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Gender differences in the relationship of lifestyle and depressive symptoms among Taiwanese older people
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Collegian (2015) xxx, xxx—xxx
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Gender differences in the relationship of lifestyle and depressive symptoms among Taiwanese older people Shu-Hung Chang, PhD, RN a,∗, Miao-Chuan Chen, MSN, RN a,1, Nai-Hui Chien, MSN, RN a,2, Tzu-Yung Lin, PhD a,3, Yi-Ya Chang, MSc, RN a,b,4 a
Department of Nursing, Chang Gung University of Science and Technology, Guishan Dist., Taoyuan City 33303, Taiwan b Graduate Institute of Nursing, National Taiwan University, Taiwan Received 7 October 2014; received in revised form 24 March 2015; accepted 18 April 2015
KEYWORDS Gender differences; Depressive symptoms; Lifestyle; Taiwan; Older people
Summary Background: Aging is a major risk for health issues, and it may relate to chronic illness, physical function degradation, and mental dysfunction. One of the critical health concerns is depressive disorders. However, very few studies examining depression among older people have focused on the combinations of different lifestyle factors. Objectives: To examine the association between lifestyles and depressive symptoms in gender differences among older people in Taiwan. Methods: A cross-sectional study and interviews were conducted to collect information. The participants were selected by using a probability proportional to size procedure. The participants (n = 1020) were community-dwelling adults who were aged 65 and older living in northern Taiwan. The list of items such as demographic characteristics, lifestyles, and depressive symptoms originated from the Center for Epidemiologic Studies Depression scale (CES-D) were applied for the interview in this study. This study used chi-square, t-test, and logistic regression to analysis the data. Results: Men who exercised regularly and consumed enough vegetables had low depressive symptoms scores; women who exercised regularly had low depressive symptoms scores.
∗
Corresponding author at: Department of Nursing, Chang Gung University of Science and Technology, 261 Wen-Hwa 1st Road, Kwei-Shan, Taoyuan 333, Taiwan. Tel.: +886 3 2118999x3239/2 28806360/939701790; fax: +886 3 2118866. E-mail addresses: [email protected], [email protected] (S.-H. Chang), [email protected] (M.-C. Chen), [email protected] (N.-H. Chien), [email protected] (T.-Y. Lin), [email protected] (Y.-Y. Chang). 1 Tel.: +886 3 2118999x3238. 2 Tel.: +886 3 2118999x3232. 3 Tel.: +886 3 2118999x5728. 4 Tel.: +886 3 2118999x3222. http://dx.doi.org/10.1016/j.colegn.2015.04.005 1322-7696/© 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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S.-H. Chang et al. Conclusion: Regular exercise and eating enough vegetables are important factors associated with depressive symptoms for men; regular exercise is an important factor associated with depressive symptoms for women. The study suggests that senior citizens need to be encouraged to exercise regularly and get enough vegetable consumption to promote good mental health. © 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction It was estimated that people 65 years of age or older will constitute 22.5% of the total population in Taiwan by 2028 (Health Promotion Administration, 2011), and Taiwan will become one of aging societies in the world. Aging is a major risk for health issues, and it may relate to chronic illness, physical function degradation, and mental dysfunction. One of the critical health concerns is depressive disorders. The estimation of disability adjusted life years (DALY) for depressive disorders increased 37.5% between 1990 and 2010. In the year 2010, depressive disorder accounted for 3.0% of 2.5 billion DALY, population growth and aging were accounted for the increase of DALY (Ferrari et al., 2013). According to some previous studies on communitydwelling elders, the prevalence rates of depression were 11—44% in the United States of America (Blazer, Burchett, Service, & George, 1991; Blazer et al., 1988; Harwood, Barker, Ownby, Mullan, & Duara, 1999; Pettit et al., 2008), 12.9% in Japan (Aihara, Minai, Aoyama, & Shimanouchi, 2011), and 21—40% in Taiwan (Lin, Chen, & Lin, 2010; Lin, Yang, & Yang, 2010; Lyu & Lin, 2000). Lifestyle is an umbrella term which encompasses various elements such as exercise, diet, and smoking; several factors are found to associate with depressive symptoms in older people. Nevertheless, most researchers analyzed only the correlations between demographic characteristics and depressive symptoms. For instance, older people with low level of education, widows, widowers, and female were more likely to experience depression (Greer & Trivedi, 2009; Lin, Yang, et al., 2010b; Pettit et al., 2008). Some other research results showed depression in terms of its relationship to physical function, chronic disease, and pressure (Forlani et al., 2013; Katsumata et al., 2005). Yet, recent studies that have reviewed the correlation between lifestyle factors and depression are receiving more attentions than before (Gariballa & Forster, 2007; Greer & Trivedi, 2009; Hodge, Osvaldo, Dallas, Graham, & Flicker, 2013; Lin, Yang, et al., 2010; Pettit et al., 2008). Many studies indicated that exercise can help to reduce depressive symptoms (Greer & Trivedi, 2009; Lin, Chen, et al., 2010; Lin, Yang, et al., 2010; Pettit et al., 2008). Moreover, the higher rate of fish and fruit consumption was associated with a lower rate of depressive symptoms (Barberger-Gateau et al., 2005; Hodge et al., 2013). However, most research topics still primarily targeted on the connection between physical activity and depression or the connection between diet and depression. Very few studies examining depression have focused on the combinations of different lifestyle factors. To identify and develop effective interventions, it would be significant to evaluate the relationships between depression and the combinations of different lifestyle behaviors.
Several studies applied gender as an independent variable into the research design to examine if any critical difference could be discovered (Greer & Trivedi, 2009; Lin, Chen, et al., 2010; Lin, Yang, et al., 2010; Pettit et al., 2008). Some studies focused on the differences of prevalence of depressive symptoms and various signs of depressive symptoms among older males and females (Escobar Bravo, Botigué Satorra, Jürschik Giménez, Nuin Orrio, & Blanco Blanco, 2013; Forlani et al., 2013). Others studies discussed the differences of demographic characteristics (e.g. education level, marital status) and health status related of depressive symptoms among older men and women (Forlani et al., 2013; Jang, Kim, & Chiriboga, 2011). But mechanisms underlying the gender differences remain unclear. Until today, very few studies have analyzed the cause and effect relationship between different lifestyle factors and depressive symptoms by gender. Therefore, this study aims to investigate the association between the combination of lifestyles and depressive symptoms in gender differences among older people in Taiwan.
2. Subjects and methods 2.1. Design and sample A cross-sectional survey was conducted to collect data on lifestyle variables including regular exercise (maintaining 20 min, heart rate above130 beats/min and sweating at 3 times a week for one half hour), dietary habits, smoking, and other relevant factors influencing the depressive symptoms in older individuals. Trained interviewers conducted face-to-face interviews and collected the data during August and October 2011. This study was approved by the Medical Foundation Institutional Review Board. Individual written consents of participants were obtained before the interviews. We used probability proportional to size sampling procedure to choose community-dwelling adults who were 65 years and older in northern Taiwan. The Primary Sampling Units were townships and the Secondary Sampling Units were villages (Taiwan National Health Research Institutes, 2001). The Basic Sampling Units were community-dwelling elders. The head officers from each village helped to recruit villagers to join this research survey. Older people who were over 65 years old living in northern Taiwan community-dwelling were included, and those who could not communicate orally were excluded. In 2011, older male to female ratio was 1.04:1 (Taoyuan County Government, 2014). At first, 539 male participants and 561 female potential participants were selected from 1100 participants. As a result, among 1020 participants, 454 men and 566 women
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Lifestyle and depressive symptoms by gender in community-dwelling elders completed the questionnaires. Six interviewers were well trained prior to the research and the inter-rater reliability was 0.90.
2.2. Measures Demographic variables included occupations, gender, levels of education, age, and marital status.
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Administration, 2011) in 5-point Likert scale, (1) Do you avoid excess salt and fat? (2) Do you eat appropriate proteins daily (less than 60 grams of protein)? (3) Do you eat enough vegetables daily (at least 1.5 bowls of cooked vegetables)? (4) Do you eat enough fruits daily (at least two kinds of fruit)? (5) Do you consume milk products daily (at least one to two glasses of milk)?
2.5. Health status 2.3. Depressive symptoms The study used the brief self-report 10-item CES-D, which were adapted from the 20-item version of Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977). CES-D has been widely used to measure the degree of depressive symptoms in community older residents (Chien & Cheng, 1985; Lin, Chen, et al., 2010; Lin, Yang, et al., 2010). The sensitivity and specificity were 92.0% and 91.0% respectively, while the positive predictive value was 67.7% in Taiwanese community sample (Chien & Cheng, 1985). The 10-item version has been administrated repeatedly in the Taiwan Longitudinal Study on Aging (TLSA). Subscale Somatic Symptoms, Depressed Affect, and Positive Affect were found among older adults in Taiwan (Lee, Ou, Chen, & Weng, 2009). This short form showed good internal consistency reliability and validity (Lee et al., 2009). The scores ranged from 0 to 30, and the cut-off point for the prevalence of depression in the present study was above 8 according to previous study (Lin, Yang, et al., 2010).
2.4. Lifestyles To assess participants’ lifestyles during last six months before the interview, the participants were asked to describe their lifestyles by using a recall method based on a structured questionnaire including the following items: Exercise: there were two questions to assess regular exercise behaviors; (1) Do you exercise regularly in the past six months (maintain 20 min, heart rate above 130 beats/min and sweating)? (yes/no); (2) How often is it? (If yes, provide the time period). The respondent who exercised three or more times a week was defined as a regular exerciser. This questionnaire was based on Gionet and Godin’s questionnaire sample. In Gionet and Godin’s research, they found simple question of regular exercise was significantly relevant to vigorous physical activity time (Gionet & Godin, 1989). The relationship factor between self-report exercise behavior and a 12-min walk-run test was 0.54 (Martin et al., 1984). It showed simple self-reported exercise was valid. Our study in self-reported regular exercise time and vigorous physical activity time were relevant. Smoking habits: (1) Do you smoke now? (Never, I used to smoke but quitted already, current smoking) (2) If yes, how many cigarettes do you smoke per day? Drinking habits: (1) Do you drinking now? (Never, I used to drink but quitted already, current drinking) (2) If yes, how many drinks do you have per day? Dietary habits: the following five questions derived from National Dietary Guidelines in Taiwan (Food and Drug
Subjects were asked to report their health status by good, fair or poor.
2.6. Analytic strategy The data was analyzed using SPSS software 18.0 (SPSS Inc., Chicago, IL, USA). Chi-square tests and t-tests were applied to exam the correlations between lifestyles and gender. Logistic regression analyses were adapted to estimate the effect of lifestyles on depressive symptoms. The variables were entered as a dichotomous variable (yes vs. no) in the logistic regression equations.
3. Results The demographic characteristics, lifestyles, and depressive symptoms by gender are shown in Table 1. The average ages of the subjects were 75.92 years old for men and 73.98 years old for women. More than two thirds of the participants completed only elementary school or did not graduate from elementary school. The majority of the subjects were married. Over half of the subjects reported that their health status was good. 36.6% of men and 36.9% of women exercised regularly. The prevalence rates of depressive symptoms were 21.3%, 20.5%, and 21.9% for all subjects, men and women respectively. Near 60% of the subjects reported their dietary behaviors of avoiding excess amount of salt and fat; they also ate enough vegetables and fruits. 41.4% of men and 45.4% of women consumed enough milk products daily. Bivariate analyses showed significant differences between gender and following factors: age, education, eating enough protein, and smoking. In this study, only ten participants (eight males and two females) regularly drank; therefore, drinking behavior was not included to analyze. After adjusting age, education, occupation, married status, and health status, the result of logistic regression showed that regular exercise was significantly related to a lack of depressive symptom for both men and women (OR (Odds ratio) = 3.75, 95% CI (Confidence Interval) = 1.26—11.02 for men; OR = 2.59 and 95% CI = 1.23—6.96 for women). Regarding dietary habits, older men who ate enough vegetables (OR = 2.36, 95% CI = 1.23—4.54) were less likely to have depressive symptoms. There was no significant gender differences found in avoiding excess amount of salt and fat, eating enough fruits, eating enough proteins, consuming milk products daily, and smoking. The details of logistic regression are shown in Table 2.
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S.-H. Chang et al. Table 1
General characteristics of the subjects variables. Men n = 454 (%)
Age Education 0—6 years 7 years Occupation Employee (include part time job) Not employed Marital status Married Others Health status Good Fair + poor Regular exercise Yes No Dietary habits Avoid excess salt and fat Yes No Eat enough vegetables Yes No Eat enough fruits Yes No Eat enough proteins Yes No Consume milk products daily Yes No Smoking Yes No Depressive symptoms Yes No ** ***
Women n = 566 (%)
75.92 (7.65)
73.98 (6.75)
P value .000***
309 (68.1) 145 (31.5)
490 (86.6) 76 (13.4)
.000***
77 (17.0) 377 (83.0)
91 (16.1) 475 (83.9)
.706
448 (98.7) 6 (1.3)
551 (97.3) 15 (2.7)
.138
261 (57.5) 193 (42.5)
313 (55.3) 253 (44.7)
.484
166 (36.6) 288 (63.4)
209 (36.9) 357 (63.1)
.905
267 (58.8) 187 (41.2)
344 (60.8) 222 (39.2)
.524
277 (61.0) 177 (39.0)
370 (57.2) 196 (34.6)
.151
248 (54.6) 206 (45.4)
330 (58.7) 236 (41.7)
.239
217 (47.8) 237 (52.2)
217 (38.3) 349 (61.7)
.002**
188 (41.4) 266 (58.6)
257 (45.4) 309 (54.6)
.201
56 (12.3) 398 (87.7)
7 (1.2) 559 (98.8)
.000***
93 (20.5) 361 (79.5)
124 (21.7) 442 (78.1)
.581
p < .01. p < .001.
4. Discussion The prevalence of depressive symptoms in this study was 21.3% similar to the previous study results (Lin, Chen, et al., 2010; Lin, Yang, et al., 2010; Lyu & Lin, 2000), which implied mental health status among community-dwelling elders needs more attention. Most studies have discovered that more females experienced depressive symptoms than males did (Forlani et al., 2013; Jang et al., 2011; Nishi et al., 2012). However, since the suicide mortality rate is higher among males than females (Ministry of Health and Welfare, 2013), it would be helpful to identify male individuals with high risk of depression. Although this study has not found the statistical differences of depressive symptoms between
males and females, more lifestyle related factors such as not exercising regularly and not eating enough vegetables were found to correlate with male depressive symptoms. The possible intervention needs further investigation. This study found that subjects with regular exercise had a lower prevalence rate of depressive symptoms among older individuals and this finding was consistent with other research findings (Aihara et al., 2011; Derbeneva et al., 2012; Fortes et al., 2012; Greer & Trivedi, 2009; Lin, Yang, et al., 2010; Pettit et al., 2008; Williamson, 2009). In our study, older males who ate enough vegetables during the last six months had a lower risk of developing depression than those who did not eat enough vegetable. It was recommended that depressed people take vitamin B and
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Lifestyle and depressive symptoms by gender in community-dwelling elders Table 2
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Relationship between lifestyle and depressive symptoms by gender (N = 1020).
Variables
Men Odds ratio (95% CI)
Women Odds ratio (95% CI)
Regular exercise (no/yes) Dietary habits Avoid excess salt and fat (seldom/often) Eat enough vegetables (seldom/often) Eat enough fruits (seldom/often) Eat enough proteins (seldom/often) Consume milk products daily (seldom/often) Smoking (yes/no)
3.75 (1.26, 11.02)*
2.59 (1.23, 6.96)*
1.25 2.36 1.25 1.38 0.56 0.42
1.40 1.41 1.47 1.20 1.05 1.96
(0.70, (1.23, (0.63, (0.73, (0.30, (0.17,
2.22) 4.54)** 2.51) 2.62) 1.04) 1.01)
(0.87, (0.84, (0.88, (0.71, (0.63, (0.36,
2.26) 2.36) 2.47) 2.03) 1.68) 10.59)
Adjusted for age, education, occupation, marital status, and health status. * p < .05. ** p < .01.
omega-3 fatty acids to decrease the incidence of depression (Kamphuis, Geerlings, Grobbee, & Kromhout, 2008; Rondanelli et al., 2011). A healthy diet is more important than a single nutrient. A well-balanced diet is suggested and supported by research for older people to prevent symptoms of depression. In Japan, a study of dietary quality and depressive symptoms among community older people indicated that high dietary variety scores were related to the occurrence of less depressive symptoms (Aihara et al., 2011). The higher rate of traditional French diet (fish and fruit consumption) was associated with a lower rate of depressive symptoms in women (Barberger-Gateau et al., 2005). In Australia, the Mediterranean diet was associated with a low depressive symptoms score (Hodge et al., 2013). Therefore, well-balanced meals may decrease the incidence of depressive symptoms. Enough vegetables consumption during the last six months was significantly associated with low prevalence of depressive symptoms, only in males. The gender difference in diet intake may affect the findings. Females had better eating habits than males in Taiwan. The intake of nutrients was significantly different in men and women in Taiwan, and females were more likely to take nutrition supplements than males (Chen, Lin, & Pan, 2008). Oishi, Doi, and Kawakami (2009) found that taking nutrition supplements can influence depressive symptoms. In this study, we did not obtain information on supplements intake. If women took more supplements, the association between the dietary intake of these nutrients and depression could be smaller. Moreover, in a study of over 2000 Taiwanese older people’s changes in eating habits, males ate more soy products, eggs, fish, and meat while females drank more milk and ate more vegetables (Wang, Chang, Yeh, Chang, & Pa, 2010). Therefore, the relationship between enough amount of vegetables females ate and depressive symptoms was not clear. However, eating enough vegetables and depressive symptoms were related among males and this result was consistent with the research conducted by Oishi et al. (2009). In the future, community health nurses need to encourage older people, especially males, to intake enough vegetables in order to promote their mental health. Dietary habits are often related to morbidity and mortality in chronic illness (Kant, Schatzkin, Graubard, & Schairer, 2000; Michels & Wolk, 2002). Hence, it would be
beneficial to identify older people’s dietary habits. The Taiwanese government provided health guidelines for adult on food selection and dietary habits: less fatty food, less fried food, suitable protein, suitable low fat dairy products protein, suitable carbohydrates (above 1/3 whole grains), more vegetables, more fruits, more boiled water and regular exercise (Food and Drug Administration, 2011). To identify people’s lifestyles that associated with depressive symptoms is critical to promote their mental health. The results of this study may draw some health promotion strategies. For instance, educational programs may put national dietary guidelines into practice. Although traditional Taiwanese food was nutritious, research showed that people’s eating habits have changed in Taiwan. Taiwanese older people had an average rate of eating 2.96 times a day and 3.6 types of food groups per meal. They ate less types of food than people from other generations did (Wang et al., 2010). To encourage Taiwanese older people to eat more different types of food and vegetables may be a key to prevent them from having depressive symptoms. There are several limitations of this study that need to be addressed. At first, memory errors must be considered in this cross-sectional study. Secondly, in order to learn predictive factors between lifestyle factors and depressive symptoms, follow-up of the subjects is necessary. Third, CES-D can only examine the tendency toward depression rather than clinical depression. Also, the information about participants’ dietary habits was not conclusive because the limitations of the validity in the food assessment questionnaire. For future studies, information about the frequency of social activities and sleeping hours would help to improve the validity in the questionnaire regarding lifestyles. Even though there were some limitations of this study, older adults’ lifestyles during last six months were evidently shown related to depressive symptoms. To educate the general public on healthy dietary habits and regular exercise may help to prevent depressive symptoms when they reach to their senior status.
Acknowledgements The authors would like to thank all the participants for participating in this study. This study was supported by the Chang Gung Medical Foundation (CMRPF1A0011).
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Lifestyle and depressive symptoms by gender in community-dwelling elders Rondanelli, M., Giacosa, A., Opizzi, A., Pelucchi, C., La Vecchia, C., Montorfano, G., et al. (2011). Long chain omega 3 polyunsaturated fatty acids supplementation in the treatment of elderly depression: Effects on depressive symptoms, on phospholipids fatty acids profile and on health-related quality of life. Journal of Nutrition, Health & Aging, 15(1), 37—44. http://dx.doi.org/ 10.1007/s12603-011-0011-y Taiwan National Health Research Institutes. (2001). National Health Interview Survey. Retrieved from http://nhis.nhri.org.tw/ 2001download.html (October 1)
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Taoyuan County government, Civil Affairs Bureau, Taiwan. (2014). Demographic statistics. Retrieved from http://cab.tycg.gov.tw/ home.jsp?id=175&parentpath=0,24 (October 1) Wang, K. C., Chang, Y. M., Yeh, M. L., Chang, Y. M., & Pa, J. T. (2010). The effects of dietary behaviors and related factors on health status change among the elderly in Taiwan. Health Promotion & Health Education Journal, 30, 63—85. Williamson, C. (2009). Dietary factors and depression in older people. British Journal of Community Nursing, 14(10), 422.
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Collegian (2015) xxx, xxx—xxx
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Gender differences in the relationship of lifestyle and depressive symptoms among Taiwanese older people Shu-Hung Chang, PhD, RN a,∗, Miao-Chuan Chen, MSN, RN a,1, Nai-Hui Chien, MSN, RN a,2, Tzu-Yung Lin, PhD a,3, Yi-Ya Chang, MSc, RN a,b,4 a
Department of Nursing, Chang Gung University of Science and Technology, Guishan Dist., Taoyuan City 33303, Taiwan b Graduate Institute of Nursing, National Taiwan University, Taiwan Received 7 October 2014; received in revised form 24 March 2015; accepted 18 April 2015
KEYWORDS Gender differences; Depressive symptoms; Lifestyle; Taiwan; Older people
Summary Background: Aging is a major risk for health issues, and it may relate to chronic illness, physical function degradation, and mental dysfunction. One of the critical health concerns is depressive disorders. However, very few studies examining depression among older people have focused on the combinations of different lifestyle factors. Objectives: To examine the association between lifestyles and depressive symptoms in gender differences among older people in Taiwan. Methods: A cross-sectional study and interviews were conducted to collect information. The participants were selected by using a probability proportional to size procedure. The participants (n = 1020) were community-dwelling adults who were aged 65 and older living in northern Taiwan. The list of items such as demographic characteristics, lifestyles, and depressive symptoms originated from the Center for Epidemiologic Studies Depression scale (CES-D) were applied for the interview in this study. This study used chi-square, t-test, and logistic regression to analysis the data. Results: Men who exercised regularly and consumed enough vegetables had low depressive symptoms scores; women who exercised regularly had low depressive symptoms scores.
∗
Corresponding author at: Department of Nursing, Chang Gung University of Science and Technology, 261 Wen-Hwa 1st Road, Kwei-Shan, Taoyuan 333, Taiwan. Tel.: +886 3 2118999x3239/2 28806360/939701790; fax: +886 3 2118866. E-mail addresses: [email protected], [email protected] (S.-H. Chang), [email protected] (M.-C. Chen), [email protected] (N.-H. Chien), [email protected] (T.-Y. Lin), [email protected] (Y.-Y. Chang). 1 Tel.: +886 3 2118999x3238. 2 Tel.: +886 3 2118999x3232. 3 Tel.: +886 3 2118999x5728. 4 Tel.: +886 3 2118999x3222. http://dx.doi.org/10.1016/j.colegn.2015.04.005 1322-7696/© 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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S.-H. Chang et al. Conclusion: Regular exercise and eating enough vegetables are important factors associated with depressive symptoms for men; regular exercise is an important factor associated with depressive symptoms for women. The study suggests that senior citizens need to be encouraged to exercise regularly and get enough vegetable consumption to promote good mental health. © 2015 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction It was estimated that people 65 years of age or older will constitute 22.5% of the total population in Taiwan by 2028 (Health Promotion Administration, 2011), and Taiwan will become one of aging societies in the world. Aging is a major risk for health issues, and it may relate to chronic illness, physical function degradation, and mental dysfunction. One of the critical health concerns is depressive disorders. The estimation of disability adjusted life years (DALY) for depressive disorders increased 37.5% between 1990 and 2010. In the year 2010, depressive disorder accounted for 3.0% of 2.5 billion DALY, population growth and aging were accounted for the increase of DALY (Ferrari et al., 2013). According to some previous studies on communitydwelling elders, the prevalence rates of depression were 11—44% in the United States of America (Blazer, Burchett, Service, & George, 1991; Blazer et al., 1988; Harwood, Barker, Ownby, Mullan, & Duara, 1999; Pettit et al., 2008), 12.9% in Japan (Aihara, Minai, Aoyama, & Shimanouchi, 2011), and 21—40% in Taiwan (Lin, Chen, & Lin, 2010; Lin, Yang, & Yang, 2010; Lyu & Lin, 2000). Lifestyle is an umbrella term which encompasses various elements such as exercise, diet, and smoking; several factors are found to associate with depressive symptoms in older people. Nevertheless, most researchers analyzed only the correlations between demographic characteristics and depressive symptoms. For instance, older people with low level of education, widows, widowers, and female were more likely to experience depression (Greer & Trivedi, 2009; Lin, Yang, et al., 2010b; Pettit et al., 2008). Some other research results showed depression in terms of its relationship to physical function, chronic disease, and pressure (Forlani et al., 2013; Katsumata et al., 2005). Yet, recent studies that have reviewed the correlation between lifestyle factors and depression are receiving more attentions than before (Gariballa & Forster, 2007; Greer & Trivedi, 2009; Hodge, Osvaldo, Dallas, Graham, & Flicker, 2013; Lin, Yang, et al., 2010; Pettit et al., 2008). Many studies indicated that exercise can help to reduce depressive symptoms (Greer & Trivedi, 2009; Lin, Chen, et al., 2010; Lin, Yang, et al., 2010; Pettit et al., 2008). Moreover, the higher rate of fish and fruit consumption was associated with a lower rate of depressive symptoms (Barberger-Gateau et al., 2005; Hodge et al., 2013). However, most research topics still primarily targeted on the connection between physical activity and depression or the connection between diet and depression. Very few studies examining depression have focused on the combinations of different lifestyle factors. To identify and develop effective interventions, it would be significant to evaluate the relationships between depression and the combinations of different lifestyle behaviors.
Several studies applied gender as an independent variable into the research design to examine if any critical difference could be discovered (Greer & Trivedi, 2009; Lin, Chen, et al., 2010; Lin, Yang, et al., 2010; Pettit et al., 2008). Some studies focused on the differences of prevalence of depressive symptoms and various signs of depressive symptoms among older males and females (Escobar Bravo, Botigué Satorra, Jürschik Giménez, Nuin Orrio, & Blanco Blanco, 2013; Forlani et al., 2013). Others studies discussed the differences of demographic characteristics (e.g. education level, marital status) and health status related of depressive symptoms among older men and women (Forlani et al., 2013; Jang, Kim, & Chiriboga, 2011). But mechanisms underlying the gender differences remain unclear. Until today, very few studies have analyzed the cause and effect relationship between different lifestyle factors and depressive symptoms by gender. Therefore, this study aims to investigate the association between the combination of lifestyles and depressive symptoms in gender differences among older people in Taiwan.
2. Subjects and methods 2.1. Design and sample A cross-sectional survey was conducted to collect data on lifestyle variables including regular exercise (maintaining 20 min, heart rate above130 beats/min and sweating at 3 times a week for one half hour), dietary habits, smoking, and other relevant factors influencing the depressive symptoms in older individuals. Trained interviewers conducted face-to-face interviews and collected the data during August and October 2011. This study was approved by the Medical Foundation Institutional Review Board. Individual written consents of participants were obtained before the interviews. We used probability proportional to size sampling procedure to choose community-dwelling adults who were 65 years and older in northern Taiwan. The Primary Sampling Units were townships and the Secondary Sampling Units were villages (Taiwan National Health Research Institutes, 2001). The Basic Sampling Units were community-dwelling elders. The head officers from each village helped to recruit villagers to join this research survey. Older people who were over 65 years old living in northern Taiwan community-dwelling were included, and those who could not communicate orally were excluded. In 2011, older male to female ratio was 1.04:1 (Taoyuan County Government, 2014). At first, 539 male participants and 561 female potential participants were selected from 1100 participants. As a result, among 1020 participants, 454 men and 566 women
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Lifestyle and depressive symptoms by gender in community-dwelling elders completed the questionnaires. Six interviewers were well trained prior to the research and the inter-rater reliability was 0.90.
2.2. Measures Demographic variables included occupations, gender, levels of education, age, and marital status.
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Administration, 2011) in 5-point Likert scale, (1) Do you avoid excess salt and fat? (2) Do you eat appropriate proteins daily (less than 60 grams of protein)? (3) Do you eat enough vegetables daily (at least 1.5 bowls of cooked vegetables)? (4) Do you eat enough fruits daily (at least two kinds of fruit)? (5) Do you consume milk products daily (at least one to two glasses of milk)?
2.5. Health status 2.3. Depressive symptoms The study used the brief self-report 10-item CES-D, which were adapted from the 20-item version of Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977). CES-D has been widely used to measure the degree of depressive symptoms in community older residents (Chien & Cheng, 1985; Lin, Chen, et al., 2010; Lin, Yang, et al., 2010). The sensitivity and specificity were 92.0% and 91.0% respectively, while the positive predictive value was 67.7% in Taiwanese community sample (Chien & Cheng, 1985). The 10-item version has been administrated repeatedly in the Taiwan Longitudinal Study on Aging (TLSA). Subscale Somatic Symptoms, Depressed Affect, and Positive Affect were found among older adults in Taiwan (Lee, Ou, Chen, & Weng, 2009). This short form showed good internal consistency reliability and validity (Lee et al., 2009). The scores ranged from 0 to 30, and the cut-off point for the prevalence of depression in the present study was above 8 according to previous study (Lin, Yang, et al., 2010).
2.4. Lifestyles To assess participants’ lifestyles during last six months before the interview, the participants were asked to describe their lifestyles by using a recall method based on a structured questionnaire including the following items: Exercise: there were two questions to assess regular exercise behaviors; (1) Do you exercise regularly in the past six months (maintain 20 min, heart rate above 130 beats/min and sweating)? (yes/no); (2) How often is it? (If yes, provide the time period). The respondent who exercised three or more times a week was defined as a regular exerciser. This questionnaire was based on Gionet and Godin’s questionnaire sample. In Gionet and Godin’s research, they found simple question of regular exercise was significantly relevant to vigorous physical activity time (Gionet & Godin, 1989). The relationship factor between self-report exercise behavior and a 12-min walk-run test was 0.54 (Martin et al., 1984). It showed simple self-reported exercise was valid. Our study in self-reported regular exercise time and vigorous physical activity time were relevant. Smoking habits: (1) Do you smoke now? (Never, I used to smoke but quitted already, current smoking) (2) If yes, how many cigarettes do you smoke per day? Drinking habits: (1) Do you drinking now? (Never, I used to drink but quitted already, current drinking) (2) If yes, how many drinks do you have per day? Dietary habits: the following five questions derived from National Dietary Guidelines in Taiwan (Food and Drug
Subjects were asked to report their health status by good, fair or poor.
2.6. Analytic strategy The data was analyzed using SPSS software 18.0 (SPSS Inc., Chicago, IL, USA). Chi-square tests and t-tests were applied to exam the correlations between lifestyles and gender. Logistic regression analyses were adapted to estimate the effect of lifestyles on depressive symptoms. The variables were entered as a dichotomous variable (yes vs. no) in the logistic regression equations.
3. Results The demographic characteristics, lifestyles, and depressive symptoms by gender are shown in Table 1. The average ages of the subjects were 75.92 years old for men and 73.98 years old for women. More than two thirds of the participants completed only elementary school or did not graduate from elementary school. The majority of the subjects were married. Over half of the subjects reported that their health status was good. 36.6% of men and 36.9% of women exercised regularly. The prevalence rates of depressive symptoms were 21.3%, 20.5%, and 21.9% for all subjects, men and women respectively. Near 60% of the subjects reported their dietary behaviors of avoiding excess amount of salt and fat; they also ate enough vegetables and fruits. 41.4% of men and 45.4% of women consumed enough milk products daily. Bivariate analyses showed significant differences between gender and following factors: age, education, eating enough protein, and smoking. In this study, only ten participants (eight males and two females) regularly drank; therefore, drinking behavior was not included to analyze. After adjusting age, education, occupation, married status, and health status, the result of logistic regression showed that regular exercise was significantly related to a lack of depressive symptom for both men and women (OR (Odds ratio) = 3.75, 95% CI (Confidence Interval) = 1.26—11.02 for men; OR = 2.59 and 95% CI = 1.23—6.96 for women). Regarding dietary habits, older men who ate enough vegetables (OR = 2.36, 95% CI = 1.23—4.54) were less likely to have depressive symptoms. There was no significant gender differences found in avoiding excess amount of salt and fat, eating enough fruits, eating enough proteins, consuming milk products daily, and smoking. The details of logistic regression are shown in Table 2.
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S.-H. Chang et al. Table 1
General characteristics of the subjects variables. Men n = 454 (%)
Age Education 0—6 years 7 years Occupation Employee (include part time job) Not employed Marital status Married Others Health status Good Fair + poor Regular exercise Yes No Dietary habits Avoid excess salt and fat Yes No Eat enough vegetables Yes No Eat enough fruits Yes No Eat enough proteins Yes No Consume milk products daily Yes No Smoking Yes No Depressive symptoms Yes No ** ***
Women n = 566 (%)
75.92 (7.65)
73.98 (6.75)
P value .000***
309 (68.1) 145 (31.5)
490 (86.6) 76 (13.4)
.000***
77 (17.0) 377 (83.0)
91 (16.1) 475 (83.9)
.706
448 (98.7) 6 (1.3)
551 (97.3) 15 (2.7)
.138
261 (57.5) 193 (42.5)
313 (55.3) 253 (44.7)
.484
166 (36.6) 288 (63.4)
209 (36.9) 357 (63.1)
.905
267 (58.8) 187 (41.2)
344 (60.8) 222 (39.2)
.524
277 (61.0) 177 (39.0)
370 (57.2) 196 (34.6)
.151
248 (54.6) 206 (45.4)
330 (58.7) 236 (41.7)
.239
217 (47.8) 237 (52.2)
217 (38.3) 349 (61.7)
.002**
188 (41.4) 266 (58.6)
257 (45.4) 309 (54.6)
.201
56 (12.3) 398 (87.7)
7 (1.2) 559 (98.8)
.000***
93 (20.5) 361 (79.5)
124 (21.7) 442 (78.1)
.581
p < .01. p < .001.
4. Discussion The prevalence of depressive symptoms in this study was 21.3% similar to the previous study results (Lin, Chen, et al., 2010; Lin, Yang, et al., 2010; Lyu & Lin, 2000), which implied mental health status among community-dwelling elders needs more attention. Most studies have discovered that more females experienced depressive symptoms than males did (Forlani et al., 2013; Jang et al., 2011; Nishi et al., 2012). However, since the suicide mortality rate is higher among males than females (Ministry of Health and Welfare, 2013), it would be helpful to identify male individuals with high risk of depression. Although this study has not found the statistical differences of depressive symptoms between
males and females, more lifestyle related factors such as not exercising regularly and not eating enough vegetables were found to correlate with male depressive symptoms. The possible intervention needs further investigation. This study found that subjects with regular exercise had a lower prevalence rate of depressive symptoms among older individuals and this finding was consistent with other research findings (Aihara et al., 2011; Derbeneva et al., 2012; Fortes et al., 2012; Greer & Trivedi, 2009; Lin, Yang, et al., 2010; Pettit et al., 2008; Williamson, 2009). In our study, older males who ate enough vegetables during the last six months had a lower risk of developing depression than those who did not eat enough vegetable. It was recommended that depressed people take vitamin B and
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Lifestyle and depressive symptoms by gender in community-dwelling elders Table 2
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Relationship between lifestyle and depressive symptoms by gender (N = 1020).
Variables
Men Odds ratio (95% CI)
Women Odds ratio (95% CI)
Regular exercise (no/yes) Dietary habits Avoid excess salt and fat (seldom/often) Eat enough vegetables (seldom/often) Eat enough fruits (seldom/often) Eat enough proteins (seldom/often) Consume milk products daily (seldom/often) Smoking (yes/no)
3.75 (1.26, 11.02)*
2.59 (1.23, 6.96)*
1.25 2.36 1.25 1.38 0.56 0.42
1.40 1.41 1.47 1.20 1.05 1.96
(0.70, (1.23, (0.63, (0.73, (0.30, (0.17,
2.22) 4.54)** 2.51) 2.62) 1.04) 1.01)
(0.87, (0.84, (0.88, (0.71, (0.63, (0.36,
2.26) 2.36) 2.47) 2.03) 1.68) 10.59)
Adjusted for age, education, occupation, marital status, and health status. * p < .05. ** p < .01.
omega-3 fatty acids to decrease the incidence of depression (Kamphuis, Geerlings, Grobbee, & Kromhout, 2008; Rondanelli et al., 2011). A healthy diet is more important than a single nutrient. A well-balanced diet is suggested and supported by research for older people to prevent symptoms of depression. In Japan, a study of dietary quality and depressive symptoms among community older people indicated that high dietary variety scores were related to the occurrence of less depressive symptoms (Aihara et al., 2011). The higher rate of traditional French diet (fish and fruit consumption) was associated with a lower rate of depressive symptoms in women (Barberger-Gateau et al., 2005). In Australia, the Mediterranean diet was associated with a low depressive symptoms score (Hodge et al., 2013). Therefore, well-balanced meals may decrease the incidence of depressive symptoms. Enough vegetables consumption during the last six months was significantly associated with low prevalence of depressive symptoms, only in males. The gender difference in diet intake may affect the findings. Females had better eating habits than males in Taiwan. The intake of nutrients was significantly different in men and women in Taiwan, and females were more likely to take nutrition supplements than males (Chen, Lin, & Pan, 2008). Oishi, Doi, and Kawakami (2009) found that taking nutrition supplements can influence depressive symptoms. In this study, we did not obtain information on supplements intake. If women took more supplements, the association between the dietary intake of these nutrients and depression could be smaller. Moreover, in a study of over 2000 Taiwanese older people’s changes in eating habits, males ate more soy products, eggs, fish, and meat while females drank more milk and ate more vegetables (Wang, Chang, Yeh, Chang, & Pa, 2010). Therefore, the relationship between enough amount of vegetables females ate and depressive symptoms was not clear. However, eating enough vegetables and depressive symptoms were related among males and this result was consistent with the research conducted by Oishi et al. (2009). In the future, community health nurses need to encourage older people, especially males, to intake enough vegetables in order to promote their mental health. Dietary habits are often related to morbidity and mortality in chronic illness (Kant, Schatzkin, Graubard, & Schairer, 2000; Michels & Wolk, 2002). Hence, it would be
beneficial to identify older people’s dietary habits. The Taiwanese government provided health guidelines for adult on food selection and dietary habits: less fatty food, less fried food, suitable protein, suitable low fat dairy products protein, suitable carbohydrates (above 1/3 whole grains), more vegetables, more fruits, more boiled water and regular exercise (Food and Drug Administration, 2011). To identify people’s lifestyles that associated with depressive symptoms is critical to promote their mental health. The results of this study may draw some health promotion strategies. For instance, educational programs may put national dietary guidelines into practice. Although traditional Taiwanese food was nutritious, research showed that people’s eating habits have changed in Taiwan. Taiwanese older people had an average rate of eating 2.96 times a day and 3.6 types of food groups per meal. They ate less types of food than people from other generations did (Wang et al., 2010). To encourage Taiwanese older people to eat more different types of food and vegetables may be a key to prevent them from having depressive symptoms. There are several limitations of this study that need to be addressed. At first, memory errors must be considered in this cross-sectional study. Secondly, in order to learn predictive factors between lifestyle factors and depressive symptoms, follow-up of the subjects is necessary. Third, CES-D can only examine the tendency toward depression rather than clinical depression. Also, the information about participants’ dietary habits was not conclusive because the limitations of the validity in the food assessment questionnaire. For future studies, information about the frequency of social activities and sleeping hours would help to improve the validity in the questionnaire regarding lifestyles. Even though there were some limitations of this study, older adults’ lifestyles during last six months were evidently shown related to depressive symptoms. To educate the general public on healthy dietary habits and regular exercise may help to prevent depressive symptoms when they reach to their senior status.
Acknowledgements The authors would like to thank all the participants for participating in this study. This study was supported by the Chang Gung Medical Foundation (CMRPF1A0011).
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