Research Article

Received: 10 July 2019 Revised: 24 January 2020 Accepted article published: 7 February 2020 Published online in Wiley Online Library: 24 February 2020

(wileyonlinelibrary.com) DOI 10.1002/jsfa.10322

Association between a low-carbohydrate diet

and sleep status, depression, anxiety, and
stress score
Elnaz Daneshzad,a Seyed-Ali Keshavarz,b Mostafa Qorbani,c,d
Bagher Larijanie and Leila Azadbakhta,f*

Abstract
BACKGROUND: Dietary intakes, especially carbohydrates, play an important role in blood glucose control in patients with dia-
betes. It is suggested that carbohydrate amounts may be effective in diabetes complications. This study aimed to reveal the
association of low-carbohydrate diet (LCD) and sleep and mental status among patients with diabetes.
METHODS: This cross-sectional study was conducted among 265 women with type 2 diabetes. Anthropometric measures, as
well as biochemical tests, were recorded. Dietary intakes were recorded using a validated food-frequency-questionnaire to cal-
culate LCD score. To assess mental disorders and sleep quality, the Depression, Anxiety and Stress Scale and the Pittsburgh
Sleep Quality Index were used respectively.
RESULTS: Patients in the highest LCD quartile were the ones with the lowest carbohydrate consumption. There was no signif-
icant association between cardiovascular risk factors and LCD score even after controlling confounder variables (P > 0.05). Sub-
jects in the highest quartile of LCD score compared with those within the lowest quartile had a 69% lower risk of poor sleep after
adjusting confounders. The odds of depressive symptoms were negatively related to the highest quartile of LCD score in the
crude model and even after full-adjusted model (odds ratio: 0.42; 95% confidence interval: 0.17–1.01). Participants in the high-
est quartile of LCD score compared with those in the lowest quartile had a 73% lower risk of anxiety.
CONCLUSION: It seems that patients who consumed lower carbohydrate have better sleep status and are less involved with
mental disorders. However, regarding the nature of the present study, well-designed cohort studies are suggested to be con-
ducted in the future.
© 2020 Society of Chemical Industry

Keywords: low-carbohydrate diet; dietary pattern; diabetes; depression; anxiety; sleep

INTRODUCTION
Diabetes mellitus is a highly prevalent chronic disease that causes
a wide range of complications. Poor sleep quality and mental dis-
orders containing stress, anxiety, and depression are several com-
mon complications in diabetic patients. Sleep disorders, as well as
anxiety and depression, are more common among diabetic
patients than among non-diabetics.1–3 About one-third of
patients with type 2 diabetes have subthreshold depression.4
Management of these complications is important for the
improvement of the patient's mood.
Dietary carbohydrates play an important role in blood glucose
control and controlling the development of diabetes and its com-
plications. Therefore, a low carbohydrate diet (LCD) as an effective
program to manage diabetes has been developed.5,6 Previous
studies have shown that an LCD can improve insulin sensitivity
and reduce body fat, weight, blood glucose, cholesterol, triglycer-
ide, hemoglobin A1c, and fasting insulin among patients with dia-
betes.7,8 Moreover, LCD patterns have been associated with
reduced risk of some chronic diseases, such as coronary heart dis-
2946
* Correspondence to: L Azadbakht, Department of Community Nutrition, School
of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, PO
Box 1416643931, Tehran, Iran. E-mail: azadbakhtleila@gmail.com
a Department of Community Nutrition, School of Nutritional Sciences and
Dietetics, Tehran University of Medical Sciences, Tehran, Iran
b Department of Clinical Nutrition, School of Nutritional Sciences and
Dietetics, Tehran University of Medical Sciences, Tehran, Iran
c Non-Communicable Diseases Research Center, Alborz University of Medical
Sciences, Karaj, Iran
d Chronic Diseases Research Center, Endocrinology, and Metabolism Population
Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
e Endocrinology and Metabolism Research Center, Endocrinology and
Metabolism Clinical Sciences Institute, Tehran University of Medical Sci-
ences, Tehran, Iran

f Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences

ease, metabolic syndrome, and cancers, as well as diabetes.9–11 Institute, Tehran University of Medical Sciences, Tehran, Iran

J Sci Food Agric 2020; 100: 2946–2952 www.soci.org © 2020 Society of Chemical Industry
LCD and sleep and depressive symptoms
Based on a previous study, sleep deprivation was associated with
energy-dense foods.12
To the best of our knowledge, there is no study about the asso-
ciation of LCD score and sleep status and mental disorders among
patients with type 2 diabetes. Regarding the traditional dietary
pattern in Iran, large amounts of carbohydrates containing
refined grains, especially rice, bread, and potato, are consumed
among the Iranian population.13 Hence, regarding the important
role of dietary intakes in the management of diabetes and its
complications, the present cross-sectional study was conducted
to reveal the association between LCD, sleep status, depression,
anxiety, and stress score among patients with type 2 diabetes.
METHODS
Study design and participants
The present cross-sectional study was conducted among
265 (⊍ = 0.05, ⊎ = 0.2, r = 0.2) type 2 diabetic women who referred
to health centers or diabetes research in Tehran, Iran. The sample
size was selected randomly among women with type 2 diabetes
who were referred to these centers for checkup visits. A dietician
and expert in nutrition science carried out the sampling processes
and data collection. All subjects filled out a written informed con-
sent to declare their willingness to participate. Diabetic women
who were involved with another chronic disease such as cancers,
thyroid problems, and kidney and cardiovascular diseases were
excluded. Therefore, all women have no complicated medical
problems. Moreover, individuals who reported total energy intake
of <800 and >4200 kcal day−1 were excluded.14 This study was
approved by the ethical committee of Tehran University of Medi-
cal Sciences (Ethical Code: 96‑03‑161‑36923). All participants
filled in a sociodemographic questionnaire, food frequency ques-
tionnaire (FFQ), Pittsburgh Sleep Quality Index (PSQI), Depression,
Anxiety and Stress Scale (DASS-21), and physical activity records
in the presence of a nutrition expert in health centers.
Assessment of anthropometric measures
Weight was measured while patients were minimally clothed
using a calibrated digital SECA 803 scale (Hamburg, Germany).
Height was measured in the standing position by using an
unstretched wall tape to the nearest 0.1 mm. Body mass index
(BMI, kg m−2) was calculated as weight divided by height squared.
Assessment of dietary intake
A validated and reliable 168-item semi-quantitative FFQ was used
to obtain dietary intakes of women through the past year.15 Indi-
viduals filled out the frequency and amount of foods consumed
on a daily, weekly, or monthly during the past year. The reported
portion sizes of consumed foods converted to grams per day.
Nutritionist IV software (version 7.0; N-Squared Computing,
Salem, OR, USA) adapted for Iranian foods was used for nutrients
analysis.
The percentage of energy from macronutrients (carbohydrate,
protein, and fat) was divided into 11 categories. Participants in
the highest category of fat and protein consumption scored
10 points and the lowest intake scored 0. The lowest category of
carbohydrate consumption received 10 points and the highest
one scored 0 points. Finally, scores of fat, protein, and carbohy-
drate were summed together to create the overall LCD score,
which ranged from 0 to 30, with the highest score revealing an
LCD.16 In fact, individuals who will be in the highest LCD quartile
are the ones with the lowest carbohydrate consumption. The
J Sci Food Agric 2020; 100: 2946–2952 © 2020 Society of Chemical Industry
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hypothesis is that it is more beneficial for health to be in the high-
est category of LCD score.
Assessment of sleep
A validated self-report sleep instrument, named the PSQI, was
filled out by patients.17 The PSQI measures the pattern and quality
of sleep over the past month and consists of nine items that differ-
entiate poor from good value with a range of 0 to 3 (0, not in the
past month; 1, less than once per week; 2, once or twice per week;
and 3, three or more times per week). These nine items explain
duration, and efficiency, sleep disturbances, using sleep medica-
tion, sleep latency, and daytime dysfunction. This scale presents
a total score of 0 to 21 in which a score of ≥5 indicates poor sleep
quality and shows the problem in at least two components of the
instrument.
Assessment of stress, anxiety level, and depressive
symptoms
DASS-21 is a validated self-report questionnaire and contains
21 questions to assess the symptoms in depression, anxiety, and
stress in the last week.18 Each question scores from 0 (never) to
3 (always). The depression subscale includes seven questions,
from which a total score of 0–9 is normal, 10–13 presents marginal
depressive symptoms, 14–20 is medium, 21–27 is severe, and ≥28
is very severe. Th e anxiety subscale includes seven questions,
from which a total score of 0–7 is normal, 8–9 is marginal, 10–14
is medium, 15–19 is severe, and ≥20 is very severe anxiety. The
stress subscale includes seven questions, from which a total score
of 0–14 is normal, 15–18 is marginal, 19–25 is medium, 25–33 is
severe, and ≥34 is very severe stress.
Assessment of other variables
Sociodemographic information was obtained through a general
questionnaire and included age, women and their husbands’ edu-
cation levels and jobs, income, medical history and smoking
habits hours of nap time and night sleep, duration of diabetes,
menopause status, current medication, and supplements con-
sumption. Biochemical tests were recorded from the patient's
medical profile and included hemoglobin A1C, fasting blood
sugar, 2 h postprandial blood sugar, total cholesterol, triglyceride,
and low‑ and high-density lipoprotein cholesterol. Physical activ-
ity level was expressed by a metabolic equivalent hours per
week.19
Statistical analysis
The Kolmogorov–Smirnov test was used to evaluate the normality
of data. Patient characteristics were compared by chi-square or
analysis of variance (ANOVA) tests through the adherence of the
LCD score for categorical and continuous variables, respectively
which reported as a percentage or mean and standard deviation
(SD). Dietary intakes compared across quartiles of LCD score were
adjusted for energy intake by the residual method. Biochemical
tests were assessed among quartiles of LCD score by analysis of
covariance (ANCOVA) in crude and two adjusted models. Sleep
and psychological status, including depressive symptoms, anxiety
level, and stress, were presented in crude and two adjusted
models using logistic regression. In model 1, we adjusted for
age, BMI, energy intake, socio-economic status (SES), nap time,
night sleep, physical activity, medication, and supplement con-
sumption. Further adjustment was performed in model 2 for men-
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opause status and duration of diabetes plus model 1. SPSS
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Table 1. Characteristics of diabetic women among different quartiles Q1–Q4 of LCD score

Variable All Q1 (≤9) Q2 (9.01–14) Q3 (14.01–20.5) Q4 (>20.5) P value

Number 265 73 63 63 66
Age (years) 59.66 ± 8.94 61.11 ± 10.05 58.52 ± 8.62 59.81 ± 8.27 59.02 ± 8.50 0.350
BMI (kg m−2) 23.32 ± 3.44 22.84 ± 3.28 23.77 ± 3.67 23.68 ± 3.22 23.07 ± 3.56 0.315
22.88 ± 0.40 23.74 ± 0.43 23.68 ± 0.43 23.06 ± 0.43 0.369 a
Nap time (min day−1) 29.22 ± 36.56 28.50 ± 34.37 32.49 ± 41.62 30.06 ± 37.14 26.10 ± 33.64 0.792
Night sleep (h day−1) 6.49 ± 2.65 7.13 ± 4.33 6.51 ± 1.39 5.92 ± 1.71 6.32 ± 1.53 0.060
SES 13.94 ± 3.19 13.34 ± 3.32 13.57 ± 3.32 13.76 ± 2.83 15.13 ± 2.98 0.005
PA (MET h day−1) 29.54 ± 5.27 28.68 ± 5.06 29.65 ± 5.01 29.25 ± 4.90 30.68 ± 5.94 0.156
Medication (% [n]) 0.225 b
Just for diabetes 18.9 [50] 38.0 [19] 26.0 [13] 20.0 [10] 16.0 [8]
Diabetes and hypertension 6.0 [16] 18.8 [3] 31.3 [5] 37.5 [6] 12.5 [2]
All other medications 75.1 [199] 25.6 [51] 22.6 [45] 23.6 [47] 28.1 [56]
Supplements (% [n]) 0.614
Yes 29.1 [77] 32.5 [25] 23.4 [18] 19.5 [15] 24.7 [19]
No 70.9 [188] 25.5 [48] 23.9 [45] 25.5 [48] 25.0 [47]
Duration of diabetes (% [n]) 0.128
≤5 years 41.9 [111] 32.4 [36] 26.1 [29] 17.1 [19] 24.3 [27]
>5 years 58.1 [154] 24.0 [37] 22.1 [34] 28.6 [44] 25.3 [39]
Menopausal status (% [n]) 0.308
Menopause 11.7 [31] 35.5 [11] 19.4 [6] 12.9 [4] 32.3 [10]
Post-menopause 88.3 [234] 26.5 [62] 24.4 [57] 25.2 [59] 23.9 [56]

PA, physical activity; MET h metabolic equivalent hour.

Data presented as mean plus/minus standard deviation.
a
P value calculated by ANCOVA and adjusted for age and SES.
b
P value calculated by Fisher test.
Bold P values indicate a significant association.

Table 2. Dietary intakes among quartiles Q1–Q4 of LCD score among subjects

Q2(n = 63) Q3(n = 63) Q4

Variable All Q1(n = 73) (≤9) (9.01–14) (14.01–20.5) (n = 66) (>20.5) P value
−1
Energy (kcal day ) 2326.82 ± 29.99 2324.40 ± 54.66 2205.38 ± 58.84 2194.69 ± 58.84 2571.56 ± 57.49 <0.0001
Protein (g day−1) 70.75 ± 1.02 63.83 ± 0.93 68.20 ± 1.01 69.63 ± 1.01 81.51 ± 1.01 <0.0001
Fat (g day−1) 84.48 ± 2.15 63.35 ± 1.48 76.52 ± 1.61 90.06 ± 1.61 110.11 ± 1.61 <0.0001
CHO (g day−1) 338.94 ± 4.43 389.01 ± 3.13 357.44 ± 3.40 327.48 ± 3.40 276.85 ± 3.40 <0.0001
MUFAs (g day−1) 28.62 ± 0.97 19.10 ± 0.81 23.99 ± 0.88 30.56 ± 0.88 41.70 ± 0.88 <0.0001
PUFAs (g day−1) 18.98 ± 0.50 14.38 ± 0.55 15.96 ± 0.60 20.96 ± 0.60 25.07 ± 0.60 <0.0001
Fiber (g day−1) 19.93 ± 0.41 17.01 ± 0.59 19.29 ± 0.65 19.72 ± 0.65 23.96 ± 0.65 <0.0001
K (mg day−1) 3507.61 ± 62.82 3150.28 ± 92.89 3573.18 ± 100.81 3479.50 ± 100.95 3867.09 ± 101.03 <0.0001
P (mg day−1) 1098.56 ± 19.12 934.73 ± 20.49 1073.67 ± 22.24 1102.94 ± 22.27 1299.32 ± 22.29 <0.0001
Calcium (mg day−1) 839.58 ± 15.75 733.39 ± 26.28 861.54 ± 28.52 823.81 ± 28.56 951.10 ± 28.58 <0.0001
Sodium (mg day−1) 3790.56 ± 97.60 3586.87 ± 164.60 3958.69 ± 178.63 4255.25 ± 178.89 3411.78 ± 179.02 0.005
Iron (mg day−1) 17.13 ± 0.22 16.30 ± 0.32 17.11 ± 0.35 17.18 ± 0.35 18.02 ± 0.35 0.006
Folate (Ug day−1) 311.23 ± 7.61 264.40 ± 12.12 298.65 ± 13.16 293.62 ± 13.18 391.83 ± 13.19 <0.0001
Vitamin B1 (mg day−1) 1.88 ± 0.02 1.99 ± 0.02 1.88 ± 0.03 1.80 ± 0.03 1.85 ± 0.03 <0.0001
Vitamin B12 (Ug day−1) 2.72 ± 0.06 2.42 ± 0.12 2.87 ± 0.13 2.64 ± 0.13 2.98 ± 0.13 0.010
Vitamin D (μg day−1) 1.22 ± 0.04 1.01 ± 0.09 1.22 ± 0.10 1.32 ± 0.10 1.36 ± 0.10 0.045
Fruits (g day−1) 264.15 ± 7.60 240.75 ± 14.16 283.68 ± 15.37 247.82 ± 15.39 286.99 ± 15.40 0.054
Vegetables (g day−1) 412.79 ± 12.21 387.67 ± 23.05 416.79 ± 25.02 374.90 ± 25.05 472.88 ± 25.07 0.031
Refined grains (g day−1) 375.32 ± 9.37 481.19 ± 14.46 415.63 ± 15.69 340.65 ± 15.72 252.83 ± 15.73 <0.0001
Whole grain (g day−1) 52.92 ± 3.34 31.21 ± 5.99 43.43 ± 6.50 73.39 ± 6.50 66.46 ± 6.51 <0.0001
Red/processed meat 29.50 ± 1.17 28.40 ± 2.19 29.70 ± 2.38 30.47 ± 2.38 29.60 ± 2.39 0.934
(g day−1)

CHO, carbohydrate; MUFAs, mono-unsaturated fatty acids; and PUFAs, polyunsaturated fatty acids; K, potassium; P, phosphorus.
Data presented as mean plus/minus standard error, and calculated by ANCOVA adjusted for energy intake. However, the energy intake was compared
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by ANOVA.

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Table 3. Biochemical tests among quartiles Q1–Q4 of LCD score among subjects

Variable All Q1(n = 73) (≤9) Q2(n = 63) (9.01–14) Q3(n = 63) (14.01–20.5) Q4(n = 66) (>20.5) P value

FBS (mg dL−1) 154.23 ± 2.97

Crude 157.17 ± 5.67 146.03 ± 6.10 159.22 ± 6.10 154.06 ± 5.96 0.434
Model 1 157.11 ± 5.81 146.54 ± 6.18 159.99 ± 6.20 152.90 ± 6.27 0.432
Model 2 156.84 ± 5.84 147.53 ± 6.18 159.76 ± 6.25 152.46 ± 6.26 0.512
2hPP (mg dL−1) 200.00 ± 3.76
Crude 206.58 ± 7.12 189.58 ± 7.67 210.57 ± 7.67 192.56 ± 7.49 0.137
Model 1 204.64 ± 7.18 191.94 ± 7.63 211.70 ± 7.66 191.38 ± 7.74 0.164
Model 2 203.83 ± 7.20 193.53 ± 7.62 211.94 ± 7.70 190.53 ± 7.71 0.178
HbA1c (%) 7.75 ± 0.26
Crude 7.51 ± 0.49 8.45 ± 0.53 7.62 ± 0.53 7.50 ± 0.52 0.526
Model 1 7.56 ± 0.50 8.40 ± 0.53 7.64 ± 0.53 7.47 ± 0.54 0.596
Model 2 7.63 ± 0.50 8.41 ± 0.53 7.53 ± 0.54 7.48 ± 0.54 0.576
TC (mg dL−1) 160.79 ± 2.45
Crude 160.32 ± 4.67 167.11 ± 5.03 158.00 ± 5.03 157.93 ± 4.91 0.527
Model 1 161.60 ± 4.75 166.41 ± 5.05 156.03 ± 5.07 159.07 ± 5.13 0.518
Model 2 162.15 ± 4.81 165.96 ± 5.09 155.47 ± 5.14 159.42 ± 5.15 0.517
TG (mg dL−1) 160.76 ± 4.66
Crude 170.50 ± 8.86 154.85 ± 9.54 168.92 ± 9.54 147.83 ± 9.32 0.239
Model 1 172.27 ± 8.98 152.23 ± 9.54 165.91 ± 9.58 151.25 ± 9.68 0.299
Model 2 173.90 ± 9.05 151.91 ± 9.58 163.61 ± 9.69 151.95 ± 9.70 0.277
HDL-C (mg dL−1) 45.67 ± 0.60
Crude 46.53 ± 1.15 43.95 ± 1.24 44.73 ± 1.24 47.27 ± 1.21 0.193
Model 1 46.41 ± 1.18 44.27 ± 1.25 44.59 ± 1.25 47.22 ± 1.27 0.301
Model 2 46.40 ± 1.19 44.35 ± 1.26 44.55 ± 1.27 47.19 ± 1.27 0.338
LDL-C (mg dL−1) 97.88 ± 1.96
Crude 100.61 ± 3.73 98.87 ± 4.02 100.00 ± 4.02 91.89 ± 3.92 0.364
Model 1 100.50 ± 3.87 98.71 ± 4.11 99.78 ± 4.13 92.38 ± 4.17 0.504
Model 2 101.12 ± 3.90 98.10 ± 4.13 99.21 ± 4.17 92.81 ± 4.18 0.532

Model 1: adjusted for age, BMI, energy intake, SES, nap time, night sleep, physical activity, medication, and supplement consumption.
Model 2: model 1 + menopause status and duration of diabetes.
P value provided by ANOVA for crude model and ANCOVA for adjusted models. Data presented as mean plus/minus standard error.
FBS, fasting blood sugar; 2hPP, 2 h postprandial glucose; HbA1c, hemoglobin A1C; TC, total cholesterol; TG, triglyceride; LDL-C, low-density lipopro-
tein cholesterol; HDL-C, high density lipoprotein cholesterol.

software (v. 16) was used for all statistical analysis, and the signif-
icance value set as P < 0.05.
RESULTS
The mean age and BMI of subjects were 59.66 ± 8.94 years and
23.32 ± 3.44 kg m−2 respectively. There was a significant associa-
tion between SES and adherence of LCD score. Table 1 shows
baseline characteristics of participants. Table 2 shows the dietary
intakes of diabetic women across the quartiles of LCD score. Die-
tary intake of energy, protein, fat, mono‑ and polyunsaturated
fatty acids, vitamins B12 and D, folate, iron, calcium, phosphorus,
potassium, and fiber was greater in the highest quartile of LCD
score (P < 0.05). Biochemical tests among quartiles of LCD score
in type 2 diabetic women are shown in Table 3. There was no sig-
nificant association between cardiovascular risk factors and LCD
score even after controlling confounder variables. Table 4 shows
the odds of poor sleep and psychological disorders, including
depressive symptoms, anxiety level, and stress, among quartiles
of LCD score in participants. Subjects in the highest quartile of
LCD score compared with those within the lowest quartile had a
69% lower risk of poor sleep after adjusting for confounders.
the highest quartile of LCD score in the crude model and even
after the fully adjusted model (odds ratio: 0.42; 95% confidence
interval: 0.17–1.01). Participants in the highest quartile of LCD
score compared with those within the lowest quartile had a 58%
lower risk of depressive symptoms after adjusting for con-
founders. Participants in the highest quartile of LCD score com-
pared with those in the lowest quartile had a 73% lower risk of
anxiety. There was no significant association between LCD score
and stress.
DISCUSSION
This cross-sectional study indicated that lower consumption of
carbohydrates is associated with improving poor sleeping and
decreasing the risk of psychological disorders, including depres-
sive symptoms and anxiety level, among diabetic patients. To
the best of our knowledge, this is the first study that has investi-
gated the association between LCD and psychological disorders
and sleeping status among type 2 diabetic patients.
Epidemiological surveys have presented that individuals with
short sleep duration have higher intakes of refined carbohydrates
and energy-rich foods compared with individuals who sleep for
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The odds of depressive symptoms were negatively related to longer.20–22 An interventional study suggests a causal relationship

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Table 4. Odds of poor sleep and psychological disorders among quartiles Q1–Q4 of LCD score in type 2 diabetic women

Odds ratio (95% confidence interval)

Q1(≤9) N = 73 Q2(9.01–14) N = 63 Q3(14.01–20.5) N = 63 Q4(>20.5) N = 66 P trend

Poor sleep (n = 188)

Crude 1 0.75 (0.35; 1.64) 1.29 (0.56; 2.96) 0.36 (0.17; 0.75) 0.021
Model 1 1 0.66 (0.27; 1.63) 1.26 (0.46; 3.45) 0.32 (0.12; 0.79) 0.048
Model 2 1 0.68 (0.27; 1.71) 1.28 (0.45; 3.65) 0.31 (0.12; 0.78) 0.038
Depression (n = 82)
Crude 1 1.18 (0.59; 2.38) 0.78 (0.38; 1.60) 0.40 (0.18; 0.88) 0.016
Model 1 1 1.10 (0.52; 2.35) 0.67 (0.30; 1.49) 0.41 (0.17; 0.98) 0.030
Model 2 1 1.20 (0.55; 2.59) 0.80 (0.35; 1.82) 0.42 (0.17; 1.01) 0.046
Anxiety (n = 91)
Crude 1 0.61 (0.30; 1.23) 0.66 (0.33; 1.31) 0.25 (0.11; 0.55) 0.001
Model 1 1 0.71 (0.34; 1.49) 0.82 (0.39; 1.71) 0.28 (0.12; 0.65) 0.009
Model 2 1 0.68 (0.32; 1.45) 0.77 (0.36; 1.64) 0.27 (0.12; 0.64) 0.007
Stress (n = 117)
Crude 1 0.91 (0.46; 1.80) 1.34 (0.68; 2.64) 0.53 (0.26; 1.07) 0.198
Model 1 1 0.84 (0.40; 1.77) 1.08 (0.50; 2.30) 0.44 (0.19; 0.98) 0.108
Model 2 1 0.87 (0.41; 1.85) 1.12 (0.52; 2.44) 0.44 (0.20; 0.99) 0.111

Model 1: adjusted for age, BMI, energy intake, SES, nap time, night sleep, physical activity, medication, and supplement consumption.
Model 2: model 1 + menopause status and duration of diabetes.
P trend provided by binary logistic regression.
Bold P values indicate a significant association.

between higher carbohydrate intake and high sleep latency.23 On
the other hand, sleep deprivation may lead to an increase in appe-
tite for high-calorie foods that are not appropriate in diabetes
management.24 In the present study, the LCD score was positively
associated with sleep status. In a study conducted on healthy
good sleepers, a very low carbohydrate diet promoted the per-
centage of deep sleep stage and reduced the percentage of
dreaming sleep. These beneficial effects may be related to the
fat content of the LCD.25 Variation of macronutrients content
may differ depending on sleep status, in that some of the nutri-
ents are pro-inflammatory and some others are anti-inflamma-
tory.25 Moreover, an LCD is effective for weight management in
obese individuals. A case-report study in an obese Japanese
man with obstructive sleep apnea revealed that weight was
improved as well as lipid and glucose levels through following
an LCD program. The authors have suggested that LCD helps to
improve the management of patients with obstructive sleep
apnea.26 LCD can improve endothelial function and inflammatory
status, which is an important mechanism to manage mental
health and cardiovascular diseases.27
Also, LCD may be associated with some psychological symp-
toms. A highly refined carbohydrate diet may lead to develop-
ment of depressive behaviors and anxiety in mice.28 A
processed food pattern that is composed of refined carbohydrate
and sweet desserts29 and a western dietary pattern that contains
high amounts of refined carbohydrates and sugar were associ-
ated with increased risk of psychological problems, especially
depression, through increased levels of inflammatory cytokines
such as interleukin-6 and C-reactive protein.30 An animal study
has revealed that minipigs fed with a high-fat LCD were less
aggressive, and also had more social contact.31 Khayyatzadeh
et al. conducted a study on 750 adolescent girls and found there
was an inverse association between healthy dietary pattern and
2950
study should be explained. Although the carbohydrate intake of
participants in the highest quartile of the healthy dietary pattern
was lower than those in the first quartile, the lower depressive
symptoms may be associated with higher intakes of vegetables,
fruits, fish, and dairy products.32 In a study that assessed
45 women with major depression and 90 patients with no mental
disorders revealed that individuals who consumed more refined
grains, fried potatoes, cookies, and sugar in an unhealthy dietary
pattern showed more risk for having major depression.33 Halybur-
ton et al. found that individuals who consumed a high-fat LCD had
no differences in mood measures compared with individuals who
consumed an isocaloric low-fat high-carbohydrate diet. However,
the effect of these diets on weight changes is discussible regard-
ing weight influence on mood.34 Based on a systematic review
and meta-analysis on 11 studies, very low calorie diets that con-
tain low amounts of carbohydrate and lead to weight loss
decreased depressive symptoms and improved psychological
well-being.35 Additionally, low-calorie diets significantly
improved sleep apnea and blood pressure in overweight patients
with obstructive sleep apnea syndrome.36 Moreover, these diets
improved lipid profile and glucose and insulin levels in patients
with diabetes.37,38
One of the mechanisms that may affect mood and psychologi-
cal traits could be attributed to a change of the composition of
the gut microbiota following the dietary changes. Immune and
inflammatory processes could be influenced through gut
microbiota.39–41 Moreover, a variation of macronutrients content
in the diet may lead to differences in mental status, in that that
some of the foods are pro-inflammatory and some others are
anti-inflammatory.42
This is the first time that LCDs have been investigated with
regard to sleep status and psychological health among patients
with type 2 diabetes. Moreover, diabetic women from different

depressive symptoms. However, the causal relationship in that socioeconomic groups were selected randomly; therefore, this

wileyonlinelibrary.com/jsfa © 2020 Society of Chemical Industry J Sci Food Agric 2020; 100: 2946–2952
LCD and sleep and depressive symptoms
study could be a representative sample of diabetic women in Teh-
ran province, Iran. Besides these strengths, however, this study
has some limitations. The cross-sectional nature of the study can-
not reveal the causal association. Use of a semi-quantitative FFQ,
which has recall bias and misclassification, is another limitation.
Moreover, the DASS and PSQI tools do not provide a diagnostic
of depression and sleep disorders and we used them as assess-
ment tools. Also, we could not assess the percentage of energy
as animal fat and protein among patients, since we have no sep-
arate data for these items in Iran food-intake databases.
CONCLUSION
In conclusion, the present cross-sectional study which holds on
among women with type 2 diabetes indicated a significant asso-
ciation between LCD and poor sleeping and mental health; how-
ever, no significant association was observed between LCD and
cardiovascular disease risk factors. Further large prospective stud-
ies in both genders with consideration of various unknown con-
founders should be conducted to prove our results or reveal the
exact relationship.
ACKNOWLEDGEMENTS
We would like to express our thankfulness to Dr Nasli, secretary of
the Diabetes Research Center of Tehran University of Medical Sci-
ences, and all staffs in this center in Tehran, Iran.
CONFLICT OF INTEREST
The authors declare that they have no conflict of interest.
FUNDING SOURCE
This study is supported by Tehran University of Medical Sciences
(grant number: 36923).
AUTHOR CONTRIBUTION
ED and LA designed and LA supervised the study. ED conducted
the study, and ED and MQ performed the statistical analyses. ED
prepared a first draft of the manuscript, and LA, S-AK, and BL
finalized it.
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