Dietary diversity linked to fewer symptoms in women across three countries

Women who ate from at least five food groups had lower odds of depressive symptoms, anxiety symptoms and both conditions occurring together in a cross-sectional analysis of 34,576 women aged 15–49 in Zambia, Mozambique and Nepal. After adjustment for demographic, socioeconomic, reproductive and environmental factors, meeting the minimum dietary diversity for women benchmark was associated with 31% lower odds of depressive symptoms, 37% lower odds of anxiety symptoms and 42% lower odds of co-occurring symptoms. The results point to an association between broader diets and psychological distress, but they do not establish that eating more varied foods prevents depression or anxiety.

The study combined nationally representative Demographic and Health Survey data from Zambia 2024, Mozambique 2022–2023 and Nepal 2022. Researchers included women with complete dietary, mental health and covariate information: 13,951 participants from Zambia, 13,183 from Mozambique and 7,442 from Nepal. The weighted prevalence of depressive symptoms was 5.7%, while 6.4% of participants had anxiety symptoms and 3.9% met thresholds for both. The analysis accounted for the surveys’ sampling weights, clusters and strata, allowing the pooled estimates to represent the target populations rather than simply treating all respondents as equally representative.

Dietary diversity was measured with a 24-hour recall covering the previous day and night. Women received a score from zero to 10 according to whether they consumed foods from ten groups, including grains and roots, pulses, nuts and seeds, dairy, flesh foods, eggs, dark green leafy vegetables, vitamin A-rich fruits and vegetables, other vegetables and other fruits. The study classified consumption of fewer than five groups as inadequate diversity and five or more as adequate, following the minimum dietary diversity for women, or MDD-W, indicator. Although higher scores generally suggest a greater likelihood of meeting micronutrient needs, the measure is not a complete assessment of diet quality, nutrient quantities or habitual eating patterns.

Depressive symptoms were assessed with the nine-item Patient Health Questionnaire-9, with a score of at least 10 defining symptoms, while the seven-item Generalized Anxiety Disorder-7 scale used the same threshold for anxiety symptoms. Participants scoring at least 10 on both scales were classified as having co-occurring depressive and anxiety symptoms. The scales assess symptoms over the preceding two weeks; because the surveys did not include clinical diagnostic interviews, the researchers could not independently assess criterion validity against clinical diagnoses. Country-specific weighted Cronbach’s alpha coefficients were 0.81, 0.92 and 0.86 for depression in Zambia, Mozambique and Nepal, respectively, and 0.79, 0.92 and 0.86 for anxiety.

The inverse associations persisted as the models incorporated progressively broader sets of possible confounders. Adjustment for country alone produced odds ratios of 0.62 for depressive symptoms, 0.59 for anxiety symptoms and 0.52 for co-occurring symptoms. Models accounting for age, marital status, urban or rural residence, education, media exposure, household wealth and employment yielded odds ratios of 0.70, 0.64 and 0.59, respectively. The fully adjusted estimates were 0.69 with a 95% confidence interval of 0.58–0.82 for depressive symptoms, 0.63 with an interval of 0.54–0.73 for anxiety symptoms and 0.58 with an interval of 0.47–0.72 for co-occurring symptoms. All three confidence intervals excluded 1, indicating statistically significant associations in the pooled models.

Food-group models offered a more complicated picture than a simple message that every category of produce behaves in the same way. After correction for multiple comparisons, consumption of other vegetables, pulses, eggs, flesh foods, other fruits and dairy was associated with lower odds of all three mental health outcomes. For other vegetables, the adjusted odds ratios were 0.55 for depressive symptoms, 0.65 for anxiety symptoms and 0.47 for co-occurring symptoms. Pulses had an odds ratio of 0.62 for anxiety symptoms, while the corresponding estimate for other vegetables was 0.65. Vitamin A-rich fruits and vegetables were associated with lower odds of anxiety and co-occurring symptoms but not depression after false-discovery-rate correction. Dark green leafy vegetables were the exception, with higher odds of depressive symptoms, anxiety symptoms and co-occurring symptoms, yielding odds ratios of 1.42, 1.28 and 1.67, respectively.

That exception should not be interpreted as evidence that leafy greens cause mental distress. The food-group models were separate, mutually unadjusted analyses, so each estimate describes consumption of one category in the context of the broader diet and participants’ characteristics rather than the effect of adding or removing a specific food. A single 24-hour recall may also not capture usual intake, day-to-day or seasonal variation, or portion size. The observed leafy-green association could reflect differences in the foods eaten alongside them, socioeconomic patterns or other factors not captured by the models, while the large number of comparisons also creates a continuing risk of chance findings despite statistical correction.

Subgroup analyses suggested that the overall relationship might not be identical across every setting. The inverse association was generally present across age, education and child-death categories, but statistical interactions were detected for residence in relation to depressive and co-occurring symptoms, wealth status in relation to depression, and marital status in relation to co-occurring symptoms. For example, the adjusted odds ratio for depressive symptoms was 0.63 among urban women and 0.82 among rural women, although the confidence interval for the rural estimate included 1. Among married women, adequate diversity was associated with lower odds of co-occurring symptoms, with an odds ratio of 0.49, compared with 0.79 among single women. These comparisons were exploratory and should not be treated as evidence that the relationship differs causally between groups.

Sensitivity analyses broadly supported the main result but also exposed its complexity. Separate models for each country generally yielded inverse associations, although their magnitudes and statistical significance varied. Modeling dietary diversity as a continuous score with natural cubic splines found evidence of nonlinearity for all three outcomes, each with a P value for nonlinearity below 0.001. This means the relationship cannot be summarized confidently as the same change in odds for every additional food group. Results were also similar after excluding the 2,181 participants who were currently pregnant, an important check because the MDD-W indicator was not developed specifically to assess micronutrient adequacy during pregnancy.

Several limitations constrain what can be concluded. The cross-sectional design measures diet and symptoms around the same period, so it cannot determine whether dietary patterns preceded the symptoms, whether poor mental health influenced eating, or whether both reflected shared conditions. Household food insecurity was not measured, and potentially relevant factors such as trauma, menopausal status and attitudes toward help-seeking were unavailable, leaving possible residual confounding. Self-report can introduce recall and reporting bias, and one day of dietary recall may not represent usual intake, seasonal variation or portion size. The findings therefore demonstrate adjusted associations rather than a dietary intervention effect.

Researchers proposed several plausible but unproven explanations for the pattern. A more diverse diet may provide a broader range of proteins, B vitamins, minerals, antioxidants and essential fatty acids involved in neurotransmitter synthesis and synaptic signaling. Greater food-group diversity may also be linked to differences in gut microbial composition and gut–brain signaling, while serving as a marker of food security and living conditions that themselves influence psychological well-being. None of these mechanisms was directly tested, and the study did not measure food insecurity or establish any biological pathway. Longitudinal studies that track diet before symptoms emerge, together with randomized intervention trials, will be needed to determine whether changing dietary diversity can affect women’s mental health. For now, the results identify a measurable dietary pattern associated with fewer depressive and anxiety symptoms, rather than a proven preventive strategy.

Subject of Research: Cross-sectional associations between dietary diversity and depressive and anxiety symptoms among reproductive-age women in Zambia, Mozambique and Nepal

Article Title: Associations of dietary diversity with depressive symptoms, anxiety symptoms and their co-occurrence among reproductive-age women in three low- and middle-income countries: a cross-sectional analysis

Article References: Fang, J., Huang, L., & Fang, N. (2026). Associations of dietary diversity with depressive symptoms, anxiety symptoms and their co-occurrence among reproductive-age women in three low- and middle-income countries: a cross-sectional analysis. Frontiers in Public Health, 14, Article 1955678. https://doi.org/10.3389/fpubh.2026.1955678

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1955678

Keywords: dietary diversity, depressive symptoms, anxiety symptoms, co-occurring symptoms, women’s health, nutrition, cross-sectional study, Zambia, Mozambique, Nepal, Associations, dietary