Anxiety is a very common but often misdiagnosed psychiatric problem in late adulthood, with subclinical anxiety symptoms being an even more frequent risk event [1]. The ever-increasing burden and prevalence of depression, estimated to reach more than 300 million people worldwide in coordination with its association with anxiety disorders [2], highlighting the importance of early diagnoses and appropriate treatment or even early prevention strategies. Anxiety disorders are reported to be the fourth cause of years lost due to disability [3], and the recent financial crisis in Europe has actively increased the risk factors related to anxiety in Greece, as well as in other European countries [4].

Anxiety disorders have been associated with impaired physical and role functioning; they adversely influence the course of chronic disease mainly through the adoption of unhealthy coping strategies and have been reported to increase illness susceptibility [5-7], indicating the importance of early intervention to relieve the burden of anxiety disorders in modern times.

Recent evidence shows that certain lifestyle strategies have beneficial effects on anxiety, but only a third of the people suffering usually seek any treatment [8]. Studies focusing on single food groups indicate that high fish, fruit, vegetable, and fibre consumption can significantly decrease depressive symptoms [9]. The benefits of a balanced diet and healthy lifestyle (exercising, adequate sleeping and moderate alcohol, junk food, and caffeine consumption) have been widely accepted to reduce and protect from the development of anxiety disorders and depression and their sustainability. In particular, practices such as a balanced nutrient load, appropriate hydration (in combination with limited alcohol and caffeine consumption), complex carbohydrate consumption, shown to control blood glucose levels, Magnesium (found in spinach, legumes, nuts, seeds, and whole grain), Zinc sources (like in cashews, liver, beef and egg yolks), Omega-3 fatty acids (found in fatty fish), Probiotics (from kefir and asparagus), rich vitamin B food (part of avocado and almonds) and Antioxidants (usually found in beans, berries, walnuts, broccoli artichoke, turmeric, and ginger), are all associated with lower anxiety and may help reduce anxiety symptoms, therefore becoming important dietary choices to implement in everyday life [9]. Recent nutritional research focusing on dietary patterns, reveals the importance of consuming protein and each association with a low prevalence of depression, possibly related to higher tryptophan levels, a serotonin precursor, in the brain [10, 11]. Furthermore, processed carbohydrates and sweets, may trigger high blood glucose and increase the physiological symptoms of stress, whereas low carb diets may decrease nutrient availability and initiate a cortisol response, resulting in anxiety. Therefore, minimally processed, complex carbohydrates that produce steady streams of glucose may minimize the effect of anxiety and should account for at least 20% of your daily caloric intake [12], and higher consumption of fibre, fish and Omega-3 fatty acids may be protective to anxiety and anxiety-related disorders [13]. Nutrients including tryptophan, vitamins B6, B12, A and C, folic acid, tyrosine, phenylalanine, histidine, glutamic acid and choline, are necessary for the production of neurotransmitters, primarily involved in mood, appetite and cognition, such as serotonin, dopamine and norepinephrine [14]. Healthy patterns that include Omega-3 fatty acids, vitamin B12, magnesium, zinc, vitamin D, C and E, iodine, selenium and protein may reduce anxiety and supplementation in certain cases, are highly recommended [15].

In addition, an increasing number of studies are providing important evidence that self-management also presents an important intervention strategy for decreasing the risk factors associated with anxiety and for treating mild anxiety [8].

The aim of this quantitative observational explorative research was to elucidate the characteristics of lifestyle, nutritional habits, medical history, and socioeconomic status, that strongly associate and affect anxiety scores and/or anxiety coping strategies, to extend and exploit new lifestyle and dietary intervention methods for mild anxiety in the general population.

The analysis of dietary/lifestyle patterns under the prism of self-reported trait anxiety (STAI-X-2 inventory) and coping strategies (brief-COPE), was applied in a group of healthy adults, with no known anxiety diagnosis, from the prefectures of Laconia and Messenia in Greece.

Consumption of fruits and tomatoes, is believed to be healthy nutritional choices, associated with lower scores of trait anxiety (both total and negative) and higher scores of positive STAI. It was also of interest that lettuce consumption predicted higher scores of trait anxiety (total and negative). Bioactive ingredients in tomatoes, such as gamma-aminobutyric acid (GABA), esculeoside A, and lycopene, as well as vitamins A, B and C, can restore fatigue, control levels of blood sugar, have anti-oxidants effects and have been shown to have anxiolytic effects [21]. In accordance, phytochemicals found in fruit and vegetables, including vitamins C, E and K, B-group vitamins, carotenoids and phenolic compounds, may play a role in reducing stress levels, in agreement with the current results [22]. Perceived trait anxiety was not associated with changes in fruit and vegetable consumption, suggesting that higher fruit and tomato intake (via their constituents), may reduce perceived stress and not that anxiety had an effect on the dietary patterns of the participants. This is in agreement with other research that has associated consumption of fruit and vegetable with a reduction in anxiety levels [22]. On the contrary, the lettuce consumption paradox may be attributed to increased copper ions usually found in industrialized cultivations of lettuce; these have been associated in a previous study with increased anxiety symptoms [23, 24].

On the other hand, only smoking/exposure to smoking is associated with the coping strategies, increasing substance use but decreasing religious practices. Religion practices are often characterized by structure and rules that usually restrain individuals from substance use and hence smoking/exposure to smoking [25]. However, it is evident that the population’s, understudy coping strategies were not affected by the dietary/lifestyle patterns, as observed in previous studies [26].

As far as trait anxiety and coping are concerned, the combination of maladaptive coping strategies, like denial/behavioural disengagement, substance use and self-blame, is associated in our study group with higher scoring in total, as well as negative and emotional trait anxiety. These are often referred to in the literature as avoidance coping and have been related to higher anxiety levels. Whereas more adaptive strategies, such as positive reframing/humour and acceptance planning, often described as positive coping, are associated with better positive STAI scores and lower negative and total scores. In addition, seeking emotional/instrumental support was associated with both positive STAI, as well as negative STAI, reflecting each dual role in problem-focused solving, which is not active but a step towards solving.

Some coping styles may contribute to anxiety vulnerability and may also be strong predictors of anxiety symptomatology, with greater emotion-oriented coping being reported by individuals with higher anxiety [27]. Instrumental or emotional support in some studies is categorised as a maladaptive, emotional-focused strategy and, in others, is reported as a positive, adaptive approach to anxiety coping. Furthermore, emotion-focused coping is usually predictive of higher anxiety and functional impairment in clinical and non-clinical contexts [27-30]. This controversy might be partially explained by the notion that searching support, although in itself may help manage and reduce stress, might at the same time trigger or allow the maintenance of maladaptive strategies, such as self-blame and denial [27, 28]. On the contrary, problem-solving and changing perspective appears to be a valid approach to anxiety moderation and psychopathology in general and has been associated with better mental health outcomes [29].

Fruit consumption associated with women did not counteract their increased anxiety levels in comparison to men, possibly due to the higher stress vulnerability related to women. In particular, emotion-focused coping strategies are considered to be a more female role-orientated strategy, as previously demonstrated by higher expression of positive feelings, greater responsiveness to emotional stimuli and higher vulnerability to anxiety [31]. Healthier eating habits are often associated with women more than men, but the amount and frequency of healthier choices might not be able to control anxiety responses, in more vulnerable individuals and could reflect the need for more profound changes and richer in macronutrients and oligo-elements, dietary habits.

Older participants exhibited higher consumption of fruits and salads, better STAI negative scores, and use of acceptance planning, characteristics that all individually contribute to decreased anxiety. Although healthier eating habits seem to establish over the whole lifespan, they are more frequently adopted in older individuals than younger adults who tend to choose more high-fat and high-sugar products and follow a more Westernized diet [32]. Younger age, may also explain the lack of anxiety resilience and use of an avoidance strategy like substance use, whereas acceptance and planning are more of an active problem-solving strategy that is found in the more experienced older in age individuals [33], whereas coping strategies, for the younger are usually dependent more on the stressors [34].

Urban living (Sparta residents), is associated with higher consumption of peppers, legumes and vegetables cooked in olive oil, smaller emotional STAI and use of emotional/instrumental support and positive reframing/humour. Living in a small city in Greece increases the likelihood of higher adherence to the Mediterranean style eating [35], may impose a lower emotional burden, than that reported by residents of a large city, possibly reflecting the benefits of a smaller and greener urban environment [36] and provides a closer social environment, more easily accessible for support, without the deprivation of education, employment and access to specialised care offered by city living [37].

Some limitations of the present study should be considered. Although the present findings according to the sociodemographic characteristics are in agreement with previous studies, they should be interpreted with caution due to the fact that the majority of the studied population that accepted to participate and fill up the questionnaires were younger in age, mostly at a superior educational level, single and unemployed, which is not the case for the general population of Greece. Therefore, further studies in a more balanced population might confirm the relationships observed and may elucidate the association of anxiety with sociodemographic status in Greece. For these reasons, results cannot be generalized. Also, self-reported questionnaires are limited by biases such as question interpretation, introspective ability and honesty. Since the participants were not followed for a period of time in the present study, the causal relationship between dietary/lifestyle patterns and anxiety should be interpreted with caution. Further exploration of the population under study could elucidate the existence of a true relationship. Furthermore, anamnestic features, like the presence of an anxiety disorder or other psychiatric disorder was not evaluated clinically, and to our knowledge, none was present, but the anxiety scores should be interpreted with caution. Only 1/3 of the participants, though, scored high (≥45) for trait anxiety. In addition, the factor analysis of brief-COPE excluded factors that are described in the literature to contribute to active problem-solving strategies and emotional expression. These strategies are often proposed to beneficially contribute to anxiety reduction and resilience and can inverse the effects of anxiety following stressful events in everyday life [38]. Therefore, their inclusion might have provided more insightful ways of nutritional and anxiety-orientated coping.

In the current study, women, younger (≤34 years of age) individuals, living in larger cities, married or cohabitating, with a superior educational status, might be at a higher risk (approximately 1 fold increase in trait anxiety scores) for developing subclinical anxiety and maladaptive coping practices and thus, would benefit more from future interventions.

The discussion of the results of this study provides meaningful information to support the necessity of developing interventions that not only enhance and support a healthier lifestyle in terms of dietary patterns, quality sleeping, and physical activity, but also attempt to enhance positive and adaptive coping strategies. Strategies, such as active problem solving, positive reframing, humour, acceptance and planning, together with a healthier lifestyle and dietary habits, might improve anxiety and coping with anxiety-related events, but it might also limit the use of maladaptive coping strategies, contributing therefore to an overall healthier body and mind. Maladaptive strategies, like denial and behavioural disengagement, substance use and self-blame may limit the positive effects of other daily habits and, in some cases, counteract anxiety coping.