Soc Psychiatry Psychiatr Epidemiol (2013) 48:1297–1306

DOI 10.1007/s00127-012-0623-5

ORIGINAL PAPER

Diet quality and mental health problems in adolescents from East

London: a prospective study
Felice N. Jacka • Catherine Rothon •
Stephanie Taylor • Michael Berk • Stephen A. Stansfeld

Received: 21 February 2011 / Accepted: 2 November 2012 / Published online: 18 November 2012
Ó Springer-Verlag Berlin Heidelberg 2012

Abstract problems. Compared to those in the lowest quintile of

Purpose In this study, we aimed to examine the rela-
tionship between diet quality and depression in a pro-
spective study of adolescents from varied ethnic and
cultural backgrounds.
Design In this prospective cohort study, data were col-
lected at two time points (2001 and 2003) from nearly
3,000 adolescents, aged either 11–12 years or 13–14 years,
participating in RELACHS, a study of ethnically diverse
and socially deprived young people from East London in
the UK. Diet quality was measured from dietary ques-
tionnaires, and mental health assessed using the Strengths
and Difficulties Questionnaire (SDQ) and the Short Mood
and Feelings Questionnaire (SMFQ).
Results In cross-sectional analyses, we found evidence for
an association between an unhealthy diet and mental health
Unhealthy diet score, those in the highest quintile were more
than twice as likely to be symptomatic on the SDQ (OR 2.10,
95 %CI 1.38–3.20) after taking all identified confounders
into account. There was also some evidence for a cross-
sectional inverse association between a measure of healthy
diet and mental health problems. A prospective relationship
between the highest quintiles of both Healthy (OR 0.63,
95 %CI 0.38–1.05) and Unhealthy (OR 1.75, 95 %CI
1.00–3.06) diet scores and SDQ scores at follow-up was
also evident, but was attenuated by final adjustments for
confounders.
Conclusion This study is concordant with previous obser-
vational studies in describing relationships between measures
of diet quality and mental health problems in adolescents.
Keywords Diet
Nutrition
Mental health
Depression

Adolescents

F. N. Jacka (&)
M. Berk Abbreviations

Deakin University, School of Medicine, Geelong, Australia
SDQ Strengths and Difficulties Questionnaire
e-mail: felice@barwonhealth.org.au; felicejacka@gmail.com
SMFQ Short Mood and Feelings Questionnaire
M. Berk
OR Odds ratio
e-mail: mikebe@barwonhealth.org.au
CI Confidence interval
C. Rothon
S. A. Stansfeld BMI Body Mass Index
Wolfson Institute of Preventive Medicine, Centre for Psychiatry,
Barts and The London School of Medicine and Dentistry,
Queen Mary University of London, London, UK
e-mail: c.rothon@qmul.ac.uk
Background
S. A. Stansfeld
e-mail: s.a.stansfeld@qmul.ac.uk
Recent epidemiological data have pointed to a relationship
S. Taylor between the quality of habitual diet and the common
Institute of Health Sciences Education, Barts and the London
mental disorders, depression and anxiety. The published
School of Medicine and Dentistry, Queen Mary University
of London, London, UK studies in adults have shown that diet quality is inversely
e-mail: s.j.c.taylor@qmul.ac.uk related to the likelihood of clinically significant depressive

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and anxiety disorders and symptoms in women cross-sec-
tionally [1] and to the risk for incident depression in adults
over time [2–4].
We have recently investigated the association between
diet quality and depression in more than 7,000 young
Australian adolescents (10–14 years), from a diverse range
of socio-economic and demographic backgrounds, using
the Short Mood and Feelings Questionnaire (SMFQ) [5].
In this study, we found that adolescents scoring higher on
a measure of Healthy diet were less likely to report
symptomatic depression, while those with an increased
consumption of processed and ‘junk’ foods were more
likely to report depression. These associations demon-
strated a dose–response pattern and remained robust after
adjustment for a wide range of potential confounding
factors including dieting behaviours, socio-economic sta-
tus, family factors and other health behaviours. Similarly,
another study in Australian adolescents has reported an
inverse association between consumption of fruits and
leafy green vegetables and both internalising and exter-
nalising behaviours, and a positive association between a
‘Western’ dietary pattern and increased behavioural
problems [6]. Finally, we have recently documented that
diet quality is associated with adolescent mental health
over time [7]. In this prospective study of more than 3,000
Australian adolescents, predominantly from higher socio-
economic backgrounds, better diet quality at baseline
predicted better mental health at follow-up even after
adjustment for mental health at baseline. Moreover,
improvements in diet quality were mirrored by improve-
ments in mental health, while reductions in diet quality
were associated with declining psychological functioning.
Importantly, the reverse causality hypothesis, that the
reported associations reflect poorer eating habits as a
consequence of mental health problems, was not supported
by the data. These are robust prospective data demon-
strating that diet quality is an independent risk factor for
the development of adolescent mental health problems.
However, the available studies are limited in that they are
confined to adolescents predominantly from the same
ethnic and cultural backgrounds.
In this study, we aimed to examine the relationship
between measures of diet quality and adolescent mental
health in the Research with East London Adolescents:
Community Health Survey (RELACHS) [8, 9]. This study
focuses its investigations on adolescents from ethnically
diverse and socially deprived backgrounds, and comprises
data from more than one time point. As such, the posited
relationship can be examined prospectively, as well as
cross-sectionally, in a sample of adolescents with dietary
habits likely to be diverse. We hypothesised that unhealthy
dietary patterns would be related to increased mental health
problems, and healthy dietary patterns related to reduced
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Soc Psychiatry Psychiatr Epidemiol (2013) 48:1297–1306
mental health problems, both cross-sectionally and
prospectively.
Methods
Study design and setting
The RELACHS cohort study [8, 9] was designed to
investigate relationships between ethnicity, measures of
social disadvantage and psychological distress in adoles-
cents, and assessed adolescents recruited from three Local
Education Authority boroughs in East London (Hackney,
Newham and Tower Hamlets) in 2001. These participants
were followed up in 2003.
Participants
The baseline sample (2001) comprised pupils from years
seven (aged 11–12 years) and nine (aged 13–14 years)
attending a representative sample of state funded schools in
the three catchment boroughs. The RELACHS study
sample was selected using two-stage stratified random
sampling. Of the 3,322 pupils eligible for the study, the
overall response rate at baseline was 84 % (2,790 pupils).
Of these, 2,093 (75 %) were assessed at time two in 2003.
Data collection and ethics
Information about the study was given to teachers, parents
and pupils a week before the school visits. Parents could
choose to opt out their child. Pupils who had not been
opted out were invited to take part and asked for written
consent. Pupils could withdraw from the study at any time,
and did not have to answer questions they did not want to.
A team of researchers administered the questionnaire in
classrooms in one 40–50 min session. Pupils provided self-
reported data on a self-completion questionnaire. Physical
measurements were taken by trained researchers. Pupils
were monitored to ensure that they were not distressed.
Ethical approval was given by the ethics committees of
East London and the City, as well as relevant local edu-
cation authorities.
Measurements: exposures
Dietary data were collected at the baseline assessment
only. Questions on healthy eating were taken from the
Health and Behaviours of Teenagers Study (HABITS), and
included consumption of fruit and vegetables [10] and
regularity of eating breakfast. Breakfast consumption was
assessed with the question ‘‘Before going to school, how
often do you have breakfast at home or school breakfast
Soc Psychiatry Psychiatr Epidemiol (2013) 48:1297–1306
club?’’ with answers ranging from never (0) to every day
(3). Questions on fruit and vegetable consumption com-
prised the following: ‘‘About how many lots of fruit do you
usually eat in a day (how many ‘‘lots’’ means ‘‘how many
portions’’ e.g. one apple/small bunch of grapes)’’; and
‘‘About how many lots of vegetables do you usually eat in
a day?’’ Answers on these three questions were summed to
give a ‘Healthy’ diet score.
Consumption of unhealthy foods including fast foods,
snacks and biscuits high in saturated fats and sugars was
assessed with the question ‘‘About how often do you eat or
drink the following? (for each): (a) Crisps or savoury
snacks; (b) sweets, ghee sweets or chocolate; (c) biscuits;
(d) fried food, chips, samosas or bhajis, or fried English
breakfast; (e) fizzy drinks e.g. Coke’’, with answers ranging
from never (0) to more than once a day (4). These answers
were summed to give an ‘Unhealthy’ diet score.
Measurements: outcomes
Depressive symptoms were measured using the Short
Moods and Feelings Questionnaire (SMFQ) [11]. This
includes 13 statements about emotions and behaviour over
the past 2 weeks. The scores for the items were summed to
produce an overall magnitude of symptoms, with a score
of eight or above indicating the presence of depression.
In the original validation against the Diagnostic Interview
Schedule for Children—Depressive Scale, this threshold
yielded a positive predictive value of 80 % and a negative
predictive value of 68 % [11]. Psychological distress
was measured by the 25-item self-report version of the
Strengths and Difficulties Questionnaire [12]. The SDQ
comprises five sub-scales: hyperactivity, conduct problems,
emotional symptoms, peer problems and prosocial behav-
iour (reverse scored). A total SDQ score ranging from 0 to
40 was generated by adding together the scores for all of
the scales, apart from prosocial behaviour. The higher the
total score, the higher the level of distress. A score of 18
was chosen as the threshold for a high scorer as this was
equivalent to prevalence rates in national data using multi
model assessments [13]. The measure has been used pre-
viously in ethnically mixed youth samples, which supports
the SDQ as a valid instrument for ethnically diverse sam-
ples [13–15].
Measurements: confounders
A number of confounding variables were tested for: gen-
der, age, ethnicity, religion, length of time lived in UK,
family structure, social deprivation (eligibility for free
school meals, parental employment status, car ownership,
over-crowding), general health, health behaviours (physical
activity, alcohol use, smoking and drug use), dieting
1299
behaviour, body mass index (BMI) and family factors
(parental conflict and social support). Questions on smok-
ing and drinking (frequency) and drug use (ever used and
how recently) were taken from the Office for National
Statistics Survey for teenagers [16]. Questions on physical
activity were taken from the Health Education Authority
Survey [17]. Family social support came from the multi-
dimensional scale of perceived social support [18]. Soci-
odemographic data (gender, religion, ethnicity and
eligibility for free school meals) were drawn from the
questionnaire and 2001 Census questions. Height and
weight were measured according to a standardised proto-
col. Questions on dieting and perceived weight were also
included.
Data management
All data management and analysis was carried out using
Stata version 10.0. There were some missing data at
baseline: 64 respondents did not have data on depression
(2 %), 79 respondents did not have data on Healthy diet
(3 %) and 134 respondents did not have data on Unhealthy
diet (5 %). As the amount of missing data was relatively
small for most of the key variables, it was considered
reasonable to exclude pupils who did not have complete
data.
Statistical analyses
Since the school was the primary sampling unit for the
study, it was necessary to make adjustments for clustered
survey design in the analyses. An equal number of classes
were selected in each school regardless of school size; data
were therefore re-weighted to adjust for unequal proba-
bility of selection.
Cross-sectional analyses were carried out on the data
collected in 2001. Descriptive statistics were generated,
taking account of survey design. In the univariable analy-
sis, crude odds ratios (ORs) were calculated for the asso-
ciation between each variable and psychological distress
(SDQ) and depressive symptoms (SMFQ) separately using
logistic regression. Confounding was assessed using clas-
sical (Mantel–Haenszel) and univariable logistic regression
analyses. Effect modification was investigated by exam-
ining the results of the v2 test for homogeneity and by
looking at the stratum specific ORs.
Multivariable analysis was carried out using logistic/lin-
ear regression to examine the association between diet and
mental health. Two outcomes were examined: psychological
distress (SDQ) and depressive symptoms (SMFQ). Two
main exposures were used in separate regression analyses:
Healthy diet and Unhealthy diet. These two dietary scales
were categorised into quintiles to reduce any impact of
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outliers, and to aid in identification of non-linear relation- Table 1 Characteristics of the sample at baseline
ships. Potential confounders were identified on the basis of N Percentage
relationships between at least one exposure and one outcome (adjusted for
survey design)
and added to the models in groups (gender, dieting behav-
iour, health behaviours and family factors). If adding a Gender
confounder or group of confounders resulted in an Male 1,356 48.8
improvement in model fit, as assessed by the Wald test, they Female 1,433 51.2

were retained in the model. Year group

Year 7 1,381 49.0
Multivariable longitudinal logistic regression analyses
Year 9 1,408 51.0
examined the impact of diet in 2001 on case level psy-
Ethnicity
chological distress and symptomatic depression in 2003. In White 581 20.8
secondary analyses, cases on the SDQ and SMFQ at White other 161 5.9
baseline were excluded from the analyses, and continuous Bangladeshi 690 25.6
scores on the mental health questionnaires were used as Asian Indian 250 9.0
outcome measures in linear regression analyses. Con- Pakistani 184 6.8
founders were added to the model in the same way as for Black Caribbean 166 6.0
the cross-sectional analyses. Black African 279 10.1
Black British 121 4.3
Mixed Ethnicity 193 7.0
Chin/Viet and other 124 4.5
Religious group
Results None 325 11.5
Jewish 3 0.1
Survey Christian 994 35.7
Muslim/Islam 1,169 42.7
A total of 2,789 pupils completed the baseline survey in Hindu 101 3.7
2001. There was some evidence for lower response Sikh 72 2.7

among pupils who were eligible for school meals Agnostic/Atheist/Don’t know 59 2.1
Other 43 1.6
(P = 0.055), and strong evidence for lower response
Case on SDQ 286 10.3
amongst white pupils (P \ 0.0001). Seventy-five per cent
Not a case on SDQ 2,458 89.7
of these, 2,093 pupils, were followed up in 2003. Some Case on SMFQ 671 24.5
groups were less likely to be followed up: those depressed Not a case on SMFQ 2054 75.6
in 2001 (P = 0.002), girls (P = 0.005), those eligible for Healthy diet score
free school meals (P = 0.002) and white pupils 0 466 17.2
(P B 0.0001). 1 274 10.0
Table 1 describes the sample at baseline. Of the pupils, 2 782 29.0
approximately 21 % were white and another 26 % Ban- 3 636 23.2
4 552 20.6
gladeshi, with smaller proportions distributed amongst a
Unhealthy diet score
multitude of other ethnicities. Almost 40 % of students
0 498 18.6
reported both parents unemployed and nearly half were
1 476 18.1
eligible for free school meals. 2 492 18.4
At baseline, 9.2 % of boys and 11.3 % of girls were 3 506 19.1
SDQ cases, while 10.2 % of boys and 13.2 % of girls were 4 683 25.8
cases on the SDQ at follow-up. Of these, 8.4 % of boys and Either parent employed
10.1 % of girls were ‘new’ cases at follow-up. At baseline, Neither 1,004 37.5
18.9 % of boys and 29.8 % of girls were cases on the At least one 1,681 62.5

SMFQ, while 19.6 % of boys and 34.6 % of girls were Eligible for free school meals
Eligible 1,453 48.1
cases on the SMFQ at follow-up. Of these, 14.8 % of boys
Not eligible 1,550 51.9
and 25.4 % of girls were new cases at follow-up.
Healthy diet scores were normally distributed, while
Unhealthy diet scores showed a negatively skewed distri- Cross-sectional univariable analysis
bution. Healthy diet scores ranged from 0 to 13
(SD ± 2.82), while Unhealthy ranged from 1 to 20 Table 2 reports the results of univariable analyses. Healthy
(IQR = 6). diet scores were inversely related to both the SMFQ and

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Table 2 Odds of psychological distress in 2001 by dietary and other variables: results of univariable logistic regression analyses
SDQ SMFQ
OR 95 % CI N OR 95 % CI N

Eligible for free school meals 1.03 0.77–1.38 2,522 1.00 0.83–1.20 2,505
BMI
Below 85th percentile 1 2,479 1 2,462
Overweight (85th–95th percentile) 0.89 0.58–1.34 1.04 0.72–1.49
Obese (over 95th percentile) 1.26 0.91–1.76 1.45 1.17–1.81
Dieting behaviour
Not trying to change weight 1 2,596 1 2,592
Trying to lose weight 1.88 1.37–2.57 2.30 1.86–2.85
Trying to gain weight 2.00 1.24–3.21 1.90 1.38–2.61
Physical activity h/week
None 1 2,716 1 2,705
About 0.5 h 0.81 0.59–1.11 0.94 0.71–1.25
About 1 h 0.68 0.41–1.13 0.90 0.67–1.21
About 2–3 h 0.55 0.36–0.85 0.67 0.49–0.91
About 4–6 h 0.61 0.30–1.25 0.58 0.37–0.90
More than 7 h 0.68 0.34–1.34 0.48 0.30–0.77
Cigarette smoking
Never smoked 1 2,710 1 2,704
Less than one per week 1.68 1.31–2.12 1.48 1.14–1.92
One or more per week 2.91 1.87–4.52 1.92 1.23–2.98
Units of alcohol consumed last week
Did not drink 1 2,678 1 2,679
1–5.5 units 2.29 1.09–4.80 1.06 0.59–1.88
More than 6 units 6.33 2.36–16.92 3.18 1.31–7.68
Ever tried drugs
No 1 2,738 1 2,719
Yes 2.39 1.72–3.33 1.49 1.21–1.83
Parents argued or fought
No 1 2,,489 1 2,719
Yes 1.40 1.05–1.88 1.49 1.21–1.84
Family social support (continuous) 0.74 0.68–0.81 2,670 1.75 1.42–2.15 2,666
Family social support
Low 1 2,670 1 2,666
Moderate 0.48 0.34–0.67 0.43 0.35–0.52
High 0.46 0.33–0.66 0.35 0.27–0.43

SDQ. Unhealthy diet scores were positively related to the
SDQ, with a dose–response pattern observed, but the
relationship of Unhealthy diet scores to the SMFQ; whilst
in the same direction, was less strong and not statistically
significant. Cigarette smoking, alcohol consumption and
drug use were also associated with increased risk of case-
ness on the mental health scales, as were family conflict
and low family support. Dieting behaviour (actively trying
to lose or gain weight) was also associated with mental
health problems, although BMI was related only to the
SMFQ and only for those identified as obese (over 95th
percentile). Eligibility for free school meals, as a measure
of social deprivation [19] was not associated with either
mental health scale.
Multivariable analysis: baseline
No effect modification was observed for gender
(P [ 0.05). Potential confounders in analyses with SDQ as
an outcome variable were identified in several categories:
dieting behaviours, health behaviours and family factors.
For those examining the SMFQ as an outcome, gender was

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Table 3 Odds of psychological distress on the SDQ in 2001 per quintile of Healthy and Unhealthy diet score: results of multivariable logistic
regression analyses
Crude odds ?Dieting ?Health behaviours* ?Family factors**
OR 95 %CI OR 95 %CI OR 95 %CI OR 95 %CI

Healthy diet score (Quintiles)

Least healthy 1 1 1 1
1 0.84 0.50–1.43 0.88 0.51–1.51 0.96 0.54–1.70 0.97 0.54–1.72
2 0.64 0.40–1.03 0.69 0.42–1.13 0.78 0.48–1.24 0.83 0.53–1.34
3 0.59 0.37–0.93 0.63 0.39–1.00 0.75 0.46–1.23 0.82 0.51–1.34
Most healthy 0.66 0.47–0.94 0.70 0.49–0.99 0.87 0.61–1.25 1.00 0.69–1.44
Wald p value (N = 2,383) \0.001 0.003 \0.001
Unhealthy diet score (Quintiles)
Most healthy 1 1 1 1
1 1.56 0.80–3.01 1.57 0.80–3.09 1.54 0.80–2.96 1.56 0.82–2.97
2 1.66 1.05–2.62 1.75 1.10–2.76 1.60 0.97–2.64 1.60 1.00–2.57
3 2.14 1.24–3.68 2.34 1.37–4.00 2.10 1.19–3.69 2.17 1.22–3.83
Least healthy 2.15 1.44–3.21 2.43 1.64–3.58 2.07 1.36–3.15 2.10 1.38–3.20
Wald p value (N = 2,339) \0.001 0.003 0.001
* Health behaviours: smoking, alcohol consumption, drug use and physical activity
** Family factors: parental conflict and family social support

also a confounder, but health behaviours were not.
Tables 3 and 4 report the multivariable regression analyses
for both the SDQ and the SMFQ at each stage of
adjustments.
There was strong evidence for an association between
Unhealthy diet scores and caseness on the SDQ both before
and after adjustments (Table 3). Compared to those in the
lowest quintile for Unhealthy diet scores, those in the
highest quintile were more than twice as likely to be a case
on the SDQ, both before and after adjustments. After
adjustment for confounders, there was also evidence for an
association between higher Unhealthy diet scores and
increased odds of symptomatic depression on the SMFQ.
This relationship was only apparent after adjusting for
dieting and family factors, suggesting that these were act-
ing as suppressor variables in the analyses (Table 4).
There was weaker evidence for an association between
healthy diet scores and the mental health outcomes. The
inverse association between healthy diet scores and the
SDQ observed in univariable analyses was fully explained
by adjustments for other health behaviours (Table 3), while
the relationship of healthy diet scores to the SMFQ was
somewhat attenuated by adjustments for gender, then fully
attenuated by adjustments for family factors (Table 4).
Multivariable analysis: prospective
In analyses examining Unhealthy diet scores at baseline as
predictors of case level mental health outcomes at follow-
up, a relationship was observed with the SDQ for those in
the highest quintile of unhealthy diet, but not the SMFQ.
Prior to adjustments, those in the highest quintile of
Unhealthy diet scores at baseline were significantly more
likely to be a case on the SDQ at follow-up (OR 1.75, 95 %
CI 1.00–3.06). However, after all adjustments, including
adjustment for caseness at baseline, the relationship was in
the same direction but no longer significant (OR 1.50,
95 % CI 0.80–2.81).
Weak inverse relationships between Healthy diet scores
and mental health at follow-up were observed for the
SMFQ [Q1 = reference (Q2: OR 0.82, 95 % CI 0.60–1.11;
Q3: OR 0.65, 95 % CI 0.46–0.92; Q4: OR 0.70, 95 % CI
0.52–0.94; Q5: OR 0.75, 95 % CI 0.55–1.04)], but were
fully attenuated by adjustments. A similar pattern of
inverse associations was observed between Healthy diet
scores and the SDQ at follow-up [Q1 = reference (Q2: OR
0.74, 95 % CI 0.39–1.41; Q3: OR 0.60, 95 % CI
0.33–1.11; Q4: OR 0.61, 95 % CI 0.39–0.97; Q5: 0.63,
95 % CI 0.38–1.05)] in univariable analyses, but these
were also attenuated by adjustments for other factors.
Results of analyses with continuous scores on the SDQ
as the outcome variable revealed that diet scores at baseline
were inversely related to SDQ scores at follow-up until
final adjustments for family factors, wherein only the
highest quintile of healthy diet score maintained a rela-
tionship of borderline significance with lower SDQ scores
(ß = -0.91, 95 % CI -1.84–0.01). Once again, only the
highest quintile of Unhealthy diet score demonstrated a

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Table 4 Odds of psychological distress on the SMFQ in 2001 per quintile of Healthy and Unhealthy diet score: results of multivariable logistic
regression analyses
Crude odds ?Gender ?Dieting ?Family factors**
OR 95 %CI OR 95 %CI OR 95 %CI OR 95 %CI

Healthy diet score (Quintiles)

Least healthy 1 1 1
1 0.72 0.50–1.04 0.77 0.54–1.08 0.80 0.56–1.12 0.81 0.58–1.14
2 0.64 0.48–0.85 0.68 0.51–0.91 0.73 0.54–1.00 0.83 0.61–1.14
3 0.60 0.46–0.79 0.64 0.50–0.83 0.68 0.51–0.91 0.80 0.60–1.07
Most healthy 0.70 0.50–0.99 0.78 0.56–1.09 0.82 0.57–1.18 1.05 0.71–1.55
Wald p value (N = 2,382) \0.001 \0.001 \0.001
Unhealthy diet score (Quintiles)
Most healthy 1 1 1 1
1 1.37 1.02–1.84 1.39 1.03–1.87 1.39 1.01–1.91 1.41 1.03–1.92
2 1.19 0.83–1.72 1.24 0.86–1.78 1.28 0.89–1.84 1.26 0.88–1.80
3 1.21 0.93–1.58 1.28 0.99–1.65 1.37 1.03–1.81 1.41 1.04–1.89
Least healthy 1.33 0.94–1.87 1.40 0.97–2.01 1.54 1.05–2.26 1.51 1.04–2.19
Wald p value (N = 2,338) \0.001 \0.001 \0.001
** Family factors: parental conflict and family social support

positive relationship to SDQ scores (ß = 0.78, 95 % CI Strengths and limitations

0.03–1.52), which was attenuated by adjustments for other
health behaviours. There were no relationships observed
between scores on either dietary measure and SMFQ scores
at follow-up.
Discussion
Key results
In a cross-sectional study, we found evidence for an asso-
ciation between an Unhealthy diet and mental health prob-
lems in this sample of ethnically diverse and socially
deprived adolescents; those in the highest quintile of
Unhealthy diet score were more than twice as likely to be
symptomatic on the SDQ, and nearly 50 % more likely to be
symptomatic on the SMFQ after taking all identified con-
founders into account. There was also weaker evidence for
an inverse association between a measure of Healthy diet and
mental health problems. There was less evidence for a pro-
spective association between measures of diet quality and
case level mental health problems, although the patterns of
associations between high scorers on both Healthy (inverse)
and Unhealthy (positive) diet scales and caseness on the SDQ
were the in the same direction as cross-sectional analyses.
When continuous scores on the mental health questionnaires
were examined as outcome measures, weak relationships
between high scores on the Healthy diet scale and lower SDQ
scores at follow-up were evident.
To our knowledge, this study is the first to report on the
prospective relationship between diet quality and mental
health in adolescents from highly disadvantaged and eth-
nically diverse backgrounds. An obvious strength of the
study is the inclusion of a wide range of potentially con-
founding variables such as socio-economic status, family
conflict and support, dieting behaviours, as well as drug use
and other lifestyle behaviours. However, as in all such
studies, we may not have adequately accounted for these
factors, and residual confounding may be an explanation
for these findings. Socio-economic status is a potentially
important confounder in the relationship between diet
quality and mental health, but we did not find that measures
of socio-economic status confounded the relationships
under investigation. This is likely to be a result of the
relatively homogeneous nature of the study cohort with
regards to social class, which is another strength of this
study. A further strength of the study was the utilisation of
two well-validated mental health scales for adolescents,
capturing constructs of both depression and behaviour, and
affording a replication of our previous Australian study
using the SMFQ [7].
The main limitation relates to the Healthy diet scale in
this study. Only three items were collected for this scale—
fruit and vegetable intake and breakfast consumption.
There may have been a particular problem for adolescents
to adequately identify how many vegetables they con-
sumed per day given the composition of meals such as

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curries and stir-fries, which are more likely to be consumed
by adolescents from Asian and African backgrounds.
Neither did the questions used to assess Healthy diet
quality include several other accepted components of a
healthy diet (such as whole grains, low fat dairy and fish).
Moreover, we had no information on the quality of the
breakfasts consumed in this cohort, where regular unheal-
thy food consumption was common and likely to be also
reflected in breakfast choices. On the other hand, junk and
processed foods, such as crisps, savoury snacks, sweets,
biscuits, fried food, chips and soft drinks are ubiquitous in
the community and their consumption less culturally
determined. As such, the Unhealthy scale is likely to have
adequately captured the consumption of these foods.
Although the survey items used would have been less
accurate than more in-depth measures of dietary intake, we
have previously used simple dietary questionnaires to
adequately rank students in this age group on their dietary
quality [5, 7].
It is quite likely that statistical power was an issue in this
study. In this cohort of socially disadvantaged adolescents,
smoking, alcohol and drug use and family factors were
more strongly related to the mental health outcomes than
diet, and it is likely that any effect of diet on mental health
would have been ‘washed out’ by the larger contribution of
these other factors. The contention that statistical power
was an issue in this study is supported by the stronger
relationships observed in analyses utilising continuous
outcomes rather than case level illness. The recognised
limitations of the dietary scales may have also reduced
statistical power and limited the ability to detect true
associations. The fact that weak prospective relationships
between Healthy diet scores and mental health were
observed suggests that utilising larger samples may yield a
clearer picture of the prospective relationship between diet
and mental health in future studies.
A response rate of 84 % is reasonable, and a number of
strategies were used to encourage reliable response for an
adolescent sample. The overall follow-up was 75 % and
there was no difference in follow-up by Unhealthy diet
scores. On the Healthy diet measures, however, those that
scored very high or very low were less likely to be fol-
lowed up (P = 0.04). This would have the effect of
reducing variance, and thus statistical power. Other groups
were also less likely to be followed up. These were: ado-
lescents who were depressed at baseline, girls, those eli-
gible for free school meals and white pupils. These patterns
of follow-up may have had an impact on the associations
found, and have contributed to an underestimation of the
strength of association between diet quality and mental
health at follow-up. There may have been some degree of
social desirability bias in the answers to questions regard-
ing the frequency of fruit and vegetable consumption, as
123
Soc Psychiatry Psychiatr Epidemiol (2013) 48:1297–1306
educational programs directed at this age group encourage
the consumption of these foods. Moreover, given that both
diet and mental health measures were reliant on self-reports
by the adolescents, bias may have also resulted from dif-
ferential dietary reporting by those with depressive symp-
toms; depressed adolescents may be more likely to report
negative eating habits. Additionally, reverse causality may
explain our results; mental health problems may have
resulted in impaired eating habits and reduced self-care,
with a concomitant reduction in dietary quality. As we did
not have data on dietary intakes at follow-up, we were
unable to test this hypothesis. Finally, unrecognised con-
founding cannot be ruled out as an explanation for these
findings; we lacked data on variables such as maternal
depression and personality factors, which may explain
these demonstrated relationships.
Interpretation
The finding of a cross-sectional relationship between a
measure of Unhealthy food intake and adolescent mental
health in this study is concordant with our previous find-
ings in Australian adolescents [5]. In the Australian study,
participants were deliberately sampled from a wide range
of socio-economic, geographical and demographic back-
grounds which is in contrast to this study, wherein partici-
pants were drawn from a small area of East London with a
similar sociodemographic profile. The fact that similar
patterns of association between Unhealthy diets and mental
health were seen in both studies, over and above the con-
tribution made by a wide range of possible confounding
factors, supports the veracity of this relationship. Another
Australian study also reported positive associations
between the consumption of takeaway foods and sweets
and internalising and externalising behaviours in nearly
2,000 adolescents [6]. In that study, the strength of the
association was stronger for externalising than internalising
behaviours. This is concordant with our study where we
consistently found stronger associations between diet and
SDQ scores than with SMFQ scores. This is surprising,
given that there were far fewer cases on the SDQ than on
the SMFQ. This finding may reflect an impact of diet on
behaviour more than depression and also indicate that boys,
who tend towards external manifestations of emotional
distress more than females [20], may be particularly
affected by excessive consumption of poor quality foods.
The lack of a strong evidence for a longitudinal asso-
ciation between diet quality and mental health does not
mean that such a relationship does not exist; results of the
longitudinal analyses, whilst not statistically significant,
demonstrated similar patterns of association to the cross-
sectional analyses for high scorer on both scales, and were
largely in the directions predicted by the hypothesis,
Soc Psychiatry Psychiatr Epidemiol (2013) 48:1297–1306
particularly for the healthy diet scale. Moreover, recent
research in a large study of Spanish adults has demon-
strated an inverse association between the level of adher-
ence to a Mediterranean dietary pattern and the risk for
incident depression [3], while the Whitehall II cohort study
of middle-aged adults reported an increased risk for self-
reported depression after 5 years for those adhering more
strongly to an Unhealthy dietary pattern, and a reduced risk
for those following a healthy dietary pattern [2]. Similarly,
a recent prospective study of Australian adolescents dem-
onstrated an independent contribution of diet quality to
adolescent depression over a 2-year period [7]. In each of
these prospective studies, the associations did not appear to
be explained by reverse causality i.e. depression prompting
dietary changes, or by confounding by sociodemographic
factors or health behaviours. These recent data, therefore,
support a causal role for diet quality in depressive illness.
As discussed, any influence of diet on mental health is
likely to be difficult to detect in the presence of a large
number of potentially more powerful detrimental social,
behavioural and environmental factors, and further studies
in cohorts with increased social and other environmental
problems may require larger sample sizes. It is also the
case that diet is a long-term exposure with the potential to
influence the development of the brain [21, 22] and the
immune system [23] over a long period. Even peri-natal
and early post-natal nutritional exposures may be of critical
importance to later physical and mental health [24, 25]. As
such, detecting an impact of dietary quality on mental
health in adolescence may require cohort studies that
examine the relationship from a much earlier period of life.
Conclusion
Mindful of the aforementioned caveats, our findings are
broadly in line with the association of diet quality with
depression previously reported in Australian adolescents
[5, 7], and offer some support for the contention that poor
diet is a risk factor for mental health problems in adoles-
cents. However, this is a nascent field of investigation, with
further research necessary to confirm diet as a causal factor
in depressive illnesses. Given the substantial burden of
illness of adolescent depression and the fact that the
majority of mental illnesses in the population manifest
before age 25 [26], establishing whether or not poor quality
diets are a risk factor for mental health problems in ado-
lescents is of primary public health importance. As addi-
tional prospective cohort studies are warranted, further
research should also incorporate intervention studies to
examine whether dietary improvement results in improve-
ments in mental health in both adults and adolescents.
1305
Acknowledgments We are grateful for the support of the schools,
parents and students involved in this study, as well as the Community
Advisory Board. We also thank the field team, including Wendy Is-
enwater, Giash Ahmed, Sarah Brentnall, Sultana Choudry-Dormer,
Franca Davenport, Davina Woodley-Jones, Amanda Lawrence,
Rachel Cameron and Hannah Bennett. Phase 1 of the RELACHS
study was commissioned by the East London and the City Health
Authority and Phase 2 by the Teenage Pregnancy Unit at the
Department of Health: we thank them for their support. We also thank
Tower Hamlets, City and Hackney and Newham Primary Care Trusts
for additional funding. Associate Professor Jacka was the recipient of
post-graduate scholarship funding from Australian Rotary Health and
is supported by a NH&MRC Post-Doctoral Fellowship (#628912). Dr
Rothon is funded by a Medical Research Council Special Training
Fellowship (G0601707).
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