Modeling multiple health behaviors and general health

Highlights

• Structural equation models examined associations among health behaviors and functioning.

• Overall model fit is improved when behaviors directly predict health functioning.

• Perceived health status mediated between behaviors and health functioning.

• Superior model fit and invariance suggests generalizability of preferred model.

Abstract

Multiple Health Behavior Change assumes health behaviors are related to one another, although research evidence is mixed. More research is needed to understand which behaviors are most closely related and how they collectively predict health. Principle component analysis and structural equation modeling were used to establish a model showing relations between health behaviors, including fruit/vegetable consumption, aerobic and strength exercise, alcohol intake, and smoking, and how these behaviors relate to general physical and mental health functioning in a large, national sample. Although health behaviors were found to coalesce into a health-promoting factor of diet, and exercise, a better overall model fit was found when all behaviors were modeled as separate independent variables. Results suggest that health behaviors relate to one another in complex ways, with perceived health status serving as a mediating variable between specific health behaviors and a factor of physical and mental health. Future research should further investigate how other health behaviors relate to perceptions and overall health, especially among subpopulations.

Introduction

The United States' current disease burden involves chronic illnesses, such as cardiovascular illness, cancer, and diabetes (Mathers and Loncar, 2006). Healthy behaviors can decrease the risk of these illnesses (Blair et al., 1996, National Research Council, 1989). Good physical and mental health is aided by eating fruits and vegetables, exercising regularly, avoiding smoking, and responsible alcohol intake (USHHS and USDA, 2015). Evidence suggests multiple healthy behaviors further decrease health risk overall (Baer et al., 2010, Berrigan et al., 2003).

Unfortunately, few American adults meet guidelines regarding fruit intake (13.1%), vegetable intake (8.9%) (CDC, 2015a), and exercise (20.9%) (Centers for Disease Control and Prevention, 2017, U.S. Department of Health and Human Services, 1991). Moreover, 15.1% of adults smoke (CDC, 2017) and 23.4% abuse alcohol (CDC, 2017)— health behaviors that are the leading causes of death among American adults (Mokdad et al., 2004). Encouraging healthier diets, more physical activity, smoking cessation, and responsible alcohol consumption are major public health priorities.

Health behavior change emphasizes individual behaviors. However, research is now considering intervention on multiple behaviors. Because multiple health behavior change (MHBC) research is developing, many questions remain (Noar et al., 2008, Prochaska et al., 2008a, Prochaska et al., 2008b), including which behaviors to treat together (Spring et al., 2012). Certain behaviors, such as diet and exercise, tend towards co-action (Chiolero et al., 2006, Mawditt et al., 2016). Lippke et al. (2012) found health behaviors tended to assemble into a health-enhancing or a health-reducing cluster. Theoretically, such clustered behaviors would show the greatest co-action; MHBC interventions may maximize their impact by this synergy (Paiva et al., 2012).

The best behaviors for MHBC interventions often focus around a theme such energy balance (Paiva et al., 2012). Other research suggests that participants choose their behavioral combinations (Allegrante et al., 2008). Since behavioral combination efficacy is a fundamental aspect of MHBC, more research is clearly needed. Chosen behaviors must also demonstrate a strong effect on physical and mental health.

Health behaviors may not be as linked as theorized. Newsom et al. (2005) examined smoking, exercise, alcohol consumption, and diet behaviors within several North American public health datasets and suggested that shared variance is miniscule. Therefore MHBC interventions are conceptually unfounded. This suggests associations between health behaviors and overall health should be examined.

Our research examined links between health behaviors and whether these behaviors were collectively predictive of good health, using a large, nationally representative sample. If the health behaviors are significantly related, it suggests sufficient co-action for a joint intervention. If the health behaviors were relatively independent, it implies behaviors may be addressed separately. Specifically, we examined whether diet, exercise, smoking, and alcohol consumption would form one of two health behavior factors, one promoting good health and one reducing good health, consistent with Lippke et al. (2012). An alternate model assessed whether health behaviors acted as separate variables. In each model, the health behaviors were hypothesized to relate to an outcome factor representing physical and mental health.