Association Of Lifestyle Factors With Depressive Symptoms And Anxiety Symptoms During Pregnancy:Separate And Cumulative Effects

BackgroundPregnancy is a vulnerable period for women experiencing physical,psychological and social changes in their lives,and during this time,pregnant women are at increased risk for psychological problems.Depression and anxiety are the most frequent psychological problems during pregnancy,with serious and lasting risks for women and their offspring.Lifestyle behaviors are key factors affecting health and are central to the management of all types of chronic diseases because they can be intervened by individual self-help.The relationship between lifestyle and mental health has been explored in non-pregnant populations.The separate and cumulative effects of lifestyle associations with mental health in women during pregnancy are unclear and need to be urgently explored.Objectives(1)Based on the separate effect model,the associations of diet quality,sleep quality,physical activity,sedentary behavior,and smoking and alcohol consumption with depressive symptoms and anxiety symptoms in pregnancy were explored separately,and the lifestyle factors most strongly associated with depressive symptoms and anxiety symptoms in pregnancy were identified by XGBoost.(2)To explore the cumulative effects of multiple lifestyles on depressive symptoms and anxiety symptoms in pregnancy based on the cumulative effect model.MethodsThis was a cross-sectional study,conducted from October 2021 to October 2022 in the obstetrics outpatient department of a tertiary care hospital in Jinan,Shandong Province.A total of 851 pregnant women who met the criteria for nadir were enrolled,and their depressive symptoms and anxiety symptoms were assessed using the Edinburgh Postnatal Depression Scale(EPDS)and the Generalized Anxiety Disorder(GAD-7),respectively.The Chinese Dietary Guidelines Compliance Index for Pregnant Women(CDGCI-PW),the Pittsburgh Sleep Quality Index(PSQI),the Danish Physical Activity Scale,Sedentary Behavior Two Domain Questionnaire(SB2D),and self-administered smoking and alcohol history questionnaires were used to assess the quality of diet,sleep,physical activity,sedentary behavior,smoking history,and alcohol history of pregnant women.The study also collected:maternal socio-demographic data(maternal age,education level,etc.),pre-pregnancy BMI,and pregnancy-related data(history of adverse pregnancy and delivery,parity,pregnancy complications,etc.).The correlation between lifestyle and depressive symptoms and anxiety symptoms during pregnancy was explored using chi-square tests.After controlling for covariates,binary logistic regression was used to explore the association of various lifestyles with depressive symptoms and anxiety symptoms in pregnancy.The study used eXtreme Gradient Boosting(XGBoost)to identify the lifestyle factors most strongly associated with depressive and anxiety symptoms in pregnant women.Cumulative adverse lifestyle risk scores were calculated and one-way ANOVA or chi-square tests were used to explore differences in cumulative risk scores on general information,and binary logistic regression was used to explore the association of cumulative lifestyle risk scores with depressive symptoms and anxiety symptoms during pregnancy after controlling for covariates.Outcomes(1)The positive rate of depressive symptoms in pregnancy in this study was 19.3%,and the positive rate of anxiety symptoms in pregnancy was 4.8%.(2)Associations of each lifestyle factor with depressive symptoms and anxiety symptoms in pregnancy after controlling for covariates:separate effects1)Association with depressive symptoms in pregnancy:binary logistic regression analysis showed that exposure to poorer quality of diet was associated with a higher risk of depressive symptoms in pregnancy(OR=2.010,95%CI:1.318～3.066);exposure to poorer quality of sleep was associated with a higher risk of depressive symptoms in pregnancy(OR=2.263,95%CI:1.329～3.852);exposure to lower levels of physical activity was associated with a higher risk of depressive symptoms in pregnancy(OR=1.621,95%CI:1.102～2.384);the associations between sedentary,smoking and alcohol history and the risk of depressive symptoms in pregnancy were not significant.The results of the XGBoost model showed that the strongest association of lifestyle with depressive symptoms in pregnancy was physical activity,followed by sleep quality,diet quality,sedentary behavior,history of alcohol consumption,and history of smoking.2)Association with anxiety symptoms in pregnancy:binary logistic regression analysis showed that exposure to poorer sleep quality was associated with a higher risk of anxiety symptoms in pregnancy(OR=5.940,95%CI:2.736～12.896)and exposure to lower levels of physical activity was associated with a higher risk of anxiety symptoms in pregnancy(OR=2.103,95%CI:1.056～4.187),while the association between other lifestyles and pregnancy anxiety symptoms was not significant.The results of the XGBoost model showed that the strongest association of lifestyle with pregnancy anxiety symptoms was sleep quality,followed in order by physical activity,sedentary behavior,diet quality,history of alcohol consumption,and history of smoking.(3)Association of lifestyle with depressive symptoms/anxiety symptoms in pregnancy:cumulative effects1)Differences in cumulative risk scores for adverse lifestyle factors among women with different characteristics of pregnancyThe cumulative adverse lifestyle risk factors were normally distributed and classified into three categories according to the trichotomous method:Q1(0～1 adverse lifestyle factors),Q2(2～3 adverse lifestyle factors),and Q3(≥ 4 adverse lifestyle factors).The results showed that different age(F=13.141,P<0.001),different pre-pregnancy BMI(F=3.276,P=0.038),a different education level(χ2=13.141,P<0.001)and the different working status during pregnancy(χ2=49.129,P<0.001)differed in cumulative risk scores.Post hoc analyses revealed that younger pregnant women reported a higher proportion of 2～3 adverse lifestyle/≥ 4 adverse lifestyle factors(compared with 0～1 adverse lifestyle factors),a higher proportion of pregnant women with college or less education,working before pregnancy and idle during pregnancy reported≥ 4 adverse lifestyle factors(compared with 0～1 adverse lifestyle factors)(all P<0.05).2)Association of poor lifestyle with depressive symptoms and anxiety symptoms in pregnancy after controlling for covariates:a cumulative effect① Association with depressive symptoms in pregnancy:Binary logistic regression showed that the risk of depressive symptoms during pregnancy was 2.515 times higher in pregnant women with 2～3 adverse lifestyle factors than in those with only 0～1 adverse lifestyle factors(OR=2.515,95%CI:1.679～3.769).The risk of depressive symptoms during pregnancy was 5.126 times higher in pregnant women with≥ 4 adverse lifestyle factors than in those with only 0～1 adverse lifestyle factor(OR=5.126,95%CI:2.220～11.835).②Association with depressive symptoms in pregnancy:Binary logistic regression showed that the risk of anxiety symptoms during pregnancy was 2.194 times higher in pregnant women with 2～3 adverse lifestyle factors than in those with only 0～1 adverse lifestyle factors(OR=2.194,95%CI:1.037～4.646).Pregnant women with≥ 4 adverse lifestyle factors had a 5.243 times higher risk of developing anxiety symptoms during pregnancy than those with only 0～1 adverse lifestyle factor(OR=5.243,95%CI:1.455～18.897).ConclusionThe results of this study suggest that pregnant women with poor sleep quality and low physical activity levels may be at high risk for psychological problems and that health care workers may target them to develop targeted interventions.At the same time,healthcare workers should not neglect women in pregnancy who report multiple adverse lifestyle factors.