal), whereas 41 (14.7%) had mild depressive symptoms and 23 (8.2%) had moderate or
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severe depressive symptoms. For women, 204 (57.0%) had no depressive symptoms, whereas
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95 (26.5%) had mild depressive symptoms and 59 (16.5%) had moderate or severe depressive
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symptoms. The degree of depression differed significantly according to the participants’
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gender (p<.001).
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To examine the association of K-BDI scores among KEAT-26 scores and self-esteem scores, we carried out the Spearman correlation analysis (Table 3). There was a positive
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correlation between K-BDI and KEAT-26 scores (r = 0.307, p<.001) and a negative
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correlation between K-BDI and self-esteem scores (r = -0.45, p<.001). Table 4 shows K-BDI scores according to health-related variables. We found an
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inverse association between K-BDI scores and body image satisfaction in both men and
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women. For body image, the highest K-BDI score was in the ‘dissatisfied’ group and the
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lowest K-BDI score was in the ‘satisfied’ group (p<.001). In addition, there was a positive
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association between K-BDI scores and the reported level of life stress in both men and
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women. The highest K-BDI score was in the group with a high level of life stress, and the
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lowest K-BDI score in the group who had almost no life stress (p<.001). Among the health-
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related variables, the perception of body shape positively correlated with the K-BDI score in
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higher than that in the other groups (p<.001). In contrast, coffee consumption positively
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correlated with the K-BDI score in men only. The group that consumed two or more cups of
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coffee per day had a higher K-BDI score than the other groups of men (p = 0.034). For
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exercise and alcohol consumption, the K-BDI scores differed significantly among the groups,
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but the significance disappeared when stratified by gender. For smoking status, female
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smokers had a significantly higher K-BDI score than non-smokers, whereas the difference
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was not significant in men. For BMI, women who were overweight or obese (BMI ≥ 23
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kg/m2) had a higher K-BDI score than those with normal weight or underweight, but the
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difference was not significant (p = 0.068).
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Table 5 shows the results of the multivariable-adjusted logistic regression of factors related to depressive symptoms. Significant associations were seen between depressive
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symptoms and gender, life stress, disturbed eating behavior, body image satisfaction, and
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self-esteem (p<.05). Female gender (OR = 1.86, 95% CI = 1.26 to 2.76; p = 0.002), high level
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of life stress (OR = 4.37, 95% CI = 2.23 to 8.55; p<.001), and disturbed eating behavior (OR
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= 5.14, 95% CI = 2.52 to 10.5; p<.001) were positively associated with depressive symptoms.
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In contrast, a high level of body image satisfaction (OR = 0.37, 95% CI = 0.20 to 0.68; p =
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0.001) and high self-esteem (OR = 0.29, 95% CI = 0.20 to 0.43; p<.001) were inversely
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associated with depressive symptoms.
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Discussion
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In this study, women had a significantly higher mean K-BDI depression score than men. We
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found that university students with depressive symptoms in Korea tended to have disturbed
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eating behavior, low body image satisfaction, low self-esteem, and high level of stress.
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The results were consistent with previous studies which also found the prevalence of
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ACCEPTED MANUSCRIPT depression to be higher in women than men [27-29]. These findings seem to be explained by
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the tendency of women to be more emotionally sensitive than men [30]. In terms of the
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relationship between disturbed eating behavior, self-esteem, and depression, we found that
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the more severe the depressive symptoms, the greater the risk of disturbed eating behavior
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(p<.001). Similarly, the more severe the depressive symptoms the lower the self-esteem
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(p<.001). These results were similar to those of previous studies, which showed that disturbed
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eating behavior was positively associated with depression [31-33] and that self-esteem was
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inversely associated with depression [34-37].
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We also found some associations between depressive symptoms and health-related
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variables. In this study, body image satisfaction and life stress were significantly associated
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with depressive symptoms in both men and women. There was an inverse association
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between body image satisfaction and depressive symptoms, and people who were not
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satisfied with their body image had a higher depression score than those who were satisfied
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with their body image. College students are reported to have greater concerns about their
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body shape and weight [38]. Previous studies have shown that a negative self-evaluation of
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appearance was a notable risk factor for college students to suffer from depression. Likewise,
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studies have found that a high level of life stress was positively associated with depression
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[39]. In Korea, many college students are under significant stress. Above all, stress due to
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job-seeking accounts for a great part of life stress among Korean college students. The
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National Statistical Office of Korea, for instance, stated that nine out of 10 college students
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are under stress due to job-seeking [15]. Anxiety associated with job seeking may thus affect
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levels of depression among college students in Korea. In this study, there was a positive
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association between coffee consumption and depression. This finding was similar to Kim’s
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study, which found that the frequency of coffee intake increased among university students
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with depression symptoms [40]. A recent meta-analysis of epidemiological studies suggested
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a non-linear J-shaped relation between coffee consumption and risk of depression with a peak
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of inverse association for 400 mL/day, which was stable toward slight increase for higher
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intakes [41]. In the multivariable analysis of our study, there was no association between
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coffee consumption and depressive symptoms. Alcohol drinking and exercise were inversely
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associated with depression in this study, but disappeared when the data were analyzed for
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gender. This may be because the proportion of women was higher in the group who rarely
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drank alcohol or exercised. In our study, we found no significant associations between
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depression and BMI. This is in contrast to other studies, such as Son et al., which found that
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the prevalence of depressive symptoms was significantly higher in overweight groups than
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other groups (p=0.009) [42]. Other studies have also found significant associations between
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depression and obesity [43, 44]. However, there was a suggestive association between BMI
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and depression in women (p=0.068). When we re-categorized the BMI variable into two
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groups (BMI<23, ≥23) rather than 3 groups, we found a significant association between BMI
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and depression in women (p=0.016, data not shown) indicating that overweight women
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(BMI≥23) had a higher depression score than non-overweight women.
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with depressive symptoms after multivariable adjustment, we conducted a logistic regression
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analysis. This showed that depressive symptoms were positively associated with female
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gender, high levels of life stress and disturbed eating behavior, and were inversely associated
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with body image satisfaction and high self-esteem among university students. The BMI
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variable was positively associated with depression when the variable was included as a
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continuous variable in the multivariable model. The significance, however, disappeared when
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the variable of body image satisfaction was added in the model.
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Our study has several limitations. This study is a cross-sectional design, which is likely to suffer of reverse causation, and thus it is not possible to identify whether the variable
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ACCEPTED MANUSCRIPT of interest determines the outcome or the opposite. In addition, although we used the
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validated FFQ to assess depression status, for measurement of health behaviors, validated
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questionnaires were not used. Lastly, we excluded a few subjects from the analysis due to lots
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of missing on many variables, which may reduce statistical power of the tests conducted.
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Nonetheless, the exclusion is not that problematic because the reason for missing data is
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random and the proportion of the exclusion is relatively small (~3%).
Our study showed that students with depressive symptoms tended to have disturbed
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eating behaviors, low body image satisfaction, low self-esteem, and high levels of stress. If
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poor lifestyle behaviors persist over a long time, the risk of metabolic syndrome and
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cardiovascular diseases may increase. If we overlook psychological and mental problems like
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depression or we do not provide adequate care for those who suffer from depression, these
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problems can lead to malnutrition, creating a vicious cycle that further exacerbates depression
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among university students. Individuals with depressive symptoms should thus be identified at
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an early stage and provided with adequate nutrition education to relieve the depressive
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symptoms and correct poor eating habits, and intervention activities to increase self-esteem
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and raise awareness about desirable weight and body image. Further well-designed large
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prospective studies using validated measurement tools for health behaviors are needed to
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investigate causal relationships between depression and lifestyle behaviors in Korean
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university students.
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Statement of authorship
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Y.S. collected data, wrote the manuscript, and contributed to the discussion and reviewed the
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manuscript. Y.J. developed study concept and design, conducted statistical analysis, wrote the
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manuscript, and reviewed/edited the manuscript. All authors have read and approved the final
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version submitted for publication.
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There are no conflicts of interest to disclose.
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Funding
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This work was supported by the Basic Science Research Program through the National
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Research Foundation of Korea, funded by the Ministry of Science, ICT and Future Planning
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(NRF-2015R1A1A1A05001362). Funders had no role in the study design, data collection and
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analysis, decision to publish, or preparation of the manuscript.
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[31] Park HR. The effect of female college student’s self-compassion, depression and anxiety on eating attitude. The study of child-family therapy. 2014;13:35-53.
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[32] Sung MH. The relationship between eating disorder and depression among college women. J Korean Acad Funda Nurs. 2004;11:59-66. [33] An SY, Oh KJ. Effect of body dissatisfaction on self-esteem and depression in binge eater group. Kor J Clin Psychol. 1995;14:29-40. [34] Kim SO, Jeon YJ. A study on relationships among university students’ selfdifferentiation, self-esteem and mental health: focused on depression and anxiety. Korean J Hum Ecol. 2013;22:539-558.
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[35] Lee SH, Kim SJ. The degree of perceived stress, depression and self-esteem of university students. J Korean Public Health Nurs. 2012;26:453-464.
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[36] Choi YK, Park JH. Evaluation of relationship between depression and anxiety, selfesteem, BMI, blood types, blood pressure of university students. Kor J Oriental Preventive Medical Society. 2013;17:99-102. [37] Kernis MH, Brockner J, Frankel BS. Self-esteem and reactions to failure: the mediating role of over generalization. Pers Soc Psychol. 1989;57:707-714.
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[38] Quick VM, Byrd-Bredbenner C. Disturbed eating behaviours and associated psychographic characteristics of college students. J Hum Nutr Diet. 2013;26:53-63. [39] Ehlingera PP, Blashill AJ. Self-perceived vs. actual physical attractiveness: associations with depression as a function of sexual orientation. J Affect Disord. 2016;189:70-76. [40] Kim HY. Lifestyle and prevalence of depression in university students. Research on student life. Studies of Life of Students. 2004;12:81-90. [41] Grosso G, Micek A, Castellano S, Pajak A, Galvano F. Coffee, tea, caffeine and risk of depression: A systematic review and dose-response meta-analysis of observational studies. Mol Nutr Food Res 2016; 60: 223-234.
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ACCEPTED MANUSCRIPT [42] Son YJ, Kim GY. The relationship between obesity, self-esteem and depressive symptoms of adult women in Korea. J Korean Soc Study Obes. 2012;21:89-98. [43] Crisp AH, McGuiness B. Relation between obesity and psychoneurosis in general population. Br Med J. 1975; 1:7-9.
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[44] de Wit LM, van Straten A, van Herten M, Penninx BW, Cuijpers P. Depression and body mass index, a u-shaped association. BMC Public Health. 2009;9:14.
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ACCEPTED MANUSCRIPT Table 1. General characteristics of study subjects. Men (N=279)
Women (N=358)
22.9 (2.2)
23.4 (2.4)
22.5 (1.9)
1st or 2nd year
245 (38.5)
111 (39.8)
134 (37.4)
≥ 3rd year
392 (61.5)
168 (60.2)
224 (62.6)
Grade, N (%)
Monthly household income (1,000 won), N (%) <1,500
24 (3.8) 114 (17.9)
3,000 to < 5,000
4 (1.4)
20 (5.6)
44 (15.8)
70 (19.6)
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1,500 to < 3,000
SC
Age (years), mean (SD)
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All subjects (N=637)
Characteristics
249 (39.1)
112 (40.1)
137 (38.3)
250 (39.3)
119 (42.7)
131 (36.6)
40 (6.3)
16 (5.7)
24 (6.7)
137 (21.5)
53 (19.0)
84 (23.5)
293 (46.0)
128 (45.9)
165 (46.1)
167 (26.2)
82 (29.4)
85 (23.7)
35 (5.5)
15 (5.4)
20 (5.6)
602 (94.5)
264 (94.6)
338 (94.4)
Body mass index (kg/m2)
21.2 (2.7)
22.6 (2.7)
20.1 (2.2)
KEAT-26
8.8 (7.5)
6.6 (6.2)
10.5 (7.9)
Self-esteem score
31.1 (4.5)
32.0 (4.3)
30.4 (4.6)
≥5,000 Monthly allowance (won), N (%)
150,000 to < 300,000 300,000 to < 500,000 ≥500,000
Illness
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No illness
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Disease status
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<150,000
Abbreviations: KEAT, Korean version of the Eating Attitudes Test; N, number; SD, standard deviation.
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ACCEPTED MANUSCRIPT Table 2. Mean score of K-BDI and prevalence of depressive symptoms. All subjects (N=637)
Men (N=279)
Women (N=358)
p-value
8.50 (7.46)
6.44 (6.48)
10.1(7.78)
<.001b
Normal (<10 points), N (%)
419 (65.8)
215 (77.1)
Mild (10-16 points), N (%)
136 (21.4)
41 (14.7)
K-BDI score,a mean (SD)
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Categories of depressive symptoms 204 (57.0) 95 (26.5)
<.001c
69 (10.8)
21 (7.5)
Severe (≥30 points), N (%)
13 (2.0)
2 (0.7)
48 (13.4)
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Moderate (17-29 points), N (%)
11 (3.1)
Fisher s exact test.
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Abbreviations: K-BDI, Korean version of the Beck Depression Inventory; N, number; SD, standard deviation a A high K-BDI score indicates a high degree of depression. b By two-sample t-test.
Table 3. Correlation of K-BDI scores among KEAT-26 scores and self-esteem scores. K-BDI score a
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KEAT-26 score b
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Spearman correlation r (p-value)
Self-esteem score c
All subjects (N=637)
Men (N=279)
Women (N=358)
0.307 (<.001)
0.155 (.010)
0.288 (<.001)
-0.450 (<.001)
-0.457 (<.001)
-0.421(<.001)
Abbreviations: K-BDI, Korean version of the Beck Depression Inventory; KEAT, Korean version of the Eating Attitudes Test; N, number a A high K-BDI score indicates a high degree of depression. b A high KEAT-26 score indicates disturbed eating behavior. c A high self-esteem score indicates a high degree of self-esteem.
ACCEPTED MANUSCRIPT
19 Table 4. K-BDI scores according to health-related variables All subjects (N=637)
Body image satisfaction
Smoking status Alcohol consumption
Exercise
Coffee consumption
Self-assessed level of life stress
Mean (SD)
91 (14.3)
9.96 (8.05)
5 (1.79)
11.6 (5.94)
18.5-22.9
405 (63.6)
8.36 (7.46)
178 (63.8)
6.67 (7.05)
≥23
141 (22.1)
7.95 (0.59)
96 (34.4)
Thin
97 (15.2)
6.73 (5.88)
Average
412 (64.7)
8.06 (7.70)
Fat
128 (20.1)
11.2 (7.04)
Dissatisfied
306 (48.0)
10.0 (7.78)
Average
228 (35.8)
7.97 (7.27)
Satisfied
103 (16.2)
5.13 (5.40)
Smokers
113 (17.7)
8.73 (8.92)
Non-smokers
524 (82.3)
8.45 (7.11)
Rarely
259 (40.7)
9.37 (7.48)
1-2 times/week
304 (47.7)
8.04 (6.99)
≥3 times/week
74 (11.6)
Rarely
Women (N=358) P valuea
N (%)
Mean (SD)
86 (24.0)
9.86 (8.17)
227 (63.4)
9.69 (7.52)
5.77 (5.16)
45 (12.6)
12.6 (8.04)
50 (17.9)
6.12 (5.99)
47 (13.1)
7.38 (5.76)
192 (68.8)
6.30 (6.71)
220 (61.5)
9.60 (8.18)
37 (13.3)
7.68 (5.83)
91 (25.4)
12.7 (7.00)
108 (38.7)
7.26 (6.33)
198 (55.3)
11.5 (8.09)
114 (40.9)
7.21 (7.25)
114 (31.8)
8.73 (7.24)
57 (20.4)
3.39 (3.68)
46 (12.9)
7.28 (6.37)
96 (34.4)
7.13 (6.71)
17 (4.8)
17.8 (13.6)
183 (65.6)
6.09 (6.33)
341 (95.3)
9.71 (7.19)
87 (31.2)
6.66 (6.93)
172 (48.0)
10.8 (7.39)
149 (53.4)
6.73 (6.48)
155 (43.3)
9.29 (7.25)
7.32 (8.86)
43 (15.4)
5.05 (5.37)
31 (8.7)
10.5 (11.5)
255 (40.0)
9.29 (7.57)
53 (19.0)
6.68 (6.00)
202 (56.4)
9.97 (7.79)
1-2 times/week
235 (36.9)
7.60 (6.66)
138 (45.9)
6.02 (5.30)
107 (29.9)
9.50 (7.60)
≥3 times/week
147 (23.1)
8.56 (8.31)
98 (35.1)
6.89 (7.98)
49 (13.7)
11.9 (8.02)
Rarely
320 (50.2)
8.17 (7.10)
162 (58.1)
6.23 (6.16)
158 (44.1)
10.2 (7.46)
1 cup/d
256 (40.2)
8.12 (6.77)
99 (35.5)
5.98 (6.24)
157 (43.9)
9.47 (6.76)
≥2cups/d
61 (9.6)
11.8 (10.7)
18 (6.5)
10.9 (8.87)
43 (12.0)
12.1 (11.5)
Almost none
93 (14.6)
4.77 (4.62)
51 (18.3)
3.51 (4.17)
42 (11.7)
6.31 (4.73)
Low
343 (53.9)
7.63 (6.91)
158 (56.6)
6.25 (6.19)
185 (51.7)
8.80 (7.29)
High
201 (31.6)
11.7 (8.19)
70 (25.1)
9.03 (7.48)
131 (36.6)
13.1 (8.23)
0.112
<.001
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N (%)
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<18.5
p valuea
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Perception of body shape
Mean (SD)
<.001
0.748
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(kg/m2)
N (%)
Men (N=279)
EP
Body mass index
Contents
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Variables
0.037
0.043
0.001
<.001
0.127
0.459
<.001
0.207
0.304
0.581
0.034
<.001
p valuea
0.068
<.001
<.001
0.004
0.229
0.185
0.136
<.001
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20 Disease status
Illness No illness
35 (5.5)
10.6 (10.6)
602 (94.5)
8.37 (7.22)
0.223
15 (5.4)
6.60 (6.93)
264 (94.6)
6.44 (6.46)
0.958
AC C
EP
TE D
M AN U
SC
By ANOVA, Kruskal Wallis test, two sample t-test or Wilcoxon rank-sum (Man-Whitney) test.
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Abbreviations: K-BDI, Korean version of the Beck Depression Inventory; N, number; SD, standard deviation a
20 (5.6)
13.7 (12.0)
338 (94.4)
9.88 (7.43)
0.079
21
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Table 5. Multivariable-adjusted prevalence odds ratios and 95% confidence intervals (CIs) of depressive symptomsa among university students Variables
Odds Ratio (95% CI)
p-value
Men
1.00 (reference)
Women
1.86 (1.26-2.76)
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Gender 0.002
Almost none
1.00 (reference)
Low High
1.94 (1.01-3.73) 4.37 (2.23-8.55)
Disturbed eating behaviorb 1.00 (reference)
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No Yes
5.14 (2.52-10.5)
Body image satisfaction Dissatisfied
Yesc
0.52 (0.34-0.79)
0.002
0.37 (0.20-0.68)
0.001
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Satisfied
No
<0.001
1.00 (reference)
Average
High self-esteem
0.046 <0.001
SC
Self-assessed level of life stress
1.00 (reference)
0.29 (0.20-0.43)
Defined as mild depressive symptoms or above (K-BDI score ≥10).
b
Defined as KEAT-26 score ≥20.
c
Defined as self-esteem score ≥30.
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EP
a
<.001
S2352-9393(17)30055-6
DOI:
10.1016/j.yclnex.2018.02.001
Reference:
YCLNEX 53
To appear in:
Clinical Nutrition Experimental
Received Date: 1 August 2017 Revised Date:
21 February 2018
Accepted Date: 23 February 2018
Please cite this article as: Seo Y, Je Y, Disturbed eating tendencies, health-related behaviors, and depressive symptoms among university students in Korea, Clinical Nutrition Experimental (2018), doi: 10.1016/j.yclnex.2018.02.001. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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Disturbed eating tendencies, health-related behaviors, and depressive symptoms among university students in Korea Running head: Factors related to depression among Korean students
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Authors: Yuri Seo and Youjin Je* (The last name of each author: Seo and Je)
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Affiliation: Department of Food and Nutrition, Kyung Hee University, Seoul, South Korea (Y.S., Y.J.)
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Corresponding author*
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Youjin Je, ScD
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Associate Professor
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Department of Food and Nutrition,
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Kyung Hee University,
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26 Kyunghee-daero, Dongdaemun-gu,
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Seoul 130-701, South Korea
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Tel: +82-2-961-0258
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Email: [email protected]
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Keywords: Depression, Disturbed eating attitude, Health behavior, Depressive symptoms,
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Korean students
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Abbreviations used in this paper:
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BMI, body mass index;
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BDI, Beck Depression Inventory;
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EAT, Eating Attitudes Test;
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RSES, Rosenberg Self-Esteem Scale;
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OR, odds ratio;
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CI, confidence interval.
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ABSTRACT
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Background and aims: There were few studies to investigate the related factors of
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depression among Korean students. Therefore, this study examined disturbed eating
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tendencies, health-related behaviors, and depressive symptoms among university students in
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Korea.
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Methods: We conducted a cross-sectional survey on a total of 637 students (279 men and 358
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women), and the Korean version of the Beck depression rating scale (K-BDI) was used to
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evaluate the students’ depression status.
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Results: Of the 637 students, 419 (65.8%) had no depressive symptoms (normal: K-
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BDI<10), whereas 136 (21.4%: K-BDI 10-16), 69 (10.8%: K-BDI 17-29), and 13 (2.0%: K-
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BDI ≥30) had mild, moderate, and severe depressive symptoms, respectively. Multivariable
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logistic regression showed that depressive symptoms (K-BDI≥10) were associated with
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female gender (odds ratio [OR] = 1.86, 95% confidence interval [CI] = 1.26 to 2.76;
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p=0.002), high level of life stress (OR = 4.37, 95% CI = 2.23 to 8.55; p<0.001), and disturbed
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eating behaviors (Korean version of Eating Attitude Test-26 ≥20; OR = 5.14, 95% CI = 2.52
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to 10.5; p<0.001). In contrast, depressive symptoms were inversely associated with a high
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body image satisfaction (OR = 0.37, 95% CI = 0.20 to 0.68; p=0.001) and self-esteem (self-
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esteem score ≥30) (OR = 0.29, 95% CI = 0.20 to 0.43; p<0.001).
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Conclusions: This study confirmed that students with depressive symptoms tended to have
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disturbed eating behaviors, low body image satisfaction, low self-esteem, and high levels of
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stress.
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ACCEPTED MANUSCRIPT Introduction
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Depression is a major contributor to the overall global burden of disease. The World Health
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Organization estimated that 322 million people live with depression worldwide. In 2015, 4.4%
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of the global population was estimated to live with depression. This figure was higher among
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women (5.1%) than men (3.6%) [1]. Between 2005 and 2015, the total estimated number of
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people with depression increased by 18.4% [2]. The prevalence of depression varies by
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country, with a rate of 4.2% in Japan and China, compared to 5.9% in the United States. In
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Korea, the prevalence of depression was 4.1% in 2015 and was more prevalent among
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women (4.8%) than men (3.4%) [3]. Although the prevalence of depression in Asian
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countries is lower than in Europe or America, the number of patients treated for depression in
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Korea exceeded 601,152 in 2015, representing an increase of 12.4% from 2011 [4].
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Depression has been associated with poor interpersonal relations, impaired memory, and, in extreme cases, suicide. In addition, depression and depressive symptoms are
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associated with undesirable lifestyle factors, such as physical inactivity, sedentary behavior,
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and poor dietary habits [5-8]. Several studies also associated depression and depressive
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symptoms with an increased risk of metabolic syndrome [9, 10], cardiovascular disease [11,
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12], and their risk factors [13].
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In Korea, the prevalence of depression was 4.9 % in the 20-24 years, which was
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much higher in females (6.4%) than males (3.5%) in 2015, and the prevalence has been
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steadily increased for the past decade [14]. Many college students in Korea are under
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significant stress due to job-seeking [15], which may affect their depressive symptoms and
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overall health. People with depressive symptoms in their twenties or younger may have a
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higher risk of cardiovascular disease and related diseases due to their disturbed eating
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behaviors and poor nutritional status. Nutrition interventions are therefore critical to treat
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people with depressive symptoms. Few studies have investigated depression among Korean
4
ACCEPTED MANUSCRIPT university students using validated measurement tools to identify related factors. We
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conducted a cross-sectional survey of university students in Korea to examine their eating
95
attitudes, health-related behaviors, and depression status and to explore the associations of
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these variables among the students. Given the increasing prevalence of depression in Korea,
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it is important to identify subjects with depressive symptoms at an early stage and provide
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them with targeted nutrition education intervention.
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Methods
101
Participants and study design
102
This study was a cross-sectional survey. The participants were selected by convenient
103
purposive sampling of students attending universities in Seoul, South Korea. The survey used
104
questionnaires and was conducted from March 10 to April 10, 2014. Twenty-three students
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with incomplete questionnaires were excluded. In total, 637 students (279 men, 358 women)
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were included. The Kyung Hee University Institutional Review Board approved this study for
107
exemption review (KHSIRB-14-005[EA]).
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Study contents
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The questionnaire included questions regarding general and health-related characteristics,
111
eating attitudes, self-esteem, and depression assessment.
112 113
General and health-related characteristics
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The general characteristics of participants included their gender, age, grade, monthly
115
household income, and monthly allowance. The health-related characteristics included the
116
participants’ height, weight, perception of body shape, body image satisfaction, smoking
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status, alcohol consumption, exercise, coffee consumption, self-assessed level of life stress,
118
and disease status. The body mass index (BMI, kg/m2) was calculated from the reported
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ACCEPTED MANUSCRIPT height and weight of participants. Using the Asia-Pacific Perspective (2000) selected by the
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Korean Society for the Study of Obesity, the BMI was classified into underweight (<18.5),
121
normal weight (18.5 to 22.9), and overweight/obese (≥23) [16].
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Depression
124
The depression status of subjects was measured using a validated Korean version of the Beck
125
Depression Inventory (K-BDI), modified by Hahn et al. [17] from the original version by
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Beck et al. [18] The K-BDI was composed of 21 questions, each with a score of 0, 1, 2, or 3.
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The total scores of K-BDI ranged from 0 to 63. A higher score indicated more severe
128
depressive symptoms. In this study, scores of 0 to 9 were defined as normal, and scores of 10
129
to 15, 16 to 23, and 24 and above were defined as mild, moderate, and severe depressive
130
symptoms, respectively [19]. The Cronbach’s alpha for internal consistency or reliability of
131
this test was 0.90.
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Eating attitudes
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Eating attitudes were measured using a validated Korean version of the Eating Attitudes Test-
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26 (KEAT-26), modified by Rhee et al. [20] from the original version by Garner et al. [21].
136
The KEAT-26 is composed of 26 questions, each with a score of 0, 1, 2, or 3. The total scores
137
of the KEAT-26 range from 0 to 78. A higher score indicates more abnormal eating attitudes
138
and behaviors. In this study, scores of 20 or more indicated disturbed eating behavior [22,
139
23]. The Cronbach’s alpha of this test was 0.84.
140 141 142
Self-esteem
143
Self-esteem was measured using a validated Korean version of the Rosenberg Self-Esteem
144
Scale (K-RSES), modified by Jeon [24] from the original version by Rosenberg [25]. This
145
tool incorporates five positive and five negative questions, with each question scored by the
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Likert 4-point scale. The total scores for the K-RSES range from 10 to 40. In this study,
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scores of 30 or more indicated relatively high self-esteem [26]. The Cronbach’s alpha of this
148
test was 0.82.
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Statistical analysis
151
The data was analyzed using STATA software (v14.2, Stata Corporation, College Station,
152
TX). Two sample t-tests (or Mann-Whitney test) and analysis of variance (or Kruskal-Wallis
153
test) were used to compare the K-BDI scores among the groups. For categorical data, chi-
154
square tests (or Fisher’s exact test) were used to compare the differences in frequency among
155
the groups. We also used a general linear model to examine the difference in the scores for
156
eating attitudes according to depression status, after adjusting for gender. To test the
157
association of K-BDI scores among KEAT-26 and K-RSES scores, we carried out the
158
Spearman correlation analysis. To determine factors related to depression (K-BDI≥10), we
159
performed a multivariable logistic regression analysis and calculated adjusted odds ratios
160
(ORs) and 95% confidence intervals (CIs). For the consistency of the questionnaire,
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Cronbach’s alpha values were used to evaluate the K-BDI, KEAT-26, and K-RSES.
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Results
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Table 1 shows the characteristics of the sample. In total, 358 students (56.2%) were women
165
and 392 (61.5%) were in their third or fourth year of university. As for monthly household
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income, 249 students’ families (39.1%) earned 3 to 5 million won a month and 250 families
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(39.3%) earned more than 5 million won a month. In terms of monthly allowance, 293
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students (46.0%) spent 200,000 to 500,000 won a month, and 167 students (26.2%) spent
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more than 500,000 won a month. In terms of disease status, most students (94.5%) reported
170
that they had no illness. The participants’ mean BMI was 21.2 kg/m2. The mean scores of
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KEAT-26 and self-esteem were 8.78 and 31.1, respectively. Table 2 shows the participants’ degree of depression. The K-BDI score ranged from 0 to 57, with a mean of 8.50. The K-BDI score was significantly higher among women than
174
men (10.1 vs 6.44, p<.001). According to the K-BDI scores, participants were categorized
175
into four groups: normal (<10), mild (10 to 16), moderate (17 to 29), and severe (≥30). The
176
results showed that 419 participants (65.8%) were in the normal group, 136 (21.4%) were in
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the mild depression group, 69 (10.8%) were in the moderate depression group, and 13 (2.0%)
178
were in the severe depression group. For men, 215 (77.1%) had no depressive symptoms
179
(normal), whereas 41 (14.7%) had mild depressive symptoms and 23 (8.2%) had moderate or
180
severe depressive symptoms. For women, 204 (57.0%) had no depressive symptoms, whereas
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95 (26.5%) had mild depressive symptoms and 59 (16.5%) had moderate or severe depressive
182
symptoms. The degree of depression differed significantly according to the participants’
183
gender (p<.001).
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To examine the association of K-BDI scores among KEAT-26 scores and self-esteem scores, we carried out the Spearman correlation analysis (Table 3). There was a positive
186
correlation between K-BDI and KEAT-26 scores (r = 0.307, p<.001) and a negative
187
correlation between K-BDI and self-esteem scores (r = -0.45, p<.001). Table 4 shows K-BDI scores according to health-related variables. We found an
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185
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inverse association between K-BDI scores and body image satisfaction in both men and
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women. For body image, the highest K-BDI score was in the ‘dissatisfied’ group and the
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lowest K-BDI score was in the ‘satisfied’ group (p<.001). In addition, there was a positive
192
association between K-BDI scores and the reported level of life stress in both men and
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women. The highest K-BDI score was in the group with a high level of life stress, and the
194
lowest K-BDI score in the group who had almost no life stress (p<.001). Among the health-
195
related variables, the perception of body shape positively correlated with the K-BDI score in
8
ACCEPTED MANUSCRIPT women only. The K-BDI score of those who perceived themselves as fat was significantly
197
higher than that in the other groups (p<.001). In contrast, coffee consumption positively
198
correlated with the K-BDI score in men only. The group that consumed two or more cups of
199
coffee per day had a higher K-BDI score than the other groups of men (p = 0.034). For
200
exercise and alcohol consumption, the K-BDI scores differed significantly among the groups,
201
but the significance disappeared when stratified by gender. For smoking status, female
202
smokers had a significantly higher K-BDI score than non-smokers, whereas the difference
203
was not significant in men. For BMI, women who were overweight or obese (BMI ≥ 23
204
kg/m2) had a higher K-BDI score than those with normal weight or underweight, but the
205
difference was not significant (p = 0.068).
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206
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196
Table 5 shows the results of the multivariable-adjusted logistic regression of factors related to depressive symptoms. Significant associations were seen between depressive
208
symptoms and gender, life stress, disturbed eating behavior, body image satisfaction, and
209
self-esteem (p<.05). Female gender (OR = 1.86, 95% CI = 1.26 to 2.76; p = 0.002), high level
210
of life stress (OR = 4.37, 95% CI = 2.23 to 8.55; p<.001), and disturbed eating behavior (OR
211
= 5.14, 95% CI = 2.52 to 10.5; p<.001) were positively associated with depressive symptoms.
212
In contrast, a high level of body image satisfaction (OR = 0.37, 95% CI = 0.20 to 0.68; p =
213
0.001) and high self-esteem (OR = 0.29, 95% CI = 0.20 to 0.43; p<.001) were inversely
214
associated with depressive symptoms.
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216
Discussion
217
In this study, women had a significantly higher mean K-BDI depression score than men. We
218
found that university students with depressive symptoms in Korea tended to have disturbed
219
eating behavior, low body image satisfaction, low self-esteem, and high level of stress.
220
The results were consistent with previous studies which also found the prevalence of
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ACCEPTED MANUSCRIPT depression to be higher in women than men [27-29]. These findings seem to be explained by
222
the tendency of women to be more emotionally sensitive than men [30]. In terms of the
223
relationship between disturbed eating behavior, self-esteem, and depression, we found that
224
the more severe the depressive symptoms, the greater the risk of disturbed eating behavior
225
(p<.001). Similarly, the more severe the depressive symptoms the lower the self-esteem
226
(p<.001). These results were similar to those of previous studies, which showed that disturbed
227
eating behavior was positively associated with depression [31-33] and that self-esteem was
228
inversely associated with depression [34-37].
SC
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We also found some associations between depressive symptoms and health-related
230
variables. In this study, body image satisfaction and life stress were significantly associated
231
with depressive symptoms in both men and women. There was an inverse association
232
between body image satisfaction and depressive symptoms, and people who were not
233
satisfied with their body image had a higher depression score than those who were satisfied
234
with their body image. College students are reported to have greater concerns about their
235
body shape and weight [38]. Previous studies have shown that a negative self-evaluation of
236
appearance was a notable risk factor for college students to suffer from depression. Likewise,
237
studies have found that a high level of life stress was positively associated with depression
238
[39]. In Korea, many college students are under significant stress. Above all, stress due to
239
job-seeking accounts for a great part of life stress among Korean college students. The
240
National Statistical Office of Korea, for instance, stated that nine out of 10 college students
241
are under stress due to job-seeking [15]. Anxiety associated with job seeking may thus affect
242
levels of depression among college students in Korea. In this study, there was a positive
243
association between coffee consumption and depression. This finding was similar to Kim’s
244
study, which found that the frequency of coffee intake increased among university students
245
with depression symptoms [40]. A recent meta-analysis of epidemiological studies suggested
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a non-linear J-shaped relation between coffee consumption and risk of depression with a peak
247
of inverse association for 400 mL/day, which was stable toward slight increase for higher
248
intakes [41]. In the multivariable analysis of our study, there was no association between
249
coffee consumption and depressive symptoms. Alcohol drinking and exercise were inversely
250
associated with depression in this study, but disappeared when the data were analyzed for
251
gender. This may be because the proportion of women was higher in the group who rarely
252
drank alcohol or exercised. In our study, we found no significant associations between
253
depression and BMI. This is in contrast to other studies, such as Son et al., which found that
254
the prevalence of depressive symptoms was significantly higher in overweight groups than
255
other groups (p=0.009) [42]. Other studies have also found significant associations between
256
depression and obesity [43, 44]. However, there was a suggestive association between BMI
257
and depression in women (p=0.068). When we re-categorized the BMI variable into two
258
groups (BMI<23, ≥23) rather than 3 groups, we found a significant association between BMI
259
and depression in women (p=0.016, data not shown) indicating that overweight women
260
(BMI≥23) had a higher depression score than non-overweight women.
SC
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To determine factors related to depressive symptoms and quantify the associations
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261
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246
with depressive symptoms after multivariable adjustment, we conducted a logistic regression
263
analysis. This showed that depressive symptoms were positively associated with female
264
gender, high levels of life stress and disturbed eating behavior, and were inversely associated
265
with body image satisfaction and high self-esteem among university students. The BMI
266
variable was positively associated with depression when the variable was included as a
267
continuous variable in the multivariable model. The significance, however, disappeared when
268
the variable of body image satisfaction was added in the model.
269 270
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Our study has several limitations. This study is a cross-sectional design, which is likely to suffer of reverse causation, and thus it is not possible to identify whether the variable
11
ACCEPTED MANUSCRIPT of interest determines the outcome or the opposite. In addition, although we used the
272
validated FFQ to assess depression status, for measurement of health behaviors, validated
273
questionnaires were not used. Lastly, we excluded a few subjects from the analysis due to lots
274
of missing on many variables, which may reduce statistical power of the tests conducted.
275
Nonetheless, the exclusion is not that problematic because the reason for missing data is
276
random and the proportion of the exclusion is relatively small (~3%).
Our study showed that students with depressive symptoms tended to have disturbed
SC
277
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271
eating behaviors, low body image satisfaction, low self-esteem, and high levels of stress. If
279
poor lifestyle behaviors persist over a long time, the risk of metabolic syndrome and
280
cardiovascular diseases may increase. If we overlook psychological and mental problems like
281
depression or we do not provide adequate care for those who suffer from depression, these
282
problems can lead to malnutrition, creating a vicious cycle that further exacerbates depression
283
among university students. Individuals with depressive symptoms should thus be identified at
284
an early stage and provided with adequate nutrition education to relieve the depressive
285
symptoms and correct poor eating habits, and intervention activities to increase self-esteem
286
and raise awareness about desirable weight and body image. Further well-designed large
287
prospective studies using validated measurement tools for health behaviors are needed to
288
investigate causal relationships between depression and lifestyle behaviors in Korean
289
university students.
290 291
Statement of authorship
292
Y.S. collected data, wrote the manuscript, and contributed to the discussion and reviewed the
293
manuscript. Y.J. developed study concept and design, conducted statistical analysis, wrote the
294
manuscript, and reviewed/edited the manuscript. All authors have read and approved the final
295
version submitted for publication.
296 297
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ACCEPTED MANUSCRIPT Conflict of interest
299
There are no conflicts of interest to disclose.
300 301
Funding
302
This work was supported by the Basic Science Research Program through the National
303
Research Foundation of Korea, funded by the Ministry of Science, ICT and Future Planning
304
(NRF-2015R1A1A1A05001362). Funders had no role in the study design, data collection and
305
analysis, decision to publish, or preparation of the manuscript.
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ACCEPTED MANUSCRIPT References
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[27] Ko BJ, Chun EJ, Bae YY, Lee JH, Park KA, Jang MJ, et al. Depressive symptoms in a rural community: prevalence and related risk factors. Korean J Health Promot Dis Prev. 2008; 8:228-234. [28] Lee KH. The depression scales and the college students’ health care. J Korean Community Nurs. 1997;8:144-154.
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[29] Son YJ, Kim GY. The relationship between obesity, self-esteem and depressive symptoms of adult women in Korea. J Korean Soc Study Obes. 2012; 21:89-98.
[30] Sung MJ, Chang KJ. Correlations among life stress, dietary behaviors and food choice of college students. J East Asian Soc Diet Life. 2006;16:655-662.
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[31] Park HR. The effect of female college student’s self-compassion, depression and anxiety on eating attitude. The study of child-family therapy. 2014;13:35-53.
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[38] Quick VM, Byrd-Bredbenner C. Disturbed eating behaviours and associated psychographic characteristics of college students. J Hum Nutr Diet. 2013;26:53-63. [39] Ehlingera PP, Blashill AJ. Self-perceived vs. actual physical attractiveness: associations with depression as a function of sexual orientation. J Affect Disord. 2016;189:70-76. [40] Kim HY. Lifestyle and prevalence of depression in university students. Research on student life. Studies of Life of Students. 2004;12:81-90. [41] Grosso G, Micek A, Castellano S, Pajak A, Galvano F. Coffee, tea, caffeine and risk of depression: A systematic review and dose-response meta-analysis of observational studies. Mol Nutr Food Res 2016; 60: 223-234.
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ACCEPTED MANUSCRIPT Table 1. General characteristics of study subjects. Men (N=279)
Women (N=358)
22.9 (2.2)
23.4 (2.4)
22.5 (1.9)
1st or 2nd year
245 (38.5)
111 (39.8)
134 (37.4)
≥ 3rd year
392 (61.5)
168 (60.2)
224 (62.6)
Grade, N (%)
Monthly household income (1,000 won), N (%) <1,500
24 (3.8) 114 (17.9)
3,000 to < 5,000
4 (1.4)
20 (5.6)
44 (15.8)
70 (19.6)
M AN U
1,500 to < 3,000
SC
Age (years), mean (SD)
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All subjects (N=637)
Characteristics
249 (39.1)
112 (40.1)
137 (38.3)
250 (39.3)
119 (42.7)
131 (36.6)
40 (6.3)
16 (5.7)
24 (6.7)
137 (21.5)
53 (19.0)
84 (23.5)
293 (46.0)
128 (45.9)
165 (46.1)
167 (26.2)
82 (29.4)
85 (23.7)
35 (5.5)
15 (5.4)
20 (5.6)
602 (94.5)
264 (94.6)
338 (94.4)
Body mass index (kg/m2)
21.2 (2.7)
22.6 (2.7)
20.1 (2.2)
KEAT-26
8.8 (7.5)
6.6 (6.2)
10.5 (7.9)
Self-esteem score
31.1 (4.5)
32.0 (4.3)
30.4 (4.6)
≥5,000 Monthly allowance (won), N (%)
150,000 to < 300,000 300,000 to < 500,000 ≥500,000
Illness
AC C
No illness
EP
Disease status
TE D
<150,000
Abbreviations: KEAT, Korean version of the Eating Attitudes Test; N, number; SD, standard deviation.
18
ACCEPTED MANUSCRIPT Table 2. Mean score of K-BDI and prevalence of depressive symptoms. All subjects (N=637)
Men (N=279)
Women (N=358)
p-value
8.50 (7.46)
6.44 (6.48)
10.1(7.78)
<.001b
Normal (<10 points), N (%)
419 (65.8)
215 (77.1)
Mild (10-16 points), N (%)
136 (21.4)
41 (14.7)
K-BDI score,a mean (SD)
RI PT
Categories of depressive symptoms 204 (57.0) 95 (26.5)
<.001c
69 (10.8)
21 (7.5)
Severe (≥30 points), N (%)
13 (2.0)
2 (0.7)
48 (13.4)
SC
Moderate (17-29 points), N (%)
11 (3.1)
Fisher s exact test.
TE D
c
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Abbreviations: K-BDI, Korean version of the Beck Depression Inventory; N, number; SD, standard deviation a A high K-BDI score indicates a high degree of depression. b By two-sample t-test.
Table 3. Correlation of K-BDI scores among KEAT-26 scores and self-esteem scores. K-BDI score a
AC C
KEAT-26 score b
EP
Spearman correlation r (p-value)
Self-esteem score c
All subjects (N=637)
Men (N=279)
Women (N=358)
0.307 (<.001)
0.155 (.010)
0.288 (<.001)
-0.450 (<.001)
-0.457 (<.001)
-0.421(<.001)
Abbreviations: K-BDI, Korean version of the Beck Depression Inventory; KEAT, Korean version of the Eating Attitudes Test; N, number a A high K-BDI score indicates a high degree of depression. b A high KEAT-26 score indicates disturbed eating behavior. c A high self-esteem score indicates a high degree of self-esteem.
ACCEPTED MANUSCRIPT
19 Table 4. K-BDI scores according to health-related variables All subjects (N=637)
Body image satisfaction
Smoking status Alcohol consumption
Exercise
Coffee consumption
Self-assessed level of life stress
Mean (SD)
91 (14.3)
9.96 (8.05)
5 (1.79)
11.6 (5.94)
18.5-22.9
405 (63.6)
8.36 (7.46)
178 (63.8)
6.67 (7.05)
≥23
141 (22.1)
7.95 (0.59)
96 (34.4)
Thin
97 (15.2)
6.73 (5.88)
Average
412 (64.7)
8.06 (7.70)
Fat
128 (20.1)
11.2 (7.04)
Dissatisfied
306 (48.0)
10.0 (7.78)
Average
228 (35.8)
7.97 (7.27)
Satisfied
103 (16.2)
5.13 (5.40)
Smokers
113 (17.7)
8.73 (8.92)
Non-smokers
524 (82.3)
8.45 (7.11)
Rarely
259 (40.7)
9.37 (7.48)
1-2 times/week
304 (47.7)
8.04 (6.99)
≥3 times/week
74 (11.6)
Rarely
Women (N=358) P valuea
N (%)
Mean (SD)
86 (24.0)
9.86 (8.17)
227 (63.4)
9.69 (7.52)
5.77 (5.16)
45 (12.6)
12.6 (8.04)
50 (17.9)
6.12 (5.99)
47 (13.1)
7.38 (5.76)
192 (68.8)
6.30 (6.71)
220 (61.5)
9.60 (8.18)
37 (13.3)
7.68 (5.83)
91 (25.4)
12.7 (7.00)
108 (38.7)
7.26 (6.33)
198 (55.3)
11.5 (8.09)
114 (40.9)
7.21 (7.25)
114 (31.8)
8.73 (7.24)
57 (20.4)
3.39 (3.68)
46 (12.9)
7.28 (6.37)
96 (34.4)
7.13 (6.71)
17 (4.8)
17.8 (13.6)
183 (65.6)
6.09 (6.33)
341 (95.3)
9.71 (7.19)
87 (31.2)
6.66 (6.93)
172 (48.0)
10.8 (7.39)
149 (53.4)
6.73 (6.48)
155 (43.3)
9.29 (7.25)
7.32 (8.86)
43 (15.4)
5.05 (5.37)
31 (8.7)
10.5 (11.5)
255 (40.0)
9.29 (7.57)
53 (19.0)
6.68 (6.00)
202 (56.4)
9.97 (7.79)
1-2 times/week
235 (36.9)
7.60 (6.66)
138 (45.9)
6.02 (5.30)
107 (29.9)
9.50 (7.60)
≥3 times/week
147 (23.1)
8.56 (8.31)
98 (35.1)
6.89 (7.98)
49 (13.7)
11.9 (8.02)
Rarely
320 (50.2)
8.17 (7.10)
162 (58.1)
6.23 (6.16)
158 (44.1)
10.2 (7.46)
1 cup/d
256 (40.2)
8.12 (6.77)
99 (35.5)
5.98 (6.24)
157 (43.9)
9.47 (6.76)
≥2cups/d
61 (9.6)
11.8 (10.7)
18 (6.5)
10.9 (8.87)
43 (12.0)
12.1 (11.5)
Almost none
93 (14.6)
4.77 (4.62)
51 (18.3)
3.51 (4.17)
42 (11.7)
6.31 (4.73)
Low
343 (53.9)
7.63 (6.91)
158 (56.6)
6.25 (6.19)
185 (51.7)
8.80 (7.29)
High
201 (31.6)
11.7 (8.19)
70 (25.1)
9.03 (7.48)
131 (36.6)
13.1 (8.23)
0.112
<.001
RI PT
N (%)
SC
<18.5
p valuea
M AN U
Perception of body shape
Mean (SD)
<.001
0.748
TE D
(kg/m2)
N (%)
Men (N=279)
EP
Body mass index
Contents
AC C
Variables
0.037
0.043
0.001
<.001
0.127
0.459
<.001
0.207
0.304
0.581
0.034
<.001
p valuea
0.068
<.001
<.001
0.004
0.229
0.185
0.136
<.001
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20 Disease status
Illness No illness
35 (5.5)
10.6 (10.6)
602 (94.5)
8.37 (7.22)
0.223
15 (5.4)
6.60 (6.93)
264 (94.6)
6.44 (6.46)
0.958
AC C
EP
TE D
M AN U
SC
By ANOVA, Kruskal Wallis test, two sample t-test or Wilcoxon rank-sum (Man-Whitney) test.
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Abbreviations: K-BDI, Korean version of the Beck Depression Inventory; N, number; SD, standard deviation a
20 (5.6)
13.7 (12.0)
338 (94.4)
9.88 (7.43)
0.079
21
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Table 5. Multivariable-adjusted prevalence odds ratios and 95% confidence intervals (CIs) of depressive symptomsa among university students Variables
Odds Ratio (95% CI)
p-value
Men
1.00 (reference)
Women
1.86 (1.26-2.76)
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Gender 0.002
Almost none
1.00 (reference)
Low High
1.94 (1.01-3.73) 4.37 (2.23-8.55)
Disturbed eating behaviorb 1.00 (reference)
M AN U
No Yes
5.14 (2.52-10.5)
Body image satisfaction Dissatisfied
Yesc
0.52 (0.34-0.79)
0.002
0.37 (0.20-0.68)
0.001
TE D
Satisfied
No
<0.001
1.00 (reference)
Average
High self-esteem
0.046 <0.001
SC
Self-assessed level of life stress
1.00 (reference)
0.29 (0.20-0.43)
Defined as mild depressive symptoms or above (K-BDI score ≥10).
b
Defined as KEAT-26 score ≥20.
c
Defined as self-esteem score ≥30.
AC C
EP
a
<.001