Abstract
Background:
Vitamins play an important role in improving mental health. Healthy diets can significantly influence the development, progression, and treatment of mental health disorders.Objectives:
This study aimed to investigate the correlation between dietary intake and anthropometric profiles with anxiety in female students of Zahedan University of Medical Sciences.Methods:
This cross-sectional study evaluated 200 female medical students for daily intake of B vitamins, omega-3, anthropometric indices, and their correlation with anxiety. The Food Frequency Questionnaire and Bronze Anxiety Questionnaire were used to examine the relationship between dietary intake and anxiety. The associations between parameters were analyzed using Pearson’s correlation.Results:
The findings revealed that the mean age of the female medical students was 22.60 ± 2.10 years, with a Body Mass Index (BMI) of 23.37 ± 4.01, a waist-to-hip ratio (WHpR) of 0.81 ± 0.11, a waist-to-height ratio (WHtR) of 10.55 ± 0.10, and an anxiety score of 44.83 ± 17.71. Positive correlations were observed between BMI (r = 0.89, P = 0.0001), WHpR (r = 0.86, P = 0.0001), and WHtR (r = 0.898, P = 0.0001) with anxiety. The mean anxiety scores were 23.84 ± 4.36, 38.59 ± 4.62, 61.44 ± 13.63, and 74.44 ± 5.96 in underweight, normal, overweight, and obese participants, respectively. A negative correlation was identified between the consumption of vitamins and omega-3 and anxiety scores (r = -0.63, P < 0.001).Conclusions:
This study suggests that a higher intake of dietary B vitamins and omega-3 is associated with lower anxiety scores in Zahedan medical students.Keywords
1. Background
The prevalence of mental health disorders has increased in recent years, posing a significant challenge to public health (1). Anxiety, one of the most common mental health disorders, is characterized by subjective feelings of tension, nervousness, worry, and the activation and discharge of the autonomic nervous system (2). Globally, the prevalence of anxiety disorders is estimated to be 7.3% (95% CI: 4.8 - 10.9%) (3). However, the prevalence of anxiety is notably higher among physicians. Physicians are particularly vulnerable to mental health disorders such as anxiety, depression, and occupational burnout due to high levels of occupational stress (4). A study in China reported 25.6% anxiety, 28.1% depression, and 19% comorbid anxiety and depression among physicians (5). Similarly, a study in Iran found 39.4% situational anxiety and 36.7% personality anxiety among physicians (6). Additionally, a high rate of anxiety was observed in physician residents under 30 years of age in Iran (7).
Anxiety disorders are frequently under-recognized and misdiagnosed. As a result, anxious individuals may not receive appropriate treatment, leading to reduced quality of life and social functioning (8). Research has indicated that healthy diets can play a significant role in the development, progression, and treatment of some mental health disorders. Polyunsaturated fatty acids, such as omega-3, are involved in the synthesis, release, reuptake, degradation, and binding of neurotransmitters, all of which can influence anxiety (9). Studies have reported a negative correlation between social anxiety disorder and erythrocyte membrane omega-3 levels (10). Vitamin B12 and folic acid also play critical roles in central nervous system development and health (11). Severe deficiencies in these vitamins have been associated with an increased risk of psychological disorders (12). Specifically, deficiencies in micronutrients such as B12 or folate are linked to a higher prevalence of depression (13).
Previous research has highlighted the correlation between anthropometric indices and depressive symptoms (14). Associations between obesity indices and psychological disorders have also been documented (15). While medical professionals provide care to the general public, they themselves require significant attention to their mental health. The prevalence of anxiety among physicians and physician residents can hinder their professional performance and negatively impact the quality of healthcare they deliver (16).
2. Objectives
Given this context, it was necessary to investigate the correlation between dietary intake and anthropometric indices with anxiety in female medical students. Thus, this study aimed to examine the relationship between dietary intake and anthropometric indices with anxiety in female medical students at Zahedan University of Medical Sciences (ZAUMS).
3. Methods
3.1. Study Design and Participants
This descriptive-analytical cross-sectional study was conducted in 2020. The study population included all female medical students at ZAUMS, Iran. A sample size of 202 students was calculated using the correlation estimation sample size formula (17), with a correlation coefficient (r) of -0.32 between omega-3 and anxiety (18), a significance level of 0.05, a power of 0.95, and a non-response rate of 0.40.
Since the students of interest were likely to have varying anxiety levels, stratified random sampling was employed during the data collection process. The academic years of the students were used as strata. Samples were then equally and randomly selected from each academic year based on a list provided by the Department of Educational Affairs.
It should be noted that despite follow-up efforts, two participants did not fully complete their questionnaires. Consequently, the data from 200 participants were analyzed.
3.2. Eligibility Criteria
The inclusion criteria for this study consisted of female medical students at ZAUMS who provided informed consent for participation. Students who were taking antidepressant drugs or dietary supplements, as well as those with a history of psychological or medical disorders, were excluded from the study.
3.3. Measurements
A validated self-administered questionnaire was used to collect data on demographic variables and population characteristics. Female medical students were also assessed for anthropometric indices, including waist-to-hip ratio (WHpR), waist-to-height ratio (WHtR), and Body Mass Index (BMI). Body Mass Index was calculated by dividing weight in kilograms (kg) by height in meters squared (m²). Waist-to-height ratio was calculated as waist circumference (cm) divided by height (cm), and WHpR was calculated as waist circumference (cm) divided by hip circumference (cm). In this study, BMI classifications were defined as follows: Body Mass Index < 18.50 (underweight), 18.5 ≤ BMI < 24.9 (normal), 25.00 ≤ BMI < 29.9 (overweight), and BMI ≥ 30 (obese).
A Food Frequency Questionnaire (FFQ) was used to collect information on dietary intake over the past year. The 168-item FFQ, whose validity and reliability have been confirmed in previous studies (19, 20), was employed. Participants were asked to answer two questions regarding the frequency and quantity of food consumption, using a ten-option multiple-choice scale ranging from "never or less than once a month" to "10 or more times per day." Additionally, a photo book was used to enhance the precision and accuracy of portion size estimation. The information provided by participants through the FFQ was entered into specialized software, N4, which analyzed and provided detailed data on the nutrients and energy consumed by each subject.
Anxiety data were collected using the Bronze Anxiety Questionnaire, which comprises 33 questions scored on a 4-point Likert Scale, ranging from 0 ("never") to 3 ("very much"). The minimum possible score is 0, and the maximum is 99. Scores were categorized as follows: 0 - 33 (low anxiety intensity), 33 - 94 (moderate anxiety intensity), and above 94 (high anxiety intensity). The content validity (CVI = 0.90, CVR = 0.87) and reliability (Cronbach's alpha = 0.94) of the Bronze Anxiety Questionnaire were confirmed in a study by Salehi Morkani (21).
3.4. Ethical Considerations
Written informed consent was obtained from all participants. This study was approved by the Ethics Committee of ZAUMS (ethics code: IR.ZAUMS.REC.1398.102; project code: 2274).
3.5. Data Analysis
The normality of the data was assessed using the Kolmogorov-Smirnov test. Dietary intakes were calculated by multiplying the grams of food consumed by the nutrient content of the food and the frequency of consumption. The data were reported as mean ± SD and analyzed using SPSS software (version 23). Pearson’s correlation was applied to evaluate the relationships between parameters, with a P-value < 0.05 considered statistically significant.
4. Results
Table 1 presents the demographic, anxiety, and anthropometric data of the participants. The mean age of the female students was 22.60 ± 2.10 years, with a BMI of 23.37 ± 4.01, WHpR of 0.81 ± 0.11, WHtR of 0.55 ± 0.10, and an anxiety score of 44.83 ± 17.71. The results indicated that 19% (n = 38) of participants were underweight, 44% (n = 88) were normal weight, 32.5% (n = 65) were overweight, and 4.5% (n = 9) were obese or very obese.
The Results for Demographic, Anxiety and Anthropometric Indices
| Variables | Mean ± SD | Minimum-Maximum |
|---|---|---|
| Age (y) | 22.60 ± 2.10 | 18 - 29 |
| BMI (kg/m2) | 23.37 ± 4.01 | 16 - 32.20 |
| WHpR | 0.81 ± 0.11 | 0.58 - 1.30 |
| WHtR | 0.55 ± 0.10 | 0.37 - 0.81 |
| Anxiety (score) | 44.83 ± 17.71 | 15 - 87 |
Table 2 summarizes the intake of B vitamins and omega-3 among participants. The results showed that participants consumed B1, B2, B3, B5, B12, and omega-3 in amounts higher than or within the recommended normal range. However, their intake of B6, B7, and B9 was below the recommended levels.
The Data for B Vitamins and Omega-3 Received by Participants
| Vitamins | Mean ± SD | RDA (Recommended) |
|---|---|---|
| B1 (mg) | 1.18 ± 0.68 | 1.10 - 1.20 |
| B2 (mg) | 1.17 ± 0.79 | 1.10 - 1.30 |
| B3 (mg) | 12.90 ± 6.29 | 14.00 - 16.00 |
| B5 (mg) | 4.16 ± 2.86 | 5.00 |
| B6 (mg) | 0.87 ± 0.50 | 1.30 |
| B7 (mg) | 22.86 ± 9.42 | 30.00 |
| B9 (µg) | 130.53 ± 75.52 | 400.00 |
| B12 (µg) | 3.47 ± 1.93 | 2.40 |
| Omega-3 (g) | 0.91 ± 0.55 | 1.10 |
The findings revealed a positive correlation between BMI (R = 0.887, P = 0.0001), WHpR (R = 0.855, P = 0.0001), and WHtR (R = 0.898, P = 0.0001) with anxiety. The mean anxiety scores were 23.84 ± 4.36, 38.59 ± 4.62, 61.44 ± 13.63, and 74.44 ± 5.96 in underweight, normal, overweight, and obese participants, respectively. Additionally, a negative correlation was observed between vitamin intake and anxiety scores, as shown in Table 3.
The Correlation Between Receiving B Complex Vitamins and Omega-3 with Anxiety
| Vitamins | R a | P-Value |
|---|---|---|
| B1 (mg) | -0.785 | 0.0001 |
| B2 (mg) | -0.731 | 0.0001 |
| B3 (mg) | -0.753 | 0.0001 |
| B5 (mg) | -0.757 | 0.0001 |
| B6 (mg) | -0.712 | 0.0001 |
| B7 (mg) | -0.804 | 0.0001 |
| B9 (µg) | -0.391 | 0.0001 |
| B12 (µg) | -0.612 | 0.0001 |
| Omega-3 (g) | -0.630 | 0.0001 |
5. Discussion
The results indicated that most students exhibited moderate to high levels of anxiety and had a normal BMI. These findings are consistent with those reported by Anderson et al., who evaluated the correlation between depression, anxiety disorders, and weight changes in a prospective community study, showing a positive relationship between overweight and anxiety (22). Similarly, Rivenes found that a high WHpR is associated with an increased prevalence of anxiety and depression (23), which aligns with the current study's findings.
A review article examining the correlation between anxiety and BMI reported an inverted U-shaped association between anxiety and weight status (24). However, in contrast to the present findings, another population-based study exploring anxiety disorder diagnoses and BMI across different age, sex, and racial groups found no correlation between anxiety and BMI (25). The discrepancy between this study and others may stem from differences in the studied populations. The current study focused exclusively on female students, whereas other studies included both genders.
The correlation between obesity and psychological disorders is thought to be influenced by leptin metabolites, which affect dopamine pathways (26). Furthermore, anxiety may closely correlate with social avoidance. Puhl and Heuer reported a strong association between obesity, overweight, and social discrimination, particularly among women (27).
The results revealed a negative correlation between B vitamins and anxiety. A similar negative relationship has been reported between mental disorders and cobalamin, pyridoxine, folate, and riboflavin (12). Consistent with the present findings, a study investigating the association between adolescent mental health and B vitamin consumption found that B vitamins were significantly related to a reduction in psychological disorders (28). Additionally, a study conducted among 636 British women demonstrated that low dietary intake of vitamin B12 was associated with higher psychological distress (29).
The efficacy of B vitamins and folate in alleviating anxiety symptoms can be attributed to their critical roles in central nervous system development (11). B vitamins are essential for brain development, maintenance, and functioning, with deficiencies linked to increased psychological disorders (12). Furthermore, studies have shown that vitamins B6, B9, and B12 have protective effects against hyperhomocysteinemia, which is associated with mood disorders (30). Homocysteine can be converted to glutathione with the help of vitamin B6 and the enzyme cystathionine beta-synthase, contributing to antioxidant defense (31). Deficiencies in vitamin B12 and folate are also associated with poor responses to antidepressant medications in individuals with depression (32). Thus, B vitamins play significant roles in the antioxidant system, protect the nervous system, and influence medication efficacy. Moreover, vitamins B6, B9, and B12 are essential for proper methylation cycle functioning and the production of monoamine oxidase, which is involved in the synthesis of serotonin and other monoamine neurotransmitters (33). Impaired methylation function is associated with psychiatric disorders, including anxiety.
The findings regarding the correlation between omega-3 and anxiety align with those reported by Natacci et al., who highlighted the beneficial effects of omega-3 consumption in reducing anxiety (34). Other studies have also demonstrated a relationship between somatic anxiety and omega-3 deficiencies (35-37). Brain membranes are rich in omega-3 and its derivatives, and omega-3 deficiencies can lead to behavioral and neuropsychiatric disorders such as anxiety (38). Omega-3 fatty acids are involved in regulating several neurobiological processes, including neurotransmitter systems, neuroplasticity, and inflammation, which are all implicated in anxiety (39). Furthermore, polyunsaturated fatty acids like omega-3 play essential roles in the synthesis, release, reuptake, degradation, and binding of neurotransmitters (9), thereby influencing anxiety levels.
This study has several limitations, including potential errors in assessing food consumption and the lack of evaluation of various confounding factors, as some were unknown and, therefore, not controlled. Additionally, the study was conducted exclusively among female university students, which limits the generalizability of the findings to the broader population. Female university students may have higher nutritional literacy and greater attention to dietary intake compared to the general population, potentially influencing the results. Thus, these findings should be interpreted with caution. However, a notable strength of this study is that it is the first of its kind conducted at this university, providing valuable insights for policymakers to guide decision-making.
5.1. Conclusions
In conclusion, the data analysis for this population suggests a negative correlation between dietary intake of omega-3 and B vitamins with anxiety among female medical students at ZAUMS. Nonetheless, further longitudinal studies are needed to better understand the relationship between B vitamins and omega-3 intake and anxiety. Additionally, future research should include male students to broaden the findings. This study did not evaluate serum concentrations of vitamins and omega-3, which could be an important area for investigation in subsequent studies.
References
-
1.
Phillips CM, Shivappa N, Hebert JR, Perry IJ. Dietary inflammatory index and mental health: A cross-sectional analysis of the relationship with depressive symptoms, anxiety and well-being in adults. Clin Nutr. 2018;37(5):1485-91. [PubMed ID: 28912008]. https://doi.org/10.1016/j.clnu.2017.08.029.
-
2.
Spielberger CD. Anxiety. In: Kuper J, editor. Social Problems and Mental Health. Milton Park, Abingdon: Routledge; 2022. p. 15-9. https://doi.org/10.4324/9781003261919-7.
-
3.
Baxter AJ, Scott KM, Vos T, Whiteford HA. Global prevalence of anxiety disorders: a systematic review and meta-regression. Psychol Med. 2013;43(5):897-910. [PubMed ID: 22781489]. https://doi.org/10.1017/S003329171200147X.
-
4.
Wallace JE. Mental health and stigma in the medical profession. Health (London). 2012;16(1):3-18. [PubMed ID: 21177717]. https://doi.org/10.1177/1363459310371080.
-
5.
Gong Y, Han T, Chen W, Dib HH, Yang G, Zhuang R, et al. Prevalence of anxiety and depressive symptoms and related risk factors among physicians in China: a cross-sectional study. PLoS One. 2014;9(7). e103242. [PubMed ID: 25050618]. [PubMed Central ID: PMC4106870]. https://doi.org/10.1371/journal.pone.0103242.
-
6.
Nooryan K, Sasanpour M, Sharif F, Ghafarian Shirazi HR. Anxiety in Physicians and Nurses Working in Intensive Care Units in Yasuj's Hospitals/Iran. Procedia-Soc Behav Sci. 2014;122:457-60. https://doi.org/10.1016/j.sbspro.2014.01.1372.
-
7.
Kousha M, Bagheri HA, Heydarzadeh A. Emotional intelligence and anxiety, stress, and depression in Iranian resident physicians. J Family Med Prim Care. 2018;7(2):420-4. [PubMed ID: 30090787]. [PubMed Central ID: PMC6060923]. https://doi.org/10.4103/jfmpc.jfmpc_154_17.
-
8.
Kasper S. Anxiety disorders: under-diagnosed and insufficiently treated. Int J Psychiatry Clin Pract. 2006;10 Suppl 1:3-9. [PubMed ID: 24931537]. https://doi.org/10.1080/13651500600552297.
-
9.
Larrieu T, Laye S. Food for Mood: Relevance of Nutritional Omega-3 Fatty Acids for Depression and Anxiety. Front Physiol. 2018;9:1047. [PubMed ID: 30127751]. [PubMed Central ID: PMC6087749]. https://doi.org/10.3389/fphys.2018.01047.
-
10.
Green P, Hermesh H, Monselise A, Marom S, Presburger G, Weizman A. Red cell membrane omega-3 fatty acids are decreased in nondepressed patients with social anxiety disorder. Eur Neuropsychopharmacol. 2006;16(2):107-13. [PubMed ID: 16243493]. https://doi.org/10.1016/j.euroneuro.2005.07.005.
-
11.
Erensoy H. Vitamin B12 and Folic Acid in Depression and Anxiety: A Pilot Study. J Neurobehavioral Sci. 2020;7(3). https://doi.org/10.4103/jnbs.jnbs_32_20.
-
12.
Mahdavifar B, Hosseinzadeh M, Salehi-Abargouei A, Mirzaei M, Vafa M. Dietary intake of B vitamins and their association with depression, anxiety, and stress symptoms: A cross-sectional, population-based survey. J Affect Disord. 2021;288:92-8. [PubMed ID: 33848753]. https://doi.org/10.1016/j.jad.2021.03.055.
-
13.
Almeida OP, Ford AH, Flicker L. Systematic review and meta-analysis of randomized placebo-controlled trials of folate and vitamin B12 for depression. Int Psychogeriatr. 2015;27(5):727-37. [PubMed ID: 25644193]. https://doi.org/10.1017/S1041610215000046.
-
14.
Barghandan N, Dolatkhah N, Eslamian F, Ghafarifar N, Hashemian M. Association of depression, anxiety and menopausal-related symptoms with demographic, anthropometric and body composition indices in healthy postmenopausal women. BMC Womens Health. 2021;21(1):192. [PubMed ID: 33962601]. [PubMed Central ID: PMC8105920]. https://doi.org/10.1186/s12905-021-01338-w.
-
15.
Lee BJ. Association of depressive disorder with biochemical and anthropometric indices in adult men and women. Sci Rep. 2021;11(1):13596. [PubMed ID: 34193938]. [PubMed Central ID: PMC8245492]. https://doi.org/10.1038/s41598-021-93103-0.
-
16.
Zhang C, Li M, Zhao H, Zhu R, Zheng X, Lu J, et al. Are overweight people more susceptible to anxiety? Int J Geriatr Psychiatry. 2019;34(4):555-62. [PubMed ID: 30548677]. https://doi.org/10.1002/gps.5050.
-
17.
Chow S, Shao J, Wang H, Lokhnygina Y, Chow S, Shao J, et al. Sample Size Calculations in Clinical Research: Third Edition. New York, USA: Chapman and Hall/CRC; 2017. https://doi.org/10.1201/9781315183084.
-
18.
Wilson PB, Madrigal LA. Associations among Omega-3 Fatty Acid Status, Anxiety, and Mental Toughness in Female Collegiate Athletes. J Am Coll Nutr. 2017;36(8):602-7. [PubMed ID: 28910189]. https://doi.org/10.1080/07315724.2017.1335249.
-
19.
Esfahani FH, Asghari G, Mirmiran P, Azizi F. Reproducibility and relative validity of food group intake in a food frequency questionnaire developed for the Tehran Lipid and Glucose Study. J Epidemiol. 2010;20(2):150-8. [PubMed ID: 20154450]. [PubMed Central ID: PMC3900814]. https://doi.org/10.2188/jea.je20090083.
-
20.
Mirmiran P, Esfahani FH, Mehrabi Y, Hedayati M, Azizi F. Reliability and relative validity of an FFQ for nutrients in the Tehran lipid and glucose study. Public Health Nutr. 2010;13(5):654-62. [PubMed ID: 19807937]. https://doi.org/10.1017/S1368980009991698.
-
21.
Salehi Morkani B. [A Comparative Study of Affective Self-Regulation Strategies among Students with Differences in Anxiety and Depression with Normal Students in Isfahan[Thesis]]. Tehran, Iran: Alzahra University of Tehran; 2006. FA.
-
22.
Anderson SE, Cohen P, Naumova EN, Must A. Association of depression and anxiety disorders with weight change in a prospective community-based study of children followed up into adulthood. Arch Pediatr Adolesc Med. 2006;160(3):285-91. [PubMed ID: 16520448]. https://doi.org/10.1001/archpedi.160.3.285.
-
23.
Rivenes AC, Harvey SB, Mykletun A. The relationship between abdominal fat, obesity, and common mental disorders: results from the HUNT study. J Psychosom Res. 2009;66(4):269-75. [PubMed ID: 19302883]. https://doi.org/10.1016/j.jpsychores.2008.07.012.
-
24.
Haghighi M, Jahangard L, Ahmadpanah M, Bajoghli H, Holsboer-Trachsler E, Brand S. The relation between anxiety and BMI - is it all in our curves? Psychiatry Res. 2016;235:49-54. [PubMed ID: 26708439]. https://doi.org/10.1016/j.psychres.2015.12.002.
-
25.
DeJesus RS, Breitkopf CR, Ebbert JO, Rutten LJ, Jacobson RM, Jacobson DJ, et al. Associations Between Anxiety Disorder Diagnoses and Body Mass Index Differ by Age, Sex and Race: A Population Based Study. Clin Pract Epidemiol Ment Health. 2016;12:67-74. [PubMed ID: 27857777]. [PubMed Central ID: PMC5090775]. https://doi.org/10.2174/1745017901612010067.
-
26.
Popova D, Vandeva D, Tsurakova F, Georgiev G. [Leptin is associated with anxiety in women within a wide range of weight]. Archives of the Balkan Medical Union vol. 2016;51(1):29-33. FA.
-
27.
Puhl RM, Heuer CA. The stigma of obesity: a review and update. Obesity (Silver Spring). 2009;17(5):941-64. [PubMed ID: 19165161]. https://doi.org/10.1038/oby.2008.636.
-
28.
Herbison CE, Hickling S, Allen KL, O'Sullivan TA, Robinson M, Bremner AP, et al. Low intake of B-vitamins is associated with poor adolescent mental health and behaviour. Prev Med. 2012;55(6):634-8. [PubMed ID: 23010437]. https://doi.org/10.1016/j.ypmed.2012.09.014.
-
29.
Mishra GD, McNaughton SA, O'Connell MA, Prynne CJ, Kuh D. Intake of B vitamins in childhood and adult life in relation to psychological distress among women in a British birth cohort. Public Health Nutr. 2009;12(2):166-74. [PubMed ID: 18503720]. [PubMed Central ID: PMC2748268]. https://doi.org/10.1017/S1368980008002413.
-
30.
Kamphuis MH, Geerlings MI, Grobbee DE, Kromhout D. Dietary intake of B(6-9-12) vitamins, serum homocysteine levels and their association with depressive symptoms: the Zutphen Elderly Study. Eur J Clin Nutr. 2008;62(8):939-45. [PubMed ID: 17538543]. https://doi.org/10.1038/sj.ejcn.1602804.
-
31.
Mitchell ES, Conus N, Kaput J. B vitamin polymorphisms and behavior: evidence of associations with neurodevelopment, depression, schizophrenia, bipolar disorder and cognitive decline. Neurosci Biobehav Rev. 2014;47:307-20. [PubMed ID: 25173634]. https://doi.org/10.1016/j.neubiorev.2014.08.006.
-
32.
Tolmunen T, Hintikka J, Ruusunen A, Voutilainen S, Tanskanen A, Valkonen VP, et al. Dietary folate and the risk of depression in Finnish middle-aged men. A prospective follow-up study. Psychother Psychosom. 2004;73(6):334-9. [PubMed ID: 15479987]. https://doi.org/10.1159/000080385.
-
33.
Mikkelsen K, Stojanovska L, Prakash M, Apostolopoulos V. The effects of vitamin B on the immune/cytokine network and their involvement in depression. Maturitas. 2017;96:58-71. [PubMed ID: 28041597]. https://doi.org/10.1016/j.maturitas.2016.11.012.
-
34.
Natacci L, Marchioni MD, Goulart CA, Nunes MA, Moreno BA, Cardoso OL, et al. Omega 3 Consumption and Anxiety Disorders: A Cross-Sectional Analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). Nutrients. 2018;10(6). [PubMed ID: 29882923]. [PubMed Central ID: PMC6024589]. https://doi.org/10.3390/nu10060663.
-
35.
Chang JP, Guu TW, Chen YC, Galecki P, Walczewska A, Su KP. BanI polymorphism of cytosolic phospholipase A2 gene and somatic symptoms in medication-free acute depressed patients. Prostaglandins Leukot Essent Fatty Acids. 2018;136:111-5. [PubMed ID: 28108057]. https://doi.org/10.1016/j.plefa.2017.01.001.
-
36.
Thesing CS, Bot M, Milaneschi Y, Giltay EJ, Penninx B. Omega-3 and omega-6 fatty acid levels in depressive and anxiety disorders. Psychoneuroendocrinol. 2018;87:53-62. [PubMed ID: 29040890]. https://doi.org/10.1016/j.psyneuen.2017.10.005.
-
37.
Su KP, Matsuoka Y, Pae CU. Omega-3 Polyunsaturated Fatty Acids in Prevention of Mood and Anxiety Disorders. Clin Psychopharmacol Neurosci. 2015;13(2):129-37. [PubMed ID: 26243838]. [PubMed Central ID: PMC4540034]. https://doi.org/10.9758/cpn.2015.13.2.129.
-
38.
Bentsen H, Solberg DK, Refsum H, Gran JM, Bohmer T, Torjesen PA, et al. Bimodal distribution of polyunsaturated fatty acids in schizophrenia suggests two endophenotypes of the disorder. Biol Psychiatry. 2011;70(1):97-105. [PubMed ID: 21546001]. https://doi.org/10.1016/j.biopsych.2011.02.011.
-
39.
Su KP, Tseng PT, Lin PY, Okubo R, Chen TY, Chen YW, et al. Association of Use of Omega-3 Polyunsaturated Fatty Acids With Changes in Severity of Anxiety Symptoms: A Systematic Review and Meta-analysis. JAMA Netw Open. 2018;1(5). e182327. [PubMed ID: 30646157]. [PubMed Central ID: PMC6324500]. https://doi.org/10.1001/jamanetworkopen.2018.2327.