INTRODUCTION

Psychological disorders like depression and anxiety have a significant impact on global health. In Iran,
about 21% of adults experience mental disorders, with depression and anxiety being the most common
conditions.

Various factors, including social, environmental, and biological factors, contribute to psychological
disorders. Diet is a modifiable factor that plays a crucial role in mental health. Research has mainly
focused on micronutrients, and limited information is available on macronutrients. However, diets low in
carbohydrates and high in fats and proteins have been associated with a higher risk of mood disorders.

High protein intake has shown a protective association with depressive symptoms, while low protein
intake is associated with a higher prevalence of mental illnesses. Dietary glycemic index, which measures
the impact of carbohydrates on blood sugar levels, has been linked to incident depression and
psychological disorders. High-fat diets can impact stressful behaviors, and high protein intake affects
brain functioning and mental health through the production of neurotransmitters.

Most previous studies have examined individual macronutrients, but a newly suggested dietary pattern
called the low carbohydrate diet considers the proportion of all macronutrients. This diet has been
extensively studied in relation to metabolic diseases but has not been explored in terms of psychological
disorders. This study aims to investigate the association between adherence to a low carbohydrate
dietary pattern and psychological disorders among Iranian adults, which is particularly relevant in Middle
Eastern countries where carbohydrate intake is high.

In summary, diet plays a role in mental health, and the low carbohydrate diet is being studied for its
potential impact on psychological disorders in Iran.

METHODS

(STUDY POPULATION)

This study was conducted as part of the SEPAHAN project, which aimed to investigate the relationship
between lifestyle factors and functional gastrointestinal disorders. Participants were recruited from the
general population of Isfahan province, specifically from health centers affiliated with Isfahan University
of Medical Sciences (IUMS).
Data collection occurred in two phases from April 2010 to May 2010. In the first phase, self-administered
questionnaires were distributed to 10,087 individuals, of which 8,691 responded (response rate:
86.16%). The second phase involved sending questionnaires on psychological health to 9,652
participants, with 6,239 questionnaires completed and returned (response rate: 64.6%). The
demographic data of those who responded and those who did not respond did not differ significantly.

Data from both phases were merged, resulting in a sample size of 4,763 people. After excluding
individuals with under- or over-reporting of energy intake and those with missing data, data from 3,362
participants were included in the current study. Written informed consent was obtained from all
subjects, and the study was approved by the Regional Bioethics Committee of IUMS.

In summary, participants were selected from the general population of Isfahan province through health
centers, and data from 3,362 individuals were included in the study after exclusions.

(ASSESSMENT OF DIETARY INTAKE)

The study used a questionnaire called the Willett-format dish-based semi-quantitative food frequency
questionnaire (DS-FFQ) to assess participants' daily dietary intake of energy, macronutrients, and
micronutrients. This questionnaire was specifically designed and validated for Iranian adults.

The DS-FFQ consisted of 106 items categorized into five main food groups: mixed dishes, grains, dairy
products, fruits and vegetables, and miscellaneous food items and beverages. Participants provided
information on their frequency of consumption for each item.

To calculate the low carbohydrate diet (LCD) score, participants were categorized into deciles based on
the percentage of energy they obtained from carbohydrates, proteins, and fats. The lowest decile of
carbohydrate intake received the highest score of 10 points, while the highest decile received 1 point.
The scoring for fat and protein intakes was reversed. The scores for the three macronutrients were then
added together to obtain the overall diet score, ranging from 3 (highest carbohydrate intake and lowest
fat and protein intake) to 30 (lowest carbohydrate intake and highest fat and protein intakes). A higher.

(Assessment of psychological health)

The study used two validated questionnaires to assess psychological health: the Hospital Anxiety and
Depression Scale (HADS) and the General Health Questionnaire (GHQ).

HADS is a brief questionnaire consisting of 14 items that measure anxiety and depression symptoms.
Each item is rated on a four-point scale, and higher scores indicate more severe symptoms. Scores of 8 or
higher on either subscale were considered as psychological disorders, while scores of 0-7 were
considered as "normal."
The GHQ-12 is a simple questionnaire with 12 items used to assess psychological distress. Participants
rate each item on a four-point scale, and higher scores indicate greater distress. In this study, a score of 4
or higher was considered as psychological distress.

The validity of both questionnaires was examined in separate studies with Iranian adults and young
people, respectively. The results showed that the questionnaires provide relatively valid measures of
psychological health.

In summary, the HADS and GHQ-12 questionnaires were used to assess anxiety, depression, and
psychological distress in the study, providing valuable insights into participants' psychological well-being.

(Assessment of other variables)

The study collected information on various variables including age, sex, marital status, socioeconomic
status (SES), smoking status, gestational and lactating status, chronic conditions (diabetes and colitis),
and the use of antidepressants and supplements (vitamins, minerals, calcium, and iron).

SES score was calculated based on family size, education level, and property ownership. A score of 1 was
given if participants had a family size of ≤4, had academic education, or owned a house, and a score of 0
was given if participants had a family size of >4, had non-academic education, or had leasehold property.
The total SES score ranged from 0 to 3, with a score of 3 indicating high SES.

Physical activity was assessed using the General Practice Physical Activity Questionnaire (GPPAQ) and
participants were categorized as physically active (≥1 hour/week) or physically inactive (<1 hour/week).
Even 1 hour per week of walking was considered beneficial for reducing the risk of chronic conditions.

Anthropometric measures such as weight, height, and waist circumference were self-reported by
participants. The validity of self-reported values was assessed by comparing them with measured values
in a pilot study. The correlation coefficients showed a high level of agreement between self-reported and
measured values.

Body mass index (BMI) was calculated using self-reported weight and height. Participants were
categorized into three groups based on their BMI status: obese (BMI ≥ 30 kg/m2), overweight (25 ≥ BMI
> 30 kg/m2), and normal (BMI < 25 kg/m2).
In summary, the study collected information on age, sex, marital status, SES, smoking status, gestational
and lactating status, chronic conditions, antidepressant and supplement use, physical activity, and
anthropometric measures such as weight, height, waist circumference, and BMI.

(Statistical Analysis)

To compare the characteristics of the study participants based on their adherence to the low
carbohydrate diet (LCD), statistical tests were used. One-way ANOVA was used to compare continuous
variables like age, weight, BMI, and waist circumference, while the Chi-square test was used for
categorical variables. The mean dietary intakes were obtained using one-way ANOVA.

The prevalence of depression, anxiety, and psychological distress across different categories of LCD score
was assessed using the Chi-square test. To investigate the relationship between adherence to the LCD
and depression, anxiety, and psychological distress, multivariable logistic regression analysis was
performed in different models. The models were adjusted for various factors such as age, sex, marital
status, socioeconomic status, smoking, physical activity, presence of chronic diseases, antidepressant
and supplement use, and pregnancy or lactation.

Additional adjustments were made for dietary fiber and EPA plus DHA intake, and BMI was included in
the final model. The first quartile of the LCD score was used as the reference category. The trend of odds
ratios across increasing categories of LCD was assessed by using the median score as a continuous
variable.

To correct the adjusted odds ratios obtained from logistic regression, a formula suggested by Zhang and
Yu was used. Statistical analyses were performed using SPSS software, and a significance level of p < 0.05
was considered statistically significant.

RESULTS

The prevalence of depression, anxiety, and psychological distress in the whole population was 28.0%,
13.3%, and 22.6% respectively. Participants in the highest quartile of the low carbohydrate diet (LCD)
score had higher weight, BMI, and waist circumference. They were more likely to be male, obese,
physically active, have a higher socioeconomic status, and be university graduates compared to those in
the lowest quartile. The prevalence of chronic conditions and smoking was also higher among
participants in the highest quartile.

There were no significant differences in the prevalence of depression, anxiety, and psychological distress
across different categories of LCD score. Participants with psychological disorders had lower intakes of
fiber, EPA and DHA, vitamin B6, and magnesium, as well as lower consumption of fruits, vegetables, and
low-fat dairy compared to those without psychological disorders.
Participants in the highest quartile of the LCD score had higher intakes of energy, protein, fats, saturated
fats, polyunsaturated fats, EPA and DHA, various vitamins, vegetables, white meat, red meat, eggs,
legumes, nuts, and high-fat dairy products compared to those in the lowest quartile. They had lower
intakes of carbohydrates, fiber, vitamin B1, folate, iron, magnesium, fruits, refined grains, whole grains,
sugar-sweetened beverages, and tea or coffee.

After adjusting for potential confounders, no significant associations were found between adherence to
the LCD and the prevalence of depression, anxiety, or psychological distress. These associations did not
change when analyzing the data by gender or BMI status.

In summary, adherence to the LCD was not significantly associated with the prevalence of depression,
anxiety, or psychological distress, after considering various factors.

DISCUSSION

This study conducted in a large group of Iranians found no significant association between adherence to
the low carbohydrate diet (LCD) and the prevalence of psychological disorders. Previous studies mostly
focused on individual macronutrient intakes rather than considering the whole dietary macronutrient
composition.

Some studies suggested an inverse association between high carbohydrate and high protein intakes and
depression, while others reported no significant associations. The quality of carbohydrates, such as
glycemic index, may also play a role in psychological health. The effects of specific fats and proteins on
psychological health need further investigation.

It is important to note that this study had limitations. The cross-sectional design does not establish
causal relationships, and self-administered questionnaires may introduce misclassification of exposure
and outcome variables. There were also measurement errors in assessing anthropometric indices, diet,
and physical activity. The study population consisted of university staff, limiting generalizability. Despite
controlling for various confounding factors, residual confounding effects cannot be completely ruled out.

In summary, further research is needed to examine the relationship between different types of
macronutrients together and their impact on psychological health.
CONCLUSION

In summary, this cross-sectional study did not find a significant association between adherence to the
low carbohydrate diet (LCD) and the likelihood of experiencing psychological disorders. Although
previous research has suggested links between specific macronutrients and mental health issues, our
study did not find evidence to support the idea that a combination of high fat and protein intake with
low carbohydrate intake, as measured by the LCD score, is associated with psychological disorders in our
study population. Further longitudinal studies focusing on different types of macronutrients are needed
to provide more clarity on this association.