COMPREHENSIVE EXAM 1

Question 1 Health and Human Performance

Introduction

For fifty years, the U.S. population has seen a distinct increase in obesity, thus creating a

rise in health conditions such as heart disease, diabetes, stroke, and certain cancers (De Lorenzo

et al., 2019; Sarma et al., 2021). Obesity can be defined and described as “The state of being

overweight, exceeding recommended BMI, or excessive fat accumulation’ (Fruh, 2017).

According to Fruh (2017) obesity is when a person has abnormal or excessive body fat that can

present chronic dieses and other health risks. Yet Cavuto & Nussbaum describe obesity as “being

associated with a decrease in capillary density and reduced blood flow to skeletal muscle”

(Cavuoto, & Nussbaum,2014). The global obesity epidemic and its prevalence continues to grow

among many adults with stress and other negative emotions acting as a major cause of excessive

weight gain. According to Centers for Disease Control and Prevention obesity affects more than

42% of American adults and is a significant health concern that has led to premature deaths in

more than half of U.S adults (Centers for Disease Control and Prevention, 2023). Research using

cohorts based on age groups showed that over 15% in the ages 20 to 24 range are overweight,

with nearly 40% of older adults over the age of 50 years recorded as obese (Centers for Disease

Control and Prevention, 2023; Chooi et al., 2019). Experts suggested that this increase in obesity

has occurred because society has become heavily involved in technological use in their daily

lives (Blüher, 2019; De Lorenzo et al., 2020).

In contrast, such involvement leads to increased time sitting in front of a computer screen

while working rather than doing manual labor which involves actively moving around. For

example, this may include basic work duties such as walking to the printer, gathering supplies,

lunchtime breaks, etc. Studies have shown individuals choose to spend their time utilizing
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technology, with a significantly increased amount of time spent playing computer games,

watching television and film, and otherwise becoming much more sedentary than ever before.

Instead of participating in sports or being physical after work and school or on weekends, many

choose to continue with their sedentary behaviors throughout the work and school day, offering

the body no ability to exercise or burn calories the way individuals did during previous

generations who did not have the advanced technology that the world has today(Park et al.,

2020). Sedentary lifestyles are spreading worldwide because of a lack of interest in exercise,

increased occupational sedentary behaviors such as office work, and the increased usage of

television and cellular devices. According to Park et al. (2020) sedentary behaviors are defined as

“any waking behavior such as sitting or leaning with an energy expenditure of 1.5 metabolic

equivalent task (MET) or less. Consequently, the associated health problems are on the rise

affecting the human body through various mechanisms such as impaired lipid metabolism and

diminished carbohydrate metabolism making it harder for the body to breakdown food. As a

result, this leads to a slower metabolism in which food cannot be converted into energy as

efficiently as it should, this leading to weight gain, and fatigue.

O’Brien et al. (2018) investigated the relationship between physical activity participation, screen

time and weight status amongst adolescents. The data gathered in the present study included

physical activity, screen time (self-report) and body measurements. Overweight and obese

participants accumulated more minutes of screen time daily compared to normal weight

participants. The results suggested that there was a significant weight difference with overweight

and obese participants spending more minutes per day of screen time than normal weight

participants (t (147) = −2.105, p = 0.037) (O’Brien et al., 2018). With the upcoming generations
COMPREHENSIVE EXAM 3

technology has been one of the biggest distractions and many people don’t want to spend time

preparing heathy meals in addition to the price of heathier foods being more expensive.

Additionally, families focus on the speed of meal preparation, leading to many

individuals choosing simpler and more convent options such as fast food, drive-thru items, and

pre-packaged food, which results in the consumption of empty and calorie-laden foods and

beverages (De Lorenzo et al., 2020). This causes concern for individuals to highly resist calorie-

rich foods, with evidence suggesting that the difficulty to withstand from highly calorie-rich

foods represents a concern for addictive unhealthy behaviors (De Lorenzo et al., 2020). As fast

food tends to become an emerging trend around the world it has caused obesity rates to skyrocket

among individuals particularly in adolescents (Banik et al., 2019). De Lorenzo et al. (2020)

suggested that college students are prone to consuming fast food which increases the risk of

obesity in their future life. Students are more prone due to the stress of school along with

depression rates (Baik et al., 2019). In this study done by Baik et al. (2019) results revealed that

68.1% of students consumed fast foods at least once during the week with pressure and

convenience being the main drivers that triggered students. There was significant difference

between students who took and did not take fast food in the previous week regarding to gender,

and educational majors (p<0.05) (Baik et al., 2019). The study found a significant association of

fast-food consumption with a higher prevalence of obesity with (29.9% in fast food consumers

vs 9.1% in non-fast-food consumers, p<0.05) (Baik et al., 2019). Although these may be quick

meals, for many these quick and convenient meals lack nutritional values which can lead to not

only obesity but other chronic diseases such as heart disease, and certain cancers with breast

cancer being the most common (Chan et al., 2019). According to Pati et al. (2023) there are 4–

8% of all cancers that are caused due to obesity. Obesity is a risk factor for several major
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cancers, including breast, colorectal, endometrial, kidney, esophageal, pancreatic, liver, and

gallbladder cancer (Pati et al.,2023). Quicker food options can contribute to obesity, while these

food options tend to be low in essential nutrients like vitamins, minerals, and fiber (Pati et al.,

2023).

Hence, quicker food options may be more convenient than cooking meals from scratch at

home, they often lead to a sedentary lifestyle. However, they are often laden with fats, salts,

sugar, and other unhealthy ingredients (Pati et al., 2023). Wadolowska et al. (2018) investigated

the association between fast food and lifestyle behaviors among polish teens. Teens who

consumed more fast-food had sedentary behaviors along with the highest frequency consumption

of fast foods, carbonated beverages, energy drinks and sweets, vs teens who were active and

consumed vegetables, and fruits. In Fast-food sedentary teens, the chance of obesity was 2.22

times higher than active teens (Wadolowska et al., 2018). Consistent consumption of these food

items can easily lead to weight gain, in addition to consuming carbonated beverages, together the

two can add extra weight causing obesity from high sugar content. (Chan et al., 2019). For

instance, sugar is a type of carbohydrate that is quickly broken down by the body, leading to a

spike in blood sugar levels. When blood sugar levels rise too quickly, the body releases insulin to

help regulate them (Wadolowska et al., 2018). Insulin is to help regulate in which promotes fat

storage around the abdominal area leading to weight gain (Wadolowska et al., 2018).

Therefore, not only has unhealthy eating been a cause for obesity but it has led to

increased cases of depression both as a diagnosis and those who self-report experiencing

consistently low moods (Blondal et al., 2022; Fulton et al., 2022). Blondal et al. (2022) reported

weight gain was associated with an increased risk of depression. According to the World Health

Organization, more than 300 million people suffer from depression (WHO,2023). Depression is
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a severe mental illness characterized by many different psychological and physical symptoms,

such as negative emotions of sadness, guilt, and sleep disorders (Wang et al., 2023). Depression

has become one of the leading causes of obesity in which has led to many to disability and even

death (Wang et al., 2023). Emerging evidence indicated that depression included a combination

of genetic factors such as obesity, and disorders that affect one’s metabolism causing weight loss

issues. Obesity is a growing health concern around the world and has been implicated in the

development of depression. Previous studies have recognized body weight as being closely

related to the risk of depression (Luppino et al., 2010). The study done by Wang et al. (2023) aim

was to investigate the effect of weight change and depression through the National Health and

Nutrition Examination Survey (NHANES). The results suggested that 10 years before the survey

285 out of 1895 participants vs age 25 years to the survey 719 participants out of 5994 self-

reported being depressed due to weight gain (p0.001 vs p0.281) (Wang et al.,2023).

As individuals age, they are more likely to gain weight as metabolism slows down the

process of converting food to energy (Fulton et al., 2022). The slowing of metabolism, combined

with less activity as many who age become more sedentary, causes an increase in weight

increasing the propensity for poor health and health conditions or creating a multimorbidity of

potential diseases (Dodds et al., 2020; Lin et al., 2021). Within the medical and psychiatric

communities, there is extensive anecdotal evidence through observational validation of the

potential risk factor of diet as it is associated with depression (Fulton et al., 2022; Ma et al.,

2022). This evidence indicates that there has been a long-term experience of these professionals

in correlating poor eating habits to increased experiences of low moods or a depression

diagnosis. Experts have examined this potential, recognizing how specific nutritional values are

associated with symptomologies found within depression (Fulton et al, 2022; Milaneschi et al.,
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2019). Using levels of vitamin and mineral deficiency as a baseline for study participants,

researchers examined and found an association of depression in particular individual treated

patients (Fulton et al., 2022; Okereke et al., 2020). However, this phenomenon has limited

research, with Fulton et al. (2022) and Blondal et al. (2022) suggesting future studies focus on

methods to decrease depression through nutrition and weight loss. Even with substantial and

continued research that currently exists, there are still many medical professionals who feel that

the best treatment for depression is prescription medication. Davis et al., (2016) found that 42-

70% of depressed patients improve with drugs and 21%-39% improved with placebo. These

same professionals believe the chemical imbalance of depression found within the brain can only

be appropriately corrected through pharmaceutical compounds (Fulton et al, 2020; Milaneschi et

al., 2019).

Although, this is not an intentional oversight by those in the medical community, it can

be challenging to motivate individuals in the medical community to prescribe healthier eating

habits instead of relying on medications with extensive research supporting their efficacy (Fulton

et al, 2022; Milaneschi et al., 2019). Some in the field may also question whether it would be

ethical to prescribe changes to diet rather than the proven medication, as some might see this as

being harmful to patients or acting outside of the scope of the professional code of ethics in not

prescribing a medication known to work for others with depressive disorders (Milaneschi et al.,

2019; Okereke et al., 2020). The best way to change the minds and training programs for health

professionals is to do more research on this topic. To examine the nutritional effects and

possibilities within patients diagnosed with depression, a detailed explanation of how depression

occurs is necessary.

Nutrition in Older Adults

There is a high potential for risk factors of depression based on the nutritional value of

certain facets of a diet (Godos et al., 2023; Ma et al., 2019). Research suggests a correlation

between poor dietary habits and mental health, including depression. Diets that are rich in

omega-3 fatty acids, antioxidants, and B vitamins have positive effects on the brain (Dighriri et

al., 2022). Conversely, diets that include foods high in sugar might contribute to a higher risk of

mental health issues, especially depression (Dighriri et al., 2022). However, omega-3 fatty acid is

involved in the regulation of neurotransmitters such as serotonin and dopamine which are

responsible for mood regulation (Dighriri et al., 2022). With ongoing research some studies have

shown that increasing omega-3 fatty acids in the diet influence depression (Dighriri et al., 2022).

A study done by Zheng (2023) evaluated the effectiveness of omega-3 fatty acid supplements in

decreasing depression symptoms in patients with mild to moderate depression. The results

suggested that there was a statistically significant improvement in depression symptoms in which

researchers measured using the Hamilton Depression Rating Scale (HDRS)(Zheng,2023). The

HDRS scores at the third follow-up were significantly lower in patients with depression vs the

first follow up visit (Q = 5.89; p = 0.0001) (Zheng,2023). This indicating that an omega-3 fatty

acid supplement elicited significantly higher improvements in depressive symptoms (Zheng,

2023).

Thus, there has been a major depressive disorder in women who past the childbearing age

who in which are at an increased by 10%-25% for occurrence of depressive systems at least once

during these years (Guo et al., 2018). According to Zheng (2023) nutritional modifications to a

diet can correct the same nutritional deficiencies that contribute to poor mental health such as

depression. The study by Lassale et al. (2018) found that there was a significant association
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between a lower risk of depression following a mediterranean diet even though diets fluctuate

from person to person this diet had the most success on lowering depressive symptoms.

Such changes to the diet are significant because they provide a low-cost option in addition to

Medicare. Medicare is for those who cannot afford to see a mental health professional and for

those who cannot afford medication prescribed to them to treat their depressive symptoms

(Medicare,2023). Medicare, the U.S. government health insurance program helps provide a

health care coverage primarily for individuals 65 and older, as well as certain younger

individuals with disabilities (Medicare,2023). This program helps to provide coverage for mental

health options through outpatients or inpatient services both including visits to a psychiatrist,

psychologist, clinical social workers, etc. (Medicare,2023). Additionally, many people with

depression issues often have a higher chance of metabolic abnormalities, which dramatically

incur a higher nutritional requirement (Fulton et al., 2022; Milano et al., 2020). Fulton et al.

(2022) and Sarma et al. (2021) suggested that the improvement in nutrition has a positive effect

on the way antidepressants work in a person’s system. This is due to nutrients like omega 3 fatty

acids, particularly eicosatetraenoic and docosahexaenoic helping to boost production of brain

derived neurotrophic factor in which help support the growth neurons (Sarma et al., 2021).

Whether healthcare providers prescribe medication, patients could boost their happiness by

adding healthier foods to their diets.

Nutrition, Exercise, and Weight

Even though this project mainly discusses the relationship between diet and depression, it

is important to discuss the relationship between exercise and depression mainly because it could

be an alternative, non-pharmaceutical depression treatment that researchers like Izquierdo et al.

(2021) argued. Exercise appears to produce both inflammatory cytokines and reactive oxygen
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species, but these effects lower the inflammatory responses in the long term. After completing

exercise there is a notable reduction in the inflammatory response, accompanied by a surge in

oxidative activity (Thirupathi et al.,2021).

As a person exercises regularly, it leads to an overall reduction of systemic and chronic

inflammation in one’s body (Thirupathi et al., 2021). Additionally, the levels of leptin are also

reduced, which also helps to lower depression risk. Leptin is a hormone produced by fat cells

that influence appetite and metabolism by communicating to the body’s basal metabolic rate also

known as the body’s energy status (Thirupathi et al., 2021). Another important component

related to exercise is the connection between inflammation, sedentary tendencies, and depression

(Thirupathi et al., 2021). Being sedentary most of the time (regardless of how much exercise one

exercises) leads to inflammation that is related to adiposity (Azzolino et al., 2020). A sedentary

lifestyle has been associated with increased mortality risk, but more research is needed to fully

understand its association with depression.

Alternative Treatments for Depression and Obesity

According to Apovian et al. (2016) health practitioners are very slow to change and still

rely heavily on pharmaceuticals to treat obesity and depression. Consequently, nutrition,

vitamins, minerals, and overall diet have typically not been examined as contributors to

depression or how modifications to medicine of these factors could be considered an alternative

(Apovian et al., 2016). For example, yoga has been increasingly popular in the West, even

though it is an ancient practice known for at least 5000 years. The positive effect of yoga has yet

to be fully understood, but researchers discussed the possibility that the results of yoga are

directly connected to its complex practice (Manoharan et al., 2021; Yadav et al., 2022). Yoga has

been argued to be an effective alternative treatment for depression because it appears to

positively affect the regulation of the sympathetic nervous system (Manoharan et al., 2021).

Consequently, it could downregulate cortisol levels in an organism (stress hormone) and reduce

blood pressure (Yadav et al., 2022). Pranayama, or breathing component, could decrease the

activation of the sympathetic nervous system and positively impact brain functions (Yadav et al.,

2022).

Mindfulness and meditation were considered significant and positive alternative

depression treatments, and it has been proposed that two components are of particular

importance with a calm of acceptance that everything that is happening is bad or good (Hooker et

al., 2022; Pellegrini et al., 2021). Results from multiple studies demonstrated that in nearly 50%

of participants, the incidents of depression relapse were reduced (Kendrick, 2021; McCartney et

al., 2021). Mindfulness and meditation possess crucial elements that can aid in addressing

depression. By fostering a serene observation and acceptance of one's present state, regardless of

its difficulty, these practices lead to reduced denial, less rumination, and more moderated

avoidance. Additionally, they diminish tendencies for self-judgment (Hooker et al., 2022;

Kendrick, 2021). The positive impact of meditation and mindfulness, serving as an alternative

intervention, indeed alleviates symptoms in individuals diagnosed with depression (Kendrick,

2021).

Depression in Older Adults

In the past centuries, depression has been both difficult to identify and typically ignored

by the medical community, declaring it to be just imaginary particularly in women (Spacks,

2022). It took decades for mental health professionals to begin to consider the symptoms and to

create a process of identifying symptoms of depression and giving the psychological health

disorder a name. Contemporary society, however, recognizes that depression is an officially

defined mental illness with specific symptomology and diagnostic benchmarks that impact a

person’s brain as well as providing daily struggles and difficulties for those who have the

affliction (Sheikh, 2019). However, as technology has advanced, such research and brain scans

have enabled the medical community to see certain practical elements in the neurological system

rather than to assume that mental health disorders exist only in the way individuals feel about

themselves and the world around them.

During the 20th century, psychological experts in brain activity and therapeutic

techniques began examining humanistic and existential theories that represented the affirmation

of healthy individuality rather than focusing solely on individual parts of the body (Gong et al.,

2020). One such expert, Austrian psychiatrist Viktor Frankl, examined how feelings of despair

and futility were associated with depression. Frankl used logotherapy to see how brain activity

caused feelings of sadness and hopelessness. Logotherapy is defined as a psychotherapeutic

approach that focuses on finding meaning in life as a central motivating force for psychological

well-being (Rahgozar, & Giménez-Llort,2020). Also, Frankl investigated specific errors in brain

activity that he felt were the cause of certain depressed behaviors.

Other famed mental health theorists and experts, such as May, Maslow, Ellis, and Beck,

continued Frankl’s exploration into the brain, frequently suggesting different theoretical

constructs to determine the reasoning behind depression and to use that information to formulate

plans and protocols to treat depression in those who suffer. Although these professionals

remained focused on identifying external sources that led to depression symptoms, other experts

believed depression was caused by the lack of synapses in the brain between neurons (Filatova et

al., 2021; Marek et al., 2022). Even other experts recognized that the size of the hippocampus

and its respective interplay with the amygdala is responsible for depression, suggesting that a
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smaller hippocampus will have ongoing stress hormone impairment of the growth of nerve cells

(Cheng et al., 2019; Filatova et al., 2021).

With consistently improving advancements in medical technology such as positron

emission tomography (PET), functional magnetic resonance imaging (fMRI), and single-photon

emission computed tomography (SPECT), experts were able to monitor brain activity closely.

This technology allowed medical professionals to observe brain regions and their respective

functions while scientifically visualizing how these functions regulate brain activity regarding

emotions such as mood. Using such means and technologies, researchers examined the brain’s

ability to convert nutritional values into brain functions by absorbing the nutrients from the food

such as glucose, amino acids, and fatty acids. These nutrients are then absorbed by the blood

stream during digestion. The blood stream then transports these nutrients to the brain, in which

glucose is used most often as a main contributor for energy sources for the brain (Marek et al.,

2022). (Marek et al., 2022). Finding that levels of vitamins and minerals of patients diagnosed

with depression were much lower than patients without depression, the authors recognized the

correlation between depressed behavior and nutritional intake, citing that poor nutrition with

other secondary factors can be a precursor to a depression diagnosis (Marek et al., 2022).

Nutrition and Depression

While research began to definitively indicate a connection between high sugar content,

high glycemic content, and individuals experiencing symptoms and feelings of depression, this

was only the beginning. Researchers continued to examine the correlation between nutrition and

mood. Understanding that definitive proof of a relationship could result in a non-medicated

treatment plan to benefit individuals who suffer from depression and depressive symptoms;
COMPREHENSIVE EXAM
13

researchers decided to continue considering just how connected nutrition and mental health may

be.

Current evidence supports nutritional interventions in the treatment of unipolar

depression (Blondal et al., 2022; Fulton et al., 2022). Evidence from the existing literature

suggested nutritional elements do affect individuals diagnosed with unipolar depression,

although there is not enough strong support for this evidence, particularly with variables such as

obesity and age (Blondal et al., 2022; Fulton et al., 2022). Based on this, further study was

recommended, as the implications of a clear result could be considered groundbreaking for many

who live each day with debilitating or draining feelings tied to low moods or diagnosable

depressive disorders.

Summary

As society continues to grow and change and as more people spend their time in a

sedentary lifestyle while eating increasingly unhealthy diets, researchers must discover how to

counter these lifestyles to prevent or help minimize the number of people who spend each day

battling negative moods or diagnostic levels of depression. The first step to overall well-being is

acknowledging the importance of nutritional diets on mental health. Embracing a balanced diet,

regular exercise, and sufficient sleep not only empowers individuals to influence their mental

health success but also significantly impacts their overall well-being().

Nutrition influences depression through various mechanisms. Certain nutrients play an

important role in the production of neurotransmitters such as dopamine, which are linked to

mood regulation. For example, omega-3 fatty acids found in fish have been linked to a reduced

risk of depression (Dighriri et al., 2022). Consequently, maintaining a balanced diet not only

supports overall brain function but also leverages the antioxidant properties in fruits and
COMPREHENSIVE EXAM
14

vegetables to protect against oxidative stress, which is implicated in menta health disorders

(Dighriri et al., 2022). Researchers have only started to recognize that a person’s diet could be

both a contributor to developing depression (or at least being at risk for depression) and a

perfectly modifiable factor that could help a person battle their depression or reduce their

depression risk. One recent direction of the research has been to understand better how an

inflammation-promoting diet could be a factor that connects chronic low-grade inflammation and

depression. It appears that we now have enough data to argue the connection, where cytokines

appear to play a significant role. Additionally, and also related to poor dietary choices is the

phenomenon of leaky gut, where gram-negative bacteria, typically isolated and confined in a

healthy gut, are being translocated, triggering additional chronic and low-grade inflammation

brought on by the constant immune response.

Diet modification, healthy food choices, and treating nutrition as a factor contributing to

depression offer alternative approaches on how to treat depression. Healthcare professionals have

been slow to change and still see pharmaceuticals as the primary depression treatment mode.

However, as was discussed in this project, in addition to diet, there are other alternative ways to

treat depression that do not include drugs. Exercise has been shown to reduce inflammation in

the long term and should be seen as an effective alternative treatment. Other alternative

approaches like yoga, mindfulness, and meditation have also been shown to be effective

treatment options that could reduce symptoms, prevent relapses in chronic cases, prevent

symptoms worsening, and provide additional physiological benefits like hormonal regulation,

positive impact on the sympathetic nervous system, and others.

Overall, there is significant research to support the claim that nutrition can help minimize

and eliminate signs and symptoms related to depression and as additional research continues to
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occur, society becomes increasingly aware of modifiable factors like diet or exercise and

alternative treatments for depression that could ultimately help to change or at least minimize

depressive symptoms so that patients could eventually emerge victorious from their battle with

depression.
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Question 2 Research Study

Introduction

Older adults over the age of 50 years show an increase in obesity (Fulton et al., 2022).

The Centers for Disease Control and Prevention (2023) recognizes an increase in older adult

obesity, with the prevalence increasing from 30.5% in 2017 to over 40% in 2022. Combating this

increase, healthcare professionals provide advice for obese patients to prevent diseases and

conditions, including heart disease, high cholesterol, and diabetes, by maintaining a healthy

weight. The proposed study will examine the impact that nutrition has on a population of older

adults who are diagnosed as being obese and having depression but not yet treated with

pharmaceuticals.

Such examinations correlating depression symptoms with nutrition offered specific

validations for their beliefs and justifications (Cheng et al., 2019; Marek et al., 2022). With the

turn of the 21st century providing little question that depression was, in fact, a growing severe

mental illness problem for society overall, many experts began looking beyond pharmacological

treatment methods and investigating the body’s reactions to certain environmental factors and

whether they may contribute to symptoms of depression (Filatova et al., 2021; Gong et al., 2020)

With depression classified as a mental illness and remarkably increasing in older adults, the

medical community frequently trained their mental health professionals to favor antidepressant

medication recommendations rather than considering a more holistic method of treatment

(Filatova et al., 2021; Marek et al., 2022).

For those wishing to take a more comprehensive approach to managing depressive

symptoms, many believe that there are methods that are more advantageous in treating

depression in adults and include changes in diet with an emphasis on healthy food choices, as
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well as pairing healthier diets with exercise. The problem is that it is not known how older adults

who are diagnosed with both obesity and depression describe the impact nutritional changes have

on their depression and obesity status. While there is a limited amount of research focused on

obesity in older adults, there is a need to determine how diet and nutrition impact depression in

this population. Fulton et al. (2022) and Blondal et al. (2022) suggested more research is needed,

and future studies should focus on how changes in nutrition decrease depression through

nutrition and weight loss in older obese adults.

Purpose

The purpose of the proposed qualitative descriptive research is to learn how older adults

who are diagnosed with both obesity and depression describe the outcomes of their depression

and obesity when provided with methods for nutritional changes. The current study will use a

qualitative methodology with a descriptive research design and will establish a nutritional diet

plan for each participant based on expert nutritionist and healthcare providers' suggestions. To

fulfill this purpose which addresses the stated problem, the three following research questions

will be answered:

Research Questions

RQ1: How do older adults, diagnosed with both obesity and depression, describe the

methods their healthcare provider currently uses to treat obesity?

RQ2: How do older adults, diagnosed with both obesity and depression, describe the

methods their healthcare provider currently uses to treat depression?

RQ3: How do older adults, diagnosed with both obesity and depression, describe the

success or failure that occurs when treated for depression and obesity through nutritional

changes?
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Hypothesis (REVIEW)

H 0 1: There will be no significant changes to depression due to participants diets.

H 1 1: There will be significantly greater reductions in depression participants.

H 0 2: There will be no reduction in obesity in participants who are depressed.

H 1 2: There will be a reduction in obesity rates for participants who are depressed.

Theoretical Framework

The proposed study is guided by the Health Belief Model (HBM) theory, whose

theoretical concepts originate from cognitive theories. The HBM theory is used in medical

research as an intervention for observing and examining health-related behaviors (Rosenstock,

1974). Established by Rosenstock (1974), the HBM theory focuses on health decision-making.

Researchers use the HBM theory to explain conditions under which an individual engages in

reviewing and evaluating health behaviors that can include ignoring prevention methods for

conditions such as depression and obesity (Green et al., 2020; Orbell et al., 2020). Several

constructs are observed between individuals and predictive engagement in health-related

behaviors, including perceived susceptibility, severity, benefits, and barriers (Rosenstock, 2000).

Figure 1 illustrates the constructs and their connectivity with health-related behaviors.

Figure 1

The Health Belief Model

Note. From Rosenstock, I. M. (2000). Health Belief Model. In A. E. Kazdin (Ed.), Encyclopedia
of Psychology (Vol. 4, pp. 78–80). Oxford University Press.

The use of the HBM theory in the current study will provide a foundation for observing

the sample of older adults who have been diagnosed with both obesity and depression for

changes in their behavior patterns. The HBM theory has been used to understand human intent

based on changes in a particular behavior (Green et al., 2020; Rosenstock, 2000). The researcher

of this study will interview a sample of older adults who meet specific criteria and will assess

their responses using the factors of HBM theory that influence such changes in health-related

behaviors.

Methodology

The researcher will use a qualitative methodology with a descriptive research design.

Researchers use qualitative descriptive research to explore complex phenomena by thoroughly

examining individual perspectives, experiences, and social contexts (Doyle et al., 2020). The

qualitative researcher collects and analyzes non-numerical data, such as interviews, observations,

and textual materials, to generate rich, detailed, and nuanced insights (Doyle et al., 2020).
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Through qualitative methods, researchers can explore the complex interplay of personal, social,

and organizational factors that impact health-related behaviors (Hamilton & Finley, 2019).

Qualitative research permits researchers to capture a specific sample's lived experiences and

narratives, providing a humanistic perspective. This study's qualitative methodology allowed for

exploring older adults’ subjective experiences with being treated for obesity and depression, thus

offering an in-depth understanding of the circumstances influencing changes in these conditions.

Population, Sampling Strategy, and Sample Size

The population for this study includes obese older adults in the U.S. The targeted

population from which the researcher will recruit includes obese older adults who have been

diagnosed with depression and who live in an urban city in the southwestern regions of the U.S.

The researcher will use purposive sampling for recruiting purposes and will recruit 12-20

participants, with interviews continuing until saturation is reached. Data saturation is a concept

used in qualitative research to determine how collecting additional data no longer yields new or

significant information or insights (Guest et al., 2020). It is the stage at which the researcher

feels confident that they have gathered enough data to understand the research topic or answer

the research questions thoroughly. Data saturation helps ensure the collected data is

comprehensive and sufficient to support robust analysis and interpretation.

Purposive sampling is a sampling technique that allows a researcher to narrow their target

population for recruiting purposes to only individuals who would have the necessary

characteristics and experiences with the phenomenon of a study (Campbell et al., 2020). The

specific, purposeful selection of a sample thus allows participants to answer open-ended

questions that will answer the research questions (Campbell et al., 2020). A purposive sampling
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technique for this study encompasses the recruitment of older adults who meet the following

criteria:

1. The selected individual must be over the age of 50 years.

2. The selected individual must have a diagnosis of obesity.

3. The selected individual must have a diagnosis of depression.

4. The selected individual must be willing to participate in a 6-month activity in which they

will be provided with nutritional changes to their diet and a specific menu for meals.

5. The selected individuals will not be on any prescribed medication for depression.

6. The selected individual must be willing to participate in a Zoom conference call

interview, answering honest questions related to the changes (or lack thereof) from the

nutritional changes to their diet.

The individuals who meet these criteria will be invited to participate in this research and

will further be required to answer a demographic questionnaire and sign an informed consent

form. All of which will be delivered via email. Recruiting will occur through social media sites

such as Facebook and LinkedIn, using postings for volunteers after the researcher receives site

authorization from each social media site administrator and Institutional Review Board

permission. Based on the Belmont Report, established in 1979, the latter is required to protect

human subjects who participate in research (The National Commission for the Protection of

Human Subjects of Biomedical and Behavioral Research, 1979). The Belmont Report provides

the ethical considerations that all researchers must abide by when using human participants.

The researcher will remove any identifiable information and replace names with

pseudonyms. This change is done to protect each participant's identity. Using such

confidentiality measures not only ensures the protection of the participants but can directly
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influence the credibility or trustworthiness of the study's results (Adler, 2022). Additionally, all

collected data will be saved to an encrypted flash drive locked in the researcher's office. Further,

the signed informed consent with identifying information will be secured on a separate encrypted

flash drive and locked in a separate place in the researcher's office. Keeping this information

separate from the data collected and analyzed further protects the participant's security and

confidentiality.

Each selected participant will be provided with a six-week dietary plan (established by a

dietitian and healthcare provider before this study). The participants must email their menu

weekly with notes on what they ate daily. They will weigh themselves and record their weight

each week. Each participant will keep a journal recording their depressive symptoms and if they

are better or worse than when they first started this study. After the fourth week, the researcher

will set up interviews on the participant's most convenient day and time. The researcher will then

set up the Zoom call and send each participant the link.

Outcome Measures

Data Collection Method

Data will be collected using semi-structured interviews. Semi-structured interviews are a

research method commonly used in qualitative research to gather rich and detailed data from

participants (Adeoye-Olatunde & Olenik, 2021). Unlike structured interviews that follow a rigid

set of predetermined questions, semi-structured interviews provide a flexible framework that

allows for a more in-depth exploration of participants' perspectives, experiences, and opinions.

In a semi-structured interview, the researcher has a general list of topics or open-ended questions

to guide the interview (Husband, 2020). These questions serve as a starting point and ensure that

key areas of interest are covered. However, the interviewer has the freedom to adapt the
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interview based on the participant's responses, allowing for a more conversational and interactive

exchange.

Semi-structured interviews are valuable for gaining a deep understanding of participants'

subjective experiences, perspectives, and meanings attached to a particular topic (Husband,

2020). They allow for flexibility and adaptability while still ensuring a systematic and focused

exploration of the research area. The current study will collect data from a sample of healthcare

professionals who volunteered to participate in a one-on-one interview using a Zoom conference

call platform. The responses will be audio recorded and transcribed through Zoom and saved to

an encrypted flash drive. The data will then be analyzed.

Intervention Strategy

The current study will engage in an intervention strategy prior to collecting data. The

participants recruited will agree to work with the researcher and follow the instructions for this

intervention. Each participant will share their current weight, photographing their weight on a

scale and sending it to the researcher. These photographs will be assigned pseudonyms. This will

include providing each participant with a menu plan for six weeks that has been validated by a

nutritionist and health-care provider who specializes in diet. The participants will record their

meals eaten and email the researcher weekly. They will also weigh themselves weekly, noting

this weight in a journal. The researcher will ask each participant to keep a journal, noting any

changes in mood or differences in their depressive symptoms. At the end of six weeks, the

participants will provide a final weight and share their journal entries with the researcher.

Compliance/ Ethical Considerations

Data Analysis
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The researcher will analyze the collected date using a thematic analysis guided by Braun

& Clarke’s (2020) six-step thematic analysis process. These six-steps enable a researcher to

thoroughly examine the data collected and search for patterns and commonalities stated by the

sample. Once extracted, these themes will answer the research questions. Data gathered will be

coded, placed in categories, and established as themes. The phases of thematic analysis are

shown in Figure 2.

Figure 2

Braun and Clarke’s Six Steps to Thematic Analysis

Note. From. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative
Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa

The transcribed textual data from semi-structured interviews will then be analyzed. The

software used for the data analysis process was NVivo version 12. The textual data was in file

form and imported into NVivo version 12. The NVivo project was created to code data per the

protocol Braun and Clarke (2006) described in reflexive thematic analysis. Braun and Clarke’s

(2006) six-phase reflexive thematic analysis is a widely used qualitative research approach that

allows researchers to analyze and interpret rich and detailed data. This methodological
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framework consists of six interconnected phases, providing a systematic and rigorous process for

uncovering themes and patterns within qualitative data. The first phase involves familiarizing

oneself with the data and actively immersing oneself in the material to gain a comprehensive

understanding.

The second phase focuses on generating initial codes and extracting meaningful units of

data that capture essential aspects of the research topic. In the third phase, codes are organized

into potential themes, identifying patterns and connections across the data set. These themes are

then refined and reviewed in the fourth phase, ensuring they accurately represent the dataset and

reflect the research aims. The themes are named and defined in the fifth phase, creating a

coherent and concise thematic map. Finally, in the sixth phase, the researcher produces a detailed

analysis report, highlighting the main themes, their relationships, and their relevance to the

research questions. Braun and Clarke’s (2006) reflexive thematic analysis offers researchers a

flexible and iterative approach to analyzing qualitative data, providing a comprehensive and

rigorous method for generating rich insights and understanding the complexity of human

experiences and phenomena.

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