Diet quality and sociodemographic, lifestyle, and health-related determinants among people with depression in Spain: new evidence from a cross-sectional population-based study (2011–2017)

nutrients Article Diet Quality and Sociodemographic, Lifestyle, and Health-Related Determinants among People with Depression in Spain: New Evidence from a Cross-Sectional Population-Based Study (2011–2017) Jesús Cebrino 1and Silvia Portero de la Cruz 2,*   Citation: Cebrino, J.; Portero de la Cruz, S. Diet Quality and Sociodemographic, Lifestyle, and Health-Related Determinants among People with Depression in Spain: New Evidence from a Cross-Sectional Population-Based Study (2011–2017). Nutrients 2021,13, 106. https://doi. org/10.3390/nu13010106 Received: 6 December 2020 Accepted: 27 December 2020 Published: 30 December 2020 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Copyright: © 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). 1Department of Preventive Medicine and Public Health, Faculty of Medicine, University of Seville, Avda. Doctor Fedriani S/N, 41009 Seville, Spain; [email protected] 2Department of Nursing, Pharmacology and Physiotherapy, Faculty of Medicine and Nursing, University of Córdoba, Avda. Menéndez Pidal S/N, 14071 Córdoba, Spain *Correspondence: [email protected]; Tel.: +34-957-218-093 Abstract: The role of diet quality in depression is an emerging research area and it appears that diet quality could be an important modifying factor. The aims of this study were to report the prevalence of diet quality among individuals with and without a self-reported diagnosis of depression aged from 16 to 64 years old in Spain, to analyze the time trends of the frequency of food consumption and diet quality from 2011 to 2017 in individuals with a self-reported diagnosis of depression, and to explore the associations between poor/improvable diet quality and sociodemographic, lifestyle, and health-related factors. A nationwide cross-sectional study was conducted in 42,280 participants with and without a self-reported diagnosis of depression who had participated in the 2011/2012 and 2017 Spanish National Health Surveys and the 2014 European Health Survey in Spain. A logistic regression analysis was performed to identify the variables associated with diet quality. The overall prevalence of diet quality among depressive and non-depressive individuals revealed 65.71% and 70.27% were in need of improvement, respectively. Moreover, having a poor or improvable diet quality is associated with male gender, people aged 16–24 years old and 25–44 years old, separated or divorced, and also in smokers. Keywords: depressive disorder; diet; mental disorders; nutrition surveys; population; trends 1. Introduction Depression ranks globally among the top 10 disability causes [ 1 , 2 ], affecting approximately 5% to 6% of people each year worldwide and 11% to 15% of people in their lifetime [ 3 ]. Moreover, depression is often recurrent or chronic and has a negative impact on people’s functioning and somatic health [ 4 ]. Additionally, it has been associated with a poor quality of life, physical decline, higher risk of premature death, and a greater economic burden [ 5 ]. Thus, depression is an important public health concern, for which there is an urgent need to identify modifiable factors to reduce its prevalence [6]. The role of diet quality in mental health illnesses and, in particular, depression is an emerging research area, and it appears that diet quality could be a major modifying factor [ 7 – 10 ]. Although some authors have found no associations [ 8 ], others show a link between a healthy dietary pattern and a reduced likelihood of depressive symptoms [ 7 , 11 ]. However, direct evidence is not readily available [12–14]. Some studies have found that depressive symptoms were associated with higher intakes of sugar, sodium, and saturated fat [ 15 , 16 ] or frequent consumption of meat and eggs [ 9 , 17 ] and lower intakes of low-calorie foods [ 18 ] and antioxidants, fruit and vegetables [ 19 ], fish [ 9 ], or legumes [ 20 ]. However, further studies are needed to assess the influence of types of diet on depression [ 21 ]. For example, the impact of soft drinks on Nutrients 2021,13, 106. https://doi.org/10.3390/nu13010106 https://www.mdpi.com/journal/nutrients Nutrients 2021,13, 106 2 of 19 mental health has drawn considerable interest from researchers in recent years due to the fact that numerous studies have suggested a consistent association between soft drink consumption and depressive symptoms [22–24]. It seems clear that the factors associating depression with diet quality include sociodemographic and economic conditions. For example, depression is more prevalent in people with low socioeconomic status [ 25 , 26 ], probably due to the fact that higher diet quality or “healthy foods” often have limited uptake because they are more costly [ 27 , 28 ]. In addition, any observed association between depression and diet quality might be accounted for by lifestyle habits, given that people with depression engage in less leisure-time physical activity than those without depression [ 29 ], due to a lack of energy and greater fatigue, which are common symptoms of depression [ 30 ]. Moreover, the lack of interest in various activities, for example, the motivation to cook or enjoy meals, may be explained by depressive symptoms [31]. Nowadays, drugs and psychological interventions are used to reduce symptoms of depression. Nevertheless, psychological interventions only reduce the incidence rate of depression by 20–25% [ 32 ] and medications show minimal benefits in the sub-threshold of depression [ 33 ]. Considering the rise in the number of people with depression worldwide [ 34 ], preventive strategies are needed in order to reduce its prevalence. For this reason, it is important to reflect on numerous factors affecting the development of depression [ 35 ], with particular attention given to modifiable behavior such as a diet that can potentially prevent this disorder [ 36 ]. In recent years, there has been a shift of focus from studying single nutrients toward dietary patterns [ 37 ]. This particular study uses diet quality scores to evaluate dietary patterns, based on the dietary guidelines of the Spanish Society of Community Nutrition (SSCN) [ 38 ]. Moreover, this study is the first to show the relationship between numerous different sociodemographic, lifestyle, and health-related characteristics and diet quality independently and simultaneously in a large, representative sample of the population with a self-reported diagnosis of depression in Spain, aged between 16–64 years old, conducted from 2011 to 2017. Therefore, the main objectives of the present study were to report the prevalence of diet quality among individuals with and without a self-reported diagnosis of depression aged from 16 to 64 years old in Spain, to analyze the time trends of the frequency of food consumption and diet quality from 2011 to 2017 in individuals with a self-reported diagnosis of depression, and to explore the associations between poor/improvable diet quality and sociodemographic, lifestyle, and health-related factors. 2. Materials and Methods 2.1. Study Design A quantitative, observational, nationwide, cross-sectional study. 2.2. Data Source and Study Population The data were obtained from the personalized interviews in the Spanish National Health Survey (SNHS) 2011/2012 (from July 2011 to July 2012) [ 39 ], the European Health Survey in Spain (EHSS) 2014 (from January 2014 to January 2015) [ 40 ], and the SNHS 2017 (from October 2016 to October 2017) [ 41 ]. The SNHS and EHSS had a cross-sectional and population-based design and were conducted at the national level, focusing on the non-institutionalized population (representativeness is ensured by assigning a weighting coefficient to each participant), through an interview. These surveys were carried out by the National Institute of Statistics and the Ministry of Health, Consumer Affairs, and Social Welfare in Spain. These personal interviews were multistage probabilistic, stratified sampling by census areas (first stage), sections (second stage), and individuals (third stage). The selected households were initially contacted through a letter from the Ministry of Health, Consumer Affairs, and Social Welfare in Spain requesting their collaboration, in which they were informed that they had been selected for the survey and that this survey was Nutrients 2021,13, 106 3 of 19 confidential and they were notified of the upcoming visit of a duly authorized interviewer. A detailed description of SNHS and EHSS methodologies can be found elsewhere [ 39 – 41 ]. For the data analyzed, the inclusion criteria were: people aged from 16 to 64 years old, who were resident in Spain during the years of the surveys. Figure 1shows the flowchart of the study population. From the initial 47,962 participants (SNHS 2011/2012: n = 14,988; EHSS 2014: n = 16,136; SNHS 2017: n = 16,838), we excluded 5682 individuals who did not respond or refused to answer the interview questions (SNHS 2011/2012: n = 1534; EHSS 2014: n = 1458; SNHS 2017: n = 2690). For the cross-sectional analysis, we included 3217 participants with a self-reported diagnosis of depression (SNHS 2011/2012: n = 930; EHSS 2014: n = 1168; SNHS 2017: n = 1119) and 39,063 without a self-reported diagnosis of depression (SNHS 2011/2012: n = 12,524; EHSS 2014: n = 13,510; SNHS 2017: n = 13,029). Nutrients 2021, 13, x FOR PEER REVIEW 3 of 21 The selected households were initially contacted through a letter from the Ministry of Health, Consumer Affairs, and Social Welfare in Spain requesting their collaboration, in which they were informed that they had been selected for the survey and that this survey was confidential and they were notified of the upcoming visit of a duly authorized interviewer. A detailed description of SNHS and EHSS methodologies can be found elsewhere [39–41]. For the data analyzed, the inclusion criteria were: people aged from 16 to 64 years old, who were resident in Spain during the years of the surveys. Figure 1 shows the flowchart of the study population. From the initial 47,962 participants (SNHS 2011/2012: n = 14,988; EHSS 2014: n = 16,136; SNHS 2017: n = 16,838), we excluded 5682 individuals who did not respond or refused to answer the interview questions (SNHS 2011/2012: n = 1534; EHSS 2014: n = 1458; SNHS 2017: n = 2690). For the cross-sectional analysis, we included 3217 participants with a self-reported diagnosis of depression (SNHS 2011/2012: n = 930; EHSS 2014: n = 1168; SNHS 2017: n = 1119) and 39,063 without a self-reported diagnosis of depression (SNHS 2011/2012: n = 12,524; EHSS 2014: n = 13,510; SNHS 2017: n = 13,029). Figure 1. Flowchart of the study population. SNHS: Spanish National Health Survey 2011/2012 and 2017; EHSS: European Health Survey in Spain 2014. For the purpose of the current study, we assessed the presence of depression through the health status module of an adult questionnaire from SNHS 2011/2012 [39] and 2017 [41] and EHSS 2014 [40]. The adult questionnaire collects individual information on a person aged 15 and over (for SNHS 2011/2012 and SNHS 2017) and 16 and over (for EHSS 2014). This information covers all the survey’s health variables and is structured into three modules: (i) health status module, (ii) healthcare module, and (iii) health determinants module. The health status module collects information on perceived health status, chronic disease and limitation, diseases and health problems, accidents, restriction of activity, physical, sensory, and cognitive limitations, limitations on daily activities, mental health, stress, and job satisfaction. We identified individuals suffering from depression as those Figure 1. Flowchart of the study population. SNHS: Spanish National Health Survey 2011/2012 and 2017; EHSS: European Health Survey in Spain 2014. For the purpose of the current study, we assessed the presence of depression through the health status module of an adult questionnaire from SNHS 2011/2012 [ 39 ] and 2017 [ 41 ] and EHSS 2014 [ 40 ]. The adult questionnaire collects individual information on a person aged 15 and over (for SNHS 2011/2012 and SNHS 2017) and 16 and over (for EHSS 2014). This information covers all the survey’s health variables and is structured into three modules: (i) health status module, (ii) healthcare module, and (iii) health determinants module. The health status module collects information on perceived health status, chronic disease and limitation, diseases and health problems, accidents, restriction of activity, physical, sensory, and cognitive limitations, limitations on daily activities, mental health, stress, and job satisfaction. We identified individuals suffering from depression as those that answered “yes” to the question “Have you ever been diagnosed depression by a physician?”. 2.3. Variables 2.3.1. Diet Quality The dependent variable was diet quality. This variable was measured using the Spanish Health Eating Index (SHEI) [ 42 ]. This instrument was developed to measure Nutrients 2021,13, 106 4 of 19 how well diets meet the food-based dietary guidelines of the Spanish Society of Community Nutrition (SSCN) [ 38 ] and contain 10 items that represent food groups from the dietary guidelines. Each variable represents: (i) bread or grains, (ii) leafy greens, salads, and vegetables, (iii) fresh fruit (excluding juices), (iv) dairy products (milk, cheese, yoghurt), (v) meat (chicken, beef, pork, lamb, etc.), (vi) legumes, (vii) cold meats and cuts, (viii) sweets (biscuits, pastries, jams, cereals with sugar, sweets, etc.), (ix) soft drinks with sugar, and (x) variety of the diet, built on the recommendations of SSCN. These items were identically worded in the questionnaires and identical in the SNHS 2011/2012 and 2017, and EHSS 2014. Each of the items is divided into 5 categories, which refer to the frequency of food consumption: never or hardly ever, less than once a week, once or twice a week, three or more times a week, but not daily, and daily. The food groups were categorized as follows: bread or grains, leafy greens, salads and vegetables, fresh fruit (excluding juices), dairy products (milk, cheese, yogurt), which represent the food groups for daily consumption; meat (chicken, beef, pork, lamb, etc.) and legumes correspond to the weekly consumption food groups; cold meats and cuts, sweets (biscuits, pastries, jams, cereals with sugar, sweets, etc.) and soft drinks with sugar correspond to the occasional food groups; and the last represents the variety of the diet, a fundamental objective in a healthy diet. Each food group received a score, which ranged from 0 to 10 according to the criteria established in the Supplementary Table S1, where 10 points in a food group means that it complies with the recommendations proposed by the Spanish Society of Community Nutrition [ 38 ]. Total (overall) SHEI scores range from 0 to 100 and are the sum of the frequency of consumption of 10 food groups. The SHEI result contains three categories: poor diet, diet in need of improvement, and good diet, using the cut-off points previously established in the questionnaire validation [ 42 ]: poor diet quality (SHEI score <51 ), diet in need of improvement (SHEI score between 51 and 80), and good diet quality (SHEI score >80). 2.3.2. Sociodemographic Variables The independent variables were: year of the surveys (2011/2012, 2014, 2017), gender (female, male), age group (16–24 years, 25–44 years, 45–64 years), marital status (single, married, widowed, separated/divorced), level of education (without studies, primary, secondary or professional training, university), nationality (Spanish, foreign), and size of the town of residence (<10,000 inhabitants, ≥10,000 inhabitants). Social class, as an independent variable, was assigned according to the categories proposed by the Spanish Society of Epidemiology [ 43 ]. This variable was classified into: Class I (directors and managers of companies with 10 or more employees and professionals normally qualified with university degrees), Class II (directors and managers of companies with less than 10 salaried employees and professionals normally qualified with university degrees and other technical support professionals. Athletes and artists), Class III (intermediate professions and self-employed workers), Class IV (supervisors and workers in skilled technical work), Class V (skilled workers in the primary sector and other semi-skilled workers), Class VI (unskilled workers). For the purposes of this study, these six original classes were rearranged into three groups (Classes I and II, Classes III and IV, Classes V and VI). 2.3.3. Health-Related Variables Body mass index (BMI), which was calculated from the self-reported values of body weight and height, was classified according to the World Health Organization [ 44 ]. Thus, the following categories were used: underweight (BMI <18.50 kg/m 2 ), normalweight (BMI ranged between 18.50 and 24.99 kg/m 2 ), overweight (BMI ranged between 25.00 and 29.99 kg/m2), and obesity (BMI ≥30 kg/m2). Other health-related variables in the study were: current smoking habit (yes, no), consumption of alcoholic beverages in the past 12 months prior to the survey (yes, no), and self-perceived health status (very good, good, fair, poor, very poor). Nutrients 2021,13, 106 5 of 19 2.3.4. Lifestyle Behavior Lifestyle behavior included: physical activity in main activity (physically active in the main activity, not physically active in main activity), physical activity during leisure time (yes, no), and the number of days in the last 7 days when the respondent walked for at least 10 min at a time (maximum 7 days). 2.4. Ethical Aspects The data obtained from these surveys are available on the Ministry of Health, Consumer Affairs, and Social Welfare of Spain and the National Institute of Statistics websites [ 39 – 41 ] in the form of anonymized microdata: no special authorization is, therefore, required for their use. According to the SNHS and EHSS methodology, the microdata files are stored anonymously and are available to the public. In accordance with Spanish law, when secondary data are used, there is no need for approval from an Ethics Committee. The research data is available here as a Supplementary File. 2.5. Statistical Analysis A descriptive analysis was performed by calculating the counts and percentages for the qualitative variables and the continuous variables by calculating the arithmetic mean and standard deviation (SD). Sociodemographic, lifestyle, health-related characteristics, and the diet quality of people with and without a self-reported diagnosis of depression were compared using the Chi-square test for contingency tables or Fisher’s exact test if the number of expected frequencies was greater than 5. For the bivariate analysis, Student’s t-test for means in normal distribution variables was used. Linear regression models were used to identify statistically significant trends in the frequency of food consumption in the period of 2011–2017. The regression coefficient and the coefficient of determination (R 2 ) were calculated to assess the direction, average magnitude of the change, and performance of the models. In addition, logistic regression was performed to identify the variables associated with the diet quality of people with a self-reported diagnosis of depression. It should be noted that the variable for diet quality of people with a self-reported diagnosis of depression was classified as “good diet” (a score over 80 on the SHEI) and “poor/improvable diet” (a score less than or equal to 80) for the bivariate and multivariate analysis. All the variables with a significant association in the bivariate analysis were included in the multivariate analysis. Crude and adjusted Odds Ratios (OR) were calculated with 95% confidence intervals. The Wald statistic was used to exclude one by one from the model any variables with a p ≥ 0.15 (backward methodical selection procedure). The goodness of fit was verified with the Hosmer–Lemeshow test. All the hypothesis contrasts were bilateral and in all the statistical tests with a 95% confidence level (p< 0.05) were considered significant values. The statistical power for all the analyses conducted was 80%. The variables that were part of the final multivariate-adjusted model were gender, age group, marital status, current smoking habit, consumption of alcoholic beverages in the past 12 months prior to the survey, and number of days in the last 7 days when the respondent had walked for at least 10 min at a time. The statistical analysis was carried out using IBM SPSS Statistics version 25 (IBM Corp, Armonk, NY, USA), licensed to the University of Seville (Spain). 3. Results 3.1. Sociodemographic, Lifestyle Habits and Health-Related Variables The total number of individuals with a self-reported diagnosis of depression included in the study was 3217. Participants with a self-reported diagnosis of depression were more often females (68.67% vs. 48.97%, p< 0.001), 45–64 years old (72.09% vs. 45.57%, p< 0.001), Spanish (95.37% vs. 91.62%, p< 0.001), current smokers (37.24% vs. 31.09%, p< 0.001), and not physically active (86.23% vs. 80.42%, p< 0.001) compared to people without a self-reported diagnosis of depression (Table 1). Nutrients 2021,13, 106 6 of 19 Table 1. Sociodemographic, lifestyle, and health-related variables according to depressive status in people aged from 16 to 64 years (N = 42,280) (2011–2017). Variables Participants with a Self-Reported Diagnosis of Depression n = 3217 (%) Participants without a Self-Reported Diagnosis of Depression n = 39,063 (%) p-Value Gender <0.001 Female 2209 (68.67%) 19,130 (48.97%) Male 1008 (31.33%) 19,933 (51.03%) Age group <0.001 16–24 years old 52 (1.61%) 3726 (9.54%) 25–44 years old 846 (26.30%) 17,535 (44.89%) 45–64 years old 2319 (72.09%) 17,802 (45.57%) Marital status <0.001 Single 779 (24.21%) 13,041 (33.38%) Married 1627 (50.58%) 22,207 (56.85%) Widowed 265 (8.24%) 799 (2.05%) Separated/Divorced 546 (16.97%) 3016 (7.72%) Level of education <0.001 Without studies 272 (8.46%) 1361 (3.48%) Primary 636 (19.77%) 4023 (10.30%) Secondary or PT 1948 (60.55%) 24,672 (63.16%) University 361 (11.22%) 9007 (23.06%) Nationality <0.001 Spanish 3068 (95.37%) 35,789 (91.62%) Foreign 149 (4.63%) 3274 (8.38%) Size of town of residence 0.71 <10,000 inhabitants 693 (21.54%) 8527 (21.83%) ≥10,000 inhabitants 2524 (78.46%) 30,536 (78.17%) Social class <0.001 Classes I and II 384 (11.94%) 8531 (21.84%) Classes III and IV 967 (30.06%) 13,561 (34.72%) Classes V and VI 1866 (58.00%) 16,971 (43.44%) Body Mass Index <0.001 Underweight 64 (1.99%) 917 (2.35%) Normal weight 1221 (37.95%) 18,922 (48.44%) Overweight 1189 (36.96%) 13,448 (34.43%) Obese 743 (23.10%) 5776 (14.78%) Current smoking habit <0.001 Yes 1198 (37.24%) 12,146 (31.09%) No 2019 (62.76%) 26,917 (68.91%) Consumption of alcoholic beverages in the past 12 months prior to the survey <0.001 Yes 1638 (50.92%) 26,911 (68.89%) No 1579 (49.08%) 12,152 (31.11%) Physical activity in main activity <0.001 Physically active 443 (13.77%) 7647 (19.58%) Not physically active 2774 (86.23%) 31,416 (80.42%) Number of days in the last 7 days when the respondent had walked for at least 10 min at a time (maximum 7 days) M SD M SD <0.001 4.29 2.92 4.64 2.81 PT = Professional Training; M = mean; SD = Standard Deviation. Nutrients 2021,13, 106 7 of 19 3.2. Diet Quality As can be seen in Table 2, the prevalence of daily consumption of leafy greens, salads and vegetables, and fresh fruit was higher among participants with a self-reported diagnosis of depression (44.33% vs. 43.67% p< 0.001; 61.95% vs. 60.72% p< 0.001, respectively). Nonetheless, the daily consumption of bread was lower in that population (82.47% vs. 83.28% p< 0.001). Regarding diet quality, the prevalence of poor and good diet quality was higher in individuals with depression (3.05% vs. 2.71% p< 0.001; 31.24% vs. 27.02% p< 0.001, respectively). In addition, a diet in need of improvement was more prevalent in participants without a diagnosis of depression (70.27% vs. 65.71% p< 0.001). Table 2. Frequency of food consumption and diet quality according to depressive status in participants aged from 16 to 64 years (N = 42,280) (2011–2017). Variables Participants with a Self-Reported Diagnosis of Depression n = 3217 (%) Participants without a Self-Reported Diagnosis of Depression n = 39,063 (%) p-Value Frequency of consumption of bread or grains <0.001 Never or hardly ever 108 (3.36) 718 (1.84) Less than once a week 73 (2.27) 671 (1.72) Once or twice a week 129 (4.00) 1564 (4.00) Three or more times a week, but not daily 254 (7.90) 3579 (9.16) Daily 2653 (82.47) 32,531 (83.28) Frequency of consumption of leafy greens, salads and vegetables <0.001 Never or hardly ever 61 (1.90) 469 (1.20) Less than once a week 99 (3.07) 925 (2.37) Once or twice a week 403 (12.53) 4548 (11.64) Three or more times a week, but not daily 1228 (38.17) 16,061 (41.12) Daily 1426 (44.33) 438 (43.67) Frequency of fresh fruit (excluding juices) consumption <0.001 Never or hardly ever 156 (4.85) 1315 (3.37) Less than once a week 166 (5.16) 1491 (3.82) Once or twice a week 305 (9.48) 4017 (10.28) Three or more times a week, but not daily 597 (18.56) 8519 (21.81) Daily 1993 (61.95) 23,721 (60.72) Frequency of consumption of dairy products (milk, cheese, yoghurt) <0.001 Never or hardly ever 124 (3.85) 990 (2.54) Less than once a week 76 (2.36) 803 (2.06) Once or twice a week 125 (3.89) 1525 (3.90) Three or more times a week, but not daily 240 (7.46) 3497 (8.95) Daily 2652 (82.44) 32,248 (82.55) Frequency of meat (chicken, beef, pork, lamb, etc.) consumption <0.001 Never or hardly ever 56 (1.74) 443 (1.13) Less than once a week 130 (4.04) 693 (1.77) Once or twice a week 972 (30.22) 9585 (24.54) Three or more times a week, but not daily 1807 (56.17) 24,380 (62.41) Daily 252 (7.83) 3962 (10.15) Nutrients 2021,13, 106 8 of 19 Table 2. Cont. Variables Participants with a Self-Reported Diagnosis of Depression n = 3217 (%) Participants without a Self-Reported Diagnosis of Depression n = 39,063 (%) p-Value Frequency of legumes consumption 0.01 Never or hardly ever 91 (2.83) 956 (2.45) Less than once a week 370 (11.50) 4236 (10.85) Once or twice a week 1890 (58.75) 23,970 (61.36) Three or more times a week, but not daily 820 (25.49) 9507 (24.34) Daily 46 (1.43) 394 (1.00) Frequency of consumption of cold meats and cuts <0.001 Never or hardly ever 449 (13.96) 3868 (9.90) Less than once a week 647 (20.11) 6305 (16.14) Once or twice a week 951 (29.56) 11,627 (29.76) Three or more times a week, but not daily 784 (24.37) 11,694 (29.94) Daily 386 (12.00) 5569 (14.26) Frequency of consumption of sweets (biscuits, pastries, jams, cereals with sugar, sweets, etc.) <0.001 Never or hardly ever 574 (17.84) 5528 (14.15) Less than once a week 596 (18.53) 6550 (16.77) Once or twice a week 626 (19.46) 8453 (21.64) Three or more times a week, but not daily 515 (16.01) 7596 (19.44) Daily 906 (28.16) 10,936 (28.00) Frequency of consumption of soft drinks with sugar <0.001 Never or hardly ever 1606 (49.92) 15,503 (39.69) Less than once a week 643 (19.99) 7911 (20.25) Once or twice a week 383 (11.91) 6920 (17.72) Three or more times a week, but not daily 261 (8.11) 4247 (10.87) Daily 324 (10.07) 4482 (11.47) Diet quality <0.001 Poor diet quality 98 (3.05) 1060 (2.71) Diet in need of improvement 2114 (65.71) 27,448 (70.27) Good diet quality 1005 (31.24) 10,555 (27.02) According to the year of the survey (Table 3), there was a decrease in the number of people with a self-reported diagnosis of depression who never or hardly ever consumed legumes ( β = − 0.42, R 2 = 1.00, p= 0.03). In the same way, the percentage of people with depression who consumed soft drinks with sugar on a daily basis decreased ( β = − 0.44, R 2 = 1.00, p= 0.02). Table 3. Frequency of food consumption by people with a self-reported diagnosis of depression in Spain aged from 16 to 64 years by year of survey (N = 3217) (2011–2017). Variables 2011/2012 n = 930 (%) 2014 n = 1168 (%) 2017 n = 1119 (%) BR2p-Value Frequency of consumption of bread or grains Never or hardly ever 35 (3.76) 40 (3.43) 33 (2.95) −0.14 0.99 0.07 Less than once a week 24 (2.58) 30 (2.57) 19 (1.70) −0.15 0.76 0.33 Once or twice a week 47 (5.06) 38 (3.25) 44 (3.93) −0.19 0.38 0.58 Three or more times a week, but not daily 57 (6.13) 109 (9.33) 88 (7.86) 0.29 0.29 0.64 Daily 767 (82.47) 951 (81.42) 935 (83.56) 0.18 0.26 0.66 Nutrients 2021,13, 106 9 of 19 Table 3. Cont. Variables 2011/2012 n = 930 (%) 2014 n = 1168 (%) 2017 n = 1119 (%) BR2p-Value Frequency of consumption of leafy greens, salads and vegetables Never or hardly ever 22 (2.36) 24 (2.05) 15 (1.34) −0.17 0.95 0.14 Less than once a week 36 (3.87) 31 (2.65) 32 (2.86) −0.17 0.60 0.44 Once or twice a week 125 (13.44) 149 (12.76) 129 (11.53) −0.32 0.97 0.10 Three or more times a week, but not daily 309 (33.23) 452 (38.70) 467 (41.73) 1.42 0.97 0.10 Daily 438 (47.10) 512 (43.84) 476 (42.54) −0.76 0.94 0.15 Frequency of fresh fruit (excluding juices) consumption Never or hardly ever 67 (7.21) 41 (3.51) 48 (4.29) −0.49 0.56 0.46 Less than once a week 45 (4.84) 49 (4.19) 72 (6.43) 0.27 0.48 0.52 Once or twice a week 88 (9.46) 103 (8.82) 114 (10.19) 0.12 0.28 0.64 Three or more times a week, but not daily 136 (14.62) 242 (20.72) 219 (19.57) 0.83 0.58 0.45 Daily 594 (63.87) 733 (62.76) 666 (59.52) −0.72 0.93 0.18 Frequency of consumption of dairy products (milk, cheese, yoghurt) Never or hardly ever 43 (4.62) 43 (3.68) 38 (3.40) −0.20 0.91 0.19 Less than once a week 17 (1.83) 32 (2.74) 27 (2.41) 0.10 0.40 0.57 Once or twice a week 30 (3.23) 50 (4.28) 45 (4.02) 0.13 0.52 0.49 Three or more times a week, but not daily 47 (5.05) 105 (8.99) 88 (7.86) 0.47 0.48 0.51 Daily 793 (85.27) 938 (80.31) 921 (82.31) −0.49 0.35 0.60 Frequency of meat (chicken, beef, pork, lamb, etc.) consumption Never or hardly ever 22 (2.37) 13 (1.11) 21 (1.88) −0.08 0.15 0.75 Less than once a week 40 (4.30) 50 (4.28) 40 (3.57) −0.12 0.77 0.32 Once or twice a week 304 (32.69) 346 (29.62) 322 (28.78) −0.65 0.90 0.20 Three or more times a week, but not daily 493 (53.01) 671 (57.45) 643 (57.46) 0.74 0.75 0.33 Daily 71 (7.63) 88 (7.54) 93 (8.31) 0.11 0.65 0.40 Frequency of consumption of legumes Never or hardly ever 39 (4.19) 33 (2.83) 19 (1.70) −0.42 1.00 0.03 Less than once a week 113 (12.15) 131 (11.21) 126 (11.26) −0.15 0.71 0.36 Once or twice a week 538 (57.85) 662 (56.68) 690 (61.66) 0.63 0.54 0.48 Three or more times a week, but not daily 222 (23.87) 330 (28.25) 268 (23.95) 0.01 0.00 0.99 Daily 18 (1.94) 12 (1.03) 16 (1.43) −0.09 0.31 0.62 Frequency of consumption of cold meats and cuts Never or hardly ever 195 (20.96) 132 (11.30) 122 (10.90) −1.68 0.78 0.31 Less than once a week 198 (21.29) 250 (21.41) 199 (17.79) −0.58 0.72 0.35 Once or twice a week 255 (27.42) 367 (31.42) 329 (29.40) 0.33 0.25 0.67 Three or more times a week, but not daily 151 (16.24) 289 (24.74) 344 (30.74) 2.42 0.99 0.06 Daily 131 (14.09) 130 (11.13) 125 (11.17) −0.49 0.74 0.34 Frequency of consumption of sweets (biscuits, pastries, jams, cereals with sugar, sweets, etc.) Never or hardly ever 245 (26.34) 180 (15.41) 149 (13.31) −2.17 0.87 0.24 Less than once a week 158 (16.99) 212 (18.15) 226 (20.20) 0.54 0.98 0.10 Once or twice a week 131 (14.09) 238 (20.38) 257 (22.97) 1.48 0.95 0.15 Three or more times a week, but not daily 99 (10.64) 217 (18.58) 199 (17.78) 1.19 0.67 0.39 Daily 297 (31.94) 321 (27.48) 288 (25.74) −1.03 0.94 0.16 Frequency of consumption of soft drinks with sugar Never or hardly ever 527 (56.67) 539 (46.15) 540 (48.26) −1.40 0.57 0.45 Less than once a week 139 (14.95) 256 (21.92) 248 (22.16) 1.20 0.77 0.31 Once or twice a week 94 (10.11) 140 (11.99) 149 (13.31) 0.53 0.99 0.06 Three or more times a week, but not daily 63 (6.77) 115 (9.84) 83 (7.42) 0.11 0.04 0.87 Daily 107 (11.50) 118 (10.10) 99 (8.85) −0.44 1.00 0.02 Nutrients 2021,13, 106 16 of 19 21. 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