Association of domain-specific physical activity with depression: findings from NHANES 2007-2018

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Association of domain-specific physical activity with depression: findings from NHANES 2007-2018

https://doi.org/10.21203/rs.3.rs-1655320/v1

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It remains unclear whether all PA domains (e.g., occupation related [OPA], transportation related [TPA] and leisure-time [LTPA]) have equivalent beneficial effects. We aimed to investigate associations of OPA, TPA and LTPA with depression in adults. We included and analyzed 31221 participants (aged ≥18 years) from cross-sectional survey of 2007-2018 U.S. National Health and Nutrition Examination Survey (NHANES). The PA domains were assessed by self-reported questionnaire and categorized based on the PA Guidelines. Depressive symptoms were measured by the 9-item Patient Health Questionnaire. Participants achieving PA guidelines (≥150 min/week) were 26% (Odd ratio [OR] 0.74, 95% confidence interval [CI] 0.68-0.80) and 43% (OR 0.57, 95% CI 0.51-0.62) less likely to have depression depending on total PA and LTPA, respectively; while OPA or TPA was not demonstrated lower risks of depression. LTPA at levels of 1-149, 150-299 and ≥300 min/week was associated 31% (OR 0.69, 95% CI 0.60-0.78), 43% (OR 0.57, 95% CI 0.49-0.67) and 51% (OR 0.49, 95% CI 0.43-0.55) lower odds of depression, respectively. LTPA, but not OPA or TPA, at any amount, was associated with lower risk of depression, suggesting significant mental health would benefit from increased PA, even at levels below the recommendation.

Domain-specific Physical activity

Depression

Epidemiology

Depression is a common mental disorder that affecting approximately 322 million people in general population¹. The Global Burden of Disease Study reported that depression is the leading cause of mental health-related disability burden worldwide². Additionally, depression is still on the rise and associates with all-cause and cardiovascular disease cause mortality among adults^3-5. Therefore, the effective intervention strategy is vital for prevention or treatment of depression^6,7. Emerging researches has linked depression to lifestyles, such as physical activity (PA), diet, smoking and sleep^8-10. Among these potentially beneficial lifestyles, PA was demonstrated to be a low-risk augmentation therapy for depression¹¹. For example, prospective cohort studies reported that increased PA is associated with reduced depression risk^12-14 Mendelian randomization studies also demonstrated a potential protective role of PA on depression^15,16.

PA is a complex behavior that consists of different domains, including occupation related PA (OPA), transportation related PA (TPA) and leisure-time PA (LTPA). Different PA domains may contribute to healthy through different ways in lifespan^17-20. However, most researches paid their attentions on the associations of total PA or LTPA with depression, little evidences exist investigating whether the same health-enhancing effects are observed across different PA domains in general population^12,13. Pearce et.al found an inverse curvilinear dose-response association between PA and depression in meta-analysis of 15 prospective cohort studies¹². Additionally, a recent meta-analysis of 111 prospective cohort studies reported that customary and increasing levels of LTPA are inversely associated with incident depression among adults regardless of global region, gender, age or follow-up period¹³. Therefore, it remains unclear whether all domains of PA (e.g., OPA, TPA and LTPA) have equivalent beneficial effects on depression.

This study responds to this knowledge gap by investigating associations between different PA domains (including OPA, TPA, LTPA and total PA) and risk of depression in adults across a wide age spectrum. We hypothesized that each domain of PA would have inequality beneficial effects on depression, and examined whether the association between the effective domain of PA and depression differs by age, gender, body mass index, race, economic level, marital and smoke status. Additionally, we assessed the dose-response association between the effective domain of PA and depression.

Study population

The National Health and Nutrition Examination Survey (NHANES) is a nationally representative cross-sectional survey of civilian, non-institutionalized persons living in the U.S.²¹. We used data from the NHANES 2007-2008, 2009-2010, 2011-2012, 2013-2014, 2015-2016, and 2017-2018 (Figure 1). Participants aged 20 years or older with complete 9-item Patient Health Questionnaire (PHQ-9) and self-reported questionnaire of PA were included. The final sample included 31221 individuals. Due to the data in our study was publicly available data and was a secondary analysis, no additional ethical review was necessary.

Physical Activity (PA)

PA was self-reported by participants using the Global Physical Activity Questionnaire²², which assessed three PA domains: OPA, TPA and LTPA. The questionnaire about frequency (time per week), duration (minutes per time) and intensity (vigorous or moderate) of PA in one typical week was measured for OPA and LTPA. Minutes of the vigorous-intensity of PA were doubled and added to minutes of the moderate-intensity for OPA and LTPA¹⁹. The total PA was defined as the sum of the OPA, TPA, and LTPA. PA was categorized according to the 2018 PA Guidelines, which recommending adults should engaged in ≥150 minutes per week of moderate-intensity PA, or 75 minutes per week of vigorous-intensity PA, or an equivalent combination²³. In brief, the participants were dichotomized into two groups: 1) participants who achieved the 2018 PA Guidelines (the summed minutes of PA were 150 min or more in a typical week), 2) participants who did not achieve the 2018 PA Guidelines (the summed minutes of PA were less than 150 min in a typical week). In order to assess the dose-response association between effective domains of PA and depression, we also categorized the summed minute of PA into four groups: 1) 0 min/week, 2) 1-149 min/week, 3) 150-299 min/week, and 4) ≥300 min/week¹⁹.

Depression

Depression was assessed by the 9-item Patient Health Questionnaire (PHQ-9) ^24,25, which assessing frequencies at certain symptoms experienced in the last two weeks, ranging from 0 (‘not at all’) to 3 (‘nearly every day’). These questionnaires were self-administered and the total scores ranged from 0 to 27. A cutoff score of 10 was used to define probable cases of depression, with the sensitivity of 88% and the specificity of 88%²⁴.

Covariates

Covariates included sociodemographic information, lifestyle behaviors and clinical characteristics. In detail, sociodemographic information included age, gender (male vs female), marital status (married or living with partners vs single), education (less than college vs college or more), race/ethnicity (Mexican Hispanic, Other Hispanic, Non-Hispanic White, Non-Hispanic Black and Other race), poverty income ratio (<1, 1-1.99, 2-4, and ≥4). Poverty index ratio was based on the Department of Health and Human Services’ poverty measure. Calculated by dividing family income by poverty guidelines specific to family size, year, and state²¹. Lifestyles included smoking status (never, former and current smokers) and body mass index (low to normal, overweight and obese). Clinical characteristics included hypertension, diabetes, heart disease, stroke, pulmonary disease and cancer. Hypertension was defined as having at least one of the following: systolic blood pressure ≥140 mmHg; diastolic blood pressure ≥90 mmHg; been told diagnosis by a doctor or other health professional. Diabetes was defined by being told by a doctor or health professional that have diabetes, or blood glycosylated hemoglobin (HbA1c) ≥ 6.5%, or fasting plasma glucose ≥126 mg/dL, or random plasma glucose ≥ 200 mg/dL²⁶. Arthritis, stroke, cancer, congestive heart failure, coronary heart disease, angina/angina pectoris, heart attack, asthma, emphysema, chronic bronchitis, chronic obstructive pulmonary disease was defined by being told by a doctor or health professional that have the disease. Heart disease included congestive heart failure, coronary heart disease, angina/angina pectoris, heart attack, pulmonary disease included asthma, emphysema, chronic bronchitis, chronic obstructive pulmonary disease.

Statistical Analysis

Continuous and categorical variables were presented as the mean with standard deviation (SD) or frequency (%), respectively. Group differences were analyzed by the student-t test or ANOVA. Logistic regression models were conducted to evaluate the association between PA and risk of depression. All analyses were conducted using three models: age- and sex- adjusted model; Multivariable model 1 was adjusted for age, sex, body mass index, race, education level, marital status, smoking status, poverty ratio, and years of NHANES; Multivariable model 2 was adjusted for stroke, diabetes, arthritis pulmonary disease, hypertension, heart disease, cancers and polypharmacy in addition to multivariable model 1. We also investigated the association of PA with depression risks across various strata defined by age, gender, body mass index (BMI), race, economic level, marital and smoke status, by using Multivariable model 2. All the tests were considered significant at a P value < 0.05 (2-tailed). All analyses were completed using R statistical software (version 4.1.2; www.r-project.org).

In this study, we pooled data set included 31221 participants (15377 males and 15844 females) from NHANES 2007-2018 (Table 1 and Figure 1). The mean age was 48.22 (18.55) years. Of these participants, 13821 (43.27%), 10278 (32.92%) and 7122 (22.81%) participants were young (aged 20-44 years), middle (aged 45-64 years) and older adults (aged ≥65 years), respectively. A total of 2837 (9.09%) participants were defined as depression in this population. According to the 2018 PA Guidelines, 18953 (60.71%) participants achieved the recommendation of total PA (≥150 min/week). And 10642 (34.09%), 4550 (14.57%) and 10570 (33.86%) participants achieved the recommendation of OPA, TPA and LTPA, respectively. The detail information was presented in Table 1.

Table 2 shows the results of multivariable logistic regression analyses between meeting PA Guidelines for various domains of PA and risk of depression. We found that total PA (OR 0.61, 95% CI 0.56-0.66) and LTPA (OR 0.42, 95% CI 0.38-0.46) that met PA Guidelines was inversely associated with the reduced risks of depression in the age- and sex-adjusted model. After adjusted for demographic and metabolic confounders, those who met PA Guidelines for total PA had 26% lower odds of having depression (OR 0.68, 95% CI 0.63-0.74), and those who met PA Guidelines for TLPA had 37% lower odds of having depression (OR 0.53, 95% CI 0.47-0.58). After additional adjusted for chronic diseases, the associations of total PA (OR 0.74, 95% CI 0.68-0.80) and LTPA (OR 0.57, 95% CI 0.51-0.62) with depression remained significant. However, OPA and TPA were not associated with depression in the age- and sex-adjusted model, and multivariable models in our analyses (Table 1, Supplemental Table 1 and Supplemental Table 2). Furthermore, we conducted stratified analysis across various strata defined by age, gender, BMI, race, economic level, marital and smoke status, using multivariable model 2 (Figure 2). Excluded race, significant associations of total PA and LTPA with depression were found in each stratum, and the interaction tests comparing the odds ratios across the strata were not significant (P value > 0.05), suggesting that LTPA was associated with lower risk of depression, regardless of age, gender, BMI, race, economic level, marital and smoke status.

Additionally, we also categorized the amount of PA into 4 groups (0, 1-149, 150-299, and ≥300 min/week) to assess the potential dose-response relationships between various PA domains and depression, and to evaluate the additional benefits of PA beyond or below PA Guidelines (Figure 3). Similar inverse associations across LTPA categories and depression were also found. After adjusted for confounders, participants who performed <1 time (1-149 min/week), or 1-2 times (150-299 min/week), or over 2 times (≥300 min/week) the recommended level of PA Guidelines had 31% (OR 0.69, 95% CI, 0.60-0.78), 43% (OR 0.57, 95% CI, 0.49-0.67), and 51% (OR 0.49, 95% CI, 0.43-0.55) lower risk for depression, respectively. These findings suggested that LTPA was associated with lower risks of depression regardless of any levels (1-149, 150-299 and ≥300 min/week). However, no significant associations of TPA and OPA with depression was found (P value > 0.05).

In this nationally representative cross-sectional survey of NHANES, we found that meeting PA Guideline for LTPA was associated with a reduced risk of depression, regardless of age, gender, BMI, race, economic level, marital and smoke status. Interestingly, LTPA, but not OPA or TPA, at any amount, was associated with lower risk of depression, suggesting significant mental health would benefit from being physically active, even at levels below the PA recommendations. However, no significant associations of TPA and OPA with depression was found.

At present, most researches were paid their attentions on the association of total PA or LTPA with depression, little evidence exists investigating whether the same health-enhancing effects are observed across different PA domains in general population^12-14. It remains unclear whether all PA domains (e.g., OPA, TPA and LTPA) have equivalent beneficial effects on depression. Previous observational studies have demonstrated a significant association of total PA with depression, suggesting a potentially modifiable lifestyle for prevention^12,13. In a recent meta-analysis of 15 prospective cohort studies with including 191130 participants and 2110588 person-years, Pearce et.al found an inverse curvilinear dose-response association between total PA and depression¹². Compared to adults not reporting any activity, those engaged in half the recommended volume of PA (4.4 marginal metabolic equivalent task hours per week [mMET-h/wk]) had 18% (OR 0.82, 95% CI 0.77-0.87) lower risk of depression. Adults engaged in the recommended volume of 8.8 mMET-h/wk had 25% (OR 0.75, 95% CI 0.68-0.82) lower risk of depression, and adults engaged in twice times of the recommended volume of 17.5 mMET-h/wk had 28% (OR 0.72, 95% CI 0.64-0.81) lower risk of depression¹². Their findings were consistent with our results of total PA was associated with lower risks of depression, regardless of any amount (1-149, 150-299 and ≥300 min/week) of PA. In parallel, Mendelian randomization studies also validated a potential protective role of PA on depression^15,16. Choi et.al conducted a 2-sample Mendelian randomization study, which including two PA phenotypes self-reported (n = 377 234) and objective accelerometer-based (n = 91084), to assess bidirectional relationships between PA and major depressive disorder (n = 143265) among adults¹⁵. They found a protective relationship between objectively assessed PA (OR, 0.74 per 1-SD increase in mean acceleration, 95% CI 0.59-0.92), but not self-reported PA (OR 1.28 per 1-SD increase in metabolic-equivalent minutes of reported moderate-to-vigorous activity; 95% CI 0.57-3.37) and the risk for major depressive disorder¹⁵. While, there was no significant association of major depressive disorder with self-reported or objectively assessed PA (P value >0.05)¹⁵. Their findings supported the hypothesis that enhancing PA may be an effective prevention strategy for depression.

Additionally, a recent meta-analysis of 111 prospective cohort studies, which included over 3 million adults sampled from 11 nations in five continents, reported that customary and increasing levels of LTPA (OR 0.80, 95% CI 0.77-0.83) are inversely associated with incident depression among adults, regardless of global region, gender, age or follow-up period¹³. Similarly, we also found that meeting PA Guideline for LTPA was associated with a reduced risk of depression, regardless of age, gender, BMI, race, economic level, marital and smoke status. However, in our study, we just analyzed the relationship between the total amount but not detail types of LTPA and depression. Choi et.al conducted a study in longitudinal biobank cohort from 7968 individuals of European ancestry, with assessing eight different types of LTPA: walking/hiking (including commuting for work), jogging, running, biking, racquet sports, swimming, high‐intensity exercise (e.g., dance and aerobics), and low‐intensity exercise (e.g., yoga and stretching) ²⁷. They found that running (OR 0.87 per 1 SD increase, 95% CI 0.78-0.96, P value = 0.013) and walking (OR = 0.89 per 1 SD increase, 95% CI 0.80-0.97, P value = 0.013) showed nominal associations with incident depression, even after adjusting for polygenic risk. They did not find significant associations for jogging, biking, racquet sports, or swimming²⁷. While Mendelian randomization study, which consisted of 123794 adults of white British ancestry who enrolled in UK Biobank, they found exercises (e.g., swimming, cycling) (beta = 0.90, P value = 0.033), but not any walking for pleasure (beta = 1.01, P value = 0.765) were associated with depression. They also found depression was associated with any walking for pleasure (beta = 1.06, P value = 0.036) rather than exercise (e.g., swimming, cycling) (beta = 0.98, P value = 0.452). Due to the self-reported PA reflecting average levels in the past year, the true levels of PA may fluctuate over the course of a year in their study. The significant association of walking with depression may be attributed to reverse causality or confounder factors. In summary, evidences from both observational and Mendelian randomization studies provided evidences that LTPA may be an effective prevention strategy for depression.

Unfortunately, neither OPA nor TPA were associated with depression in our analyses. Few studies investigated whether the same health-enhancing effects are observed across different PA domains^28-31. A U-shaped relationship between total PA and incident depressive symptoms in Kangbuk Samsung Health Study, which including 119,069 Korean adults in the age group of 18-64 years ³⁰. Chu et.al included 2727 participants aged ≥65 years participating in the 2005 Taiwan National Health Interview Survey, and found that LTPA (0 kcal/week: OR 3.72, 95% CI 2.28-6.06; 1-999 kcal/week: OR 2.06, 95% CI 1.25-3.39) but not non-LTPA (e.g., farm work, heavy lifting, fishing work and household chores) was significantly associated with depressive symptoms compared with 2000 kcal/week³². A cross-sectional study conducted in the Brazilian National Health Survey (n = 60202; ≥18 years) was also explored associations of PA domains with depression risk³¹. They found that TPA was also associated with lower depressive symptoms among older adults (OR 0.70, 95% CI 0.53-0.94) but not young or middle-aged adults, OPA (OR 1.62, 95% CI 1.38-1.91)³¹. We suspected the reasons of inconsistent results may result from disparities of ethnicity and education. Meanwhile, Choi et.al also found that there was no causal association of any walking for pleasure (beta 1.02, 95% CI 0.92-1.12), or transport by walking (beta 0.98, 95% CI 0.87-1.11), or frequency of walking (beta 1.02, 95% CI 0.85-1.123) with depression in Mendelian randomization study¹⁶. In summary, the association of OPA and TPA with depression were still controversial, and should be validated in further study.

Our study has several strengthens. We assessed the association with depression for total PA but also for PA domains (OPA, TPA and LTPA). Due to it remains unclear whether all PA domains have equivalent beneficial effects at present, we responded to this knowledge gap. We found that LTPA, rather than OPA or TPA, was associated with depression in adults across a wide age spectrum. Our results were based on the NHANES, a nationally representative cross-sectional survey of civilian, non-institutionalized persons living in the USA. So, our findings could generalize to the US population, regardless of age, gender, body mass index, race, economic level, marital and smoke status. However, several limitations were presented in our study. First, the NHANES data is cross-sectional, we did not examine causal relationships between PA domains and depression due to reverse causality and unknown confounder factors. In further study, prospective and Mendelian randomization studies are needed to assess the potential roles of PA domains on depression to validate our findings. Second, the PA domains were assessed by self-reported questionnaires rather than objectively measurements, and the amount of PA domains was assessed for a typical week at a single time, we could not capture the stable levels and trajectories of PA domains. Further study should collect the consecutive data of PA domains by objectively measurements, to investigate the association of PA with depression. Last, the depression was assessed by PHQ-9, which was a self-reported questionnaire. And the accurate assessment of depression by clinical diagnose is needed in the future.

In this nationally representative cross-sectional survey of NHANES 2007-2018, we showed different effects of PA domains on depression. LTPA, but not OPA or TPA, at any amount, was associated with lower risk of depression, suggesting that increasing LTPA, even at levels below the PA recommendations, should be suggested as a potential lifestyle modification to prevent or treat depression. Longitudinal studies and objective measurements of PA are needed to validate our findings in the future.

Acknowledgements

The data and samples used for this research were obtained from U.S. NHANES. We would like to thank the U.S. Centers for Disease Control and Prevention.

Conflict of interest

The authors declare that they have no relevant financial interests.

Funding

This work was supported by grants from National Natural Science Foundation of China-Youth Science Fund (3210040426).

Compliance with ethical standards

The data in our study was publicly available data and was a secondary analysis, no additional ethical review was necessary.

Author Contributions

Zhang H, and He F designed, conducted the research; Zhang H analyzed the data and performed the tactical analyses; Zhang H, wrote the paper; Zhang H had primary responsibility for the final content; and all authors read and approved the final manuscript.

Data available

The datasets analyzed in the study are publicly available at https://www.cdc.gov/nchs/nhanes/index.htm. The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request

Sponsor’s Role

None.

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Table 1 Characteristics of study population.

	All	Non-depression	Depression	P value
Sample, n (%)	31221	28384 (90.91)	2837 (9.09)
Age, years, M (SD)	48.22 (18.55)	48.23 (18.69)	48.12 (17.07)	0.759
20-44	13821 (43.27)	12634 (44.51)	1187 (41.84)	<0.001
45-64	10278 (32.92)	9129 (32.16)	1149 (40.50)
≥ 65	7122 (22.81)	6621 (23.33)	501 (17.66)
Sex, n (%)				<0.001
Male	15377 (49.25)	14343 (50.53)	1034 (36.45)
Female	15844 (50.75)	14041 (49.47)	1803 (63.55)
Education, n (%)				<0.001
Less than college	13838 (44.32)	12220 (43.05)	1618 (57.03)
College or more	15759 (50.48)	14659 (51.65)	1100 (38.77)
BMI, kg/m², n (%)				<0.001
Low to normal (<25)	9129 (29.24)	8429 (29.70)	700 (24.67)
Overweight (25-30)	10002 (32.04)	9281 (32.70)	721 (25.41)
Obese (≥30)	11754 (37.65)	10381 (36.57)	1373 (48.40)
Race/Ethnicity, n (%)				<0.001
Mexican American	4818 (15.43)	4384 (15.45)	434 (15.30)
Other Hispanic	3256 (10.43)	2864 (10.09)	392 (13.82)
Non-Hispanic White	12775 (40.92)	11595 (40.85)	1179 (41.56)
Non-Hispanic Black	6732 (21.56)	6126 (21.58)	606 (21.36)
Other Race	3640 (11.66)	3414 (12.03)	226 (7.97)
PIR, n (%)				<0.001
<1 (Lowest income)	6285 (20.13)	5298 (18.67)	987 (34.79)
1-1.99	7664 (24.55)	6839 (24.09)	825 (29.08)
2-3.99	7376 (23.63)	6896 (24.30)	480 (16.92)
≥4 (Highest income)	7069 (22.64)	6802 (23.96)	267 (9.41)
Marital status, n (%)				<0.001
Married	17534 (56.16)	16328 (57.53)	1206 (42.51)
Single	12969 (38.66)	10557 (37.19)	1512 (53.30)
Smoking, n (%)				<0.001
Nonsmoker	17106 (54.79)	15952 (56.20)	1154 (40.68)
Former smoker	7366 (23.59)	6736 (23.73)	630 (22.21)
Current smoker	5924 (18.97)	4927 (17.36)	997 (35.14)
Chronic disease, n (%)
Hypertension	12892 (41.29)	11448 (40.33)	1444 (50.90)	<0.001
Diabetes	5318 (17.03)	4626 (16.30)	692 (24.39)	<0.001
Arthritis	8230 (27.84)	6994 (24.64)	1236 (43.57)	<0.001
Heat disease	2513 (8.51)	2095 (7.38)	418 (14.73)	<0.001
Stroke	1113 (3.76)	898 (3.16)	215 (7.58)	<0.001
Pulmonary disease	5986 (20.03)	5038 (17.75)	948 (33.42)	<0.001
Cancer	2925 (9.88)	2614 (9.21)	311 (10.96)	0.005
Polypharmacy, n (%)	5446 (17.45)	4442 (15.65)	1004 (35.39)	<0.001
Total PA: achieved	18953 (60.71)	17670 (62.25)	1383 (48.75)	<0.001
OPA: achieved	10642 (34.09)	9741 (34.32)	901(31.76)	0.006
TPA: achieved	4550 (14.57)	4146 (14.61)	404 (14.24)	0.617
LTPA: achieved	10570 (33.86)	10047 (35.40)	523 (18.43)	<0.001

PIR: Poverty income ratio; PA: Physical activity; OPA: occupation-related PA; TPA: Transportation-related PA; LTPA: Leisure-time PA; Unknown: Education, 1624 (5.20%); PIR, 2827 (9.05%); Marital status, 1618 (5.18%); Smoking, 825 (2.64%); Hypertension, 1 (0.003%); Arthritis, 1657 (5.31%); Heat disease, 1690 (5.41%); Stroke, 1639 (5.25%); Pulmonary disease, 1340 (4.29%); Cancer, 1622 (5.20%); Polypharmacy, 14 (0.04%).

Table 2 Multivariable OR for depression based on the meeting PA Guideline

	Event/N (%)	Age- and Sex- adjusted Model		Multivariable Model 1		Multivariable Model 2
		OR (95% CI)	P value	OR (95% CI)	P value	OR (95% CI)	P value
Total PA
No	1454/12268 (11.85)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)
Yes	1383/18953 (7.30)	0.61 (0.56, 0.66)	<0.001	0.68 (0.63, 0.74)	<0.001	0.74 (0.68, 0.80)	<0.001
Occupation-related PA
No	1936/20579 (9.41)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)
Yes	901/10642 (8.47)	0.96 (0.89, 1.05)	0.390	0.91 (0.84, 1.00)	0.042	0.95 (0.87, 1.03)	0.216
Transportation-related PA
No	2433/26671 (9.12)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)
Yes	404/4550 (8.88)	1.03 (0.92, 1.15)	0.659	0.95 (0.84, 1.06)	0.353	1.02 (0.91, 1.15)	0.682
Leisure-time PA
No	2314/20651 (11.21)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)	1 (Ref)
Yes	523/10570 (4.95)	0.42 (0.38, 0.46)	<0.001	0.53 (0.47, 0.58)	<0.001	0.57 (0.51, 0.62)	<0.001

PA, physical activity; OR, odds ratio; CI, confidence interval; Multivariable model 1 was adjusted for age, sex, body mass index, race, education level, marital status, smoking status, poverty ratio, and years of NHANES; Multivariable model 2 was adjusted for stroke, diabetes, arthritis pulmonary disease, hypertension, heart disease, cancers and polypharmacy in addition to model 1.

The authors have declared there is NO conflict of interest to disclose

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Association of domain-specific physical activity with depression: findings from NHANES 2007-2018

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