Exploring the link between depressive symptoms and obesity in rural caregivers of patients with chronic disease: the mediating effects of diet quality and physical activity

Introduction Obesity is a major risk factor of cardiovascular disease (CVD), and poor quality of diet and lower physical activity contribute to obesity. Depressive symptoms have been positively associated with obesity and CVD and may hinder engagement in healthy behaviors. Poor diet quality and physical inactivity are key behavioral pathways linking depression to obesity. However, little is known about whether these modifiable factors mediate the association between depressive symptoms and obesity, specifically among rural caregivers who may face additional barriers to engaging in healthy lifestyle due to resource-limited and inequitable rural environments. Purpose The purpose of this study was to examine the effect of depressive symptoms on obesity through diet quality and physical activity among rural caregivers of patients with chronic disease. Methods This cross-sectional study was a secondary data analysis of baseline data from rural caregivers with at least two CVD risk factors who participated in a randomized controlled CVD risk-reduction program. Obesity was assessed using body mass index (BMI), calculated from measured height and weight. Depressive symptoms were assessed with Patient Health Questionnaire-9. Physical activity was measured using a single item from the MOS-Specific Adherence Scale. Diet quality was assessed using the Health Eating Index-2015 (HEI-15) derived from a food frequent survey. Parallel mediation analysis was conducted using PROCESS (Model 4) with and without confounding factors (age, sex). Results Rural caregivers (N= 311, mean age = 54.8 years; 76% female; 96% White) had a mean BMI of 33.5 (range: 18.9- 58.1). Only 11.3% were healthy-weight range; 23.8% were overweight, and 64.9% had class I-III obesity. Without controlling age and sex, depressive symptoms were not directly associated with BMI (P=0.5644) but demonstrated significant indirect effects through diet quality and physical activity. Higher Depressive symptoms were associated with poor diet quality (indirect effect = 0.0471, 95% CI: 0.0165 to 0.0863) and lower physical activity (indirect effect = 0.0391, 95% CI: 0.0103 to 0.0798), which in turn predicted high BMI. These association remained similar after adjusting for age and sex (Figure 1). Conclusion Obesity is highly prevalent among rural caregivers. Depressive symptoms contributed to obesity indirectly by promoting poor diet quality and lower physical inactivity. Interventions to reduce obesity in this population should incorporate screening and management of depressive symptoms alongside strategies to improve diet and increase physical activity to mitigate obesity-related health risks among rural family caregivers.