Prospective Changes in Healthy Lifestyle Among Midlife Women

When Psychological Symptoms Get in the Way


      Anxiety and depression are linked to increased risk of cardiometabolic disease and mortality, and unhealthy behaviors may be the key mechanisms underlying these associations. Although higher levels of psychological symptoms are associated with individual unhealthy behaviors (e.g., physical activity, smoking), their roles in overall lifestyle remain understudied.


      Midlife women (n=55,395) from the cohort Nurses’ Health Study reported anxiety and depression symptoms in 1988 and 1992, respectively. Health behaviors (i.e., physical inactivity, BMI, diet, and alcohol and tobacco consumption) were measured in self-administered questionnaires in 1988 or 1992, and every 4 years until the last assessment available (2010; follow-up, 18–22 years). Data were analyzed in 2014–2015. Women were categorized according to initial level of psychological symptoms (e.g., lower versus higher anxiety symptoms).


      Despite slight improvements in healthy lifestyle over time among women with higher versus lower anxiety (βinteraction=0.002, 95% CI=0.001, 0.003), those experiencing more severe symptoms had a consistently less healthy lifestyle over time (p<0.0001). Each SD increase in anxiety symptoms was related to a decrease in healthy lifestyle score throughout follow-up (βpooled=−0.09, 95% CI=−0.09, −0.08). Women with higher versus lower anxiety symptoms also had decreased odds of having a healthy lifestyle in 2010 (AOR=0.78, 95% CI=0.75, 0.81), particularly among women with an initially unhealthy lifestyle (pinteraction≤0.0001). Comparable patterns were observed with depression symptoms.


      Among midlife women, anxiety and depression symptoms were associated with unhealthier lifestyle throughout follow-up and reduced odds of having a healthy lifestyle 20 years later. Treating psychological symptoms may promote healthier lifestyles.
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        • Wenger N.K.
        What do the 2011 American Heart Association guidelines tell us about prevention of cardiovascular disease in women?.
        Clin Cardiol. 2011; 34: 520-523
        • Klein W.M.
        • Bloch M.
        • Hesse B.W.
        • et al.
        Behavioral research in cancer prevention and control: a look to the future.
        Am J Prev Med. 2014; 46: 303-311
        • Narayan K.M.
        • Kanaya A.M.
        • Gregg E.W.
        Lifestyle intervention for the prevention of type 2 diabetes mellitus: putting theory to practice.
        Treat Endocrinol. 2003; 2: 315-320
        • WHO
        Global Status Report on Noncommunicable Diseases.
        WHO, Geneva, Switzerland2014
        • Kubzansky L.D.
        • Winning A.
        Mental disorders and the emergence of physical disorders.
        in: Koenen K.C. Rudenstine S. Susser E. Galea S. A Lifecourse Approach to Mental Disorders. Oxford University Press, Oxford, UK2013: 291-304
        • Kubzansky L.D.
        • Winning A.
        • Kawachi I.
        Affective states and health.
        in: Berkman L.F. Kawachi I. Glymour M.M. Social Epidemiology. 2nd ed. Oxford University Press, New York2014: 320-364
        • Baum A.
        • Posluszny D.M.
        Health psychology: mapping biobehavioral contributions to health and illness.
        Annu Rev Psychol. 1999; 50: 137-163
        • Benyamini Y.
        • Roziner I.
        • Goldbourt U.
        • et al.
        Depression and anxiety following myocardial infarction and their inverse associations with future health behaviors and quality of life.
        Ann Behav Med. 2013; 46: 310-321
        • Murray J.
        • Craigs C.L.
        • Hill K.M.
        • Honey S.
        • House A.
        A systematic review of patient reported factors associated with uptake and completion of cardiovascular lifestyle behaviour change.
        BMC Cardiovasc Disord. 2012; 12: 120
        • Brumpton B.
        • Langhammer A.
        • Romundstad P.
        • Chen Y.
        • Mai X.M.
        The associations of anxiety and depression symptoms with weight change and incident obesity: the HUNT Study.
        Int J Obes (Lond). 2013; 37: 1268-1274
        • Azevedo Da Silva M.
        • Singh-Manoux A.
        • Brunner E.J.
        • et al.
        Bidirectional association between physical activity and symptoms of anxiety and depression: the Whitehall II study.
        Eur J Epidemiol. 2012; 27: 537-546
        • Bulloch A.
        • Lavorato D.
        • Williams J.
        • Patten S.
        Alcohol consumption and major depression in the general population: the critical importance of dependence.
        Depress Anxiety. 2012; 29: 1058-1064
        • Hawkins M.A.
        • Stewart J.C.
        Do negative emotional factors have independent associations with excess adiposity?.
        J Psychosom Res. 2012; 73: 243-250
        • Jiang F.
        • Li S.
        • Pan L.
        • Zhang N.
        • Jia C.
        Association of anxiety disorders with the risk of smoking behaviors: a meta-analysis of prospective observational studies.
        Drug Alcohol Depend. 2014; 145: 69-76
        • Pinto Pereira S.M.
        • Geoffroy M.C.
        • Power C.
        Depressive symptoms and physical activity during 3 decades in adult life: bidirectional associations in a prospective cohort study.
        JAMA Psychiatry. 2014; 71: 1373-1380
        • Weinberger A.H.
        • Pilver C.E.
        • Desai R.A.
        • Mazure C.M.
        • McKee S.A.
        The relationship of dysthymia, minor depression, and gender to changes in smoking for current and former smokers: longitudinal evaluation in the U.S. population.
        Drug Alcohol Depend. 2013; 127: 170-176
        • Haynes J.C.
        • Farrell M.
        • Singleton N.
        • et al.
        Alcohol consumption as a risk factor for anxiety and depression: results from the longitudinal follow-up of the National Psychiatric Morbidity Survey.
        Br J Psychiatry. 2005; 187: 544-551
        • Chiriboga D.E.
        • Ma Y.
        • Li W.
        • et al.
        Gender differences in predictors of body weight and body weight change in healthy adults.
        Obesity (Silver Spring). 2008; 16: 137-145
        • Singh M.
        Mood, food, and obesity.
        Front Psychol. 2014; 5: 925
        • Schellekens H.
        • Finger B.C.
        • Dinan T.G.
        • Cryan J.F.
        Ghrelin signalling and obesity: at the interface of stress, mood and food reward.
        Pharmacol Ther. 2012; 135: 316-326
        • Spring B.
        • King A.C.
        • Pagoto S.L.
        • Van Horn L.
        • Fisher J.D.
        Fostering multiple healthy lifestyle behaviors for primary prevention of cancer.
        Am Psychol. 2015; 70: 75-90
        • Shaw B.A.
        • Agahi N.
        A prospective cohort study of health behavior profiles after age 50 and mortality risk.
        BMC Public Health. 2012; 12: 803
        • Pickering R.P.
        • Goldstein R.B.
        • Hasin D.S.
        • et al.
        Temporal relationships between overweight and obesity and DSM-IV substance use, mood, and anxiety disorders: results from a prospective study, the National Epidemiologic Survey on Alcohol and Related Conditions.
        J Clin Psychiatry. 2011; 72: 1494-1502
        • Willett W.C.
        • Green A.
        • Stampfer M.J.
        • et al.
        Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes.
        N Engl J Med. 1987; 317: 1303-1309
        • Colditz G.A.
        • Manson J.E.
        • Hankinson S.E.
        The Nurses’ Health Study: 20-year contribution to the understanding of health among women.
        J Womens Health. 1997; 6: 49-62
        • Crown S.
        • Crisp A.H.
        A short clinical diagnostic self-rating scale for psychoneurotic patients. The Middlesex Hospital Questionnaire (M.H.Q.).
        Br J Psychiatry. 1966; 112: 917-923
        • Albert C.M.
        • Chae C.U.
        • Rexrode K.M.
        • Manson J.E.
        • Kawachi I.
        Phobic anxiety and risk of coronary heart disease and sudden cardiac death among women.
        Circulation. 2005; 111: 480-487
        • Ware Jr, J.E.
        • Sherbourne C.D.
        The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection.
        Med Care. 1992; 30: 473-483
        • Rumpf H.J.
        • Meyer C.
        • Hapke U.
        • John U.
        Screening for mental health: validity of the MHI-5 using DSM-IV Axis I psychiatric disorders as gold standard.
        Psychiatry Res. 2001; 105: 243-253
        • Gingras D.
        • Beliveau R.
        Colorectal cancer prevention through dietary and lifestyle modifications.
        Cancer Microenviron. 2011; 4: 133-139
        • Khan M.U.
        Lifestyle modification in the prevention of type II diabetes mellitus.
        Oman Med J. 2012; 27: 170-171
        • Chiuve S.E.
        • Cook N.R.
        • Shay C.M.
        • et al.
        Lifestyle-based prediction model for the prevention of CVD: the Healthy Heart Score.
        J Am Heart Assoc. 2014; 3: e000954
        • Sun Q.
        • Shi L.
        • Prescott J.
        • et al.
        Healthy lifestyle and leukocyte telomere length in U.S. women.
        PLoS One. 2012; 7: e38374
        • Chiuve S.E.
        • Rexrode K.M.
        • Spiegelman D.
        • et al.
        Primary prevention of stroke by healthy lifestyle.
        Circulation. 2008; 118: 947-954
        • Chasan-Taber S.
        • Rimm E.B.
        • Stampfer M.J.
        • et al.
        Reproducibility and validity of a self-administered physical activity questionnaire for male health professionals.
        Epidemiology. 1996; 7: 81-86
        • Rimm E.B.
        • Stampfer M.J.
        • Colditz G.A.
        • et al.
        Validity of self-reported waist and hip circumferences in men and women.
        Epidemiology. 1990; 1: 466-473
        • Rimm E.B.
        • Giovannucci E.L.
        • Stampfer M.J.
        • et al.
        Reproducibility and validity of an expanded self-administered semiquantitative food frequency questionnaire among male health professionals.
        Am J Epidemiol. 1992; 135 (discussion 1127–1136): 1114-1126
        • Giovannucci E.
        • Colditz G.
        • Stampfer M.J.
        • et al.
        The assessment of alcohol consumption by a simple self-administered questionnaire.
        Am J Epidemiol. 1991; 133: 810-817
        • McCullough M.L.
        • Feskanich D.
        • Stampfer M.J.
        • et al.
        Diet quality and major chronic disease risk in men and women: moving toward improved dietary guidance.
        Am J Clin Nutr. 2002; 76: 1261-1271
        • Stampfer M.J.
        • Hu F.B.
        • Manson J.E.
        • Rimm E.B.
        • Willett W.C.
        Primary prevention of coronary heart disease in women through diet and lifestyle.
        N Engl J Med. 2000; 343: 16-22
        • Chiuve S.E.
        • Fung T.T.
        • Rimm E.B.
        • et al.
        Alternative dietary indices both strongly predict risk of chronic disease.
        J Nutr. 2012; 142: 1009-1018
        • Kushi L.H.
        • Doyle C.
        • McCullough M.
        • et al.
        American Cancer Society Guidelines on nutrition and physical activity for cancer prevention: reducing the risk of cancer with healthy food choices and physical activity.
        CA Cancer J Clin. 2012; 62: 30-67
        • Mosca L.
        • Benjamin E.J.
        • Berra K.
        • et al.
        Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association.
        J Am Coll Cardiol. 2011; 57: 1404-1423
        • Rose S.A.
        • Poynter P.S.
        • Anderson J.W.
        • Noar S.M.
        • Conigliaro J.
        Physician weight loss advice and patient weight loss behavior change: a literature review and meta-analysis of survey data.
        Int J Obes (Lond). 2013; 37: 118-128
      1. Allison P. Handling missing data by maximum likelihood. Presented at SAS Global Forum, Orlando, FL, April 22–25, 2012.

        • Fitzmaurice G.M.
        • Laird N.M.
        • Ware J.H.
        Applied Longitudinal Analysis.
        2nd ed. John Wiley & Sons, New Jersey2011
        • Hernan M.A.
        • Hernandez-Diaz S.
        • Robins J.M.
        A structural approach to selection bias.
        Epidemiology. 2004; 15: 615-625
        • McKenzie S.H.
        • Harris M.F.
        Understanding the relationship between stress, distress and healthy lifestyle behaviour: a qualitative study of patients and general practitioners.
        BMC Fam Pract. 2013; 14: 166
        • Haller C.S.
        • Etter J.F.
        • Courvoisier D.S.
        Trajectories in cigarette dependence as a function of anxiety: a multilevel analysis.
        Drug Alcohol Depend. 2014; 139: 115-120
        • Epstein E.E.
        • Fischer-Elber K.
        • Al-Otaiba Z.
        Women, aging, and alcohol use disorders.
        J Women Aging. 2007; 19: 31-48
        • Holahan C.K.
        • Holahan C.J.
        • Powers D.A.
        • et al.
        Depressive symptoms and smoking in middle-aged and older women.
        Nicotine Tob Res. 2011; 13: 722-731
        • Hingle M.D.
        • Wertheim B.C.
        • Tindle H.A.
        • et al.
        Optimism and diet quality in the Women’s Health Initiative.
        J Acad Nutr Diet. 2014; 114: 1036-1045
        • Olthuis J.V.
        • Watt M.C.
        • Mackinnon S.P.
        • Stewart S.H.
        CBT for high anxiety sensitivity: alcohol outcomes.
        Addict Behav. 2015; 46: 19-24
        • Adams S.A.
        • Matthews C.E.
        • Ebbeling C.B.
        • et al.
        The effect of social desirability and social approval on self-reports of physical activity.
        Am J Epidemiol. 2005; 161: 389-398
        • Hebert J.R.
        • Ebbeling C.B.
        • Matthews C.E.
        • et al.
        Systematic errors in middle-aged women’s estimates of energy intake: comparing three self-report measures to total energy expenditure from doubly labeled water.
        Ann Epidemiol. 2002; 12: 577-586
        • Barlow D.H.
        Clinical Handbook of Psychological Disorders: A Step-by-Step Treatment Manual.
        5th ed. Guilford Press, New York2014