Physical activity buffers the negative relationship between multimorbidity, self-rated health and life satisfaction

Physical activity buffers the negative relationship between multimorbidity, self-rated health and... Abstract Background This study aimed to examine the relationship between multimorbidity, self-rated health and life satisfaction, and to test the moderating effect of physical activity on the relationship between multimorbidity, self-rated health and life satisfaction. Methods This is a cross-sectional study based on data from the European Social Survey 2014. Participants were 25 713 adults (12 830 men), aged 18–64 years old, from 18 European countries and Israel. Self-reported information regarding chronic diseases, health perception, life satisfaction and physical activity was collected through interview. Multimorbidity was defined as the co-occurrence of ≥ 2 chronic diseases. Linear regression models were used to estimate the effects of multimorbidity, physical activity and the interaction effect of multimorbidity × physical activity on self-rated health and life satisfaction. Results Multimorbidity was negatively related to self-rated health (d = 0.03) and life satisfaction (d = 0.03). Physical activity was positively related to self-rated health and life satisfaction. There was a significant interaction effect between multimorbidity and physical activity with regard to self-rated health (β = 0.01, P < 0.001) and life satisfaction (β = 0.04, P < 0.001). Conclusions Physical activity buffered the negative relationship between multimorbidity, self-rated health and life satisfaction; contributing to better self-rated health and life satisfaction. chronic diseases, European, exercise Introduction Self-rated health reproduces the subjective experience of health, and it has been shown to be a significant predictor of morbidity and mortality,1,2 related to several biomarkers such as blood pressure, blood levels of albumin, white blood cell count, haemoglobin, HDL cholesterol, serum creatinine and a barometer of physiological states.1,3,4 Life satisfaction can be defined as a general evaluation of an individual’s personal life, and has been related to several mental adverse health outcomes such as depression and psychiatric problems,5 along with somatic disability and mortality.6 The association between self-rated health and life satisfaction with health outcomes enables a conceptual understanding of the health from people’s perspective. Multimorbidity, defined as the co-occurrence of two or more chronic diseases7 is a consequence of the aging of the population; it results from both an increase in the prevalence of chronic diseases,8 and the number of diseases from which a patient suffers.9 Multimorbidity influences health perception and subjective wellbeing perhaps because of its physical and psychological consequences.10 Chronic diseases affect people ability to manage their daily functioning, and those people usually experienced a decline on their quality of life.11 Thus, the presence of multimorbidity is negatively associated with both self-rated health2,12,13 and life satisfaction.14 Most studies relating self-rated health or life satisfaction to chronic diseases focus on specific populations or specific diseases or group of diseases. For example, among middle-aged and older adults, poorer self-rated health is strongly associated with single chronic diseases, particularly cardiovascular diseases, multimorbidity and poor psychosocial function,2,13,15 while life satisfaction is inversely associated with multimorbidity.14,15 Similarly, cardiovascular mortality in the general populations with and without prior cardiovascular disease is associated with poor self-rated health.16 Also, increased risk of specific diseases, such as cancer, stroke and type 2 diabetes mellitus are associated with lower life satisfaction.17 In opposition to multimorbidity, physical activity has been shown to have a significant and positive association with self-rated health and life satisfaction.18,19 Furthermore, physical activity can reduce chronic diseases and the risk of disease progression,20–22 and it is inversely associated with multimorbidity.12 However, the possibility for physical activity moderating the relationship between multimorbidity and self-rated health and life satisfaction has yet to be explored. It is thus expected that, by having a positive effect on self-rated health and life satisfaction, and by having a protective health effect against chronic diseases, physical activity might moderate the relationship between multimorbidity and self-rated health and life satisfaction. Therefore, the purpose of this study was two-pronged: (i) to examine the relationship between multimorbidity, self-rated health and life satisfaction; and (ii) to test the moderating effect of physical activity on the relationship between multimorbidity, self-rated health and life satisfaction. Methods Study design and participants The present study was based on the seventh wave of the European Social Survey, 2014, which included 20 European countries (Austria, Belgium, Switzerland, Czech Republic, Germany, Denmark, Estonia, Spain, Finland, France, Hungary, Ireland, Lithuania, Netherlands, Norway, Poland, Portugal, Sweden, Slovenia, UK) and Israel. The European Social Survey is a survey that has been conducted every two years to measure the attitudes, beliefs, and behaviours of European adults. The survey uses representative samples among countries. Participants were sampled by postal code, address files, social security registry data, population registers and/or telephone books. The information was collected in each country, using a questionnaire filled-in through an hour-long face-to-face interview. The questionnaire was translated, by language experts, into the language spoken in each of the participating countries. Further details about the European Social Survey are available elsewhere.23 The study protocol subscribes to the Declaration on Professional Ethics of the International Statistical Institute. Probability sampling from residents aged 15 years and older was applied (excluding the homeless, and institutionalized people), comprising 40 185 participants. For the present study participants under 18 years and above 64 years of age were excluded (n = 9851), because the focus was on the adult population. Participants from Czech Republic and Estonia, and others that also did not report information on chronic diseases and were therefore excluded (n = 4255). Respondents without information in more than two socio-demographic variables were also excluded (n = 366). These restrictions resulted in a sample of 25 713 participants (12 830 men and 12 883 women) (Fig. 1). Fig. 1 View largeDownload slide Flow chart diagram of participants. Fig. 1 View largeDownload slide Flow chart diagram of participants. Measures Chronic diseases Most of the chronic diseases (heart or circulation problems, high blood pressure, diabetes, stomach or digestion problems, breathing problems, allergies, headaches and cancer) were assessed by asking participants to indicate whether they currently have, or had, chronic diseases (yes/no) in the last 12 months. For obesity, body mass index (BMI) was calculated from self-reported height and weight (kg/m2). Body mass index categories were calculated in accordance with the WHO guidelines24 and dichotomized into non-obese (<30.0 kg/m2) and obese (≥30 kg/m2). Multimorbidity was defined as the co-occurrence of two or more of the nine aforementioned diseases.7 Physical activity Physical activity was assessed with a single item asking, ‘On how many of the last 7 days did you walk quickly, do sports or other physical activity for 30 min or longer?’ Although physical activity was assessed with a single item, there is evidence in previous studies that a single question is an acceptable alternative;25 this approach was used previously with European Social Survey data.26,27 Self-rated health Self-rated health was assessed with a single item question. Participants were asked, ‘How is your health in general?’ The response options were very bad, bad, fair, good or very good. This single item question has been widely validated in epidemiological studies.26–28 Previous studies have found a relationship between levels of self-rated health and adverse health outcomes, indicating its validity.1,29 Life satisfaction Life satisfaction was assessed with the item, ‘How satisfied are you with your life as a whole nowadays?’ Responses were indicated using a scale ranging from 0 ‘extremely dissatisfied’ to 10 ‘extremely satisfied’. Studies have shown that life satisfaction is associated to mental health outcomes,5 can predict mortality,30 and that one single item is a robust measure capable of reliably estimating life satisfaction.31 Covariates Participants reported sex, age and years of full-time education. Respondents were asked to describe whether they live with or without a husband/wife/partner, and the legal situation. Response options were dichotomized into live with, or without, a partner. Household income was determined based on decile. It is a socioeconomic indicator as important as or more important than education and occupation, because is indicative of a standard of living.32 Household income also shows relationship with health status.33 Using household income decile information, first to third decile, fourth to seventh decile and 8th to 10th were grouped to create three groups. Participants were asked to report their occupation. To determine the living place, those who indicated that they lived in a big city, the suburbs or the outskirts of big city were grouped into a new category named urban areas; those who responded that they lived in the country, a village or a home in countryside were grouped into rural areas. Participants answered if they lived with or without children at home, along with the number of people living regularly as a member of the household. Data analysis Descriptive statistics were calculated for the entire sample (means, standard deviation and percentages). The relationship between the presence or absence of chronic diseases and multimorbidity, according self-rated health and life satisfaction, was tested by ANCOVA. Linear regression models were used to estimate the principal effects of multimorbidity, physical activity, and the interaction effect of multimorbidity × physical activity on self-rated health and life satisfaction. Multimorbidity enters the models as a dummy variable, and physical activity as a continuous variable. To calculate the variable that expresses the interaction effect (multimorbidity × physical activity), physical activity was transformed using grand mean centring. The grand mean centring was calculated by taking each value of physical activity (times/week) and subtracting from it the mean of the total sample. Physical activity grand mean centring was then multiplied by multimorbidity to have a variable to test the moderation effect (multimorbidity × physical activity). Analyses were not stratified by sex or age because an interaction effect between sex and age on multimorbidity was not verified. For ANCOVA and linear regression, the analysis were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. Statistical analysis was performed using IBM SPSS Statistics v.24.0. The significance level was set at P < 0.05. Results Table 1 presents the characteristics of the study sample. The most prevalent chronic diseases were: high blood pressure (17.5%), stomach or digestion problems (16.2%) and obesity (15.5%). Almost 30% of the participants had multimorbidity (≥2 chronic diseases). From 1 to 5, the mean value for self-rated health was 3.8 ± 0.9, and from 0 to 10, the mean of life satisfaction was 7.2 ± 2.2. Physical activity was practiced, on average, 3.2 ± 2.6 times/week. Table 1 Participants’ characteristics for total sample and stratified by sex in 2014   Total (n = 25713)  % or M ± SD  Sex     Male  48.7   Female  51.3  Age  47.4 ± 18.3  Education (years)  12.5 ± 3.9  Marital status     Live with partner  62.0   Live without partner  38.0  Household income     Low (first to third decile)  30.1   Middle (fourth to seventh decile)  43.1   High (8th to 10th decile)  26.8  Occupation     Employed  61.9   Unemployed  6.8   Student  8.7   Retired  22.5  Living place     Urban area  61.1   Rural area  38.9  Children     Do not have children  60.8   Have children  39.2   Household members  2.8 ± 1.4  Chronic diseases (last 12 month)     Heart or circulation problems  9.8   High blood pressure  17.5   Diabetes  4.9   Obesity  15.5   Stomach/digestion problems  16.2   Breathing problems  8.8   Allergies  12.4   Headaches  14.4   Cancer  10.3  Multimorbidity     No  70.3   Yes  29.7  Self-rated health  3.8 ± 0.9  Life satisfaction  7.2 ± 2.2  Physical activity (times/week)  3.2 ± 2.6    Total (n = 25713)  % or M ± SD  Sex     Male  48.7   Female  51.3  Age  47.4 ± 18.3  Education (years)  12.5 ± 3.9  Marital status     Live with partner  62.0   Live without partner  38.0  Household income     Low (first to third decile)  30.1   Middle (fourth to seventh decile)  43.1   High (8th to 10th decile)  26.8  Occupation     Employed  61.9   Unemployed  6.8   Student  8.7   Retired  22.5  Living place     Urban area  61.1   Rural area  38.9  Children     Do not have children  60.8   Have children  39.2   Household members  2.8 ± 1.4  Chronic diseases (last 12 month)     Heart or circulation problems  9.8   High blood pressure  17.5   Diabetes  4.9   Obesity  15.5   Stomach/digestion problems  16.2   Breathing problems  8.8   Allergies  12.4   Headaches  14.4   Cancer  10.3  Multimorbidity     No  70.3   Yes  29.7  Self-rated health  3.8 ± 0.9  Life satisfaction  7.2 ± 2.2  Physical activity (times/week)  3.2 ± 2.6  Table 1 Participants’ characteristics for total sample and stratified by sex in 2014   Total (n = 25713)  % or M ± SD  Sex     Male  48.7   Female  51.3  Age  47.4 ± 18.3  Education (years)  12.5 ± 3.9  Marital status     Live with partner  62.0   Live without partner  38.0  Household income     Low (first to third decile)  30.1   Middle (fourth to seventh decile)  43.1   High (8th to 10th decile)  26.8  Occupation     Employed  61.9   Unemployed  6.8   Student  8.7   Retired  22.5  Living place     Urban area  61.1   Rural area  38.9  Children     Do not have children  60.8   Have children  39.2   Household members  2.8 ± 1.4  Chronic diseases (last 12 month)     Heart or circulation problems  9.8   High blood pressure  17.5   Diabetes  4.9   Obesity  15.5   Stomach/digestion problems  16.2   Breathing problems  8.8   Allergies  12.4   Headaches  14.4   Cancer  10.3  Multimorbidity     No  70.3   Yes  29.7  Self-rated health  3.8 ± 0.9  Life satisfaction  7.2 ± 2.2  Physical activity (times/week)  3.2 ± 2.6    Total (n = 25713)  % or M ± SD  Sex     Male  48.7   Female  51.3  Age  47.4 ± 18.3  Education (years)  12.5 ± 3.9  Marital status     Live with partner  62.0   Live without partner  38.0  Household income     Low (first to third decile)  30.1   Middle (fourth to seventh decile)  43.1   High (8th to 10th decile)  26.8  Occupation     Employed  61.9   Unemployed  6.8   Student  8.7   Retired  22.5  Living place     Urban area  61.1   Rural area  38.9  Children     Do not have children  60.8   Have children  39.2   Household members  2.8 ± 1.4  Chronic diseases (last 12 month)     Heart or circulation problems  9.8   High blood pressure  17.5   Diabetes  4.9   Obesity  15.5   Stomach/digestion problems  16.2   Breathing problems  8.8   Allergies  12.4   Headaches  14.4   Cancer  10.3  Multimorbidity     No  70.3   Yes  29.7  Self-rated health  3.8 ± 0.9  Life satisfaction  7.2 ± 2.2  Physical activity (times/week)  3.2 ± 2.6  Results of the relationship between the presence or absence of chronic diseases and multimorbidity, according to self-rated health and life satisfaction, are presented in Table 2. For each chronic disease, participants who did not report having the disease had significantly better self-rated health than those who reported having the disease. Similar results were observed for life satisfaction. Those who did not report the presence of the disease had better life satisfaction, with the exception of allergies. Although the effect size was small, multimorbidity was also significantly related to self-rated health and life satisfaction. Those without multimorbidity had better self-rated health (4.08 ± 0.77 versus 3.40 ± 0.89, F(1) = 2399.93, P < 0.001) and better life satisfaction (7.37 ± 20.00 versus 6.86 ± 2.30, F(1) = 243.35, P < 0.001). Tables 2 Relationship between, chronic diseases and the presence of multimorbidity and self-rated health of European adults in 2014 Chronic diseases and multimorbidity  Self-rated health  Life satisfaction  Mean ± SD  P  Mean ± SD  P  Heart or circulation problems    <0.001    <0.001   No  3.96 ± 0.81    7.28 ± 2.07     Yes  3.08 ± 0.90    6.62 ± 2.39    High blood pressure    <0.001    <0.001   No  3.99 ± 0.82    7.29 ± 2.05     Yes  3.35 ± 0.87    6.89 ± 2.33    Diabetes    <0.001    <0.001   No  3.92 ± 0.84    7.24 ± 2.09     Yes  3.09 ± 0.89    6.82 ± 2.38    Obesity    <0.001    <0.001   No  3.95 ± 0.84    7.28 ± 2.07     Yes  3.49 ± 0.87    6.90 ± 2.29    Stomach/digestion problems    <0.001    <0.001   No  3.94 ± 0.84    7.27 ± 2.08     Yes  3.59 ± 0.91    6.97 ± 2.21    Breathing problems    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.34 ± 0.96    6.88 ± 2.33    Allergies    <0.001    0.964   No  3.89 ± 0.86    7.21 ± 2.11     Yes  3.81 ± 0.87    7.27 ± 2.09    Headaches    <0.001    <0.001   No  3.92 ± 0.84    7.30 ± 2.05     Yes  3.64 ± 0.93    6.77 ± 2.37    Cancer    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.43 ± 0.95    6.93 ± 2.33    Multimorbidity    <0.001    <0.001   No  4.08 ± 0.77    7.37 ± 2.00     Yes  3.40 ± 0.89    6.86 ± 2.30    Chronic diseases and multimorbidity  Self-rated health  Life satisfaction  Mean ± SD  P  Mean ± SD  P  Heart or circulation problems    <0.001    <0.001   No  3.96 ± 0.81    7.28 ± 2.07     Yes  3.08 ± 0.90    6.62 ± 2.39    High blood pressure    <0.001    <0.001   No  3.99 ± 0.82    7.29 ± 2.05     Yes  3.35 ± 0.87    6.89 ± 2.33    Diabetes    <0.001    <0.001   No  3.92 ± 0.84    7.24 ± 2.09     Yes  3.09 ± 0.89    6.82 ± 2.38    Obesity    <0.001    <0.001   No  3.95 ± 0.84    7.28 ± 2.07     Yes  3.49 ± 0.87    6.90 ± 2.29    Stomach/digestion problems    <0.001    <0.001   No  3.94 ± 0.84    7.27 ± 2.08     Yes  3.59 ± 0.91    6.97 ± 2.21    Breathing problems    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.34 ± 0.96    6.88 ± 2.33    Allergies    <0.001    0.964   No  3.89 ± 0.86    7.21 ± 2.11     Yes  3.81 ± 0.87    7.27 ± 2.09    Headaches    <0.001    <0.001   No  3.92 ± 0.84    7.30 ± 2.05     Yes  3.64 ± 0.93    6.77 ± 2.37    Cancer    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.43 ± 0.95    6.93 ± 2.33    Multimorbidity    <0.001    <0.001   No  4.08 ± 0.77    7.37 ± 2.00     Yes  3.40 ± 0.89    6.86 ± 2.30    Tested by ANCOVA. SD, standard deviation. Analysis were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. Tables 2 Relationship between, chronic diseases and the presence of multimorbidity and self-rated health of European adults in 2014 Chronic diseases and multimorbidity  Self-rated health  Life satisfaction  Mean ± SD  P  Mean ± SD  P  Heart or circulation problems    <0.001    <0.001   No  3.96 ± 0.81    7.28 ± 2.07     Yes  3.08 ± 0.90    6.62 ± 2.39    High blood pressure    <0.001    <0.001   No  3.99 ± 0.82    7.29 ± 2.05     Yes  3.35 ± 0.87    6.89 ± 2.33    Diabetes    <0.001    <0.001   No  3.92 ± 0.84    7.24 ± 2.09     Yes  3.09 ± 0.89    6.82 ± 2.38    Obesity    <0.001    <0.001   No  3.95 ± 0.84    7.28 ± 2.07     Yes  3.49 ± 0.87    6.90 ± 2.29    Stomach/digestion problems    <0.001    <0.001   No  3.94 ± 0.84    7.27 ± 2.08     Yes  3.59 ± 0.91    6.97 ± 2.21    Breathing problems    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.34 ± 0.96    6.88 ± 2.33    Allergies    <0.001    0.964   No  3.89 ± 0.86    7.21 ± 2.11     Yes  3.81 ± 0.87    7.27 ± 2.09    Headaches    <0.001    <0.001   No  3.92 ± 0.84    7.30 ± 2.05     Yes  3.64 ± 0.93    6.77 ± 2.37    Cancer    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.43 ± 0.95    6.93 ± 2.33    Multimorbidity    <0.001    <0.001   No  4.08 ± 0.77    7.37 ± 2.00     Yes  3.40 ± 0.89    6.86 ± 2.30    Chronic diseases and multimorbidity  Self-rated health  Life satisfaction  Mean ± SD  P  Mean ± SD  P  Heart or circulation problems    <0.001    <0.001   No  3.96 ± 0.81    7.28 ± 2.07     Yes  3.08 ± 0.90    6.62 ± 2.39    High blood pressure    <0.001    <0.001   No  3.99 ± 0.82    7.29 ± 2.05     Yes  3.35 ± 0.87    6.89 ± 2.33    Diabetes    <0.001    <0.001   No  3.92 ± 0.84    7.24 ± 2.09     Yes  3.09 ± 0.89    6.82 ± 2.38    Obesity    <0.001    <0.001   No  3.95 ± 0.84    7.28 ± 2.07     Yes  3.49 ± 0.87    6.90 ± 2.29    Stomach/digestion problems    <0.001    <0.001   No  3.94 ± 0.84    7.27 ± 2.08     Yes  3.59 ± 0.91    6.97 ± 2.21    Breathing problems    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.34 ± 0.96    6.88 ± 2.33    Allergies    <0.001    0.964   No  3.89 ± 0.86    7.21 ± 2.11     Yes  3.81 ± 0.87    7.27 ± 2.09    Headaches    <0.001    <0.001   No  3.92 ± 0.84    7.30 ± 2.05     Yes  3.64 ± 0.93    6.77 ± 2.37    Cancer    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.43 ± 0.95    6.93 ± 2.33    Multimorbidity    <0.001    <0.001   No  4.08 ± 0.77    7.37 ± 2.00     Yes  3.40 ± 0.89    6.86 ± 2.30    Tested by ANCOVA. SD, standard deviation. Analysis were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. Table 3 depicts the results for linear regression analysis. Unadjusted analysis demonstrated that multimorbidity was negatively related to self-rated health and life satisfaction. When accounting for other social-demographic confounders, multimorbidity remained negatively related with self-rated health (β = −0.52, 95% CI: −0.054 to −0.50, P < 0.001) and life satisfaction (β = −0.43, 95% CI: −0.49 to −0.37, P < 0.001). In turn, in the unadjusted and adjusted model, physical activity was positively related to self-rated health (β = 0.04, 95% CI: 0.04–0.05, P < 0.001) and life satisfaction (β = 0.07, 95% CI: 0.05–0.08, P < 0.001). There was a significant interaction effect between multimorbidity and physical activity with regard to self-rated health (β = 0.01, 95% CI: 0.01–0.02, P < 0.001) and life satisfaction (β = 0.04, 95% CI: 0.02–0.06, P < 0.001), portraying physical activity as a moderator of the relationship between multimorbidity and these variables. Table 3 Main and interaction effect of multimorbidity and physical activity on self-rated health and life satisfaction of European adults in 2014   Self-rated health  Life satisfaction  Model 1  Model 2  Model 1  Model 2  β (95% CI)  β (95% CI)  β (95% CI)  β (95% CI)  Multimorbiditya  −0.60 (−0.68, −0.64)*  −0.52 (−0.54, −0.50)*  −0.48 (−0.54, −0.42)*  −0.43 (−0.49, −0.37)*  Physical activity  0.05 (0.04, 0.05)*  0.04 (0.04, 0.05)*  0.07 (0.06, 0.09)*  0.07 (0.05, 0.08)*  Multimorbidity × physical activityb  0.02 (0.02, 0.03)*  0.01 (0.00, 0.02)*  0.04 (0.02, 0.06)*  0.04 (0.02, 0.06)*    Self-rated health  Life satisfaction  Model 1  Model 2  Model 1  Model 2  β (95% CI)  β (95% CI)  β (95% CI)  β (95% CI)  Multimorbiditya  −0.60 (−0.68, −0.64)*  −0.52 (−0.54, −0.50)*  −0.48 (−0.54, −0.42)*  −0.43 (−0.49, −0.37)*  Physical activity  0.05 (0.04, 0.05)*  0.04 (0.04, 0.05)*  0.07 (0.06, 0.09)*  0.07 (0.05, 0.08)*  Multimorbidity × physical activityb  0.02 (0.02, 0.03)*  0.01 (0.00, 0.02)*  0.04 (0.02, 0.06)*  0.04 (0.02, 0.06)*  CI, confidence interval. Model 1: Unadjusted analyses. Model 2: Analyses were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. *P < 0.001. aMultimorbidity enter into the model as a dummy variable. bPhysical activity was transformed using grand mean centring. The grand mean centring was achieved by taking each value of physical activity (times/week) and subtracting from it the mean of the total sample. Table 3 Main and interaction effect of multimorbidity and physical activity on self-rated health and life satisfaction of European adults in 2014   Self-rated health  Life satisfaction  Model 1  Model 2  Model 1  Model 2  β (95% CI)  β (95% CI)  β (95% CI)  β (95% CI)  Multimorbiditya  −0.60 (−0.68, −0.64)*  −0.52 (−0.54, −0.50)*  −0.48 (−0.54, −0.42)*  −0.43 (−0.49, −0.37)*  Physical activity  0.05 (0.04, 0.05)*  0.04 (0.04, 0.05)*  0.07 (0.06, 0.09)*  0.07 (0.05, 0.08)*  Multimorbidity × physical activityb  0.02 (0.02, 0.03)*  0.01 (0.00, 0.02)*  0.04 (0.02, 0.06)*  0.04 (0.02, 0.06)*    Self-rated health  Life satisfaction  Model 1  Model 2  Model 1  Model 2  β (95% CI)  β (95% CI)  β (95% CI)  β (95% CI)  Multimorbiditya  −0.60 (−0.68, −0.64)*  −0.52 (−0.54, −0.50)*  −0.48 (−0.54, −0.42)*  −0.43 (−0.49, −0.37)*  Physical activity  0.05 (0.04, 0.05)*  0.04 (0.04, 0.05)*  0.07 (0.06, 0.09)*  0.07 (0.05, 0.08)*  Multimorbidity × physical activityb  0.02 (0.02, 0.03)*  0.01 (0.00, 0.02)*  0.04 (0.02, 0.06)*  0.04 (0.02, 0.06)*  CI, confidence interval. Model 1: Unadjusted analyses. Model 2: Analyses were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. *P < 0.001. aMultimorbidity enter into the model as a dummy variable. bPhysical activity was transformed using grand mean centring. The grand mean centring was achieved by taking each value of physical activity (times/week) and subtracting from it the mean of the total sample. Discussion Main finding of this study This study investigated the relationship between multimorbidity, self-rated health and life satisfaction, as well as the moderating effect of physical activity on the relationship between multimorbidity, self-rated health and life satisfaction. Multimorbidity was negatively related to self-rated health and life satisfaction. On the other hand, physical activity was positively related to self-rated health and life satisfaction, thereby buffering the effect of multimorbidity on self-rated health and life satisfaction. In sum, physical activity moderates the effect of multimorbidity on self-rated health and life satisfaction. What is already known on this topic Subjective health expressed, as self-rated health, is associated with single chronic diseases and with multimorbidity. Those with chronic diseases and multimorbidity had lower self-rated health. Results from this study are in line with previous findings in literature.2,12,13 These results corroborate that self-rated health is a proxy of health biomarkers,1 and a barometer of physiologic states,3 because it is sensitive to the presence of chronic diseases or multimorbidity. Self-rated health is correlated with socio-demographic factors.2,13 However, adjusting the analysis of the relationship between multimorbidity and self-rated health, for socio-demographic factors, did not significantly modify the association. This reinforces the strong relationship between the two variables, independently of socio-demographic factors. Literature shows that chronic diseases and multimorbidity are associated with lower life satisfaction.14,34 This was observed, in the present study, for all particular chronic diseases (except for allergies) and for multimorbidity, confirming that the presence of these diseases, or a cluster of these diseases, has a negative effect on subjective wellbeing. The observed negative relationship supports the fact that life satisfaction depends on the individual’s health status.35 This finding depicts life satisfaction as an important health outcome used to characterize the population’s health and wellbeing.5,36 Regarding the relationship between physical activity, self-rated health and life satisfaction, this study’s results provide evidence that regular physical activity is associated with better self-rated health and life satisfaction among adults. Previous studies have also demonstrated the positive relationship between these variables.18,19 The impact of physical activity on self-rated health and life satisfaction is observed even among people with chronic diseases,37,38 and exists across the spectra of both age and socioeconomic status.19,39 What this study adds The identification of physical activity as a mediator between multimorbidity, self-rated health and life satisfaction is of importance because this moderation effect changes the slope of the negative relationship (i.e. physically active people with multimorbidity can have better self-rated health and life satisfaction than their non-active peers). Considering that self-rated health and life satisfaction are directly linked to mortality, health biomarkers and mental health outcomes,1,2,5 improving self-rated health and life satisfaction can result in improving general health status. This study’s results offer potential targets for future public health interventions. In order to enhance overall physical and mental health status, both of which are strongly linked to self-rated health and life satisfaction, physical activity should be promoted. For those who are not physically active, even a minimum amount of physical activity has a protective health effect against chronic diseases and mortality.20–22 Limitations of this study A number of strengths and limitations should be kept in mind. The main strength of this study was the European Social Survey database, which includes a large and representative sample of adults from several European countries, as well as socio-demographic characteristics and numerous chronic diseases of the study sample. In view of the large sample and the heterogeneity of the participants, the generality of these results should be considered strengths of the study. The use of multimorbidity as a predictor variable is of importance, because multimorbidity is becoming progressively common,40 and is an increasing burden for public health.41 On the other hand, there are some limitations that should be acknowledged. The cross-sectional design implies that no causal inferences can be made. The current study cannot answer the question whether multimorbidity changes self-rated health and life satisfaction, or vice versa. Although the large and representative sample of adults contributes to the generalization of the results, when doing so and when designing public health interventions the cultural and socio-demographic differences across European countries should be taken into account. Notwithstanding, all the analyses were adjusted to socio-demographic characteristics. Multimorbidity was based on self-reports, and only nine chronic diseases were considered, albeit the major ones.42 However, studies have suggested that self-reported chronic disease is fairly to largely accurate for most diseases.43 Physical activity was self-reported which could be subject to bias in terms of over- and under-estimation.44 Nonetheless, self-reported physical activity is a reliable method for epidemiologic studies, and is still the mainstay of surveillance studies.45 Considering that only nine chronic diseases were used to calculate multimorbidity, perhaps some participants classified as not suffering from multimorbidity could be included in this group if more diseases had been asked for. Nevertheless, the chronic diseases included in the study were the most prevalent ones. Finally, the European Social Survey had no data on whether individuals had mobility limitations or not. Therefore the analyses were not adjusted for mobility limitations. Conclusion Multimorbidity was negatively related to self-rated health and life satisfaction. Physical activity buffered these relationships, contributing to better self-rated health and life satisfaction, even among European adults with multimorbidity. These findings offer potential targets for future public health interventions. Promoting physical activity, and thus improving self-rated health and life satisfaction in order to enhance overall physical and mental health status, is suggested to be an important intervention strategy. Funding There is no funding to declare. Conflicts of interest The authors declare none conflict of interests. References 1 DeSalvo KB, Bloser N, Reynolds K et al.  . Mortality prediction with a single general self-rated health question. A meta-analysis. J Gen Intern Med  2006; 21( 3): 267– 75. Google Scholar CrossRef Search ADS PubMed  2 Mavaddat N, Valderas JM, van der Linde R et al.  . Association of self-rated health with multimorbidity, chronic disease and psychosocial factors in a large middle-aged and older cohort from general practice: a cross-sectional study. BMC Fam Pract  2014; 15: 185. Google Scholar CrossRef Search ADS PubMed  3 Jylha M, Volpato S, Guralnik JA. Self-rated health showed a graded association with frequently used biomarkers in a large population sample. J Clin Epidemiol  2006; 59( 5): 465– 71. Google Scholar CrossRef Search ADS PubMed  4 Jarczok MN, Kleber ME, Koenig J et al.  . Investigating the associations of self-rated health: heart rate variability is more strongly associated than inflammatory and other frequently used biomarkers in a cross sectional occupational sample. PLoS One  2015; 10( 2): e0117196. Google Scholar CrossRef Search ADS PubMed  5 Nes RB, Czajkowski NO, Roysamb E et al.  . Major depression and life satisfaction: a population-based twin study. J Affect Disord  2013; 144( 1–2): 51– 8. 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Google Scholar CrossRef Search ADS PubMed  10 WHO. Multimorbidity: Technical Series on Safer Primary Care . Geneva: World Health Organization, 2016. 11 Mukherjee B, Ou HT, Wang F et al.  . A new comorbidity index: the health-related quality of life comorbidity index. J Clin Epidemiol  2011; 64( 3): 309– 19. Google Scholar CrossRef Search ADS PubMed  12 Cimarras-Otal C, Calderon-Larranaga A, Poblador-Plou B et al.  . Association between physical activity, multimorbidity, self-rated health and functional limitation in the Spanish population. BMC Public Health  2014; 14: 1170. Google Scholar CrossRef Search ADS PubMed  13 Perruccio AV, Katz JN, Losina E. Health burden in chronic disease: multimorbidity is associated with self-rated health more than medical comorbidity alone. J Clin Epidemiol  2012; 65( 1): 100– 6. Google Scholar CrossRef Search ADS PubMed  14 Lukkala PS, Honkanen RJ, Rauma PH et al.  . Life satisfaction and morbidity among postmenopausal women. PLoS One  2016; 11( 1): e0147521. Google Scholar CrossRef Search ADS PubMed  15 Wister A, Kendig H, Mitchell B et al.  . Multimorbidity, health and aging in Canada and Australia: a tale of two countries. BMC Geriatr  2016; 16( 1): 163. Google Scholar CrossRef Search ADS PubMed  16 Mavaddat N, Parker RA, Sanderson S et al.  . Relationship of self-rated health with fatal and non-fatal outcomes in cardiovascular disease: a systematic review and meta-analysis. PLoS One  2014; 9( 7): e103509. Google Scholar CrossRef Search ADS PubMed  17 Feller S, Teucher B, Kaaks R et al.  . Life satisfaction and risk of chronic diseases in the European prospective investigation into cancer and nutrition (EPIC)-Germany study. PLoS One  2013; 8( 8): e73462. Google Scholar CrossRef Search ADS PubMed  18 Sodergren M, Sundquist J, Johansson SE et al.  . Physical activity, exercise and self-rated health: a population-based study from Sweden. BMC Public Health  2008; 8: 352. Google Scholar CrossRef Search ADS PubMed  19 Maher JP, Pincus AL, Ram N et al.  . Daily physical activity and life satisfaction across adulthood. Dev Psychol  2015; 51( 10): 1407– 19. Google Scholar CrossRef Search ADS PubMed  20 Ekelund U, Ward HA, Norat T et al.  . Physical activity and all-cause mortality across levels of overall and abdominal adiposity in European men and women: the European Prospective Investigation into Cancer and Nutrition Study (EPIC). Am J Clin Nutr  2015; 101( 3): 613– 21. Google Scholar CrossRef Search ADS PubMed  21 Wen CP, Wai JP, Tsai MK et al.  . Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet  2011; 378( 9798): 1244– 53. Google Scholar CrossRef Search ADS PubMed  22 O’Donovan G, Lee IM, Hamer M et al.  . Association of ‘weekend warrior’ and other leisure time physical activity patterns with risks for all-cause, cardiovascular disease, and cancer mortality. JAMA Intern Med  2017; 177( 3): 335– 42. Google Scholar CrossRef Search ADS PubMed  23 Schnaudt C, Weinhardt M, Fitzgerald R et al.  . The European Social Survey: contents, design, and research potential. Schmollers Jahrbuch  2014; 134( 4): 487– 506. Google Scholar CrossRef Search ADS   24 WHO. Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation . Geneva: World Health Organization, 2000. PubMed PubMed  25 Wanner M, Probst-Hensch N, Kriemler S et al.  . What physical activity surveillance needs: validity of a single-item questionnaire. Br J Sports Med  2014; 48( 21): 1570– 6. Google Scholar CrossRef Search ADS PubMed  26 Marques A, Peralta M, Martins J et al.  . Associations between physical activity and self-rated wellbeing in European adults: a population-based, cross-sectional study. Prev Med  2016; 91: 18– 23. Google Scholar CrossRef Search ADS PubMed  27 Marques A, Sarmento H, Martins J et al.  . Prevalence of physical activity in European adults—compliance with the World Health Organization’s physical activity guidelines. Prev Med  2015; 81: 333– 8. Google Scholar CrossRef Search ADS PubMed  28 Chandola T, Jenkinson C. Validating self-rated health in different ethnic groups. Ethn Health  2000; 5( 2): 151– 9. Google Scholar CrossRef Search ADS PubMed  29 Bopp M, Braun J, Gutzwiller F et al.  . Swiss National Cohort Study G. Health risk or resource? Gradual and independent association between self-rated health and mortality persists over 30 years. PLoS One  2012; 7( 2): e30795. Google Scholar CrossRef Search ADS PubMed  30 St John PD, Mackenzie C, Menec V. Does life satisfaction predict five-year mortality in community-living older adults? Aging Ment Health  2015; 19( 4): 363– 70. Google Scholar CrossRef Search ADS PubMed  31 Cheung F, Lucas RE. Assessing the validity of single-item life satisfaction measures: results from three large samples. Qual Life Res  2014; 23( 10): 2809– 18. Google Scholar CrossRef Search ADS PubMed  32 Daly MC, Duncan GJ, McDonough P et al.  . Optimal indicators of socioeconomic status for health research. Am J Public Health  2002; 92( 7): 1151– 7. Google Scholar CrossRef Search ADS PubMed  33 Bird Y, Lemstra M, Rogers M et al.  . The relationship between socioeconomic status/income and prevalence of diabetes and associated conditions: a cross-sectional population-based study in Saskatchewan, Canada. Int J Equity Health  2015; 14: 93. Google Scholar CrossRef Search ADS PubMed  34 Hu SX, Lei WI, Chao KK et al.  . Common chronic health problems and life satisfaction among Macau elderly people. Int J Nurs Sci  2016; 3( 4): 367– 70. 35 Schuz B, Wurm S, Warner LM et al.  . Health and subjective well-being in later adulthood: different health states-different needs? Appl Psychol Health Well Being  2009; 1( 1): 23– 45. 36 Diener E. Assessing subjective well-being—progress and opportunities. Soc Indic Res  1994; 31( 2): 103– 57. Google Scholar CrossRef Search ADS   37 Lee HY, Kim J, Merighi JR. Physical activity and self-rated health status among older adult cancer survivors: does intensity of activity play a role? Oncol Nurs Forum  2015; 42( 6): 614– 24. Google Scholar CrossRef Search ADS PubMed  38 Mulroy SJ, Hatchett PE, Eberly VJ et al.  . Objective and self-reported physical activity measures and their association with depression and satisfaction with life in persons with spinal cord injury. Arch Phys Med Rehabil  2016; 97( 10): 1714– 20. Google Scholar CrossRef Search ADS PubMed  39 Trachte F, Geyer S, Sperlich S. Impact of physical activity on self-rated health in older people: do the effects vary by socioeconomic status? J Public Health (Bangkok)  2016; 38( 4): 754– 9. 40 Barnett K, Mercer SW, Norbury M et al.  . Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet  2012; 380( 9836): 37– 43. Google Scholar CrossRef Search ADS PubMed  41 Pefoyo AJ, Bronskill SE, Gruneir A et al.  . The increasing burden and complexity of multimorbidity. BMC Public Health  2015; 15: 415. Google Scholar CrossRef Search ADS PubMed  42 WHO. Global Status Report on Noncommunicable Diseases 2014 . Geneva: World Health Organization, 2014. 43 Hansen H, Schafer I, Schon G et al.  . Agreement between self-reported and general practitioner-reported chronic conditions among multimorbid patients in primary care—results of the MultiCare Cohort Study. BMC Fam Pract  2014; 15: 39. Google Scholar CrossRef Search ADS PubMed  44 Marques A, Martins J, Ramos M et al.  . Perception and reality—Portuguese adults’ awareness of active lifestyle. Eur J Sports Sci  2014; 14( 5): 468– 74. Google Scholar CrossRef Search ADS   45 Pedisic Z, Bauman A. Accelerometer-based measures in physical activity surveillance: current practices and issues. Br J Sports Med  2015; 49( 4): 219– 23. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Public Health Oxford University Press

Physical activity buffers the negative relationship between multimorbidity, self-rated health and life satisfaction

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Abstract

Abstract Background This study aimed to examine the relationship between multimorbidity, self-rated health and life satisfaction, and to test the moderating effect of physical activity on the relationship between multimorbidity, self-rated health and life satisfaction. Methods This is a cross-sectional study based on data from the European Social Survey 2014. Participants were 25 713 adults (12 830 men), aged 18–64 years old, from 18 European countries and Israel. Self-reported information regarding chronic diseases, health perception, life satisfaction and physical activity was collected through interview. Multimorbidity was defined as the co-occurrence of ≥ 2 chronic diseases. Linear regression models were used to estimate the effects of multimorbidity, physical activity and the interaction effect of multimorbidity × physical activity on self-rated health and life satisfaction. Results Multimorbidity was negatively related to self-rated health (d = 0.03) and life satisfaction (d = 0.03). Physical activity was positively related to self-rated health and life satisfaction. There was a significant interaction effect between multimorbidity and physical activity with regard to self-rated health (β = 0.01, P < 0.001) and life satisfaction (β = 0.04, P < 0.001). Conclusions Physical activity buffered the negative relationship between multimorbidity, self-rated health and life satisfaction; contributing to better self-rated health and life satisfaction. chronic diseases, European, exercise Introduction Self-rated health reproduces the subjective experience of health, and it has been shown to be a significant predictor of morbidity and mortality,1,2 related to several biomarkers such as blood pressure, blood levels of albumin, white blood cell count, haemoglobin, HDL cholesterol, serum creatinine and a barometer of physiological states.1,3,4 Life satisfaction can be defined as a general evaluation of an individual’s personal life, and has been related to several mental adverse health outcomes such as depression and psychiatric problems,5 along with somatic disability and mortality.6 The association between self-rated health and life satisfaction with health outcomes enables a conceptual understanding of the health from people’s perspective. Multimorbidity, defined as the co-occurrence of two or more chronic diseases7 is a consequence of the aging of the population; it results from both an increase in the prevalence of chronic diseases,8 and the number of diseases from which a patient suffers.9 Multimorbidity influences health perception and subjective wellbeing perhaps because of its physical and psychological consequences.10 Chronic diseases affect people ability to manage their daily functioning, and those people usually experienced a decline on their quality of life.11 Thus, the presence of multimorbidity is negatively associated with both self-rated health2,12,13 and life satisfaction.14 Most studies relating self-rated health or life satisfaction to chronic diseases focus on specific populations or specific diseases or group of diseases. For example, among middle-aged and older adults, poorer self-rated health is strongly associated with single chronic diseases, particularly cardiovascular diseases, multimorbidity and poor psychosocial function,2,13,15 while life satisfaction is inversely associated with multimorbidity.14,15 Similarly, cardiovascular mortality in the general populations with and without prior cardiovascular disease is associated with poor self-rated health.16 Also, increased risk of specific diseases, such as cancer, stroke and type 2 diabetes mellitus are associated with lower life satisfaction.17 In opposition to multimorbidity, physical activity has been shown to have a significant and positive association with self-rated health and life satisfaction.18,19 Furthermore, physical activity can reduce chronic diseases and the risk of disease progression,20–22 and it is inversely associated with multimorbidity.12 However, the possibility for physical activity moderating the relationship between multimorbidity and self-rated health and life satisfaction has yet to be explored. It is thus expected that, by having a positive effect on self-rated health and life satisfaction, and by having a protective health effect against chronic diseases, physical activity might moderate the relationship between multimorbidity and self-rated health and life satisfaction. Therefore, the purpose of this study was two-pronged: (i) to examine the relationship between multimorbidity, self-rated health and life satisfaction; and (ii) to test the moderating effect of physical activity on the relationship between multimorbidity, self-rated health and life satisfaction. Methods Study design and participants The present study was based on the seventh wave of the European Social Survey, 2014, which included 20 European countries (Austria, Belgium, Switzerland, Czech Republic, Germany, Denmark, Estonia, Spain, Finland, France, Hungary, Ireland, Lithuania, Netherlands, Norway, Poland, Portugal, Sweden, Slovenia, UK) and Israel. The European Social Survey is a survey that has been conducted every two years to measure the attitudes, beliefs, and behaviours of European adults. The survey uses representative samples among countries. Participants were sampled by postal code, address files, social security registry data, population registers and/or telephone books. The information was collected in each country, using a questionnaire filled-in through an hour-long face-to-face interview. The questionnaire was translated, by language experts, into the language spoken in each of the participating countries. Further details about the European Social Survey are available elsewhere.23 The study protocol subscribes to the Declaration on Professional Ethics of the International Statistical Institute. Probability sampling from residents aged 15 years and older was applied (excluding the homeless, and institutionalized people), comprising 40 185 participants. For the present study participants under 18 years and above 64 years of age were excluded (n = 9851), because the focus was on the adult population. Participants from Czech Republic and Estonia, and others that also did not report information on chronic diseases and were therefore excluded (n = 4255). Respondents without information in more than two socio-demographic variables were also excluded (n = 366). These restrictions resulted in a sample of 25 713 participants (12 830 men and 12 883 women) (Fig. 1). Fig. 1 View largeDownload slide Flow chart diagram of participants. Fig. 1 View largeDownload slide Flow chart diagram of participants. Measures Chronic diseases Most of the chronic diseases (heart or circulation problems, high blood pressure, diabetes, stomach or digestion problems, breathing problems, allergies, headaches and cancer) were assessed by asking participants to indicate whether they currently have, or had, chronic diseases (yes/no) in the last 12 months. For obesity, body mass index (BMI) was calculated from self-reported height and weight (kg/m2). Body mass index categories were calculated in accordance with the WHO guidelines24 and dichotomized into non-obese (<30.0 kg/m2) and obese (≥30 kg/m2). Multimorbidity was defined as the co-occurrence of two or more of the nine aforementioned diseases.7 Physical activity Physical activity was assessed with a single item asking, ‘On how many of the last 7 days did you walk quickly, do sports or other physical activity for 30 min or longer?’ Although physical activity was assessed with a single item, there is evidence in previous studies that a single question is an acceptable alternative;25 this approach was used previously with European Social Survey data.26,27 Self-rated health Self-rated health was assessed with a single item question. Participants were asked, ‘How is your health in general?’ The response options were very bad, bad, fair, good or very good. This single item question has been widely validated in epidemiological studies.26–28 Previous studies have found a relationship between levels of self-rated health and adverse health outcomes, indicating its validity.1,29 Life satisfaction Life satisfaction was assessed with the item, ‘How satisfied are you with your life as a whole nowadays?’ Responses were indicated using a scale ranging from 0 ‘extremely dissatisfied’ to 10 ‘extremely satisfied’. Studies have shown that life satisfaction is associated to mental health outcomes,5 can predict mortality,30 and that one single item is a robust measure capable of reliably estimating life satisfaction.31 Covariates Participants reported sex, age and years of full-time education. Respondents were asked to describe whether they live with or without a husband/wife/partner, and the legal situation. Response options were dichotomized into live with, or without, a partner. Household income was determined based on decile. It is a socioeconomic indicator as important as or more important than education and occupation, because is indicative of a standard of living.32 Household income also shows relationship with health status.33 Using household income decile information, first to third decile, fourth to seventh decile and 8th to 10th were grouped to create three groups. Participants were asked to report their occupation. To determine the living place, those who indicated that they lived in a big city, the suburbs or the outskirts of big city were grouped into a new category named urban areas; those who responded that they lived in the country, a village or a home in countryside were grouped into rural areas. Participants answered if they lived with or without children at home, along with the number of people living regularly as a member of the household. Data analysis Descriptive statistics were calculated for the entire sample (means, standard deviation and percentages). The relationship between the presence or absence of chronic diseases and multimorbidity, according self-rated health and life satisfaction, was tested by ANCOVA. Linear regression models were used to estimate the principal effects of multimorbidity, physical activity, and the interaction effect of multimorbidity × physical activity on self-rated health and life satisfaction. Multimorbidity enters the models as a dummy variable, and physical activity as a continuous variable. To calculate the variable that expresses the interaction effect (multimorbidity × physical activity), physical activity was transformed using grand mean centring. The grand mean centring was calculated by taking each value of physical activity (times/week) and subtracting from it the mean of the total sample. Physical activity grand mean centring was then multiplied by multimorbidity to have a variable to test the moderation effect (multimorbidity × physical activity). Analyses were not stratified by sex or age because an interaction effect between sex and age on multimorbidity was not verified. For ANCOVA and linear regression, the analysis were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. Statistical analysis was performed using IBM SPSS Statistics v.24.0. The significance level was set at P < 0.05. Results Table 1 presents the characteristics of the study sample. The most prevalent chronic diseases were: high blood pressure (17.5%), stomach or digestion problems (16.2%) and obesity (15.5%). Almost 30% of the participants had multimorbidity (≥2 chronic diseases). From 1 to 5, the mean value for self-rated health was 3.8 ± 0.9, and from 0 to 10, the mean of life satisfaction was 7.2 ± 2.2. Physical activity was practiced, on average, 3.2 ± 2.6 times/week. Table 1 Participants’ characteristics for total sample and stratified by sex in 2014   Total (n = 25713)  % or M ± SD  Sex     Male  48.7   Female  51.3  Age  47.4 ± 18.3  Education (years)  12.5 ± 3.9  Marital status     Live with partner  62.0   Live without partner  38.0  Household income     Low (first to third decile)  30.1   Middle (fourth to seventh decile)  43.1   High (8th to 10th decile)  26.8  Occupation     Employed  61.9   Unemployed  6.8   Student  8.7   Retired  22.5  Living place     Urban area  61.1   Rural area  38.9  Children     Do not have children  60.8   Have children  39.2   Household members  2.8 ± 1.4  Chronic diseases (last 12 month)     Heart or circulation problems  9.8   High blood pressure  17.5   Diabetes  4.9   Obesity  15.5   Stomach/digestion problems  16.2   Breathing problems  8.8   Allergies  12.4   Headaches  14.4   Cancer  10.3  Multimorbidity     No  70.3   Yes  29.7  Self-rated health  3.8 ± 0.9  Life satisfaction  7.2 ± 2.2  Physical activity (times/week)  3.2 ± 2.6    Total (n = 25713)  % or M ± SD  Sex     Male  48.7   Female  51.3  Age  47.4 ± 18.3  Education (years)  12.5 ± 3.9  Marital status     Live with partner  62.0   Live without partner  38.0  Household income     Low (first to third decile)  30.1   Middle (fourth to seventh decile)  43.1   High (8th to 10th decile)  26.8  Occupation     Employed  61.9   Unemployed  6.8   Student  8.7   Retired  22.5  Living place     Urban area  61.1   Rural area  38.9  Children     Do not have children  60.8   Have children  39.2   Household members  2.8 ± 1.4  Chronic diseases (last 12 month)     Heart or circulation problems  9.8   High blood pressure  17.5   Diabetes  4.9   Obesity  15.5   Stomach/digestion problems  16.2   Breathing problems  8.8   Allergies  12.4   Headaches  14.4   Cancer  10.3  Multimorbidity     No  70.3   Yes  29.7  Self-rated health  3.8 ± 0.9  Life satisfaction  7.2 ± 2.2  Physical activity (times/week)  3.2 ± 2.6  Table 1 Participants’ characteristics for total sample and stratified by sex in 2014   Total (n = 25713)  % or M ± SD  Sex     Male  48.7   Female  51.3  Age  47.4 ± 18.3  Education (years)  12.5 ± 3.9  Marital status     Live with partner  62.0   Live without partner  38.0  Household income     Low (first to third decile)  30.1   Middle (fourth to seventh decile)  43.1   High (8th to 10th decile)  26.8  Occupation     Employed  61.9   Unemployed  6.8   Student  8.7   Retired  22.5  Living place     Urban area  61.1   Rural area  38.9  Children     Do not have children  60.8   Have children  39.2   Household members  2.8 ± 1.4  Chronic diseases (last 12 month)     Heart or circulation problems  9.8   High blood pressure  17.5   Diabetes  4.9   Obesity  15.5   Stomach/digestion problems  16.2   Breathing problems  8.8   Allergies  12.4   Headaches  14.4   Cancer  10.3  Multimorbidity     No  70.3   Yes  29.7  Self-rated health  3.8 ± 0.9  Life satisfaction  7.2 ± 2.2  Physical activity (times/week)  3.2 ± 2.6    Total (n = 25713)  % or M ± SD  Sex     Male  48.7   Female  51.3  Age  47.4 ± 18.3  Education (years)  12.5 ± 3.9  Marital status     Live with partner  62.0   Live without partner  38.0  Household income     Low (first to third decile)  30.1   Middle (fourth to seventh decile)  43.1   High (8th to 10th decile)  26.8  Occupation     Employed  61.9   Unemployed  6.8   Student  8.7   Retired  22.5  Living place     Urban area  61.1   Rural area  38.9  Children     Do not have children  60.8   Have children  39.2   Household members  2.8 ± 1.4  Chronic diseases (last 12 month)     Heart or circulation problems  9.8   High blood pressure  17.5   Diabetes  4.9   Obesity  15.5   Stomach/digestion problems  16.2   Breathing problems  8.8   Allergies  12.4   Headaches  14.4   Cancer  10.3  Multimorbidity     No  70.3   Yes  29.7  Self-rated health  3.8 ± 0.9  Life satisfaction  7.2 ± 2.2  Physical activity (times/week)  3.2 ± 2.6  Results of the relationship between the presence or absence of chronic diseases and multimorbidity, according to self-rated health and life satisfaction, are presented in Table 2. For each chronic disease, participants who did not report having the disease had significantly better self-rated health than those who reported having the disease. Similar results were observed for life satisfaction. Those who did not report the presence of the disease had better life satisfaction, with the exception of allergies. Although the effect size was small, multimorbidity was also significantly related to self-rated health and life satisfaction. Those without multimorbidity had better self-rated health (4.08 ± 0.77 versus 3.40 ± 0.89, F(1) = 2399.93, P < 0.001) and better life satisfaction (7.37 ± 20.00 versus 6.86 ± 2.30, F(1) = 243.35, P < 0.001). Tables 2 Relationship between, chronic diseases and the presence of multimorbidity and self-rated health of European adults in 2014 Chronic diseases and multimorbidity  Self-rated health  Life satisfaction  Mean ± SD  P  Mean ± SD  P  Heart or circulation problems    <0.001    <0.001   No  3.96 ± 0.81    7.28 ± 2.07     Yes  3.08 ± 0.90    6.62 ± 2.39    High blood pressure    <0.001    <0.001   No  3.99 ± 0.82    7.29 ± 2.05     Yes  3.35 ± 0.87    6.89 ± 2.33    Diabetes    <0.001    <0.001   No  3.92 ± 0.84    7.24 ± 2.09     Yes  3.09 ± 0.89    6.82 ± 2.38    Obesity    <0.001    <0.001   No  3.95 ± 0.84    7.28 ± 2.07     Yes  3.49 ± 0.87    6.90 ± 2.29    Stomach/digestion problems    <0.001    <0.001   No  3.94 ± 0.84    7.27 ± 2.08     Yes  3.59 ± 0.91    6.97 ± 2.21    Breathing problems    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.34 ± 0.96    6.88 ± 2.33    Allergies    <0.001    0.964   No  3.89 ± 0.86    7.21 ± 2.11     Yes  3.81 ± 0.87    7.27 ± 2.09    Headaches    <0.001    <0.001   No  3.92 ± 0.84    7.30 ± 2.05     Yes  3.64 ± 0.93    6.77 ± 2.37    Cancer    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.43 ± 0.95    6.93 ± 2.33    Multimorbidity    <0.001    <0.001   No  4.08 ± 0.77    7.37 ± 2.00     Yes  3.40 ± 0.89    6.86 ± 2.30    Chronic diseases and multimorbidity  Self-rated health  Life satisfaction  Mean ± SD  P  Mean ± SD  P  Heart or circulation problems    <0.001    <0.001   No  3.96 ± 0.81    7.28 ± 2.07     Yes  3.08 ± 0.90    6.62 ± 2.39    High blood pressure    <0.001    <0.001   No  3.99 ± 0.82    7.29 ± 2.05     Yes  3.35 ± 0.87    6.89 ± 2.33    Diabetes    <0.001    <0.001   No  3.92 ± 0.84    7.24 ± 2.09     Yes  3.09 ± 0.89    6.82 ± 2.38    Obesity    <0.001    <0.001   No  3.95 ± 0.84    7.28 ± 2.07     Yes  3.49 ± 0.87    6.90 ± 2.29    Stomach/digestion problems    <0.001    <0.001   No  3.94 ± 0.84    7.27 ± 2.08     Yes  3.59 ± 0.91    6.97 ± 2.21    Breathing problems    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.34 ± 0.96    6.88 ± 2.33    Allergies    <0.001    0.964   No  3.89 ± 0.86    7.21 ± 2.11     Yes  3.81 ± 0.87    7.27 ± 2.09    Headaches    <0.001    <0.001   No  3.92 ± 0.84    7.30 ± 2.05     Yes  3.64 ± 0.93    6.77 ± 2.37    Cancer    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.43 ± 0.95    6.93 ± 2.33    Multimorbidity    <0.001    <0.001   No  4.08 ± 0.77    7.37 ± 2.00     Yes  3.40 ± 0.89    6.86 ± 2.30    Tested by ANCOVA. SD, standard deviation. Analysis were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. Tables 2 Relationship between, chronic diseases and the presence of multimorbidity and self-rated health of European adults in 2014 Chronic diseases and multimorbidity  Self-rated health  Life satisfaction  Mean ± SD  P  Mean ± SD  P  Heart or circulation problems    <0.001    <0.001   No  3.96 ± 0.81    7.28 ± 2.07     Yes  3.08 ± 0.90    6.62 ± 2.39    High blood pressure    <0.001    <0.001   No  3.99 ± 0.82    7.29 ± 2.05     Yes  3.35 ± 0.87    6.89 ± 2.33    Diabetes    <0.001    <0.001   No  3.92 ± 0.84    7.24 ± 2.09     Yes  3.09 ± 0.89    6.82 ± 2.38    Obesity    <0.001    <0.001   No  3.95 ± 0.84    7.28 ± 2.07     Yes  3.49 ± 0.87    6.90 ± 2.29    Stomach/digestion problems    <0.001    <0.001   No  3.94 ± 0.84    7.27 ± 2.08     Yes  3.59 ± 0.91    6.97 ± 2.21    Breathing problems    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.34 ± 0.96    6.88 ± 2.33    Allergies    <0.001    0.964   No  3.89 ± 0.86    7.21 ± 2.11     Yes  3.81 ± 0.87    7.27 ± 2.09    Headaches    <0.001    <0.001   No  3.92 ± 0.84    7.30 ± 2.05     Yes  3.64 ± 0.93    6.77 ± 2.37    Cancer    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.43 ± 0.95    6.93 ± 2.33    Multimorbidity    <0.001    <0.001   No  4.08 ± 0.77    7.37 ± 2.00     Yes  3.40 ± 0.89    6.86 ± 2.30    Chronic diseases and multimorbidity  Self-rated health  Life satisfaction  Mean ± SD  P  Mean ± SD  P  Heart or circulation problems    <0.001    <0.001   No  3.96 ± 0.81    7.28 ± 2.07     Yes  3.08 ± 0.90    6.62 ± 2.39    High blood pressure    <0.001    <0.001   No  3.99 ± 0.82    7.29 ± 2.05     Yes  3.35 ± 0.87    6.89 ± 2.33    Diabetes    <0.001    <0.001   No  3.92 ± 0.84    7.24 ± 2.09     Yes  3.09 ± 0.89    6.82 ± 2.38    Obesity    <0.001    <0.001   No  3.95 ± 0.84    7.28 ± 2.07     Yes  3.49 ± 0.87    6.90 ± 2.29    Stomach/digestion problems    <0.001    <0.001   No  3.94 ± 0.84    7.27 ± 2.08     Yes  3.59 ± 0.91    6.97 ± 2.21    Breathing problems    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.34 ± 0.96    6.88 ± 2.33    Allergies    <0.001    0.964   No  3.89 ± 0.86    7.21 ± 2.11     Yes  3.81 ± 0.87    7.27 ± 2.09    Headaches    <0.001    <0.001   No  3.92 ± 0.84    7.30 ± 2.05     Yes  3.64 ± 0.93    6.77 ± 2.37    Cancer    <0.001    <0.001   No  3.93 ± 0.84    7.25 ± 2.08     Yes  3.43 ± 0.95    6.93 ± 2.33    Multimorbidity    <0.001    <0.001   No  4.08 ± 0.77    7.37 ± 2.00     Yes  3.40 ± 0.89    6.86 ± 2.30    Tested by ANCOVA. SD, standard deviation. Analysis were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. Table 3 depicts the results for linear regression analysis. Unadjusted analysis demonstrated that multimorbidity was negatively related to self-rated health and life satisfaction. When accounting for other social-demographic confounders, multimorbidity remained negatively related with self-rated health (β = −0.52, 95% CI: −0.054 to −0.50, P < 0.001) and life satisfaction (β = −0.43, 95% CI: −0.49 to −0.37, P < 0.001). In turn, in the unadjusted and adjusted model, physical activity was positively related to self-rated health (β = 0.04, 95% CI: 0.04–0.05, P < 0.001) and life satisfaction (β = 0.07, 95% CI: 0.05–0.08, P < 0.001). There was a significant interaction effect between multimorbidity and physical activity with regard to self-rated health (β = 0.01, 95% CI: 0.01–0.02, P < 0.001) and life satisfaction (β = 0.04, 95% CI: 0.02–0.06, P < 0.001), portraying physical activity as a moderator of the relationship between multimorbidity and these variables. Table 3 Main and interaction effect of multimorbidity and physical activity on self-rated health and life satisfaction of European adults in 2014   Self-rated health  Life satisfaction  Model 1  Model 2  Model 1  Model 2  β (95% CI)  β (95% CI)  β (95% CI)  β (95% CI)  Multimorbiditya  −0.60 (−0.68, −0.64)*  −0.52 (−0.54, −0.50)*  −0.48 (−0.54, −0.42)*  −0.43 (−0.49, −0.37)*  Physical activity  0.05 (0.04, 0.05)*  0.04 (0.04, 0.05)*  0.07 (0.06, 0.09)*  0.07 (0.05, 0.08)*  Multimorbidity × physical activityb  0.02 (0.02, 0.03)*  0.01 (0.00, 0.02)*  0.04 (0.02, 0.06)*  0.04 (0.02, 0.06)*    Self-rated health  Life satisfaction  Model 1  Model 2  Model 1  Model 2  β (95% CI)  β (95% CI)  β (95% CI)  β (95% CI)  Multimorbiditya  −0.60 (−0.68, −0.64)*  −0.52 (−0.54, −0.50)*  −0.48 (−0.54, −0.42)*  −0.43 (−0.49, −0.37)*  Physical activity  0.05 (0.04, 0.05)*  0.04 (0.04, 0.05)*  0.07 (0.06, 0.09)*  0.07 (0.05, 0.08)*  Multimorbidity × physical activityb  0.02 (0.02, 0.03)*  0.01 (0.00, 0.02)*  0.04 (0.02, 0.06)*  0.04 (0.02, 0.06)*  CI, confidence interval. Model 1: Unadjusted analyses. Model 2: Analyses were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. *P < 0.001. aMultimorbidity enter into the model as a dummy variable. bPhysical activity was transformed using grand mean centring. The grand mean centring was achieved by taking each value of physical activity (times/week) and subtracting from it the mean of the total sample. Table 3 Main and interaction effect of multimorbidity and physical activity on self-rated health and life satisfaction of European adults in 2014   Self-rated health  Life satisfaction  Model 1  Model 2  Model 1  Model 2  β (95% CI)  β (95% CI)  β (95% CI)  β (95% CI)  Multimorbiditya  −0.60 (−0.68, −0.64)*  −0.52 (−0.54, −0.50)*  −0.48 (−0.54, −0.42)*  −0.43 (−0.49, −0.37)*  Physical activity  0.05 (0.04, 0.05)*  0.04 (0.04, 0.05)*  0.07 (0.06, 0.09)*  0.07 (0.05, 0.08)*  Multimorbidity × physical activityb  0.02 (0.02, 0.03)*  0.01 (0.00, 0.02)*  0.04 (0.02, 0.06)*  0.04 (0.02, 0.06)*    Self-rated health  Life satisfaction  Model 1  Model 2  Model 1  Model 2  β (95% CI)  β (95% CI)  β (95% CI)  β (95% CI)  Multimorbiditya  −0.60 (−0.68, −0.64)*  −0.52 (−0.54, −0.50)*  −0.48 (−0.54, −0.42)*  −0.43 (−0.49, −0.37)*  Physical activity  0.05 (0.04, 0.05)*  0.04 (0.04, 0.05)*  0.07 (0.06, 0.09)*  0.07 (0.05, 0.08)*  Multimorbidity × physical activityb  0.02 (0.02, 0.03)*  0.01 (0.00, 0.02)*  0.04 (0.02, 0.06)*  0.04 (0.02, 0.06)*  CI, confidence interval. Model 1: Unadjusted analyses. Model 2: Analyses were adjusted for sex, age, education, marital status, household income, occupation, living place, having children and household members. *P < 0.001. aMultimorbidity enter into the model as a dummy variable. bPhysical activity was transformed using grand mean centring. The grand mean centring was achieved by taking each value of physical activity (times/week) and subtracting from it the mean of the total sample. Discussion Main finding of this study This study investigated the relationship between multimorbidity, self-rated health and life satisfaction, as well as the moderating effect of physical activity on the relationship between multimorbidity, self-rated health and life satisfaction. Multimorbidity was negatively related to self-rated health and life satisfaction. On the other hand, physical activity was positively related to self-rated health and life satisfaction, thereby buffering the effect of multimorbidity on self-rated health and life satisfaction. In sum, physical activity moderates the effect of multimorbidity on self-rated health and life satisfaction. What is already known on this topic Subjective health expressed, as self-rated health, is associated with single chronic diseases and with multimorbidity. Those with chronic diseases and multimorbidity had lower self-rated health. Results from this study are in line with previous findings in literature.2,12,13 These results corroborate that self-rated health is a proxy of health biomarkers,1 and a barometer of physiologic states,3 because it is sensitive to the presence of chronic diseases or multimorbidity. Self-rated health is correlated with socio-demographic factors.2,13 However, adjusting the analysis of the relationship between multimorbidity and self-rated health, for socio-demographic factors, did not significantly modify the association. This reinforces the strong relationship between the two variables, independently of socio-demographic factors. Literature shows that chronic diseases and multimorbidity are associated with lower life satisfaction.14,34 This was observed, in the present study, for all particular chronic diseases (except for allergies) and for multimorbidity, confirming that the presence of these diseases, or a cluster of these diseases, has a negative effect on subjective wellbeing. The observed negative relationship supports the fact that life satisfaction depends on the individual’s health status.35 This finding depicts life satisfaction as an important health outcome used to characterize the population’s health and wellbeing.5,36 Regarding the relationship between physical activity, self-rated health and life satisfaction, this study’s results provide evidence that regular physical activity is associated with better self-rated health and life satisfaction among adults. Previous studies have also demonstrated the positive relationship between these variables.18,19 The impact of physical activity on self-rated health and life satisfaction is observed even among people with chronic diseases,37,38 and exists across the spectra of both age and socioeconomic status.19,39 What this study adds The identification of physical activity as a mediator between multimorbidity, self-rated health and life satisfaction is of importance because this moderation effect changes the slope of the negative relationship (i.e. physically active people with multimorbidity can have better self-rated health and life satisfaction than their non-active peers). Considering that self-rated health and life satisfaction are directly linked to mortality, health biomarkers and mental health outcomes,1,2,5 improving self-rated health and life satisfaction can result in improving general health status. This study’s results offer potential targets for future public health interventions. In order to enhance overall physical and mental health status, both of which are strongly linked to self-rated health and life satisfaction, physical activity should be promoted. For those who are not physically active, even a minimum amount of physical activity has a protective health effect against chronic diseases and mortality.20–22 Limitations of this study A number of strengths and limitations should be kept in mind. The main strength of this study was the European Social Survey database, which includes a large and representative sample of adults from several European countries, as well as socio-demographic characteristics and numerous chronic diseases of the study sample. In view of the large sample and the heterogeneity of the participants, the generality of these results should be considered strengths of the study. The use of multimorbidity as a predictor variable is of importance, because multimorbidity is becoming progressively common,40 and is an increasing burden for public health.41 On the other hand, there are some limitations that should be acknowledged. The cross-sectional design implies that no causal inferences can be made. The current study cannot answer the question whether multimorbidity changes self-rated health and life satisfaction, or vice versa. Although the large and representative sample of adults contributes to the generalization of the results, when doing so and when designing public health interventions the cultural and socio-demographic differences across European countries should be taken into account. Notwithstanding, all the analyses were adjusted to socio-demographic characteristics. Multimorbidity was based on self-reports, and only nine chronic diseases were considered, albeit the major ones.42 However, studies have suggested that self-reported chronic disease is fairly to largely accurate for most diseases.43 Physical activity was self-reported which could be subject to bias in terms of over- and under-estimation.44 Nonetheless, self-reported physical activity is a reliable method for epidemiologic studies, and is still the mainstay of surveillance studies.45 Considering that only nine chronic diseases were used to calculate multimorbidity, perhaps some participants classified as not suffering from multimorbidity could be included in this group if more diseases had been asked for. Nevertheless, the chronic diseases included in the study were the most prevalent ones. Finally, the European Social Survey had no data on whether individuals had mobility limitations or not. Therefore the analyses were not adjusted for mobility limitations. Conclusion Multimorbidity was negatively related to self-rated health and life satisfaction. Physical activity buffered these relationships, contributing to better self-rated health and life satisfaction, even among European adults with multimorbidity. These findings offer potential targets for future public health interventions. Promoting physical activity, and thus improving self-rated health and life satisfaction in order to enhance overall physical and mental health status, is suggested to be an important intervention strategy. Funding There is no funding to declare. Conflicts of interest The authors declare none conflict of interests. References 1 DeSalvo KB, Bloser N, Reynolds K et al.  . Mortality prediction with a single general self-rated health question. A meta-analysis. J Gen Intern Med  2006; 21( 3): 267– 75. Google Scholar CrossRef Search ADS PubMed  2 Mavaddat N, Valderas JM, van der Linde R et al.  . 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Journal of Public HealthOxford University Press

Published: Jan 27, 2018

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