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The Association of Depression and Anxiety with Obesity and Unhealthy Behaviors Among Community-Dwelling US Adults. Tara Strine Epidemiologist, National Center for Chronic Disease Prevention and Health Promotion, Division of Adult and Community Health.

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The Association of Depression and Anxiety with Obesity and Unhealthy Behaviors Among Community-Dwelling US Adults

Tara Strine

Epidemiologist, National Center for Chronic Disease

Prevention and Health Promotion, Division of Adult and

Community Health


Background l.jpg
Background Unhealthy Behaviors Among Community-Dwelling US Adults

  • The prevalence of mental health disorders in the United States has increased over the past several decades.

  • According to recent estimates, each year approximately 6.6% of the US adult population has a major depressive disorder and 18% has an anxiety disorder.

  • Depression and anxiety are major causes of mortality and morbidity in the United States.

  • Depression and anxiety are associated with impaired health-related quality of life and social functioning, as well as increased risk of disability and engaging in unhealthy behaviors.

  • Tobacco use, poor diet, physical inactivity, and alcohol consumption are the leading preventable causes of death in the United States.


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Objective Unhealthy Behaviors Among Community-Dwelling US Adults

  • To examine the extent to which depression and anxiety are associated with smoking, physical inactivity, obesity, and alcohol consumption among US adults using data from the 2006 Behavioral Risk Factor Surveillance System.


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Methods Unhealthy Behaviors Among Community-Dwelling US Adults

  • Anxiety and Depression data from 41 states and territories using the 2006 BRFSS.

  • Data were available for 217,379 respondents.

  • 8.6% of PHQ-8 scores were missing (i.e. one or more of the 8 questions had a missing response).

  • 0.9% did not respond to the lifetime diagnosis of anxiety question.

  • 0.8% did not respond to the lifetime diagnosis of anxiety question.


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The Patient Health Questionnaire 8 (PHQ-8) (Current Depression and Depression Severity)

“Now, I am going to ask you some questions about

your mood.  When answering these questions, please

think about how many days each of the following has

occurred in the past 2 weeks”.  

  • “Over the last 2 weeks, how many days have you had little interest or pleasure in doing things?”

  • “Over the last 2 weeks, how many days have you felt down, depressed, or hopeless?”

  • “Over the last 2 weeks, how many days have you had trouble falling asleep or staying asleep or sleeping too much?”


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  • “Over the last 2 weeks, how many days have you felt tired or had little energy?”

  • “Over the last 2 weeks, how many days have you had a poor appetite or ate too much?”

  • “Over the last 2 weeks, how many days have you felt bad about yourself – or that you were a failure or had let yourself or your family down?”

  • “Over the last 2 weeks, how many days have you had trouble concentrating on things, such as reading the newspaper or watching TV?”

  • “Over the last 2 weeks, how many days have you moved or spoken so slowly that other people could have noticed? Or the opposite –being so fidgety or restless that you were moving around a lot more than usual?”


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PHQ-8 Classification Algorithm or had little energy?”

  • Depression severity classification:

    The number of days for each question are converted to points.

    0-1 day = 0 points

    2-6 days = 1 point

    7-11 days = 2 points

    12-14 days = 3 points

    The number of points are totaled across the eight questions in order to determine the depressive symptoms severity score.

    5-9 points = mild depression

    10-14 points = moderate depression

    15-19 points = moderately severe depression

    20+ points = severe depression

  • Persons with a depression severity score of 10 or greater are considered to have current depression. (88% sensitivity and specificity for major depression)


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Lifetime diagnosis of anxiety or depression or had little energy?”

  • Respondents were considered to have a lifetime diagnosis of depression if they responded “Yes” to the question:

    “Has a doctor or other healthcare provider every told you that you have a depressive disorder (including depression, major depression, dysthymia, or minor depression)?”

  • Respondents were considered to have a lifetime diagnosis of an anxiety disorder if they responded “Yes” to the question:

    “Has a doctor or other healthcare provider ever told you that you have an anxiety disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety disorder)?”


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Combined variables or had little energy?”

  • Current depression and lifetime diagnosis of depression

    • Never depressed (No lifetime diag of depress+no current depress)

    • Previously depressed (lifetime diag of depress+no current depress)

    • Current depress with or without lifetime diag depression= currently depress

  • Lifetime diagnosis of depression and anxiety

    • No lifetime diag of anx or depress

    • Lifetime diag of anx and no lifetime diag of depress

    • Lifetime diag of depress and no lifetime diag of anx

    • Lifetime diag of anx and lifetime diag of depress


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Adverse Health Behaviors and Obesity or had little energy?”

  • Current smokers – smoked at least 100 cigarettes in lifetime and still smoke.

  • Physically inactive – no leisure-time physical activity or exercise in past 30 days.

  • Obesity - body mass index ≥30 kg/m2.

  • Heavy drinker – men more than 2 drinks/day; women more than 1 drink/day.

  • Binge drinker- men 5 or more drinks on one occasion; women 4 or more drinks on one occasion.


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Analyses or had little energy?”


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Prevalence of Current Depression and a Lifetime Diagnosis of Anxiety or Depression Among US Adults Aged ≥18 Years, by Selected Sociodemographic Characteristics


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Prevalence estimates continued Anxiety or Depression Among US Adults Aged

%=percent, SE= standard error



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Prevalence of Adverse Health Behaviors and Obesity by Lifetime Diagnosis of Depression Status


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Prevalence of Adverse Health Behaviors and Obesity by Lifetime Diagnosis of Anxiety Status


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Relationship between depression severity and the prevalence of adverse health behaviors and obesity


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Relationship between lifetime diagnosis of depression and/or anxiety and adverse health behaviors and obesity



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Limitations of study and Obesity

  • Rate could be underestimated because of potential exclusion of people of low socioeconomic status, severely impaired physical or mental health, and those institutionalized or hospitalized.

  • People might not want to report symptoms due to stigma.

  • BRFSS is based on self-reported data which may introduce bias.

  • 12 states did not report depression and anxiety data therefore our results might not be representative of the entire country.

  • Current depression status was not calculated for 8.6% of the data.

  • Cannot infer a causal relationship because of cross-sectional data.


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Conclusions and Obesity

  • Significant associations were found between mental health problems, unhealthy behaviors, and obesity.

  • This suggests that public health interventions should address mental and physical health as a combined entity and that programs to simultaneously improves people’s mental and physical health should be developed and implemented.


Article l.jpg
Article and Obesity

  • Strine TW, Mokdad AH, Dube SR, Balluz LS, Gonzalez O, Berry JT, Mandersheid R, Kroenke K. The association of depression and anxiety with obesity and unhealthy behaviors among community-dwelling US adults. Gen Hosp Psychiatry. 2008 Mar-Apr;30(2):127-37.


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Impact of depression and anxiety on quality of life, health behaviors, and asthma control among adults in the US with asthma, 2006

Tara Strine

Epidemiologist, National Center for Chronic Disease

Prevention and Health Promotion, Division of Adult and

Community Health


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Background behaviors, and asthma control among adults in the US with asthma, 2006

  • 11 million adults had been told at some point in during their lifetime that they had asthma (2005).

  • 14.6 million visited a doctor’s office or outpatient department for asthma symptoms (2004).

  • 1.8 million visited an ER (2004).

  • 3780 died from asthma complications (2004)


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  • Psychological factors such as anxiety and depression are increasingly being recognized as influencing the onset and course of asthma.

  • Psychological disorders have been linked to:

    • more severe disease.

    • poor asthma control.

    • increased lengths of hospital stays.

    • frequent visits to health care providers.

    • increased use of steroid medication.

    • non-compliance with medical regimes.

    • impaired health-related quality of life.


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Objective increasingly being recognized as influencing the onset and course of asthma.

  • To examine the impact of depression and anxiety on impaired HRQOL, asthma control, and health behaviors among persons with asthma.


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Methods increasingly being recognized as influencing the onset and course of asthma.

  • Anxiety and Depression data from 41 states and territories using the 2006 BRFSS.

  • Heath risk behaviors, social and emotional support, life satisfaction, disability, and four health-related quality of life (HRQOL) questions were available for all states and territories (n=18,856 with asthma).

  • Five additional HRQOL questions were asked in three states (n=1,345 persons with asthma)

  • Questions assessing asthma control were available for nine states (n=3,943 persons with asthma).

  • Current depression status and depression severity status were assessed using the Patient Health Questionnaire 8 (PHQ-8)

  • Two additional questions (one each) on lifetime diagnosis of anxiety and depression.


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Health-related quality of life questions increasingly being recognized as influencing the onset and course of asthma.

Asked in 41 states/territories

“During the past 30 days, how many days…

  • was your physical health, which includes physical illness or injury, not good?” (recent physical distress)

  • was your mental health, which includes stress, depression, and problems with emotions, not good?” (recent mental distress)

  • did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?” (recent activity limitations)


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Asked in 3 states increasingly being recognized as influencing the onset and course of asthma.

“During the past 30 days, how many days…

  • did you feel sad, blue, or depressed?” (recent depressive symptoms)

  • did you feel worried, tense, or anxious?” (recent anxiety symptoms)

  • have you felt you did not get enough rest or sleep?” (recent sleep insufficiency)

  • did pain make it difficult for you to do your usual activities?” (recent pain)

  • have you felt very health and full of energy?” (recent vitality)

    (30-recent vitality=recent fatigue)


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Other variables of interest increasingly being recognized as influencing the onset and course of asthma.

  • General health – rate your health on a scale from excellent to poor (excellent/very good/good versus fair/poor)

  • Life satisfaction- “In general, how satisfied are you with your life?” (very satisfied/satisfied versus dissatisfied/very dissatisfied)

  • Social and emotional support – “How often do you get the social and emotional support that you need?” (always/usually/sometimes versus rarely/never)

  • Disability

    • “Are you limited in any way in any activities because of physical, mental, or emotional problems?”

    • “Do you have a health problem that requires you to use special equipment such as a cane, a wheelchair, or special bed, or a special telephone?”


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Asthma Control increasingly being recognized as influencing the onset and course of asthma.

  • “During the past 12 months, have you had an episode of asthma or asthma attack?” (yes/no)

  • “During the past 12 months, how many times did you visit an emergency room or urgent care center because of your asthma?” (0, 1, 2, ≥3 visits)

  • “Besides and emergency room, during the past 12 months, how many times did you see a doctor, nurse, or other health professional for urgent treatment of worsening asthma symptoms?” (0, 1, 2, ≥3 visits).

  • “During the past 12 months, how many days were you unable to work or carry out your usual activities because of your asthma?” (0 days, 1 week, ≥2 weeks)


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  • “During the past 30 days, how often did you have any symptoms of asthma?” (<1 per week, 1-2 per week, ≥2 per week, every day but not all of the time, every day and all the time)

  • “During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep?” (0, 1-2, 3-4, 5, 6-10, ≥10 days)

  • “During the past 30 days, how often did you take a prescription asthma medication to prevent an asthma attack from occurring?” (0, 1-14, 15-24, 25-30 days).

  • “During the past 30 days, how often did you use a prescription inhaler during an asthma attack to stop it?” (0, 1-4, 5-14, ≥15 times)


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Analyses symptoms of asthma?” (<1 per week, 1-2 per week, ≥2 per week, every day but not all of the time, every day and all the time)


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Prevalence of Current Depression and Lifetime Diagnosis of Depression or Anxiety by Asthma Status


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Mean Number of Days in Past 30 Days of Impaired Health-Related Quality of Life Among Persons with Asthma by Current Depression Status

*Includes data from Delaware, Hawaii, and Rhode Island.


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Mean Number of Days in Past 30 Days of Impaired Health-Related Quality of Life Among Persons with Asthma by Lifetime Diagnosis of Depression Status

*Includes data from Delaware, Hawaii, and Rhode Island.


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Mean Number of Days in Past 30 Days of Impaired Health-Related Quality of Life Among Persons with Asthma by Lifetime Diagnosis of Anxiety Status

*Includes data from Delaware, Hawaii, and Rhode Island.


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Mean Number of Days in Past 30 Days of Impaired Health-Related Quality of Life Among Persons with Asthma by Depression Severity

*Includes data from Delaware, Hawaii, and Rhode Island.


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Prevalence of Fair/poor General Health, Dissatisfaction with Life, Inadequate Social Support, and Disability among Persons with Asthma by Current Depression Status

Includes 38 states, the District of Columbia, Puerto Rico, and the Virgin Islands


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Prevalence of Fair/poor General Health, Dissatisfaction with Life, Inadequate Social Support, and Disability among Persons with Asthma by Lifetime Diagnosis of Depression Status

Includes 38 states, the District of Columbia, Puerto Rico, and the Virgin Islands


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Prevalence of Fair/poor General Health, Dissatisfaction with Life, Inadequate Social Support, and Disability among Persons with Asthma by Lifetime Diagnosis of Anxiety Status

Includes 38 states, the District of Columbia, Puerto Rico, and the Virgin Islands


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Prevalence of Fair/poor General Health, Dissatisfaction with Life, Inadequate Social Support, and Disability among Persons with Asthma by Depression Severity

Includes 38 states, the District of Columbia, Puerto Rico, and the Virgin Islands.


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Prevalence of Adverse Health Behaviors and Obesity by Current Depression Status Among Persons with Asthma

Includes 38 states, the District of Columbia, Puerto Rico, and the Virgin Islands.


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Prevalence of Adverse Health Behaviors and Obesity by Lifetime Diagnosis of Depression Status Among Persons with Asthma

Includes 38 states, the District of Columbia, Puerto Rico, and the Virgin Islands.


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Prevalence of Adverse Health Behaviors and Obesity by Lifetime Diagnosis of Anxiety Status Among Persons with Asthma

Includes 38 states, the District of Columbia, Puerto Rico, and the Virgin Islands.


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Prevalence of Adverse Health Behaviors and Obesity by Depression Severity Among Persons with Asthma

Includes 38 states, the District of Columbia, Puerto Rico, and the Virgin Islands.


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Asthma Severity by Current Depression Status Depression Severity Among Persons with Asthma

Includes data from 9 states.


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Asthma Severity by Lifetime Diagnosis of Depression Status Depression Severity Among Persons with Asthma

Includes data from 9 states.


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Asthma Severity by Lifetime Diagnosis of Anxiety Status Depression Severity Among Persons with Asthma

Includes data from 9 states.


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Limitations of study Depression Severity Among Persons with Asthma

  • Rate could be underestimated because of potential exclusion of people of low socioeconomic status, severely impaired physical or mental health, and those institutionalized or hospitalized.

  • Anxiety and depression data available in only 41 states/territories, asthma data in 9 states, and 5 HRQOL question in 3 states so results might not be representative of whole county.

  • Persons with anxiety and/or depression might over-report impaired HRQOL and somatic symptoms.

  • Current depression status was missing for 10.1% of the population.

  • Cannot infer a causal relationship because of cross-sectional data.


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Conclusions Depression Severity Among Persons with Asthma

  • Indicates increased impairments in quality of life and the prevalence of adverse health behaviors as depression severity increases.

  • Indicates that depression and anxiety adversely effects asthma severity.

  • Suggests the need for a multidimensional approach to healthcare for persons with asthma.

  • Might be useful to have a screening tool, such as the PHQ-8 when evaluating persons with asthma.


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Article Depression Severity Among Persons with Asthma

  • Strine TW, Mokdad AH, Balluz LS, Berry JT, Gonzalez O. Impact of depression and anxiety on quality of life, health behaviors, and asthma control among adults in the United States with asthma, 2006. Journal of Asthma. 2008 Mar;45(2):123-33.


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My Information Depression Severity Among Persons with Asthma

  • Tara W Strine

  • Email: tws2@cdc.gov

  • Phone: 770-488-2543

    BRFSS Website

  • http://www.cdc.gov/brfss/