Although the prevalence of late-life depression reported by several studies varies from lower than 1% to more than 35% [1-3], depression is one of the major health problems in the elderly, and the burden of inadequately treated late-life depression is substantial [2,4]. The World Health Organization predicted that depression would be the second greatest cause of disease burden by the year 2020 [5,6], probably due to the remarkably accelerating rate of population aging [7]. Studies among elderly Koreans also found that the prevalence of overall late-life depression was higher than 10% and tended to increase with age [8].

Depression lowers quality of life and increases the risk of disability and morbidity [6,9,10]. In addition, depression in the elderly frequently coexists with medical illnesses and may be a risk factor for other diseases such as dementia [11,12]. However, late-life depression is often overlooked during clinical evaluation of an older population because it is mistakenly assumed to be a normal response to aging, physical loss, or other life events [12-14]. Thus, prevention of the development of depression in the elderly by promoting healthy aging and modifying risk factors for late-life depression would be desirable to the older population.

Several factors associated with depression in the elderly have been suggested, such as sex, employment status, income level, smoking, alcohol consumption, and physical activities [3,11,12,15]. Among the many risk factors, loneliness, sometimes combined with other physical and mental problems, is found to be a major risk factor increasing depressive symptoms in the elderly [16]. Therefore, it is found that most of the elderly prefer remaining engaged in social interactions [16].

Family mealtimes are when family members sit down and enjoy meals together. During the family mealtime, people may have a good opportunity to interact and communicate with each other, thus increasing intimacy and emotional bonding among family members [17,18]. However, the busy personal lives of people living in the rapidly changing modern society have reduced the opportunity for family mealtimes over the last several decades, which may have a deteriorating influence on the emotional health of modern people [19,20]. Several studies on adolescents have revealed that frequency of family mealtimes was inversely associated with substance use, depression, and suicide involvement, even after controlling for family connectedness [19,20]. However, the effect of family mealtimes on depression in the elderly has not been extensively evaluated [21,22].

In this regard, we specifically explored the association between family mealtime frequency and depressive symptoms in elderly Koreans using the data from a nationally representative sample after controlling for a range of confounding variables. We hypothesized that the elderly who frequently share their mealtimes with family would have fewer depressive symptoms than those who have fewer family meals.

Table 1 presents the demographic characteristics of study participants. The mean age was 72.3 years old for men and 73.3 years old for women. The prevalence of marital status and income level was similar between men and women. The prevalence of employment status, alcohol consumption, and smoking status was higher in men than in women. Among comorbidities, the prevalence of arthritis was significantly higher in women than in men. For family mealtimes, 75% of participants were found to have at least one family mealtime per day. The elderly who had less frequent family mealtimes (≤1) were more commonly women (46.2%) than men (23.6%) while more frequent family mealtimes (≥2) were more common in men (76.3%) than in women (53.8%). The prevalence of depressiveness was significantly higher in women than in men across all three variables assessing depressive symptoms.

Table 2 shows the association of depressive symptoms with sociodemographic and clinical characteristics. Sociodemographic variables except marital status and current smoking were inversely related with all three depressive variables. Among comorbidities, only arthritis was significantly associated with an increased risk of depressive symptoms across all three depressive variables.

Age-adjusted association between depressive symptoms and family mealtime frequency is presented in Table 3. Compared to eating alone, eating with family at least once a day was significantly associated with a decreased risk of depressive symptoms in all study participants.

Table 4 shows the multivariable adjusted association of depressive symptoms with family mealtime frequency. After full adjustment for covariates, participants who had family meals 3 times a day had fewer depressive symptoms than the eating alone group: adjusted ORs (95% CIs) were 0.72 (0.58–0.89) for point depressiveness/anxiety and 0.73 (0.56–0.94) for depressiveness lasting for at least 2 weeks. In suicidal ideation, the OR (95% CI) of eating with family twice a day was significant after full adjusting for covariates at 0.67 (0.50–0.88). In the analysis stratified by sex, participants having family meals 3 times a day showed a decreased risk of point depressiveness/anxiety after adjusting for all covariates regardless of sex; the OR (95% CI) was 0.58 (0.39–0.88) for men and 0.76 (0.59–0.97) for women. However, the association between family mealtimes and two other depressive variables was significant only in men (P<0.05). There was no significant effect of sex on the association between depressive symptoms and family mealtime (P interaction >0.05).

In this cross-sectional study conducted with a representative sample of elderly Koreans, we found that the frequency of family mealtimes was inversely associated with depressiveness as well as suicidal ideation, and the correlation was more evident in men than in women. This association persisted even after controlling for a range of sociodemographic factors and comorbid conditions. In addition, with increasing frequency of family mealtimes, ORs of point depressiveness/anxiety were decreased in a dose–response pattern.

The findings of our study are in accordance with those of previous studies, and they show that having regular family mealtimes serves as a protective factor against depressive mood, anger, and other psychological problems by enhancing family communication and building greater structure and stability in family relationships [17,19,23,24]. Family mealtimes, which allow family members to get together, communicate, and share emotions, could be helpful in alleviating negative effects of stressful experiences as well as depressive mood [14,17,22]. Family mealtimes on a regular basis also promote intimacy among family members by creating a sense of unity [17]. On the other hand, those who have meals alone tend to have relatively less interaction and lower social support compared to those who have meals with their family members [25]. The lack of communication and silence during mealtimes may result in feelings of loneliness and depressive mood [26]. Therefore, it may be necessary to emphasize the importance of participating in family mealtimes given the modern trend of living alone and the decreasing number of get-togethers within the family.

Interestingly, we found that elderly men were more likely to experience a beneficial effect on their mood by having family mealtimes compared to elderly women. According to previous studies on depression in men, sharing feelings or thoughts with others including family members has a more therapeutic effect on depression in men than in women [18,27]. In addition, having supportive relationships, such as discussing problems with trusted family members, contributes a lot to men’s ability to cope with stress or depression [27]. Therefore, men who have meals alone may feel greater loneliness than those who usually have meals with their families, because they do not get an opportunity to discuss their stressful situations with family members.

In this study, the prevalence of having meals alone was 25.0%. A previous study reported that the prevalence of having meals alone was 12.9% [22], which was much lower than in our study. Our study was conducted among elderly individuals aged 65 and older with a median age of 72.9 years old while the other study included participants younger than 65 years old (median age, 67 years old) [22]. This difference in the age distribution of study participants could explain the discrepancy between the studies. Although further studies are necessary, we assume that the prevalence of having meals alone might increase with age. In our study, the frequency of family mealtimes was higher in men than in women, which was compatible with the finding of the other study [21].

The prevalence of depressive disorders in the elderly varies markedly across the studies, even in the same ethnic population. In our study, the prevalence of point depressiveness was 18.6%, and the prevalence of depressiveness lasting for at least 2 weeks was 15.2%. According to previous studies, the prevalence of major depression was reported to range from 4.6% to 9.3%, and, for depressive disorder, the prevalence ranged from 4.5% to 37.4% [1,28]. Chong et al. [29] reported that the prevalence of depressive neurosis and major depression in the elderly in Taiwan was 15.3% and 5.9%, respectively. Another study in Taiwan reported that the 1-month prevalence of clinically significant non-major depression in community-dwelling elderly (65 years of age or older) was 8.8% [30]. This variation in depression across studies could have resulted from varying cultural sensitivity to the diagnosis of depression, the psychometric tool, or innate biologic variation.

This study had certain strengths. First, we conducted this study using a large representative sample of the Korean population. Second, we considered depressive mood in three ways: point depressiveness/anxiety, depressiveness lasting for at least 2 weeks, and suicidal ideation during the last 1 year. In addition, we checked a wide range of covariates, including a number of clinical conditions that may have adverse effects on mood.

However, the findings of the present study should be viewed in light of several limitations. First, as it was a cross-sectional study, it was unable to explain a causal relationship between family mealtime frequency and depressive symptoms, and further longitudinal research is required. Second, we could not apply the diagnostic criteria for depressive disorder because the Korea National Health and Nutrition Examination Survey data lacked detailed questions needed for diagnosing clinical depression. Instead, we considered depressive symptoms in three ways including suicidal ideation to avoid hasty generalization. Third, we asked about depressiveness lasting for at least 2 weeks and suicidal ideation experienced during the last 1 year, which might have caused recall bias. Finally, we only assessed mealtimes with family because the Korea National Health and Nutrition Examination Survey data lacked detailed questions about mealtimes, so the eating alone group could include mealtimes with friends, which could cause underestimation in our conclusion. Despite these limitations, the present study provides significant outcomes as this was the first study to investigate the association between frequency of family meals and depressive symptoms in elderly Koreans.

In conclusion, this cross-sectional study revealed that family mealtimes were closely associated with depressive symptoms in elderly Koreans, which suggests that maintaining intrafamilial bonding is important for mental health in an older population.