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Appetite 65 (2013) 3134

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Appetite
journal homepage: www.elsevier.com/locate/appet

Research report

Chewing gum may be an effective complementary therapy in patients


with mild to moderate depression
Furkan Muhammed Erbay a,, Nazan Aydn b, Tlay Sat-Krkan b
a
b

School of Medicine, Ataturk University, Yakutiye 25240, Erzurum, Turkey


Department of Psychiatry, School of Medicine, Ataturk University, Yakutiye 25240, Erzurum, Turkey

a r t i c l e

i n f o

Article history:
Received 21 July 2012
Received in revised form 26 January 2013
Accepted 3 February 2013
Available online 12 February 2013
Keywords:
Chewing gum
Depression
Stress

a b s t r a c t
Previous studies indicated that chewing gum may relieve stress and depression. There have, however, not
been a signicant number of studies on clinical usage of chewing gum. In the present study, 30 patients
with mild to moderate depression were given either medication combined with chewing gum, or medication only, for 6 weeks. Turkish adaptation of Hamilton Rating Scale for Depression (HAM-D) was used
to measure depression levels. Assessments were conducted by the same physician both before, and after
treatment. The physician who was responsible for the assessment was not aware of the group allocation.
Changes in main HAM-D scores and each item were analyzed by independent samples t test and ChiSquare test, respectively. Those patients who were administrated chewing gum responded better to
the treatment than patients who took medication only. The most benecial effect of chewing gum was
observed on the gastrointestinal symptoms, e.g. loss of appetite, and atulence among others. These
results indicate that chewing gum may not be directly effective on depressed mood; however, it may
reduce the symptoms originating from depression.
2013 Elsevier Ltd. All rights reserved.

Introduction
There have been a number of studies investigating the effects of
chewing gum on stress, anxiety and mental status (Akiyo et al.,
2011; Johnson, Jenks, Miles, Albert, & Cox, 2011; Smith, 2010;
Smith, Chaplin, & Wadsworth, 2012; Zibell & Madansky, 2009).
The results of these studies concur that chewing gum reduces
stress levels and anxiety. Although these studies provided useful
information on the reducing effect of chewing gum on stressed
conditions, there are a limited number of ndings on clinical usage
of chewing gum in stress and depression reduction. Previous studies often engaged with induced or non-induced stress conditions
but not in clinically diagnosed patients.
Problems associated with stress are closely related to mental
dysfunctions which can occur in the distant future. Depression,
as a mental health impairing disorder, is one of the conditions that
causes stress to reach a peak, and leads to cognitive disintegrations
if left untreated. Unfortunately, many undiagnosed and/or untreated cases of depression ultimately result in suicide. Cases that
do not result in suicide are closely associated with loss of ability
and cognitive dysfunctions.
Given that depression is a potentially debilitating disorder, new
alternative and complementary therapies for the treatment of

Corresponding author.
E-mail address: fmerbay@gmail.com (F.M. Erbay).
0195-6663/$ - see front matter 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.appet.2013.02.002

depression have been suggested. Therapeutic approaches, such


as omega-3 fatty acids, St. Johns wort (Hypericum), folate,
S-adenosyl-L-methionine (SAMe), acupuncture, light therapy, exercise, and mindfulness psychotherapies, revealed promising results
in the treatment of major depressive disorder (Freeman et al.,
2010). It has been shown that St. Johns wort, for example, is also
effective in treating mild to moderate depression (van der Watt,
Laugharne, & Janca, 2008).
Recently mastication has become a popular approach to prevent
cognitive dysfunction. It was reported that chewing gum is directly
linked to the maintenance of the hippocampal function and it leads
to an increase in the prefrontal cortex activity (Ono, Yamamoto,
Kubo, & Onozuka, 2010). Several psychological studies using
human subjects have shown that chewing, or even sucking a piece
of sugar-free, spearmint avored chewing gum, improves the
cognitive activity especially in working-memory tasks (Baker,
Bezance, Zellaby, & Aggleton, 2004; Scholey, 2004; Stephens &
Tunney, 2004a, 2004b; Wilkinson, Scholey, & Wesnes, 2002). Position Emission Tomography (PET) studies revealed that mastication
increases blood-ow in various cortical and cerebellar regions;
suggesting that chewing increases the availability of blood-borne
glucose, thereby improving cognitive performance (Momose
et al., 1997; Snram-Lea, Foster, Durlach, & Perez, 2002). Wilkinson
et al. (2002) also reported that chewing increases heart rate, suggesting enhanced sympathetic activity to increase blood glucose
level and/or arousal level during cognitive tasks. An fMRI based

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F.M. Erbay et al. / Appetite 65 (2013) 3134

study has supported the hypothesis that mastication increases


brain activity, particularly the performance of a sustained cognitive
task (Ono et al., 2010).
More specically, recent studies have indicated that chewing
gum has ameliorative effects on mood, anxiety, and mental status
(Akiyo et al., 2011; Johnson et al., 2011; Smith, 2010). While some
contemporary studies provided inconsistent results on the effects
of chewing gum (Torney, Johnson, & Miles, 2009; Zibell &
Madansky, 2009), other studies, such as Smith et al.s (2012) study
found benecial effects of chewing gum on occupational stress,
work performance and wellbeing. Overall, these results indicate
that chewing gum is closely related with reduced fatigue, anxiety
and depression and lead to a more positive mood (Smith et al.,
2012).
The present study
Considering that chewing gum has benecial effect on the stress
levels and anxiety, the aim of this study was to nd whether chewing gum is a useful additive to traditional medical treatment of
mild to moderate depression. The research was conducted in the
Psychiatry Department of the Teaching Hospital of Ataturk University, Erzurum, Turkey.
Method
The study was conducted with the approval of the ethics
committee, School of Medicine, Ataturk University, and with the
informed consent of the volunteers,
Participants
Four thousand eight hundred and fty-two patients visited the
psychiatry department of the hospital between October 2011 and
April 2012. 1300 out of 4852 were diagnosed with depression
and its comorbidities. There were 48 patients out of 1300 who
met the research criteria and were suitable for sertraline administration. Those 48 patients were informed that the research was
investigating the effects of chewing gum as a complementary therapy in the treatment of depression. 14 of them did not accept to
use chewing gum with some reasons such as dislike or concern
with failure to complete the study. Therefore, 34 patients remained
(n = 34). 6 out of 34 patients had a previous history of psychiatric
consultation. 11 of them were married. 8 out of 34 were smokers
and none of them consumed alcohol at the time of the study. The
ages spanned from 20 to 63 (Mean = 32.4 years old, 86.7% =
female). The participants were randomly allocated into two groups
of non-chewers (n = 17) and chewers n = 17).
In order to assess the effects of chewing gum on depression
only, the main criterion of the research was to detect pure depression cases. In order to constrain actual and potential extraneous
variables, the study selected subjects diagnosed with mild to
moderate pure depression. This was necessary because depression
is often comorbid with anxiety and obsessivecompulsive disorder. Following the pure mild to moderate depression diagnosis,
inclusionexclusion criterions were as follows: Patients with any
other organic disease or any other psychiatric disorder, except pure
depression, were excluded from the research. Patients with occlusal disharmony and loss of teeth were excluded in order to prevent
any disruptive effect on active mastication.
In order to evaluate the effects of chewing gum as a therapeutic
agent, patients who habitually used chewing gum were suspected
to demonstrate confounding variables. Patients who used 11 pieces
or more chewing gum in a week considered as habitual chewers.
Those patients were, therefore, not included in the study.

Materials
Turkish adaptation of Hamilton Rating Scale for Depression
(HAM-D) was used before and after therapy in order to assess
depression levels of the patients. Turkish adaptation of HAM-D
consists of 17 questions and investigates depression symptoms
experienced by patients in the two previous weeks before, and
including their present status. The questions focus on sleep disturbances, sexual problems, gastrointestinal symptoms, weight loss
and self-esteem. The highest mark is 53. Marks between 07 indicate no depression, 816 mild depression, 1728 moderate depression, and above 28 indicates severe depression. The validity and
the reliability of Turkish adaptation of HAM-D was tested (Akdemir
et al., 1996).
The scale was lled by the same physician for both groups,
based on the information given by the patients concerning the
two previous weeks before, and including their present status. In
order to avoid potential biases, the physician who was responsible
for lling the HAM-D scales was not aware of the group members
allocation.
The results of the research were analyzed with the help of
PASW Statistics 18, comprehensive data analysis software. In
order to calculate the main outcome, HAM-D score alterations
between the groups, independent samples t test was performed.
HAM-D score alterations within the groups were compared with
the paired samples t test. Chi-Square test was performed to analyze
the changes in the scores of each item in HAM-D.
Chewing gum
The same brand of chewing gum was administered to patients
by the physician during the weekly interviews in order to ensure
the patients used the same chewing gum and to produce unbiased
results. The chewing gum chosen was avorless and sugar-free: A
generic brand that can be found in any store, and which does not
carry any nutritional value (no fat, carbohydrates, or protein).
The safety of the chewing gum is guaranteed by the Ministry of
Agriculture and Rural Affairs of the Republic of Turkey.
Design and procedure
In the process of admission to the hospital, patients who met
the research criteria were asked if they wanted to be involved in
the research program. Those who accepted the terms of the study
signed the informed consent. Using simple random sampling, patients were allocated into two experimental groups, chewers and
non-chewers, after being diagnosed with mild to moderate pure
depression. The control group was administered traditional medication, consisting of 50 mg of sertraline per day, for 6 weeks. The
trial group was administered chewing gum in addition to medication, 50 mg of sertraline per day. Interviews were conducted once a
week, during 6-week therapy for both groups. Twenty-minute
interviews were conducted with each patient from both groups.
Based on the report of Zibell and Madansky (2009), chewers
were told to chew 11 pieces of gum on 4 consecutive days per
week. The participants were informed to chew a piece of chewing
gum for at least 20 min.
HAM-D was performed by the same physician both before, and
after the 6-week therapy.
Results
Four patients did not complete the research. They did not
appear in the interviews following the rst interview and the reason for this could not be ascertained because they could not be

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F.M. Erbay et al. / Appetite 65 (2013) 3134


Table 1
HAM-D score changes of both groups before and after treatment.
Group

Mean HAM-D score

SD

Chewers

Before
After

14

17.57
5.00

3.83
2.48

21.63

<0.001

Non-chewers

Before
After

16

15.38
5.06

4.03
3.49

11.487

<0.001

Decrement

Chewers
Non-chewers

14
16

12.57
10.31

3.59
2.17

2.112

0.045a

Equal variances not assumed.

contacted. The analyses were performed on the data from the


remaining 30 patients. Post hoc sample size calculation was based
on the main outcome variable, HAM-D scores. Taking alpha error as
0.05, and effect size as 1.1; 16 participants in non-chewers group
and 14 in chewers group were needed to reach a power of 82.6%.
The main outcome variable HAM was normally distributed.
There was no signicant difference in terms of HAM-D score between the two groups before therapy. Table 1 shows the adjusted
means of HAM-D scores of both groups before and after the
treatment.
Difference between the decrement of HAM-D scores before and
after therapy in the two groups was checked with the independent
samples t test. Levenes Test for equality of variances revealed F
and p values of 4.6 and 0.04, respectively. Equal variances not assumed, there was a signicant difference between the two studied
mean values (t = 2.11; p = 0.045).
Means of HAM-D score in the both groups after the treatment
was 5.00 and 5.06 for chewers and non-chewers, respectively.
The only signicant result was obtained from question number
12 relating to somatic symptoms of the depression, specically,
gastrointestinal problems and loss of appetite (v2(1, N = 30) =
8.57, p = 0.003). Remaining variables revealed no differences between the groups in terms of decrement. The ndings revealed
that, contrary to predictions found in extant literature, there was
no signicant difference in question number 1, relating to depressed mood (v2(1, N = 30) = 0.23, p > 0.05).
Discussion
The results of the present study indicate that chewing gum may
not be directly effective on depressed mood; however, it may reduce the symptoms originating from depression. Patients who
chewed 11 pieces of gum on 4 consecutive days weekly for a period
of 6 weeks responded to treatment signicantly better than those
who did not chew.
Previous studies on healthy subjects revealed that chewing gum
was related to a more positive mood, reduced anxiety and
improved mental status. In a web-based research, Smith (2010) reported that chewing gum was associated in a linear doseresponse
manner with lower levels of perceived stress (both at work and life
in general), anxiety and depression. Smith et al. (2012) conducted a
study on effects of chewing gum on stress of university students
and showed that perceived stress decreased as a function of the
amount of gum chewed. Scales measuring perceived stress, anxiety, depression were used in both studies. However scales used
in those studies were not suitable to detect the symptoms accompanying depression. In the present study, the HAM-D scale was
used to bring a comprehensive understanding of depression.
Depression is a condition which contains multiple aspects and
HAM-D scale is extensive to cover all aspects of depression. The results of the present study do not conclusively conrm ndings of
previous studies. There was no signicant difference found in
depressed mood, sleep disturbances, sexual problems, and
self-esteem. In conclusion, the present study has found that

improvement in depression has occurred via decrement of symptoms accompanying depression.


Depression is not only a disorder characterized by low self-esteem and depressive mood but it also is in a strong relationship
with sleep disturbances, sexual problems, and somatic, especially
gastrointestinal complaining and loss of appetite. In the present
study, it was observed that chewing gum was mostly effective on
somatic symptoms, especially gastrointestinal disturbance and loss
of appetite accompanying depression. The reducing effect of chewing gum on somatic symptoms may be explained by the modulatory activity of chewing on the gastrointestinal tract (Ohmure
et al., 2012). Hetherington and Regan (2011), reported that chewing gum was associated with controlling appetite and it assisted in
weight loss. However, the present study suggests that chewing
gum prevents loss of appetite.
Ricca et al. (1996) reported that sertraline enhanced the weight
loss of obese patients under cognitive-behavioral treatment. Moreover it has been shown that sertraline may be used in the treatment of obesity for a short term and it aided weight loss in
animal models (Mancini & Halpern, 2006). Considering that sertraline is mostly useful in improving the depressed mood and may
lead to loss of appetite, chewing gum is a good adjunct to the medication due to its ability to reduce the symptoms accompanying
depression and to prevent loss of appetite. The recent ndings from
previous studies and current study show that chewing gum may be
both a cost-effective and an easily accessible method of increasing
mental health.
Underlying mechanisms must now be considered in order to
support the present ndings. It appears that there may be any
number of variants involved in the effects of mastication. There
are several suggested mechanisms ranging from central and/or
peripheral nerve system effects to cardiovascular system effects
according to the literature. Some studies attempted to show the
effect of mastication without chewing gum. Larger studies combined with PET and functional Magnetic Resonance Imaging (fMRI),
are now needed in order to explain the underlying mechanisms
and the extent of benets or harms associated with chewing gum.
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