International Journal of

Environmental Research
and Public Health

Article
Poor Dietary Habits in Bullied Adolescents:
The Moderating Effects of Diet on Depression
Natalia Albaladejo-Blázquez 1 ID , Rosario Ferrer-Cascales 1, *, Nicolás Ruiz-Robledillo 1 ID ,
Miriam Sánchez-Sansegundo 1 ID , Violeta Clement-Carbonell 1 and Ana Zaragoza-Martí 2
1 Department of Health Psychology, Faculty of Health Science, University of Alicante, 03690 Alicante, Spain;
natalia.albaladejo@ua.es (N.A.-B.); nicolas.ruiz@ua.es (N.R.-R.); miriam.sanchez@ua.es (M.S.-S.);
violeta.clement@ua.es (V.C.-C.)
2 Department of Nursing, Faculty of Health Science, University of Alicante, 03690 Alicante, Spain;
ana.zaragoza@ua.es
* Correspondence: rosario.ferrer@ua.es; Tel.: +34-965-903-990




Received: 28 June 2018; Accepted: 23 July 2018; Published: 24 July 2018


Abstract: The prevalence of bullying has increased dramatically during recent years, with numerous
negative consequences for the health and quality of life of bullied adolescents. Although negative
psychological consequences of this type of situation have been widely investigated, no previous
research has evaluated the effects of bullying victimization on dietary habits, and its relationship
with psychological outcomes, such as depression. For this reason, the main aim of the present study
was to evaluate the association between bullying, dietary habits, and depression in a sample of
527 Spanish adolescents. The results obtained showed that being bullied was correlated negatively
with healthy dietary habits and positively with depression. Moderation analysis revealed dietary
habits as moderator of the association between bullying and depression. These results underline
the relevance of diet in the phenomenon of bullying, especially in victims, as could be related to the
high levels of depression characteristic of this population. The inclusion of nutritional education
in intervention programs oriented to victims of bullying might significantly improve their efficacy,
reducing depression levels.

Keywords: bullying; diet; depression; adolescents

1. Introduction
Bullying victimization is defined as the repeated occurrence of abuse between people from the
same age group where an imbalance of power makes it difficult for the victims to defend themselves [1].
This complex phenomenon has been increasing dramatically across the world over recent years [2]
with an estimated prevalence of 36% according to a recent meta-analysis [3]. Bullying victimization has
shown to have severe negative consequences for the health and quality of life of bullied adolescents,
such as higher levels of depression, anxiety, somatic symptoms, and suicidal ideation [4–6]. In line
with this, a recent study conducted with 6667 students concluded that being bullied has a significant
negative impact on physical, psychological, and social domains of quality of life [7,8].
Several studies have confirmed that, as expected, victims of bullying show higher levels of
depression than nonbullied adolescents [9–12], this being one of the most widely studied consequences
of bullying victimization in previous research [9–11]. Further, it has been demonstrated that bullying
victimization is followed by depression, reaching clinical levels in some cases [9]. This issue is
especially worrisome considering that depression has shown to be a significant mediator in the
association between bullying victimization and nonsuicidal self-injury [11] and a moderator of suicide

Int. J. Environ. Res. Public Health 2018, 15, 1569; doi:10.3390/ijerph15081569 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2018, 15, 1569 2 of 10

risk [12]. In fact, bullying victims are at a higher risk of self-harm, suicidal ideation, suicidal planning,
and suicide attempts than nonbullied adolescents [4].
While the phenomenon of bullying has been widely analyzed in previous research, revealing
a severe health risk, the majority of studies to date have only evaluated emotional and psychosocial
consequences of being bullied, but few studies have explored the relationship between bullying and
dietary habits [13,14]. In this sense, it has recently been found that adolescents who are victims of
bullying and cyberbullying frequently report skipping breakfast [13,14]. Taking into account that
bullying entails high levels of psychological dysfunction and stress, victims are at increased risk
of appetite deregulation and, hence, skipping meals [13,14]. To our knowledge, no research has
analyzed the possible deterioration of dietary patterns in bullying victims, and its association with
mood disorders, such as depression.
Therefore, the aims of the present study were to evaluate the relationship between bullying
victimization, dietary habits, and depression in a sample of Spanish adolescents, and to analyze
differences in dietary habits between high- and low-victimised adolescents. Furthermore, the study
aimed to identify the prediction ability of bullying and dietary habits on depression and to evaluate
the possible moderation effects of dietary habits in the relationship between bullying and depression.
Based on previous research, we hypothesized that bullying victimization would be negatively related
to healthy dietary habits [8,13,14] and positively related to depression [9,11]. Although previous
research had not evaluated the possible prediction and moderation effects of diet in this population,
we expected to find that bullying victims with high adherence to a healthy dietary habit would show
lower rates of depression [15,16].

2. Materials and Methods

2.1. Procedure
The present study is a part of a large-scale study on the Mediterranean Diet (MD), wellbeing,
and victimization carried out in schools in the Mediterranean city of Alicante (Spain). The study
was approved by the Ethics Committee of the University of Alicante (UA-2015-10-13), and parents
provided consent to the participation of their children prior to data collection. The participants
were 527 high school students (54.5% females; 45.5% males) ranging in age from 12 to 17 years
(M = 14.43, SD = 1.52) randomly selected from 5 public high schools in Alicante (Spain). Students who
assented to participate anonymously completed a battery of questionnaires in a paper-pencil format.
The distribution and completion of questionnaires was overseen by research assistants during the
second and third trimesters of the 2015/2016 academic year and the process took 60 to 70 min.
Inclusion criteria for the students were: (1) being present in the classroom on the day of the survey,
(2) being able to read and complete the questionnaires on their own, and (3) presenting an informed
consent form signed by their parents allowing participation. Participants were only retained in the
final sample if they had completed all questionnaires concerning the primary dependent measures of
bullying, dietary habits, and depression.

2.2. Measures

2.2.1. Bullying Victimization

For the analysis of bullying victimization, the subscale “victimization received” from the
Multimodal Questionnaire of School Interaction (MQSI) [17] was employed. This factor comprises
10 items, rated on a 4-point Likert scale, and evaluates the frequency of victimization received by
a bullied child or victim. Questions included in the subscale refer to victimization from verbal
(e.g., “they have insulted me”), social (e.g., “they have ignored me”), and physical (e.g., “they hit
me”) bully behaviors. This instrument has demonstrated adequate internal consistency among
adolescents [17]. Cronbach’s alpha values for the subscale of victimization received was 0.86.
Int. J. Environ. Res. Public Health 2018, 15, 1569 3 of 10

2.2.2. Dietary Habits

Dietary habits were evaluated by The MD Quality Index for children and teenagers
(KIDMED) [18,19]. It consists of 16 questions rated on a scale from 0 to 12 and can be self-administered
or administered by an interviewer following a protocol. Dietary items included in the questionnaire
evaluate the characteristic dietary pattern of the MD, a recognized healthy dietary pattern, including
items referring to the frequency of the consumption of fruits and vegetables, pulses, cereals, dairy
products and fish, the use of olive oil in cooked meals at home, and questions regarding breakfast
consumption and the characteristics of the breakfast usually consumed (if it includes dairy products,
baked goods, or pastries). The questionnaire also included two items related to the frequency of
sweets and fast food consumption. The total score on the questionnaire is classified into three levels:
≥8, indicating an “optimal” Mediterranean diet, 4–7, that improvement is needed to adjust intake
to Mediterranean patterns, and ≤3, very low diet quality. This questionnaire has demonstrated
adequate test-retest reliability [20] and construct validity [21] in previous research. In the present study,
Cronbach’s alpha for the total scale was 0.71.

2.2.3. Depression
The Short Web-Based version of the Center for Epidemiological Studies Depression Scale
(CES-D) [22] is composed of 7 items and can be used to evaluate the presence of depressive
symptomatology in children and adolescents. It covers the following domains: depressed affect,
positive affect, somatic and retarded activity, and interpersonal difficulties. Responses are rated on
a 4-point Likert scale. The total score, employed as a general measure of depressive mood, was used in
this study. The CES-D has shown adequate psychometric properties to estimate depression in several
samples [22,23]. The Cronbach’s alpha value in the current sample for this scale was 0.70.

2.3. Data Analysis

Pearson’s correlations were used to analyze the relationships between bullying, dietary habits,
and depression. Participants were divided into two groups (high-victimized n = 235 (44.6%) and
low-victimized n = 292 (55.4%) adolescents) based on their total scores on the bullying victimization
scale by using a cluster analysis. Chi-square analyses were performed to evaluate differences between
high- and low-victimized adolescents’ dietary habits. Hierarchical linear regression analysis was used
to determine the predictive value of bullying and dietary habits on depression. To test the moderation
effect of diet on the relationship between bullying and depression, the macro PROCESS by Hayes was
employed [24]. All statistical analyses were performed using SPSS (International Business Machines
Corporation (IBM), Armonk, NY, USA), Statistics for Windows, Version 24.0, considering any p < 0.05
as significant.

3. Results

3.1. Relationship between Bullying, Dietary Habits, and Depression

Pearson’s correlations between bullying, dietary habits, and depression are presented in Table 1.
Bullying was negatively associated with all of the evaluated dietary habits, except with fast food,
sweets, commercially baked goods, and breakfast consumption. The same pattern of correlations were
found for depression, except in the case of fast food and sweet consumption, in which depression
showed a significant positive association (Table 1).
Int. J. Environ. Res. Public Health 2018, 15, 1569 4 of 10

Table 1. Pattern of Pearson’s correlations between bullying, depression, and dietary habits (* p < 0.05;
** p < 0.001).

Bullying Depression
Fruit or fruit juice daily −0.723 ** −0.594 **
Second serving of fruit daily −0.541 ** −0.547 **
Fresh or cooked vegetables daily −0.478 ** −0.477 **
Fresh or cooked vegetables >1/day −0.504 ** −0.542 **
Regular fish consumption (at least 2–3/week) −0.476 ** −0.434 **
Fast-food (hamburger) restaurant >1 week 0.082 0.104 *
Pulses >1/week −0.279 ** −0.320 **
Pasta or rice almost daily (≥5/week) −0.289 ** −0.287 **
Cereal or cereal product for breakfast −0.471 ** −0.452 **
Regular nut consumption (at least 2–3/week) −0.269 ** −0.251 **
Use of olive oil at home −0.377 ** −0.260 **
No breakfast 0.123 ** 0.076
Dairy product for breakfast −0.628 ** −0.575 **
Commercially baked goods or pastries for breakfast 0.014 −0.052
Two yogurts and/or 40 g cheese daily −0.347 ** −0.349 **
Sweets and candy several times a day 0.072 0.095 *

3.2. Differences between High and Low Victimised Adolescents in Dietary Habits
To evaluate differences in dietary habits depending on bullying scores, differences between
high- and low-victimized adolescents were analyzed. Significant differences were found in all of the
evaluated dietary habits (p < 0.01), except in the case of breakfast and sweets consumption. In all cases,
high-victimized adolescents exhibit poorer dietary habits in comparison to low-victimized adolescents
(Table 2).

Table 2. Differences between high- and low-victimized adolescents in dietary habits.

High Victimization n = 235 Low Victimization n = 292

No 105 6
Fruit or fruit juice daily χ2 = 142.297, p = 0.0001
Yes 130 286
No 182 78
Second serving of fruit daily χ2 = 134.086, p = 0.0001
Yes 53 214
No 133 40
Fresh or cooked vegetables daily χ2 = 108.660, p = 0.0001
Yes 102 252
No 206 100
Fresh or cooked vegetables >1/day χ2 = 152.560, p = 0.0001
Yes 29 192
Regular fish consumption (at least No 144 56
χ2 = 97.998, p = 0.0001
2–3/week) Yes 91 236
Fast food (hamburger) No 152 216
χ2 = 5.336, p = 0.021
restaurant >1 week Yes 83 76
No 118 63
Pulses >1/week χ2 = 47.356, p = 0.0001
Yes 117 229
No 133 83
Pasta or rice almost daily (≥5/week) χ2 = 42.722, p = 0.0001
Yes 102 209
No 147 63
Cereal or cereal product for breakfast χ2 = 91.218, p = 0.0001
Yes 88 229
Regular nut consumption (at least No 147 105
χ2 = 36.907, p = 0.0001
2–3/week) Yes 88 187
No 29 5
Use of olive oil at home χ2 = 24.369, p = 0.0001
Yes 206 287
No 179 208
No breakfast χ2 = 1.627, p = 0.202
Yes 56 84
No 139 36
Dairy product for breakfast χ2 = 128.691, p = 0.0001
Yes 96 256
Commercially baked goods or No 152 216
χ2 = 5.336, p = 0.021
pastries for breakfast Yes 83 76
Int. J. Environ. Res. Public Health 2018, 15, 1569 5 of 10

Table 2. Cont.

High Victimization n = 235 Low Victimization n = 292

No 185 128
Two yogurts and/or 40 g cheese daily χ2 = 65.713, p = 0.0001
Yes 50 164
No 194 257
Sweets and candy several times a day χ2 = 3.146, p = 0.076
Yes 41 35
Low adherence to Mediterranean
103 0
Diet (MD)
χ2 = 350.725, p = 0.0001
Medium adherence to MD 132 65
High Adherence to MD 0 227

3.3. Prediction Ability of Bullying and Dietary Habits on Depression

In order to evaluate the ability of bullying and dietary habits to predict depression, a hierarchical
regression model was constructed. For controlling the possible confounding effects of age and sex,
these two factors were included in the first step. Bullying was included in the second step, and dietary
habits in the third. When age and sex were introduced in the first step, neither were significant
predictors. In the second step, including bullying in the model, this factor was found to be significant.
In the third step, in which dietary habits were included, bullying remained significant and all of the
evaluated dietary habits except the use of olive oil were significant. In this final step, age and sex were
not significant predictors of depression (Table 3).

Table 3. Predictive values of age, sex, bullying, and dietary habits in depression (* p < 0.05; ** p < 0.001).

Model 1 β R2 ∆R2
Age −0.012
Sex −0.061
F(2, 526) = 0.972, p = 0.379 0.000 0.004
Model 2 β R2 ∆R2
Age 0.035
Sex 0.001
Bullying 0.834 **
F(3, 526) = 394.983, p = 0.0001 0.692 0.690 **
Model 3 β R2 ∆R2
Age 0.004
Sex 0.001
Bullying 0.118 *
Fruit or fruit juice daily −0.106 **
Second serving of fruit daily −0.148 **
Fresh or cooked vegetables daily −0.126 **
Fresh or cooked vegetables >1/day −0.173 **
Regular fish consumption (at least 2–3/week) −0.157 **
Fast food (hamburger) restaurant >1 week 0.115 **
Pulses >1/week −0.153 **
Pasta or rice almost daily (≥5/week) −0.142 **
Cereal or cereal product for breakfast −0.145 **
Regular nut consumption (at least 2–3/week) −0.119 **
Use of olive oil at home −0.036
No breakfast 0.132 **
Dairy product for breakfast −0.140 **
Commercially baked goods or pastries for breakfast 0.143 **
Two yogurts and/or 40 g cheese daily −0.150 **
Sweets and candy several times a day 0.095 **
F(19, 526) = 113.735, p = 0.0001 0.803 0.116 **
Int. J. Environ. Res. Public Health 2018, 15, 1569 6 of 10

3.4. Moderation Effects of Dietary Habits on the Relationship between Bullying and Depression.
The hypothesized model suggested a significant interaction effect of bullying and dietary habits
(level of adherence to MD) on depression (p = 0.00001). Taking into account that the lower and upper
limits of the 95% confidence interval for the interaction did not cross zero, the significant effects of the
interaction between both variables could be corroborated (Table 4). Hence, the model was significant
R2 = 0.81, MSE = 1.99, F(3, 523) = 764.07, p = 0.00001. The moderation effect is plotted in Figure 1.
According to the Johnson–Neyman technique, the relationship between bullying and depression was
moderated by dietary habits at all levels. For that reason, a slope analysis was conducted to observe
the moderation effects of dietary habits, depending on the level of adherence to MD (high, medium
and low). Simple slopes analyses showed that the relationship between bullying and depression was
significant at one standard deviation below the mean adherence to MD score (b = 0.223, SE = 0.047,
t = 4.68, p = 0.00001, 95% CI: 0.129, 0.317), at the mean adherence to MD score (b = 0.332, SE = 0.067,
t = 4.93, p = 0.00001, 95% CI: 0.200, 0.464), and at one standard deviation above the mean adherence
to MD (b = 0.441, SE = 0.089, t = 4.94, p = 0.0001, 95% CI: 0.266, 0.616). As can be observed, there is
an interaction effect between bullying and adherence to MD, showing those adolescents with high
adherence to MD have lower rates of depression in comparison to adolescents with medium and low
adherence to MD (Figure 1).

Table 4. Moderation of the relationship between bullying and depression by dietary habits (Adherence to MD).

B SE t p 95% CI
Bullying 0.332 0.067 4.930 0.00001 [0.200, 0.464]
Dietary habits (Adherence to MD) −0.689 0.084 −8.151 0.00001 [−0.855, −0.523]
Bullying x Dietary habits (Adherence to MD) 0.040 0.008 4.546 0.00001 [0.022, 0.057]

Figure 1. Graphical representation of the moderation of dietary habits (adherence to MD) on the
association between bullying and depression.

4. Discussion
In this study, we have examined (i) the relationship between bullying victimization, dietary
habits, and depression; (ii) differences in dietary habits between high- and low-victimized adolescents;
(iii) the prediction ability of bullying and dietary habits on depression; and (iv) the moderation effects
of diet on depression. Our results show that bullying victimization is significantly related to poor
Int. J. Environ. Res. Public Health 2018, 15, 1569 7 of 10

dietary habits together with higher levels of depression in Spanish adolescents. Hence, high-victimized
adolescents showed poor dietary habits compared to low-victimized ones. Regression and moderation
analyses exhibited a significant effect of diet on depression.
Regarding the association between bullying and dietary habits, results have demonstrated
a significant association between bullying victimization and poor dietary habits corroborated by
the analyzed differences between high- and low-victimized adolescents. It has been previously
demonstrated that bullying as a chronic stress situation is related to significant negative changes
in lifestyle in adolescents, such as a decline in diet quality [25]. In this regard, chronically-stressed
adolescents are less likely to have a healthy lifestyle in which dietary habits play a main role [25,26].
Further, it has previously been shown that highly-stressed children and adolescents tend to develop
an unhealthy dietary pattern, characterized by a higher intake of sweets and fatty foods than fruit
and vegetables [27,28] This could be explained by the high content of fats, energy, and sugar of these
kinds of foodstuff; but, it could be mediated more by psychological perception and preferences than
by nutritional composition [28]. Hence, based on the theory of “comfort foods”, the consumption of
these kinds of foodstuff, rich in sugar and fats, could represent an escape coping strategy due to the
emotional component of eating and the rewarding effects of this type of food, reducing perceived
stress [28]. Recent research indicates that leptin may play a role as a mediator between psychosocial
stress and emotional eating characteristic of stressed individuals [29]. Specifically, chronic stress
induces high cortisol levels and, in turn, high leptin concentrations due to resistance mechanisms
associated with greater intake of comfort food [29]. This fact could explain, in part, the poor dietary
habits of bullied adolescents as a chronically stressed population. All of this could determine one of
the many mechanisms studied relating bullying and a negative mood state, such as depression.
Remembering that the definition of bullying victimization excludes occasional or minor incidents
(it being necessary that the behavior is repeated over time), this situation can be characterized as
a form of chronic stress [30]. Chronic stress, defined as a situation in which the body faces numerous
challenges every day, has shown to be one of the most dangerous situations for the maintenance
of homeostasis, due to allostatic overload [6,31]. In particular, daily challenges from bullying pose
a threat to allostasis (a set of processes that allow organisms to maintain homeostasis while adapting to
the demands of the environment) [32]. Disturbances in homeostasis result in allostatic load, a state in
which physiological systems are not able to adapt to environmental changes, with severe consequences
for health and well-being [31,33]. Chronic overactivation of psychobiological stress mechanisms,
such as the release of catecholamines following activation of the sympathetic-adrenal-medullary axis
and the secretion of glucocorticoids following activation of the hypothalamic-pituitary-adrenal axis,
leaves the body at high risk of developing stress-related diseases [33] such as depression. However,
previous research has demonstrated that several variables could buffer these negative consequences
of chronic stress on mood, demonstrating that diet is closely related to allostatic load [34,35]. In this
regard, recent reviews and meta-analyses have demonstrated that a high-quality diet is associated with
a lower risk of depressive symptoms [36–38]. There are a number of biological pathways that could
explain that adolescents who maintain a high-quality diet could buffer the consequences of derived
stress from bullying, reducing the risk of suffer depressive symptoms. The dietary intake of folate,
zinc, and magnesium typical of a healthy dietary pattern, such as the MD, or the reduction of systemic
inflammation, oxidative stress, and adaptive brain development could be on the basis of the protective
effect of adequate dietary habits in chronically-stressed adolescents [36–40]. These mechanisms could
explain the obtained results in the present study, in which individuals with healthy dietary habits
suffer from lower levels of depression, although they also suffer from high levels of bullying.
The present results show the necessity of the implementation of effective antibullying strategies
in schools, considering the severity of the consequences derived from this phenomenon. A recent
systematic review has demonstrated the differential effectiveness of specific antibullying interventions
for reducing bully behaviors at schools [41]. Although several types of interventions demonstrated
a positive effect increasing positive school climate and reducing bullying at schools, multicomponent or
Int. J. Environ. Res. Public Health 2018, 15, 1569 8 of 10

whole school interventions were the most effective type of antibullying programs [41,42]. These kinds
of interventions combine classroom rules, lectures addressing bullying, activities with bullies and
victims, parents involvement, increased supervision, disciplinary methods, training of teachers, and
technological resources [41]. According to previous research, these interventions, which include
a wide variety of activities and skills development, have exhibited higher effectiveness compared
to those delivered through classroom curricula or social skills training alone [41,42]. In the schools
participating in the present study, a bullying intervention program based on emotional education is
currently being implemented. This type of intervention includes activities such as contents exposition,
group discussions, role-playing, cooperative learning, and videos, the main aim being the promotion
of emotional intelligence in students through the increase of emotional awareness and regulation.
Future studies should examine the role of emotional competences as antibullying strategies in school.
Although the present study represents an advance in our understanding of dietary habits in
bullied adolescents, some limitations should be taken into account. The cross-sectional nature of the
study is a methodological limitation; specifically, the nonexperimental design means that causality
cannot be established. In relation to this, longitudinal studies are needed to explore how dietary habits
could protect bullied adolescents from the negative consequences of bullying on health, reinforcing the
effectiveness of traditional intervention programs through the inclusion of dietary education. On the
other hand, it should be taken into account that the present study is the first to analyze the relationship
between bullying victimization, specific dietary habits, and depression.

5. Conclusions
Given that the results obtained show a low adherence to healthy dietary habits in bullied
adolescents, it is important to develop intervention programs oriented to the promotion of healthy
eating habits in this population. Furthermore, interventions oriented to emotional regulation and
coping with stress in an adaptive manner in this population could significantly benefit the health
of bullying victims through reducing emotional eating. The present study shows the importance of
nutritional variables as factors that may be protective of health in bullying victims. The inclusion
of nutritional education in intervention programs should be considered by clinicians and other
professionals involved in treating and preventing the negative consequences of being bullied. Future
studies should investigate the effectiveness of dietary interventions in the improvement of dietary
habits and the reduction of depression in bullying victims.

Author Contributions: Conceived and designed the experiments: N.A.-B., N.R.-R., R.F.-C., A.Z.-M. Analyzed the
data: N.A.-B., R.F.-C., V.C.-C., M.S.-S. Wrote the paper: N.A.-B., N.R.-R., R.F.-C., V.C.-C., M.S.-S. Data interpretation
and critical revision of manuscript: N.A.-B., N.R.-R., A.Z.-M., M.S.-S.; and all authors reviewed and approved
the manuscript.
Funding: The research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

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